The Care of Aggressive and Antisocial Children and Youth

7/31/2019 The Care of Aggressive and Antisocial Children and Youth

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The Residential Care of Aggressive and Antisocial Childrenand Youth:

A Plea to the Government of New Brunswick to Stop UsingResidential Programs for Children and Youth that are Proven

Not to Work

Presentation to New Brunswick Mental Health CommissionJan 2009 by Dr. Charles Emmrys

The largest consumer group using child and youth mental health services arethose children and youth suffering from behaviour disorders. These include thosewith conduct disorders, oppositional disorders, delinquency and attentiondisorders. The group is highly heterogeneous and is prone to a range of otherpsychopathologies such as anxiety, obsessional disorders, addictions and learningdisabilities.

The care plans for these children and youth are by definition complex andmultifaceted but the key ingredient is always to make sure the person has a

secure and safe place to live. This self evident first step for kids that have oftenlost or been rejected by their biological families may be obvious but is never thateasy to secure.

In this presentation we will look at the question of how best to secure a stablehome for children that are difficult to care for, are often traumatizing to parentsbut, like all children and youth, needing of a home that works. We will relyprimarily on what the research on the subject has said about where these childrenshould stay, who should parent them and what services parent figures need to beable to adequately carry out their responsibilities towards this suffering at risk

population.

After much deliberation and study, the province of New Brunswick chose in thelate seventies and early eighties to close down the William F. Roberts (WFR) in St.John and begin its long road to developing community based systems of care for

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developmentally handicapped and behaviourally disordered children and youth.The WFR was a large facility that had used an old and very expensive large groupresidential care model that was clearly not producing the results New Brunswickerswere expecting. The provinces decision to close it down was a bold stepconsidered by many experts across the country as a ground breaking and trend

setting. For the next twenty years, Canadians looked on to see how NewBrunswickers, now seen as leading innovator in the field, would rebuild theirsystem.

The first group to receive services were those children and youth with severedevelopmental handicaps. Care teams were created in each community of theprovince to provide in home and school centered community services. Thougheach case was unique, the strategies for improving their quality of life was fairlystraight forward. Services were primarily home and school based and centered onmedical needs, improvements in activities of daily living, mobility challenges,facilitation of communication and addressing access questions (wheel chair access)in schools and other public venues. To the greatest extent possible, children werereturned to their biological homes and robust services were provided to help oftenwilling parents make a home for their child. When biological homes were not ableto take in the child, foster homes were provided. Clearly there were challengesand some residential failures did occur but, for the most part, these homes werestable and had a good record for longevity and effectiveness.

Children and youth with behaviour disorders were quite a different problem. Theymade up 40% or more of the population of the old WFR and had always been verychallenging to the residential care staff. When the institution closed, therapists

and interventionists were confronted with diagnostic and treatment challenges thatwere almost always more complex and difficult than those posed by the childrenwith developmental handicaps. Advancing a differential diagnosis for thispopulation was then and still is today a very difficult process. Considerationshave to be given to the impact of trauma, the relationship between behavioursand brain based mood and impulse control problems, the role of family, the impactof addictions and the importance of poverty. One word diagnostic statements like

this child has an attention deficit disorder were hardly sufficient or useful tothose involved in providing complex and difficult to implement treatments. Careplans were, as already mentioned, complex and involved many players fromvarious services. Clinical research findings were and still are new and rapidlyevolving. The tools for healing these ills (medicines, therapies and communitybased interventions) were even less tried and less well supported by research.Surprisingly, one of the least well studied questions in the field was whichresidential care option worked best.

In the past, prisons and residential institutions gave authorities the attractive andconvenient Quick Fix that took the problems out of public view. Mental health

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providers and leaders in the educational and justice systems convincedthemselves that these children and youth would be better cared for in well staffedlarge facilities that could contain their behaviours and keep them safe fromthemselves. Authorities also told themselves that if these children and youth didnot get better in large facilities, they probably would never get better anywhere

else, thus justifying segregating them from society. This self serving thinking wasand still is pervasive throughout the child and youth care structures in North

America and Europe along with the old idea of they arent really sick, they arejust bad spoiled kids that need discipline.

But is this simple and straight forward way of thinking correct? An expandingbody of research in the last forty years has shown that not only is this way ofthinking false but that the exact opposite seems to be true.

As New Brunswick struggled to serve this second population from the WFR, itbecame quickly evident that the teams created to care for the developmentallyhandicapped could not also care for the behaviourally disordered. The problemswere simply too different and the expertise needed to deal with each group wastoo dissimilar. New Brunswicks solution in 1994 was to create a parallel servicebased on the community expert team idea used so successfully with thedevelopmentally handicapped. The Provincial Youth Treatment Program (YTP)

was created. It was a province wide system of care that placed multi-agency andmulti-disciplinary teams from 14 communities at the centre of its system of care.These new teams brought together interventionists from the school system, the

justice system, the mental health system and the child protection system with amandate to oversee the implementation of the complex care plans needed forthese children and youth. Success was defined as getting those affected bybehaviour disorders to survive and live successfully in their families, their schoolsand their social groups through a combination of medications, communitysupports, school adjustments and family therapies. A provincial expert groupbased in the Pierre Caissie Centre in Montcon trained and supported the 60professionals that made up the teams. The Pierre Caissie Centre itself is a shortterm (five week limited stay) four bed facility that carries out the complexdiagnostic work required for those clients that the local teams have not been ableto help.

This bold and important initiative has been and still is lauded across the country asrepresenting a good example of best practice in the field. Nationally recognized

1Authors italics.

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experts Dr. Jalal Shamsie (University of Toronto), Dr. Paul Steinhauer (SickChildrens Hospital in Toronto), Dr. Dan Offord (McMaster University) Dr. RoyHolland (Maples Centre in Vancouver)) described the system in New Brunswick ascutting edge and worthy of emulation.

At the core of the YTP program was a set of fundamental belief regarding the careof behaviourally disordered children and youth. These were:

1. that the treatment of behaviourally disordered children and youth is bestdone in their community and that treatment in the more expensiveresidential facilities, regardless of their size, does not work for those placedthere.

2. that institutional care is primarily a means by which to remove a highlydisruptive child from the community for the communitys sake, not thechilds sake.

3. that institutional care survives because mental health and social serviceplanners do not invest properly in community based services. In otherwords the there is no other place argument is simply an attestation to thefact that planners did not do their work.

4. that when children and youth with behavioural disorders are placed ininstitutions, the community itself becomes less competent in dealing with itsown disordered children and youth and becomes less tolerant ofdifferences. Intolerant communities put pressure on authorities for moreinstitutional care for children an youth. We refer to this dynamic as the

5. and that alternative community based services such as family preservation,

adoption and fostering are more effective and beneficial for the child andfor the community.

Having made these statements, let us now summarize quickly the researchfindings that support the idea that family and community based services forchildren and youth are indeed better for the child or youth and for the community.

Old ideas die hard. Despite the closing of many old style institutions across NorthAmerica, most continue to operate and disordered children and youth are stillbeing placed in institutional settings that are ineffective at best and detrimental atworst for the children and youth placed there (Chamberlain & Reid, 1998; Fisher &Chamberlain, 2000; Curtis, Alexander, & Lunghofer, 2001). Institutional carewould include long term psychiatric hospitals, more specialized residentialinstitutions such as the Peel Centre in Moncton, carceral institutions such as theNew Brunswick Youth Centre in Miramichi, residential group homes such as the

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ones run by Moncton Youth Residences in Moncton or Fredericton Group Homes inFredericton and various other large and small group residential treatment facilities.

One of the most comprehensive examinations of the question of what works inresidential care for behaviorally aggressive kids was presented by the U.S.

Surgeon General in his report titled Youth Violence published in 2001. Thisambitious and thorough review of the what works and what does not workliterature was carried out by a panel of leading researchers from the U.S. andCanada and is perhaps the best review of its kind ever conducted. In this reportthe authors clearly state the following

interventions(hospital, institutional, correctional or

group home care2) also show little promise of reducing subsequent crime and

violence in delinquent youths. While some residential programs appear to havepositive effects on youths as long as they remain in the institutional setting,research demonstrates consistently that these effects diminish once young peopleleave.

He concludes that

At present, states and communities are squandering substantial amounts ofmoney on untested programs or programs known to be ineffective.Policy makersmust be encouraged to focus existing resources on programs that work.Aninformed public is also critical in building support for effective alternatives toincarceration.

Surgeon generals report on Youth Violence, 2001http://www.surgeongeneral.gov/library/youthviolence/chapter5/sec6.html#IneffectiveTertiary

We would refer you to appendix A for a table that outlines in point form theprograms shown to be effective and those known to not work.

In an attempt to better understand the reason these facilities were so ineffective,Fisher & Chamberlain, (2000) studied what actually went on between residentsand between residents and staff from day to day. His study showed that placing

behaviorally disordered children and youth together simply increases the risk ofpeer reinforcement of their problem behaviors. Numerous other authors note thatadolescent peer support of aggression seems to increase aggressive behavior inboth residential and classroom settings, a finding that would have been predictedin the modeling literature going back to Bandura (1965). Antisocial peerreinforcement among delinquent boys, Fisher notes, has been shown to be a

2Authors note.

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predictor of later substance abuse and to increase the likelihood of these boysbecoming adult offenders (Fisher & Chamberlain, 2000). Deviant peer influence isalso a particularly strong predictor of increases in delinquent behavior if high-riskboys commit those behaviors during their prime offending years (Eddy &Chamberlain, 2000). The influence of programs offered by staff members in these

facilities was simply not sufficient to counter the negative effect of seeing peersmisbehave. The short lesson to be learned by this research is simply this

.

Should we be surprised at these findings? In fact, the cited research is consistentwith research that dates back almost half a century when these kinds of studiesfirst started being conducted (Rutter and Taylor, 2002).

This means that evenfor the sickest children, the order of services should be the following:

1. First try to save the family through in-home direct supports using modelslike family preservation. The research seems to indicate that the best

services are those that are comprehensive, that involve all parts of thechilds life and that are fairly intense in terms of hours of involvement.

2. Adoption should be seen as the second best option to staying with onesparents. Studies show consistently that adopted children do better inyoung adulthood than do children who were raised in foster care.

3. A well supported foster care systems offer a good third alternative to familypreservation or adoption. Here again, the training and support that fostercare providers receive is crucial to their success.

4. All other services such as hospital or emergency services should be shortterm ones focused on providing the child/youth and his parent figures withbetter diagnosis, improved care plans and timely respite.

We will present a brief discussion on family preservation and adoption later in thepresentation but to reinforce our position, we would like to present a brief reviewof the literature on how institutional care, including group home care, compares toa well supported foster care placement.

3Authors italics

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Institutional group care should be seen as a continuum that includes largeinstitutions like youth jails and psychiatric hospitals on one hand and small grouphomes imbedded in the community on the other. To lump together what seems atfirst to be very different kinds of establishments would seem difficult to defend butthe reader should remember that from the child or youths perspective, theseplaces are all pretty similar. They have the same kinds of rules, the same shiftmodel staffing regimes and the same kinds of programs and even the same kindsof meal routines. Staff in almost all institutional group care services do not livewith the children but work in shifts to provide 24 hour coverage. There are somefacilities that have live in staff but their role in the lives of the children and youth isquite limited as compared to that of adoptive or foster parents. Their influence isdiluted by the presence of other staff members, all of whom play a role in thechildrens lives. Program offerings in these institutions vary greatly but all aim tochange factors deemed important in supporting disordered behaviors (Curtis,

Alexander, & Lunghofer, 2001). What is also characteristic of institutional groupcare is the existence of two sub communities within a larger community. In allthese facilities, there is the community of the staff and the community of thekids. Each group has very different ideas of what the institution is about, whatsuccess is and what relationships are all about. When goals conflict, those inauthority resort more often to strict rules and the use of authority to keep the lidon. Despite what managers may claim, this simple dynamic defines life in many

group facilities.

The comparison we will draw here will be between institutional group care asdefined above and a well supported foster home system of care referred to in theliterature as Multidimensional Treatment Foster Care (MTFC). MTFC wasoriginally developed as an alternative to incarceration for boys with serious andchronic delinquency (Leve, Chamberlain, & Reid, 2005) but has since been used toserve other behaviorally disordered children and youth. The MTFC treatmentapproach has also been known as Specialized Foster Care (Chamberlain & Reid,1991; Chamberlain, Moreland, & Reid, 1992), Therapeutic Foster Care (Curtis,

Alexander, & Lunghofer, 2001), & Treatment Foster Care (Hudson, Nutter, &

Galaway, 1994). For the sake of this presentation, we will refer to all of theseapproaches as MTFC.

The essential philosophy of the MTFC treatment model suggests that a familyenvironment, with parents who are in charge and well supported in systematicallysupporting developmentally appropriate behaviors will offer the most effectivetreatment for youth exhibiting disruptive behavior. MTFC (foster) parents work as

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part of a treatment team with the youths family (biological or adoptive) and otherclinicians to develop and implement the youths treatment plan. The intentthroughout the placement is to reunite the youth with his or her family at the endof the program. The youth is closely supervised with consistent limits,consequences, and therapeutic support intended to decrease delinquent behavior

and increase pro-social behavior (Fisher & Chamberlain, 2000). It is believed thattreating young people in a setting that is similar to the target placement(biological/adoptive family) provides more generalization of learned behaviorswhen compared to traditional residential treatment (Fisher, Ellis, & Chamberlain,1999).

The MTFC approach has been studied over the years with a number of populationsincluding male and female, youth and younger children and various ethnic groups.Study findings have been consistent across populations.

A 1991 study assessed the effects of MTFC on severely emotionally disturbedchildren and adolescents who had been previously hospitalized. Cases wereassigned randomly to MTFC and to control groups in residential settings. TheMTFC experienced shorter time from referral to placement than the control groupand were slightly more successful at remaining in their targeted community settingthan the control group (Chamberlain & Reid, 1991).4

Meadowcroft et al. (1994) summarized the empirical literature on MTFC, resultscomparing MTFC to residential treatment for seriously troubled children. Thechildren were described as emotionally disturbed or behaviorally disordered.Common client problems included severe and chronic delinquency, head injury,school performance problems, mental retardation, suicidal ideations, AIDS,psychiatric disorders, and drug and substance abuse. MTFC was shown to be lessexpensive, more community based, integrated, and comprehensive compared toother out-of-home services. On discharge, MTFC outcomes showed significantlygreater behavioral improvements in the clients when compared to residentialtreatment services.

The effectiveness of MTFC compared to group care (GC) was tested again with apopulation of chronic juvenile male adolescent offenders. The study consideredthe impact of the two treatment models on criminal offending, incarceration rates,and program completion. The boys assigned to MTFC had significantly fewercriminal referrals and returned to live with relatives more often than those

4Authors italics

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assigned to GC. In the MTFC setting fewer boys ran away, more boys completedtheir programs, and fewer boys were placed less frequently in detention or intraining schools. The authors note that developmentally appropriate, intensive,and individualized family focused treatment tends to be superior to GC at anypoint in the developmental trajectory of antisocial youngsters (Chamberlain &

Reid, 1998). 5

Finally, a randomized intervention trial for girls with chronic delinquency comparedthe effectiveness of MTFC to GC (control condition) in reducing incarceration anddelinquency. Prior studies with males had shown positive outcomes using MTFC toaddress multiple risk factors. MTFC was adapted for use with a female populationfor this study (this was the first randomized study to test an intervention focusedexclusively on girls with chronic delinquency). The results of the trial suggestedthat the MTFC intervention was more effective than GC. The MTFC girls spent62% fewer days in locked settings at follow-up than the GC girls. The MTFCcriminal referral rates dropped 42% more than the GC girls (Leve, Chamberlain, &Reid, 2005).6

The above brief and admittedly very incomplete review is consistent with thefindings of the U.S. Surgeon General and clearly shows that MultidimensionalTreatment Foster Care intervention stands out as the superior model for treatmentof children/adolescents/youth when compared to group residential care.

Although MTFC may seem more labor intensive and require higher levels ofexpertise on the part of parents and clinicians to put in place (i.e. case managerscarry lower caseloads), the expense is still far less that providing long-term care ina staffed facility. In an attempt to quantify these cost savings, the WashingtonState Institute for Public Policy estimated a total savings of $5,815. per youth per

annum and savings of $11,760 in reduced crime victim costs (Fisher &Chamberlain, 2000).

5Authors italics

6Authors italics

7Authors italics

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A Canadian study examined the effectiveness of the MTFC approach in a Parent-Therapist Program (compared to residential treatment). The yearly cost to treatone child in a Parent-Therapist home was $16,890.; compared to the yearly cost oftreating one child in residential treatment at $35,329. Although the program wasstudied in 1974 the cost ratio comparison points to the significant cost-

effectiveness of MTFC (Hudson, Nutter, & Galaway, 1994). Since institutionalcosts have risen far faster than the care of fostering systems overall, the savingsnoted here are likely a rather dramatic underestimation of the savings thegovernment can realize if it adopts a lets do what works policy and abandons itsaddiction to the incompetence abuse cycle.

MFTFC is the least effective of the alternatives to institutional group care forchildren and youth when compared to adoption or to family preservation. Fosterhome children grown up have problems with joblessness, homelessness, lowerlevels of education, addiction and poor success rates in terms of partnering andchild rearing when compared to adopted children for example. We will notsummarize the literature here on the added benefits to the child or youth whosecare team opts for adoption or family preservation as a residential solution. Wewill note, however, that the supports the foster home receives, the better theoutcome and the more similar the outcomes between fostering and adoption seemto be.

We would also like to stress that our foster home system can be made moreresponsive and more successful by expanding it to offer a variety of fostering

options. MTFC is but one fostering approach that the province could and shoulddevelop. A number of other approaches to fostering have been developed andresearched in the last four decades and the province should set out to making thefoster care option one that has a range of sub-specialties. We would refer thereader to Appendix B for a more through discussion on this point but we would

Despite their limitations, all three family based residential options has been shownto be helpful and beneficial for children and youth. This seems to be the caseregardless of the level of severity of the behaviors being exhibited by the child orthe level of their illness. Since we have options, we, as a province, should beretooling our services to offer family based options to more and more children andyouth. We should also be phasing out as quickly as possible all residential servicesthat have been shown to not work.

We will also not review the considerable literature that has developed around thestudy of intensive services for biological families that we referred to as familypreservation. These approaches could have interventionists in the home for up to20 hours a week to provide mentoring for the parents and role modeling for the

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children. We do note that a number of group home providing agencies such asMoncton Youth Residences have added to their service offerings a familypreservation component. We see this activity as one that should be increasinglyemphasized and promoted.

When a system of care opts for a more family focused service delivery system, itcommits itself to developing a strong system of supports for the families who carefor behaviorally challenged children and youth. The general rule has been that tosupport this kind of system, you need smarts up front i.e., that you needinterventionists that are well trained in the methodologies of supporting familiesthrough hard times and that they need to be accessible to the families. You alsoneed a fairly strong system of respite services that can offer a break to the familywhen needed. Fortunately, the knowledge required to set up a strong andresponsive support system is readily accessible and there is no reason why NewBrunswick cannot be a leader in the field the way it was ten years ago.

As a final comment on the use of group residential care for children and youth, wewould like to address briefly the ethical question that it presents. Behaviorallydisordered children and youth are among the most traumatized and emotionallyscarred members of our society. Often issuing from homes where violence and

addiction were prominent, their lives are often a story of pain and loss. How thencan we offer to them care options that at best leave them in limbo and at worstcontinues the cycle of abuse that has characterized all of their lives. They are ourmost vulnerable citizens who have the worst prognosis of any mentally ill group.We owe the at least a residential care service that works.

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Our recommendations

The way forward

1. Adoption as the first Option for a homeless child or youth.

We strongly support New Brunswicks recent initiatives in promotingadoption as a first priority for children without homes. Expansion of thesupport system for adoptive parents taking in high risk children wouldseem to us a necessary and vital next step in making adoptions work forchildren and their families.

2. A better foster home system

A differentiated foster care system (see appendix B) that is tailored toservices to the three principle populations using the service namely

Attachment Foster Homes for those homes that will receivechildren permanently. This New Brunswick developed system ofcare is similar to MTFC homes reffered to earlier in the text.

Rehabilitation Foster homes that are trained to work withbiological parents, social workers and family therapists with aview of returning the child to their biological home as soon aspossible.

Foster Homes specializing in the care of the severely mentally ill.

Professionalizing the foster parent both in terms of training and in termsof salary. We would see tripling the basic rate of pay for foster parents.

Opening up the possibility for private agencies to offer foster homeagencies. These agencies, when properly supervised and staffed, havebeen able to put in place services that were able to serve extremelyhard to serve children and youth through using a star system of care(group of 8 or ten foster homes supported by a support team with a twobed emergency placement facility where children in crisis can stay for afew days.

3. A system of professional support team for adoptive and foster homeparents working under the leadership mental health or child protectionservices.

The creation of a series of specialized support teams for foster parentscomposed of professionals from various agencies that develop a

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specialization in the area. These professionals would be nested in theirown agencies but devote a portion of their time to the role of supportingadoptive and foster homes.

4. Decreasing funding to those interventions proven to not improve or worsenthe outcome for behaviorally disordered youth.

Putting a moratorium on the placement of children in large group carefacilities such as Youthhdale, in Toronto, Peel centre in Ontario andMoncton, outbound agencies in Main etc. safe in the case of addictedyouth such as the agency at Portage near Sussex.

Prohibiting out of province placements.

Creating a policy environment where in a child that has more than threeplacement failures in provincially run placements is automaticallyflagged for special services by an expert team that would surround thechild with intensive services aimed at securing a placement withlongevity.

Working with group home providers to help them shift from group homecare to specialized foster home services.

We would advance that making the changes here proposed will be revenue neutralat worst but will likely offer a considerable revenue saving for the government.

More importantly, it will help re-launch an initiative that started with the closure ofthe William F Roberts and perhaps help New Brunswick regain its position ofprominence in the care of behaviorally disordered children and youth.

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Bandura, A., (1965). Research in Behavior Modification: New Developments andImplications. Holt Reinheart and Winston. New York.

Chamberlain, P., Moreland, S., & Reid, K. (1992). Enhanced Services and Stipendsfor Foster Parents: Effects on Retention Rates and Outcomes for Children.Child Welfare, 00094021, 71 (5).

Chamberlain, P., & Reid, J.B. (1991). Using a Specialized Foster Care CommunityTreatment Model for Children and Adolescents Leaving the State MentalHospital. Journal of Community Psychology, 19.

Chamberlain, P., & Reid, J. B. (1998). Comparison of Two Community Alternativesto Incarceration for Chronic Juvenile Offenders. Journal of Consulting andClinical Psychology, 66 (4), 624-633.

Curtis, P. A., Alexander, G., & Lunghofer, L. A. (2001). A Literature ReviewComparing the Outcomes of Residential Group Care and Therapeutic FosterCare. Child and Adolescent Social Work Journal, 18 (5).

Eddy, J. M., Chamberlain, P. (2000). Family Management and Deviant PeerAssociation as Mediators of the Impact of Treatment Condition on YouthAntisocial Behavior. Journal of Consulting and Clinical Psychology, 68 (5),857-863.

Eddy, J. M., Whaley, R. B., & Chamberlain, P. (2004). The Prevention of ViolentBehavior by Chronic and Serious Male Juvenile Offenders: A 2-Year Follow-up of a Randomized Clinical Trial. Journal of Emotional and BehavioralDisorders, 12 (1), 2-8.

Fisher, P. A., & Chamberlain, P. (2000). Multidimensional Treatment Foster Care:A Program for Intensive Parenting, Family Support, and Skill Building.Journal of Emotional and Behavioral Disorders, 8 (3), 155-165.

Fisher, P. A., Ellis, H., & Chamberlain, P. (1999). Early Intervention Foster Care:A Model for Preventing Risk in Young Children Who Have Been Maltreated.Childrens Services: Social Policy, Research, and Practice. 2 (3), 159-182.

Hair, H. J. (2005). Outcomes for Children and Adolescents after ResidentialTreatment: A Review of Research from 1993 to 2003. Journal of Child andFamily Studies, 14 (4), 551-575.

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Hudson, J., Nutter, R. W., & Galaway, B. (1994). Treatment Foster CarePrograms: A Review of Evaluation Research and Suggested Directions.Social Work Research, 10705309, 18 (4).

Leve, L. D., Chamberlain, P, & Reid, J. B. (2005). Intervention Outcomes for Girls

Referred From Juvenile Justice: Effects on Delinquency. Journal ofCounsulting and Clinical Psychology, 73 (6), 1181-1185.

Meadowcroft, P., Thomlison, B., & Chamberlain, P. (1994). Treatment Foster CareServices: A Research Agenda for Child Welfare. Child Welfare, 00094021,73 (5).

U.S. Department of Health and Human Services, (2001) Youth Violennce:Report from the Surgeon General. Surgeon Generals Office., Washington

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Appendix A

Reproduction of the What works what does not work table from the Surgeon

Generals report on violent Youth (page106 table 5-1)

Skills TrainingBehavior monitoring and reinforcement

Behavioral techniques for classroom ManagementBuilding school capacity

Continuous progress programsCooperative learningPositive youth development programs

Parent TriningHome visitationCompensatory educationMoral reasoning

Social Problem SolvingThinking skills

Social perspective taking role taking

Multimodal interventionsBehavioral interventionsSkills trainingMarital and family therapy by tained staffWraparound Services

Peer counseling, peer mediation, peer leadersNon-promotion to succeeding grades

Gun Buyback programsFirearms TrainingMandatory Gun Ownership

Redirected youth behaviorShifting peer group norms

Boot Camps

Residential ProgramsMilieu TherapyBehavioral token economies

Waivers to adult courtSocial caseworkIndividual counseling

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Appendix B

PROPOSAL FOR A DIFFERENTIATED FOSTER CARE SYSTEM IN

N.B.

MEETING BRIEF October 1998

Presentation to the department of Family and Community Services

The development of foster care services was initially predicated onthe belief that fostering was essentially volunteer activity, a charity thatcaring parents extended to those children needing respite or temporarycare until they could be reunited to their families or to new adoptivehomes. The policy developed around foster care reflected this beliefand was therefore focused on getting the child back home or adopted assoon as possible. Training of foster care parents was generic and

consisted primarily in providing them with up to date behaviourmanagement tools.

This way of looking at foster care promoted the idea that infostering, one size fits all, i.e., that there was essentially one kind offoster care. When divisions or rankings among foster care parents wereenvisaged, it was usually done on the basis of either years ofexperience, amount of standard training completed or the severity ofbehaviours displayed by the child. In the New Brunswick of 30 yearsago when the W.F. Roberts and out of province placements were seen aspreferred treatments for all children that did not fit the mould, this

system was quite sufficient and workable. In the New Brunswick of 1998when these other types of services no longer constitute acceptableforms of practice and where foster parents are asked to take in thesemore disturbed children, a generic foster care service is no longerpractical or maintainable.

What we suggest is that it is important that we modernise ourfoster care system by seeing our parents as short or long term co-interveners with us in the lives of these children. They are our new andbetter W.F.Roberts. Our best service option and our essential supportsystem for children. We also suggest that a new non-institutional

system of service options be developed to support and supplementfoster care services in the province. These should include a provincialnetwork of emergency beds for short (2 day) respite services, familypreservation services, effective regional outpatient psychiatric backupfor behaviourally challenging children, and a system of foster homes forseverely conduct disordered children developed managed andcontracted to us by private non profit agencies.

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FOSTER CARE OPTIONS

Whatever option we select for foster care services, it is vital thatwe not only choose an option but that we plan for supporting it via

training and ongoing clinical support services. This will likely mean thatinterdepartmental cooperation will be vital to developing andmaintaining a modernised system. What we are suggesting forimplementation is a system that is fairly easy to develop and is quiteviable and sustainable via existing programs.

SUGGESTED FOSTER HOME SYSTEM STRUCTURE

It is clear that it is no longer defendable to support what amountsto a generic foster home system. Not all children are the same. Not all

children have the same symptoms and not all children have the samelife circumstances. If we are to place foster care at the centre of oursupport system, we must allow it to become more specialised andprovide it with the support to do so.

The Youth Treatment Program has been aggressively developingfoster care options through its work with severely behaviourallydisordered children. These efforts have been localised (have not beenapplied system wide) and were in response to the needs of specificchildren. Nonetheless, it has allowed us to integrate and develop anumber of effective foster care options that are implementable across

the system. Though the list is not exhaustive (we are still developingsome of these approaches), we can propose for consideration these fivepossible fostering approaches.

Rehabilitation Fostering

This foster care approach is the closest to the traditional fostercare service offered in New Brunswick. It is based on the concept thatthe child is only in the home for a limited period of time and thatreintegration back home or to an adoptive home is practicable.

a. Training:Training for these foster parents would focus on effectivebehaviour management social skills information and realitytherapy concepts. The important goals of these admissions wouldbe to provide the child with a safe place to live and to promotetaking charge of one's life and making decisions that will lead todesired results.

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b. Clients for this service:This service would be for the majority of children in care, i.e.,children for whom a return home or to an adoptive home is a clearprobability.

c. Support services:Support services would be primarily access to clinical servicesexpert in the training areas listed above as well as regular contactand support from the social worker. Too much intervention inthese families tends to reduce their effectiveness so trainingshould be formalised and occur on a regular schedule (probablyideally twice a year). Other clinicians involved with the childshould be in regular contact with the parents to coordinateservices.

d. Evaluation:

The rehabilitation home should be evaluated by the preparednessof the child to return home. This would include a sense of theproblems that led him to be placed and a realistic but positiveattitude to resolving the problems that were identified.

Attachment Based Foster Care

This foster care approach is showing itself as being a powerfulmodel for promoting stability in a subset of children that were formerlyextremely difficult to maintain in foster care. These are children with adiagnosis of reactive attachment disorder, a disorder associated with

frequent foster care displacement. The form of foster care needed forthis population is quite different from the rehabilitation model.

a. Training:Training for attachment based foster care parents is focusedprimarily on the study of attachment or the development of theparent child relationship. Training components would includeinterpreting rejection and aggressive acts within the context of therelationship, learning the attachment cycle of these children, andknowing what the best responses are to the various unusualbehaviours displayed by these children.

There is less of an emphasis on behaviour management or on selfresponsibilising interventions since these are often seen by thechild as precursors to rejection. The emphasis is no building thebasic relational competence that must come before any of thehigher life competencies are learned.

b. Clients for this service:

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Clients for this service would be those children and youth who,because of the chronic instability of their lives, have been unableto develop the relational competence or trust to be able to buildsupportive relationships with those around them. Diagnostic toolssuch as the IADS and the AAS can help in the process of

identifying who these children are.

It is also understood that the children placed in an attachmentbased foster home are those who will likely stay with the parentslong term, i.e., until they are 18.

c. Support services:The key support service is the debriefer, i.e., a person who will beresponsible for helping parents survive the effects of the frequentattacks the child will direct towards the parents as he struggles toattach. The role of the debriefer will also be to continue to train

the parents in attachment concepts and to apply them to thespecific child they are caring for.

Other support services are afforded carefully and sparingly. Thedebriefer should become the family's main support system in whatpertains to their fostering activities. Contacts with other cliniciansshould be limited.

D. Evaluation:The parents are evaluated basically on their ability to promote theattachment process and to manage their stress levels as the

attachment process takes place.

Co-Parenting Foster Care Services

Co-parenting foster home system is influenced by the Hawaiimodel where in mothers who have attached to their children and who'schildren have attached to them can continue to parent despite havingimportant and permanent limitations in their abilities to parent. In thismodel, a quasi permanent relationship is fostered between the fosterparents and the natural parents with the objectives of creating a sharedparenting arrangement. The model has not been used often in our

program but results have been predictably positive.

Training:Training for these parents would stress family dynamics andsystems theory as well as training in the establishment of arespectful client worker relationship. Child managementstrategies would also be a part of this training package but wouldbe less central than for rehabilitation families.

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Clients for this service:Clients for this service would be children or youth who displayed ahealthy but stressed attachment to their parents and who showedrelational competence in other areas of their lives. The parents

would also show similar areas of relational competence. Theparents would, however, show important limitations in theircapacity to establish reasonable limits, provide for nurturingneeds or structure the home in such a way that the child oryouth's developmental needs can be pursued and realised.

Support services:The support needed for these parents could and should probablybe contracted out to the agency in the community providingfamily preservation services. We are assuming that the agencyhas a clinician in their service that is supervising the family

preservation program. The skill set needed to support theseparents would be very similar to the set needed to supervise theirown program. In the absence of such a person, a family therapistwilling to undergo some training could provide supportive servicesto help foster families progress in their work.

Evaluation:The evaluation process for Co-Parenting foster families would bebased on client satisfaction and on the maintenance of therelationship.

Clinically specialised foster families:

Clinically specialised foster families are those families who chooseto care for children who have an important and debilitating mentalillness. Schizophrenia would be a good example.

Training:The training would be specific to the illness of the resident child.Education on the nature of the illness and information on the

recognised "best behavioral management approaches" for livingwith a person with this diagnosis would be the primary emphasisof the training.

Clients for this service:Clients for this service would be those with a debilitating diagnosiswho's parents would be unable to carry out their parentingresponsibilities.

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Support services:For these families, the primary support provider would be themental health clinician directly involved in the patient's care. Itwould be important here for all other interveners to create and

support those conditions that fostered the development of astrong relationship between clinician and parent.

Evaluation:The evaluation of the placement would be determined by the levelof skill the parent has developed in the intervention approachesdefined as appropriate by the clinician.

High Risk foster placements:

There are some children who seem resistant to all four of the

approaches listed above. Typically these are children who are highlyaggressive and severely affected in the areas of attachment andneurological complicating factors. There are usually only a smallnumber of these children in the system at any one time but the impactthese children have on the system is considerable. These are childrenthat we have seen unservable by the system's regular resources.

In other jurisdictions, success with these children has usually beenexperienced when private non profit agencies develop highly specialisedand extensively supported foster home resources that they thencontract out to government services.

Training:Training for these families would be an ongoing process guided bythe clinician attached to the agency. This means that such aservice would not be contracted to an agency with no attachedregular clinical services. The training would include informationon how to deal with extreme behaviours, how to work with severeattachment problems and how to protect the community and thefamily against the child's extreme behaviours.

The advantage of working for and being supported by a privatenon-profit agency as opposed to being managed within a largegovernment system cannot be overemphasised. Private non-profitagencies become very proficient at nurturing and supporting theirstaff since it is their effectiveness that the agency relies on fortheir success.

Clients for this service:

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The children targeted for this service would be those who haveexhausted regular government services and who have behavioursso severe that normal functioning in the school system or in thecommunity is an unreasonable expectation.

It should be noted that high levels of care can at times lead toimportant improvements in behaviours. This should not lead to atermination of services. These contracts should be seen as longterm.

Support services:The family would, through their employer (the non-profit agency)receive extensive debriefing services as well as regular andemergency respite services provided by the agency. The optionfor placing extra staff in the home during times of crisis, thepossibility of having others take over parenting during times of

exhaustion of parents and healing with community issues wouldall fall to the hiring agency. A group home and emergencyresidential services provider would be good agency with which tocontract for developing this service.

Evaluation:The evaluation of the services would have to be done by a neutralgovernmental service such as the YTP provincial team. Here thehallmarks of success would be good ethical treatment of the child,comprehensive support of the parents by the agency and thelongevity of the placement.

The five models here proposed are all implementable andimminently affordable. With the exception of the fifth service option,the foster parents involved would easily fit within the pay level system.Just as psychologist or social workers fulfil different roles within theagency, foster parents at level three can have different foster parentapproaches they are working in. The qualification scheme for thedifferent pay levels is sufficiently general that each fostering approachcan be included.

The adoption of the above service delivery system would haveimportant implications for training for foster home coordinators. Topursue this plan would have to include providing training in each of themodels to these coordinators and also training them in the evaluationmethods to determine which child needs which type of foster care.

We at the YTP provincial team has been instrumental indeveloping and training parents for each of the models described above.

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As such, this service delivery systems is not only implementable withexisting provincial resources but is also supportable in an ongoing way.Foster home development has been at the top of the priority list for theYTP provincial team for the last three years. It is identified by us as themost important clinical area in need of development. Working with

conduct disordered children is almost impossible without an advancedfoster home system to support interventions in school or in thecommunity. It would fall well within our provincial interagency mandateto dedicate resources to implementing and supporting such a servicesystem.

SUPPORT SERVICES REQUIREMENTS

I am confident that if well supported, our foster home system cangrow to provide care to the large majority of the provinces children and

youth in need of placement. There are other services, however thatneed to co-exist in each region if the system is to be robust andresponsive. We would suggest that three services in particular beenvisaged as integral to supporting a good foster home system. Hereagain the list is not exhaustive and we will not provide exhaustivedescriptions of each of these services since good descriptions of theseexist already in our agencies or in cooperating agencies. They should besketched out here however for the purpose of completeness.

Crisis Group Home Beds:

The crisis intervention approach to solving difficult familydysfunction has been well researched in both the U.S. and in Canada.The research shows that crisis interventions can be very effective butthat there are no advantages to keeping a child in a crisis unit beyondtwo days. A good crisis response approach can work to a solution withinthis time quite easily. There is even some evidence to suggest thatlonger stays are actually harmful to the resolution process in families.

At the current time, we have two communities providing this kindof service in New Brunswick (Moncton and Fredericton). We wouldsuggest that the service should be available in every region.

Regular Group Home Beds:

There will always be a group of youths (over 12 and preferablyover 14) who will not want to live in a family and who will function wellin a group home environment. These are children who are oftenattached to existing families but who cannot live with them. Others aresimply ready for or in need of a less intimate environment.

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Documents

The Care of Aggressive and Antisocial Children and Youth