Promising practice details

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C4EO theme: Vulnerable (Looked After) Children

‘Adapt’ (Attachment Difficulties and Parenting Therapeutically) – carer groups

Themes this local practice example relates to:

  • Vulnerable (Looked After) Children
  • General resources
  • Adoption and Fostering

Priorities this local practice example relates to:

    Basic details

    Organisation submitting example

    Foster Care Associates & Core Children’s Services

    Local authority/local area:

    Birmingham/national

     

    The context and rationale

    Background details to your example

    Summary
    Foster Care Associates (FCA) wanted their foster carers to understand the underlying psychological reasons for children and young people behaving in the way that they do in foster care, when they have experienced a history of trauma, abuse and neglect. In order to achieve this understanding, therapists within FCA wanted to impart theoretical knowledge to foster carers which would enable them to make sense of the behaviours they witnessed with the children/young people placed with them. Therapists sought to create an educative and training group in order to achieve this aim. It was believed that foster carers would be better able to make use of this knowledge and retain it if it was embedded within their own experiences.


    Through feedback from foster carers, Foster Care Associates (FCA) realised that many carers felt confused and overwhelmed by the challenging behaviours they were experiencing with the young people they looked after. They lived with the common misunderstanding that if they offered children and young people love and good quality care, then they would be grateful to be away from the abuse and neglect they had previously experienced and respond well to the safety of their new environment. When this did not occur and young people behaved in ways that were rejecting of the care on offer, foster carers felt disillusioned, dismayed and despairing. Invariably, this situation compromised the quality of care on offer as foster carers withdrew to protect their own emotions. Ultimately, left unchecked and unsupported, it was observed that placement stability came to be threatened.

    Given this situation, therapists and social workers within FCA wanted to equip foster carers with the skills to make psychological sense of the behaviour they were confronted with in their own homes. The hope was that this understanding could be used to transform their perspective of the situation they were facing and positively influence their responses. Enabling foster carers to depersonalise the challenging behaviours they faced and to understand that these were not aimed at rejecting or punishing them but instead connected to the child’s early traumatic experiences, had been found to be helpful in the individual consultations that FCA therapists were already holding with foster carers.

    By helping foster carers to understand that children and young people behaved in the ways that they did because such behaviours in the past had kept them safe and that by being in control they had ensured their emotional and psychological survival, therapists found that foster carers were able to detach themselves from the situation and take a more objective view. This resulted in foster carers becoming less reactive in their parenting style and more reflective; making positive, considered decisions of how to manage behaviour. Educating foster carers in the difficulty, for children and young people, of changing their world view and starting to trust adults, when previously they had experienced their caregivers/other adults to be unpredictable and untrustworthy, was found to be imperative. Being able to empathise with and comprehend this psychological dilemma, allowed foster carers to perceive the behaviours they encountered differently and respond from a more neutral, thinking place.

    Thus, experience from individual consultations with foster carers had shown that increasing understanding for foster carers of the psychological process of complex trauma and attachment difficulties altered parenting perception and behaviour. The resulting changes led foster carers to be more reflective and therapeutic in their approach and this in turn had an impact on children’s and young people’s behaviour. Being able to detach themselves from the child’s behaviour and stop experiencing themselves as the intended recipient increased foster carer resilience.

    In addition, FCA recognised that it was foster carers who held the potential to be key change agents for children and young people in foster placements, as opposed to therapists. This was by virtue of their daily presence as possible attachment figures. For this potential to be realised, though, foster carers would need to be informed about attachment theory and how to facilitate a burgeoning attachment between themselves and their child. FCA also considered that foster carers were in a powerful position to effect behavioural change through the interventions and parenting strategies that they used on a regular basis. However, when feeling exhausted, many foster carers resorted to inflexible and rigid parenting styles. Therapists within FCA therefore wanted to teach therapeutic parenting strategies and techniques within a supportive and non-judgemental environment. It was thought that the presence of other foster carers within a group would facilitate this.

    Thus, therapists within FCA believed that a well-trained, resilient foster carer base could provide:

    • Improved placement stability for children and young people in foster care.
    • Better functioning for children and their foster carers.
    • Minimise the number of children and young people moving into residential care.
    • Improved outcomes for children and young people.

    The intervention
    FCA wanted their foster carers to understand the underlying psychological reasons for children and young people behaving in the way that they do in foster care, when they have experienced a history of trauma, abuse and neglect. In order to achieve this understanding, therapists within FCA wanted to impart theoretical knowledge to foster carers which would enable them to make sense of the behaviours they witnessed with the children/young people placed with them. Therapists sought to create an educative and training group in order to achieve this aim. It was believed that foster carers would be better able to make use of this knowledge and retain it if it was embedded within their own experiences. Thus, the idea of running an experiential group was born, where theoretical teaching could be delivered within the context of foster carers reflecting upon and talking about their own placements. This would give them the opportunity to connect theory and practice together in situ.

    In addition, therapists in FCA wanted foster carers to be able to be self-reflective and to consider how their own experiences of being parented influenced their parenting style and their interactions with the children/young people they had in placement. Therefore, the idea of having a closed group that met for a number of weeks came into existence, as this would allow safety and trust to develop between the participants themselves and with the facilitators. Therapeutic theory postulates that safe working alliances allow for greater exploration and reflection and this was what the therapists wanted to achieve in the group.

    Finally, FCA wanted to improve the skill base of its foster carers specifically with the aim of enabling them to therapeutically parent the children and young people they had in their care. This would entail an understanding of the difference between therapeutic parenting and parenting their own birth children, recognising that therapeutic parenting was aimed at addressing underlying attachment difficulties, developmental trauma and emotional issues alongside providing structure, consistency, boundaries and routine.

    FCA believed that foster carers who could provide safe, consistent care alongside therapeutic, responsive parenting would be better foster carers, experience less breakdowns in placements and enable the children/young people in their care to function better emotionally, psychologically, cognitively, socially and behaviourally.

    It was thought that a group would work well to achieve these aims as it would allow:
    • A number of foster carers to be trained at the same time.
    • Facilitate training and development by the foster carers learning from each other through their shared experiences and observing others draw links between theory and practice.
    • Provide a supportive environment which would aid receptiveness to learning and new ideas.

    Aim of the intervention
    In terms of our identified cohort, we wanted to ensure that children/young people placed with FCA received therapeutic parenting that would address their emotional, developmental, social, psychological, cognitive and behavioural needs. Bearing in mind the findings emerging from the field of neuroscience and the works of Bruce Perry (2002), Allan Schore (1994; 2003) and van der Kolk (2005) regarding the impact of complex trauma on childhood development and functioning, we wanted to ensure that children and young people being fostered within FCA had the opportunity to build new neural pathways. This would enable them to become more self-regulated and consequently fulfil more of their potential. Teaching foster carers to respond therapeutically to some of their challenging behaviours would facilitate this process. Foster carers who were able to parent therapeutically would be able to help children/young people to make sense of some of their early experiences. This, together with the availability of a safe, secure attachment relationship with their foster carer, would enable children and young people to process their early traumatic experiences and become more settled and happier in their current lives. It was believed that the daily presence of the foster-carer and their role as an attachment figure, would mean that they had greater efficacy and potency in achieving these aims than relying on weekly individual sessions with a therapist.

    Thus, by teaching foster carers about attachment, attachment difficulties and therapeutic parenting, FCA hoped that children and young people, who had experienced developmental trauma, would have the opportunity to live in a therapeutic and healing environment. Training foster carers to be therapeutic carers would allow children and young people to remain within the community whilst they received a therapeutic level of care, as opposed to being placed out in residential therapeutic communities. Therapists within FCA believed that the more that foster carers were taught about the effects of abuse and the importance of attachment, the more effective they would be in their role as therapeutic foster carers.

    By running ADAPT (Attachment Difficulties and Parenting Therapeutically) groups, FCA aimed to improve placement stability for the children and young people placed with them. Placement stability would allow children and young people to develop lasting relationships with their foster-carers, teachers and peers. Placement stability would also enhance their sense of security and give them greater confidence to explore the world. This theory itself draws on attachment theory – that when an infant/toddler is securely attached they feel safer to temporarily leave the proximity of their caregiver to explore.

    The difference we wanted to make to children and young people was to enhance their capacity to have satisfactory, trusting relationships with adults; to enable them to fulfil their academic ability; to improve their ability access their cognitive capacity; to support them to enjoy healthy relationships with their peers and to lead to better emotional well-being.

    FCA recognises that fostering can be isolating for foster carers. The demands of looking after children and young people with traumatic early experiences and severely challenging behaviour without an understanding and knowledgeable support network, inevitably takes its toll. Caring for children and young people who have been abused, neglected and/or traumatised is exhausting and foster carers need nurture and support themselves. ADAPT was seen as a way of providing both peer and professional support to foster carers within the same setting. Golding, K & Picken, W (2004) postulate that group work provides foster carers with both support and psycho-education. It gives them opportunities to explore different ways of understanding and managing foster children.

    Therefore, we chose this intervention because we believed that running a closed group for foster carers would achieve the following.

    • Enable peer support and learning to take place.
    • Ensure that enough safety was available for foster carers to work outside of their comfort zones and be able to engage in self-reflective learning.
    • That the duration of the group (3 hours per week) would allow time for theoretical input and reflective/experiential exercises.
    • The on-going nature of the group would mean that learning could be re-visited and built upon.
    • That the skills of the therapists facilitating the group would both create a non-judgemental place, where foster carers could honestly disclose and share their experiences, as well as inviting them to consider how their own stories and experiences affected their abilities as foster carers.
    • We were aware of the successes of KEEP in the United States. These were groups aimed at foster and kinship carers who were looking after children with challenging behaviours. Research into the efficacy of the KEEP groups had demonstrated an increase in positive reinforcement on behalf of the foster carers; a decrease in challenging behaviour and a reduction in disruption rates as compared to the control group.

     

    The practice

    Further details about the practice

    Foster Care Associates has been running ADAPT groups since 2002. ADAPT groups are run in various regions across the country. FCA, as an organisation, has within its structure 13 regions. Each region contains within it a varying number of social work teams. Groups were run for foster carers attached to area social work teams within different regions. In the social work teams where ADAPT ran, therapists asked supervising social workers to recommend foster carers who had long-term children and young people in placement with attachment difficulties and who might be interested in attending the group. Social workers knew the foster carers on their caseload well and so were able to identify those who might be able to make best use of the group. Foster carers who were recommended received visits from their social workers. The purpose of these visits was to explain the closed nature of the group; its reflective/experiential style and the importance of committing to attendance each week. Usually 8-10 carers were selected.

    Each group was facilitated by two therapists who met prior to each group to agree on the content, theoretical interventions and the specific needs of the foster carers attending. The training modalities of the therapists varied (we have used Integrative Psychotherapists; Family therapists; Art therapists; Play therapists; Drama therapists; Psychodynamic therapists and others.) All the therapists had extensive background knowledge and experience working with Looked After Children. They, therefore, understood the effects of complex developmental trauma and abuse on developing children and the impact of attachment difficulties on all aspects of their functioning.

    The ADAPT groups were established to achieve the following goals:
    • Support fostering carers to offer successful, long-term placements and prevent placement break-down.
    • Educate foster carers about attachment difficulties.
    • Enhance foster carer understanding of the impact of attachment difficulties on all areas of children’s/young people’s functioning.
    • Enable foster carers to understand the difference between parenting birth children and parenting children who have been subject to complex trauma in their early lives.
    • Teach therapeutic parenting strategies to foster carers.
    • Enhance foster carers own reflective capacities both in their parenting and in understanding their own responses to the children they have in placement.
    • Provide a closed peer support group so that foster carers could learn from each other in a safe, trusting environment.
    • Via the closed group provide enough safety and confidentiality so that foster carers could work on their own personal and professional development.
    • Increase foster carers understanding of the specific situation, background, experiences and behaviour of the young person that they had living with them.
    • Acknowledge the difficulty of caring for a child with an attachment disorder and recognise that it is a specialist and skilled task.
    • Increase parenting skills.
    • Decrease reactivity in responding to difficult behaviours.
    • Improve childhood outcomes.
    • Reduce children’s and young people’s challenging behaviours.


    The model for the ADAPT groups was built around the following Aim and Objectives:

    Aim
    1. ADAPT aims to help carers gain a deeper understanding about their child’s attachment difficulties, in addition to increasing carers’ range of therapeutic parenting skills.


    Objectives
    1. To acknowledge the difficulty of caring for a child with attachment difficulties and recognise that it is a specialised and skilled task.
    2. To provide a consistent time and space for carers to share experiences and offer support.
    3. To offer theory, enhance understanding and develop appropriate strategies relating to attachment difficulties.
    4. To offer a confidential, non-judgemental space within which carers can share experiences and express feelings.
    5. To encourage carers development of self-awareness and reflective skills.
    6. To help carers examine and evaluate their practice.
    7. To develop carers’ skills and strategies in responding therapeutically to their child’s ‘core issues’.
    8. To offer carers the opportunity for personal development through the experience of the group.

    ADAPT groups have two stages. The first stage involves meeting for 10 weekly sessions from 10.00am – 1pm each week (with a break over the half-term week). There is a break for coffee and at 1.00pm the foster carers had lunch, coming together at the end for a brief good-bye. The second stage involves monthly meetings over a nine month period. This means that the total duration of the group, through both stages, is approximately a year.

    STAGE ONE
    The 10 weeks follows a programme in terms of the content of the theoretical teaching. The subject areas covered are as follows:

    Session 1 – Behaviour
    Theoretical Input
    An exploration of the behaviours often associated with Reactive Attachment Disorder. Foster Carers are encouraged to draw links between the material presented and the young person they have in placement.
    Exercises
    ‘What I find the hardest’ – in pairs carers discuss the most difficult behaviours their child has. What feelings does the child’s behaviour evoke in the carers? How do carers feel on the inside and behave on the outside? How do they manage their feelings and behaviours? What do carers find helpful and what do they need?

    Experiential and creative exercise where carers make a name label for their young person and are encouraged to reflect on the process and what they have chosen to make.

    Session 2 – Time Line & Child Development
    Theoretical input
    Child Development

    Exercises
    Building a brick wall: therapists draw bricks on a flipchart starting with the foundations. In each brick carers decide together where to write aspects of a child’s development. They progress up the wall in incremental steps. Therapists encourage carers to consider how some bricks need to be in place before other aspects of development can come on line.

    The group play Jenga with each member taking it in turns to pull out a piece. The group considers how if all the pieces are not present for a child in terms of their development then the stability of the whole structure can be impeded.

    Time line – therapists demonstrates how to compile a timeline and then each carer completes one for their child. The carers feedback to the group.

    ‘The Wonder Year’ on DVD is shown.

    Session 3 – Attachment, Re-enactment and Change
    Theoretical Input
    Attachment theory – therapists talk through two cycles of attachment – positive and disturbed cycles, using power-point slides.

    Re-enactment – the theory of re-enactment as described by Delaney (1995) is taught. Therapists facilitate the carers to think about how children in placement are re-enacting their past in the present. The timeline is used to aid this discussion.

    Exercise
    Change – carers are asked to think of a significant time of change in your life. They then:
    • Describe the change.
    • Explain how they recognised the need for change.
    • Detail what obstacles they had to overcome.
    • What support they received.
    • What would have made the process easier.
    • What does this tells them about the nature of change.
    • How might this apply to their child.

    Session 4 – Loss
    Theoretical Input
    Brief Separation and Loss – Bowlby

    The impact of placement moves.

    Exercise
    Carers draw the outline of a child on a large piece of paper. On post-it notes carers write three separate things they think a child should have, or need to grow up healthy and secure. The post-it notes are attached to the child picture (this could be brought to each session and referred to throughout). The carers say something about what they’ve written.

    Carers then remove things they think their child has lost – carers take 3 post-its and name what the loss is for their child. Carers then look at what they are holding and consider: how might that feel for their child? What age do they imagine their child’s loss occurred? This is discussed in the large group. Carers think about the many losses they hold for their child. A discussion is held regarding children’s inability to make sense of despair, and how the chaos of loss often means they internalise it as their fault. Therapists then make links and connect this back to behaviour. The lack of a secure attachment deeply affects the child’s sense of themselves as being whole, worthy and loveable. Foster carers are asked to think about what they do with the loss and gaps in their own lives.

    Session 5 – Parenting Patterns and Self-Reflection
    Theoretical Input
    Parenting Patterns
    Where do parenting patterns come from? What are our attachment patterns? What have we learnt from our parenting? Why are we carers, therapists and social workers? In pairs carers discuss ‘I am a foster carer because…’

    Exercise
    Parental Self-Reflection Questionnaires – carers individually complete these, then discuss in pairs and feedback to the group. Carers are encouraged to make connections between their own parenting and how they look after their child.

    Session 6 – Parts
    Theoretical Input
    Attachment Video

    Exercise
    Carers choose two different parts of their child e.g. angry, vulnerable, hurt, shamed, numb, frightened etc. Carers then choose two characters (animals, monsters, toys) that represent the different parts of their child and ‘names’ these parts. Carers work in pairs, asking open questions to the two different parts of each child. Questions to different parts of their child will probably elicit very different responses.

    Session 7 – Feelings
    Theoretical Input
    Brain development – explain the role of the amygdala & pre-frontal cortex.

    Think about Howe’s (2005) article ‘Emotions and Mind-mindedness’.

    Exercises
    Carers think of an occasion when their child communicated a feeling. How did the carer respond – by offering explanation, logic, or perhaps denying the feeling? How might the carer respond differently in order to acknowledge and accept the feeling? Naming feelings for children – carers might need to acknowledge their own feelings and confusion. I’m wondering if… I’m feeling…. How might their child respond differently?

    Carers list difficult feelings they think their child experiences and place these in a box. Ideas about containment are explored and discussed. Feelings in the box can be returned to and thought about.

    Reflection – carers are taught how to pick up on feelings and give children a language of feelings. They are encouraged not to deny feelings but to name them. Some children use umbrella terms such as ‘upset’ for a range of feelings they can’t, or are anxious to put into words.

    In pairs carers carry out a role play e.g. child going on contact with mother that afternoon. Carers are encouraged to practice asking open questions and responding to the feeling behind the behaviour.

    Carers are asked to pick a card at random. The cards have half-finished sentences on them, for example; ‘I feel like a failure when…’, ‘he makes me feel so…’, ‘I am really good at…’. Carers complete the sentences out loud in the group. They are asked to notice how it is easier to say negative things about ourselves than positive. Children receive the same message and tend to concentrate on the negatives.

    Session 8 – Looking after Ourselves and Meeting Children’s Needs
    Theoretical Input
    Principles of Therapeutic Parenting.
    Principles for Communicating Therapeutically.
    Carers consider the notion that fostering is different from parenting their own child. Therapists help carers move away from possibly thinking love is enough. Fostering as a profession is discussed. The P.A.C.E. (Playfulness, Acceptance, Curiosity and Empathy) approach of Dan Hughes is taught.

    Exercises
    Carers think about using one-liners. How do they imagine their child might respond?

    The Steel Box with the Velvet Lining – what does this represent to carers? Children need to feel safe and secure but in the context of a nurturing and loving environment in order to develop new attachments.

    Therapists connect carers’ capacity to care for their child with looking after themselves … if carers aren’t okay and their relationship isn’t ok and their own children aren’t ok, then their ability to foster well will be compromised.

    Carers complete Stamm’s (2009) ‘Professional Quality of Life Scale’. How do carers recognise when their stress levels are too high? Carers list the internal and external support mechanism’s they have in place.

    Carers consider the following:
    • Looking After Ourselves.
    • What do carers do to take care of themselves?
    • What do carers do together as a family?
    • What more could carers do?
    • What could carers do less of?

    Session 9 – Community and Team Parenting
    Theoretical Input
    A team approach is essential when caring for children with attachment difficulties. What do we hope to avoid and achieve when a reflective team approach is used? What are the characteristics of an effective team? Thinking about Team Parenting Meetings.

    Exercises
    How does your child fit into the community?
    In pairs carers think of times when their child might stand out from the crowd, for example bizarre or dangerous behaviours. What does their child do? Have carers noticed any triggers or patterns for their child’s behaviour? How could the community, school, G.P., dentist help? Does the carer’s child find it difficult to wait or queue?

    Breaking the problem down
    Carers think about what their child struggles with in the community e.g. visiting the supermarket. Carers are encouraged to break down their situation into stages and think about what they might reasonably expect of their child i.e. guiding the child step-by-step, allowing the child to take bigger steps. Carers are asked to consider what might need to be thought about before embarking on the ‘shopping trip’ e.g. is the child allowed to choose, are sweets allowed at the end? This helps carers to think about safety and containment.

    Creating the ideal community
    Carers work in pairs to create an ideal community in order to support the re-parenting of their child. What could a community offer? How could carers use their community? Carers identify a resource within their community that they could contact for help.

    Session 10 – Secondary Trauma and Ending
    Theoretical Input
    ‘Trauma is Catching’ worksheets by Kate Cairns and Chris Stanway. Discuss Secondary Trauma.

    Creative Exercise
    This exercise uses clay and encourages carers to represent themselves and their learning via this medium. The group format is used to facilitate a symbolic appreciation from each member where every carer adds some element to the clay models each carer has made.

    Carers bring to the group a card they have bought outside of the group and written some words on. Carers talk about the card they’ve chosen and the words they’ve used which say something about themselves and how they found the group. Carers then make a kite together and use their cards (if agreed) for the tail. Carers are asked to agree upon what should happen to the kite. Carers often choose to hang it in their area team office.


    Summary
    The structure of all of these sessions follows a format: there is a check-in, theoretical input and experiential/creative exercises before the coffee break. After the coffee break each foster carer takes it in turns to present a living sculpt of the child/young person they have in placement using the other group members to represent key individuals in that child’s life. This intervention is taken from Structural Family Therapy (Burnham 1980).

    The Sculpt
    The carer introduces their child (they might want to use the artwork from Session 1 and/or timeline from Session 2) and a current photograph of the child is passed around the group. The carer’s introduction might include answers to: what is it like being with the child? What behaviours does the child use? What was the child’s experience of living with their birth family? How are they progressing in school? What are their relationships like with their peers? What needs to change?

    The carer identifies significant people in the child’s life and nominates group members to play these roles including the child. After positioning the child in the centre of the room, the carer directs other group members, in role, to take up positions in relation to the child to represent their life and relationships as they are now. The therapists might encourage the carer to consider people’s stance and direction of gaze in relation to the child.

    The therapists ask every group member, in role, to describe what it’s like being in their position. Group members might consider how they feel and what they can physically see.

    The therapists encourage the carer to consider how they would change the Sculpt in order to represent how they ideally want it to be, reflecting too what they believe the child needs. The carer then directs group members to represent this change and feedback about how the change feels.

    The group members de-role. Space might be needed to acknowledge the ‘power’ and impact of the Sculpt. Time is needed for general feedback about the experience, and thinking about possible strategies to help the placement going forward.

    STAGE TWO: Follow up and Embedding

    Once the weekly sessions have ended, the group moves to meeting monthly. They meet on a monthly basis, nine times. The monthly meetings follow a similar format as before but the theoretical topics are chosen by the group session by session, giving the therapists time to prepare and providing the opportunity for the learning to match this particular group’s on-going needs. Instead of the sculpts, the therapists facilitate group discussion encouraging foster carers to engage in reflective practice, linking experiences within their own placements to the theory that has been taught.

    This process takes its practice and principles from group clinical peer supervision. Foster carers take it in turns to describe issues they are currently experiencing in placement. The therapists and other foster carers facilitate them to think analytically and reflectively about what might be occurring for them and for their foster child. Appropriate strategies are discussed and considered with particular reference to their therapeutic impact.

    Review & audit
    During the monthly sessions, the groups are reviewed each time with the foster carers. This is an informal review, assessing the groups continuing usefulness to the foster carers and what theoretical input they would like to be covered when they next met. At the end of the whole group, an audit is carried out where feedback is ascertained from the foster carers by asking them to answer an evaluation form.


    Services involved
    Local authorities of the children and young people placed were informed that the foster carers would be attending the group.

    Supervising Social Workers were involved in selecting foster carers and recruiting them to the group.

    Two FCA therapists facilitated the group together and met with a third member of the therapy team for monthly clinical supervision of the group.


    Intended measurable outcomes
    FCA expected to see placement stability improve along with foster carer resilience and responses to the challenging behaviour they encountered in placement. We believed that the consequences of both of these changes would be that young people would:
    • Have more satisfying and trusting relationships with their foster carers.
    • Improve in their functioning at school.
    • Achieve healthier and more stable peer relationships.
    • Change some of their behaviours.
    • Gain enhanced emotional well-being and greater emotional literacy and self-awareness.
    • The latter would lead to an increased ability for the children and young people to articulate and verbalise their experiences and distress instead of expressing their unconscious feelings out of awareness via their behaviour. This process in itself would lead to a decrease in ‘acting-out’ behaviours and therefore lessen the risk of placement disruption.

     

    Evidence and evaluation - making a difference to children, young people and families

    Evidencing your practice has made a difference to children, young people and families

    This has been done in several different ways:

    1. FCA has asked foster carers to complete evaluation forms at the end of each ADAPT group.

    From the evaluation forms used, foster carers have said that they gained the following from the group:

    • Knowledge of the child’s perspective.
    • Insight into attachment issues and how they affect development.
    • Support and friendship.
    • Knowledge that they are not on their own in the struggles they encounter.
    • Feeling less isolated.
    • Believe that the agency (FCA) acknowledge and value the difficult and specialised work in which they are engaged.
    • Having longer learning sessions.
    • More time to talk to other foster carers about their placements.
    • Insight into attachment difficulties.
    • Successful, close-knit support group coupled with constructive learning and techniques.

    Specifically in terms of their fostering, foster carers reported that the group has impacted their fostering in the following ways:

    • Knowing to stay calm and not take the child’s behaviour personally.
    • Not reacting to behaviour but seeking to understand what it means.
    • Having more confidence and belief in themselves.
    • Remembering to consider the child’s emotional age.
    • Meeting the child at their developmental stage.
    • Adapting their parenting, spending more time watching, observing and considering how to respond.
    • Rewarding positive behaviour.
    • Using consequences.
    • Knowing what practical things to do and say.
    • Greater awareness of the power or emotion.
    • Improving levels of patience and reflective practice.
    • Looking at situations from another perspective.
    • Questioning and modifying practice to reduce explosive situations.

    2. In 2007 FCA had a researcher carry out an Evaluative Project as to the efficacy of ADAPT.

    A selection of quotes follows, taken from the evaluative research project:

    With reference to their experience of ADAPT,

    ‘We got an awful lot out of it, it changed our approach. We have been fostering for 30 years (formally and informally). This course gave us a different outlook on children’s behaviour. Before Adapt we found negative behaviour difficult and felt untrained. Now we look at negative behaviour as a ding of a problem underneath. Now we look for the cause of the behaviour.’

    Regarding ADAPT’s usefulness,

    ‘Very useful, it was great to discuss and learn and we were given strategies to put into place at home’.

    Answering a question about how supportive they found the groups, respondents answered,

    ‘Absolutely, it really helps to have the therapists, they are brilliant’.

    In terms of Adapt affecting their confidence in managing children’s/young people’s behaviour, all 8 respondents said they felt more confident,

    ‘Definitely, absolutely, the fact you know it’s not just you, there is always someone in the group who has been through something similar. We gave each other new ideas and strategies’.

    In terms of a particular exercise that the foster carers found useful, more than 50% mentioned the sculpt,

    ‘The Sculpt was amazing, we really got into the mind of a foster child’.

    In terms of impact on their fostering careers, respondents said,

    ‘I have been close to quitting but ADAPT made a big difference. The on-going support is invaluable’.

    In terms of the monthly meetings, foster carers have said,

    ‘It is a good opportunity to check up whether the strategies are working. It continues the support and the community. All of the placements are still in place which shows that the ADAPT course is positive’.

    For more information from the evaluation please contact the C4EO team at the NFER.

    3. FCA has used the Parental Stress Index to measure changes in parental stress, parent/child interactions and the degree of difficult behaviour being exhibited by the child.
    The PSI and SDQ utilised quantitative data and are discussed in this section. Both the PSI and SDQ were completed at the beginning of the group and at the end, allowing for pre and post intervention tracking of both the foster carers and the young people they had placed with them. The feedback form evaluating changes in the children is reported on in this section.


    The Parental Stress Index
    In order to evidence outcomes and provide some quantitative data, the Parental Stress Index short form was used in an ADAPT group run with some Local Authority foster carers in 2011. The PSI is a replicated and validated test that measures three areas that are seen to affect parenting behaviours and thus child outcomes. These three areas are parental distress; parent-child dysfunctional interactions and difficult child. The diagram below and the script is taken from Richard. E. Abidin’s 3rd professional manual of the PSI. In the document he states:

    ‘At the present time, the PSI/SF does not, by itself, possess a body of independent research that supports its validity. However, because it is a direct derivative of the full length PSI, it is likely that it will share in the validity of the full length PSI.’

    The diagram below demonstrates the theoretical model for the PSI/Short Form.



    The PSI scores the following in its measures:

    Total Stress

    The Total Stress score is designed to provide an indication of the overall level of parenting stress an individual is experiencing. It must be remembered that the Total Stress scale score does not include stresses associated with other life roles and life events and, thus, should never be interpreted as anything more than an indication of the stress level experienced within the role of the parent. A parent’s Total Stress scores reflects the stresses reported in the areas of personal parental distress, stresses derived from the parent’s interaction with the child and stresses that result from the child’s behavioural characteristics.

    • The Parental Distress (PD) subscale determines the distress a parent is experiencing in his or her role as a parent as a function of personal factors that are directly related to parenting . The component stresses associated with the PD subscales are impaired sense of parenting competence, stresses associated with the restrictions placed on other life roles, conflict with the child’s other parent, lack of social support and presence of depression, which is a known correlate of dysfunctional parenting.

    • The Parent-Child Dysfunctional Interaction (P-CDI) subscale focuses on the parent’s perception that his or her child does not meet the parent’s expectations and the interactions with his or her child are not reinforcing to him or her as a parent. This parent projects the feeling that his or her child is a negative element in the parent’s life. Commonly, his or her description of the parent-child relationship suggests that the parent either sees himself or herself as abused by or rejected by the child, or he or she is disappointed in and feels alienated from the child. High scores suggest that the parent-child bond is either threatened or has never been adequately established

    • The Difficult Child (DC) subscale focuses on the basic behavioural characteristics of children that make them either easy or difficult to manage. These characteristics are often rooted in the temperament of the child, but they also include learned patterns of defiant, non-compliant and demanding behaviour… High scores produced by parents of children 2 years of age and older are related to measures of child-behavioural adjustment and to behavioural-symptom checklists.’


    In terms of scoring, the higher the score the higher the stress level; a reduction in score indicates a reduction in stress.
    (Scores in the normal range are within the boundary of ‘acceptable’ levels of stress experienced by most parents and would not normally require additional support and intervention, thus we may be less interested in changes in ‘normal range scores’. Scores in the ‘clinically significant’ range indicate that the levels of stress are outside what would be experienced by most parents, it suggests that the parent requires some further support and intervention around their stress levels).

    Group work evaluation using the PSI with foster carers completing the ADAPT group
    10 carers completed the course, filling in a parental stress index at the beginning and at completion of the group programme.

    Total stress - parent

    This scale gives an indication of the overall level of stress a parent is experiencing in relation to their parenting role. This scale is made up of a total of the other areas of stress outlined below.
    Seven out of 10 carers reported reduced levels of overall parental stress, when comparing their baseline total stress scores prior to the groups with PSI scores reported at the end of the group programme.
    Five out of 10 carers reported clinically significant levels of total stress at baseline. Out of these 5, 1 of the carers’ total stress scores decreased from clinically significant to the normal range.

    Parental distress

    This subscale refers to the distress a parent is experiencing specifically within their parenting role. High scores are associated with lack of confidence in parenting role, feelings of restriction on life due to parenting and lack of social support.

    Six out of the 10 carers reported reduced levels of parental distress after the group programme compared to baseline and of those; 2 out of the 3 carers who scored clinically significant levels of parental distress at baseline reported normal levels of parental distress after the group programme.

    Parent child dysfunctional interaction

    This subscale measures stress related to the parent’s perception of the relationship between them and the child. High scores suggest that the parent is not feeling any reinforcement/ gratification in their role as a ‘parent’. Parent may view themselves as abused or rejected by the child and may feel alienated from the child. High scores suggest that the bond between parent and child is under threat or has never been adequately established.

    Six out of 10 carers reported reduced stress levels in the domain of parent-child dysfunctional interaction after completion of the group programme.
    Prior to the group six carers’ scores indicated clinically significant levels of stress related to parent child dysfunctional interactions. Although 4 of these carers reported reduced levels of stress in this area after the groups, all scores remained in the clinically significant range.

    Difficult child

    The difficult child subscale focuses on the carers’ perception of behaviours presented by the child, and difficulty in managing them. Parents may be struggling with understanding and working with specific behaviours presented by the child.

    Seven out of 10 carers reported lower levels of stress in relation to their perception of difficult child behaviour after the group programme.

    Three out of 6 carers who reported clinically significant levels of stress around managing difficult behaviour at the beginning of the groups subsequently reported stress levels in the normal range after the groups.

    Extra information

    The largest decrease in scores between the baseline and at completion of the groups occurred within the difficult child subscale suggesting this is where the most improvement was seen after 10 weeks. The most noticeable example was from one carer who scored 41 at baseline (clinically significant – 96th percentile) to 14 after 10 weeks (normal – 1st percentile).

    It is important to note that some carers’ scores remained the same across the two time points, at baseline and after the group programme and some carers scores were increased, indicating higher levels of parental stress after the 10 weeks. As there are always factors in carers’ lives outside of the group which are likely to affect stress levels, this must be considered when thinking about what the results mean. However, the results do provided some indication that there may be a correlation between group attendance and a reduction in feelings of parental stress for carers. The impact of the group is likely to be different for each carer and as such a close look at the scores for each individual carer may be helpful in thinking about offering further support and intervention.

    ADAPT – 2012
    The PSI has also been used more recently with another group of Local Authority foster carers who attended ADAPT in 2012. The following are the reported results:

    Total Stress: Five out of ten carers reported reduced levels of overall stress, when compared to their baseline total stress scores at the beginning of the group.

    Parental Distress: All ten carers scored within the normal range both at the beginning of the group and at the ten week stage. This indicates that although the carers reported higher levels of stress in the total range than the “general population” that overall they were confident within their parenting role. Three carers reported reduced levels of parenting stress at week ten.

    Parent/Child Interaction: Seven out of the ten carers reported reduced stress levels in this domain after completion of the ten week group.

    Difficult Child: Five out of ten carers reported lower levels of stress in relation to their perception of difficult child behaviour after the completion of the 10 week group programme.


    4. FCA has used Goodman’s SDQs to measure changes in the young people’s functioning.

    Results from the SDQs suggest carers’ perception of their child's behaviour is different following the ADAPT programme. Five carers reported lower levels of overall stress from baseline to after 10 weeks with one moving two bands from ‘very high’ to ‘slightly raised’. Carers reported reduced emotional difficulties in four children, with three children moving from the ‘high’ to ‘slightly raised’ band. Carers reported that four children’s behavioural difficulties reduced, with one moving from the ‘high’ range to ‘close to average’. Of the two carers who reported ‘very high’ hyperactivity and attention difficulties, both reduced following the 10 week group. Perhaps most importantly, four carers reported a reduction in the impact of any difficulties on the child’s life, with two moving from ‘very high’ to ‘close to average’ and one moving from ‘very high’ to ‘slightly raised’. In addition, two of the nine children predicted as 'high risk' of receiving a psychiatric diagnosis moved into the medium risk prediction, and one moved from medium to low risk, at the end of the 10 week programme.

    Overall, these scores provide a good indication that participation in ADAPT can facilitate change and is helpful to carers and children in a number of ways. Whether or not their child’s behaviour actually changes, carer’s perception of change will likely enhance their resilience and prevent placement breakdown.

    5. FCA has asked foster carers to complete a feedback form evaluating the changes they have noticed with their foster child as a result of attending ADAPT.
    It must be noted that these questions evaluate foster carer’s perception of change for their foster child as opposed to objectively tested change. This qualitative questionnaire was designed to test the efficacy of ADAPT against the following aims of the intervention to improve outcomes for young people by:

    • enhancing their capacity to have satisfactory, trusting relationships with their foster carers
    • improve their functioning at school
    • change their behaviours/communication/relations with peers and foster carers
    • improve placement stability
    • greater foster carer resilience
    • change foster carer responses to the challenging behaviour they encountered in placement leading to a decrease in difficult behaviour
    • increased foster carer confidence in managing difficult behaviours
    • greater self-awareness in young person
    • improved emotional literacy for the young person
    • increased ability for young people to articulate and verbalise their experiences and distress and decreased acting out unconscious feelings via behaviour.

    In total, seventeen foster carers completed the evaluation form.

    This questionnaire indicates that ADAPT has achieved its aims, impacting positively on foster children’s relationships with their foster carers, placement stability, foster carer resilience and foster children’s levels of self-awareness and emotional literacy. As would be expected, there are areas of greater change and others where change is more moderate. Thus, most significantly, foster carers report on a change in their confidence, skills, perceptions, understanding and ability to manage challenging behaviour. They identify that these changes in themselves lead to altered relationships with their foster children, enabling them to achieve greater satisfaction in these relationships and to offer an improved level of therapeutic parenting i.e. mentalising for their foster child and helping them to understand their feelings. The areas of moderate improvement are notably foster carers reporting on foster children’s change in concentration and attainment at school. Part of this may be a reporting issue, as this evaluation tool relies solely on foster carer perception and not raw data from the school. It may be too, that whilst ADAPT has led to improved relationships for the foster child and enhanced placement stability, it may take longer for this to translate to positive changes in terms of educational attainment. Whilst we would hypothesize from our knowledge of neuroscience, that stability, security and emotional literacy will affect cognitive ability, there may also be other factors at play that are impeding the children in this sample from fulfilling their potential at school.

    What is significant about these results is the qualitative evidence they demonstrate that it working with foster carers positively benefits foster children. FCA believes that foster carers, in their role as attachment figure and their daily present in foster children’s lives, are best placed to positively affect change for children and young people. It is our intention to up-skill our foster carers to become therapeutic parents so they can support children and young people to resolve some of the trauma of their past , form secure relationships with their foster carers and achieve their potential relationally, socially, emotionally and academically. ADAPT demonstrates that working through the carers to impact foster children is a valid approach and that the methodology works.

     

    Sustaining and replicating your practice

    Helping others to replicate your practice

    Feedback means that the format for ADAPT groups has now been formalised and they run as part of a UK wide strategy for training foster carers within FCA. This means that the foster carers within FCA are receiving a consistent and uniform training package that enhances their resilience, increases their knowledge base and adds to their skills set. Currently, regions within FCA run ADAPT groups every year thus ensuring that all foster carers have the opportunity to attend. More regions in the country are running ADAPT groups in response to the positive comments made by foster carers and their view that it should be ‘mandatory’ and available to all foster carers.

    A local authority has commissioned two ADAPT groups for their foster carers and this model is now being available to other local authorities.

    The model of the groups has been reviewed and in 2012 the programme has been revised to ensure its content remains current, up to date and reflects the needs of foster carers and young people in placement. The revised programme is as follows:

    Group Programme

    Planning: Pre-Group and Sessions
    Session 1 – Behaviour
    Session 2 – Time Line & Child Development
    Session 3 – Attachment
    Session 4 – Re-enactment
    Session 5 – Parenting Patterns and Self-Reflection
    Session 6 – Review
    Session 7 – Brain Development
    Session 8 – Therapeutic Parenting
    Session 9 – Secondary Trauma
    Session 10 – Valuing Ourselves

    The success of the ADAPT group has also meant that a group for new foster carers, called SCATT (Supporting Carers and Thinking Therapeutically) has been introduced. This group is different in structure, aims and objectives. However, it builds on the success of having a closed, group of carers meet regularly together with a therapist to gain theoretical understanding and knowledge of the psychological issues that face Looked After Children. It also provides a safe space where foster carers can examine their practice reflectively and adapt their parenting to encompass therapeutic principles that address children and young people’s attachment difficulties.

    How FCA will sustaining their achievements?
    Greater resilience in foster carers; enhanced understanding and knowledge of attachment theory, attachment difficulties, complex trauma and loss and their improved skills in therapeutic and reflective parenting are all sustained by foster carers having continued access to therapists and therapeutic training. Foster carers can build on all of the above as they have access to consultation sessions with trained therapists within Foster Care Associates. In addition, Foster Care Associates run a series of standardised courses which address a range of subject areas. These courses offer the opportunity for existing knowledge to be built on and for specialist understanding to be developed in key areas. The courses offered are:
    1. Understanding Attachment and Attachment Difficulties Part One
    2. Understanding Attachment and Attachment Difficulties Part Two
    3. An Introduction to Systemic Practice within Team Parenting
    4. An Introduction to Brain Development in Infancy
    5. Responding to Sexually Harming Behaviour in Young People
    6. Understanding and Managing Self Harm
    7. The Power of Play
    8. Bereavement and Loss
    9. Reflective Practice and Therapeutic Parenting within Team Parenting

    These mean that the theoretical knowledge gained during ADAPT and the skills learnt can be built upon progressively and are not lost when the group ends

    Due to their success Foster Care Associates continue to run ADAPT groups for their foster carers. The agency is increasing the numbers of groups that run.


    Cost-Benefit Analysis
    Costs:
    • Two therapists facilitating ADAPT - £4,750 (approximately – this depends on rates of pay for the therapists)
    • Cost of Venue – FCA has run ADAPT within its own premises. However, a typical cost for a venue is £70/half-day leading to a total cost of £1,330 for the 10 weekly sessions and 9 monthly sessions
    • Cost of Lunch provided - typically £7/head – Total cost for the entire course £1,330.
    • Cost of soft equipment; stationery - £50 approximately
    • Possible travel costs to the venue


    Benefits:
    • 8-10 carers receive in total 57 hours of experiential and reflective training
    • Improved skills and sense of efficacy for foster carers as therapeutic carers
    • Increased resilience and ability to manage challenging behaviour within placement
    • Increased knowledge and understanding for foster carers on the impact of attachment difficulties, complex trauma and loss on children and young people’s lives
    • An increase in foster carers reflective capacity and to mentalise for their foster children
    • A greater range of parenting strategies available to foster carers
    • Reduced overall stress for foster carers
    • Reduced parental distress for foster carers
    • Reduced stress in the interactions between the child and foster carer
    • Reduced perception on behalf of the foster carer of the child being ‘difficult’
    • Reduced rate of placement breakdown
    • Improved outcomes for young people
    • Reduced emotional difficulties for children and young people
    • Reduction in behavioural difficulties
    • Reduction in hyperactive and attention seeking behaviours
    • Reduction in emotional harm for young people who might otherwise have had to move placement
    • Reduction in social work time in finding new placements with foster carers and schools
    • Improved foster carer retention
    • Reduction in cost of recruiting new carers
    • Peer support for foster carers

    Barriers
    The following are dilemmas that therapists have had to address in running Adapt groups:
    • Gaining a balance between psycho-educational input and space for the carers to share their experiences is important. We found that foster carers often wanted to describe in detail, during the check in, the events of the previous week in terms of their placement. Much of this description was content driven and anecdotal. It is necessary to keep tight boundaries around time to ensure that the theoretical teaching and sculpts are prioritised. If not, the group can become a support group without the training and experiential element.
    Ideas for how to manage this are to:
    • Explain that the purpose of the check-in is to help foster carers arrive and feel present, and that detailed information is not needed at this stage.
    • To reassure carers that the opportunity to discuss their placements in more detail will be provided during the theory slot, where the therapists invite the foster carers to link their current experiences with what they have learnt.
    • To limit check-in to one or two sentences answering a specific question, for example, ‘how was your journey here today?’; ‘choose 3 words to describe your week’
    • Use a 5 minute egg timer placed in the centre of the group and use the carers to monitor each other’s time boundaries.
    • How to involve carers’ partners and Supervising Social Workers who are not attending the group – what to share with them and what not to bearing in mind the confidential nature of the group and the need to create safety to facilitate open self-reflection and sharing amongst the group members. It is important to ensure that partners and SSWs are kept up to speed with the foster carer’s learning. We managed this situation by ensuring that a brief description of theoretical material covered was accessible (a copy of the manualised version of ADAPT is on the company intranet) and by giving general feedback to supervising social workers who might want to know how their carers were making use of the group. Partners were offered opportunities to attend some of the one day training courses that the Therapy Service run on attachment, trauma and brain development, where much of the same theory is taught, albeit in a different format.
    • When carers make links with each other they are then in a position to support each other between sessions and when the group ends. This means that in some circumstances the group has continued to meet informally as a peer support group, without the presence of a therapist. When this has occurred, carers are required to inform FCA of their meetings.
    • So far FCA has always used two therapists to facilitate the group. The question as to whether a group could be run by a social worker and a therapist has been posed. As yet we have chosen to remain with the model of using two therapists due to their specific therapeutic training and because they belong to the same team and working together in this way also supports their team and professional development.
    • It is imperative that the facilitators of ADAPT are professional trained and, as referenced above, in our view qualified and accredited as therapists. This ensures a detailed understanding of the material delivered, a capacity to manage group dynamics, an awareness of emotional and psychological processes and the ability to link, for the carers, their own issues with those that they struggle within their placements.
    • Some therapists have found it is better to have 8-10 separate foster carers as opposed to carers as attending as a couple or even, as we had in one instance, a daughter and a mother attending. Having individual carers attending means that the group process is not interrupted by other relational dynamics that the rest of the group might not be aware of.

    Golden threads
    • You can do it - promoting resilience
    • Together with children, parents and families - involving service users (in this case foster carers)
    • Holding the baton
    • Culture not structure
    • Shape up and keep fit
    • Prove it - making change happen
    • From good to great - leadership, vision and embedding is key

    References are available from the C4EO team at the NFER


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