Getting Better Foster Care

Ian Sinclair ian.sinclair@york.ac.uk

What’s this about? (1)

• I was asked to talk about future of foster care • Different countries will pursue this in different

ways • I have a limited idea of their current paths,

and no idea of their future ones • But it is possible to draw lessons from the

present which enable more intelligent action • I will try and do this from an English base

It is difficult to draw these lessons because ….

Countries differ in so many ways (legislation, history, the scale and type of provision, the identity of the providers, the nature and training of the workforce involved, the relative roles of the systems concerned with education, care, criminal justice and health) And all this must make a difference to what is possible and what it is sensible to do

But …

We can surely look with interest at the experience of other countries with different kinds of provision (e.g. the UK may be interested in the much greater use of kin care in other countries, other countries may be interested in the UK experience of arranging adoptions for a relatively high proportion of very young children from care)

These differences can be roughly thought of in terms of levels

• Country level (culture, history, legislation etc) • Administrative level(s) (departments etc) • Service level (1) (e,g, if in care, at home etc) • Service level (2) type/style of provision (e.g.

residential care) • Service level (3) individual unit (carer, home

etc0 • Individual child and their environment

And in England there is evidence that

• Very big differences between local authorities do not impact directly on care outcomes

• These are partly mediated by the mix of provision (e.g. ratio of kin to stranger carers)

• And by whether children are in care or not • And, strongly, by the individual foster homes,

residential homes etc • Authorities seem able to influence the mix but

lack to tools to influence the quality of care

The effectiveness of Countries’ Care Systems will depend heavily on:

• The preference for care or prevention • The relative effectiveness of different kinds of

care and the mix of these provisions a country adopts (e.g. ratio of kin care to foster care)

• The quality of the provision (e.g. how ‘good’ individual residential units or carers are)

• The quality of the ‘surrounding provision’ (including arrangements after leaving)

• The country’s ability to influence quality

This talk is about ..

• The relative effectiveness of different kinds of provision and hence different kinds of ‘mix’

• The drivers of high quality care • How a ‘good care system’ might fit with the

‘surrounding arrangements’ • What all this might mean for England (and

perhaps others?)

The majority of you who are not English may like to ..

• Think through how far what I say holds true for their situation

• Check the references I give at the end (I will be presenting an argument not really giving the evidence for it)

• Think through what the implications of those parts that are well-founded might be for their situation

In the English mix one can distinguish

• Short-stay, emergency, holding or assessment provision (foster care, residential care)

• Treatment provision – foster care, specialist foster care (MTFC), specialist residential care

• Long-term care and upbringing in a family setting (adoption, residence orders , special guardianship (SGO), long-stay fostering, including kinship care)

• Other provision (including shared care, and medical or educational boarding care)

Short-term Placements

• In England the great majority of short-term placements are in foster care

• Residential care is very much more expensive but may be used for adolescents if there is a need for control or containment (e.g. in Remand fostering)

• There is no clear evidence on the relative usefulness of these placements when like is compared with like

Treatment Provision (Residential Care, Foster Care, MTFC)

• Residential care in UK lacks an agreed theory, and has very high costs, very variable quality and a very challenging, adolescent clientele

• On average antisocial behaviour improves more in MTFC than in foster or residential care

• Other forms of care may be better for the less antisocial young people

• All these forms of care have difficulty in ensuring that improvements outlast the placement, although this may not always be so with MTFC

Stranger and Kin Foster Care

• Kin care can have particular advantages (continuity, identity etc)

• It may have marginally better outcomes in terms of stability and well-being

• It is not for everyone and tends to have particular problems (poverty, housing, education, family quarrels, formal support)

• Raises awkward questions about how far state should support all kin care

Long-term Care and Upbringing (Adoption, ROs, SGOs, Fostering)

• In all forms of placement the younger the child the greater the chances of success

• Adoption appears the most successful form of long-term placement but is reserved for children entering care under 5 and commonly under 1

• All the other forms can succeed and there are often good reasons for choosing one rather than another

• With older children long-term foster care is often the only option and it is getting more support

• Increasing provision of one form of permanence does not seem to reduce the use of others

Comparing kinds of provision within these categories one can see

• They are only partial substitutes (e.g. adoption substitutes for long-stay fostering but only for the very young entrants)

• Evidence on comparative effectiveness is weak but probably slightly favours adoption, kin care, and MTFC (albeit all require modification)

• There are often good reasons for choosing one partial substitute against another (e.g. some children long to be adopted, others hate the idea)

• So the mix has to allow for differences in effects, costs and choice and should probably develop incrementally

Quality Care: three hypotheses

• The mechanisms involved in good outcomes and high quality care are much the same in families, foster care and residential care

• They have a major effect on the well-being and behaviour of children in a particular placement, but it is difficult to ensure that this is long-term

• Outside interventions designed to improve care should target or work with these mechanisms but we lack proven models of how to do this

Mechanisms: Foster Care Outcomes in placement depend on: • The child – what they want, their age at entry and how

they are prone to behave (conduct disorder etc) • The foster carer(s) – some are ‘better than others’

(warmer, clearer about what they expect, better at understanding child etc)

• Fit – both with carer (some you bond with some you don’t) and others in family, and how this develops (‘nothing succeeds like success’)

• The birth family and contact with them • The school and how the child gets on there

These mechanisms can be interpreted in terms of

• Way families work (authoritative parenting most likely to succeed)

• Attachment theory (attachment issues likely given children’s experience and relevant to the aims and outcomes of placement)

• Social learning theory (positive discipline, clear expectations, following through etc)

• Systems theory (outcomes depend on interactions within and between systems)

• Social Pedagogy? (Not qualified to speak of this! But evidence is that doing things with the child that they like ‘works’)

The most promising interventions

seem to me to be in keeping with these theories • Dozier’s work on very young children

(attachment theory) • MTFC and its variants (social learning) • ‘Wrap around’ approaches (systemic theories)

And ideally involve

• Selection • Training • Supervision • Quality assurance But in England, we cannot claim that we can reliably do any of the above effectively

And what about ‘surrounding arrangements’

• Children who are cared for long-term do better if they are identified early and enter the care system early

• Failed attempts at reunification predict further difficulties and are painful to all concerned

• Gains made in care are often lost on leaving • So too are relationships made in care • Shared care can be very successful

So we need ..

• Determined efforts to a) identify those in difficulty early and b) enable a fair and not unduly delayed decision over whether their family can care for them with help

• Better identification of those who might return home and of what needs to change if they are to do so successfully

And

A greater emphasis on • developing those skills in care which are

needed later • profiting from the relationships that are built

in care after it • ensuring compatibility between the

expectations of care and after it • providing support on a long-term basis for

those leaving care

How far have we got?

Some way, perhaps. We have: • Some consensus over how to assess risks of remaining

in or returning to home • Some attempts to use the good relationships in care

(shared care, staying put, SGOs) • More emphasis on skills and qualifications that may be

needed later (e.g. education) • At least one model for trying to ensue coherence

between home and care • Much greater emphasis on support for care-leavers

But

• Much of the research is unconvincing (small samples, lack of comparison, lack of randomisation and generally poor controls, short or no follow-up, studies conducted by developers of method etc)

• The interventions tend to rely on a single perspective (attachment or social learning, for example)

• In the better studies evidence of effects tends to be negative, or to suggest that long-term effects are hard to reproduce consistently.

And…

Here too we lack clear cut research that shows: • We are getting the balance of risks between

home and care right • We can improve the education of children in

care • We can reliably ensure that the gains in care

outlast care itself.

So from a research point of view ….

We need studies which: • Are better designed and more often RCTs • Take seriously the issues how, for whom and

over what period the interventions work • Are theoretically informed, do not rely on one

theory, and listen to what children say • Focus particularly on what must be the keys to

improving foster care performance (selection, training, supervision and quality assurance)

And in England at least

• An incremental shift towards more long-term provision (adoption, SGOs, foster care)

• An increase in the use of Kin Care • More short-term ‘treatment’ options such as

MTFC, for conduct-disordered young people • A more ‘eclectic’ approach to care which

draws on a variety of theories • A better integration of care with its

‘surrounding arrangements’

And what do we need elsewhere?

I would be interested to hear.

For the evidence on which these arguments are based , see

• Luke, N., Sinclair, I., Woolgar, M., and Sebba, J. (Forthcoming). What works in preventing and treating poor mental health in looked-after children? NSPCC.

• Sinclair I. Baker, C, Lee.J. & Gibbs, I. (2007) The Pursuit of Permanence: a Study of the English Care System, Jessica Kingsley

• Sinclair I. (2006) Fostering Now: Messages from Research, Jessica Kingsley

• Sinclair I.(2006) Residential Care in the UK in McAuley C., Pecora P., and Rose. W. Enhancing the Well-being of Children and Families through Effective Interventions: International Evidence for Practice, Jessica Kingsley