Response to OOHC strategy 1

Child Health Targeted Support Services

Division of Women, Youth, and Children Community Health Programs

Out of Home Care Strategy 2015-2020

Response to the Information paper for consultation:

Proposed service system policy directions April 2014

This paper is being written in order to provide comment regarding the Out of Home Care Strategic Planning Information and Consultation Paper that was released in April 2014. We commend the Community Services Directorate for writing a clear, considered and focused document, which appears to have adopted relevant stakeholder recommendations.

The following principles and proposals are applauded and supported:

1)The recommendations aimed at promoting early permanency for children in need of out of home (EPA).

2)Recommendations to reduce the time a young child is on temporary orders. Including reducing the time for parents to demonstrate capacity for change sufficient to meet their children’s needs, reducing the orders for young children to 12 months. This is a welcome shift, recognising the research in this area and placing the child’s needs first.

3)Whilst also recognising the above point, a specific and dedicated reunification team, alongside the changes regarding temporary orders is commended. Reducing the amount of time children are on long term orders, is best rationalised alongside providing parents with the best possible opportunity to remain or build connection to their child, alongside developing their parenting skills and capacity to provide a safe and protective home environment.

4)Recognition of the problems that have arisen as a result of the shared responsibility between the NGOs and CPS for children in foster care.

5)Recognition that Aboriginal and Torres Strait Islander children who are in need of care and protection have equal right to that protection and should not have to endure more abuse and neglect because of historical concerns.

6)Recognition of the needs and provision of appropriate supports for kinship carers.

7)Increased recognition of the role and knowledge of foster carers and providing them with background information regarding their foster child.

8)Addressing the long standing problems of contact through recognizing the different purposes of contact.

9)Prevention of the problems which arise through failures of medical information accompanying the child as they move from one place to another.

10)Increased focus on training and support to the OOHC sector.

The following comments focus largely on the Service Elements, with commentary targeted to specific points. These comments have been collated from staff across Child Health Support Targeted Services, Division of Women, Youth, and Children Community Health Programs.

Strengthening High Risk Families Domain

  1. Placement Prevention

Response to “skilled workers” and “para professionals”

  • Itwill be important to clearly operationalise the term “skilled workers” and “para professionals”. These terms can hold a number of different meanings within different contexts.
  • It is advised that great care and consideration be given to the use of paraprofessionals. The families with whom these non professionals will be working are the most complex and challenging. It needs to be recognized that families who struggle with basic household management tasks, are usually assuaged by psychological and emotional difficulties which impact on their relationships with their children and others. Those who are employed to undertake intensive in home work with such families should be highly skilled, trained, and well supervised. Skills in observation and interpretation of parent child interaction are particularly important.

Evaluation

  • Outcome measures need to be meaningful, carefully considered, and evaluated. For example, the concept of “keeping families together” whilst extremely worthwhile, is not always the best option for children and families, and can hold different meanings. It is suggested that such broad concepts would need to be broken down, so the concept of “keeping families together” is operationlised, for example does that mean that you would see outcomes across different domains of education, social, cognitive, and physical development, measuring items such as: child engaged in education, child engaged in extracurricular activities; children meeting learning outcomes; wide range of friendships;overall level of family stress decreased.

Caution against building anew system on the assumption that improvement in placement prevention services will result in a reduction in demand for OOHC.

  • The number of children entering care may not necessarily decrease with this model. While this is a commonly asserted premise, the research does notyet support this assumption.What could beusefulis to understand birth parents propensity to make an informed decision regarding their ability to care, in a more timely fashion. For example, in Tuillane, United States, they had a similar model which involved infant mental health therapists working both with families of origin and foster families, they found that fewer children were returned home- but less of those who returned home were subsequently placed back in care; and parents made quicker and more informed decisions regarding their capacity- which created less burden on the system.

3. Parent Child Interaction Program (PCIP)

  • This is the incorrect name for the program; it is PCIT, meaning Parent Child Interaction Therapy.
  • Treatment models such as PCIT or programs such as Circle of Security need to be very carefully considered when applied to highly traumatised children. Anecdotal evidence suggests that its use with traumatised children, with very different experiences may result in atypical responses or further damage. Expert assessment or consultation is required prior to such programs commencing. Integrated trauma informed organisations, such as CARHU or the Trauma Recovery Centre, would probably be best placed to provide such services.

4. Reunification

  • This section also refers to the term “para professionals”. Concerns regarding this have been outlined earlier. It is important to consider that “para professionals” may be able to assist with practical parenting tasks; however in regards to working towards creating a secure attachment relationship for a carer and child, more targeted expertise may be required. For example this type of arrangement could mean that unhelpful attachment patterns are left to continue, which can have a detrimental impact on development.

Creating a Continuum of Care Domain

6. Empowering children and young people in decision making

  • Whilst it absolutely crucial that children’s voices and wishes are heard, caution should be given to relying on what children might say about contact.Anecdotally, in our service we have learnt that children remain very loyal to their birth parents- even though the parents they love might be causing harm. It can appear at times thatoften contact is influenced more by adult family members than children. Optimal contact is a constantly altering balance- depending on so many factors such as developmental stage, other interests such as sport, opportunity to have a relaxed uncommitted holiday or even weekend, changes in child or adult health or mental functioning etc; and it needs to be organised with sufficient flexibility to accommodate this.
  1. Case management

Concerns regarding movement towards greater agency responsibility

  • We would suggest that there are systemic and service specific issues that need to be addressed and resolved prior to Parental Responsibility for foster carersbeing devolved to non government organisations. They do not appear to be currently equipped to take on this responsibility. Two areas of concern are the rapid turn-over of staff, as well as difficulties in recruiting skilled and knowledgeable workers. Underpinning this is that workers in the sector are poorly paid in comparison with those in the government sector and private practice. The organisations themselves do not have the resources to prioritise training and quality clinical supervision. There appears to be a steady drain of competent workers from the non government sector. Building a competent and stable workforce will require:
  • Significant increased expenditure on quality clinical supervision to increase capacity as well as prevent worker burnout.
  • Parity of wages and conditions with government employees
  • Provision of quality training and ongoing education and requirements that workers either demonstrate knowledge and skills or are working towards acquiring these skills.
  • Demonstration of increased stability in the workforce.
  • Careful external monitoring of the agencies.
  • At the core of quality care of children who cannot live at home with their parents is the relationship. How NGOs establish and work with carers to foster the relationship with the child is in itself “relationship based”. Monitoring of this will need to be creative; this cannot be evaluated by checking that forms are complete.

Guardian ad Litum

  • It is proposed that all children in care have a Guardian ad Litum. The Guardian ad Litum has a specific purpose ofrepresentation. They do not provide a ‘treatment’ service, as the Guardian does not have a therapeutic role. Their role is to ensure that the child’s voice isheard (although by itself this could be argued to have a therapeutic impact) and that their interests are met by their caregivers, whether this is family, state, or both.They attend review meetings to monitor and assist decision making. It is understood that the system in the UK has been shown to work well.
  • Part of the rationale behind the Guardian ad Litum, also relates to a major problem for children in care, which is the frequency of changes regarding workers in both CPS and the NGOs. This can be minimized through good management practices but cannot be eliminated. For the children who also have considerable placement instability, this is a major problem and has significant impact on child outcomes,particularly when the details of the history of the child are not considered when attempting to resolve new problems. The development of better record keeping and sharing of information will partially address this problem. However, for children with very long and complex histories, summaries and notes will not be adequate.
  1. Therapeutic assessment and planning for every child and young person

Expertise of assessors

  • It is imperative that professionals have the range of experience and knowledge regarding the special needs of children in the care system, including the impact of trauma and the complexities of attachment in traumatised and young children. For example, the assessment of infants and preschool children requires a different set of skills to the assessment of primary aged children and teenagers. Engaging assessors who are not adequately trained for the particular age group may be counterproductive.
  • It is suggested also that those working with the infants and young children must be skilled in infant observation, early social and emotional development and the assessment of the dyadic interaction between infant and carer.

Timing and amount of assessments

  • It is not clear if the children will be observed or required to engage with the assessor as part of the assessment process, or wether information will be collated based on information gathered from significant people in the child’s life.
  • For some children, they have been seen and assessed at home prior to removal and might then need some time (at least weeks) to settle after the dislocation, before review. It is well known that the removal of children from their family home can be traumatic (or healing). Some children then settle remarkably well and ongoing assessments could become very intrusive and possibly damaging, for example through reinforcing that that they are “different”.
  • One of our doctors noted:

“There could be such a fine line between leaving a child to recover in a sensitive, nurturing environment whilst monitoring closely but almost “from afar”- only intervening for concerns- and having each child locked into a trail of assessments throughout their childhood, which could so easily become stigmatising rather than healing”

  • It is also important to consider the different panels, including how they are going to link together and what the consistency will be of panel members.Having a series of different panel members may mean too many different perspectives for one child, this could confuse decision making.
  1. Supports for Permanency

Needs of parents

  • The shift of focus towards the child’s needs should be accompanied by the recognition of the consequences for the relinquishing parents. Parents who lose the care of their children often have further pregnancies in order to deal with their loss. Counselling and support to help them come to terms with their loss and understand the reasons may prevent pregnancies before the parents have had the chance to make changes. Not all parents will engage with this,however support by an appropriately skilled counsellor should be routinely offered.

Consider consolidating recommendation with current neurobiology research

The length of initial orders is proposed to be reduced to one year for kids whom are under the age of two. Trauma-informed models indicate that children’s brains are most rapidly developing up to five or six years of age. Given this knowledge perhaps consider increasing this to include children under the age of six who enter care.

  1. Carer advocacy and support
  • It is not clear if this service would charge the carers themselves, and if so this could limit access for certain carers.
  1. Health Passport

Questions to consider

  • Implementing the health passport is a complex and multifaceted process. Some questions to consider might be: Who holds it? Who contributes to it? Who ensures it is maintained and up to date? How does is relate to e-health and to the Blue Book which is supposed to be every child’s personal health and development record.

18/ 19Training all carers in therapeutic careCare and Protection Services and agency training

Cultural integration of training

  • The increased focus on targeted training is an excellent proposal. However it is also extremely important to consider exactly how the specific training, will translate into practice. It is important to ensure that the day to interactions that case workers, foster carers, and other important people have with children in OOHC reflect the trauma informed training they have received. This is a complex task which in the face of stress, work demands, and learnt coping mechanisms (adaptive and maladaptive) can be challenging to maintain. Integration of trauma informed training across the services is crucial, but this requires a cultural change and significant shifts in practice. This approach needs to be supported across all levels of the different organisations, and will need to be integrated across all levels through management and other staff understanding and integrating knowledge into their practice, via interactions in meetings, time for reflective practice, clinical supervision, and ongoing training to refresh and build on information. Moment to moment interactions between case workers and foster carers should be utilised as role modelling and seen as a constant practice opportunity for trauma informed work.

Strengthening Accountability and Ensuring a High Functioning Care System Domain

  1. Strengthening accountability and oversight
  • There is some concern regarding the financial incentives being offered to NGO’s for achievement of targets particularly if this enables a culture of funding competition between agencies, particularly if this is to the detriment of a client focused service.

21. Information management

  • It is acknowledged that the strategic plan outlined the importance of a better information management system. This is crucial to support case work practice. There is a clear need to provide case workers both within the statutory system and within the agency system, a more efficient and secure record and information management system. It is well known that case work practice is involves increasing amounts of time on the computer rather than with children and their families. A more efficient and secure record and information system will better support case-work practice, and as in other states and territories, can negate the need for a paper file. It understood that jurisdictions such as Western Australia use systems such as “Objective”.

Other areas of feedback that are not captured in the “service elements”:

Whole of government approach

A whole of government approach is required in order to maximize on the potential for improved outcomes for children.

  • Education needs to be better engaged in supporting traumatised children in the school setting so as not to undermine placement security and therapeutic plans. E.g. suspending a child from school can destabilize a placement. This includes also the recognition of and provision of extra support for children in the classroom to address learning problems resulting from missed learning opportunities, disruption of education, and cognitive impairments including those related to trauma and antenatal substance exposure. The recognition of and provision of extra supports in the playground and classroom for children with challenging behaviours and social problems arising from early trauma and neglect. These supports should not depend on the child being given a DSM 4TR or DSM 5 diagnosis and only be available for a year.
  • Ongoing training of and support of teachers and STAs in childhood trauma. Management of these children is complex and difficult and teachers need ongoing support and training to do this well.
  • There is also need for enhanced preschool placements (special needs placements) for young children in care who are developmentally delayed and or have social and emotional problems. They need small group settings or extra supports to address these issues early so that they are better able to transition to mainstream school. Many of these children will demonstrate developmental catch up, but still require support because of behavioural dysregulation and social difficulties. With the closure of early intervention playgroups and preschools these young vulnerable children will not have a suitable service.
  • One doctor suggested:

“my strong belief is that a proven history of trauma of neglect should be accepted as meriting additional services within education just as readily as a diagnosis of ADHD or ASD...Funding for these children is often very difficult and can become a tussle between the carer, education and CPS (or the NGO).The provision of appropriate resources for traumatised children- including specific supervision and support for class teachers and special assistantswill enable them to work effectively with these children”.