Strengthening foster placements for looked after children: Development of an evidence- based tool for assessment and care planning Steve Rock & Stacey Thomson CAMHS Research Unit Institute of Psychiatry Explain what is meant by placement stability Ask about experience of working in foster care / awareness of placement stability as a problem Set tone for workshop – questions comments at any time

Background Instability related to elevated risks Placement breakdown has been highlighted in recent national practice guidelines (DCSF, 2009; NICE, 2008) Work completed for an inner London Fostering and Adoption Service funded by CLAMHS RISKs - behavioural, developmental, academic, social and attachment difficulties – placement instability potentially increases the likelihood of CLAMHS involvement

Project overview Systematic review Care plan audit Focus group Tool development Stakeholder consultation Piloting tool CLAMHS consultation

Vignette - Greg Background: Greg is a 14 year-old boy who was first placed in foster care aged 3 following the death of his mother and his father’s inability to assume care as a consequence of mental health problems and substance abuse. While his father’s condition has improved for periods and he has been able to look after Greg and his 11 year-old sister, Greg has been placed in 14 different foster homes over the past 11 years, 4 of which have broken down prematurely. Greg is bright teenager but he has generally underachieved at school and has been described by teachers as a disruptive influence. While he does not have any diagnosed mental health problems, his tendency to have aggressive outbursts has at times been problematic for his foster carers.

Vignette - Greg Immediate circumstances: Two weeks ago Greg was moved to a new placement directly from another foster placement where he was placed with his sister for 3 months. Greg had smashed a window in the carer’s home following an argument with his girlfriend, which led the carers to end the placement. Greg’s sister has remained in the previous placement as it was not possible to find a new placement at short notice that could accommodate them both. His new placement is in the same area as the previous one so he has not had to move school and can see his friends and sister easily. His new carers are in their late forties, are married and have a son of their own who is 12 years old. They have been fostering for 5 years and social worker’s describe them as carers with excellent parenting skills who have high expectations of children in their care in terms of their behaviour and academic achievement. They know that Greg has experienced a high number of previous foster placements but they are unaware of his behavioural problems and do not have a detailed knowledge of his history. In the first two weeks of the placement Greg has been rather withdrawn but has not presented with any challenging behaviour.

Vignette - Greg In your opinion, what factors presented here are salient to the risk of placement breakdown? (Background/Immediate) Are there any protective factors? What else would you want to know? Start with background information – go back to the slide, then the same for immediate Feedback from the group Summarise – something positive about the breadth of knowledge and awareness of the things that effect placement stability amongst SWs Put this in the context of the project – notion of systematising what SWs already know in a user friendly format – show awareness of SW paperwork

Systematic review

Systematic review Why? provided foundation of the project, evidence upon which everything else is based. Research using either placement moves/placement breakdowns as an outcome measure. Why? – review provided foundation of the project, evidence upon which everything else is based Methodological weaknesses – not systematic, uk only research, limited inclusion criteria FPM/PBD describe

Systematic review – including qualitative evidence Synthesis of qualitative and quantitative evidence Provides better understanding of processes Example: Quant: previous breakdowns/ placement moves predicts future instability Qual: Children have described a sense of detachment following a placement breakdown Provides potential explanations why

Systematic review Results Over 100 stability factors identified. Synthesis of data led to grouping of factors according to several themes categories of factors emerged through collating and synthesising data

PLACEMENT INSTABILITY HISTORICAL/BACKGROUND FACTORS (RISK) HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship* Describe different groups of factors: CHILD, BP, SW, PLACEMENT, CARER, RELATIONSHIP PROTECTIVE/DELETERIOUS HISTORICAL/CIRCUMSTANTIAL WHY? 1. EMERGING FROM THE EVIDENCE, 2. AND 3. IN THE CONTEXT OF THE WAY THE EVIDENCE CAN BE APPLIED TO SW PRACTICE Give them time to read through as apposed to talking about factors individually – ask if there are any comments Social worker factors - Change in social worker PLACEMENT INSTABILITY

HISTORICAL/BACKGROUND FACTORS (RISK) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker

PLACEMENT INSTABILITY HISTORICAL/BACKGROUND FACTORS (RISK) HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship* Social worker factors - Change in social worker PLACEMENT INSTABILITY

HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation

PLACEMENT INSTABILITY HISTORICAL/BACKGROUND FACTORS (RISK) HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship* Social worker factors - Change in social worker PLACEMENT INSTABILITY

CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Social worker factors - Change in social worker

PLACEMENT INSTABILITY HISTORICAL/BACKGROUND FACTORS (RISK) HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship* Social worker factors - Change in social worker PLACEMENT INSTABILITY

CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship*

PLACEMENT INSTABILITY HISTORICAL/BACKGROUND FACTORS (RISK) HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship* Social worker factors - Change in social worker PLACEMENT INSTABILITY

Project overview Systematic review Care plan audit

Care plan audit

Care plan audit Why? Effective care planning is a priority for the local authority Placement stability is a priority nationally Currently no guidance on care planning around placement stability No guidance relating to improving placement stability – care plans designed around 7 areas of developmental need, i.e. meeting child’s health, social, academic, needs

Care plan audit The purpose of this audit was to establish: The extent stability factors derived from the evidence base are identified by social workers The extent to which stability factors identified by social workers are reflected in action plans. Describe care plan layout – needs/problems/ how will needs be met e.g. IN SUMMARY WE WANTED TO LOOK AT THE APPROACH TO CARE PLANNING AROUND PLACEMENT STABILITY IN EXISTING PRACTICE

Care plan audit Method Searched care plans for stability factors identified in review Identified/evidence of intervention planning N=53, aged 0-15, referred for foster care between 1st Sept ’09 and 31st Dec ’09 Due to the forms fairly loose structure (lots of text boxes) – signif variation in what information recorded by diff SWs and where it was recorded – auditor had to take a flexible approach i.e. looking for evidence of recording a specific stability factor in several parts of care plan Sample reflected all children referred for foster care in this 3 month period

Care plan audit Findings – overview Variability in level of information recorded. Overall, there was no consistent approach to planning around placement stability. Will discuss reasons for this shortly Generally recording and planning around stability factors was absent or inconsistent Approaches varied from social worker to social worker

Care plan audit Conclusions Inconsistency/absence of information not surprising in the context of care plan design/lack of guidance → Forms designed around 7 areas of developmental need Information recorded in other documents Care planning around placement stability in need of more attention Other documents? Law team – care plans written for presentation in court contain a considerable amount of detail, not then replicated on proforma LFAS – changes to improve overall completion

Project overview Systematic review Care plan audit Focus group

Focus group Bit about participants – 6 social workers from the law team, considered most experienced, with most expertise

Focus group Purpose Get SW perspective on issues around care planning/ audit findings Use SW experience to generate ideas for improving practice Also validate review findings

Focus group Key themes Care plans are NOT a document social workers use to help them formulate around placement stability- use other documents. ‘always thinking about it’ Adding more ‘check boxes’ or supplementary documents to the care plan was NOT likely to develop a more structured approach to care planning– just more paper work. Other documents? Placement information record, CLA review, care plans written for court appearances (more detail) HOWEVER – CP IS still supposed to be the central document, point of ref for carer, child, BPs, LFAS has introduced changes to care plans – to prevent duplicity with court docs, making them compulsory before other docs accessible

Focus group Key themes Statutory visits - placement stability is at the forefront of thinking. The notion of a pre-statutory visit checklist explored – a good way of promoting a structured approach to thinking and planning around placement stability. Explain what statutory visits are, when they occur. At least twice within the first month of a placement, minimum of once a month after that. So, as apposed to developing the care plan proforma, development of tool instead First visit takes place before the first care plan is written.

Project overview Systematic review Care plan audit Focus group Tool development

Development of assessment tool GIVE OUT CHECKLISTS/GUIDANCE NOTES

Development of assessment tool Based on the review findings, audit and focus group……. Pre-statutory visit checklist (background/immediate/protective factors) Checklist guidance notes AT THIS POINT GIVE PEOPLE COPIES OF THE CHECKLIST AND GUIDANCE NOTES SAY THAT WE ARE GOING TO GO THROUGH AN EXAMPLE OF HOW IT IS USED, DESCRIBE THE FINAL STAGES OF THE PROJECT AND THEN WE WILL COME BACK TO THE VIGNETTE AND HAVE A GO AT USING THE CHECKLIST.

Using the checklist

Using the guidance notes P2- Immediate factors 4. SIBLING PLACEMENTS Generally placements are more stable if siblings can be placed together. Although in some circumstances such as when one sibling poses a serious risk to the other, it is necessary to place them separately. If a child has been separated from their sibling it may be helpful to consider: Ensuring the child is happy with frequency and quality of contact arrangements with their sibling(s). When a child has previously played a care-giving role, separation can be particularly distressing due to anxiety about their sibling’s well-being.

Corresponding evidence Sibling placements – There is consistent evidence that separation of siblings predicts instability and joint placement promotes stability. Sibling separation can be particularly distressing for children who previously played a significant care-giving role in relation to their sibling.

A preventative measure The checklist and guidance were designed to help social workers ensuring the stability of EXISTING placements. At this point it is important emphasise that the checklist and guidance notes are designed as a PREVENTATIVE Hopefully show awareness of the fact that there are certain things SWs cannot control i.e. limited by placement choices, but we have tried

Project overview Systematic review Care plan audit Focus group Tool development Final consultations and Pilot

Consultation with LFAS Use of the tool in practice LFAS would like to maintain emphasis on care planning. Pre-visit checklist/guidance notes to be used to inform care plans. Checklist to be used as point of reference for Independent Reviewing Officers. Have stability factors identified in the checklist been incorporated into CPs? Independent reviews – when care plan is evaluated, have targets been met? If not what is going to be done?

Piloting the tool Method Informal use - not tied to documentation/ care planning Sample 8 social workers Focus Group FG outcomes Checklist user friendly, quick to complete, train example Guidance notes helpful in prompting thought BUT only 1 SW gave concrete example of informing a plan (however informal nature of pilot) Need for allocating time for use of guidance notes (supervision?) Emphasis in training on developing concrete plans SWs no problem in fitting info from CL and G into care plans

CLAMHS Consultation Input from CLAMHS Psychology Using less psychological/formulation-orientated language Linking the guidance notes to relevant local services Attempting to remove as many barriers to use Positively framing guidance notes e.g. Providing concrete examples of interventions. E.g. peer support for carers, references for carers groups, national website

Back to Greg…… Have a go at using the checklist and have a look at the corresponding guidance notes when you have identified a risk factor/ the absence of a protective factor.

Group exercise How does the tool reinforce good practice? How does the tool add to or extend existing practice? What are the practical issues around integrating the tool into practice? How might the information be used to inform care planning? How else might the tool be used in practice?

Discussion points Does using the checklist and guidance notes help? How might you think about addressing these factors in care plans? Can you foresee any issues around using these tools?