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Unconditional Care

03 Oct

Arguably, nothing has discredited foster care more than the difficulty of stabilizing children in care, especially behaviorally troubled school age children. Children placed out of the home are moved from home to home for a variety of reasons, including administrative arrangements (e.g., receiving home or emergency shelter to foster home) or because of crises in the lives of foster parents or pursuant to a permanent plan. However, most unplanned placement disruptions occur because foster parents, unlicensed relatives or residential facilities cannot cope with children’s oppositional behavior or other mental health problems. Placement disruptions, rather than placement moves per se, have the greatest negative impact on children and youth with histories of trauma and maltreatment because they combine a message of rejection with a sense of powerlessness. These often sudden disruptions can do profound emotional harm to children and youth who may have already experienced the loss of birth parents, siblings, friends, school and neighborhood.

In 2007, David Rubin, et al, published an analysis of the placement histories of 1,099 children, ages 0-15, from the National Study of Child and Adolescent Well Being (NSCAW), one of the most important (and best funded) longitudinal child welfare studies ever done in this country. After 3 years, about a fifth (19%) of these children had been in more than 4 placements, but younger children had much more stable placement histories than older children. Rubin, et al, comment that “Older children were significantly more likely than younger children to have difficulties attaining stability, with 31 percent of older children classified as unstable (i.e., the child was never in a placement of at least 9 months duration) compared to only 17 percent of children under age 2.” Children younger than 2 years of age were almost twice as likely to achieve early stability as children and youth older than 10 when they entered foster care.
Rubin, et al, found that “Placement stability over the first eighteen months was significantly related to all permanency outcomes,” including adoption and reunification.

Rubin, et al, comment that “among children whose behavioral functioning at baseline was normal, the children who achieved early stability in continuous out- of- home foster care were doing better after thirty six months than children who attempted
reunification.” However, most children placed in out- of- home care who scored poorly on the Child Behavior Checklist (CBCL) at baseline continued to have serious behavior problems at 36 months even when they achieved early stability.
These authors believe that “interventions that simply promote placement stability might not be enough to improve (mental health) outcomes.”

The implications of this analysis of placement histories and behavioral functioning are worth pondering:

  • Foster care has the most beneficial effects for children with normal behavioral functioning at entry- into- care; children with normal behavioral functioning who achieve early stability in a foster home and remain in care had better functioning at 36 months than reunified children.
  • Highlyunstable placement histories have the potential to seriously harm the behavioral functioning of children who are functioning normally when they enter foster care.
  • Foster care has less beneficial effects for children with poor behavioral functioning at entry- into- care; less than 40% of children of these children who achieved early stability in a foster home had normal CBCL scores at 36 months.
  • Furthermore, about the same percentage of children (40%) with poor behavioral functioning when they entered foster care and unstable placement histories were functioning normally at 36 months, according to caregivers’ rankings on the CBCL. Stable /unstable placement histories did not account for differences in behavioral functioning at 36 months for children who entered out- of- home care with significant behavior problems.
  • Nevertheless, placement stability/ instability have a large effect on permanency outcomes, including both adoption and reunification. It is difficult to find permanen homes for children and youth who cannot be stabilized in care.

An Australian study (Barber and Delfabbro, 2007) published about the same time as Rubin, et al’s, NSCAW analysis provides a somewhat different perspective. Barber and Delfabbro followed 231 children, ages 4-17, placed in southern Australia for longer than
2 weeks between May 1998 and April 1999. The researchers tracked children through agency records and periodic interviews with children’s social workers over a two year period of time. As in Rubin’s NSCAW study, about one fifth of children still in care two years after being placed had not found a stable home. Nevertheless, the majority of children in foster care made developmental
gains, and “the overwhelming majority (90%, 94%) of respondents (i.e., children) liked living with their foster families and felt well cared for and supported.”

Barber and Delfabbro found that placement instability in the first few months of foster care did not negatively affect children’s psychosocial development but protracted placement instability was a different story. Early placement moves were usually planned
“meaning that the majority of placement change occurred for positive reasons;” however, for children remaining in foster care longer than 8 months, one quarter to one third of placement changes were the result of placement breakdown due to children’s behavior problems.

Fifty of the children in the study had numerous placement disruptions that Barber and Delfabbro refer to as “serial evictions.” They state that “it is no exaggeration to describe these children as effectively homeless in foster care.” Most of these children entered foster care with conduct disorders which leads Barber and Delfabbro to conclude “that family – based foster care is unsuitable for disruptive children…and that the child welfare field urgently needs to find an alternative.” They state that “those foster children whom we have described as “homeless in care” need to be rescued from their plight as a matter of urgency and be provided with a civilized way of life.” Barber and Delfabbro do not indicate what the alternative to foster care for conduct disordered youth might be other than to
say that they do not advocate a return to institutional care and that ”many alternatives to conventional family- based foster care now exist … but few have been subjected to the kind of controlled experimentation necessary to identify their effectiveness…”

Child welfare practitioners and policymakers have been ready to believe that safe, humane
family foster care combined with mental health services and other specialized services (as needed) and decent educational opportunities would be sufficient to meet the developmental needs of the great majority of children in out- of-home care, even children who enter care with serious behavior problems.  However, this perspective does not give adequate weight to the beliefs about
the world and the expectations of others, especially caregivers, of children  with histories of trauma and severe early neglect.

One of the best recent discussions of children’s “internal working models”, i.e., beliefs about the world and themselves in relationships with others, is contained in John Sprinson’s and Ken Berrick’s book, Unconditional Care: Relationship- Based
Behavioral Intervention with Vulnerable Children and Families
. Ken Berrick is the President / CEO of Seneca Center, a residential treatment facility in Oakland, California and Sprinson is the Center’s clinical director.

According to Sprinson and Berrick, children whose early beliefs and expectations of caregivers are shaped by maltreatment and trauma tend to cling tenaciously to their negative internal working model and to act in ways that cause caregivers, professionals
and peers to confirm the validity of their world view. They write that “… it is important to be aware that part of the reason some of the problematic behaviors that a client presents are maintained is because they are congruent with the internal working model.” Confirmation of implicit beliefs and expectations that promise children isolation, rejection, educational failure, poverty, imprisonment or even early death is a reinforcement of sorts and makes these views of the world extremely difficult to eliminate. According to Sprinson and Berrick, an assessment goal of skilled professionals should to tease out and understand the internal working model of behaviorally troubled children and to assure that residential care staff, foster parents and birth parents act in ways that gradually invalidate children’s self hurtful views of the world.

Sprinson and Berrick offer a description of a composite case, David S., an 11 year old in the highest level of residential care in California to fill out their account of an internal working model. They describe David as “tall, wiry and strong” for his age. “He announces, they state, “both verbally and by physical presence and gestures that no one can tell him what to do, force him to do anything he doesn’t want to do or stop him from doing the things he does want to do.”  David’s need to resist authority regularly leads to physical confrontations with staff and restraints. “He tends to see others primarily in terms of the dimension of strength and weakness,” they assert. David consistently attempts to intimidate new staff; he is preoccupied with power and intimidation both
with staff and with peers close to his size and strength. In his interaction with peers, he is “very alert to exchanges which result in the other being one down, humiliated or exposed as wrong or diminished,” they state.  Sprinson and Berrick describe David as having good cognitive ability but hampered in learning by his unwillingness to ask for help from female teachers. He can be kind and generous with boys younger, weaker and of lower status than himself, they state. He also
has “a reliable streak of honesty and integrity” and can be counted on to give truthful accounts of events, they assert.

Sprinson and Berrick use one of their favorite assessment tools, a Table of Life Events, to summarize David’s neglect by his alcoholic mother and abuse by his mother’s boyfriends. By age 4, David was hospitalized due to out of control behavior, severe aggression and threatening to kill other children. David was placed on psychotropic medications which appeared to have little or no effect on his
aggressive behavior. He began running away and wandering far from home before he was in first grade. He also began to kick and hit his mother. David was placed in foster care at age 7 and was moved frequently from home to home due
to his aggressive behavior. At age 9, he was placed in residential care, and before age 11 was moved to a level 14 (i.e., highest level) treatment facility.

David is described as maintaining “a posture of invulnerability” and his capacity to form relationships is limited by his need to maintain an invulnerable self.” When hurt on the playground he does not ask for help. His ability to intellectually explore the world is limited by his unwillingness to admit he doesn’t know things, according to these authors. David keeps his distance from staff, never
asks for hugs or signs of affection and never asks staff personal questions.  His attachment style is highly avoidant. Emotionally, ”he seems to favor contempt, arrogance and disinterest. He cannot tolerate anxiety or sadness but does anger with some fluency,” they state.

Sprinson and Berrick summarize David’s internal working model as follows:

  • I can’t rely on others to meet my needs therefore I don’t have (or can’t let myself know about) any needs of my own.
  • I’m on my own.
  • I don’t need other people (and if I ever feel like I do I better not show it).
  • Others are weak and therefore targets for intimidation, or strong and therefore to be
    approached with care and calculation.
  • I will never allow anyone to control me.
  • I am not afraid. I will make others afraid.
  • I will not be humiliated. I will humiliate others.
  • The world is a dangerous place and I need to be vigilant and even dangerous myself
    to survive in it.

To put it mildly, it would be difficult for any foster parents or residential staff to encounter this set of beliefs and expectations in an 11 year old boy highly experienced in resisting the directions of caregivers without being tempted to teach David some hard lessons
about strength and weakness, by physical force if necessary. However, to do so, would only confirm his world view.

Unconditional Care is one of the few books by professionals engaged in residential care that combines clear and cogent explanations of attachment styles, internal working models, reinforcement schedules, assessment tools and processes, along with strategies for managing challenging behaviors. Sprinson and Berrick have an unusual ability to combine a psychotherapeutic perspective based on attachment theory with an in- depth understanding of behavioral management principles, two conceptual frameworks that are not usually found in combination. These authors believe “an intentional weaving together of these perspectives and their methods” is what is needed to help troubled youth find a better path. However, possibly the most important virtue of the book is the authors’ commitment to stabilizing behaviorally troubled children in care regardless of the challenges they present.

Sprinson and Berrick comment about frequently encountering youth in residential settings with double digit placement histories. These youth have usually already encountered a series of failed interventions and “will often seem as though they have set a
course to actively and pointedly defeat the efforts of therapists, teachers, and counselors with an insistent demand that, once again, they be found too difficult, too dangerous, or simply too bad.” The authors state that “Unconditional care is defined …as a commitment to never discharge clients for showing the behavior that originally led to their referral for treatment or
placement.” They assert that unconditional care is not just a philosophical position; “unconditional care is an intervention always operating … ” in that “the staff’s persistent, fundamental commitment to remaining in relationship
with the client is always present and always operating in the background.”

These authors maintain that for children who have been repeatedly ejected from homes and programs, the threat of another move is “terribly compelling” and leads youth to be “exquisitely tuned to the possibility of rejection.” The likelihood of rejection has become an integral part of their beliefs about the world and expectations of adults who want to help them. Sprinson and Berrick comment that “A treatment stance that has a policy of unconditional care as its underpinning is an immediate and powerful response to this story.” Child welfare agencies should be funding and utilizing private child placing agencies and residential programs that have the willingness to make this commitment to troubled children and youth and their families and the capacity to keep it.

References

Barber, James B., and Delfabbro, Paul H., “Psychosocial well-being and placement stability in foster
care: Implications for policy and practice,” Chapter 9 in Promoting resilience in child welfare, ed. by Robert Flynn, Peter Dudding and James Barber, Ottawa Press, 2006.

Rubin, David M., O’Reilly, Amanda, Hafner, Lauren, Luan, Xianqun, Localio, A. Russell, “Placement Stability and Early Behavioral Outcomes among Children in Out- of-Home Care,” Chapter 10 in Child Protection: Using Research to Improve Policy and Practice, ed. by Ron Haskins, Fred Wulczyn and Mary Bruce Webb, Brookings Institution Press, 2007.

Sprinson, John S. and Berrick, Ken, Unconditional Care: Relationship Based Behavioral Interventions with Vulnerable Children and Families, Oxford University Press, 2010.

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