Fostering Good Relationships

Partnership Work in Therapy with Looked After and Adopted Children

Miriam Richardson, Fiona Peacock, Geoff Brown, Tracey Fuller, Tanya Smart, Jo Williams, Fuller Tracey

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367102852
• eBook ISBN:
  9780429913877
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book explores the importance of effective multi-agency and multi-disciplinary partnership work for the mental health of children and young people in care and adoption. It takes an overall systemic perspective, but the co-authors contribute different theoretical approaches. It focuses on practice, showing how practitioners can draw on their varied theoretical approaches to enhance the way they work together and in partnership with carers and with professionals from other agencies. The book provides a context that looks at the needs of children and young people in the care and adoption systems, the overall importance for their mental health of joined up 'corporate parenting', and national and local approaches to this. It then moves to focus on practical ways of working therapeutically in partnership with others who contribute diverse skills and perspectives, using specific case examples. Additional chapters look at collaborative ways of working with key carers to enhance their therapeutic role. Finally, some of the main elements of partnership collaboration are explored, as well as the challenges of work across agencies and disciplines.

CHAPTER ONE

Perspectives on the world of the looked after and adopted child

Fiona Peacock, Miriam Richardson, Geoff Brown, Tracey Fuller, Tanya Smart, and Jo Williams

“… you can define how strong a democracy is by how its government treats its child. I don’t mean children. I mean the child of the state.”

(Sissay, 2012)

Acknowledgement of the importance of context in giving meaning to everything we do is a fundamental systemic principle. In this chapter, we attempt an overview of the national context in which our work and the rest of the book are situated, with contributions from each of the co-authors. The chapter looks at the life experiences of many looked after and adopted children and the network of people involved in their lives. We pay special attention to the children’s mental health needs and the important reparative role this network of adults can play. This is set against national statistics and legislative and policy guidelines for joinedup working. We reflect on the current position of therapeutic services for vulnerable children and the impact this has on ways that we work.

Life experience and life outcomes

The life experiences of many looked after children are troubled, and it is these that we highlight in this chapter. However, less frequently celebrated, but threaded through this book, are the reparative relationships and positive experiences before and during their time in care or adoption that build resilience, enabling children and their substitute parents to face these life struggles in creative ways.

Jamie’s story is typical:

Jamie, a white British child, was referred for therapy by his social worker (his fifth) when he was eleven years old, as his behaviour at school was disruptive, he was being bullied by his peers, and he was not meeting his educational targets. At home with his foster parents, he was staying out late in the evenings and soiling his pyjamas at night. This was his sixth foster placement. His foster parents were committed to him and hoped this could be a permanent placement until he reached eighteen, so they were concerned that he and they themselves should receive help before they all faced the challenges of adolescence. Previous placements had ended because his aggressive angry behaviour could not be tolerated, or because of sickness in the foster parent’s family. He and two younger siblings had been taken into care when he was three years old, due to neglect and domestic violence. His mother had used alcohol and cannabis in attempts to control her anxiety and depression, and had violent relationships with male partners. In spite of great pressure on their services, CAMHS specialist looked after children team was able to provide individual work with Jamie, consultation to his foster parents, and multiprofessional meetings involving social workers, Jamie’s school, and a recently recruited befriender.

Looked after and adopted children and young people have needs that are often significantly higher than their peers. They might have high levels of risk-taking behaviours such as smoking and alcohol and drug misuse. Their educational achievement is often poorer. They are at increased risk of sexual exploitation, as recent high-profile media stories have identified. Also, as we go on to describe, their level of psychological distress is often higher than their peers who are not in care. Life outcomes in adulthood might be starkly different from the population of children as a whole. It has been found that those who have been in care are more than twice as likely to self-harm in adulthood. Teenage girls are more than twice as likely to become pregnant than other teenage girls. According to a 1970 study, men with experience of care were significantly more likely to have been homeless, have a conviction, have psychological morbidity, and be in poor general health than their peers, and were less likely to attain high social class (Simkiss, 2012).

English data are similar to that from other countries where there has been comparable research (Simkiss, 2012), while issues concerning children and young people in care feature prominently in the United Nations Convention on the Rights of the Child.

In England in March 2014, 68,840 children were looked after by local authorities. The following statistics are all taken from the Department of Education’s 2014 statistical report on children looked after in England (DfE, 2014), unless otherwise referenced. In spite of national policies aimed at supporting vulnerable families, there are now more children in care than at any point since 1985. Numbers have increased by 7% since 2010. This is partly due to the reaction to the death of Baby P in 2007 and the subsequent Laming report (2009), and in part to the fact that more children aged sixteen and over are coming into the care system. Seventy-four per cent of all looked after children are white British, the same proportion as the general population.

The majority of these children, 75% in 2014, are, like Jamie, in foster care. Just 9% were cared for in secure units, children’s homes, and hostels, fewer than previously. Five per cent were placed with their parents: a dramatic decrease by 22% from 2009. The number of adoptions during the year ending 31 March 2013 was at its highest since current data collection began in 1992, a possible effect of government policy to speed up the adoption process (Department for Education, 2012). Jamie was thought to be too old to be placed for adoption. Jamie is again typical of the majority in being in care due to abuse or neglect (62%). Other large categories include “family dysfunction” (15%) and “family in acute stress” (9%).

In this research, 11% of the children in care experienced three or more placements during the year. Experience in the care system can add to distress, with looked after children moving placements frequently and at short notice. Simkiss (2012) reports that some 23% were informed on the day of the move itself, and 55% were given less than one week’s notice These frequent moves and lack of any sense of stability or of unconditional care undermine a sense of belonging, which has a recursive impact on the child’s ability to trust and invest in relationships. Placement stability is a key factor associated with outcomes for children and young people in public care.

Mental health and looked after children

Ford and colleagues (2007) sought to explore whether children who were looked after had different levels of mental health concerns to children who were in the care of their parents. The figures did not set out to show causality, so cannot answer the question of whether children are more likely to be looked after if they have a mental health difficulty, or whether a mental health disorder develops because they are looked after.

Simkiss (2012) uses the data from Ford and colleagues (2007) in his exploration of the mental health needs of looked after children. He identified the following:

• 45% of children and young people looked after by local authorities were assessed as having a mental health disorder;

• for five to ten year olds, 42% of looked after children were likely to have a mental health disorder compared to 8% of children living in private households;

• for eleven to fifteen year olds, 49% of looked after children were likely to have a mental health disorder compared to 11% in private households;

• about two thirds of those in residential care were assessed as having a mental health disorder.

These are disorders that would meet the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) manual. Research quoted by DeJong (2010) shows that many children suffer from significant emotional distress but fall below the threshold of a medical diagnosis.

Online searches for papers since 2011 that look at the prevalence of mental health disorder in adopted children found no specific UK data, but virtually all of the children adopted in the UK are likely to have been in the care system and exposed to the same kinds of experiences as children who remain looked after. Boris and co-authors (1998), cited in Wilmshurst (2015), suggested that in the USA 42% of the adopted population met the criteria for an attachment disorder. It seems likely, therefore, that the issues relating to the mental health of adopted children could be very similar to those of looked after children.

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) groups a number of disorders together under the heading of “trauma and stress related” disorders. This brings together a group of disorders that in the previous editions of DSM were dispersed. Although the manual’s classification system is viewed critically, particularly among systemic therapists (Carr, 2014), the organisation of the latest volume seems to acknowledge that stressful experiences in a person’s life can have a direct impact on their mental health. Specifically, DSM-5 identifies reactive attachment disorder as something children can develop if they have been exposed to extreme lack of caring involving at least one of the following:

• social neglect or deprivation;

• recurrent changes in primary carers;

• being reared in severely limited settings (Wilmshurst, 2015).

Attachment, developmental trauma, and emotional regulation

As we can see from the notion of reactive attachment disorder suggested by DSM-5, children in the care system or who have been adopted are at significant risk of having been exposed to conditions that could contribute to difficulties resulting from poor attachment experiences. Jamie, the boy in our case study, suffered early neglect and trauma, and the issues he and the family faced are among those that, in our experience, many foster and adoptive parents identify. Others include being to quick to anger, inability to settle, “not connecting” with parents, peers, or other adults, not being able to accept comfort when hurt, defiance, not listening, as well as, sometimes, aggression, stealing, lying (to name a few) and, in the extreme, fire setting or sexualised behaviours. Attachment theory, research into the impact of early trauma and new insights into the neurobiology of infancy can all contribute to our understanding of how early experiences could lead to these kinds of presenting issues.

Bowlby (1973, 1980, 1999) in his work on attachment sought to “update psychoanalytic theory in the light of recent advances in biology” (Ainsworth, 1969). In a similar vein, Allan Schore wrote a new foreword to Bowlby’s Attachment and Loss (Volume 1) in 1999 in which he brings in his own writing on affect regulation (Schore, 1994) to illustrate the connections between the quality of attachment in infancy and a person’s ability later in life to regulate their own emotions.

The human infant is born with very limited ability to take care of herself. From infancy, therefore, humans need others to survive. Initially, those survival needs are physical: nourishment, protection, warmth, but these also connect with the emotional development that comes from a relationship that is responsive to the child’s signals. One could say biology and relationship are interdependent. The impact of not having a responsive relationship in infancy was highlighted by the developmental difficulties displayed by children who had been raised in Romanian orphanages. Their physical needs might have been met, but they had not had emotional connections with warm parent substitutes, leading to long-term impacts on emotional development and social functioning (Dunn, 2004).

The impact of an early lack of human relationship can be talked about in biological terms such as identifying the changes in the brains of children who have experienced early neglect (Sheridan et al., 2012), and by looking at children’s attachment styles (Levy, 2000). What seems common to these perspectives is that what goes on between infant and carer is important in terms of the child developing a resourceful, lasting, and creative experience that can be used beyond the immediate relationship to help them engage with others in other situations.

Some writers broaden consideration of the attachment relationship to acknowledge the importance of other people significant in the infant’s life, notably other family members (Byng-Hall, 1999). Dunn (2004), for example, explores children’s friendships and the development of intimacy, suggesting that the quality of relationship in friendship is correlated to the quality of attachment in the family. Krause (2002) suggests a slightly different method of how a child creates an internal working model of themselves in the world. She suggests that the child not only internalises their primary carer as a way to regulate their sense of the world but also how the primary carer views the child and their place in the world. Between them, Byng-Hall and Dunn and Krause help us hold in mind that a child is raised in more than a dyadic relationship. Krause (2002) suggests that elements of culture such as orientations, emotions, intentions, motivations, ideas, and memories (p. 21) are also internalised. Thus, culture, class, gender, and other social differences all become aspects of the experience of attachment.

However, where, for whatever reason, there have been insufficient good-enough attachment experiences then, in this book, we would conceptualise that as a relational trauma. This relational trauma has the potential to lead to the child being diagnosed with a mental health disorder, depending on how that trauma is expressed.

Just as, in infancy, responsive attunement to the infants’ cues leads to an attuned and reciprocal relationship between child and adult and this creative communication enables the infant to develop self-regulation of emotion (Schore, 2012), so a responsive, attuned adult network can, in time, be a resource for the child within which to start to develop self-regulation. If the adult network can form a responsive caring system around a child and learn to read and understand the communications from this particular child in this particular context, then the “symptoms” of “relational trauma” can become a key that enables the thoughts and feelings, that may be pre-verbal or nonverbal, to be received, understood, and responded to. In essence, the system around the child can become an opportunity to co-create a different and potentially reparative attachment experience. How to do this is the focus of many of the chapters in this book.

The system around the child

Zulueta (2006) writes, “to those for whom life has become a nightmare from the past, the provision of safe and consistent professional attachments can provide those desperate individuals with a sense of hope and the possibility of healing their emotional wounds.”

Looked after and many, if not all, adopted children are surrounded by a network composed of many different people and agencies closely involved in their lives. Liz Stott (2006) uses an “onion model” (pp. 39–40), based on Bronfenbrenner’s (1977) model, to map the various systems (Figure 1.1). The child at the centre first experienced the family s/he was born into: people who continue to have a direct or indirect influence in their life. Then there is the current family where they are living, with their kinship network. Stott includes here former carers and their networks, too. Her fourth layer represents culture and community networks of both birth family and carers. The fifth layer is the professional network. This will include at least the social worker for the child, social worker for the fostering or adopting family, various professionals involved in the child’s education, and health professionals. The next layer represents agencies, their policies, history, relationships, their beliefs and values. Her seventh layer represents the current discourses held by government, the media and society at large, and finally there is the legal context within which we all must operate. Systemic therapists will be reminded of Cronen (1994) and Pearce’s (2007) “co-ordinated management of meaning” (CMM) in considering how all these contexts impact on each other, and which context might be the highest, the most significant, at any point in time, depending on the particular circumstances.

Figure 1.1. Onion model of potential systems around the child (adapted from Stott, 2006, p. 39).

From the perspective of young people and their carers, we know the importance of services that are safe and containing. From this viewpoint, what matters are those people who can offer a sense of relationship and with whom an often lonely and alienated child can form an attachment. It is these adults, from within the inner layers of Stott’s onion and whose roles carry for the child emotional significance, meaning, and authority, who form the adult network. Recognition of the importance, responsibilities, and potential of such groups of varied profess...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHORS AND CONTRIBUTORS
• SERIES EDITOR’S PREFACE
• FOREWORD
• INTRODUCTION: Why partnerships?
• CHAPTER ONE Perspectives on the world of the looked after and adopted child
• CHAPTER TWO The views of adoptive parents and a foster parent on partnership working
• CHAPTER THREE Partnership with birth families
• CHAPTER FOUR Therapeutic multi-disciplinary collaboration
• CHAPTER FIVE Helping children with challenge and change: partnership working in transitions and education
• CHAPTER SIX Working together with the stories of children’s troubled lives
• CHAPTER SEVEN Finding a future beyond the crisis: looked after children in secure care
• CHAPTER EIGHT Working in partnership with adolescents in care who have experienced early trauma
• POSTSCRIPT
• REFERENCES
• INDEX