Fostering Changes: Addressing the mental health needs of fostered children in the UK

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1 Fostering Changes: Addressing the mental health needs of fostered children in the UK Dr Matt Woolgar Consultant Clinical Psychologist National Adoption & Fostering Service South London & Maudsley NHS Foundation Trust Senior Researcher, National Academy for Parenting Research, King s College London & Course Tutor Children s & Young People's IAPT UCL/KCL matt.woolgar@kcl.ac.uk

2 What are the concerns in children taken from their birth parents? The mental and physical health and well-being of children in public care is less robust than children in the general population Educationally, 12% LAC get 5 GCSE passes vs 56% in the general population 31% of juveniles in British jails are LAC (but they are 0.5% population)

3 Mental Health in UK LAC, Ford et al 2007 Birth family High Risk ONS LAC Any disorder 8.5% 14.6% 46% Anxiety disorders 3.6% 5.5% 11% PTSD 0.1% 0.5% 2% Depression 0.9% 1.2% 3% Behavioural disorders 4.3% 9.7% 39% ADHD 1.1% 1.3% 9% ASD 0.3% 0.1% 2.6% Neurodevelopmental 3.3% 4.5% 12.8% Learning disability 1.5% 1.5% 10.7%

4 Comparing ONS LAC data with Tier 4 Adoption & Fostering Service (AFS) (Woolgar & Baldock, 2014) ONS LAC N&S Adoption & Fostering CAMHS Referrals Any disorder 46% 66% 31% Anxiety disorders 11% 9% 5% PTSD 2% 3% 1% Depression 3% 4% 1% Behavioural disorders 39% 55% 4% ADHD 9% 38% 12% ASD 2.6% 4% 4% Neurodevelopmental 12.8% 12% 0% Learning disability 10.7% 10% 3%

5 Some LAC needs To have trusting relationships with adult attachment figures; what promotes this is sensitive responding with firm limits in this age group (Scott, O Connor et al 2011) To behave in away that enables them to thrive in society To achieve adequately in education A stable home

6 The Study of Adolescents in London The role of placement stability Attachment & functioning of late placed, older children, maltreated in their birth families 51 fostered young people aged (mean 13) & 50 comparisons from similar inner-city area Matched on age, gender, parental occupation, family income At least 6 months in placement

7 Teacher SDQ scores for sample and National Fostered Children figures Emotional Conduct Hyperactivity Peer problems Not Looked after Current sample-fostered ONS Looked after

8 Foster children are less secure (N=101 in placement >6 months) 70% 60% 50% 40% 44% 60% Fostered Control 30% 20% 10% 0% 0% Father χ2 (1)= 15.65, p< % Mother χ2 (1)= 28.01, p<.001

9 But foster children show more security to their current carers (N=51) 60% 50% 40% 51% 47% Birth Parent Foster Carer 30% 20% 10% 0% 0% Father 10% Mother

10 Neglect & maltreatment: Bio-psycho-social impact Emerging neuroscience demonstrates that early maltreatment increases risks for neurodevelopmental problems But the science is much more complex than some pictures of damaged brains might imply Involves more domains, in complex ways Biology responds to adversity with diversity Interventions for fostered children should be sensitive to the science and the bio-psychosocial implications of maltreatment

11 Maltreatment impacts upon many levels (Woolgar 2013) Biological Psychological Behavioural Brain Physi ology Genes Immun ology Cognition Memory Attach ment Motiv ation Aggression Crying Avoiding Prosocial Environment Maltreatment, Neglect, Care, Parenting, Peers

12 Fostering Changes Programme Addresses factors that threaten placement stability Based on social learning theory, attachment theory and sensitive to emerging neuroscience

13 Fostering Changes Programme Based on Social Learning Theory Principles Facilitators model how they want carers to treat their young people Strengths focused, nurturing and validating Practical skills taught then tried out at home Institute of Psychiatry at The Maudsley

14 What it looks like Home visit before course 12 sessions, 3 hours long Refreshments provided Have to have child in placement New and experienced carers welcome

15 Home practice vital component Maximum 12 carers Minimum 2 facilitators

16 If I had this training many years ago some of the placements I had, I would have kept them. Rather than saying I can t be bothered, I would have worked with it. Since doing this course, any place I get they are staying with me. Alice I was on a downward spiral. The course has reinforced praise and I to continue to praise. I have learnt that you get so much more out of children if you don t constantly question them. Claire

17 Participants in the RCT 67 Registered Foster Carers looking after a total of 94 foster children aged between 2 and 12 years (and 113 foster children of all ages). 37 Carers were randomly allocated to the intervention group,30 Carers to the control group

18 Characteristics of the children Age 2 to 12 years (average 8 years) Length of time in placement: 1 month to 8 years (average 2 years) Number of previous placements: 0 to 12 (87% had experienced 2 or fewer placements) No differences between treatment and control groups

19 Evaluation Interview and questionnaire measures of change in foster carers sense of competence and coping skills, relationships, and changes in child s challenging behaviour Assessments carried out at the time of recruitment and at 3 months follow-up for both the intervention and control groups

20 Carer Defined Problems Scale Example of pre- and post- assessment item: Please rate the severity of the problem you have with your child that you would most like help with. Concern...Can t control emotions... Not a Couldn t be Problem / worse Make a mark on the line to indicate how bad you think the problem is.

21 Main problems reported Disobedience 28% Social Communication Difficulties 7% Emotional Problems 11% Anger/Aggression 14% Eating Problems 8% Attention Problems 4% Enuresis / Ecopresis 7% Other 21%

22 Impact of Programme on Carer Defined problems (p=.003, es 1.0) Before After No training Training

23 Quality Attachment Relationships Questionnaire (QUARQ) Ability to use carer as a secure base: Seeking help under stressful conditions Seeking proximity to carer Talking about things that bother them Trust / allowing carer to look after them Expressing appreciation/accepting praise Ability to show/accept affection

24 Impact of Programme on Attachment Relationship (p=.04, es 0.4) No Training 48 Before After Training

25 Carer Confidence (Efficacy) Carers belief in their own ability to make positive changes in the lives of their foster children Examples: I know what I should do to ensure my child behaves I can make an important difference to my child

26 Carer Confidence (Efficacy)(p=.01, es 0.7) 28, , ,5 26 No Training 25,5 Before After Training

27 Other changes SDQ Total Problems (p= 0.027, es 0.30, mostly from conduct problems and hyperactivity reduction) Carer Coping strategies (use of praise, limit setting etc; p= 0.02, es =.5) Carer Efficacy (confidence in knowing what to do, being able to do it etc; p= 0.01, es =.7) Alabama Parenting Questionnaire: No Change

28 Feedback from Carers How do you think the course has impacted on how you feel as a carer? More confident, more aware of difficult behaviour and how to deal with it It has improved my skills and taught me new ones, and made me feel less stressed and more able to cope It has made me feel as a carer that I am professional and our job is highly regarded

29 Dissemination During DCSF funded roll-out a minimum of 2 people were trained in 107 Local Authorities Facilitators courses are now taking place 3 times a year, attended by workers from LA s and Independent Fostering Providers Whole organisations are now being trained Austria New Zealand Wales

30 The NGO Pro mente: kinder jugend familie (short form: pmkijufa) is a mid-size community based NGO working in the field of Youth welfare system as well as in the mental health system It is located in Austria (Carinthia) 2011 delivered Facilitator Course 30

31 New Zealand November 2013 delivered 5 day Facilitators Course Staff from combination of different CAMHS and Fostering agencies from both North and South Island Plans to start delivering first courses in early 2014 First targeted group programme for foster carers in New Zealand

32 Wales Won a bid in competition with other large RCT supported EBTs to implement the FC programme to whole of Wales [plus additional groups for children & facilitated post training support] FCTC will train facilitators in local Voluntary Organisations who will deliver locally Independent RCT evaluation over 5 years

33 Future developments Translation into Japanese for use in group care homes Whole organisation training - TACT Modification for adoptive carers: Adopting Changes piloted with Voluntary agency