Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Monday, February 10, 2014

Foster Care, Institutions, and International Adoption: Re-focusing on Developmentally Appropriate Practice

Eton, Harrow, Marlborough, Roedean; Lawrenceville, Andover, Hill, Hotchkiss, Miss Porter’s, Sacred Heart…  these are all boarding schools, institutions if you will, to which affluent British and American parents have been sending their children for over a hundred and fifty years now, for the purposes of education and socialization into the culture of their class. Some people have had horrible experiences there (cf. George Orwell), but great national leaders have also emerged from such schools (cf. FDR and Winston Churchill).

Can knowing these facts help us decide whether all institutions that do congregate care for children of any age are either acceptable or unacceptable? I’m afraid not, because not only are such   institutions different from each other, children of different ages and different backgrounds are also different in their needs and abilities.

However, the facts about the great independent schools do tell us that it is quite possible for an institution’s care to create excellent outcomes for some children. Similarly, Richard McKenzie’s recent piece, “Foster Care versus Modern Orphanages” (http://www.ncpa.org/pub/ib136) tells us about the successes of the Crossnore School in North Carolina--  an institution whose graduates have done well in spite of challenges rarely known to the students of Harrow or Hotchkiss.

Of course, none of this tells us that institutional care, even for adolescents, is uniformly good. To be aware of this, we need only look at the track record of the World Wide Association of Specialty Programs and Schools, quite a number of whose members have been charged with serious maltreatment of children in their care. Or we might have a glance at the Miracle Meadows School in West Virginia (www.miraclemeadows.org), where on line complaints suggest that at least some outcomes have been less than successful, in spite of--  or perhaps because of--  the school’s claim to have a policy not to expel any child, perhaps meaning that the school will act as a private prison at parents’ wishes until the child ages out. A document describing a state investigation of events at the school mentions isolation of a child in a small space and beating of another child with a board (www.caselaw.findlaw.com/wv-supreme-court-of-appeals/1042637.html). Parents who had sent children to the school evidently did not want an investigation to proceed. (Incidentally, I know of my own knowledge of a Russian girl who was placed at this school as an investigation into abuse by her adoptive parents in another state was about to begin--  this being her second set of adopters, the first having decided that they did not like her and that she was not being changed by holding therapy. I see on the school website the presence of other Russian and of Ethiopian children, who were presumably adopted, or at least I can’t picture Russian and Ethiopian parents planning their children’s education in West Virginia.)

Similar stories of excellent and of abysmal conditions and outcomes can easily be told for both foster families and international adoptions. Institutions, foster care, and adoption are equal in their capacities to facilitate or to discourage good development. The care method is not the important thing; the details of how children are treated are the essential factors, and those details have not been transparently reported in materials published about the Bucharest Early Intervention Project (BEIP), the “scientific foundation” for many current claims about care for parentless children. Neither are they made very clear in the epidemiological study by Kathryn Whetten and her colleagues, published in 2009, and concluding that health and well-being of children aged 6 to 12 are not negatively affected by institutional living (www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008169). Whetten noted the need for clarity about these details, pointing out the need to “understand which characteristics of care promote child wellbeing”, and adding, “Such characteristics may transcend the structural definitions of institutions or family homes.”

What details of care should we look for in studies about care of parentless children? Beyond simple issues like appropriate food and medical care, this depends on the ages of the children being considered.  And, I should point out, this fact makes “apples and oranges” of any attempt to set the BEIP study in direct contradiction to the Whetten report. The BEIP study dealt with an intervention that began when the children were toddlers; Whetten’s work focused on children who were already “school age” when studied.
Much is already known about the different developmental needs of children at different ages. Designing environments that satisfy these needs and foster good development is known as developmentally appropriate practice (DAP). DAP concepts have been used primarily in discussion of children in early childhood (including infancy and the toddler period), and they focus on the importance for good development of having a small number of sensitive, responsive adults  as caregivers for a small group of children, with consistent rules and practices guiding children’s social development, and a stable but interesting physical environment. Although caregivers often resist this idea, it has been suggested many times that caregivers should remain with their group of children as they move “up” to more advanced classrooms and activities (this is actually practiced, I believe, in the Waldorf Schools).

Although less has been said about this point, “school age” children also have their DAP concerns, and different ones than were the case in early childhood. Familiar caregivers are preferred, but by this age children much more easily engage with new adults who are friendly and interesting. These children still benefit from the presence of familiar people at bedtime or when sick or frightened, but they can explore new activities and people without needing the frequent “emotional refueling” of their younger days. They are strongly interested and involved in their peers and benefit from having a stable group of friends. This is a period of learning to negotiate and compromise with others and of developing skills in making social and moral decisions in a safe environment where helpful adults can buffer the effects of mistakes. Schooling and learning some adult-like tasks are another focus during this age period.

DAP with adolescents is somewhat different, as teenagers are in the process of moving toward adult status. They still appreciate and benefit from adults who respond warmly and helpfully when they are sought, but they need to be working toward independent judgment and decision-making. The advent of sexuality and increased aggressive impulses means that help is needed with insight into emotions as well as with self-control. Adolescents are also preparing for adult lives in the sense of working toward further education and refining their ability to do adult tasks, in anticipation of independent living.

Care for parentless children thus needs to be different for each of these age groups, and it also needs to be fine-tuned with respect to the child’s age when entering the care placement.  Good outcomes cannot result from “warehousing” at any of these stages, and it’s possible to see how either a good job or a poor one could be done at any stage by an institution, a foster home, or adoption. 
  
As Richard McKenzie pointed out, a “full menu” of care options for parentless children is needed world-wide. Glorification of a single option probably has real political benefits for those who do this, but it entirely avoids consideration of the real needs of orphaned and abandoned children. We need to re-focus on a variety of needs and a variety of developmentally appropriate solutions.


10 comments:

  1. Another very helpful column! Something that I have experienced with adolescents who are not "permanently placed" (using DCF lingo) is that their drive to find their personal/intimate place in the world---i.e., in a relationship or in a family-like setting---can become their only driving interest. While their "placed" peers are also invested in their relationships, especially romantic/sexual ones that provide a new source of intimacy and support outside their family, most have some time and energy left over for thinking about school, sports, arts, future career possibilities, the world around them. The adolescent who is still in need of a place to call home may not be able to focus on anything else. Thus, the high rate of pregnancy in young women who "age out" of the foster care system without landing in an adoptive home, but with no birth family home that they can return to with any stability. While the tasks of establishing one's own family, one's own home are considered---at least in current U.S. mainstream culture---tasks of the post-secondary, post-college young adult, usually in their mid to late 20s, for youth who cannot rely on a family (birth, foster, adoptive) to provide that sense of belonging and security necessary to make their way through whatever is to be their final state of education and their first "real" jobs, their family-making urge may strike when they are 14, 15, 16---sexually ready, but without the tools that will allow them to succeed as parents and as young adults. I agree that: "DAP with adolescents is somewhat different, as teenagers are in the process of moving toward adult status. They still appreciate and benefit from adults who respond warmly and helpfully when they are sought, but they need to be working toward independent judgment and decision-making. The advent of sexuality and increased aggressive impulses means that help is needed with insight into emotions as well as with self-control. Adolescents are also preparing for adult lives in the sense of working toward further education and refining their ability to do adult tasks, in anticipation of independent living." But I wonder if the prioritization of making/finding a family often drowns out the urges to attend to the other developmentally appropriate tasks. Does independence rank very high in allure when you feel alone, lonely, and/or orphaned and abandoned? I have come to respect those youths who try, in non-mainstream ways, to correct the lonelinesses visited upon them by their birth families and the foster care system at large, which does well, mostly, by the children they can adopt out into permanent families, but which offers very little in the sense of ongoing community, support, and intimacy to those who don't fit the pre-adoptive/adoptive route well. I worry about them: creating families in their mid-teens and hoping that they'll stick. But I admire their courage in seeking what they need. We could do better by them, if only in recognizing that their path is a valid one for those who have had such an extraordinary and oftentimes bereft childhood. How can we help in better ways? Surely, setting a mother-child dyad adrift on welfare, with all the transience and poor housing/community/educational options usually associated, is not the right choice of assistance. What do we do to help?

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    1. Your points are very well taken, and it may well be that when teenagers have family support, the family can buffer the difficulties of coming to terms with sexuality, aggressive impulses, and all the other baggage of adolescence-- but can any other social setting do the same thing? I was commenting on this because of the recent push on the idea that group life is never appropriate for minors of any age, but that some form of foster care is always best. Could it be that actually some form of group living could be most helpful for support in the developmental tasks of adolescence? I would think it might be-- but on the other hand, if the teenager is convinced that the impossible "real family" is the only way to go, he or she may reject even the best group home as well. It's a sad puzzle, especially in terms of the example you suggest of girls "making families" through pregnancy.

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  2. Hmmm ... Well, in reality, at least as configured now in the U.S., group homes tend to have revolving doors---with teenagers coming and going, along with the staff, at fairly high rates. I think that's because the group home is considered the last ditch attempt to socialize kids who have had tremendous struggles in foster homes.

    So, if it were a first choice placement, the population coming in might be a bit different (i.e., a bit more "intact"), which might tend to more stability for everyone. But there would still need to be measures taken to reduce the losses associated with movement for the teens between group home, acute hospital, residential treatment center, lock-up, specialized foster care, runaway/on-the-street locations, etc.

    Boarding schools work very well for a different population of teens, and there's perhaps no intrinsic reason that a boarding school-like group home (with stability, resources, and status) couldn't also provide good support for the developmental and emotional tasks of adolescents in foster care.

    But, who holds the pieces together when things fall apart---as they will, as they do, for most adolescents, any number of times? The nature of the business (and it is a business, not a relationship, first) is that when an adolescent moves on, say, for a short period of time to a lock-up facility, or for a longer period of time, to a residential treatment facility (for, let's say, an addiction-related crime, or an upswing in self-harm---neither particularly rare in the foster care population: remember, these are all children who have suffered severe enough forms of abuse and neglect to be removed from their families; not just one or two instances, or even a dozen, but repeated, sometimes innumerable) that teen's "bed" is empty, not producing any income for the home, and gets turned over to another teen.

    So, when things fall apart, a teen in a group home as configured now must move on---and loses *all* her connections in most cases, including local friends and school folks, unless there just happens to be an opening in another group home within the same school district.

    For group homes to work well, I believe that a teen would be guaranteed a "bed" in a particular group home until she was 22: and that bed would remain hers, whether she's in need of treatment/services elsewhere for a short time, or whether she runs away for a few weeks with her boyfriend du jour, or whether she goes off to college for the 13-week-long semester, etc.

    People not intimately familiar with the foster care system and its related placement opportunities may not understand just how terrible the transience can be for children who don't land in a stable placement: 3-4 moves per year are not unusual, and they're not rare. I doubt that anyone thinks that that kind of instability is supportive of adolescent development, correct? The whole system is rife with the "geographical cure" for kids who are suffering the kinds of struggles that anyone who was abused/neglected would likely be suffering.

    I'm not entirely sure it matters much whether an adolescent finds stability in a group home or a foster family for, say, the last 5-7 years of her life. The key is that constancy, though, I think. But maybe that's just my temperament speaking. I would wither and die being put through all those changes that "difficult" adolescents in foster care end up enduring.

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    1. Your description of what really happens in group homes is regrettably spot-on, and I would guess that whatever your temperament may be, constant re-adjustment to changes sucks out energy that should be going to serious developmental tasks. (This was true even for my own childhood experiences of staying with the same family but changing schools two or three times a year.)

      I didn't mean to argue here that any of our current possible placements for teenagers are functioning well and supporting good development. They certainly do not provide the transitional services that would do the jobs good families do, gradually buffering a movement toward genuine independence (not just isolation). I was only concerned in this post with countering claims that foster care is always good, group care never good, at every age from infancy through adolescence.

      By the way-- have you seen the documentary movie "Kids for Cash"? This is a remarkable production about the judges in Luzerne County, PA, who got kickbacks for sending kids away to private, for-profit detention centers. See it if you possibly can!

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  3. Thanks for the recommendation of "Kids for Cash." I followed the news story, but didn't know a documentary had been made. Not being screened near me, yet. But maybe it'll come nearby later in the year.

    A good friend of mine spent her teens and early 20s in a group home (hippie, alternative) in the 1980s, which she says saved her life, which I believe. What she describes is soooo unlike anything I know about on the current scene, though.

    I volunteered for several years at a congregate homeless shelter, where families each had their own (tiny) apartment within a large apartment building. The services available and the professional staff on site were tremendously helpful for families with complex, multiple needs. Of course, then, Massachusetts decided that such congregate shelters should be disbanded, and families should be integrated within the community, with mobile services and housing subsidies provided as needed.

    Now, many of the most burdened homeless families have not been successful in the community program and are living in motels, at great cost to the state, with none of the services or professional staff on site that they could benefit from.

    I loved working with the children at the congregate shelter and was very aware of how the presence of many adults in close proximity to the families was good for the parents who needed mental health support, addiction support, educational support, and medical support---and even better for the children, who might have otherwise been more at risk for neglect and abuse.

    This was essentially a group home for families, and it worked for that population of parents who could not function independently without intensive, daily, immediate support and interventions. So, I am not opposed to institutional care to help raise children.

    But there was an openness to the extended families in the congregate shelter that prevented it from being an isolated island, where abuse can flourish too easily. Grandparents came into the shelter to babysit while their children attended classes. Aunts and uncles could visit and bring their nieces and nephews out shopping. Children could go out into the community, with their parents' permission, and have playdates, participate in sports, etc., though their friends could not visit them at the shelter.

    And the families tended to stay in the shelter for up to 2 years, which created community and connections. It was that length of stay, however, and the costs associated with it, that was part of why Massachusetts moved to a "housing first" plan.

    Many of the children of these homeless families would have likely ended up in foster care without the support of the professionals working at the congregate shelter. Many of the homeless parents were themselves "graduates" of the foster care system.

    What am I trying to say? Maybe nothing other than that I believe that some consolidated/congregate living situations for children in foster care---with their intense and rare needs---may be very helpful in drawing together professionals who are needed to make success for those children possible. There would be no need to reinvent the wheel, as there is with each new foster family, to acquaint the caregivers with all the diagnostic, treatment, and service options available for common issues (PTSD, learning educational gaps, medical neglect). But how do we bring life-long (or, at least, years-long) relationships into that kind of setting, which are so crucial for adolescents? And how do we counter the emotional defenses that many teens will put up when they know that those who are "caring" for them are being paid to do so, and will stop when the money is no longer there or when they move on, professionally?

    We need good models of institutions of foster care that promote positive transitions to adulthood, and then we need to follow them, longitudinally, to see if they can be a decent alternative to the family model, which we understand pretty thoroughly, in its strengths and its weaknesses.

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    1. It does sound as if you're saying that a living situation needs to be part of a community in order to be most beneficial-- as was the case in the congregate situation for families, where there were people of many ages and statuses. I wonder to what extent this community sharing is ever the case for foster families-- when a child or teenager is placed in a foster family, can he or she then gradually move to share the community relationships that the foster parents presumably have? Would that sense of community help counterbalance the attribution of the foster parents' care to "money alone"? And what happens when it's not there-- does the foster child repeatedly experience the contempt of other people, even though the foster parents do an excellent job? The attitudes of school staff toward fostered children changing schools are certainly likely to be less than welcoming.

      There are so many complicating factors in the whole ecology of care, that I suppose it's no wonder that there have been no longitudinal studies of the kind you mention. Anyway, I do think it's important than when we make decisions that are not based on systematic evidence (as it seems we must), that we transparently give the reasons for the decisions, and not pretend that there is "science" behind them.

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  4. Longevity of placement in a foster home, in my experience, has everything to do with how well a foster child/teen shares in the community relationships of the foster family: friends and family, the neighborhood, the school, medical/dental professionals, coaches, shopkeepers---the whole panoply.

    With my foster children (who I've adopted or are in the pre-adoptive phase with us), 2 years seems to be the length of time it takes for solid integration into the fullness of our family---including extended relationships, which are incredibly important for any child and perhaps more so for children who have experienced neglect, abuse, abandonment, multiple transitions. But, at least in the state I live in, there are record high numbers of moves for children in foster care, and for many foster children, their sense of community is lodged in Facebook, if they're old enough to access it, in cell phone contact, and in the social/virtual "families" that they can inhabit with some longevity even as their real/material families cycle at a dizzying pace. It can create some bizarre psychological mindsets, as you can imagine.

    So, if I were designing a system that works? I'd want one that looks a bit like a university campus for children---with on-site foster families, on-site pediatric medical/dental/psychiatric/psychological offices, on-site acute pediatric hospitals, on-site residential treatment facilities for children, even on-site juvenile lock-up or detention facilities, all of which (except the foster families) would be open to children of the surrounding community who need those services. There would be fluidity between those "placements," so that ruptures of relationships would not have to occur if a child needs a higher level of care for a period of months, or was ready to be "stepped down."

    The most glaring omission is a school---so it would be an odd "campus." But integration into mainstream schools would be ideal, in my eyes: "separate but equal" schools don't work---our history shows us that. And regular schools are full of regular peers, and those role models are crucial in bringing the most severely abused/neglected children in out of the cold, so to speak. While I don't agree with everything in "The Nurture Assumption," much about the importance of peer relationships made good sense to me. And one of the most difficult traits of the current foster care system (whether in foster families or in institutions) is the speed with which foster children lose their peer relationships; it's horrendous, really. So, these Foster Care Universities would be built in settings where excellent schools already existed, with teachers and staff experienced at working with children who have suffered trauma and show it in their school lives and academic achievement.

    This is crazy talk, I know, and even in a Scandinavian country that might be child welfare--minded enough to construct such campuses, there would be limited numbers of them possible across the breadth of the nation due to the concentration of services/professionals clustered together, as I'm suggesting. So, children in need of surrogate care would likely be moved quite far from their home communities: often, honestly, not a bad thing for those children/teens willing to do some cross-cultural learning, but disorienting and fragmenting of the self for many others.

    So, there: that's my two cents, spread out over several late nights, pondering the system that is so exasperating in my life and the lives of my foster/adopted children---as well as the ones who got away, through no fault of anyone's, except a system who couldn't keep us together safely.

    Not addressing some of the your points, for sure. But you always give me lots to think about, in my own niche of concerns. Thank you.

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    1. Thanks so much for your thoughts about this and for giving the benefit of your experience and long concern with these issues. The idea of using the regular school rather than a "segregated" school is an interesting one-- if good training is done-- otherwise, I can see attitudes at a school simply pushing children back into the restricted community and away from full community membership.

      I'm really happy to see your stress on peer relationships. Someone recently pointed out to me a book bu one Gordon Neufeld who feels that all the stress should be on relationships with adult caregivers, which I think completely ignores some of the important developmental tasks of later childhood and adolescence.

      I think your 2 year period is really an accurate assessment. That's what it takes for families to settle in after a divorce.

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  5. Thanks, Jean. My experience is limited to, well, my own experience, but I've found schools (including teachers and other students) to be very welcoming of children in foster care, although some parents have been a bit concerned about the "contagion" of issues that foster children may exhibit. Interestingly, some school staff have been suspicious of me as a foster parent, buying (I suppose) the myth of foster parents doing it for the money. As if!

    You do a wonderful job of exposing common "wisdom" and misconceptions about children and their development with this blog and your published work---thank you, thank you, thank you.

    I couldn't help but think of you and your work when I read about the recent death of an adopted Korean child, Hyunsu, allegedly at the hands of his American father of 3 months. Horrific. Foreseeable. Preventable.

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    1. Thank you!

      I hadn't even heard about Hyunsu. I will look up.

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