MENTAL HEALTH OR GOOD SUPPORT?  by Cas O’Neill[i]

Cas O'Neill is a special needs adoptive parent and support foster carer. She has a PhD in Social Work, is a Research Fellow at the University of Melbourne, works on research projects in the areas of child welfare and health and is currently involved in the early stages of setting up a Centre for Post Placement Support in Melbourne.
 

Abstract
This paper will look at how mental health and support go hand in hand and what professionals can do to assist young people in care and their (biological and permanent) families. The presentation will include: -

Research findings on the numbers of children with alternative care experiences presenting at a Melbourne Child and Adolescent mental health Service over a two year period; Findings from her longitudinal PhD research project on the varied experiences of parents whose children are no longer living with them; young people in care; and permanent parents. Personal reflections on the support needs of all those connected with alternative care for children.

Cas O'Neill is a special needs adoptive parent and support foster carer. She has a PhD in Social Work, is a Research Fellow at the University of Melbourne, works on research projects in the areas of child welfare and health and is currently involved in the early stages of setting up a Centre for Post Placement Support in Melbourne.

Mental Health … needs Good Support

Cas O’Neill[ii]

This paper will present the findings of:-

·       Epidemiological research undertaken at Melbourne’s Alfred Child and Adolescent Mental Health Service on the numbers of children presenting from non-biological care (adoption, foster care, permanent care, kinship care) backgrounds (O’Neill, 1999a);

·       Longitudinal research on the support needs of biological parents,[iii] children and permanent parents in situations where the children have been removed from their original families by the child protection system (O’Neill, 1999b). 

The paper argues that, while all those involved in non-biological care (children and both sets of parents) may well need specialised intervention by mental health professionals at times, therapy with this group of families is often relatively informal and needs to be coupled with good everyday support.

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Adoption, permanent care[iv] and foster care are all systems of care which have experienced marked change in the 1980s and 1990s. They are also cost effective options for the community, which for some time has been placing some of the most emotionally damaged children in the child welfare system with private families.

The children who are most often placed in adoptive and permanent care families are those with “special needs”[v]. As a group, they are likely to have had a large number of moves between caregivers and less overall experience of a consistent family environment.

The community belief that a good loving family will necessarily be able to repair a child’s profound emotional disturbance is not congruent with the experience of many families and agency professionals. This group of children is more at risk of having a range of difficulties in the areas of identity and attachment - that is, the areas which are likely to be most central to new parents (Drury-Hudson, 1994; Howe, 1995 and 1998; Rushton and Mayes, 1997).

Research shows that children who are not being raised by their biological families have higher rates of suicide, referrals to mental health services, crime and substance abuse than other children (Hjern, Lindblad and Vinnerljung, 2002; Howe, 1998; O’Neill and Absler, 1998), although there is some evidence that adopted children in the United States may show more positive behaviours in some areas than their non-adopted siblings (Sharma, McGue and Benson, 1998).

Not all parents who care for children from disrupted backgrounds are going to need the children to provide them with the level of intimacy or primary attachment identification which they would expect with their own biological children. However, some will and the potential for a misfit between a child’s capacities and a parent’s needs is more apparent than it has been in the past (O’Neill, 1994; Rushton, Quinton and Treseder, 1993).[vi]

The provision of long term support (until the children reach independence) to families is variable and characterised by situations where:-

·            Foster parents generally receive more long-term support than adoptive or permanent care parents, due to funding provisions;[vii]

·            City families have greater access to support than those living in the country; and

·            Wealthier families, who are able to pay for private services, receive more support than those on lower incomes.

Research undertaken at Alfred Child and Adolescent Mental Health Service (CAMHS)

This research aimed to establish whether children who had experienced non-biological care in Melbourne presented to Alfred CAMHS in higher numbers than would be expected, given their prevalence in the population and, if so, whether their diagnostic profile was more serious than a matched (by age and gender) control group at the same CAMHS. An audit of all new case registrations over a two year period, 1.7.1991-30.6.1993 elicited information on 604 children. The proportions of those in non-biological care at the time of intake were then compared with the 1991 Australian Census and Victorian Department of Human Services data (for the Alfred CAMHS region of Victoria), giving rise to the finding that children in non-biological care are indeed referred to this CAMHS in far greater numbers than would be expected.

TABLE I - CHILDREN IN CARE - 4-18 YEARS (VICTORIA AND SOUTHERN REGION)

Alfred CAMHS’s New Case Registrations, 1.7.1991 - 30.6.1993

The Alfred CAMHS figures cover 604 new case registrations in the period, 1.7.1991 - 30.6.1993. Of these:-

·       70 (11.6%) had experience of foster care, including kinship foster care;

·       11 (1.8%) had experience of adoption (2 of intercountry adoption);

·       10 (1.7%) had experience of permanent care;

·       74 (12.3%) had experience of other categories of care, such as family group home care. However, as there were no comparable state figures available on children in residential care, it was not possible to look at how representative this group of children is.

In total, 103 children of the 604 new registrations (17.0%) had experienced one or more kinds of care at the time the therapists compiled this information.[viii]

As these two year audit figures contained information about children’s care status at any time in their lives (period prevalence), they could not be compared with the ABS statistics or the DHS one day census of children in alternative care (point prevalence).[ix] The Alfred CAMHS figures were therefore re-analysed to look at the child’s care status at the time of intake into the service. Of the 103 children who had experienced alternative care at some stage in their lives, 56 (54.4%) were in non-biological care at the time of intake, as follows:-

·       19 children, or 3.1%, were in foster care;

·       11 children, or 1.8%, were in the care of adoptive parents;

·       22 children, or 3.6%, were in residential care - 12 in family group homes, 10 in other categories (e.g. homeless unit, correctional unit, adolescent unit);

·       4 children, or 0.7%, were in the care of relatives - “kith and kin” placements;

·       0 children were in permanent care.

Summary of Registration Proportions

1.    Foster Care - 0.08% of the children in Southern region, 4 - 18 years, were in foster care on 30.6.94, yet 3.1% of Alfred CAMHS’s new case registrations, 1.7.1991-30.6.1993, were in foster care at the time of intake.[x]

2.    Kinship Care - 0.06% of the children in Southern region, 4 - 18 years, were in kinship care on 30.6.94, yet 0.7% of Alfred CAMHS’S total new case registrations, 1.7.91-30.6.93, were in kinship care at the time of intake.

3.    Adoption - 0.65% of the children in Southern region, 4-18 years, were estimated to be in adoptive families on 30.6.1991, yet 1.8% of Alfred CAMHS’s total new case registrations, 1.7.91-30.6.93, were in adoptive families at the time of intake.

4.    Permanent Care - although 1.7% of Alfred CAMHS’s registrations, 1.7.91-30.6.93, had experienced permanent care at some time in their lives,[xi] none of these 10 children were in permanent care at the time of intake and the figures cannot be compared to the 0.008% of children, 4-18 years, in southern region, who were in Permanent Care placements on 30.6.94.

During the period 1.7.1991 - 30.6.1993, adopted children were referred to Alfred CAMHS 2.8 times more than would be expected; children in foster care were referred 38.8 times more than would be expected, and children in kinship care were referred 11.7 times more than would be expected, given their prevalence in the population.[xii]

This study therefore supports the findings of other research that children in non-biological care situations are referred to child mental health facilities in greater numbers than would be expected, given their numbers in the community.[xiii] The analysis of Achenbach scores (below) also shows that the children are perceived to have greater problems and less competencies by their parents/caregivers than a control group of children living in their biological families.

TABLE II - ACHENBACH PROBLEM SCORES

TABLE III - ACHENBACH COMPETENCY SCORES

TABLE IV - SUMMARY OF DIFFERENCES BETWEEN GROUPS

An analysis undertaken of the diagnoses in the two groups of children has not been  presented here as the numbers in each category were too small to make reliable inferences. However, the use of diagnostic categories as the sole indicator of the mental health professional’s perception of the seriousness of a child’s disturbance is problematic for two reasons.

Firstly, diagnostic categories such as depression, anxiety and behavioural disorders are very broad, covering a spectrum from mild to severe difficulties. Thus, although the children in the non-biological care group may have the same statistical incidence of diagnostic profiles as the children living with biological families, clinical experience suggests that the level of severity of their difficulties may be more extreme. This hypothesis is supported by the marked difference between the two groups in the percentage scores  of >70 for the Problem Scores (Table II) and <30 for the Competency Scores (Table III).

A second factor which needs to be considered is whether the diagnostic category selected by the professionals does accurately reflect the level of disturbance of the children they are treating.[xiv] Professionals in child and adolescent mental health settings are frequently reluctant to attach serious psychiatric diagnoses to children, particularly young children.[xv] While this might clearly be a factor for both these groups of children, clinical experience suggests that children in non-biological care are more troubled than their peers and that this reluctance may therefore be more likely to occur with this group of children. In addition, mental health professionals may be wary about labelling children in foster care or residential care with a serious diagnosis, for fear that this will alienate potential permanent parents.

Issues which arise from these findings

Broader issues which need to be considered vis a vis referrals to mental health services must include not only the perceived mental health status of the child, but also the context in which the child exists. For example:-

·       Do the figures reported above indicate under-representation or over-representation? Should more, or even all, children in this group be referred to a child and adolescent mental health service? Are there enough resources to achieve this?

·        Should there be more training and consultative services provided to professionals in the child welfare field to ensure that children in need of mental health services are routinely referred for them?

·       At what point in the child’s life does the referral to a child and adolescent mental health service occur? Is it prior to, during, or after his/her separation experience?

·       Who is responsible for the referral to the mental health service? Who notices and identifies the child’s distress?

·       For children who have experienced difficulties for many years, why is the child being referred now? What has occurred in this child’s environment to trigger the referral? Who is unsettled by his/her behaviour?

Looking at the adoption end of the placement continuum, Warren (1992) found that adoptees were more likely to be referred for help, even when they displayed relatively few problems, compared to a group of non-adoptees. She hypothesises that this may be because:-

·       Parents see their adopted children as being potentially at risk for mental health problems;

·       Mental health problems in an adoptee may be experienced as somehow more disruptive to family identity than would similar problems in a biological child; or

·       Adoptive families may be more attuned to family welfare resources than other families.

At the other end of the continuum, children who are disruptive and/or have attachment difficulties in short term non-biological care are commonly referred for a mental health assessment or for psychotherapy by workers in the protective care system. This may be driven by a range of factors including the pressure experienced by protective workers for the “expert opinion”, which may assist decision making in a potentially adversarial case planning or court process.

In child and adolescent mental health services, the “gate keeping” system which controls entry is administratively different for children living in biological families and stable long term non-biological placements, who enter through the general intake system, than for children under the direct responsibility of state welfare services (O’Neill and Absler, 1999).

The referral of a child living with his or her biological or permanent family tends to be seen as more straightforward because it is a clinical service only which is being requested. In contrast, children in short term care bring with them complex and painful issues relating to future living arrangements.

Underlying this “gatekeeping” process is the sometimes uncomfortable boundary between the child welfare and mental health systems (Luntz, 1994 and 1995; Sheehan, 1997) and the associated issues of who the “expert” is and who takes responsibility for these children (Hatfield, Harrington and Mohamad, 1996).

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Mental health treatment delivered in a clinical setting is only one of a range of possible services for troubled children and their families. Families who are referred to child and adolescent mental health services, as well as those who are never referred, are likely to also benefit from different kinds of support (O’Neill, 1999b and 2003). In fact, support to care givers is consistently raised as essential for positive outcomes (Hatfield et al, 1996; Minnis and Del Priore, 2001). Support to teachers (O’Neill, 1999c) and other community professionals, group work and increased involvement in community activities all have important therapeutic functions for children (and their families) with difficulties.

Longitudinal Research on Support

From 1993 - 1999, I undertook a longitudinal, action-oriented study for my PhD, in which multiple perspectives on the meaning of support (and non-support), for those involved in permanent placements of children, were explored.

The research sought to explore the support needs, over a period of three years, of:-

·       Children who had been removed from their biological parents by the protective system and who were placed in permanent families through the foster care or adoption/permanent care systems;

·       Their biological and permanent families; and

·       The social workers, teachers and therapists who worked with the children and their families.

Therapy and non-biological care

I talked with seven therapists over a period of three years about their work with birth parents, children and permanent parents. A brief summary is given here of some of the findings relating to these discussions.

The less formal therapists tended to describe therapy not so much as an activity with definite rules, but more as a relationship which was responsive to particular situations.

‘There’s that absolute total need to have a friend who’ll be on her (birth mother) side. And that’s possibly where people like myself come in. So she equates me with a friend who doesn’t demand anything from her in terms of give me a meal or whatever. And I just have to go along with what she’s ready to give me’ (therapist).

‘Sometimes she (birth mother) comes here and says “I’ve just come in today so you can fill in some forms for me, because I can’t write them”. So we sit there for hours doing these forms. So I think what I’ve become is someone out there that she’s known for a long time, says she feels comfortable with - I believe to a certain extent she does, but there’s still always that certain extent that she doesn’t. And she uses me in that sort of way - and I don’t know (if) that is the same sort of support that anyone would give anyone in that situation’ (therapist).

‘What I do is I offer support until the kid can see them (agency based therapists) and with a couple of kids they’ve said “we don’t want to work with the (agency) workers” and I’ve taken that up. But it’s not something I like to do, because again, it’s that level of support and with those clients I’ve got a different relationship, like I give them a home number and it’s a 24 hour deal then, which I’m probably not supposed to do’ (school-based therapist).

Therapists face many challenges in their work with these families. One of these is the children’s very controlling behaviours.

‘V. (child) has such fantasies now of being so powerful - at 12, going into adolescence, that’s a pretty dangerous position for a young woman’ (therapist).

‘On these trips, she’s also tried some of that (allegations of abuse) - she’s aware of how powerful it can be. I imagine that she’s also aware of the line that’s there, the invisible line (that) if she acts out too much she could get rejected …as soon as you get an outside agency involved, you (therapist) lose control of that. So if Protective Services became involved, then we’ve lost complete control’ (therapist).

‘I get a sense from him that he very much feels that he’s the power broker …he also feels that he’s completely responsible for not turning their lives upside down. So it’s up to him whether this placement works or not …he doesn’t necessarily know what’s in the parents’ minds, in terms of what that critical incident (which will end the placement) is going to be or when it’s going to happen. So in that way he keeps testing, but he’s not necessarily sure how firm that boundary is’ (therapist).

Another challenge for therapists in this field is working with children whose living arrangements are unstable.

‘L. (therapist) is unsure whether she is working long-term with M. (foster mother, later the permanent mother), the grandparents or some other family - the process is “in limbo, not knowing which parents I am actually going to be working with - I assumed that I was going to be informed”’ (summary of discussion with therapist).

‘Let’s have another review in 12 months. And I’ve seen the child that goes through year after year after year, not knowing if they’re going to be able to stay where they are the following year. I just think what a muddle’ (therapist).

Overwhelmingly, therapists talked about the need to adequately support the caregivers of these troubled children.

‘And they’re (permanent parents) usually struggling and the fact that they come means that they’re trying to do something about it, it’s not like they’re pushing it under the carpet and making out that that’s what the kids deserve. People who come here are doing it voluntarily - maybe this makes a difference, I don’t know’ (therapist).

‘A child who has been as severely abused as L. has, and with as complicated a history and family setting that he has, as well as the uncertainty that continues to mar his short life so far, anybody providing care for a child under those circumstances, I think requires considerable support’ (therapist).

A brief summary of the findings on support

This final section presents some of the findings on support which arose from my research.

While practical support - financial support, respite, training and information - was undoubtedly very important to the participants of this research, emotional support was even more important - feeling heard, being believed and being kept in mind.

‘I feel that she (social worker) and I work the same way … she listens to me, reassures me and makes suggestions in a low-key way - e.g. she will say “this other family I know, they tackled it this way”’ (permanent mother).

‘Support means feeling cared for, being listened to, being able to have a bit of a grumble without being criticised’ (permanent mother).

‘From day one we had continual support - not one of them (social workers) has failed to do what they said they would do’ (birth grandfather).

In exploring how people experience support, the intrinsic connections between emotional and practical support, in particular, are inescapable. Receiving practical support is usually experienced as emotionally supportive, while receiving emotional support is likely to have practical benefits. Thus, while it may be useful to make distinctions between kinds of support, it needs to be recognised that these can be misleading.

The literature and research[xvi] give us clear guidelines on what the experience of support, from a receiver’s point of view, is based on:-

·         The overall importance of relationship, a sense of partnership and reciprocity;

·         Affirmation, acknowledgement and empathy;

·         Open communication, feeling listened to and believed; and

·         Commitment, responsiveness, reliability and a sense of ‘being there’.

In contrast, non-support, from a receiver’s point of view, is characterised by situations in which there is:

·         Lack of control and lack of information;

·         Lack of open communication, lack of honesty and experience of deception;

·         Judgemental attitudes and expectations;

·         Isolation and rejection; and

·         Feelings of anxiety and fear.

Although there were differences between birth parents, birth grandparents and permanent parents in the kinds of support they wanted and/or received, in general they valued both professional support and peer support (as well as the support of their families and friends). While peer support was valued for the importance of shared stories and the empowering nature of experiential knowledge, professional support was seen as particularly helpful when it was offered by someone who had the characteristics of a ‘professional friend’.

‘Professional friends’, who combined the warmth of a friend with the knowledge and authority of a professional, were experienced professionals who had few qualms about crossing the boundaries between their working and private lives. Many of these professionals gave support which was well beyond what their jobs required - e.g. many gave their home phone numbers to permanent parents to use in case of emergency and some of the teachers tutored, or minded, the children in the school holidays. Their years of experience allowed them to cross the public-private boundary in a way which was appropriate and which did not seem to impose any burden of obligation on those they were supporting in this way.

Conclusion

Mental health assessment and treatment is undoubtedly an important part of what needs to be offered to children and parents involved in non-biological placements. However, mental health treatment should be seen as only one part of a broad continuum of support, both emotional and practical, which should be an intrinsic part of what is routinely offered to birth families and permanent families who are involved in non-biological care.

Cas O’Neill

email: cmoneill@bigpond.com