Family Futures multi-disciplinary neuro-sequential approach to working with traumatised children

Themes this local practice example relates to:

  • General resources
  • Adoption and Fostering

Basic details

Organisation submitting example

Family Futures Consortium

Local authority/local area:

London


The context and rationale

Our big idea was to develop a model of practice based on theory and clinical research that would address the needs of older children, placed for adoption, with attachment difficulties. This would provide a specialist service for this group of children and their families, who were an emerging population requiring therapeutic intervention. 

Attachment theory had been adapted in the USA to provide a model of intensive therapeutic intervention for older, placed children. However, there were concerns about this model, as it was intrusive and involved holding/restraining children which the founders of Family Futures felt was unethical and re-traumatising. 

The principle of using attachment therapy to help parents and children make sense of their histories and their relationship, however, seemed relevant and therapeutic. A refined attachment-based approach was developed, and the experience concurred with new research and theorising which identified a syndrome called developmental trauma disorder.

Twenty years ago Family Futures’ founders were at the forefront of finding new and innovative ways of helping families who had taken on what were then called ‘hard to place’ children - older children needing permanent families. At that time, they applied attachment theory as expounded by John Bowlby in the 1960s, as a framework for understanding why it was that children placed for adoption displayed such challenging behaviour. However, after several years it became apparent that it was the child’s early experience of trauma in infancy, and of poor parenting, which were causing the attachment difficulties in new families. Family Futures realised that supporting children and their parents to process their early experiences of trauma was needed, in order for them to be able to form new and more secure attachments. 

For a theoretical and evidence-based approach, Family Futures turned to the work of an eminent group of neuroscientists and clinicians in diverse fields. This informed the development of the neuro-sequential approach/treatment programme, which follows the structure and developmental progression of brain development and functioning. It begins with processing a child’s trauma with the child and their parents/carers. The second phase focuses on mid-brain and affective developments (this work incorporates theory and research on attachment formation and interpersonal relationships). The third phase focuses on frontal lobe activities, such as identity, reflective capacity and problem-solving.

The multi-disciplinary service addresses the negative impact of trauma on every aspect of a child’s sensory-motor, emotional and cognitive development. Developmental impact of trauma is sequential, the core of which is the brain and the central nervous system, followed by sensory motor development, then emotional and cognitive development. Hence the intervention is called 'a multi-disciplinary neuro-sequential approach to working with traumatised children'. 

Using this process, these are the interventions that are used: 

1) Trauma–focussed interventions 
a) Parent mentoring to enable foster carers and adoptive parents to provide safe, calm and informed care responses to facilitate placement stabilisation. 
b) Sensory motor integration – parent/carer and child working with paediatric occupational therapist on sensory issues that are causing dysregulation in the child. For a more psychotherapeutic approach to work, a child needs to have his/her sensory system calmed and regulated.
c) Parent/carer and child with a therapist using a dyadic developmental approach which looks at the child’s life story in forensic detail, but is conveyed and discussed in an age-appropriate way. 

2) Attachment-focussed interventions
Including parent and child attachment focussed play therapy (Theraplay) and Dan Hughes’ Dyadic Developmental Psychotherapy plus, at a systemic level, school liaison and family network support. 

3) Self-esteem building and identity work (particularly important for children who come from a different ethnic identity from their adoptive parents or foster carers). This family therapy is designed to look at roles and relationships within the family and patterns of interaction.

This entire therapeutic process is underpinned by access to specialists such as a paediatrician, psychiatrist, and psychologist. The specific formulation of the treatment programme is bespoke for each individual child based upon the assessment carried out prior to treatment.

The aims:

• Adoptive families and their children are able to access an effective, evidence-based, integrated multi-disciplinary service. 
• To reduce the degree of traumatisation in children who are adopted or fostered, to enable them to form more secure attachments to parents and carers and thus develop a positive sense of self.
• To structure the service so that it offers a tri-partite collaboration, between the child, parents and the therapy team. This is because many adoptive parents who seek help from mainstream generic service providers often feel criticised and blamed for their child’s behavioural difficulties. 

The model offers reassurance and empowerment to parents to feel that they are a solution, not part of the problem. The important aspect of this for the child is that it is his/her parents who will enable him/her to change; Family Futures professionals enable this process of positive re-parenting to take place.  

The practice

1 Establish a referral system 
For this practice, adoptive parents and their children are able to access an evidence-based multi-disciplinary service via a free consultation as a point of first contact. This is designed to inform and support parents in planning how best to meet the needs of their children. Free consultations can be requested by parents, who may have heard about Family Futures by word of mouth, the Internet, or through their social worker or from any professional. Professionals can also refer a family, or request a free consultation for themselves to discuss a possible referral. 

2 Provide an assessment of needs
The next step is to provide a comprehensive multi-disciplinary assessment of the child/children in order to ascertain any areas of need for therapeutic intervention from a range of providers. There are three elements to the assessment process: 
i) Gathering historical information about the child, and self-reports from the child and his/her parents about current behaviours. 
ii) To score questionnaires designed to screen for emotional and behavioural problems, sensory motor difficulties and traumatisation. 
iii) Direct observation and interaction with children, and with children and their parents. 

3 Provide a therapy package with built-in ongoing collaborative evaluation from children, parents, allied professionals and the Family Futures team
This Family Futures practice offers a bespoke, intensive long-term therapeutic package of interventions that ‘wrap around’ the child and the family systemically. The interventions used have been evolved to follow the neuro-sequential process. 


Those involved
From the outset, adoptive parents have been a driving force in the formation of, and in the workforce of, Family Futures. 

The clinical team is made up of social workers, psychologists, child and adult psychotherapists, paediatric occupational therapists, and teachers. Also employed are a consultant child psychiatrist and a paediatrician, and access is available to a nutritionist and a pathology lab that can analyse nutrients and adrenal system functioning. 

The neuro-sequential approach is agreed, planned and monitored through the multi-disciplinary forum of Family Futures’ team supervision and case review process. Parents and children are active participants and contributors to the planning and reviewing of all treatment programmes which are contractual.

Family Futures participate in a national forum for voluntary Adoption Agencies (CVAA) by contributing to their membership meetings. 

Family Futures is currently actively commissioned by 60 local authorities (LAs) and Primary Care Trusts (PCTs) to offer assessment and treatment. Over the lifespan of Family Futures, the organisation has worked with over 500 children in the treatment programme and many more that have been assessed. 

Families Futures currently has a close collaboration, via a Service Level Agreement, with Norfolk and Suffolk LAs to provide consultation to their adoption teams. 

After an initial free consultation with parents and/or social workers, the LA or PCT may then commission an assessment. Sometimes LAs and PCTs initiate a referral because of the level of concern or complexity a family is presenting them with and it is deemed to be beyond the capabilities of local resources to respond effectively.

Evidencing your practice has made a difference to children, young people and families

Performance measures
Six-monthly case reviews during which parents and children are asked to comment on whether they believe the practice/ programme is achieving the targets set at the previous review. 
Six-monthly or yearly network meetings involving the commissioning agency at which progress is evaluated; this determines the nature and amount of future funding.
An annual service user review which includes parents, children and professionals giving anonymous feedback.
An independent person - a clinical manager at a London Teaching Hospital - carries out inspections every six months. 


Data
The statistical evidence gathered to date indicates that 95% of the families in the treatment programme remain together (representing a 5% breakdown rate), and show significant improvement. National research statistics show that, for older, placed children, the breakdown rate of placements can be between 25 and 30% depending on the age of the child at placement (the average age of children coming to Family Futures is eight).

Evaluation
The service has also been evaluated by sending questionnaires to service users; feedback from these questionnaires has been very positive.


The difference made
Changes resulting from the development of the integrated multi-disciplinary neuro-sequential approach include:

1. Recognition of the need to support children’s educational difficulties.
2. Recognition of the need to support children’s sensory-motor processing difficulties.
3. Recognition of the need to address the effects of trauma on children’s cortisol levels.
4. Recognition of the need for a comprehensive service-wide re-testing programme; the clinical psychologists have initiated this. 

(Further information on the first three of these changes can be accessed by contacting the C4EO team at NFER.)

An annual service user evaluation is also now completed.

Sustaining and replicating your practice

Family Futures places great store on the continued viability of Family Futures as an adoption agency, recognising that the key to successful outcomes for children and their families is access to ongoing support.

The need for sustainability has been addressed by reviewing Family Futures' organisational and management structure and, as a not-for-profit agency, prioritising the growth of reserves to ensure financial stability. Two key changes have been made:

1. Whilst maintaining and integrating attachment theory as part of the theoretical basis for Family Futures' work, it is no longer the overarching framework. Family Futures has moved to a neuro-sequential approach which focuses on all aspects of child development (including attachment) and is based less on psychological theory and more on neuroscientific research.
This will be maintained by: 
i A 're-test programme': which will monitor outcomes for children across a range of development areas, to provide the best possible service. 
ii Training: As a training institution, Family Futures commissions researchers, theoreticians, and practitioners across a diverse range of human sciences. Their input continues to inform and further the development of the neuro-sequential approach. 

2. A consequence of adopting the neuro-sequential approach to understanding child development and recovery from early trauma has been the need to develop an integrated multi-disciplinary team, reflecting the developmental needs of the children placed for adoption or fostering.

Costs and benefits

There are no fixed fees for the programme; each one is bespoke.
The assessment for an individual child is £3,000 plus VAT.
Treatment programmes can range from £10,000 to £60,000 over a two- to three-year period.
Baker-Tilley (Accountants), using the Government’s social investment model, have found that the adoption of an older-placed child saves the State an average of £1,000,000 over their life-span by preventing the child from growing up in care and potentially becoming a service-user of adult mental health services or involved in the criminal justice system. 

Learning from the experience

1 Post-placement support is critical to the success of complex permanent placements. 
2 An integrated multi-disciplinary service specializing in children who are in substitute family care is the form that post-placement support should take.
3 A multi-disciplinary service needs to be predicated upon a neuro-sequential model of assessment and therapeutic intervention, drawing from the emerging neuroscientific literature. 
4 The stance the service needs to take is a genuinely parent-and-child friendly approach where both are seen as co-collaborators and co-creators of the treatment programme that is wrapped around them.

Replication

Family Futures regularly shares information, practice and evolving theory through training programmes, an Associates’ Network, articles, DVDs and books, and through sharing practice with collaborating LAs and allied organisations in mapping the territory for others to follow and replicate the model developed. There are now two embryonic agencies replicating the Family Futures model as a direct result of this training and consultation.

Contact Us

t. 020 7833 6825
e. contactus@C4EO.org.uk

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