This example of practice describes the implementation and evaluation of a specialist parenting programme to support adoptive parents and their children and families.
Organisation submitting example
Royal Borough of Windsor & Maidenhead
Local authority/local area:
Royal Borough of Windsor & Maidenhead
The context and rationale
Many children who are fostered and adopted have been the victims of abuse and neglect and multiple placements. This leaves them very vulnerable to attachment difficulties. Research indicates that children with attachment difficulties have significantly higher rates of mental health difficulties than children in the general population and an especially high incidence of disruptive behaviours. It is reported that the most common causes of placement breakdown are the child’s difficult behaviour and the parent’s lack of confidence in their ability to parent the child.
As a result, parenting programmes have been delivered to foster and adoptive parents with varying results. Many of these parenting programmes are based heavily on social learning theory such as the Triple P programme and the Incredible Years Programme. These programmes have yielded positive results when delivered to birth parents; however there is limited evidence to support their use with parents of children who have suffered neglect, abuse and multiple foster placements.
In a response to this, researchers have focused on the need to adapt existing social learning theory parenting groups and develop parenting groups that address the importance of attachment, which is understood to be at the root of many of the emotional and consequently the behavioural difficulties experienced by these vulnerable children. Golding and Picken (2004) developed such a programme: ‘Fostering Attachments’. It explores attachment theory and links this to the ‘House Model of Parenting’. This model provides a coherent set of ideas for parenting the children in a way that fosters security of attachment.
The aims of the programme are:
1. To provide support for parents of children and young people with attachment difficulties.
2. To increase understanding of the children and their behavioural and emotional need through an increased understanding of attachment theory.
3. To develop ways of applying this understanding to the parenting of their children.
4. To increase the skill and confidence of the parents and children.
5. To increase the child’s security and sense of belonging.
The course was delivered by Windsor and Maidenhead’s Tier Two CAMHS team - the Healthy Minds Team. This is a relatively new team that was set up in 2009 to provide prevention and accessible early intervention.
The Healthy Minds team staff are qualified or trainee therapists from a range of backgrounds. They have also had additional training in Dyadic Developmental Psychotherapy, an attachment based treatment for childhood trauma and abuse. This approach has heavily informed Dr Kim Golding’s Fostering Attachment course. Looked after children and children on the cusp of care were identified as a highly vulnerable group within the authority and are targeted in the authority’s partnership plan for children.
The Fostering Attachment course consists of three x 6 week modules delivered over 18 weeks. The programme was delivered by 2 qualified therapists to 6 families (5 adoptive parents and one foster carer) and was evaluated by an Assistant Psychologist. Referrals were accepted from Health (GP and tier 3 specialist CAMHS) and Social Care.
The course is delivered through: PowerPoint presentations, handouts, small and large group discussions, experiential exercises, role plays, videos and home reflections between sessions. The theoretical material, handouts and activities can be purchased directly from the author Dr Kim Golding who also offers a half day training.
Module one focuses on understanding attachment theory and the development of different patterns of attachment and what that means for their child. Parents are encouraged to think about these attachment styles as adaptive to the child’s early environment and how certain behaviours developed around this time continue to be maintained as they provide a level of safety and security for the child.
Module two helps parents understand how difficult it is for a child with attachment difficulties to self regulate and also explores the impact of the parents’ own attachment history on their parenting and role in the household. Parents are encouraged to provide a positive family atmosphere where they are in a position to be able to control the emotional rhythm of the house. The model helps parents to avoid being drawn into confrontation that resembles the child’s early experience. Parents learn how to create a secure base within which the child may potentially develop the ability to regulate their own emotions.
Module three draws from all the learning from modules one and two and teaches parents/carers to use the Daniel Hughes’ approach to parenting known as PACE (Playful, Accepting, Curiosity and Empathy). The parents’ newly developed understanding of parenting a child with attachment difficulties and greater self awareness enables them to use this skill in challenging situations, as well as to emotionally attune and regulate their child.
While all three modules focus upon the child and the parenting of the child, the approach also addresses the needs of the parents, identifying personal stressors, when to seek out support and the importance of parents looking after themselves.
Evidencing your practice has made a difference to children, young people and families
To assess the impact of the intervention, two approaches were used: (1) parents completed the Parent Stress Index Short form (PSI-SF) before and after the programme, and (2) they participated in a semi-structured interview.
1. Parent Stress Index Short form (PSI-SF)
This measure was used as stress in the parenting system has been found to be a critical factor in the parent-child relationship and a child’s emotional and behavioural development. This measure has been found to have good validity and reliability.
The PSI-SF (Abidin, 1995) consists of 36 items derived from the PSI with a Total Stress scale and three further subscales: Parental Distress, Difficult Child Characteristics, and Dysfunctional Parent-Child Interaction. The Total Stress score provides an indication of the overall level of parenting stress the individual is experiencing. The stresses associated with this scale are: impaired sense of parenting competence, stresses associated with the restrictions placed on other life roles, conflict with the child’s other parent, lack of social support and presence of depression. Example items include: “I often have the feeling that I cannot handle things well” and “Since having a child I feel that I am almost never able to do things that I like to do.”
The Difficult Child subscale focuses on the behavioural characteristics that make the child difficult to manage. Example items include “My child’s eating and sleeping schedules were much harder to establish that I thought” and “My child reacts very strongly when something happens that my child doesn’t like.” The Parent-Child Dysfunctional interaction subscale focuses on the parent’s perception that his or her child does not meet the parent’s expectations, and the interactions with him or her are not reinforcing to the parent themselves. Example items include; “My child is not able to do as much as expected” and “Sometimes I feel like my child doesn’t like me and doesn’t want to be close to me.”
2. Semi-structured interview
Each parent completed a 20 minute semi-structured interview following the last session of the programme. The interview contained questions about changes within the family and the impact of the course on the parent. This was done to capture parent experiences not yielded from the quantitative measures.
Prior to intervention, parents’ total scores on the Parent Stress Index domains were all above the 99th percentile. This means that the parent scores were equal to or greater than 99% of the subjects’ scores in the normative sample. When parents receive a score above the 90th percentile they are said to be experiencing clinically significant levels of stress.
After the intervention, Total Stress scores decreased (117 to 92). Scores also decreased across all the sub domains; parent distress (32 to 28), difficult Child rating (46 to 39) and parent-child dysfunctional interaction (38 to 28). All scores were no longer clinically significant.
Results from the semi-structured interview:
• All six families felt they had established a new approach to parenting.
• All six families felt the course should be delivered on a multi-disciplinary level and to all foster and adoptive parents.
• 4 families reported improved confidence in their parenting ability.
• 5 families reported improved relationships with their children.
• 3 families reported an improvement in their children’s behaviour.
• 4 families felt there was an improvement in the household atmosphere.
• 4 families experienced improved placement stability.
While this initial cohort was very small, the outcomes noted above have been so powerful that Windsor and Maidenhead aim to collate and pool data over time through the four groups that will be run per year as well as evaluating the impact at six months post intervention. When a new foster parent is approved or a child is placed with a new adoptive family they will be offered a place on a Fostering Attachments group. The aim is to ensure that one cohort will take place in the evening so that the parent/ or parents who work can also attend. This also opens up the option of both parents attending, allowing parents to work as a team when managing their children and so maximizing the impact of the course.
As some families may need ongoing support after the intervention, this group now constitutes an entry requirement for specialist psychotherapeutic intervention such as Dyadic Developmental Psychotherapy within our teams. This is because the group provides core knowledge and ensures both parents (where applicable) have the same skill sets.
The approach lends itself to other groups of parents, such as birth parents with children who experience attachment difficulties due to bereavement, divorce or separation, but who still live with their birth family.
Sustaining and replicating your practice
The therapeutic group approach provides an environment where parents and carers can be supported through a change process that appears to enhance the experience for parent and child and thus improve placement stability: an intervention that does not exist currently in many areas.
The group must be run by therapeutic staff and be for no more than ten parents or carers. This is because it involves a large element of personal exploration of one’s own attachment and parenting style.
As some participants, particularly foster carers, worry that they will be judged negatively if they discuss the difficulties they are facing, it is important to provide a supportive and safe environment. The room where the group is run must be private and a confidentiality policy agreed.
Costs: the 3 module course using the Health Minds Team costs £1,953.35 (£325.56 per family). If a placement breaks down and the authority is unable to place the child within its own resources, the child is likely to have to go to an independent foster placement. An IFA placement costs between £36,400 and £46,800 per year and a residential placement costs between £208,000 and £260,000 per year. Specialist attachment trauma therapy for an adopted child at a specialist centre for 3 years is £70,000. The placement costs are additional to this.
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