Residential Care Do We Still Need It?

By John Stein

Date Posted: Tuesday, 14 December 2010

 

John Stein has always worked in human services. He started off as a police officer, before becoming a community organizer while he worked on his undergraduate degree in psychology. He has an M.Ed in Social Restoration and is a Certified Cognitive Behavioral Therapist. He has directed programs for both adults and children in corrections, residential treatment, and inpatient and outpatient mental health settings in Pennsylvania and Louisiana. He is the author of “Residential Treatment of Adolescents and Children: Issues, Principles, and Techniques”, 1995, Nelson-Hall, Chicago. Since his retirement six years ago, he has presented numerous workshops for parents and professionals, has written several articles on children’s issues and he travels widely. He is a generous and valued contributor to the goodenoughcaring Journal.

 

Residential Care Do We Still Need It?

 

There has been a strong tendency in recent years to avoid residential care for children.  The argument seems to be that every child deserves to grow up in a caring family.  It is certainly a fine ideal.  But what is the truth?  What does the term ‘residential care’ mean?  And what does the term ‘looked after children’ mean?  More importantly, what do these terms imply?

To many, I think the term ‘looked after children’ implies that all children need is a little ‘looking after,’ as in a parent asking a neighbor to ‘watch’ or ‘look after’ her children while she runs an errand. And to many, I think the term ‘residential care’ implies that all that children need while they grow up is a place to live and a little care or looking after.

 

The Children Who Cannot Return Home

Looking after children might be all children need for an afternoon or an evening, but for the longer term, and especially for the time it takes them to grow up, children need so much more than just a little looking after.  They need supervision and guidance.  They need nurturing.  They need relationships with caring adults to teach them self-care skills, living skills, and social skills. They need activities to help them learn.  They need some excitement and adventure.  They need  activities and relationships with peers under adult supervision.  They need some quiet time to themselves.  They also need free play, alone and with peers to try out the skills and values they are learning.  They need an education.  The list seems endless.

In my opinion, however, the most important thing that children need is a feeling of belonging and the stability, predictability, safety, and security that a sense of belonging creates.

When we are successful at finding a family who can do a reasonably good job of providing for the needs of a child who cannot live at home for whatever reasons, including that sense of belonging, all may be well.  Unfortunately, finding families to provide for these needs is not always easy nor successful. Nor is it always indicated.

Sometimes, foster placements break down for reasons that have little or nothing to do with the children who are placed there.  Families may change their minds about having children in their homes, finding the responsibilities of caring for and raising children to be more than they expected.  Or families may undergo changes, perhaps a surprise pregnancy, having to care for an elderly relative, a job change necessitating a move, a divorce, or any number of other things that affect families all the time.

More often, foster placements break down because of something that has to do with the children themselves.  Children come into care for a variety of reasons, some having to do with caregivers, whether parents, grandparents, or other family members: neglect, abandonment, or abuse, or simply the loss of a primary caregiver, perhaps due to death or incarceration,. Other reasons have more to do with children, with their unruly or ungovernable behaviour, school refusal, violent temper outbursts with destructive or aggressive behaviour, criminal behaviour, or other serious challenges.  Most often, there are a combination of reasons.  Each has its effects on children.  Such children may have needs that are well be beyond the abilities of families and communities and may pose challenges for which few families are prepared.

 

Multiple Placement Syndrome

Whenever children are moved, each move leaves its mark.  After only one or two moves, children become less secure and less open to forming relationships, both with adults and with peers, not only with people in the home but also with people in the community.  There is a tendency for such children to engage in ‘testing’ behaviour.  The common thought is that they are testing limits to see what they can get away with, as if they are devious children deliberately seeking to find out how far they can go, but I don’t think that adequately explains what is happening.

First, it is normal for people to test.  Testing is no more than learning by trail and error, by experience.  Children who are developing problems with relationships and with trust are not so ready to accept adults or peers at their word.  The only way they can know for sure is to actually see, to experience, what happens, as in, ‘They said this was important, but I need to know just how important it is to them.”  It is not a conscious process; it occurs on a preconscious level where feelings operate, on a level where ‘experience is the best teacher.’

But there is more.  Children need to feel safe and secure.  (Don’t’ we all?)  They cannot feel safe when they suspect that their placement might end and they might have to move again.  They know they have problems, but they come into a new placement planning to do everything right this time.  They are on their best behaviour.  We call it the honeymoon period.  But then their feelings take over.  They begin to feel insecure, to wonder whether their new placement can manage their problems, or whether people will just give up on them one more time. The tension becomes more and more difficult for them to manage, even overwhelming, and their behaviour deteriorates.  Even when their new placement manages their behaviour successfully, the tension continues to mount.  They sense that there is a line they dare not cross or they will be thrown out once again.  They need to know (again, this is feeling, not rational, deliberate thought) exactly where that line is.  Only then can they feel confident that they will be able to avoid it.  The closer they get to that line with their behaviour, the more insecure they feel.  And the only way they can actually be sure where the line is–is to cross over it.  Resulting in their getting discharged once again.  For some children, it can be more deliberate.  When, things become too tense for them, they know they can escape by stepping over the line.

In either case, the dynamics are the same.  These children sense something about that line, what the family simply will not or cannot tolerate.  For some families, it may be some form of disrespect.  For others, it may be damaging valued property, perhaps an heirloom.  For yet other families, it may have to do with their natural children.  The behaviour of these children meets the criteria for Oppositional Defiant Disorder and often for Conduct Disorder, but I think it is different.  It has more to do with relationships.  I call it Multiple Placement Syndrome.  After several moves, the syndrome may become seriously pathological.

Children with Multiple Placement Syndrome can pose serious challenges, even for residential programs.  It is not unusual for the cycle of multiple placements to continue for such children even after they enter residential treatment.  Even in residential treatment, there are lines that cannot be crossed, although hopefully these lines are much higher than in someone’s home. Consequently, these children have a need, perhaps a pathological need, to find that line.  Once again, they cannot feel secure until they have a very real sense of where that line is.  Is it too much aggression?  Too much property damage?  Too many runaways?  And how much is too much?  Or, once again, some of these children knowing where that line is may deliberately cross it to escape yet another placement when things become too uncomfortable for them.

A solid residential treatment program can and should have the capacity to manage and treat Multiple Placement Syndrome and can and should be prepared to do so.  In my opinion, these are the only resources that have to potential to do so.  Treatment Multiple Placement Syndrome requires managing serious challenges in such a way that relationships begin to be built, and continuing to manage challenges, including escalating behaviour, until relationships have been developed to the point where children begin to feel more secure and are responding to treatment.  It also requires a track record of not discharging children because they are not compliant or ‘not benefitting from treatment in this environment.’  It takes time and patience.

 

The Children Who Can Return Home 

I think there is another case for Residential Treatment–the situation in which children’s behaviour and family relationships have deteriorated to such an extent that the family can no longer manage a child in the home, but where the child is expected to return home after problems have been resolved.  In such cases, I think there are times when placement with another family is not indicated.  When children must be placed outside their home because of serious problems, there is the potential for parents to feel a sense of inadequacy and failure.  The attempt to place children with other families in such situations while the children and their natural family get services–counseling, therapy, parent education, whatever–has the potential to send a message on several levels that their child will do better with another family, heightening their sense of failure and inadequacy, especially when their child begins to develop relationships in that ‘new’ family.  It is not unusual for jealousy to develop, or for parents to blame their children for responding better to strangers than to their own parents who have sacrificed so much for them.   Rather than hoping their child does well, on some level they may not want their child to succeed in a different family, undermining treatment.  It also has the potential to communicate to children on several levels that the problems are not with them but with their parents.  All of these things may further damage already strained relationships.

Residential treatment has the potential to minimize these problems, promote healing of relationships, provide effective treatment for both children and families, and expedite children’s successful return home.  Residential treatment is not another family, a better family.  Rather, it is a team of trained professionals capable of meeting the special needs of children in trouble.

 

Conclusions

Children need more than a place to live–they need a place to grow up, a place that is capable of meeting their needs, including their needs for stability and security.  When children do not sense that someone is committed to meeting their needs, it is difficult for them to make any commitments, either to others or to themselves.  When they do not know where they will be living next year, or next month, or next week, they cannot even know where they will be going to school.  When there is so much uncertainty, children cannot commit to anyone or anything, not invest in anyone or anything, including themselves and their future.  How can children commit to and invest in their education when they have no idea what school they will be attending next month or next week because they are not sure where or with whom they will be living.

Many of the children who come into care, those who need ‘looking after’, have complex multiple needs.  In reality, so many of these children have serious multiple problems. Children who have not learned (for whatever reasons) things they should have learned–academically for sure, but also socially, such as values and beliefs and skills and behaviours and attitudes and empathy and respect.  Children who have learned things they should not have learned, such as beliefs in retaliation and revenge and all the attitudes and skills and behaviours that go along with that. Children who have mixed up feelings and emotions.  Children who cannot commit to anything–to others, to themselves, to their education, to their future.  These kids also have normal developmental needs in addition to their special needs.  Sometimes these normal needs seem to get neglected with all the concern about their special needs.

Residential treatment has the potential to address all these things–24 hours a day, 7 days a week.  I know of no other resource that has this potential.  Residential treatment can provide structure and guidance when children need them.  It can also provide freedom and play when children need those things.  It can provide for all of children’s special needs along with all of their normal developmental needs.  It can provide meaningful relationships with a wide variety of caring adults.  It can manage peer interactions and relationships.  It can manage family interactions and promote the healing of relationships.  It can provide consistent expectations, the expectations that children will always do the best they know how.  (Please–not consistent discipline.  Children learn more from consistent expectations when they do not know what their ‘discipline’ will be.  It requires them to think about something other than the punishment htey will get if they get caught.)

There has been a move away from residential treatment that has not been good for all children.  It has resulted in residential treatment programs not receiving the attention, support, and funding necessary for programs to maximize their potential, while at the same time delaying the placement of children when it might be most beneficial, sometimes until a time when even residential treatment may be too late.  There are times when residential treatment is indicated to meet the needs of certain children.  The sooner it is provided, the greater children’s chances for successful outcomes.  We need to stop fantasizing about finding families for every child and get better at meeting the real needs of individual children.  This is the Twenty-First Century.  The knowledge is available.  We need to start using it.

 

goodenoughcaring  editor’s note

Other articles relating to issues raised in this piece include :

Being a Residential Child Care Worker in England  by Harald Stoelting which can be found at http://www.goodenoughcaring.com/Journal/Article145.htm

Greendale : the running and working of children’s homes by John Burton which can be found at
http://www.goodenoughcaring.com/Journal/Article129.htm