Ideology, Evidence and the Great Residential Group Care Debate: Whose Keeping Score?

1. Ideology, Evidence and the Great Residential Group Care Debate: Whose Keeping Score? ALIGN Conference • Edmonton, Alberta • February 8, 2019 • James P. Anglin • Professor Emeritus • School of Child and Youth Care • University of Victoria

2. Saanich Peninsula… Traditional and unceded territory of the Wsaneć people

3. intewornational movements Robert Anglin (my great great grandfather) with his bride, Sara (Sally) Hayes, set sail from Cork, Ireland, for Canada on their wedding day, June 22, 1829. They settled in Kingston.

4. intewornational movements Winter in Victoria…

5. intewornational movements

6. “A full and rigorous examination of the theoretical and empirical underpinnings of residential group care with respect to their implications for current service policy, practice and future research is long overdue and ought to receive the highest priority on the new century’s emergent agenda.” James Whittaker (2000) cited in Anglin, 2002

7. Two international movements are currently underway regarding residential care Over the past 20 years, international documents have sometimes viewed “institutional care” and “residential care” (or “congregate care”) as synonymous, and as “having negative consequences both for individual children and for society at large” (e.g. Stockholm Declaration on Children and Residential Care, 2003).

8. This lack of differentiation does not acknowledge the evolution of residential care in many countries away from large “orphanage style” institutional settings (at their worst, “total institutions” – Erving Goffman, Asylums, 1961) to much smaller and more community-based homes, or cottages. Two international movements are currently underway regarding residential care

9. It is ironic that 17 years prior to the Stockholm Declaration, , the International Federation of Educative Communities (FICE) met in the same country (Sweden) and published the Malmö Declaration… urging “all persons holding responsible positions in society and government […] to consider ‘Children’s Homes’ and comparable provisions not as a last resort for children needing care but as an important available intervention to be used at an appropriate time in the development of those children for whom it is desirable” (Malmö Declaration, 1987, 10-14).

10. Interestingly, there is evidence that some orphanages have been experienced by many young people as not only positive, but more positive than kinship or foster care placements (Brown and Seita, 2009; McKenzie, 2009).

11. One survey of 1,000 former residents who had lived in both orphanages and foster homes revealed that 92% preferred orphanage care; only 2 percent preferred foster care (Brown and Sieta, 2009,p.158). • One former resident of both an orphanage and foster care came to the conclusion that “it is how children live that matters, not where children live” (Folman in Brown and Seita, 2009, pp. 141-158).

12. Ideological Principles Often Shape Decision Rules For example: • All children deserve (or have a right) to live in a family (What about those who can’t, for whatever reasons?) • Try (all) less intrusive services before more intrusive alternatives (But less intrusive for whom?) • Place a child in residential care only as a last resort (Even if this means years of foster care misplacements and unnecessary pain?) • Every child needs (has a right to) permanency and stability (But what do we do to ready them for such a place?) • Others?

13. It is evident that in the international literature there is both a lack of clarity about what residential care is, as well as disagreement about its desirability and appropriateness. • E.g. the term “therapeutic residential care … refers to group homes serving seven or more children, residential treatment centers, and psychiatric residential facilities (PRTF).” (Pecora et al. The Child Welfare Challenge Policy, Practice and Research - 4th edition, 2018.) • In some jurisdictions, staffed homes with 1 or 2 children are sometimes referred to as TRC resources. • What is gained and what is lost when we remove the group from residential group care?

14. Two international movements are currently underway regarding residential care 1. A move at United Nations level to eliminate “congregate care”, largely in eastern European and southern (African) countries “the continued proliferation of inappropriate forms of institutional care, the strain placed on kinship carers by the impact of HIV/AIDS, and the movement of children out of vulnerable families onto the street continue to challenge progress in this area” (Better Care Network strategic plan, 2014-2017] And also in the USA, an initiative championed by the Annie E. Casey Foundation to “rightsize” [downsize or eliminate] “congregate care.”

15. 2. A re-thinking and re-appreciation of residential care is underway in western Europe, North America and Australia, and rippling into other countries as well. As mentioned, the focus is increasingly on “therapeutic residential care” in cottage or home-like settings, sometimes with individual houses in the community and sometimes with multiple cottages or units on one property. There have been a number of attempts to eliminate residential settings in the past in the UK, USA and Australia, but none has been successful.

16. Therapeutic Residential Care for Children and Youth: A Consensus Statement of the International Work Group on Therapeutic Residential Care KEY ELEMENTS OF THE STATEMENT BY THE INTERNATIONAL WORK GROUP FOR THERAPEUTIC RESIDENTIAL CARE • Background/overview of current perspectives on residential (“congregate”, group) care • Defining therapeutic residential care • Principles of therapeutic residential care • Dimensions of therapeutic residential care/pathways for research • Promising practices and pathways for the future (RESIDENTIAL TREATMENT FOR CHILDREN & YOUTH 2016, VOL. 33 NO. 2, 89–106) http://dx.doi.org/10.1080/0886571X.2016.1215755

17. 3 Types of “TRC” Residential Care Delivery • 1. Residential Care with client-specific evidence-based treatments offered in-house (e.g. CBT, DBT, etc.) • 2. Residential Care with clients attending community located evidence-based treatments (e.g. psychiatric intervention) • 3. Milieu-Wide (evidence-based) Residential Treatment Models (may also have elements of 1. & 2.) • (Sigrid James in Whittaker, del Valle and Holmes, TRC In residential care for children and youth: Developing evidence-based international practice, 2015, pp. 143-153):

18. “a unifying something” A. E. Trieschman “The problem for the child care worker and the program administrator alike is to achieve some sort of integrative focus - what Albert E. Trieschman called a "unifying something" - as a basis for building a coherent helping environment…for professional child care work.” (xiv) • (Maier, H.W. (1987). Developmental Group Care of Children and Youth: Concepts and Practice, Binghamton, NY: Haworth Press)

19. We have heard a number of notions at this symposium that are candidates for a “unifying something”. • * relationships, or developmental relationships • * framework(s) – sometimes in the form of a model • * safety, first and foremost • * participation (voice) • * mindset, systems of thought • * love, or in the words of the late Henry Maier, “caring care”

20. I think that over the past day and a half, all of us have been challenged, in one way or another.

21. Jon Reeves – We “do” safety, but we purchase “well-being.”

22. Arlene Eaton Erikson - “To get a say does not mean you get your way.”

23. Gabrielle (Weasel Head) Lindstrom – “We need to build a solid relationship with ourselves.”

24. Gabrielle (Weasel Head) Lindstrom – “How we know makes a difference to who we become.”

25. Bruce Perry’s notion of “inertial knowledge.”

26. Martha Holden – “If you plant lettuce and it doesn’t grow, you don’t blame the lettuce.”

27. KiarasGharabaghi – “We don’t make a plan for sleep, food, sensory access, identity silence, dignity, aesthetics.” Do we need to talk about some things in our care gatherings that we may not be able to measure?

28. Cara Lewis – We may need a tailored approach to implementing CBT

29. Is residential care effective?

30. “A Review of Residential Mental Health Placements for Children and Youth”(Frensch and Cameron, 2002) “Unfortunately, any gains made by reconceptualizing the practice of residential treatment will be overshadowed at present by the limitations of current methods for studying residential treatment. Research in this area continues to be plagued by serious methodological flaws.”

31. “A Review and Meta-analysis on the Outcomes of Residential Child and Youth Care” (Knorth, Harder, Zandberg and Kendrick, 2007) “The main conclusion that can be made from our meta-analysis is that children and youth, after a period of residential care – on average – improve in their psychosocial functioning. […] The effect sizes that we found are in most cases positive and can be characterized as ‘medium’, sometimes as ‘large’. […] [R]esidential care seems to achieve better results than treatment at home with the same (very) problematic group.” (p.136)

32. From “What Works in Group Care?”(Sigrid James, 2010) • Research on 5 models was reviewed • “Four of the models were rated as either being supported by research evidence (PPC) or being promising (TFM, Sanctuary Model, Stop-Gap). The Re-Ed model could not be rated due to a lack of evaluative data which would meet CEBC* rating criteria.” * California Evidence Based Clearinghouse (i.e.randomized controlled trials)

33. Sigrid James (2010, cont’d) “ Research on group care remains in early developmental stages, and as this review indicated, far too few rigorous studies have been conducted to make a strong recommendation for one or other treatment model.” Who is keeping score? Whose scoring should we pay attention to?” My touchstone is the changed lives and testimonies of children, often dismissed as “anecdotal evidence”.

34. Residential care is not rocket science; it’s far more complex than that! However, we are discovering ways to respond to this complexity in the best interests of children.

35. Questions • Are all stakeholders in Alberta clear about the purposes and place of residential care in child welfare; are we on the same page going forward? • Are the provincial policies, guidelines, funding mechanisms and program evaluation criteria/performance standards congruent with what we know about providing quality care? • How do we maintain a productive dialogue across the various players in the child and youth care/child welfare system to ensure effective planning and operations? • Do we know where we want to be in terms of residential care provision in 12 months? 3 years? Longer term?