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Charting a new course: the future of residential treatment in a family-centred system of care

Richard Small

It seems to me crystal clear that the prevailing idea of continuum of care is a significantly flawed model for building a flexible, responsive model for a system of care. As my colleagues Earl Stuck, Jr. (Child Welfare League of America) and Frank Ainsworth (Edith Cowen University, Australia) and I have written elsewhere, there are five fundamental flaws in the concept of continuum as it plays out in American child welfare:

1. There are logical inconsistencies in the “least restrictive” standard.
The “least restrictive” standard in the 1980 Adoption Assistance and Child Welfare Act is at the conceptual heart of the continuum of care. Unfortunately, as implemented, in real-life systems, it can also be the biggest logical inconsistency. “Least restrictive”, like its “least intrusive” counterpart in medicine is only important as a guide to whether and when to intervene, not to decide how. The surgeon should not pick up a scalpel until he is certain that less intrusive measures are unlikely to work. However, once this decision is made, he cuts as deeply as his assessment of the patient’s individual case warrants. While “least restrictive” may be a fair indicator of when the child welfare system should intervene in a family. It cannot be the primary rule governing the nature of the intervention. Yet in child welfare practice, this is very often exactly the case. The result is an incremental approach to practice intervention wherein individual assessments are over-ridden by the systemic bias to begin with step-down helping options.

2. Progress along the continuum advances by failure
An approach that requires that the least intensive interventions should always be used first results in a system with case management decisions drive by failure. As in the example above, family-based foster care is the intervention of choice for a child entering out-of-home care for the first time, as it is the least intensive, lease costly option. Most of the time, only if family foster care fails, usually repeatedly, is more intensive intervention given consideration. This is in spite of evidence that the number of placements a child experiences has a negative impact on a child’s development, and heavily influences the child’s condition at the point of exit from care. (Fanshel, Finch and Grundy, 1990). The presumption of the continuum in practice is that one uses an intervention not only until it does not work, but until one can prove that it cannot work. While this is arguable proof against the use of more restrictive (and expensive) services too early, it also increases the chance they will be used too late.

3. “Progress by failure” biases the system toward crisis and blame
Movement from one stop along the continuum to another only after certified failure creates a negatively biased system adept at recognizing risk, weakness and pathology far more effectively than strengths in individuals and families. The system tends to mobilize only around problems, with case decisions too often made in response to crisis. For those clients who remain in the system over time and make the long journey from least to most restrictive services, repeated failure can mean blame and alienation. Helpers and families increasingly relate not through partnership, but through corrective action plans demanding compliance. Connections between children and biological families are eroded or broken, only to find that when exit from the system is imminent, the resources and motivation needed to make the reunification plan work are missing. Likewise, the “trial by fire” process of reaching the proper level of care tends to destroy other resources along the way. In particular, experience has given us many examples of highly motivated, caring foster parents who eventually burned out because they were unable to cope with very troubled children, well after it should have been evident that more intensive interventions were warranted. The bottom line is progress by failure for child, family and helpers alike, with each party tending to blame the other at every new crisis point.

4. Realistic family reunification is compromised
The hierarchy of least intensive helping services as “good for families” and most intensive helping services as “bad for families” widely believed imposed on the continuum by the 1980 legislation (though not in fact, spelled out P.L. 96-272 as written), in part based on the ideological position that truly functional families should raise their children with little or no outside support, also leads to an overly rigid definition of family reunification. Within this hierarchy, if incremental, time-limited services fail to prevent placement, complete separation of child and family usually results. At the other end of the continuum, work toward reunification of children in out-of-home care is seen as fully successful only if it is full-time reunification, the child returning home with minimal outside family support. In fact, the above premises are far too simplistic. Real-life practice suggests that family reunification should be defined more broadly as helping each child and family achieve and maintain, at any given time, the optimal level of reconnection – from full re-entry into family system to other forms of contact such as visiting or shared care, that affirm the child’s membership in the family (Warsh, Maluccio and Pine, 1994, p.3). From this point of view, optimum family connections are compromised by a hierarchical continuum of intervention and practice methods within which reunification is a “pass-fail” event.

5. Boundaries between services are overly rigid
One of the most perplexing problems with the continuum concept is that it leads to case management as a series of digital decisions, i.e. either family preservation or out-of-home care, either reunification or termination of parental rights, etc. This means there is little possibility to mix and use various services in combination. The sequential delivery philosophy interferes with the possibility that simultaneous interventions may be appropriate. The fact that a child has been removed from home because a family-focused intervention appears not to have worked should not mean that intensive family work ceases, quite to the contrary in many cases.

A side effect of overly rigid boundaries is competition among services in the continuum, with the “good” (i.e. less restrictive) services defining their value in terms of preventing the “bad” (i.e. more restrictive) services. Residential group care, for instance, is seen as the failure outcome of family preservation, strongly inhibiting the possibilities of integration. The capacity of a range of services to support a common goal is compromised by the competition both for resources and the political high ground of being the “correct” service for children.

Small, R. Charting a new course: the future of residential treatment in a family-centred system of care. (Based on Stuck, E.N., Small, R.W. and Ainsworth, F. (2000). Questioning the continuum of care: Towards a reconceptualization of child welfare services. Residential Treatment for Children and Youth, 17 (3), pp.79-92).

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