SPECIAL NEEDS OF A CHILD IN SUBSTITUTE CARE

by Auli Laakso-Santavirtaspecialist in child psychiatrychild-centred family psychotherapist, upper specialist level (Finnish Authority for Medicolegal Affairs, TEO)specialist in children´s psychotherapy (Finnish Medical Association, SLL)

all children and young people placed in substitute care have their own special needs; substitute care does not concern children and young people in good health (exceptions are possible)

however, substitute homes prepare for receiving an “ordinary child”

information is neither provided nor requested; acting as if starting with a clean slate

disguised behind child-centred thinking, although it is in fact adult-centred laziness!

wondering about the child’s symptoms

expecting the child to become attached immediately, not providing time for personal adjustment

wondering about the child’s loyalty to the biological parents and other close persons

expecting the child to show gratitude, although in reality at least a young child is very confused

the most common thinking errors are described above in a nutshell

Usually the children have previously experienced:

major deprivation (lack of care and attention, neglectful behaviour)

several hasty, unexplained experiences of separation

separation: separating from the mother figure but providing motherly care

deprivation: lack of motherly care even if the mother figure was present

broken or disorganised or insecure attachments

also several other traumatic experiences

The child’s background is often so terrible that

a child welfare worker or a substitute parent with

an ordinary middle-class background cannot empathise

and, therefore, cannot put him or herself in the child’s place.

the children are unintegrated, i.e. their psychic or inner structures are not even developed although this could be expected on the basis of their age

if the child is integrated, at least he or she has special difficulties, often a variety of them, as well as even major neuropsychiatric disturbances and symptoms

emotional symptoms, emotional immaturity

in other words: special types of children for whom ordinary parenthood is not enough, special parenthood is needed

furthermore, it is usually necessary to perform neuropsychiatric assessments and to prepare a treatment and rehabilitation plan

taking into care and placement in substitute care alone are not sufficient, the events during placement and the attention given are decisive

moreover, the child’s interests must be genuinely considered (cf. child-centred and adult-centred ways of thinking and acting)

furthermore, it is necessary to pay attention to contextual aspects (see also Appendix 1)

the substitute family, or institution, is actually a subcontractor of the municipality in charge of taking into care and substitute care!

therefore, a child placed in a substitute family, in a way, never becomes the family’s own child, even if the biological parents would have disappeared from his or her life

children placed in substitute care may be hurt if they are informed of the compensation paid for them, especially if they obtain this information later on; proper information must be provided from the start (Laakso & Saikku, Hyvä huostaanotto, 1998)

substitute care always involves the municipality and its employees in charge of placement; changes in personnel, insufficient resources

substitute care also always involves the biological parents or the parents from whom the child was placed in care; they are always present at least in the child’s mental images, even if they would have no real-life contacts with him or her

how should one look at parents who have physically or psychologically abused their child?

how can one maintain the respectfulness in the interests of the child in spite of the abuse?

how can one explain this contradiction to the child?

who is going to explain it?

the explanation must be repeated often and will never be exhausted; information on the child’s important phases of life needs to be repeated in different phases of his or her development

three-generation perspective may be helpful

children often feel guilt due to having been taken into care and placed in substitute care; correct information on the matter must be provided to the child

in principle, contact with biological background is important; it is easier for the child to grow knowing where he or she comes from, and to look at him or herself and other people realistically; frequency of contacts is not that essential

some children and biological parents are even better capable of making contact when it takes place only seldom and when there is no everyday responsibility – i.e. this is a remedial experience

besides, contact with the parents enables the filling in of gaps in the child’s life story

sometimes the contacts between the biological parents and the child must be restricted and supervised; one must have the courage to adopt this decision instead of sacrificing the child in the interests of the adults or in fear of the consequences

other parts of the child’s network, relatives, day care, school and other normative network must also be taken into consideration

an actor providing treatment and rehabilitation is almost always involved; this network is very complicated (see Appendix 2)

-who or which actor takes the decisions on the child’s matters “in the capacity of a guardian”?

it is important that the child is aware of this

it is against the interests of the child to shun responsibility, to make several overlapping, contradictory decisions, to fail to make decisions or to make vague decisions

in everyday matters, the substitute parents or the institution’s employees make minor on-the-spot decisions (= everyday parenthood)

the municipality in charge of placement de facto makes the major decisions

decisions on treatment and rehabilitation are made by the health care services (+ Kela, i.e. the Social Insurance Institution of Finland) in cooperation with the guardians

How can overall management be ensured?

solutions often include network consultations, treatment plan and guardianship

it would be easiest if all parties were present simultaneously; arrangements and time are required

the employee of the municipality in charge of placement is surprisingly often absent – hence, no decision can be made on rehabilitation, for example!

support to the substitute parents or institution? (supervision of work, consultations)

a good placement is based on a sound, timely initial assessment

the later measures are taken, the more difficult it is to give help

future location of placement must be assessed correctly from the start, based on the needs of the child

financial considerations, i.e. adult thinking, often outweigh the interests of the child

location of placement is often dictated by the available placement options

the decision-maker often even has obtained a recommendation concerning the location of placement given by a child psychiatrist or a family counselling centre, but it cannot be taken into consideration due to adult-related aspects

children are often so damaged that placement in a family with 1–2 adults is not sufficient, it is necessary to choose an institution with more adults with professional training and attitude

furthermore, the child may sometimes be functionally so incapable that homeschooling is necessary, at least in the beginning – location of placement must be chosen accordingly

besides, treatment and rehabilitation plan may include anaspect that favours a certain location, e.g. continuity of

psychotherapy commenced earlier with a given therapist

mistaken placement decisions will backfire in the form of frequently changing locations of placement and thus endanger the child’s developing attachments and entire development

location of placement must be provided with sufficient information, i.e. no “start with a clean slate”

in any case, the placements will make the child’s life story discontinuous

currently, information is even concealed so as not to scare off the persons taking the child or not to let the “bad information” damage the child

information can be provided only if the employee in charge of placement is sufficiently aware of the overall situation (i.e. initial assessment is sound)

the child usually has such a fragmentary background that putting the pieces together requires hard work, “detective work, archaeological investigations”

who will put the whole story together and convey it to the child? who is responsible for this?

currently, the responsibility too often lies with the actor in charge of treatment or rehabilitation

where is the common understanding between all those participating in the child’s life?

“past travelling” with the child, visits to concrete sites, drawing maps, photographs, timelines, presenting everything in concrete terms

nurture in the everyday life at the location of placement is the most important rehabilitating factor, which cannot be overly emphasised

everyday life must take the interests of the child into consideration and be geared towards the needs of the child but be managed by adults

management by adults = security

number of adults must be sufficient, cannot be replaced with anything but adults, often notable deficits, cf. financial factors

lack of adulthood only sustains the feeling of insecurity, and placement in substitute care turns against the interests of the child

no fancy and expensive therapy can substitute for this!!!!!

consistent, secure everyday structures and routines; their continuous repetition creates structures in the child’s developing mind, i.e. helps to build up psyche!

sometimes the locations of placement are characterised by chaos instead of structure!

indeed, the child’s symptoms may sometimes be more related to the chaotic nature of the location of placement

the child regards the personal nurse or the personal instructor as an important proof of significance of the self, “I am not insignificant”

besides, it is likely that the personal nurse is the very adult who has the best general view of the child in the institution

a personal nurse should not be shared between two children, every child should have his or her own

the employee must be both professional and ordinary, and use his or her personality comprehensively to the child’s advantage

simultaneous everyday life with the child and observation of the child, the child’s relationships, him or herself and other personnel – i.e. the overall situation – at the meta level

good knowledge of the self and ways of responding

when the child can choose from several caring adults, he or she can mirror different aspects of him or herself against different people and acquire different experiences of interaction

NB: different people have different viewpoints, supervision of work may be needed in the work community in order to gain an overall picture; otherwise, the child’s previous contradictory experiences translate into conflicts between employees (Jorma Piha)

in other words, every employee must place him or herself at the child’s disposal, personal feelings must be used as a diagnostic tool to guide the attitude towards the child

the child acquires experiences to substitute for and to counterbalance the earlier, traumatic ones

a new, healthier model of family, family life, interaction, lifesharing mental contents with the child, attunement, being on the same wavelength

permanence of employees instead of their high turnover!

any changes in the personnel must be managed properly so that also the experience of separation can be more remedial than in the child’s past life

the child must be informed of the changes early enough so that he or she can prepare

adults must be ready to face the reactions

Attachments (Bowlby, Ainsworth and Crittenden)

the child’s inborn inclination to become attached to the caring person, downright a vital condition for survival, emotional bond between the baby and the caring person

is activated when security is under threat, striving for closeness

on the other hand, enables a trustful introduction to the environment

1. secure attachment

2.insecure attachment-avoidant attachment-ambivalent attachment

3.disorganised attachment

insecure does not necessarily refer to psychic disturbances, other factors play a role too

secure is usually connected with good psychic health but not necessarily

disorganised attachment is most often related to psychic disturbances

a good placement with permanent adults may enhance the attachment behavior

this requires that the adults understand thinking related to attachment behavior and are not discouraged by an avoidant child, for example

the child must be permitted to become attached to new persons – do the parents approve of the placement?

“actual treatment and rehabilitation”

most of the aid given to children in substitute care takes the form of rehabilitation – damages can no longer be treated completely

classification of rehabilitation (Tamminen and Räsänen, in: Lasten- ja nuorisopsykiatria, ed. Räsänen, Moilanen, Tamminen and Almqvist, Duodecim 1996):

1. social and educational rehabilitation (day care, school,hobbies)2. rehabilitation related to child welfare3. psychotherapeutic rehabilitation (child psychiatry, youth psychiatry)

focuses directly on the child

focuses on the family/substitute family/institution

indirectly via consultations and supervision of work

most children in substitute care clearly suffer from psychic disturbances and need long-term psychiatric treatment and rehabilitation

Time and place of assessment?

assessment is often made before placement in substitute care, which enables consideration of the location of placement, but a long-term rehabilitation plan cannot usually be prepared until the future location of placement has been seen and until the child has preliminarily adjusted him or herself and become attached to it – subsequently, further needs for treatment and rehabilitation will be apparent

the child’s symptoms often appear in the location of placement only after he or she considers the location sufficiently secure, (holding context), and has preliminarily adjusted him or herself to it

NB: a child who seems to have no symptoms is neither well adjusted nor necessarily in good health

can take place elsewhere than the first assessment as the child has moved to another place of residence in the meantime - the child’s life story is in danger of breaking once again

earlier legislation is interpreted so that the municipality in charge of placement is responsible for everything (i.e. also specialised medical care within the area)

new Child Welfare Act (and amended Specialised Medical Care Act and Primary Health Care Act) are expected to change practices as the care of the child will be the joint responsibility between the municipality in charge of placement and the municipality where the child is placed

lack of resources in both child and youth psychiatry

scarce services also in the private sector even though a financier would be available

therefore, it is often appropriate to make a second assessment of rehabilitation needs

End or change of placement?

must be considered properly from the child’s standpoint, adult-centred way of thinking must not dominate, “biological parents have the right to their child”

duration of placement plays a significant role – sometimes return to the parents after several years is considered even if the contact with the parents would have been very brief (child’s interest?)

continuation of contacts with the important persons in the location of placement even after the end of the placement in one way or another, is this acceptable to the parents or the new location of placement?

continuity is the essential aspect of helping the child in substitute care

continuity of the child’s life story, no jumps or gaps

continuity of human relationships – those existing prior to placement and those established after placement

contacts of the biological family and the network, contacts of the child and adult relationships established via placement, contacts of the social worker in the municipality in charge of placement

continuity of treatment and rehabilitation (changes in personnel here too)

Continuity of everyday life!!!