Alternatives to Foster Care

Abstract

It is unequivocally clear that separating children from parents through foster care is harmful. We offer several safe alternatives to foster care, including new assessment tools focusing on family strengths and parents’ readiness to learn and six interventions tailored to local needs. These alternatives keep children with their parents while under child protection supervision. All cost substantially less than foster care. The alternatives had several characteristics in common. Child needs, especially safety, were met. Parents worked with professionals in structuring new services, resulting in co-created bespoke services with a wide buy-in in each community. Using the new tools, the alternatives were assessed for strengths and parental readiness before intervening so that success was promoted. The best services combined individual learning and group activities, especially activities that involved exercise, outdoor green-time, and social engagement. They also offered 24/7 availability and affiliated with a university to provide better program design and evidence of outcomes. We discuss the impediments to accepting alternatives to foster care, and call for policy makers, judges, supervisors, and managers, as well as case workers, to reduce the use of foster care by using safe alternatives that strengthen families.

1. Introduction

There have always been children whose parents could not care adequately for them. In this chapter we offer a rationale for keeping children at home with parents whose parenting skills are less than their children need them to be, together with examples of how to do this safely.

The chapter is structured in five parts. Part 1 reviews the history of removing children from their parents to establish that foster care was the well-intended solution to both dangerous child care and institutionalization. Part 2 describes early initiatives to prevent separations and foster care. Part 3 offers assessment tools that could help professionals to identify family strengths and, thus, avoid using foster care. The heart of this chapter is Part 4 in which we describe six alternatives to foster care; the strength of these examples is that they were developed and implemented by clinicians under real life conditions. Part 5 closes with a set of recommendations for alternatives to foster care intended for child protection workers, managers, and supervisors, educational and clinical professionals, and attorneys and judges. For an overview, some readers might want to begin with Part 5. We also address possible reasons why the use of foster care continues to increase in spite of the greater efficacy and reduced cost of home-based alternatives. Because separation and foster care cause iatrogenic harm that hurts both families and professionals, we close by urging everyone to use their professional capacity to support alternatives to foster care.

2. A brief history of separating children from their parents

Child removal to protect children from harmful parental care can be traced back to nineteenth century child rescue societies [1]. These professional societies had quasi legal authority to remove children from dangerous homes and place them into foster or residential care.

Bowlby’s attachment theory had a massive influence on the move from institutional to foster care. Nevertheless, Bowlby was very concerned about the harm done to children by separating them from their parents [2]. His theory became increasingly popular, but its practical application has been patchy [3]. Since the mid-twentieth century, child care practice in the US, Canada, Australia, and the UK has prioritized the use of foster care over residential care. The pace of change, however, was uneven; for example, the number of fostered children in the US overtook those in residential care in 1950, but this did not happen in England until the 1970s.

Now it is clear that removing children from their attachment figures causes harm because it involves separating attached children from the person they trust [4, 5]. It is also painful to parents (both biological and foster) and the professionals who must physically carry out the separations. In fact, we think it is so counter to professionals’ motivations for working in child protection that it might contribute to burnout, high rates of turnover in staff and foster carers, [6] and even to moral injury [7].

Foster care is intended to protect children from mistreatment by their parents. Since publication of The Battered Child Syndrome [8], millions of families in the United States have been investigated for child abuse and neglect, and nearly half a million children are in foster care [9]. Neglect is by far the most common form of maltreatment [10], and is highly linked to poverty, mental illness, substance abuse [11, 12], and intergenerational neglect [13]. Although the use of foster care in the US has dropped, it still disproportionally impacts minority children [14]. In the UK, use of foster care has doubled from 1994 to 2023 as child protection agencies have become more risk averse following the highly publicized deaths of children left in parental care [15]. In effect, UK policy has been made by way of multiple single case events rather than by systemic appraisal. Canada does not report national statistics for children in care. However, provinces with high percentages of First Nations people also have high rates of removing children from parental care [16], suggesting that minority status might affect placement decisions.

Two generations after Helfer and Kempe’s work on the physical abuse of children, as many as a quarter of parents who were “protected” by being raised in foster care are having their own children placed in foster or adoptive care [17]. In other words, being in foster care as a child might contribute to multi-generational harm. The outcomes for fostered children in the UK can be so poor that they have been described as a silent crisis [18].

Crittenden and Spieker’s review of a century of research documents evidence of harm to children from being separated from their parents [4, 5]. In 242 studies, separating children from their parents was evidenced to be unequivocally harmful, with not one study reporting positive effects. Strikingly, harm from separation is not one of the factors that legislation mandates be considered by courts before separating children from their parents or by child protection personnel in carrying out such separations [19]. This is important because placement in foster care causes a cascade of additional possible separations: changes of school, loss of siblings and friends, repeated brief separations during parental visitation, and, in every case that does not result in adoption by the foster parents, separation from the foster parents. Many foster children are placed multiple times as placements break down. With each separation and change of placement, children become more distressed and less likely to remain permanently in the next placement [20]. One study of fostered toddlers reported that by 18 months they averaged 2.7 caregiver separations since birth [21]. It is important to note that, although separation always causes harm, that harm must be balanced against the risk of permanent injury or death if the child is left at home.

When children are transported to family visitations by aides who are strangers to them, there is risk that children will come to accept strangers as safe and approved participants in their lives. Such acceptance is like the ‘indiscriminate attachment’ of institutionalized young children [22] which bodes poorly for children’s attachment to caregivers and, later, adult partners. Another risk lies in the way separations are performed, often abruptly without adequate time for transition and emotional preparation for both children and adults. We conclude that, despite the intention to protect children, the child protection bureaucracy and policy often harms children.

The number of children entering foster care still outstrips the number of foster carers and professionals available to help them, even though administrative budgets are increasing faster than placements [23]. This suggests that the child welfare bureaucracy has become ineffective, self-sustaining, and vulnerable to market exploitation. The introduction of marketization, increased outsourcing, and the split between purchasers of services and providers of services, has become a concern for many [11, 24]. This has also brought increased regulation in the form of targets and performance measures in social work, instrumentalizing practice with families and reducing the amount of face-to-face time that social workers spend with them [25, 26, 27]. For example, despite clear evidence of the harm of institutionalization, in England there was a 9% increase in the number of children’s homes between 2022 and 2023 [28]. The provision of residential care in the UK is dominated by a small number of private firms that have been criticized for promoting their services too strongly and making excessive profits [29].

Legislation supporting foster care has created a huge bureaucracy of child protection professionals, police, expert witnesses, attorneys, and judges that cost immense sums of money [30]. Unfortunately, this bureaucracy is caught in a self-defeating loop whereby failures in the system are met with increased bureaucracy. For example, each time there is a death that might have been prevented, the regulations guiding professionals’ decision-making are tightened and more children are placed in care – to protect both the children and the professionals. Alternatives to foster and residential care are urgently needed.

The alternatives to foster care that we offer include: (1) assessing needs and planning services around parent’s readiness to learn, or their zone of proximal development (ZPD) [31] rather than children’s needs that might exceed parents’ current caregiving abilities; (2) ways to keep children safe while their parents are learning more appropriate ways to care for them, and (3) alternatives to foster care when parents cannot change at all or in a timely way. We note, however, underlying racial bias and structural and institutional inequality in the application of child welfare policy results in racial more foster placement of minority children. This topic needs separate attention and is not covered in this chapter (see [14] for discussion). In this chapter we do, however, address economic issues to demonstrate that transferring funds from foster care and child welfare to alternatives to foster care might both lower costs and increase the efficacy of intervention. As one social worker recalled about proceedings with a mother of three young children:

The court case went on for over 2 years. One day I did a quick calculation of the cost of these proceedings and concluded that we could have paid for a nanny to go into the family home until the children had reached 18 with the money spent on trying to keep these children from their mother (Joanne James, personal email communication, Nov. 7, 2023).

3. Initiatives to prevent separations and foster placement

Early efforts to prevent foster care have added to our understanding of how to keep children safe in unsafe homes.

3.1 Improving parent competency and parent-child relationships

In the early 1970’s one of us (Crittenden) ran parent groups for mothers under child protection supervision [1]. The groups were primarily educational, using home visits and weekly group viewing of their own mother-child videos, taken just prior to the meeting. Later this would be called a ‘hybrid model’ using ‘video-feedback’; at the time it was a logical way to combine the social advantages and observational learning of a group with the power of individualized attention. In each home visit, the mother was commended for something she did in the group meeting (even just showing up), reinforced for something she did during this home visit, and given a suggestion of something she could try based on the video or what was happening right then in the home. The group discussions were regulated to be in each mother’s ZPD. Mothers served as positive examples for each other, and reflective processing occurred without children being present.

The group teaching included learning to communicate more effectively with professionals – as a way of gaining agency with them. An unexpected outcome was that the mothers made friends in the group and began to help each other outside of group meetings, for example with child care, and to meet each in town and at medical appointments. A social network was formed. Unlike formal parent education, the topics for discussion were selected ad hoc based on mothers’ immediate concerns and problems. Because the groups were on-going with members joining and leaving at different times, as mothers gained skills, they became leaders to their peers. There was also a strong element of what Robson later formalized as co-production (see below) in which the mothers strongly influenced the topics and structure of the home visits and group meetings. The limited data indicated that the parental intervention was successful for children’s development [32]. But when passed to another group leader, it was difficult to write directions for what was spontaneously generated, and the groups were soon discontinued. Understanding the role of leadership might be important [33].

A series of pre-post evaluations of teaching techniques using the mother-infant videos [34] demonstrated that positive reinforcement did not change parental behavior and self-rating scales led to improvement on the rated behavior. Role playing in which mothers first pretended to be a child and then the mother led to dramatic improvements in mother’s dyadic synchrony; today we might call this ‘embodied empathy’. Strikingly, instructional material attuned to mothers’ reading skill and need for images made no difference in maternal behavior at all and demonstrations or modeling of desired behavior reduced mothers’ dyadic synchrony with their children. Later research using these videos revealed that maltreated children often used false positive affect and compulsive compliance [35]. It should be noted that this service was not university-based, did not have research funding, and none of the professionals were trained to do research. But knowing what was effective – and what was not – was important and so research was done and reported. Moreover, every mother was invited to participate in future research that she was told would be unlikely to help her but might help other families. Almost every mother signed consent to be contacted for this research, showing willingness to give of themselves to help others.

3.2 Court procedures to divert children from foster care

Keeping children in their extended families is generally better than placing them in stranger care in terms of fewer psychological and behavioral problems, less placement disruption and higher reunification rates with birth parents [36]. Several court-based procedures have been developed to promote ‘kin care.’ Family Group Conferences originated in New Zealand as a means of reducing the high number of Maori children in care. Following traditional Maori decision-making, family group conferences decide who in the family can best look after a child. This idea is now used in many countries, with fewer children whose families had kin conferences going into care than other children [37]. UK courts use Special Guardianship Orders to give relatives legal custody of a child without adoption. In a decade, the number of such orders has overtaken the number of adoptions [38], with lower disruption rates and lower costs than foster care [39]. Nevertheless, there is concern that this reduces permanency. American Family Drug Treatment Courts promote permanence during care proceedings by having parents with addiction attend a court service using a non-adversarial approach from a multi-disciplinary team specializing in addiction. The same judge deals with their case throughout and conducts regular reviews without attorneys. The 5-year effect is generally positive [40] with four times as many children reunited with their parents as matched comparison children and half as many placed in foster care [41].

Northern Ireland attempts to obtain more accurate, non-adversarial evidences by jointly instructing expert witnesses; all parties to the proceedings generate the list of questions for expert witnesses, including a final question “Is there anything else you think the court needs to know regarding the placement of the children?” Witnesses are paid by equal contributions from all parties, thus ensuring that witnesses have no monetary loyalty of any person or outcome. When Family Functional Formulations (see 4.2 below) are offered, the assessor is almost never called to deliver testimony in court. The courts have been generous with funds for thorough assessment but coming so late in the process of supporting families, preventive work that could have been done earlier is often no longer possible at the time of court proceedings. Such thorough assessment is highly recommended but would be better placed near intake when preventive work can best be accomplished.

3.3 Readiness for change

Finally, rather than using parenting assessments to determine whether children should be removed to foster care, a pioneer project in the UK used assessment to identify parents’ readiness for specific services, leading to more attuned service delivery, improvement in outcomes, and reduced costs [41]. Using Sure Start funding, this assessment-for-intervention protocol led to services based on parents’ skills, needs, and readiness to learn. This idea developed into brief Screening Functional Formulations and diagnostic Family Functional Formulations. Although the data indicated positive outcomes, this UK program was discontinued when the entire Sure Start initiative was defunded.

3.4 Normative approaches seeking change through mandated programs

In 2010 the Italian government, in collaboration with the University of Padova and with several local administration and social services, launched the Program of Intervention for the Prevention of Institutionalization (P.I.P.P.I) [42]. The goals were to update interventions for neglectful families and to reduce harm while keeping the children at home. The four main types of new planned interventions were: (1) professionals working in the family home; (2) groups for parents and children; (3) collaborations between schools, families, and social services; (4) supportive families. The program also aimed towards standardized family assessment.

These efforts have not yet yielded satisfactory results. Among the probable reasons for limited progress are insufficient education of workers, insufficient funding of the services, inefficient communication between clinical, child protection and justice services, and lack of efficient monitoring of the developmental pathways of children removed from the families. In other words, better training, better communication, and more money were needed.

In the absence of reliable data, ideologies clash in the public debate when single cases of children removed from the families make the news. For example, in response to the reaction to a 2019 scandal [43, 44], the Piemonte region approved in 2022 a regional law called “Zero separation: Interventions to support parenthood and norms to prevent separation from families of origin”, which includes the provision of housing and financial support especially to marginalized groups. Such laws bring psychosocial priorities and legal constraints into greater agreement [45].

These laws are coherent with many of the recommendations in this paper, except the co-production principle. They appear to be “top-down” approaches to the problem, that are extremely progressive in principle, but may be slowed down or even halted by lack of cooperation from the workers who are not part of the origin of the programs. It might be necessary to ensure that professionals contribute to new programs so that they ‘buy into’ the solutions.

4. Tools to support alternatives to foster care based on family strengths

Most assessment is directed to parental deficits and child needs. To prevent parent-child separation, there needs to be a shift towards an assessment protocol that focuses on parents’ strengths and readiness to learn.

4.1 Preventing foster placement by re-defining family problems

Defining family problems in terms of child maltreatment or parental psychopathology focuses professional attention on deficits, with current understanding of deficits being based on behavioral symptoms, not etiology. The efficacy of symptom-focused treatment is limited to a few studies, most of which are methodologically flawed, and provides only limited support for the interventions, e.g. for violence reduction [46]. Furthermore, group effects do not identify individual outcomes.

A framework for functional diagnosis is needed. It should seek to understand why particular behavioral symptoms develop and what purpose they serve for the functioning of each family. The Dynamic-Maturational Model of Attachment and Adaptation (DMM) [47] explains maladaptive behavior in terms of response to danger, i.e. adverse childhood events (ACEs) [48]. Danger is considered a normal part of life, and the human brain is seen as evolved to predict danger, cope with dangerous circumstances, and learn from dangerous experiences to protect self, partner, and progeny.

When children are unprotected and uncomforted from danger, they develop self-protective strategies to increase their safety and comfort. These strategies rely on quick ‘rules’ (psychological short-cuts) to make predictions. We propose that parents whose behavior does not protect and comfort their children often use outdated self-protective strategies that they learned as endangered children. In some cases, this is identified as maltreating behavior or symptoms of mental illness. We propose that teaching parents to better protect and comfort themselves in the present can free them from the psychological short-cuts, learned in the past, that lead to dangerous parenting behavior.

4.2 Preventing foster placement by assessing needs

Selecting interventions to enable parents to learn new self- and child-protective strategies is a difficult, but crucial, task. Learning occurs best when the gap between what has been learned already and what is to be learned next does not require a leap for which there is no bridge. The optimal gap is the Zone of Proximal Development. In cases of inadequate parental caregiving, the ‘learner’ is the parent and their ZPD determines which interventions will be most successful.

When children’s needs are beyond parents’ current ZPD and interventions are selected based solely on child needs, parents can be expected to fail to benefit from intervention. We propose that choosing services based on child needs can lead to repeated parental failure as one service is followed by another, and the goals of treatment are not met. A possible outcome is that both parents and professionals feel that change is impossible. When this happens, professionals sometimes seek foster care for the children. We think this mutually defeating process can be prevented by choosing interventions based on parents’ ZPD and offering protective services while parents are learning.

We suggest evaluating parents’ readiness to learn by framing family problems using a developmental and systemic perspective to understand both the array of specific problems that the family faces and a probable critical cause [49] of the problems. Addressing the critical cause can streamline the course of intervention by focusing action to create a cascade of changes that do not require additional interventions. Three increasingly detailed approaches are recommended:

4.2.1 Level of family functioning (LFF)

Level of Family Functioning (LFF) [33] is a global assessment completed by a family’s social worker based on the case record, presenting problem, and 2–3 initial home visits. It places a family at one of five levels, each pointing to parents’ intervention needs and likely period of needing managed services (see Table 1). Levels 3–5 (Restorable, Supportable, and Needing New Services) are relevant here. Knowing a family’s LFF would promote better service planning by ordering appropriate services. Strikingly, parent education is most suitable for Levels 1 and 2 and least suitable at Levels 3–5. Ironically, it is often used first for everyone because it is inexpensive. Unfortunately, that wastes funds and adds to parent-professional friction when parents are not able to extract and use the self-relevant information. LFF 3–5 families need participatory interventions, practical household services, and sometimes psychotherapy for the parents. Using the LFF can reduce wasted services, wasted money, and parents’ and professionals’ experience of treatment failure.

I. Independent and Adequate

Families in this category are able to meet the needs of their children by combining their own skills, help from friends and relatives, and services which they seek and use. Such families, like all families, face problems and crises. It is their competence at resolving these problems which makes them adequate.

II. Vulnerable to Crisis

Families in this category need temporary, i.e., 6 months to a year, help resolving unusual problems; otherwise, the family functions independently and adequately. Examples of common precipitating crises include birth of a handicapped child, divorce, loss of employment, death of a family member, entry of a handicapped child into school, and sexual abuse in day care of a child. Because each of these crises could result in chronic problems, it is the nature of the family’s response, not the nature of the crisis, that results in the classification.

III. Restorable

Families in this category are multi-problem families who need several types of training in specific skills or therapy around specific issues. Following intervention, it is expected that the family will function independently and adequately. The period of intervention can be expected to last 1–4 years and require active case management to organize the sequence of service delivery and to integrate the services.

IV. Supportable

There are no rehabilitative services which can be expected to enable these families to become independent and adequate. With specific on-going services, the family can meet the basic physical, intellectual, emotional, and economic needs of their children. Services, and management of those services, will be needed until all the children are grown. Examples of supportable families include those with a mentally retarded mother, a depressed mother, or a parent who abuses alcohol or drugs chronically.

V. Needing New Services

There are no existing services (in the family’s locality) sufficient to enable these families to meet the basic needs of their children. New services should be tried or, if permanent injury or death are likely and imminent, permanent placement of the children in another family should be sought.

Table 1.

Levels of family functioning.

4.2.2 Screening functional formulations (SFFs)

Screening Functional Formulations (SFFs) are quick screening procedures that ensure wide coverage of relevant, but often overlooked, topics. SSFs consist of 10 topics: (1) presenting problem, (2) the family structure, (3) the history of danger for the adults (ACEs), (4) unfulfilled family needs, using Maslow’s Hierarchy of Needs (see Figure 1) [50], (5) somaticized expression of distress, (6) children’s perspectives (considering their maturational level), (7) the use of sexuality by each family member (e.g., arousal regulation, self-comfort), (8) developmental transitions for each family member, (9) conflicting responsibilities of the adults, and (10) the appropriateness of specific interventions for family members (using the Gradient of Interventions (see Figure 2) [47]. In a written summary, the 10 topics are described in no more than 300 words by the family’s primary worker. Then an intervention plan is made or, when a critical cause of the problem cannot be defined or too many important questions remain, a full Family Functional Formulation (FFF) is sought.

Figure 1.

Maslow’s hierarchy of needs.

Figure 2.

Gradient of interventions.

4.2.3 Family functional formulations

Family Functional Formulations [51, 52] use detailed diagnostic assessments of the entire family. FFFs are needed most often by those families at LFF 3 that have especially complex problems (most LFF 3 families do not require an FFF). FFFs use formal DMM diagnostic assessments for all family members and relationships. These attachment assessments are best evaluated by ‘blinded’ coders who are not biased by pre-existing information. A FFF can identify both the basic strategies used by family members, and the adaptiveness of the strategies in the current family context. A particular advantage of DMM diagnostic assessments is that they can identify active psychological traumas and losses as well as pervasive distorted states of mind, such as depression. These can derail a parent’s usual strategic functioning and result in dangerous parenting behavior.

With good, detailed intake assessment, case workers can select interventions suited to adults’ ZPD and provide services to keep the children safe until the parents have learned to care adequately for their children. Investment in early assessment can have profound long-term impacts by preventing foster care, reducing costs, reducing professionals’ distress, and, most important, protecting vulnerable children and their families. This is the opposite of the common practice of using inexpensive services first and assessing fully when all else fails.

5. Alternatives to placing children in care

In this section, we describe types of initiatives that have prevented the need for foster care. They are ordered from narrowly focused to broadly integrative.

5.1 Learning to observe and reflect

The 1-2-3 intervention was developed by Helen Johnson with Patricia Crittenden in response to a court request for an intervention to assess one mother’s relationship with her child, prior to deciding whether to reunify them. Ms. Gotwel had resolved her addiction problems and sought reunification with her 3-year-old daughter Claire whom she had not cared for since infancy. This bespoke intervention was later named ‘1-2-3’ and adapted for other families seeking reunification with their children. The central idea of 1-2-3 was to provide a personalized, sensitive response to each dyad’s needs regarding their relationship. 1-2-3 used a 5-minute video-recorded interaction Toddler CARE-Index (TCI) [53]. The TCI consists of 3 minutes of play, 1 minute of parent-introduced frustration, and 1 minute of repair.

The 1-2-3 intervention built on the quality of the relationship between mother and daughter by working within Ms. Gotwel’s ZPD, as opposed to the more usual approach of organizing intervention around the child’s needs. The goals were to help Ms. Gotwel to (1) increase her awareness of her own thoughts and feelings, (2) explore her child’s perspective, becoming aware of her likely thoughts and feelings (i.e., theory of mind work), and (3) lastly recognize what motivated her own behavior with her child (i.e., noticing when her behavior was self-protective versus child-protective). The structure of the TCI permitted the professional to begin by focusing on only the relatively positive play section, then move to the more challenging frustration and repair sections.

The professional replayed the TCI several times, sometimes in slow motion, asking Ms. Gotwel to describe what she saw. Step 1 was focused solely on identifying and naming hew own feelings, without any evaluation or approval/disapproval. Ms. Gotwel chose the moments to watch. Once saying how she felt became easy, the professional chose more challenging moments when Ms. Gotwel had negative feelings. This order is important for enabling parents to discover and accept negative feelings. Step 2 was to consider how Claire might have felt in the same moments. Step 3 was to consider whether Ms. Gotwel’s actions had been self-protective or child protective. Self-protection was treated as a legitimate reason for acting, but one that a parent should be aware of.

After Step 3, Ms. Gotwel was ready to think about what she wished she had done. This enabled her to practice problem solving when things did not turn out quite as she had wanted, but to do so in a reflective manner and without Claire being present. These steps were repeated many times with new TCI videos taken by Ms. Gotwel.

The 1-2-3 intervention initially involved the professional establishing, as far as possible, a sense of safety in the parent-professional relationship so as to support the parent’s capacity for reflection and exploration. This meant that Ms. Gotwel must not feel judged for negative feelings or behavior. To the contrary, she was praised for her recognition of these. This is especially important for birth parents seeking reunification because they all will have experienced negative evaluations and been judged to be inadequate.

To evaluate treatment efficacy, the professional observed (a) Ms. Gotwel’s capacity for concrete reflection, (b) Claire’s ability to play and explore with her mother without exaggeration or inhibition of negative affect, and (c) the degree of dyadic synchrony in their play. Because Ms. Gotwel did the filming on her mobile phone and the sessions took place over Zoom, this was a relatively low-cost intervention.

After 3 months, the court reunited Claire with her mother. One year later social services were discontinued.

It was crucial that Claire’s foster parents were also involved. In this case, the foster parents were Ms. Gotwel’s brother and his wife. They had cared for Claire since she was an infant and had expected to adopt her. They felt angry and betrayed by Ms. Gotwel seeking reunification and believed that she could not care adequately for Claire. It was vital for Claire’s well-being that they did not pass their negative views to her, and that Claire maintained relationships with them.

Through listening and joint visits, the professional helped the foster parents to understand Ms. Gotwel’s perspective and acknowledge the changes she had made. Conversely, Ms. Gotwel was able to see the importance for Claire of her relationship with her foster parents and Claire’s need for it to be sustained. Although Claire’s foster parents were family relatives, reducing the impact of separation on children and maintaining the relationship between children and foster parents are always important.

A similar, more structured, 10-week home visiting program in the United States is Promoting First Relationships (PFR) [54]. PFR is an attachment-based intervention that focuses on parents’ reflective capacity using videorecorded observations of parent-child interaction. Every other week parents are videorecorded playing or interacting for 10 to 15 minutes with their child. The following week the parent and provider review the unedited video. PFR trains providers to use ‘reflective’ questions to help the parents pause and consider their own feelings and needs in the moment and the feelings and needs of their child. Reflection is particularly potent when the interaction is strained, or the child is displaying distress. Providers use parents’ reflections to more deeply engage and support parents’ insight and understanding of themselves and their child. PFR providers are also trained to provide strengths-based feedback to develop confidence and competence, beginning in the parent’s ZPD. In a recent randomized clinical trial of PFR in a sample of reunited birth parents, one parent said:

I get it now! I get him! I want to think about him in a different way. It helped me to step back, take a breath, evaluate the situation and understand the situation, why is he acting this way? Is he scared? Is he stressed? Does he need me? It makes it a little more comforting in the situation--and for him, he is more happy and secure, knowing that mom gets what I’m saying or why I’m acting this way. I get him now ([55], p. 25).

Five randomized control trials, two within child welfare populations, demonstrated that Promoting First Relationships improved parent-child relationships, increased parent’s knowledge of child behavior and social-emotional development, regulated child stress physiology, and improved child behavior. Importantly, PFR also reduced foster care placements by 2.5 times and supported greater stability of foster care placements once they occurred [21, 55, 56, 57, 58]. PFR had very high retention in child protection populations and high rates of satisfaction, because it is strengths based and supports parents in their ZPD. Such evidence is invaluable to buttress the argument that supporting parents in their capacity to safely reflect, in their ZPD, produces desirable outcomes including reduction of placement into foster care.

5.1.1 Commentary and variations

No intervention works for everyone. In this section, we describe the central features of an intervention, its limitations, and ways that it can be modified.

5.1.2 Video feedback

Video feedback is commonly used now, but it can be ineffective or even have undesirable effects. Play-based interventions involving professionals modeling positive interactions might undermine parents’ sense of competence and are unlikely to address reflective integration and problem solving. Video-feedback using only the best moments between parents and children provides fewer opportunities for understanding negative emotions and motivations.

The 1-2-3 program was devised for a specific case because existing interventions did not appear helpful; it began with parents’ understanding of themselves, following that with parents’ understanding of the child and then more general reflection. The outcomes are anecdotal. PFR focuses more on reflection and has sound, wide-ranging evidence of positive outcomes.

Both 1-2-3 and Promoting First Relationships are tailored to each family. Both are simple, low-cost interventions that can be used when parents wish to improve their relationship with their child. They might not be suitable when parents do not want to change themselves and instead seek to change their child. Nor do they directly address tangible needs (food, safety, housing), but they can be combined with case management and other services.

5.2 Fostering families

Fostering Families in the UK is intended to implement ideas presented by Crittenden and Farnfield [59] to expand the definition of fostering to include long-term support to the whole family. The aims were to increase safety for children living with their biological family and prevent foster care with strangers. The project had three crucial components: (1) Whole family focus: parents and child’s needs are not seen competing with one another; carers focus on strengths and connection; (2) Transitional attachment figures: long-term support by a single person allows carers to act in the interest of the whole family and be trusted by family members; and (3) Long-term support: many families require support for longer than stipulated by agencies. Fostering families is temporally open-ended. When the FFF indicates, support may be available until the children are grown.

Families referred to Fostering Families are under child protection supervision and assessed as either ‘restorable’ (LFF 3) or ‘supportable’ (LFF 4). Typically, they lack kin support. Carers are recruited, assessed, and supported like foster carers, including access to training and support groups; their families are also involved. Each carer is matched to one family in need. The carers’ minimum commitment to families is 2 years for at least 15 hours per week, but often it becomes substantially more.

The activities vary to meet specific family needs, including travel to appointments, housework, and freeing parents to spend quality time with their children. The relationship is given time and space to develop as the two families merge, making it possible for the distressed family to experience a kinship connection with the fostering family.

5.2.1 A case example

Ms. Downs (19y) struggled with low mood, suicidal thoughts and managing day-to-day care of her children, Isla (3y) and Alfie (1y). The children’s fathers were unknown and there was no other family support. Child Protection was concerned that the children were being neglected. In her own childhood, Ms. Downs had been separated from her birth family as an infant and placed in foster care; at 2 years of age, she was adopted by another family. When she was 12, she reported being abused by her adoptive parents and was placed in another foster home. She then had multiple different foster placements until she was 16 and became pregnant with Isla.

Initially, Ms. Downs was reluctant to accept a referral to Fostering Families. However, she wanted life to be different for her and her children. She wanted to enjoy spending time with them and have the patience to play with them. She wanted a tidier home and she wanted to feel more confident tackling daily tasks.

The Downs family were matched with an approved Fostering Families carer. Ms. Hopewell was 20 years older than Ms. Downs and had herself been a single mother. The ‘click’ between them was immediate and has lasted. During the first 6 months, radical change occurred for the whole family. Ms. Downs seemed happier and took better care of herself. She and Ms. Hopewell cleaned and organized the home, improved the children’s nursery school attendance, and spent time together in the community. Ms. Hopewell invited the Downs family into her wider family, including family gatherings. Occasionally she offered overnight care to the children, so that Ms. Downs could have time to herself or with intimate partners.

After 2 years, there was no longer a plan to end Ms. Hopewell’s involvement. Home conditions and school attendance fluctuated, depending on Ms. Downs’s mental and physical health. Ms. Downs had several partners move into the home and leave again, usually following domestic altercations. At three and 5 years of age, life for Isla and Alife was in many ways just as, and sometimes more, challenging than it had been before Ms. Hopewell became involved. However, Ms. Hopewell remained in their life, offering time, care, love, and support to the whole family. This added the essential elements of safety and stability, enabling the children to stay with their mother. Ms. Downs sometimes did not accept specific practical elements of support, but she remained in almost daily contact with Ms. Hopewell. It seems important that compliance is not the criterion for success, as it often is when cases go to court. Ms. Hopewell offered to formally foster Isla and Alfie if that ever became needed.

Creating a safe network around a distressed family through the relationship between Ms. Hopewell and Ms. Downs and her children reduced the potential for repeated separations involving short-term foster placements with strangers, particularly strangers from a different social class or cultural group.

5.2.2 Costs

The cost differential between fostering a family in their home and fostering children outside the family is impressive. Two years of Fostering Families support for Ms. Downs’s family cost £47,200 (~$60,000) whereas foster care for her two children would have cost £62,960 (~$80,000), plus the substantial cost of court proceedings.

5.2.3 Commentary and variations

Ten Fostering Families carers have been approved to provide long-term support to vulnerable families. Such families have an opportunity to remain together, unharmed by repeated separations. Child protection workers reported feeling hopeful and inspired by the opportunity to fulfill their values and principles of care which led them into their profession. There are increasing numbers of enquiries about Fostering Families as an effective and less expensive alternative to foster care. When applied to other families or by other localities, the details of training, intake, and contractual agreements can vary to fit needs.

5.3 Engaging distressed families with each other

The Mockingbird Society in the USA sought to improve the stability of foster care and reduce youth homelessness from placement breakdown or running away. To do so, it established ‘extended families’ of six to eight foster families supported by a ‘hub home’ of trained carers. The hub functioned a bit like an extended family, but with skill-based leadership.

The trained leaders, who were foster parents themselves, emphasized social networking, shared activities and ‘normalizing foster care’. Preliminary findings suggested no differences in foster breakdown or running away for the Mockingbird children versus a comparison group. On the other hand, this program did support foster carers and the children found it easier to contact their birth parents and siblings than traditional foster care [60]. A cost-benefit analysis of the Mockingbird Program found no difference in costs.

5.3.1 Commentary and variations

The crucial question is whether this model can be adapted to support distressed biological parents with their children. The goals of social networking and shared activities might be more appropriate for troubled biological families than foster families (who have been selected partly based on their already having such skills). The hubs might promote both practical information and skills and a focus on relationships. The hub would create a network of connected families, rather like an extended family. Over time some ‘graduate’ biological parents could mentor families coming onto the network while other families might need support for a long time, even as long as childhood. This requires society’s long-term commitment to children and their families, including a fundamental shift in power away from professionals towards skilled foster carers and biological families.

5.4 Family-centered social work

Love Barrow families (LBf) [30] is the most ambitious of the alternatives that we present. LBf is a community-based pilot service to 20 families living in a severely under-resourced neighborhood in the UK. Statutory service providers jointly funded intense service delivery for very troubled and complex families to test whether coordinated, strengths-based delivery of comprehensive and integrated services would have greater impact than multiple assessments and services delivered by different agencies. The families were deemed “complex” due to intergenerational involvement with mental health and social services.

5.4.1 Setting up a new service delivery process

Initially, a group of community families involved with local services worked with local service providers and executive directors in health and social services to co-design a different approach. Data from adult and child mental health services, child protection and child-in-need cases was reviewed and shared to identify 20 families with complex unresolved problems. Resources from the services were then pooled and reorganized to co-locate a team in the community to implement the top priorities identified by families:

1. Compassion and understanding: this underpinned everything, and without these, the other priorities would not be helpful.

2. Teamwork: A team that integrated child and parent services, providing 24-hour support when needed.

3. Local input: Services developed to meet local needs.

4. Protecting families from removals: The Team agreed not to take children away without first being open and clear about their concerns. Families was not to be afraid of having children taken away; they wanted honesty and clarity about professionals’ concerns so that they could address them and not lose custody of their children.

5. Transitional attachment figures: A trusting relationship with one main professional, i.e., a transitional attachment figure for the parents who then also coordinated all other services.

The service reflected the National Health Service (NHS, UK) integration agenda at the time [61] and was intended as a catalyst for wider reform across the region.

5.4.2 Implementing the new service

The team included a lead social worker, a child and adolescent mental health professional, a systemic psychotherapist, and a consultant psychiatrist, in addition to a number of family workers. Families were assigned a qualified and trained keyworker (who functioned as a transitional attachment figure) based on the presenting issues and needs. Child protection social work, adult and child mental health services, and child-in-need social work were then managed through the project head (Robson) who was employed and managed by the NHS, i.e., within statutory services rather than outside of it.

An occupational therapist, family worker and community support worker were assigned to the team from the adult mental health service. They provided day-to-day support to families as part of the plan which was reviewed and adapted week-to-week to ensure that actions were within the parents’ zone of proximal development, were implemented in small manageable steps, and met all statutory requirements.

The project developed one initial psychosocial assessment protocol, rather than the separate assessments used by mental health and social care. This prevented families from having to tell their story repeatedly and brought the information about adult and child functioning into one place. Alongside this were the DMM assessments of attachment which provided a FFF to guide the selection and sequencing of services.

Among the innovative approaches were access to staff during evenings and weekends, group indoor and outdoor activities. Because they have been strongly associated with good mental and physical health but are infrequently included in case planning [62]. A donated building in the neighborhood provided office space for the staff and a safe, accessible meeting space for families and group activities. When the family workers led walks for the parents and children, they hit the mental health jackpot: physical activity, outdoors, in a social context, with an attachment figure leading the group. If someone brought a snack to share, that person experienced the advantages of giving. Such activities aren’t in the usual repertoire of mental health professionals, but they lay a basis for good mental health both during and long after the intervention.

The principles of co-production [63] were adhered to by the LBf team so that the service was collaborative and reciprocal - families’ views were sought constantly and used to shape intervention and learning. Co-production principles also meant that parents wanted to contribute and knew that their skills were needed. They became volunteers, cooking, painting, organizing activities and giving visitors a warm welcome. They also offered practical support to one another when needed, changing lightbulbs, knitting baby clothes or being a listening ear. These forms of agency can transform a person from the object of professional attention to an important person who contributes to the well-being of others. Pride, based on performance, lends dignity to everyone, but is especially needed by distressed parents.

One of the outcomes that families described was the sense of belonging that they experienced. Parents who experienced this wanted to pass it on to others. One example was a father who went to a medical appointment and, when he saw another family struggling, he put a note on their car under the windscreen wiper with LBf’s contact details. A further example of the ethos being enacted between one parent and another was the relationship that grew between two men, one younger who had been abstinent from alcohol for over a year and another older who was in ill health due to his drinking. When the older man lost his sight, he would come in with the letters from the children’s home where his son lived and the younger man, knowing how precious these letters were to him, would sit with him and read them to him.

Eventually, two of the original parents were employed by Love Barrow families and became valued members of staff.

5.4.2.1 A case example

Ms. Seback (32y) and her three children were referred to LBf due to longstanding concerns of emotional abuse and neglect which had led to the threat of court proceedings and removal ([52], pp. 353–334). Ms. Seback herself had been in foster care when she was a child - as had her mother. Ms. Seback and her children reached a crisis when the eldest child threatened his mother and sister with a knife and was placed in foster care. All the children were subject to child protection plans which were transferred to and jointly managed by the LBf transitional attachment figure.

Ms. Seback’s DMM Adult Attachment Interview (DMM-AAI) revealed a history of overwhelming abuse and psychological trauma leading to a disconnection from her feelings and a coping mechanism of “putting things into boxes”. The DMM-AAI helped the team to understand Ms. Seback’s terror at her son’s behavior which ultimately required her to look at the memories that she had locked away. In an amazing moment, Ms. Seback was recalling her feelings about being in foster care when she suddenly wondered if that was how her son felt. That moment of empathy [64] changed the direction of therapy and of her behavior with her son. However, understanding and empathy alone are not enough. Alongside Ms. Seback’s therapeutic support, the family also needed hands-on daily practical intervention in the home. The psychological understanding provided by the FFF was used to guide the practical interventions and ensure that they were within Ms. Seback’s ZPD. A further consequence of this way of working was that the whole staff team benefitted from the understanding provided by the FFF which enabled them to understand why Ms. Seback and her children behaved as they did and supported them to manage risk meaningfully. After 9 months of intensive support, Ms. Seback’s son was returned home and, 6 months later, the child protection cases were closed for all three children.

5.4.3 Outcomes and cost

An independent evaluation of LBf by the University of Northumbria outlined the reduced health and social care costs with this family and included a cost saving of £89,000 (~$113,000) for children’s social care and a reduction in the number of agencies involved from nine to just two [33]. A further pertinent outcome was the reduction in mental health and physical health appointments for both Ms. Seback and her children. During the intervention, Ms. Seback had lost a significant amount of weight and was no longer reliant upon mental health medications. She expressed her view as to why she felt that the approach taken by LBf helped her when other interventions had not: “Well, I’m not text book, I am unique” [65].

LBf’s evaluation evidenced that overall LBf prevented nine children from being placed in foster care, plus the reduced costs of eliminating child protection plans and other savings across services. In total, LBf cost £250,000 (~$316,000) per year, saving £100,000 (~$126,000) compared to standard service [65].

There was also an 85.3% drop in referrals to adult and child mental health services outside of the team and a 40% reduction in absences from school. There were reductions in the number of crises experienced in families including domestic violence, reduced crime and anti-social behavior, and the number of professionals involved with each family outside of the LBf team. There was also an increase in engagement with local community resources, volunteering, and employability. Volunteering was a surprise benefit; distressed families benefitted from being givers instead of only recipients. Child Protection knocking at your door is not only terrifying; takes away your dignity. Giving to someone else restores it. Families reported that the sense of belonging that they felt to the LBf team meant that they felt able to make changes and they all felt that the co-produced design of the project meant that the priorities identified at the outset were their own [65].

The savings in reduced suffering cannot be calculated and do not end when the program ends. Indeed, the real effects of LBf can already be seen in the next generation. Ms. Seback’s daughter now has two children of her own, both of whom are thriving and not subject to any statutory intervention.

5.4.4 Commentary and variations

LBf came about largely through the enthusiasm and commitment of two social workers working with local families and professionals in the health and social services. Someone needs to show dedicated leadership for such programs to succeed. The evaluation attests to the success of co-production of the service and responsiveness of the service to individual needs, cutting across agency limitations and barriers. The challenge to localities and the NHS is to enable services like LBf to become mainstream and change the wider culture and to be less dependent on specific leaders. Given the need for service and general agreement that current service provision is unsustainable [12, 66]. LBf’s success is important. LBf highlights the knowledge, passion, and commitment of both helping professionals and the families who come to them; it demonstrates what is possible when families and professionals work together to solve local problems.

5.5 Supporting families

5.5.1 Stuck in a double-bind

Even after years of work, some families continue to face serious problems that threaten their children’s well-being. The reasons include generational cycles of family distress, poverty, and structural inequalities [12]. Persistent failure to find relief can block engagement with social services, but when families withdraw, professionals have less information to guide appropriate service referrals. This can result in a double bind of parental resistance and non-compliance eliciting more professional control that produces more resistance.

5.5.2 Breaking the bind

To break this cycle, Rethinking Families, a UK initiative (Ellis), re-conceptualized child protection as family support, including exploring the functional meaning of problems and choosing responses that fit parents’ ZPDs, without triggering their self-protective strategies. The critical cause of change was providing key workers who built enduring and trusting relationships with parents, i.e. transitional attachment figures, while providing services that ranged from practical day-to-day support to therapeutic interventions. A psychiatrist and experts trained in DMM assessments were also available.

5.5.3 Assessment, service, and success

The referral criteria required that parents be willing to engage and try something different. Parents who misused substances, had intellectual disabilities, or sought to change others but not themselves were excluded. Fourteen families were identified as ‘supportable’ (LFF 4). These families had entrenched problems with the risk of foster care for the children. Using the Gradient of Interventions (see Appendix 2), most needed adult psychotherapy, indicating that they were not aware of their maladaptive behavior, nor the reasons for it. It was difficult for key workers to engage these parents in transitional attachment relationships because the parents feared the power of workers to remove their children. This threat had to be taken off the table. Daily worker support prevented potential threats from becoming critical.

The Petty family was subject to a Pre-Proceedings Protocol, with placement of the children under consideration because two children were involved in drug trafficking. The key worker’s effort increased school attendance, improved parental mental health, and strengthened family relationships, resulting in the family being moved from the Pre-Proceedings Protocol to a ‘Child in Need’ (a less urgent category) plan. There continued to be fluctuations in progress around drug use, the parental relationship, financial support, and physical neglect; these became the focus of continuing work. Almost daily social work support prevented these threats from becoming critical.

The Painter family was also subject to the Pre-Proceedings Protocol, with plans to remove the four children. After 2 years of Rethinking Families, the mental health and emotional well-being of the mother and the youngest three children had improved such that they were no longer on the edge of care. The 13-year-old girl remained troubled. She self-harmed, but this improved when her artistic talent was discovered and fostered. This enabled her to express herself more fully. Notably, only an out-of-box program could identify and meet her needs. School attendance improved for all the children.

In the Newtry family, one of the children was formally placed with his grandmother, with the other three having Residence Orders. The basis was concerns about intergenerational trauma, child neglect and emotional harm. Foster care was expected; it would have augmented harm to the children [66]. With intensive support, the home conditions, physical care, and supervision of the children improved considerably. Family conflict diminished and the children attended school regularly. The family’s status was upgraded to ‘Child in Need’, without expectation of foster care.

These results used key workers to meet unique family needs. The services were not time limited and were built on family strengths (like art lessons). Housekeeping, taking children to school, offering out-of-hours services, and small grants to cover urgent family needs are not typically offered by agencies. The parents’ trust of the key worker signaled to the children that cooperation was safe, thus permitting them to make relationships. Change was a progressive and recursive process, achieved through small steps.

A financial analysis estimated savings of more than £3.5 million (~$4.4 million) from the 41 children remaining with their families after the 2-year pilot [67].

5.5.4 Discontinuing the service

After 2 years, Rethinking Families was discontinued. Understanding the reasons is important for planning future service. Four problems stood out. First was staff turnover. The emotional effort of working in such intensive ways took a toll, especially when workers had personal vulnerabilities. Relational continuity was considered a key factor for sustaining change, yet over time, it could not be provided. Many workers became more involved than the word ‘transitional’ attachment indicated. Ms. Hopewell provided a better model because she understood and accepted the limits to advising an adult child. Professionals more often expect compliance. Second, it was hard to recruit staff for service on evenings and weekends, when it was most needed. Third, it was very hard to bring a new model of practice to an embedded service structure with such a small pilot team. Only a few senior managers had a working knowledge of the DMM and were invested in the new service. Maybe applying the principle of co-creation from the start would have engaged them. Fourth, families were not included in the planning so neither senior management nor families were invested in the new service.

5.5.5 Commentary and variations

The primary strength of Rethinking Families was establishing trusting relationships with previously hard to reach families. This was the result of a non-judgmental, non-threatening approach backed by frequent contacts that fit families’ needs. This enabled workers to challenge families’ limitations in ways that showed empathy and demonstrated the process of interpersonal repair. Key workers felt satisfied about working with families in more meaningful and supportive ways. Team members thought that previous work in risk-averse, budget-led, and time-limited services had been detrimental to families.

Difficulties included the contradiction between selecting Supportable (LFF4) families and expecting change as if they were Restorable (LFF3); instead, stabilization with long-term services would have been a more appropriate goal for these families. This misplaced expectation impacted staff well-being and retention. The lack of a manager to liaise with higher management and to ensure on-going funding was another problem. The service was more expensive than standard service unless it was compared to the costs of court proceedings and foster care; long-term budgeting and dissemination of the advantages were needed. A means of providing an on-call service, such as doctors have, was needed for these families in which life-threatening conditions could occur suddenly. The DMM assessments were essential to individualized planning, but the funds and personnel for these assessments were insufficient. Even the notion of early and detailed assessment to prevent foster placement was different from ordinary practice—which tended to withhold expensive assessment until child protection needed to confirm the need for placement. Another problem was defining what was ‘good enough’ to allow children to live with their parents. Rethinking Families defined care as good enough when the children are safe and access to intensive support is available for as long as there are children in the family. That challenged ordinary standards. Possibly less than ‘just barely good enough’ [52] should be the standard for separating children from their parents. This needed to be accepted by higher management for Rethinking Families to endure.

5.6 Repairing the damage of good intentions

A Norwegian case of reunification highlights some reasons to avoid foster care. It also demonstrates the successful application of the ideas in this chapter to repair the harm resulting from foster care [68]. Mr. and Mrs. Ibrahem fled Syria’s civil war across the Mediterranean Sea through Greece to Norway where they hoped to find safety for themselves and their two young boys. Instead, they found life hard, but in unfamiliar ways that they did not know how to manage. They began arguing and sometimes the boys saw their father hitting their mother. Child Protection placed the boys in short-term foster care to protect them and to give their parents time to repair their marriage.

Instead, the marriage broke up. A year and a half after being placed in a Norwegian foster home, the boys were returned to their mother’s care. They hardly knew her, having only seen her briefly and at long intervals, partly because she lived several hours away. She did not know them either; they had changed a lot in 18 months, and she had not been part of their development. Adding to their re-adjustment problems were that the boys now spoke Norwegian and no longer spoke Arabic, as Mrs. Ibrahem did. They had forgotten Arabic because they never heard their native language except during contact. This resulted in many misunderstandings between mother and sons. Plus, they were squeezed into a tiny apartment, the only one Mrs. Ibrahem could afford; in the middle class foster home, they had had their own bedrooms.

The boys did not settle easily, giving their mother the impression that they were unhappy with her. They protested her limits and rules, howling and screaming at her, saying she wasn’t their mother. They punched her and swore. The older boy pointed his finger at her and said he wanted another mom. Mrs. Ibrahem’s emotions overwhelmed her. At 5 years old, her son would not let her touch him while she desperately wanted to hold him. She wondered why he rejected her and blamed herself; she wasn’t told that he had behaved similarly while in care. She was scared that, if child protection saw this, they would take her sons away again. So even though she was very distressed, she never showed or talked about it to anyone, no matter how she felt. That meant no one could help her.

It took an insightful professional (Karlsen) to imagine what Mrs. Ibrahem had not said and both help her to understand what was happening and reassure her that she would not lose her boys again (like LBf). That reassurance made it possible to help her. Together they arranged family meetings so that many family members got involved to help the family (like kincare). The professional helped her get back into motherhood with personalized work so she could become a safe caregiver for her children (like a transitional attachment figure). An immigrant family from Syria was found to help with childcare (like fostering families). The older boy was offered trauma treatment. In addition, the professional believed that the children should have the opportunity to meet with the foster parents to ensure that the children’s lives were connected (like the Mockingbird program). The children saw that their mother and foster parents both loved them and could work together (like 1-2-3). That made all the loyalty issues disappear and Mrs. Ibrahem could begin to talk with her children about their experiences in the foster home. Together, they filled in the missing time when they had been apart. The professional helped the mother to understand that the children’s challenging behavior was related to adverse experiences the children had had in their early years, as well as adaptation to a new family culture and the need to develop relationships with the foster family. She also helped the mother to distinguish between her own needs and feelings and those of her children, and to realize that the children needed her to “see the world” from their point of view (like 1-2-3 and PFR).

It wasn’t easy because Mrs. Ibrahem had had unfortunate relationship experiences in her past. So had her husband; he was later diagnosed with PTSD. Child Protection workers had not understood that life in a war zone and the process of escaping it were so dangerous that psychological trauma was almost inevitable [69]. Mr. and Mrs. Ibrahem had tried to keep their children and themselves alive – and they had succeeded! As Crittenden and her colleagues state in “Staying Alive,” keeping the children alive is the single most essential responsibility of a parent and Mr. and Mrs. Ibrahem succeeded in protecting their children through extreme dangers. They were less able to manage in a safe environment and could not meet Norwegian standards for middle class life. But all of that was known when they arrived in Norway as war refugees! Why could not support and individualized treatment have been offered before the family broke down? Why could not the professionals and court see how protective the parents were and understand their need for protection themselves as they tried to cope with moving from war-torn Syria to foreign Norway? Prevention saves so much suffering – and it costs much less money. It took a year, but now Mrs. Ibrahem and her sons function well. Their case has been closed - but their father is no longer in their family.

5.6.1 Prevention is better than repair

We think preventive service might have preserved the whole family and saved everyone, especially the two young boys, from intense suffering. Moreover, now that neuroscience has made clear that early experience shapes brain development [70], we should strive to ensure that children do not experience traumatizing separation from their parents – and a second separation from their foster parents. Such separations cause avoidable iatrogenic harm. We can reunify families, but we cannot completely undo the psychological effects of adverse experience on developing brains. Fostering the Ibrahem might have worked better than fostering their children.

Everything that the professional did to support reunification is listed in this chapter as an alternative to foster care: extended family support, fostering whole families by culturally similar families, individualized parenting guidance in the parents’ ZPD, individual trauma treatment, joining biological and foster families for the children’s experience of continuity, differentiating parent and child perspectives, and age-suitable talking within the family about the children’s experiences and perspectives. Possibly most important was the shared planning between Mrs. Ibrahem and the professional who worked with her.

All these approaches could have been implemented before separating the children from their mother. All the harm that Crittenden and Spieker [4, 5] found was associated with separation happened to these two boys and their parents: broken parent-child bonds, discomfort with closeness, behavior problems, psychological trauma from separation and distrust of professionals. Why could not these painful outcomes have been avoided by offering alternatives to foster care first?

5.6.2 Commentary and variations

This case is uncomfortably reminiscent of the way Norway, Australia, Canada, and the USA treated their native peoples [5]. Some professionals might think that this case can be dismissed because the family were refugees from a war zone where everyone had suffered psychological trauma. Instead, a close look at the personal histories of maltreating parents [71, 72] and the neighborhoods in which they live [73, 74] indicates that they too live in cultures of danger and suffering that almost always interfere with meeting middle class standards for childrearing. Mrs. Ibrahem chose to share her experience in publication [68]; in doing so, she moved from being the recipient of unwanted services to using her own resources to help others. This is a powerful testimony to the success of collaborative work between parents and professionals.

We think this Norwegian case highlights the changes that are needed in the next generation of alternatives to foster care in many countries. We address these next.

6. Part 5: conclusion

The only person you can change is yourself. This truism highlights the paradox of helping professionals trying to help others to change. Our review of alternatives to foster care suggests several ways that direct service professionals, managers and supervisors, policy makers, judges, and legislators could act to reduce the harm done by foster care. A central advantage of these ideas is that all were generated and implemented by clinicians in their daily settings; these are not ivory-tower, university-based, theoretically structured ideas. Each was built to function in the real and messy world of day-to-day child protection in local settings. Strikingly, all were effective with children and families and all saved money compared to placing children in foster care. Most important, they all reduced the iatrogenic suffering caused by separating children from their caregivers. Children, families, and professionals were all protected by the alternative we offer.

Because none of these alternatives has been implemented widely, despite being more effective and less far less costly than foster care, we also consider limitations to these approaches and the possible reasons why professionals might not use them. We conclude with some specific recommendations for action.

6.1 Ideas to retain in future approaches

Interventions that protected children in economically efficient ways had several characteristics in common. We offer ten basic principles.

1. Both-and solutions: Most important is that these alternatives to foster care were what Crittenden and Spieker called ‘both-and’ solutions [4, 5]; they were not a single best solution, but instead a combination of successful solutions, each fine-tuned to local conditions.

2. Co-created services: The most successful approaches valued parent input from the beginning and throughout; this gave parents agency (a strong mental health benefit) and often improved the service itself. It was also crucial that professionals, at all levels of the service structure, participated in the planning for their locality; this provided a ‘buy-in’ across the professional bureaucracy and community. This was fundamentally different from professionals functioning as a top-down team of service providers, delivering preset or manualized programs, managing services, and separating family members when there was trouble.

3. Whole family focus: In every case, even 1-2-3, whole families were the focus. Indeed, most distressed parents have experienced the very sorts of developmental histories from which we wish to protect their children. For anyone in a family to thrive, everyone must thrive [52].

4. Communication skills: Learning how to communicate with various types of professionals enabled parents to better present their perspectives and receive the services that they needed. Families assessed and treated as ‘supportable’ (LFF4), felt supported.

5. Expanding connections: Successful approaches expanded parents’ support networks, through professionals becoming transitional attachment figures, engaging kin networks, or fostering the whole distressed family.

6. 24/7 availability: A crucial advantage was associated with being available when family problems were likely to occur, that is, on evenings and weekends.

7. Reflective integration: Another important characteristic of successful alternatives to foster placement was parents’ opportunity to observe themselves and recognize, without evaluation, their feelings, especially negative feelings [75]. Having a trusted professional to support reflecting on these and imagining their children’s perspectives elicited theory of mind in both parents and professionals. Imagining how the other person feels is crucial to attuned behavior.

8. Respecting family culture: Respecting families’ culture was central to families’ sense of safety; this included not placing children in homes unlike their parents’ home in social class, religion, ethnicity, etc.

9. University input: Affiliation with a university ensured access to a breadth of ideas, sound design, precise assessment, and critical analysis that yielded evidence about the crucial processes and their outcomes. These could then be adapted for individual professionals and families.

10. Promoting basic mental health: The most successful programs promoted basic mental health strategies as part of the intervention (for example, social connections with friends and family, physical activity outdoors, and balanced and regular meals [62]). LBf’s Saturday group walks did four of these in one easy activity: social engagement with exercise outdoors when parents were not at work.

Money is always a concern. Redirecting money spent on foster care to preventive services could be done without needing additional funds. Similarly redirecting some welfare funds to prevention services would both increase the probability of family competence and independence and also reduce the risk of parents becoming welfare dependent. In both cases, paying entry level workers, night and weekend workers, and experienced supervisors enough to retain and build their skills is crucial; paying staff well is essential to having skilled staff. At the legislative and policy levels, preventive and supportive services should be given funding priority over foster care. Reducing supervisory positions (possibly through attrition only) and reducing record-keeping requirements would change the balance of spending on services versus bureaucratic functions. Consideration should be given to ending foster care, leaving the choices of sustaining families or having their children adopted immediately and permanently. Doing this would stop the dreadful harm of multiple separations. All of these proposals rely on currently allocated funds and offer the possibility of reduced financial needs going forward.

Our final recommendation is to use local co-creation of services to allow variation among services. After several decades of developing (and selling) mandated programs, it might be time to empower the creativity of local communities (from parents to professionals) to address their own problems. Let us treasure variation in people, families, professionals, and programs, highlighting the best in each. Let us find everyone’s unique up-side and build on it. Programs built on principles might be more effective than defined, manualized, and replicable programs that do not have on-going input from service users.

6.2 Improvements to make

Most of these ideas are not new and most are validated in research and clinical literature. It is important to understand why they worked in these situations but did not spawn extensions.

Several conditions might have impeded the acceptance of these alternatives to foster care. One is an implicit, unspoken feeling that parents who endanger their children do not deserve to raise the children or to receive special individualized services. However, most of these parents were once unprotected children, often in foster care themselves, who suffered then and suffer now, as they struggle to do better than their parents did. Unfortunately, the system continues to threaten them, often with very little compassion for their experience. Recognition that today’s distressed parents were yesterday’s distressed children whom we did not protect adequately might help to soften punitive attitudes. Taking parents’ perspective when they receive a knock on the door by child protection might help. As Robson noted for LBf noted, compassion is the essential base upon which everything else is built.

Recognition that separating children from their parents (or threatening to do so) harms both the children and their parents is new and unfamiliar information. Rather than demonstrating that separation is the way to solve problems, the alternatives that we offer can help to prime children both neurologically and behaviorally to seek solutions with family and supportive people. Knowing how much iatrogenic harm is caused by ‘protective’ foster care might change professionals’ recommendations.

Another barrier to reducing the use of foster care may be a societal emphasis on independence, leading to an assumption that meeting the needs of long-term care families (LFF3-5) leads to undesirable dependency. Acceptance that change can take more than one generation is important. It begins with stopping the harm.

The advantage of professionals taking the role of transitional attachment figures was sometimes accompanied by over-involvement and burnout. Having professional support teams [5] that emphasized the limits of professional possibility and responsibility might reduce this source of stress for professionals.

Senior managers and policy makers are crucial for dissemination of new ideas and yet the discussed programs depended more on front-line clinicians and middle managers. Robson (personal communication, January 10, 2024) noted that she was mentored and protected by someone high in the command chain. Political will and leadership are critical to systemic change, yet most leadership is removed from the day-to-day challenge of keeping children safe and families together. We conclude that inclusive decision-making (from families through service providers, managers, local politicians, legislators, and attorneys and judges) generates the most effective programs and leaves no one with too much responsibility.

There will always be children who must be protected from their parents. Because foster care, as opposed to adoption, involves two separations (thus increasing the detrimental traumatic effects on brain functioning), we suggest that foster care not be used at all. Instead, high frequency, even daily, service should be provided. Nevertheless, when the home is so dangerous that even daily home visits cannot protect the children from parental outbursts, permanent adoption should be sought immediately. Because that solution is so drastic, professionals will almost always find ways to help the biological family.

For most troubled families, alternatives will be more protective than foster care. Nevertheless, because no solution can be perfect 100% of the time, professionals must be protected from problems that they did not foresee. Doing so can make child- and family-protection more prominent than professional self-protection. Right now, failure to remove a child who is later seriously harmed can put professionals at risk; laws and protocols that acknowledge the impossibility of perfect prediction of risk and that protect professionals when seriously dangerous outcomes occur are needed. That is, professionals’ need to protect themselves should not put children at greater risk. Including the emotional and neurological harm of foster care in the evaluation of the need for foster care might protect both children and professionals. Our hope is that having safe alternatives to foster care can shift the focus from protecting professionals from blame to protecting children with their families.

Finally, the goals of avoiding foster care must be clear. A central goal is to avoid the iatrogenic harm that professionals cause by separating children from their caregivers. This will also reduce multigeneration family breakdown. Preventing the iatrogenic harm from separation is easily understood. More subtle is that our best services might only maintain the safety of some families without freeing the family needing assistance (Supportable LFF4 families) and that this, too, is a worthy goal. Accepting that can be difficult for clinicians and policy makers who want families to change. Reframing such outcomes as preventing iatrogenic harm can highlight what was gained.

6.3 Limitations

Although we can demonstrate case-based successes and the cost benefits of these alternatives to foster care, we cannot claim that a program’s effectiveness was supported by gold standard research methods. An exception is Promoting First Relationships (PFR). When PFR researchers accessed administrative child welfare data years after the intervention, they found that the PFR group experienced significantly fewer child removals to out of home care. Nevertheless, as encouraging as this finding is, it can only be described at the group level. We cannot determine which specific families will and will not benefit, or even be harmed by, PFR or any alternative to foster care included in this chapter.

The reason is that success was dependent upon individualization of a range of intervention components. Individualization in turn was dependent on the skill of the providers in assessing family needs and then selecting and delivering support. Each technique or action had empirically supportive evidence, but no technique is ever 100% effective. Further, their combination in each family’s intervention was unique. In this chapter, we highlight the value of sets of clinical case studies, in which each case is based on the foundational principles, but none intervenes in precisely the same manner as any other [76, 77, 78]. It is in the gap between generalized information and person- or family-specific needs that clinical expertise is needed. Research on the characteristics and experience of successful clinicians is necessary, but beyond the scope of this chapter.

6.4 A final idea

First do no harm. Sometimes a little knowledge is a dangerous thing. If you learn only the dangers of foster care and do not learn to replace it with safe alternatives, you will have left children and their families at risk. If you use an alternative to foster care, you will have switched from doing unforeseen harm to doing the good you intended all along. If you think of a new combination of sound ideas, your creativity can propel your work further than faithful replication of someone else’s ideas. If you pass the word up your chain of command, you multiply the good you are doing. Protecting families, supporting professionals, and engaging communities creates a win-win-win situation in which everyone wins and society is strengthened.

This chapter is being completed in early 2024. Is there something you can do to protect children and their families from foster care this year? What will you offer instead?