Ruby's Story
Ruby is 8 years old and has been with her Circle Carer for 2 years
Ruby's family was already known to Child Protection when she was born and at 9 months of age she and her siblings were removed and placed in a residential family group home for 6 months, before returning to the care of her birth parents. By the age of 2, Ruby had been exposed to chronic neglect, significant family violence, parental substance misuse, criminal activity and mental health issues. She had also had multiple primary caregivers. At 3 years of age she was treated for (non-organic) failure to thrive.
Ruby re-entered the care system at 6 years and, along with her siblings, was placed in the Circle Program. She was significantly underweight and a paediatric assessment found she was the size of a 3-year-old. She also had poor self-care skills, hoarded food and was hypervigilant and hyperactive. She was wary of her carer and resisted any close contact or affection. She also had very limited social skills. Ruby commenced school soon after coming to her placement. She was already a year older than most of her peers, but had no knowledge of letters, numbers or colours. She could not read or recognise any letters, her ‘writing’ was scribble and she coloured only using black pencils. She was assessed by the school psychologist and found to have an intellectual disability, an IQ of 50. The school put pressure on the carer to transfer Ruby to a special school as it did not seem her needs would be met in a mainstream school. Given Ruby's history, Ruby's carer, supported by the care team, disagreed with this view (along with the diagnosis of ‘disability’) and advocated that she remain to at least complete the Prep year, to which the school reluctantly agreed.
Two years on, and the care team has worked hard to support Ruby in her placement. Her carer was able to provide her with a consistent and nurturing environment that met her emotional and developmental needs. The therapeutic specialist and foster-care worker provided many resources to support the carer to meet Ruby's needs where ‘she was at’, often meaning that the carer had to parent her as though she was a much younger child. Ruby responded very well to this, tolerating more and more closeness with her carer as she developed a strong attachment to her. This has enabled her to present as much calmer at home, with a greater capacity to sit still and concentrate, to develop age-appropriate self-care skills and begin to form positive friendships with other children. Ruby has grown considerably and, although still small, is now within the size range for her age.
The most significant outcome is Ruby's progress at school. Within 2 years she has demonstrated incredible gains, now being able to read, write and achieving success in all areas of learning. Ruby has gone from not knowing the alphabet to being ahead of the expected levels for literacy at the end of Grade One. The school has agreed emphatically with the carer and care team that Ruby's diagnosis of intellectual disability was completely incorrect; her delays were due to her early life experiences of trauma and neglect.
The Circle Program
The Circle Program is a therapeutic model of foster care, which is part of a strategy to improve outcomes for children in out-of-home care in Victoria, Australia. It is informed by knowledge of the neurobiology of trauma (Perry, Reference Perry2009; Schofield & Beek, Reference Schofield and Beek2005; Schonkoff & Phillips, Reference Schonkoff and Phillips2000).
The Circle Program initiative was introduced to give effect to the principles contained in the Children, Youth and Families Act 2005 (CYFA) and the Child Wellbeing and Safety Act 2005 (CWSA). A central tenet of the Circle Program from its inception in 2007 ‘is the primacy of the Carer–child therapeutic relationship. The focus becomes the Carer's ability to provide skilled therapeutic parenting’ (Frederico et al., Reference Frederico, Long, McNamara, McPherson, Rose and Gilbert2012, p. 17). This relationship is facilitated by a strong network of support around each child. The programme requires that an individually tailored care team be established for each child, which is designed to meet the specific needs of the child or young person entering the Circle Program. The programme guidelines define the care team as a multidisciplinary group comprising all professionals involved, together with circle carers and birth family members where possible; meeting at least weekly initially and then less often, as required, and providing the core ‘circle of support’ around the child (Victorian Government Department of Human Services (DHS), 2009). The core roles of care-team members include: the foster-care worker, the therapeutic specialist, the child protection practitioner, the carer and the birth family, where appropriate. Additional roles are added as needed to match each child's requirements – for example, a child psychiatrist, speech pathologist or teacher. The core professional and carer roles and the programme design are defined in the programme guidelines (DHS, 2009).
The overarching conceptual frame of reference for the Circle Program is an ecological–developmental one (Belsky, Reference Belsky1993; Bronfenbrenner, Reference Bronfenbrenner1979), informed by a knowledge of trauma and attachment, and guided by the Best Interests Case Practice Model (DHS, 2007). A recent evaluation of the Circle Program has been reported elsewhere (Frederico et al., Reference Frederico, Long, McNamara, McPherson, Rose and Gilbert2012). In this paper we explore the findings of the evaluation in relation to how the carers’ experience impacts on children in their care who have experienced trauma and attachment disruption.
Trauma and Attachment Disruption
Theories related to attachment disruption and trauma (Perry, Reference Perry2009) underpin the theoretical foundation of the Circle Program. Perry (Reference Perry2009) identified the essential role of a relational approach to caring for traumatised children. It is this focus upon relationships which is a core component of the Circle Program and the foundation of the Circle carer–child relationship.
The aim of the Circle Program is to minimise the risks of attachment disruption to the child/young person through building a strong relational response. The care team that is established, and which ideally includes the biological parents, unless counterindicated, has the potential to provide a tight circle of social support for the child.
Method
The exploration of the Circle carers’ experience in the therapeutic foster care (TFC) programme was part of the broader evaluation of the programme, which focused on the experiences of children and their families as well as the experiences of other professionals involved in the Circle Program. It was designed to identify the core components of TFC, and how these integrated to impact on the outcomes for children. Focus group participants were purposefully recruited through foster-care providers, who were asked to nominate three Circle carers and three staff to participate. Invitations were sent via Central Office to Child Protection Service staff engaged with the Circle Program, and the managers of the two therapeutic service providers nominated therapeutic specialists to participate.
The purpose of the focus groups was to explore the participants’ experience with the Circle Program and to gain qualitative data on the intervention processes and the outcomes for children, young people and carers. The participation was mixed to assist in drawing out themes about the Circle Program experience.
The focus group questions related to participants’ experience of the Circle Program, including comparison with generalist foster care; a description of outcomes for children and young people, including educational, placement stability and developmental outcomes; outcomes for carers and the child or young person's parents; and the challenges and constraints experienced by the stakeholders. The participants were also asked for their recommendations for actions that would improve the Circle Program.
The experiences of TFC carers and other stakeholders in the Circle Program, including foster-care workers, therapeutic specialists and Department of Human Services child protection practitioners, were compared with their experiences of generalist foster care.
The evaluation was not given access to direct contact with children/young people or biological families. The latter constraint clearly constitutes an acknowledged limitation of the broader evaluation (Frederico et al., Reference Frederico, Long, McNamara, McPherson, Rose and Gilbert2012).
This paper will report primarily on the outcomes of the focus groups, which explored the motivation of Circle carers, how they worked with other stakeholders in the TFC programme and how they made sense of their experiences in the programme.
Seven focus groups were conducted, with a total of 56 participants. Three groups were conducted in Metropolitan Melbourne, two groups were conducted in Regional Victoria and two groups were conducted via teleconference: one metropolitan and one regional.
The initial six focus groups were attended by Circle carers, (n = 28), foster-care workers (n = 11), therapeutic specialists (n = 9) and placement and support staff, DHS (n = 2). An additional group was conducted via teleconference in order to include child protection practitioners who had been unable to attend a group (n = 6). It should be noted that 20 of the Circle carers had previous experience as generalist foster carers and were able to draw comparisons between the two models of care. Data from the focus groups were recorded digitally and later transcribed. Based on the six-stage model of thematic analysis identified by Braun & Clarke (Reference Braun and Clarke2006), work in the analysis phase specifically involved a series of tasks that were undertaken utilising a recursive process, moving back and forth throughout the six stages as required. This was to determine whether the process was, in fact, addressing the identified research questions successfully, and to identify any potential amendments to the focus group interview guide. The stages of analysis included familiarisation with the data set and manually generating initial codes before searching for and identifying themes. These were then reviewed by returning to the detailed data extracts and reviewing the alignment between the initial codes and emergent themes, before finally defining them, with a view to confirming a ‘coherent and internally consistent account, with accompanying narrative’ (Braun & Clarke, Reference Braun and Clarke2006, p. 92). By the end of this phase a rich interpretive analysis of the data set had been produced and formed the basis of the final report.
Ethics approval to conduct the study was obtained from La Trobe University Human Research Ethics Committee (Number 11–073).
Key Findings
The results of the focus groups demonstrate that Circle Program carers took an active role in the application of therapeutic care principles with children in their care (Frederico et al., Reference Frederico, Long, McNamara, McPherson, Rose and Gilbert2012). Training provided to the Circle Program carers was identified as an important component in supporting and guiding work with the child.
Experience of Carers
Carer experience in the Circle Program can be described as extremely positive overall. Circle carers participating in the focus groups who had some experience as generalist carers offered their views in relation to both models of care. We now move on to consider key aspects of that experience and its implications for children in the programme.
Overwhelmingly, the results indicate that Circle carers are well trained, well supported and better placed to provide a healing environment for children who have experienced trauma.
“We used to care for teenagers in generalist foster care; our kids would say to us ‘we are just a number’. Now in the Circle program we are accessing therapy and we are implementing the therapy for the child. Why do we have two different programs? Every child should have access to Circle.” (Circle carer)
Carers spoke passionately at times of their commitment to their role as a Circle carer, highlighting their experience of support, training and ongoing education and access to flexible ‘brokerage’ funds as critical elements in supporting them in their role.
“It is so much better than foster care used to be – I started 16 years ago as a carer . . . Circle is a ‘step up’ from generalist foster care, you have regular contact with your workers, you have regular meetings about the child and there are resources available to all Circle carers . . . You would hope that there would be Circle availability for all children.” (Circle carer)
And from another:
“Being told and involved makes you look at the child in a different way. To some extent the therapeutic specialist sits outside all of the day-to-day administration and red tape and helps us not to become entrenched in these issues, but to focus on the child's experience, the impact of the trauma that they have experienced and (how best) to respond to their needs. There is a clear ‘value adding’ for the child.” (Circle carer)
This Circle carer had significant experience as a generalist foster carer before joining the Circle Program. In relation to generalist foster care she made the observation that:
“Lots of times you weren't told anything about the child or the child's life.” (Circle carer)
In the words of another Circle carer with generalist experience:
“If I had still been a generalist carer, it would have been ‘game over’ for me – I could not cope with that level of stress on my own. If you have a child in your home who creates secondary trauma, you are much more likely to give up without the support of the therapeutic specialist and the care team.”
Carer Retention
The broader evaluation found that carers in the Circle Program are significantly less likely to withdraw from foster care compared with those in generalist foster care. Specifically, the findings indicate that 4.4 per cent of 182 Circle carers had been identified as withdrawing from the role, creating an unplanned exit from the Circle Program for the child. This was in contrast to 9.1 per cent of 186 generalist carers who were identified as withdrawing from the role of carer in an unplanned manner. It does appear that ‘Circle works’ for carers, who are significantly more likely to remain in the role of carer, hence better placed to offer stability for the child.
The stories from Circle carers of their experience of support, education and respect for their work were consistent with this finding. A key factor contributing to carers’ success in the Circle Program was feeling ‘listened to’, that their opinions were ‘valued’ and that they were ‘supported’ in their role as foster carers by members of the care team, in particular the therapeutic specialist and the foster-care worker. Carers in the focus groups discussed their role and participation in the Circle Program with passion and enthusiasm.
“I enjoy the whole experience, I learn every day, I learn that there are many ways to help these kids. I love when my child achieves something that not only is recognised by me but is also recognised by himself.” (Circle carer)
While focus group participants articulated the focus on the Circle child in placement, the wellbeing of carers was also described as a conscious and constant point of focus of the care team. This had a clear rationale, that a well-functioning carer would be better placed to care for a Circle child. One carer indicated that at care-team meetings she was regularly asked how she is, and “they really want to know how I am!”
The Care Team Approach
A consistent message about Circle carers’ level of satisfaction was related to being a valued member of a team, and the belief that their opinion and expertise was heard and valued.
“All members of the Care Team are equal.” (Circle carer)
“Everyone is on the same page.” (foster-care worker)
“I know Therapeutic Specialists and Circle workers have children's wellbeing as paramount . . . she has a great team working for her with the mission of getting her the best life possible . . . it is the way all foster care should be.” (Circle carer)
Knowledge Development
The program rationale emphasises the primacy of the carer–child therapeutic relationship, using parenting approaches to apply individually tailored techniques designed to provide the child with the best possible opportunities to develop and heal from the impact of abuse (DHS, 2009).
Focus group participants commonly identified knowledge of developmental trauma as fundamental to the operation of the Circle Program and to understanding a particular child's or young person's experience and needs.
The expertise of the therapeutic specialist was referred to on a number of occasions in relation to the role of advocate for the child, where particular needs had been identified. In one case example offered, a young girl was becoming physically unwell on each access visit, indicating a need to advocate for a change in arrangement. The Circle carer's access to knowledge and resources, provided by the Circle Program through both the initial training, the input of the therapeutic specialist and the strength of the care team, were perceived in this case as facilitating conditions that resulted in better outcomes for the child, including a change in access arrangements.
Discussion
Themes emerging from the findings highlight real gains in children's developmental progress, with reports by focus group respondents of children having been assessed as attaining, and in some instances exceeding, developmental milestones where there had previously been specialist assessments indicating marked delay. Second, the capacity to offer continuity of care to children who were experiencing ongoing instability as a result of their legal status was seen as a major theme.
Carer retention is clearly central to the success of TFC. Revisiting the central tenet of the Circle as ‘the primacy of the Carer–child therapeutic relationship’ (Frederico et al., Reference Frederico, Long, McNamara, McPherson, Rose and Gilbert2012, p. 17), it is evident that “Circle works” (Circle carer). Circle carers are significantly more likely to remain in the programme than their mainstream foster-care counterparts. They feel valued, respected and heard by other members of the care team, and are supported to participate actively as decision makers in respect of the child. Carers are educated appropriately in the trauma-informed approach to caring that underpins the model, and supported to integrate new knowledge into practice on a daily basis. They report feeling “equal” to other members of the care team, in what could been described as holding professional status amongst peers. They enjoy slightly higher financial reimbursement than generalist carers and access to a flexible brokerage fund, allowing them some flexibility to meet the needs of the child in their care. They are supported to attend to their own needs for self-care and wellbeing in order to maintain their capacity to care therapeutically. A strength of the Circle Program is its strong theoretical foundation. This was identified by Circle carers and professional staff in focus groups. The theoretical foundation provided carers with a strong framework to work within, and appeared to assist them to make sense of their experiences and facilitated their understanding of the issues faced by the child or young person. The carers provided examples of a range of responses to difficult situations with children and young people; examples given included advocacy for changes to court conditions on the basis of an enhanced understanding of the child's needs, re-parenting the child as though she was an infant, as described earlier in the case of ‘Ruby’, and a greater capacity for carers to manage their response to the stressful nature of the work. The Circle carers consistently reported that they felt supported by the therapeutic specialist and other members of the care team. The Circle Program was described by some as elevating the role of the foster carer to one who is “equal” with the other professionals on the care team. This, combined with the Circle Program training, has professionalised the role of foster carer, and some carers reported increased levels of confidence in their competence.
Conclusion
Children and young people who come into therapeutic foster care through the child protection system have experienced trauma and difficulty with relationships and attachment disruption. A therapeutic foster-care programme focuses on helping the young person recover from the consequences of trauma. Healing occurs within the context of a relationship (Perry, Reference Perry2009). Circle carers are consistently reporting that, as a result of the integrated model of education, guidance, support and inclusion as a member of a professional team surrounding the child, they are more able to offer a stable and therapeutic environment. This enhanced experience of care-giving influenced the carers’ intention to remain therapeutic foster-care carers; increased stability of placements in the Circle Program, was associated with fewer unplanned terminations of placements and had positive outcomes for the children entrusted to those carers.
