Monday, 10 June 2013

FAMILY SUPPORT

FAMILY SUPPORT
CAMHS workers have the opportunity to employ communication and relationship skills in direct family support work, which they traditionally find rewarding and which service users find more acceptable than intrusive, investigative risk assessment (Crisp et al., 2003). The CAMHS role in multi-agency assessment and planning becomes significant in this context, where several perceptions can be expressed, based on diverse evidence and different levels of professional anxiety. CAMHS workers managing and supporting these processes with individuals or groups in planning meetings, case conferences or case reviews require advanced negotiation and decision-making skills, which are the hallmarks of professional training and supervision.
As the volume and complexity of family problems increases, there is concern the voluntary and nongovernmental sectors will be unable to match the level of skills to the level of need expressed and, therefore, creative ways of thinking are generating effective resources, such as the Family Group Conference approach to child welfare. Developed in New Zealand, it is based on a cultural-religious Indigenous concept among Maori people emphasising the relationship between celestial and terrestrial knowledge. According to Maori belief, the origin of the Family Group Conference was a rebellious initiative by the children of Ranginui, the great Sky Father, and Papatuanuku, the matriarch Earth Mother. Protected in a darkened cocoon by their parents, the children desired freedom to explore the outer limits of the universe. The family conference included close and distant relatives and grandparents, all of whom were regarded as part of a single spiritual and economic unity (Fulcher, 1999). Thus each Maori child’s cultural identity is explicitly connected to their genealogy or whakapapa. The Family Group Conference has been incorporated into mainstream child protection and adult mental health services in the UK and elsewhere, where extended family members are invited to participate in care planning and become part of the family support system rather than excluded from it (Brown, 2003; Featherstone, 2004).

Various initiatives aimed at children and their families living in disadvantaged areas are evidence of the practical implementation of the implicit preventive aspects of this policy, which was based on evidence of success from the US Head Start scheme (Gross et al., 1995). Gross et al.’s (1995) study demonstrated long-term reductions in antisocial activity, marital problems, child abuse, adult mental health difficulties, and unemployment in later life in a group of children who received the intervention, with a comparison group of children who did not receive the intervention. The Sure Start initiative was the British equivalent and the signature family support policy of the early 21st century. Recent research to evaluate its impact has produced positive findings (Hutchings et al., 2007). However, a systematic review of Family Group Conferences shows, to succeed as a family support intervention, they need to be part of a range of helping services and the start of a continuum of support (Schlonsky, 2010).

Impact of intervention

Measuring or quantifying the impact of preventive family support work is complex and achieving systematic results is expensive. Therefore, there is little in the way of evidence of long-term effectiveness in Britain or the rest of Europe. However, while outcome measures from various government projects are intangible (Robbins, 1998), there are signs small-scale social action projects could show changes in relationships between parents and professionals, as well as demonstrate how to work in partnership and engage positively with parents, all of which contribute to better family support and user-focused approaches.

The expansion of parent education or training programmes in the face of exponential demand for help from parents to deal with a range of child and adolescent difficulties from toddler tantrums to self-harm, suicide, and drug and alcohol addiction has meant this form of intervention is popular and expected to be offered as part of a repertoire of contemporary family support measures. Studies of parent education programmes, while limited in number, show they can be an effective way of supporting families by improving behaviour in pre-adolescent children (Lloyd, 1999; Miller & Prinz, 1990). They highlight the impact of group-based behaviourally oriented programmes in producing the biggest subsequent changes in children’s behaviour and are perceived by parents as non-stigmatising. Programmes where both parents are involved and which include individual work with children are more likely to result in long-term changes.

However, while enjoying a growth in popularity in Britain and other European countries, parent education programmes are generally not subject to rigorous evaluation (Donnellan, 2003, Nybell, Shook, & Finn, 2009). In a number of studies, fifty per cent of parents continue to experience difficulties. Further, it is not clear to what extent changes are due to the format or method of intervention, group support or practitioner skill. High attrition rates from some programmes are attributed to practitioner variables, such as their level of qualification and experience, and qualities such as warmth, enthusiasm or flexibility (Barlow, 1998). It may also be that some programmes are inappropriate for parents lacking motivation, especially when they are compelled to attend under the pressure of child protection concerns.

Few British studies have used randomised controlled trials. This inhibits identification of the most beneficial elements of a programme and, because most provision is geared to rectifying problems in disadvantaged groups, available research evidence reflects this bias. While over ten years old, those that have been conducted, nevertheless, have yielded important qualitative data from stakeholders’ perspectives (Ghate& Daniels, 1997; Morrow, 1998). It has been argued managerialist preference for evaluating work on the basis of the three Es (efficiency, effectiveness, and economy), which reflects service managers’ agenda for quantitative outcome measures, fails to reflect the whole picture (Leonard, 1996; Walker, 2001b). Others argue these data need to be supplemented with the three Ps (partnership, pluralism, and process), which better reflect professional social work principles seeking to incorporate service-users’ perspectives (Beresford, 2001; Dominelli, 2004; Powell& Lovelock, 1992). Further studies paying attention to normative models of parenting in the community would counter this bias by identifying skills leading to successful parenting and focus on what went right rather than what went wrong.

Effectiveness of family support

The literature on the effectiveness in family support tends to focus on the evaluation of specific service interventions but it should be acknowledged broader fiscal and social policies impact on children and their families and, therefore, contribute for good or bad to the context of children’s welfare in general, and family well-being in particular (Shaw et al., 2004). Recent research on child poverty ranked Britain bottom in a comparison of the current fifteen European Union countries with 32 per cent of children living in poor households (Crawford, 2006; Gilbert, 2003; Micklewright & Stewart, 2000). This is an important part of the equation of demand, needs, and resources when evaluating provision.

It has long been argued early intervention is the key to effectiveness because it stops problems getting worse when they become harder to tackle, and is more costly in terms of damage to children’s development, family relationships, use of scarce resources, and prevention of antisocial consequences in the long term (Bayley, 1999). However, Eayrs and Jones (1992) pointed out the accumulated evidence for the effectiveness of early intervention programmes is not as optimistic as was once hoped. On occasion there is the possibility such programmes can be damaging, deskilling parents and undermining their confidence. On the other hand, sixteen years ago a meta-analysis of early education interventions demonstrated children from disadvantaged backgrounds were less at risk from developing maladjustment, school failure, and delinquency after participating in these programmes delivered in an educational context (Sylva, 1994). More recent research supports this conclusion (Dolan, 2006). The location of family support is critical in engaging parents and children. Schools are emerging as an acceptable and accessible nonstigmatising venue for individual or group-based activity where attached social workers can engage in interprofessional work (Quinney, 2006).

A major review of consumer studies of family therapy and marital counselling analysed a variety of large- and small-scale studies, individual case studies, and ethnographic studies of specific therapeutic methods (Carr, 2000; Treacher, 1995). It concluded workers who neglected the service-user perspective and undervalued the personal relationship aspects of their family support work in favour of concentrating on inducing change ran the risk of creating considerable dissatisfaction among service users. This reinforced findings from an earlier study into the effectiveness of family therapy, which found advice and directive work needed to be balanced with reflective and general supportive elements typical of a professional social work approach (Howe, 1989). A subsequent meta-analysis of family therapy demonstrated effectiveness with specific problems, such as adolescent substance abuse and anorexia nervosa (Stanton& Shadish, 1997; Vostanis, 2007).

Systems theory can be useful in understanding the interactive nature of some family problems. It is also important in helping to take account of the natural history, social system, and environmental context of children’s problems in relation to their developmental stage. What becomes clear is there are no standardised ways of measuring childhood functioning or isolating all the family variables that can influence change. What is consistent is the general absence and rarity of service-user evaluation of, and involvement in, the design of family support (Statham, 2000). This further reinforces the need to establish professional social work methodologies, which incorporate shared social work values and preserve the cultural autonomy of groups in different societies. Taking the service-user perspective into account in determining effectiveness has become a feature of contemporary policy in social and health care contexts, but practice evidence does not support this policy aspiration (Barnes & Warren, 1999; Crawford & Kessel, 1999; Everitt & Hardiker, 1996; Kelson, 1997). In seeking to evaluate family support, it is problematic to define who the service user is. One of the challenges in defining effectiveness in family support interventions is clarifying for whom it is effective.

Family support usually means ‘mother support’ as fathers’ absence is a feature of the helping context, despite efforts to engage men in programmes to effect change. There is evidence of activity to engage men in work but what little has been undertaken has rarely been subject to rigorous evaluation (Holt, 1998). Mothers’evaluation of family support might differ in more or less ways than the evaluation of the children and or father irrespective of whether the focus of intervention was on an individual child, adult couple or the whole family (Walker, 2001d). A school-based behavioural problem might be resolved but at the expense of a deterioration in the parent-child relationship. Robust methods of differential evaluation by all participants, referrers, users, and providers would enhance the sophistication of up-to-date data on effectiveness.