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Case notes   

Practitioner: Panos Vostanis, consultant psychiatrist.

Field: Child and adolescent mental health.

Location: Leicester, east Midlands

Client: Gary Gibbons is 10 and one of three siblings. His father is an itinerant labourer and consequently the family has rarely settled in one place at any time. The family has been known to many social services departments over the years with concerns over non-attendance at school and neglect of the children.

Case history: Following concerns about physical abuse and neglect, all four children were last year placed in care. Gary's older brother Patrick Joseph, known as "PJ", (aged 14) has severe behavioural difficulties and has been placed at a number of children's homes. Gary and his younger sister Noreen (aged four) were also placed apart in separate foster homes. Despite their uncomfortable and dangerous lifestyle at home all the children missed their parents and being together. Consequently, PJ would often run away to find Gary and Noreen and return to their parents. His foster carers found it difficult to contain him.

Dilemma: Keeping Gary apart from his family, while in his best interests, could also spark more severe behavioural problems.

Risk factor: Gary's behaviour may deteriorate to an extent that he becomes a danger to himself and other children.

Outcome: Gary's foster care placement is now long-term, he is coming to terms with why he's apart from his family and he is beginning to meet his educational potential.

If children and young people in care with emotional and behavioural difficulties are to have cohesion and progress in their lives they usually need to experience a stable environment. There won't be order in their lives if, for example, their home or school lives are chaotic.

For the then nine-year-old Gary Gibbons chaos was all he knew. His father, an itinerant labourer regularly moved his family to wherever he could get work. The children rarely attended school and the family were known to social services departments up and down the country. "The only constant in Gary's life has been his family. He is intensely loyal to them and he thought that if he did anything different he would let them down. It was a very powerful force," says Panos Vostanis, consultant child and adolescent psychiatrist with the Leicestershire Partnership Trust's young people's team, who began working with Gary last year.

About 18 months ago, following concerns around physical abuse and neglect, PJ, Gary and Noreen were taken into care. With Gary it was decided to adopt a three-pronged approach with education and therapy complementing the crucial stabilising work of the foster carers. "The carers provided an ideal mixture. They were very caring but set boundaries as well. They knew how to handle him, how to sit with him and contained him well. There was a critical period lasting about three months when his behaviour was at its most testing: they could have given up on him but never did," says Vostanis.

They were well-prepared by the social worker especially around Gary's constant attempts to run away. "Often carers don't know what to expect and get overwhelmed. These knew what to expect," he adds.

Boundary-setting and discipline were crucial. "The carers were able to distinguish between what were Gary's experience and attachment difficulties and what was his here-and-now behaviour. They picked up the clues very well - which was an admirable quality - and made it very secure for the boy. They gave him clear expectations and discipline - which was important for his developmental progress," says Vostanis.

He continues: "They did not have unrealistic expectations that he would change overnight. There were very testing times. On one occasion he climbed onto the school roof and started throwing stones. It was a case of containment; they had to keep him in and keep him safe."

Vostanis believed that Gary was potentially very bright although he had little social understanding: "He hadn't been with other children his age and didn't know how to play. He couldn't relate to other children and was statemented for behaviour and learning problems. Again, as with the carers, the school could have given up - which happens a lot - but it stuck with him. It can often be a turning point when children are excluded quite quickly. At first he would study on his own in the library but the staff gradually integrated him. Now he's in a classroom.

With the foundations laid, the third element - individual therapeutic work - could be introduced. Gary was struggling to make sense of his background and experiences, but the therapy had to be handled carefully. Says Vostanis: "On the one hand you have traditional psychotherapeutic work that would work in-depth over a long period, but in most instances children can't cope with that. On the other hand, some hope that by talking in general things will get better. This often doesn't work either. My psychodynamic approach was aimed at helping Gary to gain an understanding of what he was trying to act out; of trying to put into words what his behaviour was about - which was that he was missing his family. He was desperately trying to make sense of what was going on for him. The therapy gave him space to do that."

Gary's prospects now seem good. He is settled - his placement with his carers is now confirmed long term. He is "coming on leaps and bounds" at school. However, he is still not making friends and efforts are being made to help with next year's transition into senior school. And the possibility of re-establishing contact with his siblings is being considered. "Last year he was acting out - now he's more articulate. He feels very sad about his family but is very controlled about it now. He is coping with and enjoying a new life," smiles Vostanis.

Arguments for risk

• Unlike his brother, Gary's behaviour, although challenging and dangerous, was not so deep-rooted as to be impossible to change. Although he was bright it still required a lot of patience and tolerance from his foster carers and his school to bring in enough stability to permit the time and space for effective therapy. "It was a combination of these three things that sticks out for me," says Vostanis. 
• There were two or three months that were critical when his behaviour was particularly challenging and things could have gone wrong. But his behaviour was predicted and thus could be planned for. Gary had never had stability - so it could be expected that he would test the legitimacy of the new situation. 
• Gary's age was critical. "It was much easier to work with him than PJ, who although only 14 was unlikely to change. Indeed such is PJ's behaviour that a more secure placement is being considered."   

Arguments against risk 

• It could appear to some that the risk of exposing foster carers and school staff to Gary's erratic behaviour - that was inspired solely by his wish to return to his family despite what that entailed - was too high. Too often attempts to bring order fail and a young person is then scarred with the belief that stability is a myth.  
• Gary is settled into a long-term placement. However, this appears to have happened by default rather than by planning. Through bypassing institutional care there is always the strong possibility that fostering will present its own problems. The carers themselves or the system, through no fault of Gary's, can move him on. As Vostanis admits: "It can go pear-shaped very quickly. Carers become worried about a placement and a week later it has broken down."  
• The realistic alternatives - a specialised children's home or residential school - may have been rebuffed because of budgetary implications.   

Independent comment

I would like to know what assessment was made of the parenting capacity of Gary's parents and whether there was any evidence that they could change with support, writes Dinah Morley. Mobile families frequently fail to get the sustained support they need, as services are largely boundary-led. However, some targeted services do exist and continuous support might have been available. 

In Gary's case remarkable work has been done by the foster carers, the school and the child psychiatrist. The progress made by Gary must be sustained into secondary school through dedicated support at his new school. Adolescence is upon him and the foster carers will have to manage all the changes which that brings. They will need more support.   

This appears to be an excellent wrap-around fostering service, where the foster carers are getting maximum support.  

Perhaps his relationship with his sister, Noreen, might be developed. One can see why these three siblings were placed separately but the split must have been devastating and it is the responsibility of the agencies to repair it if possible.   

If Gary's insight has really developed he might be able to re-engage his brother. However, unless things are really dangerous at home, one can't help feeling that the long-term damage to PJ will be less if he is reunited with his parents, rather than placed in a secure setting.  

Dinah Morley is acting director of mental health charity Young Minds.