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CASE NOTES

PRACTITIONERS: Alison Scott, intensive support worker, education; Jacki Hayes, education liaison, and Kath Smith, manager, intensive support service. 
FIELD: Children and families.
LOCATION: Isle of Wight.
CLIENT: Ben Turner, 10, is the oldest child who lives with his mother, brother, sister, stepfather and baby stepsister.
CASE HISTORY: Ben's parents split up three years ago and his mother has recently remarried. Ben has a high level of fear because he was placed in situations he could not handle, such as domestic violence and substance abuse. He stayed out late at night unaccompanied since he was very young and mixed with older children. He had no pre-school experiences or preparation for mainstream education, and consequently changed schools frequently. He spent time in care which meant him being moved off the island to mainland residential care, again resulting in exclusion. This also added to his emotional damage and also proved financially expensive.  Additionally, Ben has a hearing impairment, for which he did not receive treatment until he was five.

DILEMMA: Although Ben's was an education referral it became clear that his witnessing of domestic violence and his mother's inconsistent parenting were significant factors.
RISK FACTOR: With pressure to reintegrate Ben too quickly back into the mainstream, the underpinning issues may remain unresolved.
OUTCOME: Ben continues to live at home with ongoing support from the intensive support service.

As social care is these days shaped by targets and time-limits it's worth remembering that making the time and space to work at a service user's pace and reinvesting in core social work values can reap lasting dividends.

For many damaged young people, in particular, there are often no quick fixes; sometimes services have to hang in there for the long haul.

Damaged young people with testing behaviour often end up at supposedly specialist care homes, which often only fence- in problems. For the Isle of Wight, which has no children's residential services, this also means sending young people across the water to the mainland; young people such as 10-year-old Ben Turner.

However, Ben was brought back home after being referred for assessment to the island's intensive support service, a specialist team made up of four agencies - health, education, social services and substance misuse.

Ben is aggressive, especially verbally, and has symptoms of Tourette's syndrome. He has a hearing impairment and language difficulties which have delayed his social interaction, emotional development and relationship-building.

"The complexities at home mean that Ben is unable to share and talk through experiences and has become used to holding on to his fears," says education liaison Jacki Hayes. "He tends not to seek out adults as a source of comfort and doesn't trust them."

Ben had an underdeveloped sense of risk, which manifested itself in actions such as running out into the road, and asking questions such as "What would happen if I jumped out of the window?" (he lives on the second floor).

Through the work with the intensive support service, he is now able to ask questions and explore and become more aware of the world in which he is living. "Education is the focus for our work with Ben," says intensive support worker, Alison Scott, "because the way Ben needs to learn and what he needs to learn in order to move on are at odds with our mainstream education system, as is the case for many of our children. Because of this, he has a history of exclusion which included specialist mainland provision."

Manager Kath Smith continues: "In his care plan we are looking at the disparities between Ben's chronological, emotional and educational ages. This means taking Ben back to pre-school activities and curriculum, stimulating the development of the building blocks essential to both his educational and social development."

This is being interspersed with age-appropriate education. "Through this approach Ben is growing in confidence and self-esteem," adds Hayes. "Because of the way in which the educational work is carried out, we have identified areas of concern that relate to social care and to therapeutic need and address these within the weekly care-planning session."

Through a good working knowledge of each child, the team is able to identify small but significant signs of emotional or physical discomfort that the child is trying to deal with. It may be, as with Ben, a case of prompting and support to use the toilet because of his fear of monsters. Relationship-building is crucial for the team's work. "Ben's teacher is attuned to his needs, can push him and move away, can let him cope and support him, all as appropriate, thus truly meeting his needs," says Scott.

When a child is ready to begin the careful integration to mainstream the team forges strong supportive links with the school. "Those who have developed a solid understanding and capacity to work with the child link with key school staff," explains Smith. "We have been able in the past to put in the necessary classroom support to enable the child to see themselves as capable of managing the environment and therefore to develop the confidence and skills they will need for mainstream integration.

"This also allows for school staff to really get to develop their understanding of the child. Time and personnel are issues, but reducing either are false economies."


Within the package is support to help Ben's mother and family look at problems and be able to work with Ben's progress. "Mum has her own needs that we need to consider as they relate more directly to her capacity to parent," says Hayes. "We need to work with the parents to identify needs and to support them to ensure long-term maintenance of progress and to break the bonds that hold these families down."

And that, of course, will take time, patience and perseverance. 

Arguments for risk

• A mainland placement, which is the alternative, will only succeed in taking Ben away from his home, peers and community, thereby possibly adding an extra layer of rejection and isolation onto his vulnerability.
• The team needs time to develop trusting relationships to ensure its desired outcomes. "The measures we use might appear small," says Smith, "but when people ask what we have achieved with young people, we say they are getting out of the bed in the morning and coming to us, at the time that we've arranged to meet them. And they carry out a task that we had planned to do."
• The team takes a risk as a service by challenging the standard approach that moves children and families through systems hastily: the need to take steady steps may not be recognised. If Ben is moved on too quickly it is highly likely to undermine his progress, as has been seen with other children.

Arguments against risk

• It is not known to what extent the family can be engaged as a whole and this needs to be fully considered. When a challenging child remains in a home where the adults are struggling at times, there is always a degree of risk as boundaries will be pushed and routines broken. Any good work could be undermined by such behaviour.
• This chosen path means that the workers of the intensive support service will need to work hard to ensure that Ben's mother and stepfather are supported to continue the work at home. If the parents do not fully engage in the agreed service the benefits of the work will be reduced.
• In these types of cases there is often a history of difficulty in both maintaining engagement, in applying parenting skills consistently and in sustaining what is learned, whereas if Ben had been placed in a specialist residential and educational establishment these strict parameters could be consistently applied.

Independent comment

Budgetary constraints and the ever rising cost of specialist out-of-county residential provision are leading many local authorities to rethink radically
their provision for young people who display challenging behaviour, writes Patrick Ayre. 

A wide range of in-house facilities has arisen to meet this need. The least innovative, and often the least successful, are attempts to create cut-down local versions of specialist residential services. Because of their small size, such homes often lack the depth of staff expertise and specialist support available in the establishments they seek to reproduce. More effective are projects such as the Isle of Wight's intensive support service.

Even the best out-of-county residential services struggle when the child returns home. The improved behaviour is not maintained when the young people are  back among families where life is often chaotic and frequently abusive.

By contrast, the intensive support service is working creatively and effectively to help Ben to overcome his poor experiences of parenting while remaining in his family home.

However, as they recognise, their success will always be in some doubt unless it proves possible to engage Ben's parents in change as well. To achieve their full potential such services need to address both the child and his context.

This requires them to devote as much of their energy and expertise to devising strategies for engaging hard-to-reach parents as they do to devising strategies for work with young people.

Patrick Ayre is senior lecturer at the University of Luton and an independent child welfare consultant