Clinically Managed Access

1
Clinically Managed Access

• The Final Piece in the Permanency Planning Puzzle

2
Optimal Services inThe Permanency Planning
Puzzle

Address

Continuity


Resolve Limbo
Resolve Resolve Parent
Developmental -Child
Relationship
Issues

3
Resolve Limbo

• Early parenting capacity assessment
• Active services targeted to real need
• Clarity of planning, intervention, and outcomes
• Timely decision-making
• Include the child in the process

4
Address Continuity

• Achieve placement permanency as soon as possible
• Assist child to understand the rationality of
  life events
• Support active grief work
• Rebuild self-esteem through participating in
  creating own story

5
Resolve Developmental Issues

• Aim for RESILIENCY
• Social effectiveness
• Life skills
• Emotional/ affective regulation
• Self esteem, optimism
• Physical well-being
• Success in learning
• Engage a spectrum of services

6
Resolve Parent Child Relationship

• In the long term, the protection of children
  cannot be achieved in isolation from meeting
  their wider welfare needs and those of their
  parents, particularly the mothers. (Farmer, 1997)

7
From the Childs Perspective

• Preoccupation and identification of the children
  with their birth families over time (McAuley,
  1996)
•  
• Distracts them from their own life tasks (Palmer,
  1990)
• When children in care feel abandoned by their
  families, their self-esteem is diminished (Hess,
  1987)
• Unless they are helped to understand what has
  gone wrong in their families, they are likely to
  blame themselves for the separation (Marneff and
  Broos, 1997)

8
From the Parents Perspective

• Feel unwanted by agencies and foster caregivers
  have a sense of being pushed aside and of losing
  their parental responsibilities (Packman,
  Randall, Jacques, 1986)
• Rarely find traditional treatment services a good
  fit for their complex needs. Attended few
  sessions, did not achieve goals, terminated
  service prematurely (Osmond, 2002)

9
From the Caregivers Perspective

• Children exposed repeatedly to the worst of the
  parent/ child relationship in access
• Leads to distress and confusion for child
• Often results in disruptive behaviour
• Placement put at risk
• Team communication and problem solving too weak
  to assist
• Caregiver resists contact, either overtly or
  covertly

10
Barriers to Parental Involvement

• Parents have complex needs
• High levels of support needed to achieve outcomes
• Parents do not respond optimally to traditional
  services
• Agency resources insufficient to target
  improvement of parent/ child interaction

11
Child Outcomes in Well Managed Parental
Involvement

• Greater placement stability
• Improved self esteem and identity
• Improved response to clinical intervention
• Better long term adaptive functioning
• Greater likelihood of reunification
• Improvements noted in all but the most toxic
  situations

12
Parent Outcomes in Well Managed Parental
Involvement

• Reduced feelings of guilt and shame
• Increased energy available to contribute to
  childs well being
• Higher likelihood of doing the right thing on
  behalf of child
• Much higher likelihood of successful
  reunification

13
Range of Parental Involvement

• Inclusive foster or group care
• Parent Mentoring
• Clinically Managed Access

14
Clinically Managed Access

• Uses the child and parent access visit as the
  vehicle for achieving identified goals
• Intervention targets resolving outstanding
  familial issues, and foster the development of
  more functional attachment relationships

15
Tools of Intervention

• Presence of an access facilitator
• Based on accurate assessment of child and family
  functioning
• Begins with goal identification and contracting
• Proceeds with active work on goals within the
  access visit
• Ends when the goals have been met, or it is clear
  they cannot be met

16
Stages of Clinically Managed Access

• Pre Work
• Contracting
• Preparation
• Structured Visit
• Debriefing

17
Pre-Work

• Assessment of family strengths and needs
• Engagement of family members
• Reduce feelings of guilt and shame
• Develop mutual goals and objectives
• Offer an ally with whom to work on achieving goals

18
Preparation

• Engage parent and or child in planning
• Support communication skills rehearsal
• Support ability to receive communication
• Plan for fun activities
• Anticipate issues and rehearse solutions

19
Structure of Access Visits

• High Structure facilitator present throughout,
  offering active intervention
• Medium Structure visit begins and ends with
  facilitator intervention. Middle portion is
  independent with facilitator observing
• Low Structure initial check in followed by
  independent visiting and debriefing check in
• No Structure family members visit without aid
  of facilitator

20
Role of Facilitator

• Conducts parent preparation sessions
• Instructs caregiver in preparing child
• Ensures location is comfortable and equipped
• Welcomes child and family
• Conducts check in
• Supports, teaches, intervenes as needed
• Conducts debriefing session

21
Is this Supervised Access?

• Based on clinical assessment
• More interventionist
• Facilitator offers well developed clinical skills
• Combines child management with supportive
  counselling
• Facilitator acts as part of childs care team
• Generates clinical report

22
Typical Access Structure

• Goals
• Preparation
• Greeting
• Unstructured Time
• Structured Time
• Goodbye

23
Access Facilitators Report

• Observations of
• Preparation
• Greeting
• Structured Activity
• Unstructured Activity
• Meal or Snack
• Good-bye
• Goals and Interventions
• See Handout

24
Principles for Service

• Respectful of family
• Gives permission to try
• Provides effective modeling
• Active teaching, not passive
• Accentuates positives, reduces negatives

• Prepares family to make use of other services
• Assumes the resolution of relations is critical
• Aims for progress, not perfection
• Fluid and responsive to changing dynamics

25
Why It Works

• Families highly motivated to attend visits
• Immediate intervention leads to immediate success
• Facilitators role is pragmatically helpful
• Trust is developed more readily, basis of therapy
• Children perceive adults as making a
  difference, experiences reduced anxiety

26
Acknowledgements

• Staff and Parent Therapists of the Tri-CAS
  Treatment Foster Care Program
• Family Intervention Team of the York Region
  Childrens Aid Society
• Mary Rella of Thistletown Regional Centre
• The families and children from whom we learn

27
For more information

• Mary Rella, Thistletown
• Karen Wright, York Region CAS