Coaching Families with Multiple Problems...ISBN 978-90-367-7647-9 (electronic version) NUR-code 848 Drawings by Lutz Tausendfreund Design by Mali Lazell & Tim Tausendfreund Printed

University of Groningen

Coaching families with multiple problemsTausendfreund, Tim

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.

Document VersionPublisher's PDF, also known as Version of record

Publication date:2015

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):Tausendfreund, T. (2015). Coaching families with multiple problems: care activities and outcomes of theflexible family support programme Ten for the Future. [S.l.]: [S.n.].

CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.

Download date: 04-09-2020

https://www.rug.nl/research/portal/en/publications/coaching-families-with-multiple-problems(95367b06-7aa3-42dc-b3f6-24f559d1e749).html



Coaching Families with Multiple Problems Care activities and outcomes of the flexible family support programme Ten for the Future Ph.D. Thesis, University of Groningen, Groningen, the Netherlands © Tim Tausendfreund, 2015 ISBN 978-90-367-7648-6 ISBN 978-90-367-7647-9 (electronic version) NUR-code 848 Drawings by Lutz Tausendfreund Design by Mali Lazell & Tim Tausendfreund Printed by CPI – Koninklijke Wöhrmann

Coaching Families with

Multiple Problems Care activities and outcomes of the flexible family support programme Ten for the Future Proefschrift ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen op gezag van de rector magnificus prof. dr. E. Sterken en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op donderdag 5 maart om 14.30 uur door

Tim Tausendfreund geboren op 26 maart 1976 te Hamburg, Duitsland

Promotores Prof. dr. E. J. Knorth Prof. dr. H. W. E. Grietens Copromotor Dr. J. Knot-Dickscheit Beoordelingscommissie Prof. dr. M. C. Timmerman Prof. dr. E. Broekaert Prof. dr. L. Sousa

Zunächst: nichts Beobachtbares folgt aus einem reinen Allsatz — "Alle Schwäne sind weiß" zum Beispiel. Dies sieht man leicht ein, wenn man bedenkt, daß "Alle Schwäne sind weiß" und "Alle Schwäne sind schwarz" einander natürlich nicht widersprechen, sondern zusammen nur implizieren, daß es keine Schwäne gibt ... (Popper, 1976, p. 67)

CONTENTS

Chapter One General introduction 1

Chapter Two The life situation of families with multiple problems: 15 A comparative conceptual analysis of social service perspectives

Chapter Three Families in multi-problem situations: 33 Backgrounds, characteristics, and care services

Chapter Four Self-reported care activities in a home-based 49 intervention programme for families with multiple problems

Chapter Five Outcomes of a coaching program for families 77 with multiple problems in the Netherlands: A prospective study

Chapter Six General discussion 103

References 116

Summary 144

Samenvatting 148

Publications 153

Dankwoord—Acknowledgements—Danksagung 157

About the author 164

TABLES

Table 1 Ten areas of life and corresponding goals of TF 8

Table 2 Sample composition in the three waves of 59 data collection within TF

Table 3 Caseload and face-to-face contact characteristics in TF 61

Table 4 Person or people with whom the care activities were 63 performed in face-to-face contacts in TF

Table 5 Frequency and distribution of activities 64 performed in TF, by category

Table 6 The 11 most frequently performed care activities in TF 66

Table 7 Demographic sample characteristics of parents and 86 children at the start of intervention (T0)

Table 8 Problem severity at the start of the intervention (T0) 90

Table 9 Reasons for end of care 91

Table 10 Results of the multilevel analysis for parental stress 95

FIGURES

Figure 1 Living conditions divided into primary 21 and sub-dimensions

Figure 2 Dimensions and risk factors in living conditions 22 at the micro, meso and macro levels that increase the risk of social exclusion

Figure 3 Positions of well-being in relation to 24 material deprivation

Figure 4 The most important causal routes for explaining 25 the general index of social exclusion for children

Figure 5 Flow of participants through stages 84 of the research project

Figure 6 Kaplan-Meier survival curve of parental stress (NOSI) 92

Figure 7 Mean ± 1 SE for questionnaire scores over time 94 for parental stress (NOSI), family functioning (VGF), and child problem behaviour ages 1.5–6 years and 6–18 years (CBCL)

Figure 8 Scatterplots of questionnaire scores at start of 96 the intervention (T0) vs. scores at last measurement for parental stress (NOSI), family functioning (VGF), and child problem behaviour ages 1.5–6 years and 6–18 years (CBCL)

CHAPTER ONE

GENERAL INTRODUCTION

This chapter is partly based on: Knot-Dickscheit, J., Tausendfreund, T., & Knorth, E. J. (2011). Intensieve pedagogische thuishulp voor multiprobleemgezinnen: Een kijkje achter de schermen. Orthopedagogiek: Onderzoek en Praktijk, 50(11), 497–510.

CHAPTER ONE

1

General introduction

Within the social service sector, some families draw particularly heavy on the range and quality of the services, due to the nature and extent of the problems they experience. In the Netherlands this group of families is commonly referred to as multi-problem families [Dutch: multiprobleemgezinnen]. A target group that, after its initial introduction through the pioneering works of Baartman and Dijkstra (1986; 1987), and Ghesquière (1993), has become a staple in Dutch textbooks (Hellinckx, Grietens, & Ghesquière, 2008) and child and youth care interventions (Netherlands Youth Institute, 2014a). Definition of the Target Group In international literature varying names for this target group can be found. They differ between times, languages, or schools of thought. In English publi-cations labels that impute the problem not solely to the family have seen more recent use, such as families with multiple problems (Spratt & Devaney, 2009), and longer descriptive versions, as for example families with longstanding and complex problems (Thoburn, Cooper, Brandon, & Connolly, 2013), or vulnerable families with complex and enduring needs (Morris, 2013). Similar terms, found in adjacent disciplines like psychology, point at overlapping target group descriptions, as multi-stressed families, multi-crisis families or multi-assisted families (Sousa & Eusébio, 2007). Additionally, labels more closely related to the phenomena of poverty and social exclusion have also been forwarded as alternatives in German-speaking countries (Helming, Schattner, & Blüml, 2004, p. 74). For practitioners who work with these families, the identification of families from this group, perceived as ‘most difficult’ or ‘most troubled’, might seem relatively straightforward (Philp & Timms, 1957). As a whole, however, the group is rather diverse (Baartman & Dijkstra, 1987; Ghesquière, 1993), and consensus in the scientific community about a single definition or method of


2

reliable identification has not been reached (Spratt, 2011; Steketee & Vandenbrouke, 2010). Due to challenges in identifying families with multiple problems (Bodden & Deković, 2010; Spratt & Devaney, 2009), only rough estimates can be made with respect to the size of this group. Expert surveys and secondary analyses of administrative data estimate that the proportion of all families in the Netherlands ranges between 0.5–5% (van der Steege, 2010) or 3–5%, equalling a total of 70.000-116.000 families in 2011 (van den Berg & de Baat, 2012, p. 97). Beside all differences in terminology and uncertainties in identification, commonalities that characterize the target group can be identified. A common theme, next to the earlier mentioned diversity of the group as a whole, is the interrelated nature of the families’ problems, which are often described as being long-term, chronic or transgenerational (van der Steege, 2010). Earlier forms of support seem to have had little or no effect, or have failed entirely to reach the families (Ghesquière, 1993; Schout, de Jong, & Zeelen, 2011; van der Steege, 2010). Problems these families experience span over a multitude of areas, including for example: parenting issues, financial debt, psychiatric problems, troubled relationships, health and housing related issues, as well as repeated contact with social authorities, or the criminal justice system (Baartman, Garnier, van Vugt, & Vogelzang, 1989; Bodden & Deković, 2010; Holwerda, Reijneveld, & Jansen, 2014; Mehlkopf, 2008). It is not that other families do not experience issues in these areas too, but that the establishment of persistent solutions in and for these families seems to be much less successful (Spratt, 2011; Zinko, Meijer, & Oppenoorth, 1991). Most importantly, there is growing evidence that the problems these families experience significantly increase the risk for their children to be victims of neglect and child abuse, and that they may accumulate severe disadvantages over their life course (Appleyard, Egeland, van Dulmen, & Sroufe, 2005; Buehler & Gerard, 2013; Deater-Deckard, Dodge, Bates, & Pettit, 1998; Spratt, 2012; Zoon, 2012).

CHAPTER ONE

3

Challenges in Care Provision The nature and extent of the problems the families experience pose specific challenges for providing adequate care. These challenges arise not only from characteristics of the families but are also produced or amplified by general trends and policies in the welfare sectors (e.g., Morris & Featherstone, 2010). In the following four sections core issues are outlined, which encompass access to care, coordination of care, duration of care, and effectiveness of care.

Access to care Early identification of families with multiple problems is difficult (Spratt, 2011). According to Mehlkopf (2008a), families with multiple problems often display signs that they are troubled and are in need of support. But these signs do not always emerge at the same time, and signals tend to be directed towards various agencies. Service providers face the danger to solely focus on the signals that are directed at them, instead of on the entire array of problems, and thereby run the risk to underestimate the severity of the situation. This is amplified by a general tendency in Dutch child welfare to offer demand-driven services, which rely on the clients’ autonomy and capability to find adequate services on their own initiative, and at the right time. Furthermore, many social services are primarily oriented towards clients who have a single, rather specific problem, which is addressed by offering a protocolled intervention for individual family members within clearly defined areas. This consumer and product-oriented approach has its merits, however, not for all families (Rots-de Vries, Kroesbergen, & van de Goor, 2009). In this framework issues of care avoidance, problem complexity or intractability, and interdependency of problems in the family are difficult to address. Coordination of care A second related challenge is to coordinate care goals and plans if multiple service providers are involved. A file analysis by Mehlkopf (2008b, p. 14) in the province of South-Holland revealed that on average at least 5.8 youth care professionals were involved in families that had been identified as a family


4

with multiple problems. A case study by van den Berg, van der Groot and Jansen (2008) in Amsterdam reports that 6–40 different care professionals had been involved over a period of 6–16 years in their sample (n = 6), in which families had been selected for review as ‘exceptional cases’, out of a possible 800 families with multiple problems in the Amsterdam area. Their case reviews revealed a number of pitfalls in dominant working methods that can result in a ‘revolving door effect’, i.e., repeated relapse and care re-entry. As for example an isolated approach to interrelated family problems, not learning lessons from previous care involvements of the families, and increasing frustration by a repeated emphasis on the clients motivation for change, without taking the clients’ abilities and resources to facilitate this change sufficiently into account. Duration of care Based on prevailing policy and the research paradigm of Evidence Based Practice (EBP), many specific short-term programmes have been developed within the youth services sector (Boddy, Smith, & Statham, 2011). Although additional need for long-term support for families with multiple problems has been acknowledged (Mehlkopf, 2008; Statham & Holtermann, 2004; van der Steege, 2010), only few interventions translated this need into intervention methods. This is illustrated by the fact that almost all of the interventions, which were included in the Dutch Databank of Effective Youth Interventions (Netherlands Youth Institute, 2014b), end support within 12 months. With one exception being the intervention entitled Home-based Youth

Care [in Dutch: Jeugdhulp Thuis], in which support can be provided between six and 24 months (van den Berg, 2010). Effectiveness of care The last challenge for care provision presented here encompasses the others: it is providing and evaluating effective care for families with multiple problems. According to a recent systematic review by Holwerda, Reijneveld and Jansen (2014), only few qualitatively good research projects exist that describe intervention outcomes specifically for families with multiple problems, either as a relevant subgroup of an outcome study or, less frequently, as main target

CHAPTER ONE

5

group of an intervention programme. They conclude that for most inter-ventions not sufficient evidence is provided to judge their effectiveness, and for those that can be judged effect sizes were found to be generally small, with non-significant results occurring more often than not, especially for the outcome measures of improved parenting skills and family functioning (Holwerda et al., 2014, p. 16). One meta-analytic study, also included in the review mentioned above, suggests that families with multiple problems can benefit from intensive (short-term) crisis intervention, in terms of enhanced family functioning and the prevention of out-of-home placement (Al et al., 2012). But as mentioned earlier, other studies also raise concern about the sustainability of effects of short-term interventions, which indicates a possible need for intensive support over longer periods of time (Al, Stams, van der Laan, & Asscher, 2011; Berry, Cash, & Brook, 2000; Forehand & Kotchick, 2002; van Puyenbroeck et al., 2009). The provision of both, potentially long-term support programs next to brief topic-focused intensive interventions, might in conclusion be a valid intervention strategy for families with multiple problems (Moran, Ghate, & van der Merwe, 2004, p. 118). Meta-analytic studies on the prevention of child maltreatment and the promotion of family wellness provide empirical ground for which types of programs are promising. Among others, two types of programs have the most potential benefits: multi-component interventions and home visiting programs (MacMillan et al., 2009; Mikton & Butchart, 2009). For intensive home-based programmes, accredited in the Dutch databank of effective interventions, the following characteristics have been identified as common to best-practice: • parenting-related support in the family’s home, with a contact frequency of at least once a week, aimed at multiple areas of life; • establishment of a needs-led care plan, with participation and

empowerment of the family members as guiding principles; • a systemic focus on the family as a whole, and the social learning theory driven improvement of parenting skills, child behaviour, and involvement of the social network; and


6

• professional training and regularly performed supervision of care workers to enhance programme integrity and advance collaborative work (van der Steege, 2007, p. 34). The conclusions of Holwerda’s, Reijneveld’s and Jansen’s (2014) review overlap with these findings. Additionally, they mention the two characteristics of a relatively low caseload of 5–10 families per full-time professional and the provision of support, including material/financial matters. The aforementioned components can be identified by comparing them to components that are common to effective or promising programmes. However, a lack of structural, substantive information about direct activities in the primary care processes can be observed, given that the majority of effect and evaluation studies investigate primarily the outcomes of services (Sinclair, 2010). For this reason, the primary care process has also been referred to before as a ‘black box’ (Staff & Fein, 1994), and a need for more detailed scientific insight into it, has been articulated, especially for home-based interventions like family preservation services (Craig-van Grack, 1997). Promising Intervention Strategies Interventions which combine multiple service components into integrated services with a flexible intensity over longer periods of time have been reported as piloted in practice from different countries (De Melo & Alarcão, 2011; Krasiejko, 2011; Marsh, Ryan, Choi, & Testa, 2006; McCartt Hess, McGowan, & Botsko, 2000; Sousa & Rodrigues, 2012; Thoburn et al., 2013). Evidence for the effectiveness of these interventions is not yet scientifically grounded, but features of these programmes fit theoretically well with the earlier outlined challenges in providing care for families with multiple problems. As main advantages of the programmes the following were mentioned:

• offering new alternative ways to approach families (e.g., giving room to material and relational practices);

CHAPTER ONE

7

• an enhanced flexibility in personalizing care arrangements (e.g. tailored care components, needs-led programme duration and intensity); • the possibility to counter negative side-effects of service specialisation (e.g., care fragmentation) through co-ordination and/or integration; and • the reduction of stressful care re-entry moments for families with fluctuating crisis pattern (e.g., through flexible intensity and care durations). In the Netherlands one intervention model that combines multiple components in home-based care over longer periods of time is called Family

Coaching. In the study reported here, a Dutch family coaching programme named ‘Ten for the Future’ (TF) [in Dutch: Tien voor Toekomst] is explored in more detail. Two features of the programme can be seen as distinctive in Dutch child welfare: A) an integrated care approach that provides support in 10 explicitly stated areas of life and B) the flexible needs-led intensity and potentially long-term programme duration. Family Coaching—Ten for the Future In 1997 the Salvation Army of the Netherlands [in Dutch: Leger des Heils] started to develop the intervention Ten for the Future (TF) to specifically target families with multiple problems (Leger des Heils Noord, 2006). The first team started in 1999. Overarching goal of TF is: “preserving the independence of the family system within generally accepted social limits” (Leger des Heils Noord, 2006, p. 11); an intervention goal which broadly resembles that of family preservation by aiming at the prevention of out-of-home placement, while also entailing proximal and intermediate instrumental goals (Hurley et al., 2012; Rosen & Proctor, 1981), such as the improvement of parenting skills and family functioning. Individual care goals are specified for clients in relation to ten areas of life (see Table 1, p. 8).


8

Table 1 Ten areas of life and corresponding goals of TF Areas of life Intervention goalsHousekeeping Acquiring practical skills in housekeeping to self-sufficiently maintain a household. Administrationand finances Managing finances according to income.

Care responsibility Enhancing safety and well-being of the parent(s) as well as the children. Parenting Enhancing parenting skills.Education Creating learning environments for the parent(s) and the children. Daily activities Parent(s) acquiring sufficient income.Mental health Maintaining good health, including the management of possible addictions. Care management Organizing formal care arrangements if necessary. Social network Maintaining a supportive social network. Behaviour management Learning to live within socially acceptable boundaries. Note. Adapted and translated from “10 voor Toekomst. Methodiekbeschrijving” [10 for the Future. Description of intervention method] by Leger des Heils Noord, 2006, Centra voor Wonen, Zorg en Welzijn Noord: Groningen. The intensity of the intervention is expressed in (face-to-face contact) hours per week, which are negotiated for each client individually between the Salvation Army (as care provider) and the respective financing agency. The underlying programme theory is eclectic and includes systems theory, learning theory, directive and contextual therapy (Leger des Heils Noord, 2006, pp. 17–21). Family coaches working for TF are professionally trained child and youth care workers educated on higher vocational levels, with additional training in Intensive Family Home Care [in Dutch: Intensieve Ambulante

CHAPTER ONE

9

Gezinsbehandeling]; a systems theory guided 12 day course spread over eight months focusing specifically on work with families with multiple problems. The Research Project In the period 2006–2014 a research project was carried out at the University of Groningen, in order to develop more knowledge about the characteristics of the target group and to gain more detailed insight into the primary care processes, as well as to evaluate the results of the intervention. Three main research questions were guiding:

Target group characteristics 1. What characterizes clients referred to TF? Process evaluation 2. What characterizes care provided in TF? Outcome evaluation 3. Is TF associated with problem reduction? To answer these questions, two studies were carried out. The first study was designed to include all families who followed the programme TF for at least 90 days in the three Northern Provinces of the Netherlands (Drenthe, Friesland, Groningen) within the data collection period of four years and seven months (10 September 2007–1 May 2012). Data gathered in this study consisted of standardized questionnaires, and administrative data. This set-up provided information on 122 clients, and allowed to answer questions on target group characteristics and intervention outcomes, including the duration of the flexible care programme. To answer the second question a self-report instrument was developed. The instrument’s aim was to gain detailed insight into primary care activities that were performed by the family coaches in TF. In three waves (T1, T2, T3) data were collected over a time period of 22 months (T1 in April 2010, T2 in February 2011, T3 in February 2012), in the three Northern Provinces of


10

the Netherlands (Friesland, Groningen, Drenthe), which resulted in a total timeframe of 10 weeks from which care activities were sampled. Overall the work of 50 family coaches was monitored, referring to more than 650 client contacts and including over 2,500 care activities. Based on these data a detailed description of the primary care process could be given. Thesis Structure This thesis approaches its subject from two perspectives: theoretically and empirically. Chapters two and three aim at a deeper understanding of the phenomenon of families with multiple problems on the basis of the existing literature. The following two chapters (4 & 5) seek to enhance this body of knowledge by providing additional empirical ground. Both approaches are synthesized in a combined discussion, in the last chapter (6). In more detail the chapters’ contents read as follows: —Chapter two— Starting point of this thesis is the exploration of the varying conceptual approaches to the description of the target group. The greatest variation was found between Germany and the Netherlands. Only few German-speaking scholars referenced the concept in the 1990’s and the concept was later also opposed by general critical rejection. As alternatives the concept of poverty and social exclusion were advanced, suggesting a better fit with German theory and practice. This finding prompted a literature review, in which both similarities and differences in the conceptual approaches are examined, and their potential value for an ethically justified child and youth care practice is evaluated theoretically. Central to this review is the concept of life situations from which this thesis proceeds. —Chapter three— In the third chapter, following up on the different approaches in theory production, publications are reviewed that provide more detailed information on characteristics of the target group as well as the service provided for them in the Netherlands. From this second review central themes in target group

CHAPTER ONE

11

description as well as in the development of programmes for families with multiple problems are derived. The results of this review provide the theoretical ground for the following two empirical studies on the family coaching programme TF. —Chapter four— The study covered in the fourth chapter aims at a deeper understanding of primary care processes in the home-based intervention programme TF. The development of a self-report instrument is described, which serves as a tool for family coaches to systematically report the care activities which they had performed. Furthermore, results from a sequenced study are presented that give more detailed insight into the primary processes of care in TF and illustrate the complexity and intensity of care activities performed to meet the needs of the clients. —Chapter five— The focus of the study reported in the fifth chapter lies on the assessment of client characteristics, the duration of the flexible intervention programme, and the magnitude of problem reduction associated with TF. Results from the data analysis on group level as well as individual case level are presented and are subsequently discussed in the light of the earlier findings. —Chapter six— The sixth and last chapter gives a summary of the preceding chapters and reflects on the findings through a synthesizing discussion. Overarching themes are identified from which implications for practice and research are derived. Finally, suggestions for the further development of the intervention programme TF are made and conclusions for the future advancement of research on families with multiple problems are drawn.

CHAPTER TWO

THE LIFE SITUATION OF FAMILIES WITH MULTIPLE PROBLEMS: A COMPARATIVE CONCEPTUAL ANALYSIS OF

SOCIAL SERVICE PERSPECTIVES

This chapter is based on: Tausendfreund, T., Knot-Dickscheit, J., Knorth, E. J., & Grietens, H. (2012). De leefsituatie als explanans en explanandum bij multiprobleemgezinnen. Een vergelijkende conceptuele analyse van hulpverleningsperspectieven in Duitsland en Nederland. Pedagogiek, 32(3), 251–271. Tausendfreund, T., Knot-Dickscheit, J., Grietens, H., & Knorth, E. J. (2015). The life situation of families with multiple problems: A comparative conceptual analysis of social service perspectives. Manuscript submitted for publication.

CHAPTER TWO

15

The life situation of families with multiple problems: A comparative conceptual analysis of social service perspectives

Abstract Originally developed in English-speaking countries, the concept of ‘multi-problem families’ is frequently used in the Dutch child welfare sector to denote a target group characterized by experiencing complex, longitudinal and intertwined problems. In German-speaking countries only little reference is made to this concept, and if so, often in disapproval. Alternative terms to characterise families that face multiple adversaries have been forwarded in Germany instead, which link social theories on poverty and social exclusion to the concept of ‘life situations’. This conceptual difference between Germany and the Netherlands prompted a literature review, in which theoretical and practical values of concepts describing families with multiple problems were examined. Central to this review is the concept of life situations from which we proceeded. We examine both similarities and differences in the conceptual approaches, and evaluate their potential value for an ethically justified child and youth care practice. In conclusion the concept of life situations can serve as a valuable frame of reference for social work practice and research. The concept bridges the micro, meso and macro levels of family functioning and as well as the broader social context, thus making it possible to describe and analyse the multitude of problems individual families may face, as embedded within society.

LIFE SITUATION OF FAMILIES WITH MULTIPLE PROBLEMS

16

Introduction For more than two decades, the concept of multi-problem families has been used in the Dutch child welfare sector to define families who are struggling “with a chronic complex of socioeconomic and psychosocial problems, which the care professionals involved consider as refractory to care”1 (Ghesquière, 1993, p. 43). In the Netherlands, interventions have been developed or modified especially for this target group. The concept, partly equivalent to the English concept of ‘families with multiple problems’ (Spratt, 2009), is coming into increasingly common usage by researchers in the behavioural sciences and within various educational sciences, including the Dutch orthopedagogy [special needs education and youth care], and clinical psychology (Hellinckx et al., 2008). In light of the popularity of this concept in the Netherlands, it is interesting to note the scarcity of the concept in the German literature. As early as 1993, Ghesquière notes, “[We] found only a limited number of German-language publications that correspond to these traditions in the literature of the United States and the United Kingdom. . . . They are related to the relatively recent form of social services known as sozialpädagogische Familienhilfe [social pedagogical family support], which is also a form of home-based care” i (Ghesquière, 1993, p. 24). Even 19 years later, little change has taken place in the scarce number of publications (Tausendfreund, Knot-Dickscheit, Knorth, Strijker, & Schulze, 2012). One possible explanation involves the critical assessments of the concept that have appeared in German-language publications on social pedagogical family support. The concept has been pushed aside, because it is perceived as inconsistent with the core principles of the German social service sector. These principles include resource orientation [German: Ressourcenorientierung], which refers to a focus on actual or potential strengths and skills of the client system, and welfare state principle [German: Sozialstaatsprinzip], which refers to the government’s obligation to eliminate unequal opportunities as much as possible. The concepts of poverty and deprivation (of a family) have been advanced as alternatives, as described in the 1 Translated from Dutch by the author of this thesis, T. Tausendfreund

CHAPTER TWO

17

German Handbook on social pedagogical family support (Helming et al., 2004), published by the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth: The concept of poverty as accumulation of shortages . . . corresponds better than the concept of ‘multi-problem’ families with a fundamental approach characterized as ‘resource orientation’ in social-pedagogical family support. . . . The concept of ‘multi-problem families’ includes only the level of the family system (‘families that have many problems’) and hides social deprivation, the deprivation of these families, . . . The term also neglects the ‘welfare state principle’, the obligation of the state to intervene to regulate equal opportunities.2 (Helming et al., 2004, p. 74) The focus of the German system, in contrast to the Netherlands, is thus not on the description of a target group, but on the attitude or vision of the government and social services with regard to a group of citizens (or clients). Concerns regarding the stigmatization associated with the concept of multi-problem families appear to play a prominent role in this regard, although these concerns alone cannot explain why the concept of poverty should be a suitable alternative. To answer this question, we first elaborate on the German concept of poverty and the Dutch concept of social exclusion. We then consider how various aspects are related to the above-mentioned criticism of the concept of ‘multi-problem families’. Based on these insights, we formulate implications for theory on families with multiple problems. In our opinion, these implications are relevant to research, policy, and services, in an international context. Conceptualization of Poverty and Social Exclusion One key to an answer to the question posed above, i.e. why poverty is considered a suitable concept in Germany, can be found in its definition. In Germany, the concept of life situations [German: Lebenslagen] has been gaining 2 Translated from German by the author of this thesis, T. Tausendfreund.


18

considerable popularity in the social sciences since the 1990s. This multi-dimensional concept plays a central role in the analysis and description of poverty in Germany, particularly with regard to children growing up in poverty. The comparable concept of living conditions [Dutch: leefsituaties] has also been applied in research in the Netherlands, particularly in studies on social exclusion of children and families (Guiaux, Roest, & Iedema, 2011; Roest, Lokhorst, & Vrooman, 2010). Before elaborating on several substantive attributes of this concept, we outline the respective national contexts in relation to it. The Concepts of Life Situations and Poverty in Germany In Germany, a broad concept of poverty [German: Armut] is adopted, based on the 1984 European definition (Council of the European Communities, 1985) and in accordance with definitions of the World Bank (Haughton & Khandker, 2009) and the United Nations (Administrative Committee on Coordination, 1998). More specifically, in Germany, poverty refers not only to financial deficit, but also to deprivation in a number of socially relevant aspects of life (e.g. physical, social and cultural participation). The sociological concept of life situations plays a central role within this broad definition (German Federal Government, 2001). This concept, which was first elaborated theoretically in the 1930s (Neurath, 1931), was adapted empirically for use in social policy in Germany in the 1960s (Weisser, 1978). Since 2001, it has been used in the quadrennial German governmental report on poverty and wealth, entitled Life situations in Germany (German Federal Government, 2001; 2005; 2008; 2013). From that time on, the concept has played a prominent role in studies examining the impact of poverty on children, with the conviction that concepts of poverty that are restricted to matters related to income are only of limited value (e.g., Hock, Holz, Simmedinger, & Wüstendörfer, 2000; Holz & Puhlmann, 2005). It is interesting to note that the application of the concept has not been limited to sociological and political studies. It has also been recognized in the German discipline of social pedagogy [German: Sozialpädagogik] as a concept with critical-analytical value for (future) theory production (Böhnisch, Schröer,

CHAPTER TWO

19

& Thiersch, 2005; Böhnisch, 2008). The analysis of processes related to the phenomenon of poverty—in the broadest sense—is considered important as theoretical and empirical input for child and youth care, as with the above-mentioned social pedagogical family support (Otto, 2006). In Germany, many strategies that are intended to reduce or prevent the negative effects of poverty on children are therefore located at two levels of action: social policy and social pedagogical practice (e.g., Lutz & Hammer, 2010). The Concepts of Living Conditions and Social Exclusion in the Netherlands Unlike in Germany, a stricter (i.e. financial-economic) definition is used in official poverty reports in the Netherlands. Although it is assumed that poverty is often accompanied by social exclusion, it is not an identical concept, and poverty must not be automatically included in the definition of social exclusion (Jehoel-Gijsbers & Vrooman, 2007). The Dutch counterpart of the German concept of life situation is translated as living conditions. The best-known operationalization of this concept can be found in the Permanent Survey of Living Conditions [Dutch: Permanent Onderzoek naar de Leefsituatie, or POLS], as part of the NISR Living Conditions Index [Dutch: SCP Leefsituatie-Index, or SLI] conducted by Statistics Netherlands (CBS). In the Netherlands, research on living conditions is used primarily to explore cultural changes and the life circumstances of specific population groups, such as in research on the integration of young immigrants (Vroome & Hooghe, 2013). The concept plays a key role in research on intangible processes resulting from poverty, including the social exclusion of children (Nederland, Mak, Stavenuiter, & Swinnen, 2007). However, the sociological concept of living conditions plays little or no recognizable role in the development of theory in Dutch child and youth care. We return to this point in the conclusion and discussion.


20

Characteristics of Life Situations Overarching attributes of both concepts, i.e. the one of living conditions and the one of life situation, can be identified partly in reference to the works of Jehoel-Gijsbers (2003) for the Netherlands and Voges, Jürgens, Mauer and Meyer (2003) for Germany. In the following, we discuss four mutual attributes of the concepts—multidimensionality, multiple levels, objectivity and subjectivity, and dynamism and relativity—based on concrete examples from social research. In the section thereafter, we use these attributes in the further evaluation of the criticism surrounding the concept of ‘multi-problem families’, as outlined in the introduction. In each of the sections we included one example figure as a visual illustration. Multidimensionality

Multidimensionality—as the opposite of unidimensionality—is a key attribute in the conceptualization of poverty and social exclusion as life situation (Jehoel-Gijsbers, 2003; Voges et al., 2003). Key element of this attribute is the division of the life situations into a number of relevant areas of life. Examples include categorizations consisting of four sub-dimensions (e.g., Holz & Puhlmann, 2005; Jehoel-Gijsbers & Vrooman, 2007) or five domains (e.g., Hock et al., 2000; Voges et al., 2003). Jehoel-Gijsbers and Vrooman (2007) further distinguish two primary dimensions—economic-structural and sociocultural—under which the four sub-dimensions can be arranged. We included Figure 1 (p. 21) as visual example for the concept of multidimensionality.

CHAPTER TWO

21

Figure 1. Living conditions divided into primary and sub-dimensions. Adapted from “Explaining Social Exclusion. A theoretical model tested in the Netherlands,” by G. Jehoel-Gijsber and C. Vrooman, 2007, p. 17, Den Haag: The Netherlands Institute for Social Research (SCP). Multidimensional conceptualization offers several advantages. The primary advantage is that it reduces the amount of information (‘major points’) while preserving notions of complexity. This type of conceptualization emphasizes the distinction of qualitative aspects (dimensions), each of which can be analysed in greater detail subsequently (Alkire & Foster, 2011). Multidimensionality also makes it possible to interpret a single social phenomenon from multiple perspectives, and reveal possibilities of (problem) accumulation. For example, having a job can be seen as a source of income (i.e. material), as a source of guaranteed civil rights (i.e. institutional), as a source of meaningful contacts (i.e. social) and as a source of integration (i.e. cultural). Multiple Levels

In addition to being suitable for offering a concise overview and horizontal ranking of areas of life, the concept of life situations also provides a foundation for analysis at various levels of functioning for actors (or groups). Traditional distinctions include the micro, meso and macro levels. The micro level defines the smallest social unit—the interactionist sphere, the meso level focuses on institutional embeddedness—the organizational sphere, and the macro level encompasses the entirety of the social realm at its highest ranking—the societal


22

sphere (Luhmann, 1996). For example, the following model (Figure 2) can be used to create a vertical ranking of risk factors related to the phenomenon social exclusion.

Figure 2. Dimensions and risk factors in living conditions at the micro, meso and macro levels that increase the risk of social exclusion. Adapted from “Explaining Social Exclusion. A theoretical model tested in the Netherlands,” by G. Jehoel-Gijsber and C. Vrooman, 2007, p. 19, Den Haag: The Netherlands Institute for Social Research (SCP). The inclusion of multiple levels in a model allows to embed conditions of individuals or groups into greater frameworks, such as the community or the society. Links between and factors underlying individuals and their social, cultural, institutional and economic environments can be analysed and subsequently incorporated into theory, making it possible to estimate or qualify them for use in designing policy and social services. In this context,

CHAPTER TWO

23

‘qualification’ is not limited to distinctions between desirable and undesirable outcomes, but extends also to statements about the possibilities and limits of direct or indirect change (as indicated in Figure 2 (p. 22), with the distinction between factors that can and cannot be influenced). With regard to the attribute of multiple level theories, we see both agreement and fundamental difference with socio-ecological theories in the educational sciences (Bronfenbrenner, 1979). In socio-ecological theories and analyses, micro-systems, meso-systems, exo-systems and macro-systems depend on the idea of the individual as centre. (Hamburger, 2008, p. 61). In child and youth care, however, the macro-system, as a relatively constant unit (Bronfenbrenner, 1979, p. 258) is, at least in the Netherlands, often assumed as unit with little or no capacity for change (Scholte, 1999), and excluded from further analytical consideration (Bakker, Bakker, van Dijke, & Terpstra, 2000, p. 28). However as shown in the example (Figure 2, p. 22), the substantive analysis of the meso and macro levels (alone) offers an important additional perspective, particularly with regard to the target group of families with multiple problems. The social-services system, public policy and social developments can be included as contributing factors that can be seen as both, a potential risk factor and a resource (Morris, 2011; Spratt, 2009). Objectivity and Subjectivity

A third primary attribute of the concept of life situations is the theoretical link between the objective conditions or possibilities of the individual (situation) and the subjective interpretation thereof by the individual (actions or behaviour). In German, the use of the etymologically related concepts of Verhältnisse [English: situation] and Verhalten [English: behaviour] underlines this point also semantically (e.g., Holz, Richter, Wüstendörfer, & Giering, 2005, p. 47). One example of an analytic diagram emerging from this attribute is shown in Figure 3 (p. 24).


24

Well-being Subjective interpretation

Good Poor

Livelihood Objective possibilities

Good Well-being (+/+)

Dissonance Dissatisfaction

dilemma (+/-)

Poor

Adaptation Satisfaction

paradox (-/+)

Deprivation (-/-)

Figure 3. Positions of well-being in relation to material deprivation. Adapted from “Methoden und Grundlagen des Lebenslagenansatzes. Endbericht“ [Methods and foundations of the life situations approach. Final Report] by W. Voges, O. Jürgens, A. Mauer and E. Meyer, 2003, p.49. Bremen: Universität Bremen & Zentrum für Sozialpolitik. Models of this type make it possible to depict similarities or conflicts between individuals and their environments (and the associated conditions). In addition to its meta-theoretical implications (Winkler, 1988), this approach can also be operationalized methodologically for each area of life (e.g., Holz et al., 2005, p. 47), allowing the inclusion of multiple perspectives regarding the direction and level of solutions (e.g., Home-Start International, 2002, p. 39). The analysis and mediation of conflicts between the two poles (subject and environment) can be seen as characteristic of the child and youth care system in Germany (Hamburger, 2008, p. 14). Dynamism and Relativity

The fourth and final overarching feature of the concept of life situations (and the concept of social exclusion) is that it is a dynamic and relative concept. In other words, the living conditions of an individual or group (e.g. a family with multiple problems) are seen as being subject to change (over time) and as

CHAPTER TWO

25

dependent upon conditions and developments occurring in the greater population. This is in contrast to relative static concepts, which are used to describe a phenomenon according to the presence of particular features, in independents of their prevalence, as for example absolute definitions of poverty (Ravallion, Chen, & Sangraula, 2008). The characterization of a social phenomenon as dynamic and relative has several consequences for theory and practice. The following figure 4 can serve as an example of the analysis of causal, dynamic links that explain social exclusion of children.

Figure 4. The most important causal routes for explaining the general index of social exclusion for children (with standardized correlation coefficients, N=2202). Adapted from “Sociale uitsluiting bij kinderen: Omvang en achtergronden,” [Social exclusion of children: Scope and backgrounds] by A. Roest, A. M. Lokhorst and C. Vrooman, (2010), p. 81, Den Haag: Sociaal en Cultureel Planbureau. The Figure 4, which is taken from a recent study conducted by the Netherlands Institute for Social Research (SCP), identifies variables that have the greatest effect on each other, thus ‘tracing’ the route leading to the greatest probability of social exclusion amongst children.


26

Several interesting conclusions can be derived from this model. First, “. . . approximately two thirds of the variance in social exclusion amongst children” (Roest et al., 2010, p. 81) can be explained by the financial-economic route. Second, in addition to the direct effect of material deprivation on the part of the parents, the non-Western origin of a family and the experience of growing up in a single-parent family have been shown to have large indirect effects. Nevertheless, caution is advised when interpreting probabilities based on causal chains. The issue is not only that the model explains only a part of the variance, albeit a substantial part (59%) (Roest et al., 2010, p. 82). The interpretation is also limited by the dynamic nature of social exclusion and of the life situation. For both the concept of life situations (Voges et al., 2003, pp. 50 ff) and the concept of social exclusion (Jehoel-Gijsbers, 2004, pp. 135 ff), the explanatory concept (explanans) can also be the concept to be explained (explanandum). It is important to consider interactions and changes in the course of time, which are associated with individual, social and cultural developments, and which are dispersed over various levels of action and performance. The advantage of being aware of the dynamic and relative nature of the concept of life situations is that it necessarily leads to caution when interpreting the situation, drawing unilateral conclusions, and developing ‘absolute’ solutions for and with an individual and/or a family. Similarities and Differences in Theoretical Approaches Both the concept of poverty and the concept of social exclusion refer to core attributes that could be used to describe families with multiple problems. Their life situations are characterized by an accumulation of problems in multiple areas of life at the same time. Differences and similarities in theoretical approaches can be examined. Our comments in this regard are based on the four overarching attributes of the concept of life situations, as outlined above: multidimensionality, multiple levels, subjectivity/objectivity and dynamism/relativity. We proceed from the criticism of the concept of ‘families with multiple problems’ (Helming et al., 2004, p. 74). A part of the criticism can be explained by the sensitivity of the German child and youth care system for the normative capacity and possible

CHAPTER TWO

27

stigmatizing effects that concepts can have. As a concept, the term ‘multi-problem family’ has been characterized as unilateral and unidimensional. In conceptual terms, however, this criticism is unfounded. For example, with regard to the attribute multidimensionality, we observe primarily similarities between the German and Dutch descriptions. Dutch definitions of the concept of multi-problem families emphasize both the accumulation of problems in multiple areas of life and their qualitative differences through such measures as drawing clear distinctions between problem areas, e.g. psychosocial and socio-economic (cf. chapter 3). The criticism that the concept assumes a unilateral perspective thus cannot be confirmed at the conceptual level. Emphasis on an interactionist perspective that includes both the family and the social services is a core element of most Dutch definitions (cf. chapter 3). The German criticism of the concept of multi-problem families extends beyond the conceptual level. One important substantive point has to do with the definition, which should take into account the multiple levels (micro, meso and macro) with which the families are struggling. This imparts an ethical, social-functional and professional-theoretical weight to the criticism. According to the German proposition, a concept in the youth services that describes a group of clients should offer more than mere diagnostic analysis and solutions to problems in individual cases. It should also be able to detect or identify inhibiting or facilitating sources and factors at the societal level. Without concepts that can be connected analytically at the micro, meso and macro levels, it is impossible to recognize and counterbalance a tendency to individualize structural problems through individual professional services. Only in this way can integral solutions be sought that are capable of drawing substantive connections between politics, policy and practice of the care sector. The identification of existing or potential conflicts between the individual and society, the analysis of such conflicts and, ultimately, the mediation between the conflicting parties at all levels is at the heart of the social pedagogy discipline in Germany. This vision plays a central role in academic theory development (Hamburger, 2008, p. 14 ff), as well as in ethically founded professional practice (German Professional Association for Social Work,, 1997, viz., Art. 2.5-2.9). A part of the etymological and semantic sensitivity can be explained from this background as well. A concept such as that of multi-


28

problem families should be usable at all levels, both in communications with policymakers and in consultations with clients. According to this line of reasoning, a term that is potentially stigmatizing by unilaterally associating the family with ‘the problem’ is hardly suitable for this purpose. The Dutch concept of multi-problem families, along with the theoretical development associated with it (Baartman & Dijkstra, 1987; Ghesquière, 1993), also includes multiple levels, particularly the micro and meso levels. The concept nevertheless remains tied to the individual family and provides hardly any insight into the macro perspective (i.e. social structures). Socio-ecological models, which are present in Dutch child and youth care development (Bronfenbrenner, 1979; Scholte, 1999), recognize the dynamic and multiple nature of factors and levels that affect behaviour and situations in bringing up children. Nevertheless, these factors are placed outside the scope of the child and youth care interventions and identified as unchangeable. This reveals a clear difference from the German social pedagogic approach, which emphasizes social responsibility when compensating for unequal opportunities for vulnerable children and families. Finally, similarities and differences can be identified with regard to the dynamic and relative nature of such phenomena as families with multiple problems. The German criticism stresses the priority that the development of an appropriate attitude and basic social-service principles should have, beyond the identification of characteristics of the target group. This view is also reflected in several Dutch studies, as articulated in a ‘conflict of perspectives’ in the interaction between families and care professionals (Ghesquière, 1993), however in the Netherlands solutions are mainly focus on the refinement and development of specific factors, such as intervention programs, rather than general factors or social political advocacy. Conclusion As described in this chapter, a paradigm shift can be observed in the social-scientific conceptualization of poverty, social exclusion and similar phenomena, moving away from static, unidimensional interpretations towards dynamic, multidimensional concepts (Jenkins & Micklewright, 2007). Our analysis

CHAPTER TWO

29

indicated that, in Germany, the concept of life situations is such a concept used as theoretical framework to describe families facing multiple problems. The concept of life situations, with its division into areas of life and embedded levels, along with acknowledging objectivity and subjectivity, the interaction between them and the concept’s status as both explanans and explanandum, can serve as valuable framework in the refinement of social services for families with multiple problems. Research suggests that multidimensionality and flexibility in the social services provided to socially excluded children and families produce better results than do interventions aimed exclusively at training parenting skills (Thoburn et al., 2013). The inclusion of different levels in the problem analysis can reveal potential conflicts of interests relevant for designing future policy, practice and research on family interventions (Morris & Featherstone, 2010). Research on the phenomenon of resilience emphasizes the complexity of the interplay between (objective) problematic life events and (subjective) individual coping skills (Masten, 2001), hints at the importance of cumulative factors herein (Jaffee, Caspi, Moffitt, Polo-Tomás, & Taylor, 2007), and offers potential guidance in the design of interventions to influence possible pathways to problems (Dallos & Hamilton-Brown, 2000). And last but not least, the acknowledgment of dynamism and relativism, allows for a critical appraisal of research practices in the continuous struggle to identify success factors that contribute to effective and ethically responsible social services (Otto, Polutta, & Ziegler, 2009), which bear relevance beyond national borders (Boddy et al., 2011). The response to these social issues remains a national issue, as do the ways in which these issues are conceptualized, however solutions to globally arising problems should be inspired by international comparison and transnational discourse. The differences found need not be problematic; they can serve as a source of inspiration for shifting perspectives or for developing stronger arguments for retaining the current perspective. On the other hand, similarities between national perspectives can help facilitate a joint search for an approach to social issues that are on the agenda across national borders.

CHAPTER THREE

FAMILIES IN MULTI-PROBLEM SITUATIONS: BACKGROUNDS, CHARACTERISTICS, AND CARE SERVICES

This chapter is based on: Tausendfreund, T., Knot-Dickscheit, J., Knorth, E. J., Strijker, J., & Schulze, G. C. (2012). Familien in Multiproblemlagen: Hintergründe, Merkmale und Hilfeleistungen. Schweizerische Zeitschrift für Soziale Arbeit, 12(1), 33–50. Tausendfreund, T., Knot-Dickscheit, J., Schulze, G. C., Knorth, E. J., & Grietens, H. (2015). Families in multi-problem situations: Backgrounds, characteristics and care services. Child and Youth Services, 36 (conditionally accepted).

CHAPTER THREE

33

Families in multi-problem situations: Backgrounds, characteristics and care services

Abstract In this chapter practical experiences and theoretical reflections from the Dutch child welfare sector on the provision of adequate care for families with multiple problems are reviewed. Emphasis is laid upon the complex relations between socioeconomic and psychosocial problems, and subsequent issues that may arise in arranging child and youth care services for families who experience enduring and complex problems. Furthermore, the current state of the discussion in programme development for the target group in the Netherlands is introduced. The starting point for our review was the discovery that the originally English concept of families with multiple problems, commonly referred to as ‘multi-problem families’ in the Netherlands, has been used only modestly in German-speaking countries. This is remarkable from an inter-national perspective, especially considering the re-emerging prominence of social policies that define families as a site of social work practice in English-speaking countries. We conclude that the themes, as derived from our review open up possibilities for further international comparisons, and can provide valuable reference points in the transnational discourse about child and youth care services for families with multiple problems.

BACKGROUNDS, CHARACTERISTICS AND CARE SERVICES

34

Introduction The originally Anglo-American concept ‘multi-problem families’ has been used for more than two decades in the Dutch child welfare system to describe families whose life situation is characterized by a plurality of particularly complex problems in various areas of life. They are described as special target group in psychological and pedagogical sciences (Hellinckx et al., 2008; Steketee & Vandenbrouke, 2010; van der Steege, 2010) and programmes were developed and/or modified specially to meet their needs in Dutch child and youth care practice (Netherlands Youth Institute, 2014b). From a Dutch point of view it is striking that, thus far, the concept has been applied only sporadically in German child and youth care literature. As early as 1993, Ghesquière stated that the few German-language publications that used ‘multi-problem families’ as a client group description in most cases referred to English articles, which indicates a modest reception of the concept in German-speaking countries (Ghesquière, 1993). Publications in German that used the term could mainly be found in the area of family therapy (Clemenz & Dichmann, 1990; Conen, 2008) or refer to articles about Dutch child and youth care projects (Bouwkamp, 2005). One clue to the comparatively modest reception of the concept, in contrast to the Netherlands, can be deduced from the German Handbook on social pedagogical family support (Helming, Schattner, & Blüml, 2004), in which the concept of poverty is presented as alternative term: “The concept of poverty as accumulation of shortages . . . corresponds better than the concept of ‘multi-problem’ families with a fundamental approach characterized as ‘resource orientation’ in social-pedagogical family support”3 (2004, p. 74). This conclusion, which carries an undertone of the reproach of stigmatization, is justified but also bears danger, from our point of view. There is the risk of a lack of acknowledgement for unique dynamics of extensive 3 Translated from German by the author of this thesis, T. Tausendfreund.

CHAPTER THREE

35

problems, in particular the complexity of interactions between socioeconomic and psychosocial problems. Therefore, in in this chapter, we will replace the term ‘multi-problem families’ with ‘families in multi-problem situations’ so that the concept of ‘problem’ is ascribed semantically to the family’s environment rather than the family itself. A compromise that acknowledges the notion of stigmatization on one side but also tries to tie in the German discourse on poverty on the other side, by referencing the ‘life situations approach’ (German Federal Government, 2001, 2005, 2008; German Federal Ministry of Labour and Social Affairs, 2013). This form of translation corresponds also with some recent German-language publications (Barth & Schlereth, 2009; Beitzel, 2010; Schulze & Wittrock, 2005). The aim of this chapter is to expand the understanding of the complex connections between problems within the family system and the difficulties these families experience within the child and youth care system. In conclusion this justifies a closer look of lessons learned from international research and practical experiences for the Dutch child welfare system. Families in Multi-Problem Situations The works of Baartman and Dijkstra (1986; 1987) and that of Ghesquière (1993) were pioneering for theory of families in multi-problem situations in the Netherlands. Semantically, both authors followed the Anglo-American concept of the ‘multi-problem family’, cross-referenced with the Anglo-Saxon concept of ‘problem family’. The theoretical origin for these terms was, on the one hand, located historically in an American longitudinal study carried out at the beginning of the 1950s (Buell, Berry, Robinson, & Robinson, 1952; Geismar & Ayres, 1959; Geismar & La Sorte, 1964). On the other hand, phenomenological roots were found in the specific residential and social policy for families perceived as problematic at the beginning of the previous century, as for example in the Netherlands (Dercksen & Jansen Verplanke, 1987), or in the United Kingdom (Starkey, 2002; Welshman, 1999). In retrospective analysis the processes of segregation, normalization and individualization were distin-guished as developmental lines of social work in the Netherlands, portrayed via the changes in terminology and practice (Baartman & Dijkstra, 1986). Similar


36

semantic analyses of the phenomenon can be found in recent English publications as well (Sousa & Eusébio, 2007). Common to Dutch and most English interpretations is that, in principle, they presupposed a generally progressive and positively interpreted historical development that attempts to improve the life situations of those involved through processes such as de-stigmatization, emancipation and empowerment, initiated by social work interventions. More recently a critical debate about family based welfare interventions emerged (again) in Great Britain, which centres around research on the so-called Think Family Agenda and the associated Family Intervention Projects (Flint, 2012; Garrett, 2007; Hayden & Jenkins, 2013; Morris, 2011; Murray & Barnes, 2010; Nixon, 2007). In the German professional discourse the issue of care versus control has also been critically discussed since the 1970s, often under the umbrella term of a ‘double mandate’ (Böhnisch & Lösch, 1973; Helming et al., 2004, pp. 133f). The contours of this double-edged perspective become visible and are sharpened especially at examining the phenomenon of families in multi-problem situations. An example can be taken from the above mentioned American study. A central (and media-effective) result of the research project, the ‘St. Paul Family Unit Report Study’, was the finding that 6% of the families (n = 6,600) accounted for far more than half the spending’s in the city’s Social Service budget: the so-called ‘multi-problem families’ (Buell et al., 1952). A dual perspective emerges here: first, there are families that are dependent on state welfare to a considerable extent—their problems and need for support; second, these families absorb, comparatively speaking, most of the resources of social care services—extent of support and budget. This dual specificity of interrelated family and social factors can be followed down to the present day in the attempts to define the phenomenon, for example, the classic Dutch definition proposed by Ghesquière: “A multi-problem family is a family that faces a chronic complex of socio-economical and psycho-social problems, of which the involved care workers think that it is refractory to care”4 (1993, p. 42).

4 Translated from Dutch by the author of this thesis, T. Tausendfreund.

CHAPTER THREE

37

In this definition, both the nature and extent of the family’s problems as well as the difficulties of providing adequate support stand out. Both themes are worked out below. Characteristics of Families in Multi-Problem Situations Ghesquière (1993) lists a number of characteristics with regard to the problems these families experience. The problems are described as being multiple, varying and complex. The aspect of multiplicity means that the families have to cope with several problems simultaneously. These problems exist in differing areas of life, which makes them varying as such. In addition, the problems are interwoven with one another (mutually modifying each other in many ways), which leads to the situations being viewed as complex. The interaction between socioeconomic and psychosocial problems appears to be responsible for the difficulties that some of the families experience in their attempt to handle everyday life successfully (Bodden & Deković, 2010), and also for the difficulties the family care workers encounter in arranging adequate support. A file analysis from the Netherlands by Mehlkopf (2008b) supports this hypothesis. Above all, combinations of ‘financial problems’ with ‘intellectual disability’ and ‘psychological problems’ are prevalent, according to child and youth care files and statements of social workers. According to Baartman und Dijkstra (1987), aside from the manifold and varying aspects of the problem situations, the intensity or seriousness of the problems in all these areas is especially relevant. In addition to the problems the families’ experience, their ability to solve these problems needs also be taken into account; which may have a balancing effect (Bakker, Bakker, van Dijke, & Terpstra, 1998). Thus it is not the lack of problems that distin-guishes other families from families in multi-problem situations, it is their ability to solve problems in a persistent way (Dallos, Neale, & Strouthos, 1997; Janssens & van As, 2002; Zinko et al., 1991). A fourth characteristic is according to Ghesquière (1993) the chronic nature of the problem(s), i.e. the problems are experienced as protracted and/or succeed one another. Moreover, the phenomenon of transgenerational transmission in both psychosocial (Baas, 2001; Repetti, Taylor, & Seeman,


38

2002) and socioeconomic areas (Groh-Samberg & Grundmann, 2006; Hulme & Shepherd, 2003) has been observed. The fifth characteristic of persistence is related to the chronic nature of the problems. It entails that improvements in the life situation through social interventions are difficult to achieve and seldom or temporal. A phenomenon possibly also interrelated to interpretive differences between clients and social workers (Matos & Sousa, 2004; Sousa & Eusébio, 2007). Children who grow up in environments with multiple stressors are greatly limited in their further opportunities in life (Levitas et al., 2007; Maggi, Irwin, Siddiqi, & Hertzman, 2010). They experience discrimination in the education system (Organisation for Economic Co-operation and Development, 2010), inequality in the area of health (Bauman, Silver, & Stein, 2006; Repetti et al., 2002) and they appear to manifest episodic deviant behaviour more often (Asscher & Paulussen-Hoogeboom, 2005; Biglan, Brennan, Foster, & Holder, 2004). This is not surprising, however one should certainly be cautious about drawing simple causal conclusions, as research on resilience suggests (Gabriel, 2011; Werner, Bierman, & French, 1971). Not every child who grows up in a family in multi-problem situations will end up living permanently in problem situations over their life course. Results from research on child abuse however, show that the probability of an essentially resilient life decreases significantly as the number of stressors in family and neighbourhood environments increases (Jaffee et al., 2007). Children from families in multi-problem situations have fewer chances to permanently fend off in a constructive way the negative consequences of life events that put pressure on them. The overview of these characteristics reveals that families can be dependent in a special way on support outside the family system to break out of an escalating spiral of the interwoven complex of problems, or at least to stabilize the family situation in a way that ensures that the children have a necessary minimum of developmental chances; including the possibility of the out of home placement of children by intervention of the welfare state.

CHAPTER THREE

39

Problems in Arranging Support The second group of problems, after the severity and extent of the problems these families experience, is the difficulty to arrange adequate support, which Ghesquière (1993) divided into three categories: 1. organizational problems; 2. problems concerning the design of the intervention; and 3. problems in the professional relationship. In the organizational area, Ghesquière (1993) referred above all to the modest coordination between care services. It occurs frequently that several social workers are in contact with the family system at the same time, without sufficiently coordinating their activities with one another. A Dutch file analysis by Mehlkopf (2008b) concluded that, on average, at least six institutions were working with the families at the same time, whereas the coordination between the individual care services was low. Other case studies from the Dutch Child and Youth Care Services show how diverse and extensive support for families can be, with specific examples of 23 social workers being involved at the same time (Schaafsma, Hilhorst, & Hering, 2010), or up to 40 over a period of 16 years (van den Berg et al., 2008). Similar problems have been also reported from the United Kingdom (Spratt, 2011). Regarding the design of interventions, there is the danger of not taking the complexity of family problems sufficiently into account. Care services, which deal with only one of several problem areas, can overlook the interaction between the problems in various other areas of life. At the same time, there is the risk of asking too much of the families through multiple care goals and plans, for example if no clear priorities are set with respect to care goals (van Yperen, van der Steege, & Batelaan, 2006). The person of the professional as an essential element in service delivery is often not included specifically in programme methodology, at least in the Netherlands. In most cases, families in multi-problem situations have had bad experiences with public authorities and the care system. Because of this, fear and mistrust of and hostility towards care provision can be expected by the social worker (Schout et al., 2011). The personal qualities of the care workers


40

can thus be seen as of special importance (Petrie, 2011; Ribner & Knei-Paz, 2002; Schout, de Jong, & Zeelen, 2010). Services for Families in Multi-Problem Situations First, families in multi-problem situations are found in the regular welfare state care systems, for example, child and youth care or debt counselling. The difficulties listed above in arranging support can cause, as a rule, either a premature exit of the families from the care system or an increasing intensity or expansion of the intervention(s). Since the first targeted study in the United States of America in the 1950s, and in the Netherlands in the 1980s, several programmes have been developed, implemented, and partly researched (Knorth, Knot-Dickscheit, Tausendfreund, Schulze, & Strijker, 2009). Many of the care services in which families in multi-problem situations are found deal in principle with several problem areas at the same time or sequentially, often referred to as integrated or collaborative services (de Melo & Alarcão, 2011; Krasiejko, 2011; Marsh, et al., 2006; McCartt Hess, et al., 2000; Sousa & Rodrigues, 2012; Thoburn et al., 2013). The majority of the interventions are based in the families’ homes and are, ultimately, directed at a change in behaviour of the parents, and subsequently that of their children (Knot-Dickscheit, 2006). In the Netherlands, several programmes offer a combination of support on the socioeconomic level and the psychosocial level but, in principle, work on the assumption of the client’s own motivation. Methodologically, less attention is paid to the second characteristic of families in multi-problem situations, i.e. the difficulties of providing adequate support, especially in cases of care avoidance or care paralysis (Schout et al., 2011). At the beginning of the 21st century, when this situation was increasingly noted by municipalities and child and youth care services as gaps in provision, greater efforts were made to close this by tailored solutions (Ministry of Health, Welfare and Sport, 2005). In the current discussion (Netherlands Youth Institute, 2014a), more recent developments allow for some core themes to be identified in developing methodological solutions for working with families in multi-problem situations, which could also be of interest to international scholars. In the following we discuss themes that

CHAPTER THREE

41

emerged in the Netherlands: the effectiveness of intervention, the duration of the care services, the degree of voluntariness, the coordination of support, and financing. Crisis Intervention vs. Long-term Support In the current discussion increasing reference is made to the necessity of long-term home care in contrast to short-term crisis intervention programmes, which are particularly popular in the Netherlands, to prevent the out-of-home placement of children. A needs-led care approach and the construction of lasting professional networks to prevent relapse from reoccurring crisis patterns can be found in recent English publications as well (MacLeod & Nelson, 2000; Sacco, Twernlow, & Fonagy, 2007; Spratt, 2009; Thoburn, et al., 2013). In line with Dutch studies, which conclude that there is a demand for the provision of long-term support for selected severe cases (Berg-le Clercq, Zoon, & Kalsbeek, 2012; Orobio de Castro, Veerman, Bons, & de Beer, 2002; van der Steege, 2007). An interesting discussion in this context, though not yet fully developed theoretically, concerns the question of potential limits of achievable change for these families. A categorization of families into ‘teachable families’ and ‘families who can be stabilized’ surfaced recently (Schaafsma, 2005). A question arising especially in arranging family support for parents with (mild) intellectual disabilities in child and youth care (Drost, 2009). Voluntary vs Compulsory Care At the beginning of the 21st century possibilities and consequences of compulsory care in various care systems were discussed with increasing vigour in the Netherlands (Boendermaker, 2008; van Ooyen-Houben, Roeg, Kogel, & Koeter, 2008). Compulsory services were seen as a possibility to counter care avoidance by clients in child protection, as part of the problems of arranging adequate care for families in multi-problem situations. Compulsory parti-cipation in care was in the Netherlands justified theoretically, first, on the ethically and legally based duty to protect minors as a service of the society as a


42

whole (Kuypers & van der Lans, 1994), and, second, on psychological models of dynamic motivation (Miller & Rollnick, 2002). Methods of compulsory care find their references at the interface between psychiatry, addiction treatment and probation services (Choy, Pont, Doreleijers, & Vermeer, 2003; Jagt, 2010; Menger, Krechtig, & Timmers, 2008; Rooney, 2009). The earlier mentioned discussion on effectiveness and ethics of Family intervention Projects in Great Britain (cf. Families in Multi-Problem Situations) ties into this point of discussion. Coordination of Support vs. Support from One Department A third, prominent theme in the Dutch discussion on methodological solutions in working with families in multi-problem situations is the coordination or centralization of responsibility in care provision. In the Netherlands, this approach was summarized under the umbrella term of ‘family coach’ [in Dutch: ‘gezinscoach’]. The Dutch Ministry of Security and Justice introduced the concept in 2005, accompanied by a new Dutch Youth Care law. Since its introduction, the concept of family coaches has often been applied in practice, though not always with the desired clarity in the description of activities and responsibilities (Mehlkopf, 2008a). In general, two schools of thought can be distinguished, namely the ‘family coach’ as role or as function:

Role: Coordination and counselling provided by a care worker who is already involved with the family. Function: Coordination and counselling of the involved institutions by an external care worker who was not previously involved with the family (Mehlkopf, 2008a; Schaafsma, 2005). Both types of family coaches have in common that the main respon-sibility lies in the coordination of care for the family. The distinction is whether they are directly involved in care with the family or not. This differs from region to region and with respect to the type of support provided. Both forms can, if necessary, exist alongside each other, even in the same region and/or

CHAPTER THREE

43

type of support. In 2012, in the wake of a new Dutch Youth Law, it was suggested to further broaden the scope of family coaching by assigning it a principal role as primary care generalist (Raad voor Maatschappelijke Ontwikkeling, 2012). Funding by Department vs. Budgeting A fourth point, which was primarily introduced from practice and to date has been discussed only peripherally in social work theory, is financing the support for families in multi-problem situations and its consequences for care provision (Tausendfreund, Kleefman, Knot-Dickscheit, & Knorth, 2008; van den Berg et al., 2008). This not so much about the fact providing support requires funds. It is much more a question of what influence different types of funding can have on the objectives of providing support and the form of provision itself. Generally speaking, funding by a department is linked to the condition that the funds serve the set of objectives of that department. For example, programmes sponsored by the Ministry of Justice must contribute to the prevention of crime, and benefits from the Ministry of Health must contribute to the promotion of health. Funding by the Child and Youth Care Services should improve child welfare, and reduce further dependency on their services. The primary charac-teristic of families in multi-problem situations, i.e. the complexity and manifold nature of their problems, can lead to these families being dependent on substantial support in several areas. Which in turn can result in projects being funded via various financial sources and thus under different conditions, with different objectives and over different lengths of time. An attempt to methodologically solve the problems with the funding of care was introduced in the Netherlands by the governmental project ‘Integraal indiceren’ (Diephuis, van der Zijden, & van Wijk, 2007). The aim of the project was to coordinate support that encompasses more than one sector with respect to funding and content by coordinated budgeting. The first experiences from the model regions were judged positive by the (former) Dutch Ministry for Youth and Family, however, the projects were discontinued in the wake of the recent transformation and decentralisation of the Dutch child and youth care system as a whole (Bosscher, 2012).


44

Discussion and Conclusions An international phenomenon that can be observed since the 1960s at the latest is that a small number of families found in multiply-deprived life situations experience particular difficulties in the arrangement of social services. This group, which was discussed in German-speaking countries primarily in the context of poverty research, merits the attention of the social work sciences and social services in several respects, particularly when children and young people are drastically limited in their present and future life chances (Spratt, 2012). Firstly with regard to the complex interactions between socioeconomic and socio-psychological problem situations (2.1); secondly, with regard to institutional barriers and care avoidance in child protection (2.2). Here, child and youth care services need to find adequate answers to meet the needs of families in multi-problem situations. International literature suggests potential effectiveness of home-based, flexible, integrated and multi-component services (MacLeod & Nelson, 2000; MacMillan et al., 2009; Mikton & Butchart, 2009; Thoburn et al., 2013). Even though a respectable number of studies point to the effectiveness of this form of care, a lack of effectiveness studies is, however, still concluded (Dunst, Boyd, Trivette, & Hamby, 2002; MacLeod & Nelson, 2000; Sweet & Appelbaum, 2004). Similarly, only few programmes are found that directly target care avoiding families in child protection (cf. 3). In the development of Child and Youth Care programmes for these families in the Netherlands, four major points of discussion can be distinguished: 1. the duration of support, 2. the degree of voluntariness, 3. the type of funding, and 4. the coordination of the support. These themes, as derived from our overview on Dutch social work discourse, open up possibilities of international comparison, and provide discussion points for transnational dialogue in the hope of inspiring child and youth care practice. Thematic overlap or differences one finds might help to

CHAPTER THREE

45

gain new insights or critically appraise diversity (Boddy et al., 2011). Thus, for example, with regard to the developments in family support in Germany, two of the four overarching themes can also identified: the type of funding and coordi-nation of support (Frindt 2010). Through varying national perspectives different solutions can emerge to tackle similar problems. Here generalized for the sake of clarity, solutions in Germany appear to be sought primarily in structural reforms of child and youth care (Findt 2010), whereas in the Netherlands innovations are mainly implemented through methodological advancements. Thus, for example, answers to questions concerning coordi-nation and organization of family support are sought in Germany mainly in the discussion on legal classifications (Findt 2010, S. 33ff), whereas in the Netherlands the social worker in the role of the ‘family coach’ is involved in searching for case bound solutions at a methodological level. Both are stimuli that could also be of interest for a broader international discussion. From the Dutch perspective some remarks appear to us to be of importance in the discussion of the four points we mentioned. From our point of view, the professional discourse regarding the need for lengthy family support, should be performed with due care. Demanding extensive support seems plausible at first glance, if one assumes a general linear relationship between duration of family support and outcomes; the more the better. However, if the relationship is thought to be curvilinear and case dependent (Littell & Schuerman, 2002), with a ‘happy medium’ as optimal ratio, the formu-lation of clear goals and eventual stopping rules, as well as routinely moni-toring the care progress, should be seen as a pre-requisite. We also want to emphasize the need for ethical and pedagogical anchors in the discussion on degrees of voluntariness in care. Thus, for example, out-of-home placement of children is often experienced as intervention failure. Accordingly in Dutch practice the threat of an out-of-home placement is also used method of coercion, in line with the motto: ‘If you (the parents) do not change, he (the juvenile court judge) will take your child away!’ We classify this practice as questionable insofar as the out-of-home placement of a child should only be justified on the basis of the child’s well-being (Whittaker & Maluccio, 2002). It is also very short-sighted if one assumes the subsequent involvement of


46

parents as one main quality characteristic of successful residential care (Geurts, Boddy, Noom, & Knorth, 2012). New forms of funding should be explored to allow care activities being less restrained by secondary objectives. This should not be misunderstood as being achievable just by cost-effectiveness calculation and an according redistribution of resources alone, e.g., cutting budget for one type of inter-vention to enhance another. Care budget problems are usually of a deeper structural sort, with special importance of the overall coordination of care in families. Flexible, integral support is called for that tailors care components to meet specific needs of the individual families. Here, research is needed that takes structural inequalities into account, the clients’ participatory rights to effective and ethical support, as well as the communities right to a responsible use of public resources in general.

CHAPTER FOUR

SELF-REPORTED CARE ACTIVITIES IN A HOME-BASED INTERVENTION PROGRAMME FOR FAMILIES WITH MULTIPLE PROBLEMS

This chapter is based on: Tausendfreund, T., Metselaar, J., Conradie, J., Schipaanboord, N., de Groot, M. H., Knot-Dickscheit, J., Grietens, H., & Knorth, E. J. (2015). Self-reported care activities in a home-based intervention programme for families with multiple problems. Journal of Children’s Services, 10 (in press).

CHAPTER FOUR

49

Self-reported care activities in a home-based intervention programme for families with multiple problems

Abstract This chapter describes the development and application of the KIPP-list of care activities. The acronym KIPP stands for knowledge and insight into primary processes. The instrument is intended as a tool for family coaches to systematically report care activities conducted in the Dutch family support programme ‘Ten for the Future’ [in Dutch: Tien voor Toekomst]. The design of the instrument was based on the methodological description of the programme, literature about similar instruments in the Netherlands, and a staff survey. Subsequently, a series of three studies was carried out to test the instrument’s face validity and user friendliness, and to assess its potential for programme evaluation. The majority of care activities were performed in cooperation with one or both parents alone, and only to a lesser extent with children or external professionals. Main focus of the family coaches fell into the categories of ‘collecting information’ and ‘working towards (behavioural) change’ with the families. The relatively high frequency of the care contacts emphasizes the intensity of the intervention to meet the needs of a complex target group in family support. Data gathered with the instrument provided meaningful information by descriptive analysis. KIPP thereby proofed its general feasibility in increasing insight into service provision. The instrument can be useful in several stages and on several levels of quality assurance and service opti-mization, including reflective practice, supervision, team management and research.

SELF-REPORTED CARE ACTIVITIES

50

Introduction There is considerable demand for interventions proven as effective in child welfare (Axford, & Morpeth, 2013; Carr, 2009). Evaluation studies are meant to provide knowledge about and insight into the effects and effectiveness of inter-ventions, and they can do so via various research methods and with differing degrees of certainty (Veerman & van Yperen, 2007). Focus of evaluation studies often lies on pre-post-test designs that compare the client’s situation before the intervention to relevant outcomes after. While this set up can provide valuable information at either time, only little can be inferred about possible connec-tions between the intervention and the observed changes if no comparison group is available or detailed data about the inner workings of the intervention exist. Group comparisons certainly have a high scientific value, such as attributed to randomized control trials (RCT), but are not always feasible in child and youth care (Otto et al. 2009) or may have undesirable consequences in researching more complex, less controllable interventions like family-oriented services (Boddy et al. 2011) or complex target groups like families with multiple problems (Devaney & Spratt, 2009). Both, the target group of families with multiple problems, as well as the provision of intensive long-term family support programs for them, are issues of international interest. The need to specifically and adequately address this target group in child welfare has been articulated repeatedly in English public-cations from various countries (e.g., Morris 2013; Sousa & Eusébio 2007; Spratt & Devaney, 2009) and descriptions of long-term family interventions that are geared to specifically address their needs have been reported from a range of countries (De Melo & Alarcão, 2011; Krasiejko, 2011; Marsh et al., 2006; McCartt Hess, et al., 2000; Sousa & Rodrigues, 2012; Thoburn et al., 2013). For intensive home-based programmes that are accredited in the Dutch database of effective interventions (Netherlands Youth Institute, 2014), the following characteristics have been identified as common to best-practice: • Parenting-related support in the family’s home, with a contact frequency of at least once a week, aimed at multiple areas of life; • establishment of a needs-led care plan, with participation and empowerment of the family members as guiding principles;

CHAPTER FOUR

51

• a systemic focus on the family as a whole, and the social learning theory driven improvement of parenting skills, child behaviour, and involvement of the social network; and • professional training and regularly performed supervision of care workers to enhance program integrity and advance collaborative work (Van der Steege, 2007, p. 34). The conclusions of a recent Dutch meta-analysis on programmes for families with multiple problems, conducted by Holwerda, Reijneveld and Jansen’s (2014), overlap with these findings. Additionally they mention the two characteristics of a relatively low caseload of 5–10 families per full-time professional and the provision of support also in material/financial matters. The above components can be identified by comparing components that are common to effective or promising programmes. However, a lack of structural, substantive information about direct activities in the primary care processes can been observed, given that the majority of effect and evaluation studies investigate primarily the outcomes of services (Sinclair, 2010). For this reason, the primary care process has also been referred to before as a ‘black box’ (Staff & Fein, 1994), and a need for more detailed scientific insight into it, has been articulated, especially for home-based interventions like family preservation services (Craig-van Grack, 1997). Intensive family support is such a less specific form of social services, given that interventions falling into this category are geared towards a rela-tively wide target group with a variety of problems (Morris, 2011). One example of these services is the Salvation Army’s home-based long-term care programme entitled ‘Ten for the Future’ (TF) [in Dutch: ‘Tien voor Toekomst], which is targeted towards families with multiple problems with children between the ages of birth and 18 years. This is a wide target group, not only because of variations in the ages of the children and the parents, but also because of the high levels of diversity in family composition, differences in levels of child development, diverse cultural backgrounds and the number of areas in which the clients experience problems. In the period 2006–2014 a research project was carried out in the period at the University of Groningen, in order to develop more knowledge about the characteristics of the target group and results of the services


52

provided in TF, as well as to gain more detailed insight into the primary care processes of the intervention. Overall the research project was based on theoretical foundations about care arrangements for families with multiple problems (cf. chapter 2 & 3), the characteristics of the target group as well as related client based outcomes (cf. chapter 5), and the content of the inter-vention programme (this chapter). In TF, the primary process—the black box—is shaped by the contact of the family coaches [in Dutch: gezinscoaches] with the client’s family. Gaining insight and knowledge about the primary care processes through self-reported care activities would not only allow us to draw more rigorous inferences in a following outcome study but could also contri-bute generally to knowledge about the provision of family support. To obtain structural information about the content of the intervention TF, an instrument was developed that enables the documentation of the primary process of services through self-reports by the family coaches: the KIPP-list of care activities. The acronym KIPP stands for ‘knowledge and insight into primary processes’. In this chapter, we firstly explain what a list of care activities is and how the KIPP-list of care activities was developed, and, secondly, present preliminary results of the data we obtained with the list. The central research question of the study was as follows: What care activities do family coaches regularly report to perform in TF? Method Family coaches have unique and valuable information over the primary care they provide. This information can be made available by asking the family coaches to document the care activities that they have performed for each of their client visits. An activity can be defined as follows: “a nameable set of coherent care activities worked out in concrete steps to form a time-limited intervention” (ten Brink et al., 1997, p. 5). In order to simplify the self-reported documentation of the care activities performed, a list (KIPP) was developed, which aimed at taking not more than five minutes per visit to complete. Cate-gorization of care activities into a list further provided a uniform way of data collection and minimized the burden of lengthy journal documentation, as well

CHAPTER FOUR

53

as simplified subsequent data analysis. For the list an overview of possible care activities was compiled that care professionals use, adapted to specific tasks of family coaches. Intervention The intervention Ten for the Future (TF) [Dutch: Tien voor Toekomst] was developed by the Salvation Army of the Netherlands [in Dutch: Leger des Heils] in 1997 (Leger des Heils Noord, 2006), with the first team starting in 1999. The overarching goal of TF is: “preserving the independence of the family system within generally accepted social limits” (Leger des Heils Noord, 2006, p. 11); an intervention goal which broadly resembles that of family preservation by aiming at the prevention of out-of-home placement, while also entailing proximal and intermediate instrumental goals (Hurley et al., 2012; Rosen & Proctor, 1981), such as the improvement of parenting skills and family func-tioning. Individual care goals are further specified for clients in relation to ten areas of life (cf. chapter 1, Table 1, p. 8). The intensity of the intervention is expressed in (face-to-face contact) hours per week, which are negotiated for each client individually between the Salvation Army (as care provider) and the respective financing agency. The underlying programme theory is eclectic and includes systems theory, learning theory, directive and contextual therapy (Leger des Heils Noord, 2006, pp. 17–21). Family coaches working for TF are professionally trained child and youth care workers educated on higher vocational levels, with additional training in Intensive Family Home Care [in Dutch: Intensieve Ambulante Gezinsbehandeling]; a systems theory guided 12 day course spread over eight months focusing specifically on work with families with multiple problems. Decision-making on intake of potential clients is allocated to one specific care worker in each province, referred to as intake-manager. Criteria handled by intake-managers for programme admission were: 1) the family must have a permanent address; 2) at least one child under 18 years must be living at the family’s home at admission; 3) the client administered to the pro-gramme must signal the need for support on at least four of the ten areas of life (see chapter 1, Table 1, p. 8); 4) there must be no direct threat to the safety of


54

the family coach; 5) if severe mental health problems are present a mental health care professional must be allocated to meet mental health care needs. The specific care goals as well as care intensity in terms of face-to-face contact hours per week were negotiated individually per client on the basis of a standardized needs assessment protocol every 6–12 months between intake-manager and funding agency, in agreement with the client. The median dura-tion of the intervention was found to be 15 months (SD = 10.4; range 3–47 months) for clients for whom care ended (n = 67) within the research period of our outcome study (cf. chapter 5). Instrument The goal of this study was to develop and apply an empirically and theoretically sound list of care activities for the intervention TF. Before further research into the validity and reliability of the KIPP can be performed, we must ensure that the list of care activities should correspond to services in practice, and it should be possible to link the care activities to theoretical concepts that play a role in intensive family support, specifically in TF. In order to satisfy these demands, a literature study and a staff survey were conducted.

Reliability and validity of the KIPP The KIPP is an experimental self-report instrument. Main focus of the early stage of development reported in this study was on enhancing the face and content validity of the instrument. This meant we had to ensure that the items used in the instrument included all basic principles of the program theory and that family coaches felt capable of communicating all core elements of their daily practice via the instrument. We therefore studied TF’s program description (Leger des Heils Noord, 2006), and compiled literature on comparable instruments that already had been implemented in the Netherlands for either (a) a similar target group or (b) a similar type of intervention. Based on the literature study a preliminary version of the KIPP was constructed and later refined through a staff survey (Conradie, Tausendfreund, Knot-Dickscheit, 2011). The staff survey involved

CHAPTER FOUR

55

attending team meetings, and client visits as well as conducting semi-structured interviews with family coaches and team managers. In addition, selected digital and physical case files from TF were analysed and family coaches provided written feedback on the user friendliness of the instruments which resulted in further refinements that led to the experimental version used in this study. More in-depth information on psychometric qualities is not yet avail-able, which is an issue that is shared with other studies that utilized self-report instruments on activities performed in home-interventions (cf. Evenboer et al., 2012; ten Brink, Veerman, de Kemp, & Berger 2004). Activities A large portion of the activities that were included in this preliminary version came from existing lists of care activities designed for similar pro-grammes (Berger, 2006; Bolt & Metselaar, 2005; Damen, 2007; Metselaar & Doornbos, 2006; Schaeffer-van Leeuwen, et al. 2005; ten Brink et al., 1997). From this existing lists of care activities, 227 potentially useful care activities were compiled, from which the care activities that were likely to be suited best for TF were selected. In an initial selection round, care activities were eliminated if one of the following criteria was applicable (Damen, 2007):

• The activity does not fit within the range of services offered by TF (e.g., ‘medical assistance’); • the procedure is too general (e.g., ‘listening’); • the procedure is too specific (e.g., ‘asking the miracle question’); • the activity is a basic activity (e.g., ‘being kind and tolerant’); • the activity is a means (e.g., ‘address, compel to consider’ is a part of the activity ‘provide feedback’). After the first selection round, 129 care activities remained, several of which were duplicates or largely comparable activities. A second selection round was held using two additional criteria for exclusion:

• The activity is identical to another more well-defined and operationalized activity on the list, or


56

• the procedure is part of one of the other selected activities. After the two initial selection rounds 46 care activities remained that were judged as suitable candidates for describing the primary care processes in TF. Additionally four care activities were added or substantially reformulated in order to provide a better fit between the activities on the KIPP and the services offered through TF, namely the care activities: • Paying attention to mental and/or addiction problems, • stimulating or providing education, • activating housekeeping skills, and • assistance with record-keeping and financial management.

Categorization Subsequently the 50 selected care activities were divided thematically into five categories. The rationale behind the division into categories was three fold. First of all, categories can generally enhance orientation and thereby readability of the list of care activities. Secondly, the categories could aid in differentiating care activities that target the same area of life but differ in their form of delivery. The classification distinguishes, for example, direct practical aid by taking over tasks (in housekeeping, or finances, etc.) from more indirect support by stimulating behaviour change through for example assigning tasks to family members (in housekeeping, or finances etc.). And last but not least, categories can provide theoretical ground for general statements about different types of activities, as we will elaborate later. Furthermore an option to add additional activities was added to each category as ‘Other (please specify)’. The number of activities on the final KIPP-list of activities was thereby increased to 55 (cf. appendix A). The categorical division selected for this study was adapted from the Verrichtingenlijst Intensieve Gezinsbegeleiding [List of Activities for Intensive Family Counselling] (Bolt & Metselaar, 2005). The following categories were included: Establishing and maintaining a working relationship: This category involves care activities that contribute to a positive working relationship between the family coach and the family. The development of a good

CHAPTER FOUR

57

relationship and trust between family and coach enhances the effectiveness of the services, given that it is a generally effective element of services (Mason, 2012). Of all 55 care activities 13% (n = 7) were grouped in this category. Collecting information: The collection of information involves care activities with the primary objective of gathering information about the family, the problems they experience, and which goals they would like to achieve. Because family coaches work needs-led (Metselaar, et al. 2007), it is important to involve the family directly in formulating care goals (van Yperen et al. 2006). This is to ensure the preserved fit between the problem, and need for care, and realization of the intervention goals. Of all 55 care activities 35% (n = 19) were grouped in this category Working towards change (including change in behaviour): The care activities in this category have the objective of realizing change. In TF this can be achieved by various means linked to theories on systems theory, learning

theory, directive and contextual therapy (Leger des Heils Noord, 2006, pp. 17-21). Of all 55 care activities 33% (n = 18) were grouped in this category. Finding solutions and support in the environment: An important characteristic of TF is that services are integrated, combining elements of home care, youth services and other forms of organizing support, to address both socioeconomic and psychosocial types of problem (Ghesquière, 1993). This necessitates maintaining contact with the various institutions involved with the family, as well as with the family’s own social network (Sousa & Rodrigues, 2009). Of all 55 care activities 9% (n = 5) were grouped in this category. Easing the burden of tasks: Given that the target group for TF is characterized by a chronic and complex set of problems, it is often difficult for the families to address the large number of problems that they are expe-riencing. As part of the services, therefore, the family coach can play a practical role, partially taking over tasks or care activities until the family is once again able to manage them on their own (Dallos & Hamilton-Brown, 2000). Of all 55 care activities 11% (n = 6) were grouped in this category.


58

Additional information In addition to coding care activities, we judged the following information as relevant to further specify each reported care activity: the type of contact (face-to-face, phone or email), which clients were involved in the care activity (one or more children, one or both parents, one or both parents and one or more children, one family member and at least one external professional), and the date and duration of the care activity. Per contact a maximum of six unique care activities could be coded via KIPP. Finally a manual was compiled that provided codes for the care activities that could be filled into the report form by the family coaches (cf. appendix A), and care activities were briefly specified for clearer understanding (cf. example given in appendix B). Our first draft was presented to family coaches, team leaders, and managers and further adjusted on the basis of their feedback. An additional questionnaire was used after the first wave of data collection (T1) to assess the manual’s user-friendliness and to identify if further adjustments would be essential. For the second wave of data collection (T2) an additional speci-fication was added: in which phase of the care process is the client (start, main phase, end, aftercare). At a later stage a digitalized version in form of a MS Excel sheet was used to better streamline data collection with the workflow of the family coaches (cf. appendix C). Design Three waves of data collection (T1, T2, T3) with the KIPP were conducted over a time period of 22 months (T1 in April 2010, T2 in February 2011, T3 in February 2012), in the three Northern Provinces of the Netherlands (Friesland, Groningen, Drenthe), which resulted in a total timeframe of 10 weeks from which care activities were sampled. After each of the data collection waves, interim reports were compiled and summarized results were presented to the team management. Anonymity of the family coaches and clients was maintained in data presentation.

CHAPTER FOUR

59

Sample Over the course of 10 weeks a total of 2,562 care activities were reported for 665 contacts with 188 clients from 50 family coaches, who had filled in a KIPP-list. We excluded contacts for which more than six activities were scored via the Excel version of the KIPP-list used in the third wave of data collection (T3), because this deviated from instructions and would skew comparisons through the difference in data range compared to the paper version used in the other two waves of data collection (T1 & T2). The number of contacts that were excluded for this reason was relatively small (n = 16). The groups of clients and coaches between the waves of data collection were not unique, because coaches and clients could participate in more than one sample wave depending on care duration and staffing. The characteristics of the samples for each wave are presented in Table 2. Table 2 Sample composition in the three waves of data collection within TF Characteristic T1 T2 T3 Total Duration, in weeks 2 4 4 10 Family coaches 19 9 22 50 Clients 76 30 82 188 Contacts 196 145 324 665 Care activities 855 613 1,094 2,562 Note. T1 and T3 were implemented in three teams of approximately 50 family coaches. Data collection at the second wave (T2) was limited to one of the three provinces with 12 coaches working in the province at that time. Analysis Descriptive statistics were used to explore characteristics of contacts and care activities in terms of proportions, means, range and standard deviations. In our results we distinguish: type of contact, persons involved in the care activity, care phases, categories of care activities, and most frequently used individual care activities.


60

Results

Type of Contact Clients in our sample had on average close to once per week face-to-face contact with their family coaches (see Table 3, p. 61). The duration of home visits was in all data collection waves found to be longer than two-hours. The shortest visit lasted 10 minutes, and the longest lasted 480 minutes. Telephone contacts were reported in the first (T1) and third wave (T3), with a total of 12 and 50 telephone contacts that lasted on average 47 minutes (SD = 42.7; 2–120) and 36 minutes (SD = 28.3; 5–135) respectively.

CHAPTER FOUR 61

Table 3

Caseload, and face-to-face contact characteristics in TF

TP T2 b T3 c

Workload M SD Range M SD Range M SD Range

Clients reported per coach 4 1.5 2-6 3.3 1.6 1-6 3.7 1.8 1-7

Average contacts per 1.2 .6 .5-2.5 1.2 .6 .3-2.5 .8 .4 .3-1.8 client, per week

Contact duration, in 156 73.5 10-480 _ , - - 127 48.6 15-328 minutes

Care activities oer contact 4.5 1.5 1-6 4.6 1.5 1-6 3.8 1.4 1-6 Note. Only for face-to-face contacts reported in this table. M =mean. SD =standard deviation. Range =minimum-maximum. a face-to-face contacts Tl: n = 179. h face-to-face contacts T2 n = 145. c face-to-face contacts T3 n = 244. d data on contact duration were missing for T2.


62

Client Involvement For 423 face-to-face contacts the person or people with whom the activity was performed was recorded for T1 and T3 (see Table 4, p. 63). In the majority of cases (65%, n = 1,048) this was with one of the parents alone, with a similar ratio found for telephone contacts (n = 62). Of the 139 care activities scored in T1 and T3 as telephone contacts, 63% (n = 87) were conducted with one or both parents alone, and 29% (n = 41) with and external professional alone. Care Phases Information about the phase of care was added to the KIPP from the second wave onward (T2–T3). The data indicated that most of the families (80%, n = 24) were in the core phase of care. In the third wave (T3) the majority of contacts (83%, n = 269) also fell within this main phase of care, with 11% (n = 35) of the contacts in the start phase and 3% (n = 11) in the end phase of care. Theoretical Categories The division of the care activities into categories allows for more general statements regarding the content of the intervention. Table 5 (p. 64) provides an overview of the absolute and relative shares of each category in which care activities were performed. The name of each category indicates the goal of the care activities therein. Care activities belonging to the first three categories, ‘collecting information’, ‘working towards change (including change in behaviour)’ and ‘establishing and maintaining a working relationship’, are the ones most frequently used. ‘Easing the burden of tasks’, which accounts for 13% of the total care activities performed, plays a smaller but still recognizable role. The least utilized category is ‘finding solutions and support in the environment’. Nevertheless, 10% of the care activities that were performed belonged to this category.

CHAPTER FOUR 63

Table 4

Person or people with whom the care activities were performed in face-to-face contacts in TF

T1 T2a T3 Total Activity performed with n o/o n o/o n o/o n %

One or both parents 479 67 - 569 63 1,048 65

One or both parents and one or 100 14 - 170 19 270 17 more children

Family member and 62 9 - 103 11 165 10 external party

One or more children 43 6 - 33 4 76 5

External party without 33 5 - 29 3 62 4 fam il me mber

Total h 717 100 - 904 100 1,621 100 Note. a Data on cl ient involvement were not repo rted fo r the second wave. b Sum of the percentages in the co lumn add up to 101 o/o, 99% and 101% respectively due to rounding of fina l numbers.


64

Table 5

Frequency and distribution of activities performed in TF, by category

T1 T2 T3 Total Category n % n % n % n %

Collecting information 222 26 191 31 339 31 752 30

Working towards change 215 25 151 24 356 33 722 28 (including behaviour change)

Establishing and maintaining 189 22 129 21 195 18 513 20 a working relationship

Finding solutions and support 96 11 71 12 82 7 249 10 in the environment

Easing the burden of tasks 133 15 71 12 122 11 326 13

Total 855 100 a 613 100 1,094 100 2,562 100 a

Note . Including telephone contacts. a Sum of the percentages in the column add up to 99% and 101% respectively due to rounding of final numbers.

CHAPTER FOUR

65

Individual Activities The most detailed insight into the primary service process is obtained by analy-sing the care activities performed at the level of the individual activity. It can be assumed that if certain care activities are carried out frequently, they are likely to play a more central role in the primary care process. Table 6 (p. 66) provides an overview of the most frequently performed care activities. These 11 care activities were selected here because they amount to more than half of the total number of care activities recorded in each wave and add up to more than 50% of all care activities reported in the three periods of data collection. In addition to the frequently performed care activities listed in Table 6 (p. 66), several care activities were seldom performed. With the exception of the activities ‘network analysis’ (n = 4), ‘competence analysis’ (n = 3), ‘debriefing questionnaires’ (n = 3), and ‘aftercare’ (n = 3), all of the care activities were performed overall more than five times. Thereby all of the codes proved potential usability for a list of care activities in TF.


66 Table 6

The 11 most frequently performed care activities in TF

T1 ' T2 b T3 ' Total d

Code Activity n % n % n % n %

C1 : Discussing a specific situation or 58 6.8 35 5.7 100 9.1 193 7.5

problem in the family A3: Providing emotional support 53 6.2 37 6.0 65 5.9 155 6.0

A2 : Blending in 57 6.7 36 5.9 41 3.7 134 5.2

E4: Coordinating with external 50 5.8 23 3.8 57 5.2 130 5.1 profess ionals

89: Information through conversations 8 0.9 29 4.7 75 6.9 112 4.4

E2: Assistance with record-keeping and 36 4.2 35 5.7 41 3.7 112 4.4 financial management

D2: Support in contacting authorities 43 5.0 33 5.4 29 2.7 105 4.1

81: Discuss ing the needs of the family 31 3.6 29 4.7 37 3.4 97 3.8

811: Discuss ing problems ... between 35 4.1 13 2.1 43 3.9 91 3.6 family members

83: Discuss ing strengths in and around 32 3.7 23 3.8 32 2.9 87 3.4 the family

D3: Accom2anying client to agencies 29 3.4 24 3.9 33 3.0 86 3.4 Total 432 50.5 317 51.7 553 50.5 1,302 50.8

Note. Cut off point for inclusion of care activities in the table was reaching a frequency of;, 50% of all care activities performed in total (N = 2,562). ' n = 855. b n = 613. ' n = 1,094. d n = 2,562.

CHAPTER FOUR

67

Discussion and Conclusions According to self-reports by family coaches, the majority of care activities were performed in cooperation with one or both parents alone (more than 60% in both waves that recorded client involvement). Although it was expected that the parents would play a central role in the services, the share of care activities reported as performed in direct contact with children (5%) or other external agencies (4%) seems comparatively small. It does, however, not solely depend upon choices made by the family coach in deciding with whom care activities are performed. It is also determined by characteristics of the client system (e.g., children in baby age), objectives of the referral agency (e.g., focal point on change of parent behaviour) and the preferences of individual family members (e.g., care avoiding children). Nevertheless, the systems orientation of the services seems to be jeopardized by the large share of care activities that are carried out in cooperation with one or both parents alone (Knot-Dickscheit, Tausendfreund, & Knorth, 2011). The study also provided information about the categories to which the care activities belong. It can be concluded that care activities from each of the categories were used. Furthermore, family coaches were largely concerned with ‘collecting information’ and ‘working towards change (including behavioural change)’. Less activities were reported for the category ‘estab-lishing and maintaining working relationships’. That only a small share of clients care was found to be in the starting phase of care during the research period, which itself is not surprising given the relatively long programme duration (cf. chapter 5), puts both findings into perspective. That the majority of data stemmed from the main phase can explain, on one hand, a lower direct emphasis on relational aspects, because of the greater role it potentially plays in the initial care phase. The prominent share of the category ‘collecting information’ in overall care activities, on the other hand, is striking. It illustrates to which extent continual needs and goal assessment is part of a monthly routine in a family-oriented, home-based intervention for families with multiple problems. Care activities aiming at ‘easing the burden of tasks’ and ‘finding solutions and support in the environment’ played only a limited role in the overall share of reported care activities. Individual care activities, however, as


68

for example ‘coordination with external professionals’ or ‘support in contacting authorities’ were still found among the most frequently performed care activ-ities, which, in conclusion, suggests a lower extent of the category, yet also points out a relevant contribution of individual activities from these categories to the overall package of service provision. That activities were reported as seldom performed, such as ‘network analysis’ (n = 4), ‘competence analysis’ (n = 3), ‘debriefing questionnaires’ (n = 3), and ‘aftercare’ (n = 3), might hint at their relevance, but also point out limits of our study design. Care activities that have a frequency of occurrence of lower than once per month, have naturally a smaller chance of being reported in our samples, as for example an annual debriefing of questionnaires. Low shares, however, might also indicate that family coaches judged these activities as less relevant for their service provision. In case of network analysis, earlier findings of this study (as the strong emphasis on direct contact with the parents) further underline the need for re-assessing the relevancy of a systems orientation in practice. Strengths and Limitations Overall, this study knows several strengths. First of all, not many studies were found that report in detail about the primary care processes in home-based interventions for families with multiple problems (Evenboer, Huyghen, Tuinstra, Reijneveld, & Knorth, 2012). In that way, our approach of measuring intervention activities in a family-support programme might be called rather unique. The interpretation of data gathered with the instrument provided meaningful information already on a descriptive level of data analysis and thereby proofed its general feasibility in increasing insight into the ‘black box’ of service provision. Ultimately, this opens up new opportunities for evaluation research by systematically adding information about the ‘throughput’ into input-output oriented study designs. Furthermore, the data gathered with the instrument can be useful already in earlier stages and on several levels of quality assurance and service optimization. It offers family coaches guidance by routinely adding a moment of systematic reflection on the care activities they performed, it can potentially aid

CHAPTER FOUR

69

communication in intervision or supervision if (interim) case-based data analysis was made available, and can provide information that is potentially valuable for decision-making on a team level. This study also knows several limitations. The first methodological constraint is caused by the studies scope. Although a good amount of data could be gathered, the study was limited in terms of time, participating family coaches, and their clients. Nevertheless, the work of 50 family coaches was monitored, referring to more than 650 client contacts and including over 2,500 care activities. A second type of limitation is related to reliability, validity, and acceptability of the instrument. Family coaches spent a significant amount of their time with routine administration. Asking for additional reports on routine task performance adds to this. We designed the instrument with this in mind, yet it is of it is of primary importance to further ensure acceptability by giving coaches incentives which they perceive as valuable in their own workflow. Possibilities of streamlining the instrument with existing routine adminis-tration should be explored as well as the provision of easy to access case summaries for family coaches. Up until now the KIPP was used in TF in addition to routine administration. In the future, the KIPP could be merged into day-to-day record keeping, providing data for routine outcome measurement and program integrity monitoring. Furthermore, the use of the KIPP can stimulate program integrity maintenance itself by providing the family coaches a concise list of the toolkit they have at their disposal for reaching care goals. The KIPP list can therefore not only serve as an instrument through which care activities are registered retrospectively, but also as a guide for day-to-day program provision, and a refined description of the program in the process of admission to the Dutch databank for effective interventions (Netherlands Youth Institute, 2014c). Furthermore, it would have been desirable to train the family coaches still more extensively in working with the list of care activities, to further enhance reliability. Despite the fact that the manual accompanying the list of care activities attempts to operationalize the care activities as objectively as possible through nomenclature, description, explanation and possible methods, some degree of subjectivity and interpretation in scoring might be inevitable.


70

However, the lack of information on the psychometric qualities we report is shared with other studies that utilized self-reports instruments to record care activities (see 2.2.1). Two considerations are important in this regard from our point of view. First, the yet unsolved question about the psychometric qualities of these self-report instruments should be weighed against alternative research methods that provide insight into the primary care process, such as observa-tional methods. Main advantage of the self-report instruments is that they can be implemented on a broad scale and be conducted repeatedly, providing a more general overview of the care activities carried out in total. Studies on the family preservation program Families First demonstrated that the information gathered from self-report instruments can be used for meaningful inter-pretations of outcomes measured with standardized instruments, if the methodological restrains are carefully considered (Veerman, de Kemp, ten Brink, Slot, & Scholte, 2003). Further research on psychometric properties of the instrument is warranted. Especially, the inter-rater consistency through for example complementary observation should be tested in the future. Conclusion Data gathered with the instrument provided meaningful information. KIPP thereby proofed its general feasibility in increasing insight into service provision. The instrument can be useful in several stages and on several levels of quality assurance and service optimization, including reflective practice, supervision, and team management. More research is recommended.

CHAPTER FOUR

71

Appendix A: Overview of activities in Ten for the Future

A: Establishing and maintaining a working relationshi11

A I Introductions A2 Blending in A3 Providing emotional support A4 Communication or feedback about

the cooperation in care AS Confli ct management A6 Increasing motivation A 7 Other (please specifY)

B: Collecting information B I Discussing the needs of the family B2 Discussing the family's perception of possible

solutions B3 Discussing strengths in and around the family B4 Setting goals with the family B5 Evaluating/adjusting goals and goal attainment

process B6 Setting points to be addressed with the family B7 Evaluating/adjusting working points to be addressed B8 Gathering information through observation

(including participation) B9 Lnformation tbrougl1 conversations BIO Working with observation and (homework)

assignments B II Discussing problems in the communication and

ime-raction between family members B 12 Competence analysis B 13 Network analysis Bl4 Analysisofsafcty B 15 Analysis of leisure activities B 16 Analysis of functioning at school B 17 Introducing and administering questionnaires B I R Debriefing questionnaires B 19 Other (please specifY)

C Working towards change (inclutling change in beha,·iour)

C l Discussing a specific situation or problem in the family

C2 Describing a problem in tcnns of observable behaviour

C3 Instn•ctions and suggestions for changing behaviour C4 Behaviour exercises C5 Providing feedback on behaviour C6 Discussing and practising a daily routine and the

day-to-day functioning of the family C7 Activating housekeeping skills CS Practising communication and interaction in the

family C9 Working on skills for coping with cognition and

emotions C I 0 Working on authority relationships in the fami ly

C II Working on the cooperation between parents/guardians

C 12 Providing information about and practising parenting skills

Cl3 Interventions conceming leisure activities Cl4 Paying attention to mental and/or addiction problems C 15 Providing therapeutic materials C 16 Stimulating or providing education C 17 Aftercare C I R Other (please specifY)

D: Finding solutions and support in the environment D 1 Mobilizing social support and building a social

nclwork D2 Support in contacting authorities D3 Accompanying client to agencies D4 Referring to services or service agencies D5 Other (please specifY)

E: Easing the burden of tasks El Support in housekeeping E2 Assistance with record-keeping and financial

management E3 Finding alternative housing for t1unjly member

in crisis E4 Coordinating with external professionals E5 Organizing care £6 Other (please specify)


72

Appendix B: Example of an operationalized activity: Blending in

A2. Blending in Activities through which the family coach seeks a connection with or shows understanding of the family, their lifestyle, language, customs and insights. Explanation The primary goal of blending in is to establish or reaffirm the connection (i.e. the working relationship) with the family. Possible techniques and skills:

• ‘Tracking’: addressing the topics that the family presents and asking follow-up questions; • Adapting to the family’s use of language; • Adapting to and participating in the habits and conventions of the family; • Showing interest in ordinary family situations, in habits, values and norms; • Taking notice of the views of the family in relation to their problems; • Acknowledging and showing understanding of the client’s perception of reality.

CHAPTER FOUR 73

Appendix C: KIPP-list M

S Excel version

Bijlage A: Verrichtingenlijst onderzoek RUG

Gezinscoach: -Clientnummer:

.

Dalllm BeglndJd - Elnddjd ultgevoerde verrlchdngen Vorm van contact Fase

ddlmmm uu:mm VRT 1 met VRT 2 met VRT 3 met VRT 4 met VRT5 met VRT6 met Bezoek Telefonisch email start hulpver1 afbouw nazoro

Opmerking:

~ - •1 ! JAN j FEB ) HRT .m:r4Di!' •. IJllt .. ]li.I 7&it.ty£#if~llJ0\1:7 DEC ;" t;J / 111 <1 • I

CHAPTER FIVE

OUTCOMES OF A COACHING PROGRAM FOR FAMILIES WITH MULTIPLE PROBLEMS IN THE NETHERLANDS: A PROSPECTIVE STUDY

This chapter is based on: Tausendfreund, T., Knot-Dickscheit, J., Post, W. J., Knorth, E. J., & Grietens, H. (2014). Outcomes of a coaching program for families with multiple problems in the Netherlands: A prospective study. Children and Youth Services Review, 46(11), 203–212. doi: 10.1016/j.childyouth.2014.08.024

CHAPTER FIVE

77

Outcomes of a coaching program for families with multiple problems in the Netherlands: A prospective study

Abstract Families who face a multitude of severe and persistent problems in a number of different areas of life are commonly referred to as multi-problem families in Dutch child welfare. Although evidence suggests that short-term crisis inter-ventions can have positive effects in these families, they have up to now not sufficiently succeeded in facilitating sustainable change. Interventions, which offer integrated care over longer periods of time, have been piloted in different European countries, but only few evaluation studies are available yet. In our study we therefore explored an integrated flexible family support program from the Netherlands, called ‘Ten for the Future’ [in Dutch: Tien voor Toekomst]. The research included 122 families over a period of four years and seven months. Analyses on group level and individual case level were carried out. Our results suggest that the intervention is associated with a decrease in family stress. Furthermore, families with lower initial parental stress were found to have a higher chance to end the program significantly earlier. Child behavior problems and family functioning, as perceived by care workers, show less coherent patterns of change. This might be connected to a main focus of family coaches on the direct work with parents alone. We conclude that the care program has potential to decrease family stress and suggest focusing on the further development of a dual key worker approach that offers allocated care for children next to parenting support in families with multiple problems.

OUTCOMES

78

Introduction Families who face a multitude of severe and persistent problems in a number of different areas of life are commonly referred to as multi-problem families in the Dutch child welfare system (cf. chapter 2 & 3). Similar labels are given to families in English literature, such as families with longstanding and complex problems (Thoburn, Cooper, Brandon, & Connolly, 2013), vulnerable families with complex and enduring needs (Morris, 2013), families with multiple and complex needs (McLean, 2012), or families with multiple problems (Spratt & Devaney, 2009). The practical relevance of specifically targeting these families is generally associated with an increased risk of child maltreatment (Denholm, Power, Thomas, & Li, 2013; Fuller-Thomson & Sawyer, 2014; MacKenzie, Kotch, & Lee, 2011), an increased risk for their children to develop severe behavior problems over the life course (Appleyard, Egeland, van Dulmen, & Sroufe, 2005; Buehler & Gerard, 2013; Deater-Deckard, Dodge, Bates, & Pettit, 1998; Spratt, 2012), as well as a high impact on the allocation of resources through multiple service use (Buell, Berry, Robinson, & Robinson, 1952; Goerge, Smithgall, Seshadri, & Ballard, 2010; Horstik & Veuger, 2012; Sacco, Twernlow, & Fonagy, 2007). Estimates on the number of families with multiple problems are affected by various challenges in research, policy and practice (Spratt, 2009). Intervention programs and evaluation studies can vary in their scope and focus as well as their underlying definitions, biases can be introduced through research procedures or through client administration, and the data quality is generally low due to reliance on secondary analyses of administrative data (van Burik & van Vianen, 2006, p. 23–24) or expert surveys (Bodden & Deković, 2010). Reliably identifying families with multiple problems is nonetheless of primary importance in child welfare (Spratt, 2012). Careful estimates can be made if the outlined methodological constraints are considered. The number of families with multiple problems ranges between 0.5–5% (van der Steege, 2010) or 3–5% of all families in the Netherlands, with the latter equalling a total of 70.000–116.000 families in 2011 (van den Berg & de Baat, 2012, p. 97). Demographic characteristics indicate overlap with (risk) factors that are (also) associated with relative poverty and social exclusion (cf. chapter 2; Statham, & Holterman, 2004), especially low socioeconomic status (low educational levels,

CHAPTER FIVE

79

low income), single-parenthood and having migrated from a non-Western country (Bot et al., 2013; van Burik & van Vianen, 2006; van den Berg & de Baat, 2012). Research on interventions for families with multiple problems indicates mixed results. Meta-analytic evidence suggests that families with multiple problems can benefit from intensive (short-term) crisis intervention, in terms of enhanced family functioning and the prevention of out-of-home placement (Al et al., 2012). But comparative and meta-analytic studies also raise concern about the sustainability of effects after short-term interventions, indicating a possible need for intensive support over longer periods of time (Al, Stams, van der Laan, & Asscher, 2011; Berry, Cash, & Brook, 2000; Forehand & Kotchick, 2002; van Puyenbroeck et al., 2009). The provision of both, poten-tially long-term support programs next to brief topic-focused intensive interventions, might in conclusion be a valid intervention strategy for families with multiple problems (Moran, Ghate, & van der Merwe, 2004, p. 118). Meta-analytic studies on the prevention of child maltreatment and the promotion of family well-being provide empirical ground for which types of programs are promising. Among others, two types of programs have the most potential benefits: multi-component interventions and home visiting programs (MacMillan et al., 2009; Mikton & Butchart, 2009). Interventions which combine multiple service components into integrated services with a flexible intensity over longer periods of time have been reported as piloted in practice from different countries (De Melo & Alarcão, 2011; Krasiejko, 2011; Marsh, Ryan, Choi, & Testa, 2006; McCartt Hess, McGowan, & Botsko, 2000; Sousa & Rodrigues, 2012; Thoburn et al., 2013). Mentioned as main advantages of these programs were: the opportunities offered by alternative ways to approach families (e.g., giving room to instru-mental and relational practices), an enhanced flexibility in personalizing care arrangements (e.g., tailored care components, needs-led program duration and intensity), the possibility to counter negative side-effects of service special-ization (e.g., care fragmentation) through co-ordination and/or integration, and the reduction of stressful care re-entry moments for families with fluctuating crisis pattern.

OUTCOMES

80

In the Netherlands one intervention model that combines multiple components in home-based care over longer periods of time is Family Coaching. We explored a coaching program based on this model named ‘Ten for the Future’ (TF) [in Dutch: Tien voor Toekomst], and report on it in this study. Two features of the program can be seen as distinctive in Dutch child welfare: a) an integrated care approach providing support in 10 explicitly stated areas of life, and b) the flexible needs-led, potentially long-term, program duration and intensity. Three research questions were guiding in exploring client characteristics, care duration and associated outcomes: 1. What were demographic and problem characteristics of clients referred to TF? 2. Can factors be identified that were associated with extended care duration? 3. Is TF associated with problem reduction? Answering the first research question allows to judge if the target group was reached and connects theoretically to the earlier mentioned lacunas in reliably identifying families with multiple problems. The second research question subsequently links client related information to program specifics by exploring differences in care trajectories. Aim is to gain knowledge about the hypothesized relations between problem intensity, case complexity, and care duration in long-term programs such as TF. The third research question is targeted at measuring family well-being through outcome measures that are relevant for child welfare interventions. Parental stress, family functioning and child behavior problems were selected in our study as outcome measures because they can provide infor-mation on theoretically important key aspects of parenting (Belsky & Vondra, 1989; ten Brink et al., 2000), and can be measured with standardized instru-ments which were used in evaluation studies on comparable programs before (e.g., Hurley et al., 2012; van Puyenbroeck et al., 2009).

CHAPTER FIVE

81

Method

Intervention In 1997 a survey from the Dutch province Groningen identified an additional need for integral long-term parenting support in the local child and youth care services (Wijnen, 1997); a finding that resonated with the ongoing program development of The Salvation Army of the Netherlands in the region (Leger des Heils Noord, 2006). As a result the intervention TF was developed to speci-fically target parents with multiple problems and their children, with the first regional team starting work in 1999, and subsequent nationwide expansion in the following years. The overarching goal of TF is: “preserving the independence of the family system within generally accepted social limits” (Leger des Heils Noord, 2006, p. 11); an intervention goal which broadly resembles that of family preservation by aiming at the prevention of out-of-home placement, while also entailing proximal and intermediate instrumental goals (Hurley et al., 2012; Rosen & Proctor, 1981), such as the improvement of parenting skills and family functioning. Individual care goals are further specified for clients in relation to ten areas of life (cf. chapter 1, Table 1, p. 8). The intensity of the intervention is expressed in (face-to-face contact) hours per week, which are negotiated for each client individually between the Salvation Army (as care provider) and the respective financing agency. The underlying program theory is eclectic and includes systems theory, learning theory, directive and contextual therapy (Leger des Heils Noord, 2006, pp. 17–21). Family coaches working for TF are professionally trained child and youth care workers educated on higher vocational levels, with additional training in Intensive Family Home Care [in Dutch: Intensieve Ambulante Gezins-behandeling]; a systems theory guided 12 day course spread over eight months focusing specifically on work with families with multiple problems. Categories under which care activities of family coaches can be subsumed, include: estab-lishing and maintaining a working relationship, working toward (behavioral) change, finding solutions and support in the environment, and easing the burden of practical tasks (cf. chapter 4). Standardized self-reports of family

OUTCOMES

82

coaches on care activities suggest that the majority of activities were conducted in direct contact with the parents alone (more than 60%), and less regularly in the presence of children (17% or less), or with children (6% or less) alone (cf. chapter 4). Decision-making on intake of potential clients is allocated to one specific care worker in each province, referred to as intake-manager. Criteria handled by intake-managers for program admission were: 1) the family must have a permanent address; 2) at least one child under 18 years must be living at the home at admission; 3) the client administered to the program must signal the need for support on at least four of the ten areas of life (see chapter 1, Table 1, p. 8); 4) there must be no direct threat to the safety of the family coach; and 5) if severe mental health problems are present a mental health care profes-sional must be allocated to meet mental health care needs. The specific care goals as well as care intensity in terms of face-to-face contact hours per week were negotiated individually per client on the basis of a standardized needs assessment protocol every 6–12 months between intake-manager and funding agency, in agreement with the client. Design Our study was designed as a prospective one-group repeated measures outcome study. Questionnaires for each of the dependent variables were filled in within the first three months (T0), and every 12 months while the family was receiving TF (T1–T3), with a possible maximum follow-up of four years. Additionally a flexible measurement was scheduled if the end of the inter-vention was signaled. The flexible measurement was assigned to a time-bound measurement (T1–T3) if it fell within three months before or after respective scheduled measurement. Sample Procedure The research was designed to include all families who followed the program TF for at least 90 days in the three Northern Provinces of the Netherlands (Drenthe, Friesland, and Groningen) within the research period (four years and

CHAPTER FIVE

83

seven months; 10 September 2007–1 May 2012). A period of 90 days was chosen because that is the timeframe in which intake-managers determine whether or not a family meets the inclusion criteria of the program TF. Only families were included that filled in questionnaires during the intake phase (T0). Per family only one parent and one child were included. Parent selection was linked to program admission; the person for whom the intervention was indicated was asked to participate. If more than one child was living in the family’s home, the participating parent was asked to fill in the questionnaires in regard to the one child he or she perceived at that time as most troubled. In the subsequent measurements (T1–T3) the parent was asked to fill in the question-naire for the same child. The flow of participants through each stage of our research is illustrated in Figure 5 (p. 84). In this figure three types of missing observations can be distinguished: The category missing refers to cases where the measure-ment was not received or valid while a valid follow up measurement exists. Dropout refers to cases where a measurement was not received or valid and no valid follow-up measure exists (e.g., participants leaving the study but continuing the intervention). This could either be caused by not receiving questionnaires within 90 days of a scheduled measurement after two reminders, not receiving questionnaires at the end of the intervention, or by receiving questionnaires at the last measurement that report on a different parent and/or child than in the initial measurement(s). Censored by research period refers to cases where the research period ended and therefore by design no follow-up measurement was taken. Last measurement refers to valid cases where the program had ended (no subsequent measurement).

OUTCOMES

84

Figure 5. Flow of participants through stages of the research project. Hundred and twenty two families participated in the research. For more than a third of the research participants (45%; n = 55) the program did not end within the research period; a phenomenon to which we refer in the following as ‘censored measurements’. This group includes all participants categorized in Figure 5 as ‘censored by research period’ (n = 25), 26 participants from the ‘dropout’ group that continued the intervention, and four participants who continued the intervention after the ‘fourth measurement’. The 122 participants were part of a larger group of the programs clients. In 20 cases questionnaires were returned at the start of the inter-vention (T0) but could not be used (e.g., missed first measurement, change in respondents and/or child, missing values exceeded the necessary minimum to calculate total scores for the first measurement). In 282 cases clients were signalled as excluded before T0 by the Salvation Army Netherlands, due to the following reasons: “not having followed the program for more than 90 days” (n = 121), “not having received TF but a different program (false positive in client administration)” (n = 143), “declining to participate” (n = 8), “research was

CHAPTER FIVE

85

considered disruptive in crisis intervention by the family coach” (n = 6), and “client not proficient enough in Dutch to complete questionnaires” (n = 4). For 506 potential clients information could not be traced retrospectively by the Salvation Army Netherlands. This high proportion of unknowns can mainly be explained by the fusion with another service provider in the province Groningen in 2010, and the subsequent merge of databases, in which data on database origin were not categorized. Participant Characteristics Background data for all research participants, at the start of the intervention (T0) is shown in Table 7 (p. 86). Some variables showed relatively high propor-tions of missing data but were included in the analysis (namely, number of children [69% missing], educational level [46% missing], and marital status [37% missing]).

OUTCOMES

86

Table 7 Demographic sample characteristics of parents and children at the start of intervention (T0) Characteristic M SD (range)Parent age in years a 32.8 7.7 (19–52)Child age in years b 7.1 4.5 (0–16)Children in family c 2.4 .9 (1–4)Characteristic n %Parent genderFemale Male 113107 6 100.0 94.7 5.3 Child gender Female Male 120 56 64 100.0 46.7 53.3 Marital statusNot married Married Divorced

77 40 14 23 100.0 51.9 18.2 29.9 Education Pre-vocational Lower vocational Higher secondary

56 40 15 1 100.0 71.4 26.8 1.8

Note. M = mean. SD = standard deviation. range = minimum–maximum. a n = 92. b n = 111. c n = 38. Differences between clients who dropped out of the research (n = 73) and those who did not (n = 49) were explored statistically revealing only one variable, whether or not the intervention ended, as being significant, (χ2 [1, n = 122] = 4.81, p = .028), with 46 clients (63%) having ended the intervention in the dropout group compared to 21 clients (43%) in the group that did not drop out of the research. This can be explained by higher dropout rates at the last measurement. We originally included the variable ethnicity in the research design (according to national standards defined by parental ancestry, Alders, 2001). However the proportion of missing data in the category fathers country of birth was too high (97% missing).

CHAPTER FIVE

87

Instruments

Parental stress perception and occurrence of stressful life events were measured with the Nijmeegse Ouderlijke Stress Index (de Brock, Vermulst, Gerris, & Abidin, 1992), the Dutch adaptation of the Parenting Stress Index (Loyd & Abidin, 1985). In this questionnaire parents are asked to rate 123 items, while keeping one specific child in mind, on a six point Likert scale (ranging from [1] strongly disagree to [6] strongly agree). The items reflect on statements related to fulfilling the role of being a parent (e.g., “I feel limited by my obligations as a parent”), well-being (e.g., “physically I feel good most of the time”), and charac-teristics of a child (e.g., “my child does things that upset me”). Additionally, a list of 40 items at the end of the questionnaire reports on the occurrence of critical life events within the past 12 months (e.g., “death of a relative”, “significant financial loss”). Reliability scores for the total NOSI scale (α = .95–.97) indicate high levels of internal consistency (de Brock et al., 1992).

Child behavior problems were measured with the two age dependent Dutch versions (Verhulst & van der Ende, 2013) of the Child Behavior Checklist (Achenbach & Rescorla, 2000; Achenbach & Rescorla, 2001). The questionnaire allows caregivers to report problem behavior of a specific child within the past six months by scoring questions on a three-point scale (ranging from [0] Not true (as far as you know), [1] Somewhat or sometimes true, to [2] Very true or often true). The number and type of items differ between versions, with 118 items for children aged 6–18 years and 99 items for children aged between 1.5–5 years. In addition to total problem scores, both versions allow for grouping items into two subcategories: externalizing and internalizing problems (Achenbach & Rescorla, 2001). Reliability scores for the total problem scale and the subscales internalizing and externalizing behavior problems of the inter-national sample indicate high levels of internal consistency (α = .85–.94) for both versions of the CBCL (Achenbach & Rescorla, 2007; Achenbach & Rescorla, 2010).

Family functioning was measured with the Questionnaire Family Functioning [Vragenlijst Gezinsfunctioneren]; a Dutch questionnaire developed to determine levels of family functioning within care arrangements (ten Brink et al., 2000). A professional care worker (e.g., the family coach) can use the questionnaire to rate 95 items in relation to specific family members and their

OUTCOMES

88

relationships, on a five point Likert scale (ranging from [1] does totally not apply to [5] totally applies, and additionally offering a sixth option [0] more information is needed). The items consist of statements related to basic care (e.g., “Parents devote sufficient attention to the physical care of the children”), social contacts (e.g., “The family has enough contacts in the neighborhood”), parenting skills (e.g., “The mother/father rewards the children and encourages them sufficiently”), parents childhood experience (e.g., “The mother/father is optimistic about his/her own childhood”), child safety (e.g., “The mother/father is heavy handed in dealing with one or more children”), parent functioning (e.g., “The mother/ father struggles to understand the children”), and the parents relationship (e.g., “The partners are satisfied with the way the household chores are divided”). Reliability scores for the total scale (α = .94) indicate high internal consistency (ten Brink et al., 2000). Data Collection Data gathering and provision were assigned to the involved family coach or intake-manager. Master students and the first author subsequently provided feedback to the respective family coach and client through interim outcome-reports in form of standardized questionnaire profiles for each measurement. The ethical procedures of informed consent to research in accordance with Dutch law and professional standards were followed in all stages of the research. The first author received additional administrative information on demographic variables from the Salvation Army, namely regarding gender, age, ethnicity, marital status, highest educational degree, and number of children, as well as information describing care trajectories, namely whether the program ended or not, duration of the intervention, and reason for end of program (if applicable). Irregularities and missing information in the administrative data were compiled and sent to the respective intake-managers to provide additional information and comments.

CHAPTER FIVE

89

Statistical Analysis Chi-square tests and descriptive statistics were used to check for possible selection bias and to explore client and problem characteristics in terms of proportions, means, range and standard deviations. Moreover, care trajectories are presented by median durations, whether or not the intervention ended, which is known for all respondents regardless of if they dropped out the research or not, and if appropriate stated reason for the end of the intervention. Additionally, care duration was explored by log-rank test and Kaplan–Maier survival plots. Moreover, development of child behavior problems, parental stress, and family functioning over time were analyzed using multilevel models with families on the highest level, and repeated measures on the lowest level to take correlations between different measures within families into account. Time after baseline was included as continuous predictor, together with family characteristics, as well as possible correlations. Random as well as fixed effects were considered. We regarded p-values ≤ .05 as significant. Finally, models with only significant effects were reported. In addition, we computed the reliable change index (RCI) for each individual client by subtracting the score of the first measurement from the score of the last measurement, and dividing the outcome by the standard error (SE) of the difference between the test scores (Jacobson & Truax, 1991; Ogles, 2013, p. 155ff). We applied a 95% confidence criterion to determine whether or not (clinically significant) problem reduction for each participant had occurred. Standard deviations and Cronbach's alphas for RCI calculation were obtained from the questionnaire manuals5.

5 Nijmeegse Ouderlijke Stress Index α = .96, SD = 19.3 (de Brock et al., 1992); Vragenlijst Gezinsfunctioneren. α = .94, SD = 0.71 (ten Brink et al., 2000); Child Behaviour Checklist Preschool age, α = .90, SD = 18.71 (Achenbach & Rescorla, 2010); Child Behaviour Checklist School age, α = .94, SD = 18.00 (Achenbach & Rescorla, 2007).

OUTCOMES

90

Results

Problems at the Start of the Intervention We explored problem severity at the start of the intervention (T0) by the use of available norm groups (de Brock et al., 1992). Our data suggests above average parental stress for the majority (60%; n = 64) of participants. Family functioning as perceived by the family coaches was in the majority of cases (60%; n = 59) comparable to families who typically were referred to intensive home care (ten Brink et al., 2000) with a third of the families (33%; n = 33) functioning better than this norm group. The severity of child behavior problems at the start of the intervention (T0) differed between the two age groups. The majority (57%; n = 26) of children aged 1.5–5 scored in the normal range, while the majority (56%; n = 31) of children aged 6–18 years scored in the clinical range. Descriptive data on problem severity at the start of the intervention are shown in Table 8. Table 8 Problem severity at the start of the intervention (T0) Measure n %Parental stress (NOSI) aVery low–below average Average Above average–very high 19 17.8 24 22.4 64 59.8 Family functioning (VGF) bAbove norm Within norm Below norm 33 33.3 59 59.6 7 7.1 Behavior problems, 1.5–5 (CBCL) cNormal Borderline Clinical 26 56.5 1 2.2 19 41.3 Behavior problems, 6–18 (CBCL) dNormal Borderline Clinical 16 29.1 8 14.5 31 56.4 Note. a n = 107. b n = 99.c n = 46. d n = 55

CHAPTER FIVE

91

Parents reported via the NOSI on average the occurrence of 5.1 (SD 3.2; 0–14) critical life events within the last 12 months before start of the inter-vention (T0), with the majority (78%; n = 76) reporting significant loss of income or debts, and/or increase of conflict within the family (61%; n = 65) of which half (30%; n = 32) were associated with a divorce or breaking up with the partner. Care Trajectories The median duration of the intervention for participants for whom care ended within the research period (n = 67) was 15 months (SD = 10.4; 3–47 months). Participants for whom care did not end within the research period (n = 55) had a higher median of 19 months (SD = 13.6; 2–47+). Information on the reason for the end of care is shown in Table 9. Table 9 Reason for end of care End of care n %as planned prematurely… … in agreement … by client … by coach client involuntary continued at other provider

34 9 8 2 3 9

52.3 13.8 12.3 3.1 4.6 13.8 Note. Administrative information available for n = 65. Testing the equality of survival curves showed statistically significant differences, χ2 (2, n = 107) = 11.54, p = .003, for program duration in relation to parental stress at the start of the intervention (T0). Families with parental stress classified as very low to below average stress (n = 19; censored n = 4) had the shortest program durations with an estimated median of 13 months (SE = 2.63), while families who perceived stress on an average level (n = 24; censored n = 14) had significantly longer program durations, with an estimated median of 34 months (SE = 8.86). Parents who perceived stress on above average to very

OUTCOMES

92

high levels (n = 64; censored n = 29) stayed in the program for an estimated median duration of 25 months (SE = 1.18). A visual comparison of program duration in relation to parental stress is depicted in Figure 6. The figure shows the probability to continue the inter-vention (y-axis) in relation to the duration of the program (x-axis), for different groups of parental stress (stepped lines). A step in the graphs line occurs if one or more members of the respective group in the sample ended the intervention at the given program duration, which results in a lower probability for longer care durations in that group. A cross marks the duration at which a research participant was censored by the research period.

Figure 6. Kaplan–Meier survival curve of parental stress (NOSI) in the norm ranges from very low to below average (n = 19; censored n = 4), average (n = 24; censored n = 14), and above average to very high (n = 64; censored n = 29). The horizontal dotted line symbolizes the median probability of continuation. χ2 (2, n = 107) = 11.54, p = .003.

CHAPTER FIVE

93

Other variables, namely gender of respondent and child, educational level, marital status, family functioning, and child behavior problems, did not show statistically significant results or their relevant subgroups were too small to conduct meaningful chi-square analysis, namely for fathers (n = 6), higher secondary education (n = 1), family functioning below norm group (n = 7), and borderline behavior problems for children aged 1.5–5 years (n = 1). Two non-significant results were unexpected, namely 1) the high proportion (86%) of censored cases in the group of families with below average family functioning, so no median could be estimated, and 2) the short care duration for families with school aged child behavior problems in normal range (mdn = 16 months). The log-rank test was close to statistical significance, χ2 (1, n = 47) = 3.764, p = .052, if this group was compared only to the group with behavior problems in clinical range (leaving borderline cases [n = 8] out of the equation). Problem Reduction Visual exploration of error bars indicated improvement in parental stress perception mainly within the first year (T0–T1), as illustrated in Figure 7 (p. 94). Mean score differences for family functioning showed a contrasting pattern with a small (thus uncertain) but visually observable tendency to deteriorate over time. Mean scores for behavior problems for pre-school children showed a declining tendency over time, with a noteworthy difference between the start of the intervention (T0) and the third measurement (T3). School-aged children showed an ambiguous pattern of smaller differences between measurements. Between the start of the intervention and the second measurement mean behavior problems declined, but increased between the second measurement and the third measurement. The fourth measurement is mainly characterized by its relatively huge increase in SE caused by the small number of families (n = 6) continuing the program and research for four years.

OUTCOMES

94

Figure 7. Mean ± 1 SE for questionnaire scores over time for parental stress (NOSI), family functioning (VGF), and child behavior problems, ages 1.5–6 years and 6–18 years (CBCL). Problem reduction was further explored with multilevel analysis revealing a decrease of parental stress over time and a significant increase if the child was a boy. Coefficients and standard errors of the multilevel analysis are reported in Table 10 (p. 95).

CHAPTER FIVE

95

Table 10 Results of the multilevel analysis for parental stress Fixed effects coefficient SE Intercept 288.14 11.99Time after T0 -1.77 0.48Gender ChildMale Female (reference) +56.65 16.08 Random effects Level two variance 5867.59 1020.96Residual variance 2173.81 383.6Deviance 207793Note. SE = standard error. n = 180 of 488 measurements We calculated reliable change scores for each family individually to explore the magnitude of problem reduction between start of the intervention (T0) and the last measurement alone. The difference between scores is graph-ically presented as scatterplots for each of the instruments in Figure 8 (p. 96). Questionnaire scores at the start of the intervention (T0) are ordered on the x-axis and scores of the last measurement on the y-axis, that could be T1, T2, and T3. The solid diagonal line in the center symbolizes the break points for no change. The two dashed lines running parallel to the line of no change symbolizes the threshold for reliable change with a 95% confidence. Change is considered uncertain if an individual marker falls within the two dashed lines because measurement errors could not be ruled out as source of the change. Individual markers to the left of the upper vertical dashed line symbolize reliable deterioration for problem focused scales (NOSI, CBCL) and improve-ment for family functioning (VGF). Individual markers to the right of the lower dashed line symbolize reliable improvement for the problem focused scales (NOSI, CBCL) and deterioration for family functioning (VGF). Additionally, we inserted a horizontal and a vertical dashed line for norm group cut off scores which we judged as indicative for no (further) need for intervention. As a result the scatterplot can be mapped into four quadrants which, for problem focused scales (NOSI, CBCL), can be read as follows: 1) Top-left: clinical deterioration

OUTCOMES

96

from normal to clinical range; 2) Top-right: change within clinical range; 3) Bottom-right: clinical improvement from clinical range to normal; and 4) Bottom-left: change within normal range. For family functioning (VGF) the interpretation of the quadrants needs to be mirrored diagonally to the rightside.

Figure 8. Scatterplots of questionnaire scores at the start of the intervention (T0) vs. scores at last measurement for parental stress (NOSI), family functioning (VGF), and child behavior problems, ages 1.5–6 years and 6–18 years (CBCL). The solid diagonal line marks zero change. Diagonal dashed lines symbolize break points for reliable change with a 95% confidence, equivalent

Improvem

ent

Improvem

ent Deterioration

Improvem

ent

Deterioration

Deterioration Deterioration

Improvement

Measurement

Care T1 T2 T3

Continued Ended

CHAPTER FIVE

97

to the RCI cut off scores: NOSI = 10.70; VGF = 214,9. CBCL 1.5–5 = 16.39; and CBCL 6–18 = 12.22. The horizontal and vertical dashed lines symbolize break points for relevant norm groups: parental stress below average (NOSI, 214.9), family functioning above average (VGF, 3.56), non-clinical behavior problems, ages 1.5–5 years (CBCL, 60.9), and non-clinical behavior problems, ages 6–18 (CBCL, 48.9). Individual markers differ in form, symbolizing different measure-ment moments for the last measurement, and differ in fill, symbolizing whether the intervention had ended or not. Reliable change categories were too small to statistically test differences between most of the relevant subgroups. However, descriptive data still offered information worthy of interpretation. Parental stress scores improved for the majority of cases (60%; n = 29), with comparable proportions for parents who were still in the program (61%; n = 17) and those for whom the intervention had ended (60%; n = 12). Clinically significant improvement past the threshold of below average stress was found for 16% (n = 7) of the parents who had at least two measurements and scored initially (T0) above average (n = 45). Reliable deterioration in parental stress scores was found in 13 cases (27%). The change in family functioning was uncertain for the majority of cases (56%; n = 24) with equal sized proportions of cases for whom the score reliably improved (21%; n = 9) or deteriorated (23%; n = 10). No significant differences in the magnitude of change between the groups were found. The majority of families whose score could potentially deteriorate below the clinical significant threshold (n = 15) did so (53%; n = 8). In contrast, only a fifth (18%; n = 5) of the families improved below the clinical threshold of those who scored initially above this threshold (n = 28). Reduction in behavior problems for preschool children was in the majority of cases uncertain (60%; n = 9), but in the majority of cases (57%; n = 4) behavior problems had reduced past the clinical threshold at the last measurement. Behavior problems of school-aged children show a more certain change with an improvement in behavior problems in almost half the cases (46%; n = 12), and deterioration in a quarter of the cases (23%; n = 6). Four out of 16 improved clinically significantly (25%).

OUTCOMES

98

Discussion and Conclusions The data summarized to address our first research question, “What were demographic and problem characteristics of clients referred to TF?”, revealed potential socio-economic stressors and limited (social) capital for problem solving in the majority of cases, as indicated by self-reported financial loss, or debt in the year before the intervention, and a relatively low (mainly pre-vocational) level of education. It seems unlikely that committed relationship functioned as reliable and robust coping resource in most families, inferred from reports of increased family conflicts or breaking up with the partner in the majority of cases, combined with a relatively low rate of legal marriages. That almost all of our respondents were women, with similar proportions found in other Dutch research projects (Bodden & Deković, 2010), connects these findings theoretically to broader issues surrounding gender disparities in child welfare (e.g., Choi & Pyun, 2014; Ewart-Boyle, Manktelow, & McColgan, 2013; Zanoni, Warburton, Bussey, & McMaugh, 2014). The majority of participants reported above average to very high parental stress levels at the start of care which further hints at a complex life situation of most of TF's clients at the start of care. This is an interpretation with relevance for the assessment of care durations, if one assumes that case complexity and the presence of intractable stressors are important moderators (Littell & Schuerman, 2002). The significant difference we found between participants grouped by parental stress in answer to our second research question, “Can factors be identified that were associated with extended care durations?”, partly under-lines this notion. Participants who initially reported below average parental stress reached in our survival analysis the median probability to end the intervention 12 months earlier than participants who reported higher parental stress. In answer to the third research question, “Is TF associated with problem reduction?”, our multilevel analysis revealed a general tendency of reduced parental stress. The comparison of group means suggests that a reduction in parental stress was mainly achieved in the first year of inter-vention. A comparison between the family stress at the start of the intervention and the last measurement by calculating individual change scores (RCI) further

CHAPTER FIVE

99

differentiated the picture. Reliable improvement in the majority of cases was found, and change was observed also past the first year, as well as reliable deterioration in some cases. Our findings on care duration prompted additional controls for bias being possibly introduced by non-random missing data. We therefore applied the ‘pattern mixture approach’ (Post, Buijs, Stolk, De Vries, & Le Cessie, 2010) in order to check whether this bias could be adjusted. It appeared that the magnitude of possible adjustments was very small also due to the relative small size of subgroups for this analysis. The initial scores on family functioning indicate that care workers judged most of the families being comparable to families who were typically in need of home care (the norm group of the questionnaire), as would have been expected. The magnitude of change reported for family functioning however was mainly uncertain, which contrasted with our earlier finding on reduced parental stress. There are various possible explanations. First of all, family functioning might be more resilient to change through family interventions, even in long-term interventions, if it is conceptualized as a higher order outcome which follows parental stress reduction as intermediate outcome (Hurley et al., 2012). It is also possible that, secondly, the questionnaire we used was a less sensitive measurement instrument. And, last but not least, it might prove more difficult for outsiders to gather relevant information in complex family situations (cf. chapter 4), compared to parental self-reports. Child behavior problems at the start of the intervention differed between age groups, with the majority of pre-school children scoring in the normal range and the majority of school-aged children scoring in the clinical range. Child-related outcome measures did not show a coherent pattern of change, which might be influenced by the main focus on parent-related activities of the family coaches (cf. chapter 4). Additionally, child behavior problems also can be thought of as higher order outcomes in family inter-ventions if achieved through parental stress reduction (Hurley et al., 2012). Evaluation studies from the United Kingdom suggest promising results for dual key worker approaches that offer allocated care for children next to parent support in family oriented flexible services (Thoburn et al., 2013). In 2010 the Salvation Army Netherlands also started a pilot program to further develop

OUTCOMES

100

child-centered coaching in addition to family coaching. Our findings underline the importance of such an approach and we recommend the development and evaluation of child coaching programs. This study knows several strengths and limitations. Initially we explored the possibility for the inclusion of a comparison group to allow for more rigorous inferences. However, recruitment of meaningful comparison groups from the small number of potential candidates in the area was unsuc-cessful, which can partly be attributed to the very specific targeted group and type of intervention in this study. In future research, designs that allow for direct comparisons with a norm group from the general population should be considered as alternative, as well as case-based research methods. They could provide valuable information for the interpretation of change in outcome variables over time. Meaningful fluctuations in parental stress levels, for example, might be associated with other characteristics of change in a family life cycle, such as the number of children in the household, the age of the child(ren), or loss or gain in partnership. Reliable problem assessment and routine outcome measurement should be considered a pre-requisite for tailoring integrated care components to individual needs as well as to develop clear stopping rules for open ended care trajectories. Administrative data management and monitoring play a crucial rule in gathering information about families with multiple problems, and our research revealed further need for improvement herein. In conclusion, gathering data about a flexible, integrated, and longitudinal family intervention, allowed us to analyze problem development over years for a complex target group and offered valuable information with implications for practice and future research.

CHAPTER SIX

GENERAL DISCUSSION

CHAPTER SIX

103

General discussion

Identifying families with multiple problems and providing care for them, both reliably and effectively, has been a major challenge in child welfare for more than half a century, and remains till today an issue of high priority (cf. chapter 1). Herein, the way how we, as researchers and practitioners in child welfare, perceive and approach these families matters. In the second and third chapter of this dissertation, differences and similarities between definitions and approaches were examined, and their potential value for an ethically justified child and youth care practice was evaluated theoretically. These chapters provide the theoretical ground for answering the first two research questions on (1) the target group and (2) intervention characteristics. The conceptual literature review in the second chapter illustrated, on the one hand, exemplary differences in target group descriptions between the Netherlands and Germany. It revealed, on the other hand, communalities in the mode of theory production in both countries, which cumulated in the concept of the life situation. The attributes of (a) multidimensionality, (b) multiple levels, (c) objectivity and subjectivity, and (d) dynamism and relativity were identified as theoretical pillars that could bridge the conceptual differences without losing the benefits of approaching a subject from different angles, as both approaches provided valuable perspectives. The German literature on social exclusion and poverty contributed to the understanding of the phenomenon by laying emphasis on analyses and intervention strategies that specifically include the macro level of social policies and society. Intractable factors, like for example disparities in gender roles, or single parenthood, and their cumulative experience in life situations marked by social exclusion and poverty, can have a significant impact on the long-term prospects of child welfare interventions. Signalling them in practice and analysing them through research is important, as it allows for the identification and communication of structural inequalities in the welfare system that can cause or amplify negative results of otherwise individualized care provision.

GENERAL DISCUSSION

104

Meeting the needs of families with multiple problems can only be achieved effectively, under these assumptions, if interventions link different social levels (micro, meso, and macro) collaboratively through shared responsibility and a joint plan of action. Dutch publications on multi-problem families contributed to the subject by providing detailed analyses of intervention dynamics and program-matic solutions in client-centred social work interventions, which were further elaborated in the third chapter of this thesis. Dutch target group descriptions emphasized, on the one side, the complex relations of experiencing multiple socioeconomic and psychosocial problems, and highlighted, on the other side, issues that arise from not adequately addressing those needs in child welfare. The latter point overlaps thematically with the earlier mentioned German notion that failing care arrangements may be a contributing factor for the existence of the target group. In the Dutch discipline of Orthopedagogy solutions are foremost sought through the development of intervention programmes (at the micro and meso level) that specifically target these issues. Four major points of discussion were distinguished in programme development for the target group in the Netherlands, (a) the duration of the care services, (b) the degree of voluntariness, (c) the coordination of support, and (d) financing. In conclusion integral support with a flexible duration was called for in which multiple care components are tailored to meet the specific needs of individual families. One such intervention model has been introduced in the Netherlands under the name of the family coach, for which a prominent role as generalist in child welfare was suggested in the wake of the latest transformation of the Dutch welfare system (Raad voor Maatschappelijke Ontwikkeling, 2012). Ten for the Future (TF) [Dutch: Tien voor Toekomst] is a family coaching programme that was developed by the Salvation Army of the Netherlands to meet the needs of families with multiple problems (cf. chapter 1). The study reported in the fourth chapter of this thesis aimed at a deeper understanding of primary care processes of the programme, and thereby tried to answer the second research question of this thesis empirically: ‘what characterizes care provided in TF?’. A self-report instrument was developed in order to meet this objective and results from a sequenced study with the instrument were presented. Data showed that the main focus of the family

CHAPTER SIX

105

coaches fell into the categories of ‘collecting information’ and ‘working towards (behavioural) change’ in the families. The prominent share of the category ‘collecting information’ in overall care activities illustrated to which extent continual needs and goal assessment was part of a monthly routine in the flexible home-based intervention. This finding taken together with the relatively high frequency of the care contacts (cf. chapter 4) demonstrated the complexity and intensity of care directed at families with multiple problems. The results also showed that care workers mainly performed activities in contact with parents alone, and only to a lesser extent with children and external professionals. While the focus on parents was not surprising, it could potentially jeopardize the systems’ orientation of the service, even more so when other indirect network-oriented activities, such as ‘network analysis’, were found to be least frequently used. These interpretations of data gathered with the instrument provided meaningful feedback for the care organization already on a descriptive level of data analysis and thereby proofed its general feasibility in increasing insight into the ‘black box’ of service provision. The instrument provided new oppor-tunities for systematically adding information about the ‘throughput’ into input-output oriented study designs, and allowed for grounding interpretations in intervention specific knowledge in the following outcome study (cf. chapter 5). The focus of the study reported in the fifth chapter of this thesis sought empirical answers to the first and third research question, which aimed at the assessment of client characteristics and outcomes, including the magnitude of problem reduction and duration of the flexible care programme. Data on 122 families were gathered via questionnaires and the client administration system over a period of four years and seven months. Analyses on group level and individual case level were carried out. The results revealed potential socio-economic stressors and limited (social) capital for problem solving in the majority of cases and demonstrated the central role of parental stress in evaluating outcomes and care duration of TF. The results suggested that the intervention was associated with a decrease in family stress. And that, furthermore, families with lower initial parental stress were found to have a higher chance to end the programme significantly earlier. Less coherent

GENERAL DISCUSSION

106

patterns of change were found for the outcome measures of family functioning and child problem behaviour. These findings can be connected to the earlier mentioned focus of family coaches on the direct work with parents alone. Practical Implications On the basis of our findings presented above practical implications can be drawn. Two overarching themes are emphasized in the following sections that are of relevance for intervention design in general and further development of the intervention programme TF in particular: (a) the need to address children directly in home-based services, and (b) to provide multi-layered long-term support that acknowledges the impact of structural inequalities on child welfare services for families with multiple problems. Implications for future research follow in the sections thereafter.

Attention to children through dual key worker approaches Comparative research on effects of different child care interventions conducted in Germany by Schmidt and colleagues (2002) showed that, relatively speaking, children and young people realized the least benefit from home-based family support. In addition, Veerman and colleagues (2005) concluded in their meta-analysis of 17 intensive home-based care programmes in the Netherlands that, even though a moderate effect-size (ES = 0.52) on externalizing behaviour problems of young people was found, in many cases these problems persisted. They argued that, “even after the completion of by far the most of the methods discussed in this study, the risk that the problem behaviour will continue or become worse is so great that subsequent treatment is indicated”6 (Veerman et al., 2005, p. 186). One explanation for relatively low effects and problem persistence could be that the children simply received less and partly insufficient direct attention in the home-based care process; a hypothesis which is underlined by the findings of chapter four and five of this thesis. Other Dutch publications, 6 Translated by the author of this thesis, T. Tausendfreund.

CHAPTER SIX

107

which also reported results similar to the ones mentioned above, call in conclusion for increased and continuous attention to children and strategies for their long-term support (Knorth, Knot-Dickscheit, & Tausendfreund, 2007; Knot-Dickscheit & Blommert, 2009; Slot, van Tooren, & Bijl, 2004; Tabibian, 2006). The Salvation Army of the Netherlands introduced the function of Child Coach [Dutch: Kindercoach], with first pilots in 2010, to complement the services of their programme TF. The Child Coach methodology is still in development, however the core principal is set: it is providing home-based services alongside the family coach, which primarily focuses on direct support and care for the child(ren). Findings from a process study of a multi-disciplinary team working with families with long standing and complex problems in the United Kingdom suggest that such dual-key worker approaches can have promising results (Thoburn, et al. 2013). A second argument for addressing children directly in home-based care for families with multiple problems, next to the effectiveness of the intervention, is ethical. Children in families with multiple problems are particularly vulnerable (Devaney & Spratt, 2009). Prevalence rates of child abuse and neglect should be expected to be higher in this target group (e.g., van Burik & van Vianen, 2006). In consequence, there the danger of stabilizing a family situation in which undisclosed abuse or maltreatment of a child continues. Offering children a unique and reliable contact person, which is not perceived as giving primarily support to parents but is mainly concerned with direct care for the child, can serve as additional route to disclosure in these situations. In conclusion, the further development and research of such dual key worker approaches—both nationally and internationally—should be encouraged. Collaborative long-term support in a continuum of care Van Yperen, van der Steege, Addink and Boendermaker (2010, pp. 22f) suggest that increased effectiveness of social interventions was and will further be achieved, among others, mainly through the inclusion of factors that

GENERAL DISCUSSION

108

formerly were outside the scope of the intervention (viz., extra therapeutic factors). According to them, multimodal programmes, like for example family coaching, increased the reach of interventions, which were formerly centred on individual clients (on a micro level), by successfully including resources from social networks and agencies into their intervention strategies (on a meso level). This type of care is invariably based on an ecological perspective that links intervention strategies at different social levels, vertically, and operates according to the principles of social systems theories, horizontally (Spratt, 2011). Most, if not all, intensive home-based care programmes, including the intervention programme TF (Leger des Heils Noord, 2006), refer to social systems theories as one of their main theoretical pillars (e.g., Veerman, Janssens, & Delicat, 2004, p. 36). However, specific details on how underlying programme theories are brought into practice are often only scarcely outlined in most programme descriptions and additional room of improvement herein, including the regular assessment of care activities, has been generally attested (Veerman et al., 2004, p. 49). The findings from chapter four show that this is also the case for the programme TF. Further investments into programme description (Boendermaker, 2012), regular monitoring of care activities, inter- and supervision as well as regular job-complementing training should be considered in order to enhance and maintain the programme integrity in general, and the systems orientation in particular. The theoretical considerations in the first chapters of this thesis (cf. chapter 2 & 3) suggest further room for improvement through including also the social macro level into intervention strategies. One attempt to formulate such a strategy was made by us in an earlier publication (Knorth et al., 2007), in which we (re-)conceptualized child welfare as a continuum of care with fluent transitions between different types of care, in which parents can be perceived as potential partners (see also, Bullard & Johnson, 2005; Geurts, Boddy, Noom, & Knorth, 2012). The vision of a continuum allows to conceptualise care from a biographical perspective. It can include varying types of care and support and offers long-term perspectives for families and children, whose problems approach the limits of service provision with short-term (crisis) interventions. This long-term care should be characterized by flexibility of programmes, which

CHAPTER SIX

109

tailor care components, intensity, and duration to the needs of individual families, and by a collaborative care approach that links different forms of intervention at all social levels (micro, meso, and macro). Reliable problem assessment, administrative data management, database maintenance, routine outcome measurement, and process evaluation should be considered pre-requisites for such a tailored integrated care approach, as will be elaborated in the following section on research implications. Research Implications To date, we know relatively little about the effectiveness of youth interventions in general (Van Yperen & Veerman, 2013), nor do we have much knowledge about interventions for families with multiple problems (Holwerda, Reijneveld, & Jansen, 2014), particularly with regard to the question, ‘What works for whom, under which circumstances and why?’ (Hood, 2012; Kazi, Pagkos, & Milch, 2011; Pawson & Tilley, 1997). This might be due to several reasons, some of which will be further discussed in the next two sections.

Problem assessment and administrative data management Client administration of individual welfare services usually is geared to meet the informational demands of the financing agency, focusing only on specific problem areas or categories in a parcelled welfare environment (Spratt, 2011). Reliably identifying families with multiple problems in this environment can be severely limited by the lack of synchronized categorization and problem assessment across services (van den Berg & de Baat, 2012). For example, in our research gathering meaningful information on partnership and wider social support was restricted by administrative data only being available for the category of legal marriage. Relevant information on other forms of committed relationship, including systematic data on partner cohabitation and shared parenthood, would allow more detailed target group characterisation and subsequent analysis in future research. A second issue is database maintenance. The almost complete lack of information to be found on ethnicity inherited from the father’s side (cf. chapter

GENERAL DISCUSSION

110

5), even though this category was available, reveals that not only meaningful categorisation is required, but that the information asked for also needs to align with the workflow of the involved care worker. Categorised ethnicity might not be perceived as relevant in a day-to-day routine of face-to-face care provision, but can be used, for example, in inter- or supervision to identify and thematise gender- and culture-sensitive care practices. A first step to open up possibilities for synchronized data sharing across services would be to collaboratively develop a blueprint for a concise information matrix that includes child welfare relevant categorization and aligns with (inter)national, standards, and ethical and legal regulations. In the future, the utilisation of technical advancements, in designing databases, their interfaces, and visualising their data, could help to stimulate the wider internal use and allow for a more streamlined communication. Individual case sum-maries should be easy to access on demand for the involved care worker to share with his clients and supervisor, and for clients to share with their care workers or case manager. Furthermore, the databases should be suitable for secondary analysis by researchers or policy makers if access was approved.

Measuring change through outcome and process evaluation The last point of the previous paragraph should be considered reciprocal: Programme evaluation should also meet the informational needs of care practice. This is not to be misunderstood as a plea to subsume research under the logic of practical utilization, but is meant as appeal to identify common research interests and focus on the development and implementation of research designs that are informative for various stakeholders at multiple levels and stages of an evaluation process. Research methods that can provide relevant information on case level but are also suitable for continuous data aggregation on group level, such as the Reliable Change Index (RCI), have promising potential and should play prominent role in routine outcome measurement and process evaluation (Van Yperen & Veerman, 2013). Group comparisons in experimental research designs play a key role in programme evaluation and are a core concept of the paradigm entitled evidence-based practice (EBP). The merits and disadvantages of both, the EBP

CHAPTER SIX

111

paradigm and experimental research designs, have been subject to one of the broadest and most vivid discussions between scholars in child welfare for more than a decade (Axford & Morpeth, 2013; Hodge, Lacasse, & Benson, 2012). One of the central questions in this discussion is, how statistical significance on group level relates to practical relevance in individualized service provision (Axford, Little, Morpeth, & Weyts, 2005). Opponents of EBP warn of naïve notions that dichotomize services simply into ‘what works / what does not work?’ and propose to ask alternatively ‘why does something work, for whom and under what circumstances?’ (Pawson & Tilley, 1997). The plea for priori-tising this latter question has been made repeatedly in child and youth care (Hood, 2012; Kazi et al., 2011; Orobio de Castro, 2010), in order to strengthen theory-driven programme development by gaining deeper insight into the contextualized efficacy of programme elements, and the assessment of their potential (cross-cultural) transportability. It has been argued that experimental designs and group comparisons can have superior value in making individualized statements if they are embedded in extensive research programmes (Marley & Levin, 2011). However, this research strategy might not be readily amenable for all types of practices in child and youth care, as it has been noted for longitudinal family support (Boddy et al., 2011) or complex child protection cases (Thoburn, 2010), which are both services with relevancy for families with multiple problems. A methodological alternative, which is in line with the afore-mentioned questions of ‘what works, for whom, when and why?’, are case-based methods (Byrne & Ragin, 2009; Campbell, 1975). The Reliable Change Index (RCI, Jacobson & Truax, 1991; see also, Ogles, 2013) is one of such case-based statistics used in psychotherapy research to answer the question of whether clients have experienced (uncertain, positive or negative) change in relevant outcomes measures, and if a measured change is assumed clinically relevant (passing norm group thresholds or not). This is in so far important as it allows for a diversified view on the programme population. Evaluators who focus only on group averages might conclude that a programme is not effective while, in reality, it might be effective for a sub-group of the participants and harmful for others. Case-based methods can help to distinguish characteristics which can possibly explain

GENERAL DISCUSSION

112

varying results through revealing associations with subgroups of the client population and particular care activities (see also, Barlow, 2010; Dimidjian & Hollon, 2010). Another advantage of case-based analysis with an RCI is, that it can be suitable for continuous data aggregation in routine outcome measurement. Data can be interpreted meaningful for single clients as well as for (a growing) group of clients within the same categorical system (or visualisation matrix; cf. figure 8, p. 96). A similar research design was proposed under the label of realist evaluation, in which a growing body of continuously aggregated data is analysed with complex regression models (Kazi et al., 2011). While complex regression models certainly are of high analytic value, their theoretical benefits need to be weighed against the ease of access of simpler models like the RCI, especially in routine outcome evaluation. Research in clinical neuropsychology demonstrated that complex regression models have no superior value in measuring change (Heaton et al., 2001). Although case-based assessment methods, like the RCI, are also available for programme evaluation of child welfare services, they have only been used sparingly (Deković, 2010, p. 100; Kazi et al., 2011). One of the few examples from the Netherlands that applied case-based analysis with the RCI is the evaluation of the Home-Start programme (Asscher, Deković, Prinzie, Hermanns, & van den Akker, 2009). The study demonstrated that similar programmes should target the most troubled clients if they wish to achieve the greatest magnitude of change, and should target, on the contrary, clients closest to the norm group of the general population if change should fall below the clinical threshold. A result in line with this reasoning was also reported in this thesis (cf. chapter 5): parents with the lowest initial stress scores had the highest chance to end the intervention significantly earlier. Furthermore, in this research, combining various analytical methods on group level and on case level, which were interpreted on the ground of process evaluation and theoretical conceptual analysis, allowed for detailed description of the TF programme, its clients and associated outcomes.

CHAPTER SIX

113

Final Conclusion A central theme of this thesis was the acknowledgement of complexity in engaging families with multiple problems. The second and third chapter showed that concepts or interventions that narrow their focus down to single aspects or problems are only of limited value. In conclusion, multi-causal and collaborative approaches are called for that link theory production and intervention at individual, family, network and policy level, in order to address the multi-layered complexity of life situations of families with multiple problems. It was further concluded that the provision of flexible care over extended periods has potential in supporting parents with multiple problems. It seems warranted to compliment this approach in families with multiple problems by also providing allocated home-based care directly to children. A plea was made to endorse methodological diversity in research on families with multiple problems. Methods are called for that can provide sound evidence on an individual level, and at the same time provide data which can be used for further research synthesis to provide an evidence base for interventions that target families with multiple problems. Furthermore, reliable problem assessment and routine outcome measurement should be considered a pre-requisite for tailoring integrated care components to meet individual needs, as well as to develop eventual stopping rules in flexible care provision. Administrative data management and database maintenance play a crucial role in providing reliable information about families with multiple problems. Our research revealed further need for improvement herein. In the end, successfully tackling these challenges to improve the life situation of children in families with multiple problems is a collaborative task.

REFERENCES

REFERENCES

116

References

Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA preschool forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Achenbach, T. M., & Rescorla, L. A. (2007). Multicultural supplement to the manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Achenbach, T. M., & Rescorla, L. A. (2010). Multicultural supplement to the manual for the ASEBA preschool forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Administrative Committee on Coordination. (1998). Statement of commitment for action to eradicate poverty. Retrieved from http://www.unesco.org/most/acc4pov.html Al, C. M. W., Stams, G. J. J. M., Bek, M. S., Damen, E. M., Asscher, J. J., & van der Laan, P. H. (2012). A meta-analysis of intensive family preservation programs: Placement prevention and improvement of family functioning. Children and Youth Services Review, 34(8), 1472–1479. doi:10.1016/j.childyouth.2012.04.002 Al, C. M. W., Stams, G. J. J. M., van der Laan, P. H., & Asscher, J. J. (2011). The role of crisis in family crisis intervention: Do crisis experience and crisis change matter? Children and Youth Services Review, 33(6), 991–998. doi:10.1016/j.childyouth.2011.01.009 Alders, M. (2001). Classification of the population with a foreign background in the Netherlands. Paper presented at the conference ‘The measure and mismeasure of populations. The statistical use of ethnic and racial categories in multicultural societies’, 17–18 December Paris, France. Paper retrieved from http://www.cbs.nl/nr/rdonlyres/d314ba81-b4a9-492f-8c9b-b50e7d3a3e5d/0/classificationforeign.pdf

REFERENCES

117

Alkire, S., & Foster, J. (2011). Understandings and misunderstandings of multidimensional poverty measurement. Journal of Economic Inequality, 9(2), 289–314. doi:10.1007/s10888-011-9181-4 Appleyard, K., Egeland, B., van Dulmen, M., & Sroufe, L. (2005). When more is not better: The role of cumulative risk in child behavior outcomes. Journal of Child Psychology and Psychiatry, 46(3), 235–245. doi:10.1111/j.1469-7610.2004.00351.x Asscher, J. J., Deković, M., Prinzie, P., Hermanns, J. M. A., & van den Akker, L. (2009). De betekenis van veranderingen in gezinnen die hebben deelgenomen aan het Home-Start programma en voorspellers van deze veranderingen [The significance of changes in families who participated in the Home-Start programme and predictors of these changes]. Pedagogiek, 21(3), 247–269. Asscher, J. J., & Paulussen-Hoogeboom, M. C. (2005). De invloed van protectieve en risicofactoren op de ontwikkeling en opvoeding van jonge kinderen [The influence of protective and risk factors on the development and upbringing of young children]. Kind en Adolescent, 26(1), 56–69. Axford, N., Little, M., Morpeth, L., & Weyts, A. (2005). Evaluating children's services: Recent conceptual and methodological developments. British Journal of Social Work, 35(1), 73–88. doi:10.1093/bjsw/bch163 Axford, N., & Morpeth, L. (2013). Evidence-based programs in children's services: A critical appraisal. Children and Youth Services Review, 35(2), 268–277. doi:10.1016/j.childyouth.2012.10.017 Baartman, H., & Dijkstra, J. S. (1986). Multi-problem gezinnen. Interpretatiekaders, I [Multi-problem families. Interpretation Frameworks, I]. Tijdschrift voor Orthopedagogiek, 25(12), 609–624. Baartman, H., & Dijkstra, J. S. (1987). Multi-problem gezinnen II. De opvoedings-problematiek. [Multi-problem families II. The problems in upbringing]. Tijdschrift voor Orthopedagogiek, 26(1), 2–20. Baartman, H., Garnier, M., van Vugt, M., & Vogelzang, B. (1989). Het Project Aan Huis. Verslag van het onderzoek Praktisch Pedagogische Thuishulp in multiprobleemgezinnen [The Project On House. Report of the research project Practical Pedagogical Home Care in multi-problem families]. Amsterdam: Vrije Universiteit Amsterdam, Sectie Speciale Pedagogiek, RIAGG Zuid Nieuw-West, & De Triangel.

REFERENCES

118

Baas, N. J. (2001). Probleemouders, probleemkinderen? Een literatuurstudie van transgenerationele overdracht van problemen die tot kinderbeschermingsmaatregelen (kunnen) leiden [Problem parents, problem children? A literature study on transgenerational transmission of problems which (may) lead to child protection issues] Den Haag: Wetenschappelijk Onderzoek- en Documentatiecentrum. Bakker, I., Bakker, K., van Dijke, A., & Terpstra, L. (1998). O&O in perspectief [O&O in perspective]. Utrecht: Nederlands Instituut voor Zorg en Welzijn (NIZW). Bakker, I., Bakker, K., van Dijke, A., & Terpstra, L. (2000). O + O = O2. Naar een samenhangend beleid en aanbod van opvoedingsondersteuning en ontwikkelingsstimulering voor kinderen en ouders in risicosituaties [Towards a coherent policy and provision of educational support and stimulation of development for children and parents at risk]. (3rd ed.). Utrecht: Nederlands Instituut voor Zorg en Welzijn (NIZW). Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65(1), 13-20. doi:10.1037/a0015643 Barth, G., & Schlereth, A. (2009). Familienhilfe: Über den Umgang mit Familien in multiplen Problemlagen [Family Support: About dealing with families in multi-problem situations]. Baltmannsweiler: Schneider Verl. Hohengehren. Bauman, L. J., Silver, E. J., & Stein, R. E. K. (2006). Cumulative social disadvantage and child health. Pediatrics, 117(4), 1321–1328. doi:10.1542/peds.2005-1647 Beitzel, E. (2010). Das Hilfeparadoxon. Familien in Multiproblemlagen niedrigschwellig helfen [The Care Paradox. Low-thresholds in helping families in multi-problem situations]. Marburg: Tectum. Belsky, J., & Vondra, J. (1989). Lessons from child abuse: The determinants of parenting. In D. Cicchetti, & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 153–202). Cambridge: Cambridge University Press. doi:10.1017/CBO9780511665707.007

REFERENCES

119

Berg-le Clercq, T., Zoon, M., & Kalsbeek, A. (2012). Wat werkt in multiprobleemgezinnen? [What works in multi-problem families?]. Utrecht: Netherlands Youth Institute. Retrieved from: http://www.nji.nl/nji/dossierDownloads/Watwerkt_Multiprobleemgezinnen.pdf Berger, M. (2006). IOG-erger voorkomen: De methodiekhandleiding. [List of Activities for Avoiding Complications in Intensive Family Support Programmes]. Lichtenvoorde: Forium. Berry, M., Cash, S. J., & Brook, J. P. (2000). Intensive family preservation services: An examination of critical service components. Child & Family Social Work, 5(3), 191–203. doi:10.1046/j.1365-2206.2000.00164.x Biglan, A., Brennan, P. A., Foster, S. L., & Holder, H. D. (2004). Helping adolescents at risk. Prevention of multiple problem behaviors. New York, NY: Guilford Press. Bodden, D., & Deković, M. (2010). Multiprobleemgezinnen ontrafeld. [Multi-problem families unraveled] Tijdschrift voor Orthopedagogiek, 49(6), 259–271. Boddy, J., Smith, M., & Statham, J. (2011). Understandings of efficacy: Cross-national perspectives on ‘what works’ in supporting parents and families. Ethics and Education, 6(2), 181–196. doi:10.1080/17449642.2011.622992 Boendermaker, L. (2008). Jeugdzorgplus: Drang en dwang in de jeugdzorg [Youth Careplus: Pressure and coercion in youth care]. Jeugd en Co—Kennis, 2(1), 8–20. Boendermaker, L. (2012). Richtlijnen voor behandelintegriteit [Guidelines for treatment integrity]. Kind en Adolescent, 33(3), 160–163. Böhnisch, L. (2008). Sozialpädagogik der Lebensalter. Eine Einführung [Social Pedagogy of the ages. An introduction] (5th ed.). Weinheim: Juventa. Böhnisch, L., & Lösch, H. (1973). Das Handlungsverständnis des Sozialarbeiters und seine institutionelle Determination [Understanding the actions of the social worker and its institutional determination] In H.-U. Otto, & S. Schneider (Eds.), Gesellschaftliche Perspektiven der Sozialarbeit [Societal perspectives of social work] Band 2 (pp. 21–40). Neuwied & Berlin: Luchterhand.

REFERENCES

120

Böhnisch, L., Schröer, W., & Thiersch, H. (2005). Sozialpädagogisches Denken. Wege zu einer Neubestimmung [Social pedagogical thinking. Towards a redefinition]. Weinheim: Juventa. Bolt, A., & Metselaar, J. (2005). Verrichtingenlijst Intensieve Gezinsbegeleiding [Activities List Intensive Family Support]. Leiden: Cardea. Bosscher, N. (2012). The decentralisation and transformation of the Dutch youth care system. Retrieved from: www.youthpolicy.nl/yp/downloadsyp/Publications-The-decentralisation-and-transformation-of-the-Dutch-youth-care-system.pdf Bot, S., de Roos, S., Sadiraj, K., Keuzenkamp, S., van den Broek, A., & Kleijnen, E. (2013). Terecht in de jeugdzorg. Voorspellers van kind- en opvoedproblematiek en jeugdzorggebruik [Ending up in youth care. Predictors of child and parenting issues and use of child welfare services]. Den Haag: Sociaal en Cultureel Planbureau. Bouwkamp, R. (2005). Hilfen für Multiproblemfamilien: Zur kulturellen Differenz bei therapeutischen und sozialpädagogischen Unterstützungsangeboten für Klienten aus unterprivilegierten gesellschaftlichen Schichten [Professional support for families with multiple problems: About cultural diversity concerning the therapeutic and social work practice with clients, living in underprivileged social circumstances]. Kontext, 36(2), 150–165. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge: Harvard University Press. Buehler, C., & Gerard, J. (2013). Cumulative family risk predicts increases in adjustment difficulties across early adolescence. Journal of Youth and Adolescence, 42(6), 905–920. doi:10.1007/s10964-012-9806-3 Buell, B., Berry, M., Robinson, R., & Robinson, C. W. (1952). Community planning for human services. New York: Columbia University Press. Bullard, L. B., & Johnson, K. (2005). Residential services for children and youth in out-of-home care: A critical link in the continuum of care. In G. P. Mallon, & P. McCartt Hess (eds.), Child welfare for the twenty-first century: A handbook of practices, policies, and programs (pp. 558-572). New York: Columbia University Press.

REFERENCES

121

Byrne, D., & Ragin, C. C. (2009). The Sage handbook of case-based methods. London: Sage. Campbell, D. T. (1975). III. “Degrees of freedom” and the case study. Comparative Political Studies, 8(2), 178-193. doi:10.1177/001041407500800204 Carr, A. (Ed.) (2009). What works with children, adolescents, and adults? A review of research on the effectiveness of psychotherapy. London: Routledge. Choi, J., & Pyun, H. (2014). Nonresident fathers’ financial support, informal instrumental support, mothers’ parenting, and child development in single-mother families with low income. Journal of Family Issues, 35(4), 526–546. doi:10.1177/0192513X13478403 Choy, J., Pont, S., Doreleijers, T., & Vermeer, J. (2003). Moet-willige hulpverlening: Systeemtheoretische methodiek voor gezinsvoogden en jeugdreclasseerders [Involuntary care: Methodology of systems theory for family supervision and youth probation]. Amsterdam: SWP Publishers. Clemenz, M., & Dichmann, R. (1990). Soziale Krise, Institution und Familiendynamik. Konfliktstrukturen und Chancen therapeutischer Arbeit bei Multiproblem-Familien [Social crisis, Institution and family dynamics. Structures of conflict and opportunities for therapeutic work with multi-problem families]. Opladen: Westdeutscher Verlag. Conen, M. (Ed.). (2008). Wo keine Hoffnung ist, muss man sie erfinden. Aufsuchende Familientherapie [Where there is no hope, one must invent it. Outreaching Family Therapy]. Heidelberg: Carl-Auer-Systeme. Conradie, J., Tausendfreund, T., & Knot-Dickscheit, J. (2011). De verrichtingenlijst KIPP: de ontwikkeling van een registratie-instrument voor het primaire hulpverleningsproces [The KIPP activities list: development of an instrument to monitor the primary care process]. Orthopedagogiek: Onderzoek en Praktijk, 50(7/8), 339–353. Council of the European Communities. (1985). Council decision of 19 December 1984 on specific community action to combat poverty, 85/8/EEC. Retrieved from http://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1400834299503&uri=CELEX:31985D0008

REFERENCES

122

Craig-van Grack, A. (1997). A taxonomy and recording instrument for process measurement of family preservation services. Child Welfare, 76(2), 349–371. Dallos, R., & Hamilton-Brown, L. (2000). Pathways to problems - an exploratory study of how problems evolve vs dissolve in families. Journal of Family Therapy, 22(4), 375–393. Dallos, R., Neale, A., & Strouthos, M. (1997). Pathways to problems—the evolution of 'pathology'. Journal of Family Therapy, 19(4), 369–399. Damen, H. (2007). Het handelen van gezinswerkers in beeld: Tussentijds verslag van het project ‘Actualisering verrichtingensysteem IPT’ [Activities of family workers in focus: Interim report of the project 'Actualization of the Activity System for Intensive Family Support']. Nijmegen: Praktikon. de Brock, A. J. L. L., Vermulst, A. A., Gerris, J. R. M., & Abidin, R. R. (1992). NOSI. Nijmeegse Ouderlijke Stress Index. Handleiding experimentele versie [NOSI. Nijmegen parental stress index. Manual experimental version]. Lisse: Swets en Zeitlinger. de Melo, A. T., & Alarcão, M. (2011). Integrated family assessment and intervention model: A collaborative approach to support multi-challenged families. Contemporary Family Therapy, 33(4), 400–416. doi:10.1007/s10591-011-9168-0 Deater-Deckard, K., Dodge, K., Bates, J., & Pettit, G. (1998). Multiple risk factors in the development of externalizing behavior problems: Group and individual differences. Development and Psychopathology, 10(3), 469–493. doi:10.1017/S0954579498001709 Deković, M. (2010). Effecten van interventies: Baat het niet, dan schaadt het niet? Kind en Adolescent, 31(2), 98–103. Denholm, R., Power, C., Thomas, C., & Li, L. (2013). Child maltreatment and household dysfunction in a British birth cohort. Child Abuse Review, 22(5), 340–353. doi:10.1002/car.2235 Dercksen, A. M. M., & Jansen Verplanke, L. H. (1987). Geschiedenis van de onmaatschappelijkheidsbestrijding in Nederland, 1914-1970 [History of antisocial behavior control in the Netherlands, 1914–1970]. Amsterdam: Boom.

REFERENCES

123

Devaney, J., & Spratt, T. (2009). Child abuse as a complex and wicked problem: Reflecting on policy developments in the United Kingdom in working with children and families with multiple problems. Children and Youth Services Review, 31(6), 635–641. doi:10.1016/j.childyouth.2008.12.003 Diephuis, K., van der Zijden, Q., & van Wijk, P. (2007). Kader integraal indiceren. Jeugdzorg – Speciaal Onderwijs – AWBZ-zorg. [Integral care indication framework. Youth care – Special Education – Care under the Exceptional Medical Expenses Act (EMEA)]. Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport. Dimidjian, S., & Hollon, S. D. (2010). How would we know if psychotherapy were harmful? American Psychologist, 65(1), 21-33. doi:10.1037/a0017299 Drost, J. Y. (2009). Maatschappelijk maatwerk bij langdurig problematische gezinssituaties. Lectoraat voor maatschappelijke participatie door (jonge) mensen met een licht verstandelijke beperking [Social work in prolonged problematic family situations. Associate Professorship for social participation by (young) people with mild intellectual disabilities] Leeuwarden: NHL Hogeschool Leeuwarden & Tjallinga Hiem. Dunst, C. J., Boyd, K., Trivette, C. M., & Hamby, D. W. (2002). Family-oriented program models and professional helpgiving practices. Family Relations, 51(3), 221–229. Evenboer, K. E., Huyghen, A. M. N., Tuinstra, J., Reijneveld, S. A., & Knorth, E. J. (2012). Taxonomic systems in the field of health care, family care, and child and youth care: A systematic overview of the literature. Children and Youth Services Review, 34(12), 2304–2310. doi: 10.1016/j.childyouth.2012.08.007. Ewart-Boyle, S., Manktelow, R., & McColgan, M. (2013). Social work and the shadow father: Lessons for engaging fathers in Northern Ireland. Child & Family Social Work. Advance Online Publication. doi:10.1111/cfs.12096 Flint, J. (2012). The inspection house and neglected dynamics of governance: The case of domestic visits in family intervention projects. Housing Studies, 27(6), 822–838. doi:10.1080/02673037.2012.714465 Forehand, R., & Kotchick, B. (2002). Behavioral parent training: Current challenges and potential solutions. Journal of Child and Family Studies, 11(4), 377–384. doi:10.1023/A:1020913422609

REFERENCES

124

Fuller-Thomson, E., & Sawyer, J.-L. (2014). Is the cluster risk model of parental adversities better than the cumulative risk model as an indicator of childhood physical abuse? Findings from two representative community surveys. Child: Care, Health and Development, 40(1), 124–133. doi:10.1111/cch.12024 Gabriel, T. (2011). Resilienz. [Resilience] In H.-U. Otto, & H. Thiersch (Eds.), Handbuch Soziale Arbeit. Grundlagen der Sozialarbeit und Sozialpädagogik [Handbook of Social Work. Foundations of social work and social pedagogy]. (4th ed., pp. 1240–1245). München: Ernst Reinhardt. doi:10.2378/ot4a.art124 Garrett, P. M. (2007). `Sinbin' research and the `lives of others': A rejoinder in an emerging and necessary debate. Critical Social Policy, 27(4), 560–564. doi:10.1177/02610183070070040101 Geismar, L. L., & Ayres, B. (1959). Patterns of change in problem families. A study of the social functioning and movement of 150 families served by the family centered project. St. Paul, MN: Family Centered Project Greater St. Paul Community Chest and Councils, Inc. Geismar, L. L., & La Sorte, M. A. (1964). Understanding the multi-problem family: A conceptual analysis and exploration in early identification. New York: Association Press. German Federal Government (Ed.) (2001). Lebenslagen in Deutschland. Erster Armuts- und Reichtumsbericht der Bundesregierung [Life Situations in Germany. The German Federal Government's 1st Report on Poverty and Wealth]. (Offizielle Drucksache 14/5990). Berlin: Bundesanzeiger Verlagsgesellschaft mbH. German Federal Government (Ed.) (2005). Lebenslagen in Deutschland. Zweiter Armuts- und Reichtumsbericht der Bundesregierung [Life Situations in Germany. The German Federal Government's 2nd Report on Poverty and Wealth]. (Offizielle Drucksache 15/5015). Berlin: Bundesanzeiger Verlagsgesellschaft mbH. German Federal Government (Ed.) (2008). Lebenslagen in Deutschland. Dritter Armuts- und Reichtumsbericht der Bundesregierung [Life Situations in Germany. The German Federal Government's 3rd Report on Poverty and Wealth]. (Offizielle Drucksache 16/9915). Berlin: Bundesanzeiger Verlagsgesellschaft mbH.

REFERENCES

125

German Federal Ministry of Labour and Social Affairs (Ed.) (2013). Lebenslagen in Deutschland. Vierter Armuts- und Reichtumsbericht der Bundesregierung [Life Situations in Germany. The German Federal Government's 4th Report on Poverty and Wealth]. (Artikel A 334). Bonn: Hausdruckerei des BMAS. German Professional Association for Social Work [Deutscher Bundesverband für Soziale Arbeit]. (1997). Berufsethische Prinzipien des DBSH [Professional ethics of the DBSH]. Göttingen: Deutscher Berufsverband für Soziale Arbeit e.V. Geurts, E. M. W., Boddy, J., Noom, M. J., & Knorth, E. J. (2012). Family-centred residential care: The new reality? Child & Family Social Work, 17(2), 170–179. doi:10.1111/j.1365-2206.2012.00838.x Ghesquière, P. (1993). Multi-problem gezinnen. Problematische hulpverleningssituaties in perspectief [Multi-problem families. Problematic care situations in perspective]. Leuven: Garant. Goerge, R., Smithgall, C., Seshadri, R., & Ballard, P. (2010). Illinois families and their use of multiple service systems. Chicago: Chapin Hall at the University of Chicago. Groh-Samberg, O., & Grundmann, M. (2006). Soziale Ungleichheit im Kindes- und Jugendalter [Social inequality in childhood and adolescence]. Aus Politik und Zeitgeschichte, (26), 11–18. Guiaux, M., Roest, A., & Iedema, J. (2011). Voorbestemd tot achterstand? Armoede en sociale uitsluiting in de kindertijd en 25 jaar later [Destined to disadvantage? Poverty and social exclusion in childhood and 25 years later]. Den Haag: Sociaal en Cultureel Planbureau (SCP). Hamburger, F. (2008). Einführung in die Sozialpädagogik [Introduction to Social Pedagogy] (2nd ed.). Stuttgart: W. Kohlhammer. Haughton, J., & Khandker, S. R. (2009). The international bank for reconstruction and development/the World Bank. Washington, DC: The International Bank for Reconstruction and Development/The World Bank. doi:10.1596/978-0-8213-7613-3 Hayden, C., & Jenkins, C. (2013). Children taken into care and custody and the 'troubled families' agenda in England. Child & Family Social Work, Advanced online publication. doi:10.1111/cfs.12095

REFERENCES

126

Heaton, R., Temkin, N., Dikmen, S., Avitable, N., Taylor, M., Marcotte, T., & Grant, I. (2001). Detecting change: A comparison of three neuropsychological methods, using normal and clinical samples. Archives of Clinical Neuropsychology, 16(1), 75–91. doi:10.1016/S0887-6177(99)00062-1 Hellinckx, W., Grietens, H., & Ghesquière, P. (2008). Kinderen en jongeren met psychosociale problemen [Children and adolescents with psychosocial problems]. In H. Grietens, J. Vanderfaeillie, W. Hellinckx, & W. Ruijssenaars (Eds.), Handboek orthopedagogische hulpverlening; 1: Een orthopedagogisch perspectief op kinderen en jongeren met problemen (3rd ed., pp. 91–125). Leuven: Acco. Helming, E., Schattner, H., & Blüml, H. (Eds.). (2004). Handbuch sozialpädagogische Familienhilfe. [Handbook social pedagogical family support] Baden-Baden: Nomos. Hock, B., Holz, G., Simmedinger, R., & Wüstendörfer, W. (2000). Gute Kindheit - schlechte Kindheit? Armut und Zukunftschancen von Kindern und Jugendlichen in Deutschland: Abschlußbericht zur Studie [Good childhood – bad childhood? Poverty and future prospects of children and adolescents in Germany: final report on the study]. Frankfurt am Main: AWO Bundesverband e.V. & ISS. Hodge, D. R., Lacasse, J. R., & Benson, O. (2012). Influential publications in social work discourse: The 100 most highly cited articles in disciplinary journals: 2000–09. British Journal of Social Work, 42(4), 765–782. doi:10.1093/bjsw/bcr093 Holwerda, A., Reijneveld, S. A., & Jansen, D. E. M. C. (2014). De effectiviteit van hulpverlening aan multiprobleemgezinnen: Een overzicht [The effectiveness of care for multiproblem families: An overview]. Groningen: Universitair Medisch Centrum Groningen. Holz, G., & Puhlmann, A. (2005). Alles schon entschieden? Wege und Lebenssituation armer und nicht-armer Kinder zwischen Kindergarten und weiterführender Schule; Zwischenbericht zur AWO-ISS-Längsschnittstudie [Everything already decided? Pathways and life situations of poor and non-poor children between kindergarten and transiton to school; Interim report on the AWO ISS longitudinal study]. Frankfurt am Main: ISS-Eigenverlag.

REFERENCES

127

Holz, G., Richter, A., Wüstendörfer, W., & Giering, D. (2005). Zukunftschancen für Kinder. Wirkung von Armut bis zum Ende der Grundschulzeit. Endbericht der 3. Phase der AWO-ISS-studie [Future opportunities for children. Effect of poverty by the end of primary school. Final report of the 3rd phase of the AWO-ISS study]. Bonn: AWO-Eigenverlag. Home-Start International. (2002). De aanpak van sociale uitsluiting in gezinnen met jonge kinderen [Tackling social exclusion in families with young children]. Amsterdam: Home-Start International. Hood, R. (2012). A critical realist model of complexity for interprofessional working. Journal of Interprofessional Care, 26(1), 6–12. doi:10.3109/13561820.2011.598640 Horstik, I., & Veuger, A. (2012). Rapport Stade over kwetsbare gezinnen in Woerden [Stade report on vulnerable families in Woerden]. Woerden: Stade Advies BV. Hulme, D., & Shepherd, A. (2003). Conceptualizing chronic poverty. World Development, 31(3), 403–423. doi: 10.1016/S0305-750X(02)00222-X Hurley, K. D., Griffith, A., Ingram, S., Bolivar, C., Mason, W. A., & Trout, A. (2012). An approach to examining the proximal and intermediate outcomes of an intensive family preservation program. Journal of Child and Family Studies, 21(6), 1003–1017. doi:10.1007/s10826-011-9563-z Jaffee, S. R., Caspi, A., Moffitt, T. E., Polo-Tomás, M., & Taylor, A. (2007). Individual, family, and neighborhood factors distinguish resilient from non-resilient maltreated children: A cumulative stressors model. Child Abuse & Neglect, 31(3), 231–253. doi:10.1016/j.chiabu.2006.03.011 Jacobson, N., & Truax, P. (1991). Clinical-significance—a statistical approach to defining meaningful change in psychotherapy-research. Journal of Consulting and Clinical Psychology, 59(1), 12–19. doi:10.1037/0022-006X.59.1.12 Jagt, L. (2010). Onvrijwillige hulpverlening: Moet dat nou? [Compulsory care: Must that be?] (2nd ed.). Houten: Bohn Stafleu van Loghum.

REFERENCES

128

Janssens, J., & van As, N. (2002). Gezinsfunctioneren en gedragsproblemen van kinderen [Family functioning and behavioural problems of children]. In L. Vandemeulebroecke, H. van Crombrugge, J. Janssens, & H. Colpin (Eds.), Gezinspedagogiek. Deel II: Opvoedingsondersteuning (pp. 53–69). Leuven: Garant. Jehoel-Gijsbers, G. (2003). Sociale uitsluiting. Een conceptuele en empirische verkenning [Social exclusion. A conceptual and empirical exploration]. Den Haag: Sociaal Cultureel Planbureau (SCP). Jehoel-Gijsbers, G. (2004). Sociale uitsluiting in Nederland [Social exclusion in the Netherlands]. Den Haag: Sociaal Cultureel Planbureau (SCP). Jehoel-Gijsbers, G., & Vrooman, C. (2007). Explaining social exclusion. A theoretical model tested in the Netherlands. Den Haag: The Netherlands Institute for Social Research (SCP). Jenkins, S. P., & Micklewright, J. (2007). New directions in the analysis of inequality and poverty. IZA discussion paper no. 2814. Retrieved from http://ssrn.com/abstract=99550 Kazi, M. A. F., Pagkos, B., & Milch, H. A. (2011). Realist evaluation in wraparound: A new approach in social work evidence-based practice. Research on Social Work Practice, 21(1), 57–64. Knorth, E. J., Knot-Dickscheit, J., & Tausendfreund, T. (2007). Zorg voor jeugdigen: Ambulant én niet-ambulant [Caring for children and young people: in ambulatory and non-ambulantory settings]. Tijdschrift voor Orthopedagogiek, 46(3), 113–126. Knorth, E. J., Knot-Dickscheit, J., Tausendfreund, T., Schulze, G. C., & Strijker, J. (2009). Jugendhilfe: Ambulant und stationär—Plädoyer für ein kontinuum [Child and youth care: ambulatory and residential care—a plea for a continuum]. Praxis der Kinderpsychologie und Kinderpsychiatrie, 58(5), 330–350. Knot-Dickscheit, J. (2006). Forms of intensive ambulant (pedagogical) home care for multi-problem families in the Netherlands. In G. C. Schulze, M. Wittrock, & B. Lütgenau (Eds.), Children at risk in family and school (pp. 85-94). Oldenburg: Universitätsverlag.

REFERENCES

129

Knot-Dickscheit, J., & Blommert, E. M. (2009). De ondertoezichtstelling in de gezinsvoogdij: Een effectieve vorm van interventie? In A. E. M. G. Minnaert, H. lutje Spelberg & H. Amsing (Eds.), Het pedagogisch quotiënt. Pedagogische kwaliteiten in opvoeding, hulpverlening, onderwijs en educatie (pp. 83–101). Houten: Bohn Stafleu van Loghum. Knot-Dickscheit, J., Tausendfreund, T., & Knorth, E. J. (2011). Intensieve Pedagogische Thuishulp voor multiprobleemgezinnen: een kijkje achter de schermen [Intensive home support for high risk families: a look behind the scenes]. Orthopedagogiek: Onderzoek en Praktijk, 50(11), 497–510. Krasiejko, I. (2011). Changes in the social work with multiple problem families in Poland. New Educational Review, 24(2), 184–193. Kuypers, P., & van der Lans, J. (1994). Naar een modern paternalisme. Over de noodzaak van sociaal beleid. [Towards a modern paternalism. On the need for social policy]. Amsterdam: De Balie. Leger des Heils Noord. (2006). 10 voor toekomst. Methodiekbeschrijving [10 for the Future. Description of intervention method]. Groningen: Leger des Heils Noord. Levitas, R., Pantazis, C., Fahmy, E., Gordon, D., Lloyd, E., & Patsios, D. (2007). The multi-dimensional analysis of social exclusion. Bristol: University of Bristol. Littell, J. H., & Schuerman, J. R. (2002). What works best for whom? A closer look at intensive family preservation services. Children and Youth Services Review, 24(9/10), 673–699. doi:10.1016/S0190-7409(02)00224-4 Loyd, B. H., & Abidin, R. R. (1985). Revision of the Parenting Stress Index. Journal of Pediatric Psychology, 10(2), 169–177. doi:10.1093/jpepsy/10.2.169 Luhmann, N. (1996). Social systems (4th. Ed.). Redwood City, CA: Stanford University Press. Lutz, R., & Hammer, V. (Eds.). (2010). Weg aus der Kinderarmut. Gesellschaftspolitische Rahmenbedingungen und sozialpädagogische Handlungsansätze [Ways out of child poverty. Social policies and social pedagogical approaches]. Weinheim: Juventa.

REFERENCES

130

MacKenzie, M. J., Kotch, J. B., & Lee, L. (2011). Toward a cumulative ecological risk model for the etiology of child maltreatment. Children and Youth Services Review, 33(9), 1638–1647. doi:10.1016/j.childyouth.2011.04.018 MacLeod, J., & Nelson, G. (2000). Programs for the promotion of family wellness and the prevention of child maltreatment: A meta-analytic review. Child Abuse & Neglect, 24(9), 1127–1149. doi:10.1016/S0145-2134(00)00178-2 MacMillan, H. L., Wathen, C. N., Barlow, J., Fergusson, D. M., Leventhal, J. M., & Taussig, H. N. (2009). Interventions to prevent child maltreatment and associated impairment. The Lancet, 373(9659), 250–266. doi: 10.1016/S0140-6736(08)61708-0 Maggi, S., Irwin, L. J., Siddiqi, A., & Hertzman, C. (2010). The social determinants of early child development: An overview. Journal of Paediatrics and Child Health, 46(11), 627–635. doi:10.1111/j.1440-1754.2010.01817.x Marley, S., & Levin, J. (2011). When are prescriptive statements in educational research justified? Educational Psychology Review, 23(2), 197-206. doi:10.1007/s10648-011-9154-y Marsh, J. C., Ryan, J. P., Choi, S., & Testa, M. F. (2006). Integrated services for families with multiple problems: Obstacles to family reunification. Children and Youth Services Review, 28(9), 1074–1087. doi:10.1016/j.childyouth.2005.10.012 Masten, A. (2001). Ordinary magic – resilience processes in development. American Psychologist, 56(3), 227–238. doi:10.1037//0003-066X.56.3.227 Mason, C. (2012). Social work the art of relationship? Parents' perspectives on an intensive family support project. Child & Family Social Work, 17(3), 368–377. doi:10.1111/j.1365-2206.2011.00791.x Matos, A. R., & Sousa, L. M. (2004). How multiproblem families try to find support in social services. Journal of Social Work Practice, 18(1), 65–80. McCartt Hess, P., McGowan, B. G., & Botsko, M. (2000). A preventive services program model for preserving and supporting families over time. Child Welfare, 79(3), 227–265.

REFERENCES

131

McLean, S. (2012). Barriers to collaboration on behalf of children with challenging behaviours: A large qualitative study of five constituent groups. Child & Family Social Work, 17(4), 478–486. doi:10.1111/j.1365-2206.2011.00805.x Mehlkopf, P. J. (2008a). Een kwestie van goed regelen: Over multiprobleemgezinnen, coördinatie van zorg en gezinscoaching. Handreiking bij implementatie [A question of good organisation: About multi-problem families, coordination of care and family coaching. Guide to implementation.]. Gouda: JSO Expertisecentrum voor Jeugd, Samenleving en Opvoeding. Mehlkopf, P. J. (2008b). Tussen regels en handelingsruimte: Over multiprobleemgezinnen, coördinatie van zorg en gezinscoaching. Handreiking bij uitvoering [Between rules and space for action: About multi-problem families, coordination of care and family coaching. Guide to implementation]. Gouda: JSO Expertisecentrum voor Jeugd, Samenleving en Opvoeding. Menger, A., Krechtig, L., & Timmers, I. (2008). Het delict als maatstaf. Methodiek voor werken in gedwongen kader [The offense as the yardstick. Methodology for working with coercion] (3rd ed.). Utrecht: Reclassering Nederland. Metselaar, J., & Doornbos, R. (2006). Verrichtingenlijst daghulp en verblijf [List of Activities for day care and residential treatment]. Leiden: Cardea Jeugdzorg. Metselaar, J., Knorth, E. J., & van den Bergh, P. M. (2007). Needs-led and family-centered child and youth care: Theoretical considerations and evaluation in practice. Relational Child and Youth Care Practice, 20(2), 38–46. Mikton, C., & Butchart, A. (2009). Child maltreatment prevention: A systematic review of reviews. Bulletin of the World Health Organization, 87(5), 353–361. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York, NY: Guilford Press. Ministry of Health, Welfare and Sport. (2005). Impuls opvoeden gezinsondersteuning. Doel en werkwijze [Impulse regarding parenting and family support. Purpose and method]. Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport.

REFERENCES

132

Moran, P., Ghate, D., & van der Merwe, A. (2004). What works in parenting support? A review of the international evidence. London: Department for Education and Skills. Morris, K. (2011). Thinking family? The complexities for family engagement in care and protection. British Journal of Social Work, 42(5), 906–920. doi:10.1093/bjsw/bcr116 Morris, K. (2013). Troubled families: Vulnerable families' experiences of multiple service use. Child & Family Social Work, 18(2), 198–206. doi:10.1111/j.1365-2206.2011.00822.x Morris, K., & Featherstone, B. (2010). Investing in children, regulating parents, thinking family: A decade of tensions and contradictions. Social Policy and Society, 9(4), 557–566. doi:10.1017/S1474746410000278 Murray, L., & Barnes, M. (2010). Have families been rethought? Ethic of care, family and ‘whole family’ approaches. Social Policy and Society, 9(04), 533–544. doi:10.1017/S1474746410000254 Nederland, T., Mak, J., Stavenuiter, M. M. J., & Swinnen, H. R. A. M. (2007). Tackling child poverty and promoting the social inclusion of children. A study of national policies. Netherlands. Utrecht: Verwey-Jonker-Institute. Netherlands Youth Institute. (2014a). Dossier multiprobleemgezinnen [Dossier multi-problem families]. Retrieved from http://www.nji.nl/Multiprobleemgezinnen Netherlands Youth Institute. (2014b). Dossier multiprobleemgezinnen. Erkende interventies [Dossier multi-problem families. Accredited interventions]. Retrieved from http:// http://www.nji.nl/Multiprobleemgezinnen-Praktijk-Erkende-interventies Netherlands Youth Institute. (2014c). Database of Effective Youth Interventions. Retrieved from http://www.youthpolicy.nl/yp/Youth-Policy/Youth-Policysubjects/Netherlands-Youth-Institute-Effective-youth-interventions/Database-of-Effective-Youth-Interventions

REFERENCES

133

Neurath, O. (1931). Empirische Soziologie. Der wissenschaftliche Gehalt der Geschichte und Nationalökonomie [Empirical sociology. The scientific content of history and political economy]. In P. Frank, & M. Schlick (Eds.), Schriften zur wissenschaftlichen Weltauffassung. Band 5. Wien: Verlag von Julius Springer. Nixon, J. (2007). Deconstructing 'problem' researchers and 'problem' families: A rejoinder to Garrett. Critical Social Policy, 27(4), 546–556. doi:10.1177/02610183070081813 Ogles, B. M. (2013). Measuring change in psychotherapy research. In M. J. Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy and behavior change (6th ed., pp. 134–166). Hoboken,NJ: John Wiley & Sons. Organisation for Economic Co-operation and Development. (2010). PISA 2009 results: Overcoming social background: Equity in learning opportunities and outcomes (volume II). doi:10.1787/9789264091504-en Orobio de Castro, B. (2010). What works, when, for whom, and why? Very specific factors determine effectiveness of prevention and intervention programs for disruptive behavior problems. In E. J. Knorth, M. E. Kalverboer, & J. Knot-Dickscheit, (Eds.), Insideout: How interventions in child and family care work. An international source book (pp. 50–53). Antwerp: Garant. Orobio de Castro, B., Veerman, J. W., Bons, E., & de Beer, L. (2002). Kansen gekeerd? Gezinsondersteuning ter voorkoming van criminaliteit [Chances turned? Crime prevention through family support]. Den Haag: Ministerie van Justitite. Otto, H.-U., Polutta, A., & Ziegler, H. (2009). Reflexive professionalism as a second generation of evidence-based practice. Some considerations on the special issue "What works? Modernizing the knowledge-base of social work". Research on Social Work Practice, 19(4), 472–478. doi:10.1177/1049731509333200 Otto, U. (2006). Sozialpädagogisierte Armutspolitik—auf Armut verengte Soziale Arbeit? [Social pedagogicalized poverty policy— Social work narrowed down to poverty?] Neue Praxis, 36(1), 3–8. Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage.

REFERENCES

134

Petrie, P. (2011). Communication skills for working with children and young people: Introducing social pedagogy (3rd ed.). London: Jessica Kingsley Publishers. Philp, A. F., & Timms, N. (1957). The problem of the problem family: A critical review of the literature concerning the problem family and its treatment. London: Family Service Units. Popper, K. R. (1976). Logik der Forschung (6th ed.). Tübingen: J. C. B. Mohr (Paul Siebeck). Post, W. J., Buijs, C., Stolk, R. P., de Vries, E. G. E., & Le Cessie, S. (2010). The analysis of longitudinal quality of life measures with informative drop-out: A pattern mixture approach. Quality of Life Research, 19(1), 137–148. doi:10.1007/s11136-009-9564-1 Raad voor Maatschappelijke Ontwikkeling. (2012). Ontzorgen en normaliseren. Naar een sterke eerstelijns jeugd- en gezinszorg. [Care reduction and normalization. Towards a strong first line in Youth and Family Care] Den Haag: Raad voor Maatschappelijke Ontwikkeling. Ravallion, M. Chen, S., Sangraula, P. (2008). Dollar a Day Revisited. Washington DC: Development Research Group, World Bank. Retrieved from http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2008/09/02/000158349_20080902095754/Rendered/PDF/wps4620.pdf Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128(2), 330–366. doi:10.1037//0033-2909.128.2.330 Ribner, D. S., & Knei-Paz, C. (2002). Client's view of a successful helping relationship. Social Work, 47(4), 379–387. Roest, A., Lokhorst, A. M., & Vrooman, C. (2010). Sociale uitsluiting bij kinderen: Omvang en achtergronden [Social exclusion of children: Scope and backgrounds]. Den Haag: Sociaal en Cultureel Planbureau (SCP). Rooney, R. H. (2009). Strategies for work with involuntary clients (2nd ed.). New York: Columbia University Press.

REFERENCES

135

Rosen, A., & Proctor, E. (1981). Distinctions between treatment outcomes and their implications for treatment evaluation. Journal of Consulting and Clinical Psychology, 49(3), 418–425. doi:10.1037/0022-006X.49.3.418 Rots-de Vries, C., Kroesbergen, I., & van de Goor, I. (2009). Armoede en gezondheid van kinderen. Praktische handleiding voor interventie [Poverty and child health. Practical intervention guid]. Breda: GGD West-Brabant. Sacco, F. C., Twernlow, S. W., & Fonagy, P. (2007). Secure attachment to family and community: A proposal for cost containment within higher user populations of multiple problem families. Smith College Studies in Social Work, 77(4), 31–51. doi:10.1300/J497v77n04_03 Schaafsma, K. (2005). Het banen van een pad. Methodische beschrijving van gezinscoaching op basis van de ervaringen met het experiment in Limburg [Trailblazing. Methodical description of family coaching based on experiences from the experiment in Limburg]. Apeldoorn: Garant. Schaafsma, K., Hilhorst, N., & Hering, M. (2010). Dicht op de huid. gezinsmanagement bij multiprobleemgezinnen in de stadsregio Amsterdam. [Close to the skin. Family management in multi-problem families the city of Amsterdam] Amsterdam: DSP Groep. Schaeffer-van Leeuwen, K., Damen, H., & Veerman, J. W. (2005). Contactregistratie integrale pleegzorg Gelderland: Pleegzorg Verrichtingenlijst (PVL) [Contact documentation for integral foster care in Gelderland: Foster Care Activities list (PVL)]. Nijmegen: Praktikon & Radboud University Nijmegen. Schmidt, M. H., Schneider, K., Hohm, E., Pickartz, A., Macsenaere, M., Petermann, F., . . . Knab, E. (2002). Effekte erzieherischer Hilfen und ihre Hintergründe [Effects of child welfare services and their backgrounds] (Band 219, Schriftreihe des Bundesministeriums für Familie, Senioren, Frauen und Jugend ed.). Stuttgart: Kohlhammer. Scholte, E. M. (1999). Aandachtsgebieden bij psychosociale basisdiagnostiek [Focus areas for basic psychosocial diagnostics]. In E. J. Knorth, & M. Smit (Eds.), Planmatig handelen in de jeugdhulpverlening (pp. 115–134). Leuven: Garant. Schout, G., de Jong, G., & Zeelen, J. (2010). Establishing contact and gaining trust: An exploratory study of care avoidance. Journal of Advanced Nursing, 66(2), 324–333. doi:10.1111/j.1365-2648.2009.05171.x

REFERENCES

136

Schout, G., de Jong, G., & Zeelen, J. (2011). Beyond care avoidance and care paralysis: Theorizing public mental health care. Sociology, 45(4), 665–681. doi:10.1177/0038038511406591 Schulze, G. C., & Wittrock, M. (Eds.). (2005). Familien in multiproblemlagen – Kinder in Multiproblemlagen [Families in multi-problem situations – Children in multi-problem situations]. Oldenburg: Universitätsverlag. Sinclair, I. (2010). Inside the black box: What makes for success in care? In E. J. Knorth, M. E. Kalverboer, & J, Knot-Dickscheit (Eds.), Inside out: How interventions in child and family care work. An international source book (pp. 41–44). Antwerp: Garant Publishers. Slot, N. W., van Tooren, A., & Bijl, B. (2004). Bescherming in ontwikkeling. De evaluatie van de methodische vernieuwing in het kader van het 'Deltaplan kwaliteitsverbetering gezinsvoogdij [Guardianship under development. Evaluation of methodological innovation in the context of the ‘Delta plan quality improvement family guardianship’]. Duivendrecht: PI-Research. Sousa, L., & Eusébio, C. (2007). When multi-problem poor individuals' myths meet social services myths. Journal of Social Work, 7(2), 217–237. doi:10.1177/1468017307080281 Sousa, L., & Rodrigues, S. (2009). Linking formal and informal support in multiproblem low-income families: The role of the family manager. Journal of Community Psychology, 37(5), 649–662. doi:10.1002/jcop.20313 Sousa, L., & Rodrigues, S. (2012). The collaborative professional: Towards empowering vulnerable families. Journal of Social Work Practice, 26(4), 411–425. doi:10.1080/02650533.2012.668878 Spratt, T. (2009). Identifying families with multiple problems: Possible responses from child and family social work to current policy developments. British Journal of Social Work, 39(3), 43–-450. doi:10.1093/bjsw/bcm150 Spratt, T. (2011). Families with multiple problems: Some challenges in identifying and providing services to those experiencing adversities across the life course. Journal of Social Work, 11(4), 343–357. doi:10.1177/1468017310379256

REFERENCES

137

Spratt, T. (2012). Why multiples matter: Reconceptualising the population referred to child and family social workers. British Journal of Social Work, 42(8), 1574–1591. doi:10.1093/bjsw/bcr165 Spratt, T., & Devaney, J. (2009). Identifying families with multiple problems: Perspectives of practitioners and managers in three nations. British Journal of Social Work, 39(3), 418–434. doi:10.1093/bjsw/bcm151 Staff, I., & Fein, E. (1994). Inside the black-box. An exploration of service delivery in a family reunification program. Child Welfare, 73(3), 195–211. Starkey, P. (2002). Can the piper call the tune? Innovation and experiment with deprived families in Britain, 1940–1980s: The work of family service units. British Journal of Social Work, 32(5), 573–587. doi:10.1093/bjsw/32.5.573 Statham, J., & Holtermann, S. (2004). Families on the brink: The effectiveness of family support services. Child & Family Social Work, 9(2), 153–166. doi:10.1111/j.1365-2206.2004.00308.x Steketee, M., & Vandenbrouke, M. (2010). Typologie voor een strategische aanpak van multiprobleemgezinnen in Rotterdam. Een studie in het kader van klein maar fijn - CEPHIR [Typology for a strategic approach to multi-problem families in Rotterdam. A study in the context of small but fine]. Utrecht: Verwey-Jonker Instituut. Retrieved from http://www.verwey-jonker.nl/doc/vitaliteit/Typologie_multiprobleemgezinnen_Rotterdam.pdf Sweet, M. A., & Appelbaum, M. I. (2004). Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75(5), 1435–1456. Tabibian, N. (2006). Effectiviteit van interventies voor multiprobleemgezinnen [Effectiveness of interventions for multiproblem families]. Utrecht: Verwey-Jonker Instituut. Retrieved from http://www.verwey-jonker.nl/doc/jeugd/D8749512_3_027E.pdf Tausendfreund, T., Kleefman, M., Knot-Dickscheit, J., & Knorth, E. J. (2008). Hulpverlening aan multi-probleem gezinnen met het interventieprogramma STABIEL. resultaten van een vooronderzoek [Support for multi-problem families with intervention programme STABLE. Results of a pilot study]. Groningen: University of Groningen—Nieuwenhuis Institute.

REFERENCES

138

Tausendfreund, T., Knorth, E. J., Knot-Dickscheit, J., Strijker, J., & Schulze, G. C. (2012). Familien in Multiproblemlagen: Hintergründe, Merkmale und Hilfeleistungen [Families in multi-problem situations: Backgrounds, characteristics and care services]. Schweizerische Zeitschrift für Soziale Arbeit, 12(1), 33–51. ten Brink, T., van der Steege, M., van der Haar, A. N., Jagers, J. D., Veerman, J. W., & Baartman, H. E. M. (2000). VGF. Experimentele gebruikershandleiding van de Vragenlijst Gezinsfunctioneren [VGF. Experimental user guide of the Questionnaire Family Functioning]. Utrecht: Nederlands Instituut voor Zorg en Welzijn (NIZW) & PI Research. ten Brink, L. T., Veerman, J. W., Berger, M., Flipse, M. L., Joosten, W., & Kerkstra, G. (1997). Handleiding Verrichtingen Intensieve Ambulante Gezinsbegeleiding [Activities Manual for Intensive Family Support]. Utrecht: Nederlands Instituut voor Welzijn en Zorg (NIZW). ten Brink, L., Veerman, J., de Kemp, R., & Berger, M. (2004). Implemented as intended? Recording family worker activities in a Families First program. Child Welfare, 83(3), 197–214. Thoburn, J. (2010). Towards knowledge-based practice in complex child protection cases: A research-based expert briefing. Journal of Children's Services, 5(1), 9–24. doi:10.5042/jcs.2010.0114 Thoburn, J., Cooper, N., Brandon, M., & Connolly, S. (2013). The place of “think family” approaches in child and family social work: Messages from a process evaluation of an English pathfinder service. Children and Youth Services Review, 35(2), 228–236. doi:10.1016/j.childyouth.2012.11.009 Thompson, B. T., & Schoenfeld, D. (2007). Usual care as the control group in clinical trials of nonpharmacologic interventions. Proceedings of the American Thoracic Society, 4(7), 577–582. doi:10.1513/pats.200706-072JK van Burik, A. E., & van Vianen, R. T. (2006). Multiprobleemgezinnen in de agglomeratie Amsterdam. een onderzoek naar de omvang en samenstelling van multiprobleemgezinnen en de hulpverlening van de geïndiceerde jeugdzorg aan deze gezinnen.[Multi-problem families in the metropolitan area of Amsterdam. A study of scope and composition of multi-problem families and the support of the indicated youth care to these families]. Woerden: Adviesbureau van Montfoort.

REFERENCES

139

van den Berg, G. (2010). Databank effectieve jeugdinterventies: Beschrijving 'Jeugdhulp Thuis' [Database effective youth care interventions: Description 'Youth Care at Home']. Utrecht: Nederlands Jeugdinstituut. Retrieved from http://www.nji.nl/pdf/Kennis/Databanken/Databank-Effectieve-Jeugdinterventies/Erkende-interventies/Jeugdhulp-Thuis van den Berg, G., & de Baat, M. (2012). Gezinnen met meervoudige problemen [Families with multiple problems]. In M. de Klerk, M. Prins, P. Verhaak & G. van den Berg (Eds.), Mensen met meervoudige problemen en hun zorg-gebruik (pp. 75–97). Den Haag: Raad voor Volksgezondheid & Zorg. van den Berg, D., van der Goot, S., & Jansen, M.-B. (2008). Cirkel van onmacht. Mechanismen in hulpverlening. Hulpverlening aan multiprobleemgezinnen vanuit de praktijk geanalyseerd; een experiment in het kader van het Amsterdamse project Systeem in Beeld [Circle of inability. Mechanisms in care. Support for multi-problem families analysed from practice; an experiment in the context of the Amsterdam project System in Focus]. Amsterdam: Project- en Adviesbureau SPA. Retrieved from http://www.amsterdam.nl/publish/pages/430922/cirkel_van_onmacht.pdf van der Steege, M. (2007). Naar een gouden standaard. Intensieve pedagogische thuishulp komt tot wasdom. [To a gold standard. Intensive pedagogical home care comes to maturity] Jeugd en Co—Kennis, 1(4), 23–36. van der Steege, M. (2010). Multiprobleemgezinnen [Multi-problem families]. In G. A. Bakker, D. M. C. B. van Zeben-van der Aa, J. Dewispelaere, R. Vecht-van den Bergh, M. van der Meulen-van Dijk, & V. H. Soyez (Eds.), Kinderen en adolescenten—problemen en risicosituaties. Deel 6: Gezin (pp. 318–337). Houten: Bohn Stafleu van Loghum. van Ooyen-Houben, M., Roeg, D., Kogel, C. H. D., & Koeter, M. (2008). Zorg onder dwang en drang; een verkenning van mogelijkheden en grenzen [Care under duress and coercion; an exploration of possibilities and limits]. Justitiële Verkenningen, 34(3), 11–41. van Puyenbroeck, H., Loots, G., Grietens, H., Jacquet, W., Vanderfaeillie, J., & Escudero, V. (2009). Intensive family preservation services in Flanders: An outcome study. Child & Family Social Work, 14(2), 222–232. doi:10.1111/j.1365-2206.2009.00626.x

REFERENCES

140

van Yperen, T. A., van der Steege, M., Addink, A., & Boendermaker, L. (2010). Algemeen en specifiek werkzame factoren in de jeugdzorg. Stand van de discussie [Common and specific factors in child and youth care. State of the debate]. Utrecht: Nederlandse Jeugdinstituut. van Yperen, T., van der Steege, M., & Batelaan, S. (2006). Voor het goede doel: Werken met hulpverleningsdoelen in de jeugdzorg [For a good cause: Working with care goals in child and youth care]. Amsterdam: SWP Publishers. van Yperen, T. A., & Veerman, J. W. (2013). Zicht op effectiviteit: Handboek voor praktijkgestuurd effectonderzoek in de jeugdzorg [Focusing on effectiveness: Handbook for practice-based effectstudies in child and youth care]. Delft: Eburon. Veerman, J., de Kemp, R., ten Brink, L., Slot, N., & Scholte, E. (2003). The implementation of families first in the Netherlands: A one year follow-up. Child Psychiatry & Human Development, 33(3), 227–244. doi:10.1023/A:1021456630670 Veerman, J. W., Janssens, J. M. A. M., & Delicat, J. W. (2004). Opvoeden in onmacht, of…? Een meta-analyse van 17 methodieken voor intensieve pedagogische thuishulp bij normovertredend gedrag [Education in helplessness, or ...? A meta-analysis of 17 intensive pedagogical methods for home-based care in behaviour problems]. Nijmegen: Katholieke Universiteit Nijmegen (KUN) & Praktikon/Academisch Centrum Sociale Wetenschappen (ACSW). Veerman, J. W., Janssens, J., & Delicat, J. (2005). Effectiviteit van intensieve pedagogische thuishulp: Een meta-analyse [Effectiveness of intensive home-based care: A meta-analysis]. Pedagogiek, 25(3), 176–196. Veerman, J. W., & van Yperen, T. A. (2007). Degrees of freedom and degrees of certainty: A developmental model for the establishment of evidence-based youth care. Evaluation and Program Planning, 30(2), 212–221. doi:10.1016/j.evalprogplan.2007.01.011 Verhulst, F. C., & van der Ende, J. (2013). Handleiding ASEBA-vragenlijsten voor leeftijden 6 t/m 18 jaar: CBCL/6–18, YSR en TRF [Manual ASEBA questionnaires for the ages 6 until 18 year: CBCL/6-18, YSR en TRF]. Rotterdam: ASEBA Nederland.

REFERENCES

141

Voges, W., Jürgens, O., Mauer, A., & Meyer, E. (2003). Methoden und Grundlagen des Lebenlagesansatzes. Endbericht [Methods and foundations of the life situations approach. Final report]. Bremen: Universität Bremen & Zentrum für Sozialpolitik. Vroome, T., & Hooghe, M. (2013). Life satisfaction among ethnic minorities in the Netherlands: Immigration experience or adverse living conditions? Journal of Happiness Studies. Advanced online publication. doi:10.1007/s10902-013-9483-2 Weisser, G. (1978). Beiträge zur Gesellschaftspolitik [Contributions to social policy]. Göttingen: Schwartz. Welshman, J. (1999). The social history of social work: The issue of the 'problem family', 1940–70. British Journal of Social Work, 29(3), 457–476. Werner, E. E., Bierman, J. M., & French, F. E. (1971). The children of Kauai: A longitudinal study from the prenatal period to age ten. Honolulu: University of Hawaii Press. Whittaker, J. K., & Maluccio, A. N. (2002). Rethinking "child placement": A reflective essay. Social Service Review, 76(1), 108–134. doi:10.1086/324610 Winkler, M. (1988). Eine Theorie der Sozialpädagogik: Über Erziehung als Rekonstruktion der Subjektivität [A theory of Social Pedagogy: About education as reconstruction of subjectivity]. Stuttgart: Klett-Cotta. Wijnen, H. (1997). Opvoedingsondersteuning in Groningen, 0–12 jarigen. Een inventariserend onderzoek naar vraag, aanbod en knelpunten ten aanzien van opvoedingsondersteuning in de Provincie Groningen [Parenting support in Groningen, ages 0–12. A survey of demand, supply and bottlenecks regarding parenting support in the province of Groningen]. Groningen: Stichting Provinciaal Ontwikkelingsinstituut Zorg en Welzijn Groningen. Zanoni, L., Warburton, W., Bussey, K., & McMaugh, A. (2014). Are all fathers in child protection families uncommitted, uninvolved and unable to change? Children and Youth Services Review, 41, 83–94. doi:10.1016/j.childyouth.2014.03.014

REFERENCES

142

Zinko, T., Meijer, A. M., & Oppenoorth, W. H. (1991). Een onderzoek bij multi-problem gezinnen [A study of multi-problem families]. Nederlands Tijdschrift Voor Opvoeding, Vorming en Onderwijs, 7(6), 353–365. Zoon, M. (2012). Kenmerken en risicofactoren van multiprobleemgezinnen [Characteristics and risk factors of multiproblem families]. Utrecht: Nederlands Jeugdinstituut. Retrieved from http://www.nji.nl/nji/dossierDownloads/Risicofactoren_Multiprobleemgezinnen.pdf

SUMMARY

SUMMARY

144

Summary

Coaching Families with Multiple Problems Care activities and outcomes of the flexible family support programme Ten for the Future This thesis describes families with multiple problems as a priority target group in child welfare interventions and explores care activities and outcomes of a flexible family support programme, entitled Ten for the Future (TF). These topics are approached from two perspectives: theoretically and empirically. The first chapter introduces central issues and methodological challenges in care provision for the target group. Chapters two and three aim subsequently at a deeper understanding of the target group on the basis of the existing literature. Chapters four and five enhance this body of knowledge by providing additional empirical ground on the care provided with a flexible family support programme (TF). Both approaches are synthesized in the sixth and final chapter by drawing implications for practice and research. In more detail the chapters’ contents read as follows. —Chapter one— In the introduction four categories are used to outline issues with specific relevance in providing care for families with multiple problems: (a) access to care, (b) coordination of care, (c) duration of care, and (d) effectiveness of care. Publications from various countries suggested interventions as promising that combine multiple service components into integrated services with a flexible intensity over longer periods of time. One such intervention is the family coaching programme TF, which is described in more detail. Three guiding research questions are posed that concern: (1) the target group description, (2) the primary care process evaluation, and (3) the associated outcomes. —Chapter two— The second chapter proceeds from the exploration of varying conceptual approaches to the description of the target group. The greatest variation was found between Germany and the Netherlands. Only few German-speaking

SUMMARY

145

scholars referenced the concept in the 1990’s and the concept was later also opposed by general critical rejection. As alternatives the concept of ‘poverty’ and ‘social exclusion’ were advanced, suggesting a better fit with German theory and practice. This finding prompted a conceptual literature review, which directly compares the differing approaches in the Netherlands and Germany. The review illustrates, on the one hand, exemplary differences in target group descriptions between the Netherlands and Germany. It reveals, on the other hand, communalities in the mode of theory production in both countries, which cumulated in the concept of life situation. The attributes of (a) multidimensionality, (b) multiple levels, (c) objectivity and subjectivity, and (d) dynamism and relativity were identified as theoretical pillars that could bridge the conceptual differences without losing the benefits of approaching a subject from different angles, as both approaches provided valuable perspectives. —Chapter three— Following up on the different approaches to theory production, Dutch publications are reviewed that provide more detailed information on characteristics of the target group and the services provided in the Netherlands. Dutch target group descriptions emphasize, on the one side, the complex relations of experiencing multiple socioeconomic and psychosocial problems, and highlight, on the other side, issues that arise from not adequately addressing those needs in child welfare. In the Dutch discipline of Orthopedagogy answers are foremost sought through the development of intervention programmes (at the micro and meso level) that specifically target these issues. Four major points of discussion are distinguished in program development for the target group in the Netherlands: (a) the duration of the care services, (b) the degree of voluntariness, (c) the coordination of support, and (d) financing. In conclusion, integral support with a flexible duration is called for in which multiple care components are tailored to meet the specific needs of individual families. One such intervention model has been introduced in the Netherlands under the name of the family coach, for which a prominent role as generalist in child welfare was suggested in the wake of the latest transformation of the Dutch welfare system. TF was developed as family coaching programme (TF) to specifically meet the needs of families with

SUMMARY

146

multiple problems by the Salvation Army of the Netherlands. The programme is further explored in following chapters. —Chapter four— The study covered in the fourth chapter aims at a deeper understanding of primary care processes in the home-based intervention TF. The development of a self-report instrument is described. Next results from a sequenced study of three data collection waves are presented. The work of 50 family coaches was monitored, referring to more than 650 client contacts and including over 2,500 care activities. Central findings are that the majority of care activities were performed in cooperation with one or both parents alone, and only to a lesser extent with children or external professionals. Main focus of the family coaches’ work fell into the categories of ‘collecting information’ and ‘working towards (behavioural) change’ with the families. The relatively high frequency of the care contacts emphasises the intensity of the intervention to meet the needs of a complex target group in family support. —Chapter five— The focus of the study reported in the fifth chapter is on the assessment of client characteristics and the magnitude of problem reduction associated with the intervention TF. The research included 122 families over a period of four years and seven months. Analyses on group level and individual case level are carried out. The results suggest that the intervention was associated with a decrease in family stress. Furthermore, families with lower initial parental stress were found to have a higher chance to end the programme significantly earlier. Child problem behaviour and family functioning, as perceived by care workers, showed a less coherent pattern of change. This might be connected to a main focus of family coaches on the direct work with parents, and not with children. It is concluded that the care programme has potential to decrease family stress and it is suggested, based on the earlier findings, to focus on the further development of a dual key worker approach that offers allocated care for children next to parenting support in families with multiple problems.

SUMMARY

147

—Chapter six— In the sixth chapter and last chapter, a combined overview is given about implications for practice and research, based on the theoretical and empirical findings outlined above. Central theme is the acknowledgement of complexity in engaging families with multiple problems whose life situations are often marked by social exclusion or poverty. Multi-causal approaches should be favoured that can link intervention strategies at individual, family, social network and policy levels. The provision of flexible care over extended periods has potential in supporting parents with multiple problems, but it seems warranted to compliment this approach in the future by providing allocated home-based care also directly to children. One such complementary programme, entitled Child Coach, is currently under development by the Salvation Army of the Netherlands. Further research is called for. Furthermore, it is suggested to consider reliable problem assessment and routine outcome measurement a pre-requisite for tailoring integrated care components to individual needs as well as to develop clearer stopping rules for open ended care trajectories. Administrative data management and database maintenance play a crucial rule in gathering information about families with multiple problems, and our research revealed further need for improvement herein. Finally, a plea is made for methodological diversity in gathering information on families with multiple problems in research. Methods are called for that can provide sound evidence on an individual level, and at the same time provide data which can be used cumulatively in further research synthesis, such as the Reliable Change Index. In the end, successfully tackling these challenges to improve the life situation of children in families with multiple problems is a collaborative task.

SAMENVATTING

148

Samenvatting

Hulpverlening aan multiprobleemgezinnen Verrichtingen en resultaten van het flexibele gezinscoaching programma Tien voor Toekomst Dit proefschrift gaat in op (de achtergronden van) multiprobleemgezinnen, opgevat als een prioritaire doelgroep voor de jeugdzorg, en rapporteert over onderzoek naar verrichtingen en resultaten van het voor deze doelgroep ontwikkelde gezinscoaching programma Tien voor Toekomst (TvT). Deze topics worden benaderd vanuit twee invalshoeken: theoretisch en empirisch. Het eerste hoofdstuk introduceert centrale vraagstukken en metho-dische uitdagingen in de hulpverlening aan de doelgroep. Hoofdstukken twee en drie zijn vervolgens gericht op een nadere verkenning van de doelgroep door literatuuronderzoek. In de hoofdstukken vier en vijf wordt deze kennis verdiept door empirisch onderzoek naar het flexibele en langdurende gezinscoachingsprogramma TvT. Beide benaderingen, de theoretische en de empirische, worden in het zesde en laatste hoofdstuk met elkaar in verband gebracht, uitmondend in implicaties voor praktijk en onderzoek. De inhoud van de hoofdstukken is als volgt. —Hoofdstuk één— In de inleiding worden vier onderwerpen geïntroduceerd om specifieke problemen in de hulpverlening aan multiprobleemgezinnen te schetsen: (a) de toegang tot zorg, (b) de coördinatie van de zorg, (c) de duur van de zorg, en (d) de effectiviteit van de zorg. Publicaties uit verschillende landen beschrijven die interventies als veelbelovend, die meerdere hulpcomponenten verbinden tot geïntegreerde zorg over langere duur met een flexibele intensiteit. Een dergelijk programma is de gezinscoachingsmethodiek TvT, dat vervolgens wordt beschreven. Aansluitend formuleren we de drie leidende onderzoeks-vragen. Deze focussen op (1) een beschrijving van de doelgroep, (2) het in kaart brengen van het primaire hulpverleningsproces, en (3) een assessment van de uitkomsten die aan de interventie verbonden zijn.

SAMENVATTING

149

—Hoofdstuk twee— In hoofdstuk twee onderzoeken we internationale verschillen in de conceptuele benadering van de doelgroep. Het grootste verschil werd gevonden tussen Duitsland en Nederland. Slechts een beperkt aantal Duitstalige publicaties verwees in de jaren 1990 naar het oorspronkelijk Engelstalige concept van de ‘multi-problem family’; dit concept werd vervolgens op basis een kritische beoordeling zelfs terzijde geschoven. In Duitsland zijn als alternatief de concepten ‘armoede’ en ‘sociale uitsluiting’ naar voren gebracht die, zo is de veronderstelling, beter passen bij de theorie en praktijk van de jeugdzorg in Duitsland. Dit verschil gaf aanleiding om aan de hand van een literatuurstudie te onderzoeken welke theoretische en praktische meerwaarde deze verschil-lende concepten hebben bij een beschrijving van de bedoelde gezinnen. Naast de verschillen in de beschrijving van doelgroep tussen Nederland en Duitsland zijn er overeenkomsten gevonden die in het begrip ‘leefsituatie’ culmineren. De attributen (a) multidimensionaliteit, (b) meerdere niveaus, (c) objectiviteit en subjectiviteit, en (d) dynamiek en relativiteit werden geïdenti-ficeerd als theoretische pijlers, die conceptuele verschillen kunnen overbruggen zonder het voordeel van een verschil in (internationale) benadering te verliezen. Immers, beide benaderingen bieden waardevolle perspectieven. —Hoofdstuk drie— In aansluiting bij de verschillende theoretische benaderingen werden publicaties bestudeerd, die ingaan op de kenmerken van de doelgroep en de hulpverlening in Nederland. Nederlandse beschrijvingen van de doelgroep benadrukken, aan de ene kant, de complexiteit van de interacties tussen sociaal-economische en psychosociale problemen, en beklemtonen, aan de andere kant, de problemen die ontstaan door een niet adequate afstemming van de jeugdzorg op deze behoeften. Oplossingen hiervoor werden en worden in de orthopedagogiek vooral gezocht in de (door)ontwikkeling van geëigende interventieprogramma's (op micro- en meso-niveau). Vervolgens bespreken we vier thema’s die bij de ontwikkeling van programma’s voor de doelgroep in Nederland van belang zijn: (a) de duur van de zorg, (b) de mate van vrijwilligheid, (c) de zorgcoördinatie, en (d) de zorgfinanciering. Als

SAMENVATTING

150

‘veelbelovend’ worden die programma’s beschreven die integrale zorg met een flexibele looptijd verbinden en waarin de zorgcomponenten individueel worden afgestemd op de specifieke behoeften van gezinnen. In een dergelijk interventiemodel wordt in Nederland een sleutelrol toegedicht aan de ‘gezinscoach’; een professional die in het kader van de transitie en transfor-matie van de zorg voor jeugd in Nederland overigens ook in meer algemene zin een prominente rol als generalist-hulpverlener zou moeten gaan spelen. Het Leger des Heils heeft een gezinscoaching methodiek onder de naam Tien voor Toekomst ontwikkeld die gericht is op hulpverlening aan multiprobleemgezinnen. In de volgende hoofdstukken wordt het programma verder verkend op basis van empirisch onderzoek. —Hoofdstuk vier— De studie waarover in het vierde hoofdstuk wordt gerapporteerd, is gericht op het verkrijgen van meer inzicht in het primaire hulpverleningsproces van de interventie TvT. Na een beschrijving van de ontwikkeling van een zelfrapportage-instrument gaan we in op de resultaten van een gefaseerde studie met drie meetmomenten. Het onderzoek betreft de werkzaamheden van 50 gezinscoaches die in de onderzoeksperiode meer dan 650 cliëntcontacten hadden waarbij meer dan 2,500 zorgverrichtingen aan de orde waren. Centrale bevindingen zijn dat de meeste verrichtingen zijn uitgevoerd in samenwerking met één of beide ouders (zonder de kinderen), en in mindere mate met kinderen of externe professionals. Het merendeel van de verrich-tingen van de gezinscoaches viel in de categorieën 'informatie verzamelen' en 'werken aan (gedrags-)verandering'. De relatief hoge frequentie van zorgcontacten toont de intensiteit van de interventie die wordt ingezet om de hulpvragen van deze complexe doelgroep te kunnen beantwoorden. —Hoofdstuk vijf— Het onderzoek waarover wordt gerapporteerd in het vijfde hoofdstuk is gericht op het in kaart brengenvan cliëntkenmerken en op het verkennen van de mate van probleemreductie die geassocieerd is met de interventie TvT. In het onder-zoek zijn 122 gezinnen geïncludeerd over een periode van vier jaar en zeven maanden. Analyses werden uitgevoerd op zowel groeps- als casusniveau.

SAMENVATTING

151

De resultaten suggereren dat de interventie geassocieerd is met een afname van ouderlijke stress. Bovendien bleken gezinnen met een aanvankelijk lager stressniveau een grotere kans te hebben om het programma eerder te beëindigen. Gedragsproblemen bij kinderen en het gezinsfunctioneren, zoals waargenomen door hulpverleners, toonden een minder coherent patroon van verandering. De eerder aangegeven focus van gezinscoaches op verrichtingen met ouders (hoofdstuk 4) kan hiervoor een verklaring zijn. Geconcludeerd wordt dat TvT ouderlijke stress kan verminderen en dat—mede op basis van de eerdere bevindingen—het programma een parallel aanbod dient te creëren van directe hulp voor kinderen, naast en in aanvulling op de hulpverlening voor ouders. —Hoofdstuk zes— In het zesde en laatste hoofdstuk geven we een samenvattend overzicht van de theoretische en empirische bevindingen van het onderzoek en de implicaties die deze hebben voor praktijk en wetenschap. Centraal thema is de erkenning van de complexiteit in het benaderen van multiprobleemgezinnen; gezinnen wier leefsituaties vaak gekenmerkt zijn door sociale uitsluiting of armoede. Multicausale en multimodale benaderingen en interventiestrategieën waarin verbindingen worden gelegd tussen het individuele, gezins-, netwerk-, en beleidsniveau van analyse en interventie verdienen de voorkeur. Een aanbod van flexibele en langdurige gezinsondersteuning is veelbelovend voor ouders in multiprobleemgezinnen. Toch lijkt het gerechtvaardigd om deze aanpak aan te vullen met hulp in de thuissituatie die direct gericht is op de kinderen in het gezin. Een dergelijk aanvullend programma, getiteld Kindercoaching, is momen-teel in ontwikkeling bij het Leger des Heils. Verder onderzoek hiernaar wordt aanbevolen. Voorts bepleiten we om betrouwbare diagnostiek en outcome-monitoring als voorwaarden te zien om respectievelijk zorgcomponenten op individuele behoeften af te stemmen en duidelijker stopregels te ontwikkelen voor interventieprogramma’s met een flexibele duur. Administratief databeheer en het beschikbaar zijn van data over de inhoud van zorgtrajecten spelen een cruciale rol in het genereren van betrouwbare informatie over

SAMENVATTING

152

multiprobleemgezinnen. Uit ons onderzoek bleek dat er op dit punt behoefte bestaat aan verbetering. Vervolgens wordt gepleit voor methodologische diversiteit in het verzamelen van informatie over multiprobleemgezinnen in onderzoek. (Statistische) methoden en technieken zijn gewenst die betekenisvolle informatie op individueel niveau kunnen leveren, en die tegelijkertijd gebruikt kunnen worden voor het combineren van gegevens op een meer geaggregeerd niveau (zoals een regio). Een voorbeeld is de zogenaamde Reliable Change Index. Tot slot willen we beklemtonen dat de aanpak van deze uitdagingen als doel heeft de leefsituatie van kinderen in multiprobleemgezinnen te verbeteren en bij voorkeur gezien moet worden als een gezamenlijke taakstelling van praktijk, beleid en onderzoek.

PUBLICATIONS

153

Publications

Dutch

Conradie, J., Tausendfreund, T., & Knot-Dickscheit, J. (2011). De verrichtingenlijst KIPP: de ontwikkeling van een registratie-instrument voor het primaire hulpverleningsproces. Orthopedagogiek: Onderzoek en Praktijk, 50(7/8), 339–353. Knorth, E. J., Knot-Dickscheit, J., & Tausendfreund, T. (2007). Zorg voor jeugdigen: ambulant én niet-ambulant. Tijdschrift voor Orthopedagogiek, 46(3), 113–126. Knorth, E. J., Noom, M. J., Tausendfreund, T., & van den Berg, M. A. M. (2005). Kapselzorg voor jeugdigen? Een onderzoek naar kenmerken en aanpak van jeugdigen met sterk antisociaal en oppositioneel gedrag. Tijdschrift voor Orthopedagogiek, 44(9), 367–379. Knot-Dickscheit, J., Drost, J. Y., Kalverboer, M. E., Harder, A. T., Knorth E. J., & Tausendfreund, T. (2008). Gezinsondersteuning in de residentiële justitiële setting: standaard?. In E. J. Knorth, H. Nakken, C. E. Oenema-Mostert, A. J. J. M. Ruijssenaars & J. Stijker (Eds.), De ontwikkeling van kinderen met problemen: gewoon anders (pp. 147–161). Antwerpen: Garant. Knot-Dickscheit, J., Tausendfreund, T., & Knorth, E. J. (2011). Intensieve Pedagogische Thuishulp voor multiprobleemgezinnen: een kijkje achter de schermen. Orthopedagogiek: Onderzoek en Praktijk, 50(11), 497–510. Tausendfreund, T. (2007). Boekbespreking: Vijf eeuwen opvoeden in Nederland. Idee en praktijk 1500–2000. Kind en Adolescent, 28(2), 103–104. Tausendfreund, T., Kleefman, M., Knot-Dickscheit, J., & Knorth, E. J. (2008). Hulpverlening aan multi-probleem gezinnen met het interventieprogramma Stabiel. Groningen: Nieuwenhuis Instituut (pp. 1–125). ISBN 978-90-9023712-1.

PUBLICATIONS

154

Tausendfreund, T., Knot-Dickscheit, J., Knorth, E. J. & Grietens, H. (2012). De leefsituatie als explanans en explanandum bij multiprobleemgezinnen. Een vergelijkende conceptuele analyse van hulpverleningsperspectieven in Duitsland en Nederland. Pedagogiek, 32(3), 251–271. German

Colla, H. E., Krüger, R., Tausendfreund, T., Tetzer, M., Tarnowski, T., & Reimann, G. (2005). Planung für Menschen mit Behinderung der Landeshauptstadt Kiel. Kiel, Germany: Universität Lüneburg & Landeshauptstadt Kiel. Knot-Dickscheit, J., Drost, J. Y., Kalverboer, M. E., Harder, A. T., Knorth, E. J., & Tausendfreund, T. (2010). Familienunterstützung im geschlossenen justiziellem Setting: Eine orientierende Forschung. In H. Ricking & G. C. Schulze (Eds), Förderbedarf in der emotionalen und sozialen Entwicklung: Prävention, Interdisziplinarität und Professionalisierung (pp. 136–149). Bad Heilbrunn, Germany: Klinkhardt. Knorth, E. J., Knot-Dickscheit, J., Tausendfreund, T., Schulze, G. C., & Strijker, J. (2009). Jugendhilfe: ambulant und stationär. Plädoyer für ein Kontinuum. Praxis der Kinderpsychologie und Kinderpsychiatrie, 58(5). 330–350. Tausendfreund, T., Knorth, E. J., Knot-Dickscheit, J., Strijker, J., & Schulze, G. C. (2012). Familien in Multiproblemlagen: Hintergründe, Merkmale und Hilfeleistungen. Schweizerische Zeitschrift für Soziale Arbeit, 12(1), 33–51. van den Bergh, P. M., Knorth, E. J., Tausendfreund, T., & Klomp, M. (2004). Grundlagen der psychosoziale Diagnostik in der Niederländischen Kinder- und Jugendhilfe: Entwicklungen und Aufgaben. Praxis der Kinderpsychiatrie und Kinderpsychologie, 53(10), 637–651

English

Knorth, E. J., Koopmans, A. C., Buijs-van Nieuwenhuizen, M., Folkerts, L. M., Harder, A. T., Smit, M., & Tausendfreund, T. (2010). Two decades of research on child and family welfare in Europe and beyond: Within EUSARF, who talked about what, when, where and why? In E. J. Knorth, M. E. Kalverboer, & J. Knot-Dickscheit (Eds.), Insideout. How interventions in child and family care work. An international source book (pp. 35–38). Antwerp: Garant Publishers.

PUBLICATIONS

155

Knorth, E. J., Noom, M. J., Tausendfreund, T., & Kendrick, A. J. (2008). Characteristics and service responses to young people with serious antisocial and oppositional behaviour: Outlines of a practice-based model of residential care. In H. Grietens, E. J. Knorth, P. Durning & J. Dumas (Eds.), Promoting Competence in Children and Families. Scientific Perspectives on Resilience and Vulnerability (pp. 199–222). Leuven, Belgium: Leuven University Press/EUSARF. Knot-Dickscheit, J., & Tausendfreund, T. (2010). Intensive home-based care: A look inside. In E. J. Knorth, M. E. Kalverboer & J. Knot-Dickscheit (Eds.), Insideout: How interventions in child and family care work. An international source book (pp. 53–58). Antwerp: Garant Publishers. Tausendfreund, T., Conradie, J., Knot-Dickscheit, J., & Knorth, E. J. (2010). Assessing care workers' actions in home care for multi-problem families. In E. J. Knorth, M. E. Kalverboer & J. Knot-Dickscheit (Eds.), Insideout: How interventions in child and family care work. An international source book (pp. 165–168). Antwerp: Garant Publishers. Tausendfreund, T., Knot-Dickscheit, J., Grietens, H. & Knorth, E. J. (2015). The life situation of families with multiple problems: A comparative conceptual analysis of social service perspectives. Manuscript submitted for publication. Tausendfreund, T., Knot-Dickscheit, J., Post, W. J., Knorth, E. J. & Grietens, H. (2014). Outcomes of a coaching program for families with multiple problems in the Netherlands: A prospective study. Children and Youth Services Review, 46(11), 203–212. doi: 10.1016/j.childyouth.2014.08.024 Tausendfreund, T., Knot-Dickscheit, J., Schulze, G. C., Knorth, E. J. & Grietens, H. (2015). Families in multi-problem situations: Backgrounds, characteristics and care services. Child and Youth Services, 36 (conditionally accepted). Tausendfreund, T., Metselaar, J., Conradie, J., Schipaanboord, N., de Groot, M. H., Knot-Dickscheit, J., Grietens, H., & Knorth, E. J. (2015). Self-reported care activities in a home-based intervention programme for families with multiple problems. . Journal of Children’s Services, 10 (in press).

ACKNOWLEDGEMENTS

157

Acknowledgements—Dankwoord—Danksagung

Erik J. Knorth, mijn eerste promotor en ‘Doktorvater’: Ik herinner mij nog goed toen ik jou voor het eerst zag. Het was in Leiden in 2003, ik was een student van 27 jaar. Ik had een treinreis van zeven uur achter de rug en zat voor je, in een veel te groot pak, om je te vragen of ik stage bij jou mocht komen lopen. Jij zag daar wel wat in en had allerlei ideeën over projecten of de een of andere publicatie waar ik goed een bijdrage aan kon leveren, en Nederlands dat kon ik ook wel leren, toch? Wij schudden elkaar de handen, ik miste vervolgens de trein, ik heb noch geld, noch onderdak en ben dol enthousiast. Twaalf jaar later zit het pak wat strakker, ben jij mijn ‘Doktorvater’, spreek ik wat Nederlands, hebben wij zo’n 17 artikelen samen gepubliceerd, en kan ik nooit meer naar een literatuurlijst kijken zonder aan jou te denken. Ik ben trots dat ik bij jou mocht promoveren, Erik, en ben je voor altijd dankbaar dat je me wegwijs hebt gemaakt in het vakgebied van de Orthopedagogiek. Je begrip en vertrouwen hebben dit proefschrift mogelijk gemaakt. Hans Grietens, mijn tweede promotor of ‘Doktoronkel’: Jij kwam als laatste bij het promotie-team, maar niet minder dankbaar ben ik voor je inbreng tijdens de laatste jaren van het onderzoek. Jouw kritische blik, je gedetailleerde commentaar, en je oog voor het bredere perspectief, dat op het kind gericht moest blijven, had ik niet willen missen. Daarnaast wil ik je ook danken Hans, voor je inzet als mijn leidinggevende, en je persoonlijke begrip voor de behoeftes van ons promovendi. Jana Knot-Dickscheit, mijn co-promotor en ‘Doktormutter’: Ik word er stil van, zo dankbaar ben ik dat je mijn begeleider bent geweest. Trots ben ik, dat ik bij jou mocht promoveren! Ik zou nog een proefschrift kunnen vullen, met alleen maar verhalen over de tijd met jou samen: hoe jij er altijd was voor mij, hoe ik met alles bij jou mocht komen, hoe goed je raad wist te geven, wat een verrijking je bijdragen waren, hoe betrokken je steeds was, en hoe je probeerde mij aan een wilde aap te voeren. Topper, jij! Het Leger des Heils: Het vergt veel van een organisatie om evaluatie-onderzoek te faciliteren. Naast de tijd en ruimte die gegeven moet worden, wordt er ook persoonlijke inzet van medewerkers gevraagd. En veel

ACKNOWLEDGEMENTS

158

belangrijker: er wordt lef gevraagd. Lef om jullie eigen werk kritisch onder de loep te laten nemen door iemand van buitenaf. Ook al doen we dit als wetenschappers graag, dan toch is het niet vanzelfsprekend dat we erbij betrokken mogen zijn. Vertrouwen is nodig, geduld wordt geëist, en men heeft als praktijkwerker in eerste instantie simpelweg meer werk te verrichten. Zonder de bereidheid van de medewerkers en gezinnen om deel te nemen aan de dataverzameling had dit proefschrift er niet gelegen. En ook al kan ik jullie namen hier niet noemen, graag wil ik nog eens nadrukkelijk de gezinscoaches en gezinnen bedanken die aan het onderzoek hebben deel genomen. Ik kan mij goed voorstellen dat het niet altijd gemakkelijk was voor hen om gemotiveerd te blijven voor het onderzoek, naast alles wat er speelt in de ambulante begeleiding. Ook de inzet en vasthoudendheid van de afdelings- en traject-managers bij het uitzetten van het onderzoek was bewonderingswaardig. Wij hebben dit alles gedurende vele jaren van het Leger des Heils gekregen en mijn dank daarvoor is groot. Naast mijn algemene dank voor het Leger des Heils wil ik hier in het bijzonder een aantal mensen noemen: Jaap van Vliet, ik ken maar weinig mensen die weten praktijk en onderzoek zo geslaagd in balans te brengen als jij, ik heb er ongelooflijk veel bewondering voor. Cornel Vader en Bothilde Buma, jullie enthousiasme, deskundigheid en ondersteuning, als resp. directeur van het Leger des Heils Noord en manager primaire proces, hebben niet alleen dit onderzoek in het leven geroepen maar hebben er ook voor gezorgd dat het doel haalbaar en het onderzoek uitvoerbaar bleef. Mijn dank! Mirjam van Driel, je ideeën voor het vormgeven van het onderzoek en de daadkrachtige ondersteuning, ook door je bijzonder deskundige en betrokken begeleiding van stagiaires, hebben dit onderzoek gezicht gegeven! Ylse Veenstra, Sylvia de Boer, Janneke Knol, Karin Agema, Johanna Buter en Inge Hoekstra, heel hartelijk dank voor jullie doorzettingsvermogen en de daadkrachtige ondersteuning. Willie de Boer, Roos Bunt, Jaap Berghuis, Lobke Kooistra, Bea Zomer, Thalina van Rensen, Iris van der Veen, Renate Harkema, bedankt voor het meedenken en faciliteren van het onderzoek op jullie afdelingen! Nico Veenstra en Greetje de Valk, ik weet niet wat ik zonder jullie had gedaan… waarschijnlijk niets, toen alles weer eens was vastgelopen.

De Rijksuniversiteit Groningen en de afdeling Orthopedagogiek: Ik heb als medewerker en promovendus op de RuG veel ondersteuning mogen ervaren

ACKNOWLEDGEMENTS

159

en vertrouwen mogen voelen door de jaren heen, en daar ben ik zeer dankbaar voor. Er is een groot aantal mensen, die door de kwaliteit van het werk dat ze leverden – in de vorm van algemene voorzieningen hier op de RuG – een indirecte bijdrage hebben geleverd aan het tot stand komen van dit proef-schrift. Hieronder vallen de bibliotheek, en in het bijzonder de bibliotheek Gedrags- en Maatschappij Wetenschappen, net zoals de Instrumentatiedienst, of de medewerkers van de Bode- en Concièrgedienst en de Kantine op de Grote Kruisstraat, en last but not least het administratieve team van Ortho: Mijn hartelijke dank voor de jaren van samenwerking, Cintha, Agnes, Miranda, Susanne, Margreet, Irene, en Gerda! De RuG is vooral ook een plaats van ontmoeting, als je op zoek bent naar enthousiaste onderzoekers, docenten en studenten in de Ortho-pedagogiek. Een aantal van jullie wil ik hier toch graag persoonlijk bedanken. Wendy, jij eerst. Het is moeilijk om bij jou de juiste woorden te vinden. Wat vind je van deze: Als chocola gelukkig maakt, dan kan je nooit zoveel chocola eten om je gelukkiger te voelen dan ik nu ben, over het feit dat ik met je samen mocht werken. Het enige nadeel aan deze vergelijking is, dat ik dan nog niets heb gezegd over de vele dingen die ik van je heb geleerd. Jelle, de enige die mij ooit een kusje op mijn achterhoofd heeft gegeven, en de enige echte ‘Sozialpädagoge’ die ik in Nederland mocht leren kennen, dat ben jij. T’jonge, wat heb ik graag met je samen gewerkt. Hans, er is veel waarvoor ik je zou willen danken: het onderdak dat ik kreeg bij jullie op mijn eerste dag in Groningen, de jarenlange Krantenservice, het delen van zeldzame muziek of het ‘er zijn’ voor al die kleine en grote dingen op een universiteit, maar dan wordt dit een heel lang boek, dus in het kort: Dank je wel voor alles! Anne-Marie, je bent niet alleen een geweldige collega, maar ook nog top co-paranimf, een belachelijk leuk reisgenootje, een oprechte vertegenwoordiger en de enige die om mijn flauwe grappen in het Nederlands kon huilen. Daar dank ik je van harte voor! Simon, ook al is het al een tijdje geleden, maar je mag in deze rij niet ontbreken. Tot op de dag van vandaag is woensdag Deutschredentag! Janneke, al in Leiden was op jouw kamer altijd een vriendschappelijke schouder, hulp met de syntax van SPSS of een doosje Nederlands drop te vinden. Een droom van collega! Wondimu, I deeply miss you as my neighbour, colleague, and friend in thought. Be proud of who you are! Ellis, onze gezamenlijke studiereis naar

ACKNOWLEDGEMENTS

160

Engeland lijkt inmiddels een eeuw geleden maar ik voel mij nog steeds een bofkont dat ik in jou toen een zo wijze gesprekspartner en bewogen weten-schapper heb gevonden. Ernst, ik koester nog steeds de referenties die ik van jou heb gekregen. Alexander, ook aan jou mijn dank voor al de diepe gesprekken, je hartelijke lach, en hooggeleerde steun. Wied, je bent voor mij een held, serieus, geen grap; er kan namelijk niemand zo goed grappen maken als jij. Je speeches zal ik nooit vergeten net als je gitaarspel, of je definitie van Orthopedagogiek. Bieuwe, ook jij hebt een idee over de definitie van de Orthopedagogiek. Net zo precies als over hoe gedegen onderzoek eruit ziet of welke wetten de logica te volgen heeft, zoals het lex parsimoniae bijvoorbeeld; ook al voldoet dit dankwoord daar zeker niet aan. Laura, wat ben ik blij dat er in ons vak mensen zijn zoals jij. Slim, oprecht, woedend, groot, blond, en nooit bang het juiste woord te gebruiken. Ik ben trots je collega geweest te mogen zijn! Ook al hadden we wat mij betreft wat vaker kunnen borrelen. Borrelen is trouwens ook ontzettend leuk met Selma, bijna net zo leuk als zomaar jouw kamer in te lopen! Jacques, Gert en Gideon, ook jullie zou ik niet willen missen, noch in de wetenschap noch in 'de Minnaar' aan de Kleine Rozenstraat. Ik kijk met plezier uit naar jullie publicaties! Rink, wat een plezier om met jou in discussie te mogen gaan, ik heb er van genoten! Marleen, Carla, Leonieke en Margrite, jullie staan voor mij synoniem voor het gepassioneerd uitzetten van geheel nieuwe onderzoekslijnen, ik ben er diep van onder de indruk. Tenslotte mijn bijzondere dank aan de studenten, die onder Jana’s, Mirjam’s en mijn begleiding, in het onderzoek daadkrachtig hebben meegewerkt. Marijke, Esther, Janneke, Jelte, Nicolien, Marleen, Karin en Marjan, bedankt! En dan zijn er natuurlijk nog al die geweldig leuke bewoners van het (toenmalige) AiO-huisje en (nu) de Bladergroenvleugel, jullie dachten waarschijnlijk al dat ik jullie was vergeten. . . niks! Je naaste collega’s mag je nooit vergeten, evenmin als de vijver van liefde en verdriet in de geheime tuin van de verborgen lunch. Daar kan je namelijk een heleboel leuke gasten ontmoeten zoals Kirsten, die ongelooflijk veel over wetenschappelijk geluid en tatoeages weet, die Jorien dan zelfs voor je kan teken, wat bijna zo mooi is als perenijs, waar Marlies, Eleonora en Wubs alles over weten, dat is iets meer dan Mónica over het Nederlands weet, maar die kan je als excuus even het heerlijkste verstopte jazzcafé in Groningen laten zien, dat lijkt wel een beetje op

ACKNOWLEDGEMENTS

161

één van Vera’s snoezelkamertjes, waar Mijntje eens een leuk verhaal voor Sija over zou kunnen schrijven, dat zou dan zeker minstens zo leuk zijn als met Elianne in Padova te verdwalen, of van Daan muziek aanbevolen krijgen, of met Hassan samen één van Daniëlle’s leuke documentaires over vreemde culturen kijken, wat een beetje voelt als met Barry over spiegelneuronen discussiëren, die zijn namelijk bijna net zo flink als Linda bij het hardlopen, of Anke bij het schrijven van gedichten voor haar kamergenootje Annemiek, waar Sanne in een haverklap het leukste liedje van kan maken, dat zelfs Els zou kunnen zingen als ze niet overgelopen was naar het UMCG, waar Ineke zeker treurig over was, al had ze dan niet een grotere kamer gehad, wat een ongelooflijke luxe is als je eens de kamer van Kwik, Kwek en Kwak, eh, ik bedoel, Erika, Saskia, en Marga had gezien – of niet Aafke? – dan hadden zelfs Remo, Josien, en Anne-Fleur moeite gehad om niet jaloers te worden, wat Kim goed op video had kunnen opnemen, als Carolien de gaderobe had uitgekozen, die men het beste bij Carien uit de kast zou kunnen halen, ook al staat dat dan waarschijnlijk Bé niet meer zo goed, maar met een beetje geluk kan Prince hem coachen en dan komt het wel goed, anders had Marlous hem zeker niet gekozen, maar in principe is dat alles niet zo belangrijk als tenminste Kirti op Lidian en de planten gaat oppassen, in de hoop dat ik niemand ben vergeten, die hier wel had willen staan! Apropos, bijzondere dank geldt natuurlijk voor mijn paranimfen: Lidian, er is geen kantoor op de wereld dat perfect is zonder jou als kamergenootje en dat niet alleen omdat je de prachtigste Nederlandse krachtermen kan gebruiken, als weer eens je computer vastloopt, maar ook omdat je met hart en ziel een prachtig mooi mens bent. Daarom, dat je er als collega en als vriend altijd bent geweest voor mij, heb je levenslang sterretjes verdiend. Annemiek, wat is het toch leuk te weten dat als ik eens een paard zou willen stelen of een kathedraal zou willen bouwen, ik altijd naar jou toe zou kunnen komen en dan was het zo gebeurd, met “cum laude!” zelfs, daar ben ik zeker van, omdat jij er weer het beste van had gemaakt. Dat jij op de verjaardag van jouw zoon mijn paranimf wilt zijn is voor mij meer dan een bak vol eer!

(Oud) collega’s en Kollegen: Peter, ook hier nog een keer mijn dank voor je vriendschap en het zolderkamertje in Leiden. Zonder jou had ik mijn eerste Nederlandse avontuur nooit overleefd! Thomas, es gäbe so viel zu danken, und

ACKNOWLEDGEMENTS

162

nur wenige Worte treffen es: Du bist mein Sugimura. Lieber Herbert, eine Prüfung ohne Dich in meinem Geiste ist es nicht wert bestanden zu werden. Mijn vrienden in Groningen: Janyte, Devrim, Laura, Jeroen, René, Pé,

Boaz, en Martijn, bedankt voor de vriendschap en al de mooie herinneringen! Groningen is mij dierbaar, omdat jullie er waren. Meinen Familien: So ihr Lieben, wenn ihr es bis hierher geschafft habt, habt ihr euch ein wenig Deutsch verdient! Sischa, Lutz, Jana, Arne, Otis, Lilou,

Werner, Renate, Maggy, Zoltan, Lucas, Mausi und, ja auch lieber Heinzi im Himmel, ihr seid so toll, da kann man ja nur dankbar sein. Die dicken Küsse für ein Leben lang an Unterstützung kriegt ihr später, und immer wieder, ob ihr wollt oder nicht! Roli, Harald, und Donna, dass ihr mir Mali mitgegeben habt, ist das größte Geschenk das ich je bekommen habe! Meinen ewigen Freunden und ihren tollen Kindern: Wenzel, Lena,

Charlie, Philipp, Hannah, Linus, Juri, Kalle, Hannes, Susan, Levy, Mikki, Anne Katrhrin, Leon, und Karl eins der größten Opfer für dieses Buch ist, dass ich die letzten Jahre nicht jeden Abend mit euch zusammen rumlungern konnte!

Meiner Liebe: Mali, ich liebe Dich wie verrückt, jetzt und die nächsten 57 Jahre, mindestens . . .

164

About the Author

Tim Tausendfreund was born on March 26 1976 in Hamburg, Germany. He holds a diploma in social pedagogy from the University of Lüneburg, Germany, and was awarded one of the faculty’s prices for graduates of the year in 2005. He gave the graduation speech for the graduates of that year by invitation of the Dean of Educational Sciences. From his second year of study onwards, he was involved as a student research assistant in various research projects, among others in three international comparative research projects in collaboration with the Thomas Coram Research Unit of the University of London. Over two years he organized and lectured in complementary seminars as tutor for first year students. His course of study was further enriched with practical experiences in case work with highly vulnerable youth at the social service provider Stadtteilbezogene Milieunahe Erziehungshilfen e.V. (SME) in Hamburg, Germany, where he worked part-time between April 2001 and September 2003. A self-organized internship as research assistant, over six months, followed at the Centre for Special Education and Child Care of the University of Leiden in the Netherlands, where he collaborated in various research projects and co-authored scientific articles. In 2006, Tim returned to the Netherlands to further advance in research and academic teaching as Ph.D. Candidate at the Department of Special Needs Education and Youth Care of the University of Groningen. Since August 2014, Tim works as lecturer in social work theories at the University of Applied Sciences St. Gallen in Switzerland. Tim’s work and research focuses on international comparative research, social work theories, and the evaluation of child welfare interventions, in particular for families with multiple problems and highly vulnerable youth.

Documents

Coaching Families with Multiple Problems...ISBN 978-90-367-7647-9 (electronic version) NUR-code 848 Drawings by Lutz Tausendfreund Design by Mali Lazell & Tim Tausendfreund Printed