From Adversity to Stability to Integration: how One Australian Program is Making a Difference in Therapeutic Foster Care

Abstract

This paper discusses two key strategies detailing how “relationship-focused” and “trauma-informed” intervention practices, which form the basis of an Australian therapeutic program called Treatment and Care for Kids (TrACK), made a difference in the lives of highly traumatised children. The TrACK program fosters highly traumatised children who, due to the complexity of their trauma needs, cannot be placed in traditional generalist foster care. Case files of 48 children were reviewed. Children were either current or former clients over a period of 18 years since the program was initiated. In analysing the data, we noticed that children who were once highly dysregulated in the domains of foster care placement, education, arousal regulation and peer relationships were now enjoying an enhanced level of stability in their lives.

Children enter out-of-home care (OOHC) for a variety of reasons. It may be due to exposure to significant physical, sexual, or emotional abuse and neglect, and/or because their caregiver’s ability to care for them has been severely compromised by factors such as mental illness, substance misuse or family violence (McPherson et al. 2018). These factors often combine with structural disadvantage, poverty and intergenerational trauma to create entrenched patterns of dysfunction and child safety issues (Australian Institute of Family Studies (AIFS) 2017). Angel and Blekesaune (2017) argued that when children endure trauma within the very relationships that should provide them safety and stability, their lives become dysregulated and the mechanisms by which trust is developed and maintained are blurred. As a coping mechanism, children can dissociate from the self to escape their painful realities (Waters 2016).

In Australia, the number of children entering the OOHC system is increasing dramatically. The current report from the Australian Institute of Health and Welfare (2017) has shown that 1 in 32 Australian children have experienced child protection services, with 74% being repeat clients. The experience of childhood trauma is one of the nation’s most important public health concerns, with adverse childhood experiences (ACEs) being a key predictor for difficulties in later life (Anda et al. 2006; Felitti 2009). The 1 in 32 children who are at risk of being removed from their caregivers due to abuse and neglect in Australia are the most vulnerable of all our children. For those who are removed, there is a predisposition to early death, greater suicidality, overrepresentation in the criminal justice system, chronic homelessness, unemployment, mental illness and poor social relationships after aging out of care (Mendes 2009; Mendes and Moslehuddin 2006; Wade and Dixon 2006). In his seminal work, Cozolino (2014, p. 278) argued that:

Early interpersonal trauma in the form of emotional and physical abuse, sexual abuse and neglect shape the structure and the functioning of the brain in ways that negatively affect all stages of social, emotional and intellectual development. …[The] catch-22 of their experiences is that they need to feel connected in order to heal, but are too afraid to trust because [they have] become fearful and dysregulated in relationships…. [As such] they are stuck…in a cycle of loneliness, terror, and avoidance that is difficult to escape from.

One Australian program designed to address the complexity of the challenges highlighted above is the Treatment and Care for Kids (TrACK) program. This is an intensive therapeutic foster care program for children and young people who have experienced complex trauma. The program is delivered in partnership by two charitable organisations and sponsored by the local child protection agency. It evolved in the context of a growing recognition that existing programs and systems of care were not meeting the needs of children presenting with complex needs and challenging behaviours. The program design is strongly influenced by a growing awareness of neurobiology and the clinical implications of exposure to trauma. Central to the program design is a focus on the caregiver–child relationship as the primary therapeutic milieu, supported by professional roles surrounding this dyad including therapeutic specialists and foster care workers (Australian Childhood Foundation, 2017).

The Treatment and Care for Kids (TrACK) Program

As an intensive therapeutic foster care program, TrACK targets children and young people who may otherwise have been placed in a residential care setting as a result of their challenging behaviours. Typically, these children present with early experiences of complex developmental trauma. A key element of the TrACK program includes coordinated therapeutic intervention for carers to establish and maintain a therapeutic milieu within the carer’s home. This central focus of the program involves meeting the carer’s needs for training, mentoring and day-to-day coaching to enable them to establish and maintain a relationship that actively addresses the impact of the trauma experienced by the child in past relationships (McPherson et al. 2018). The specialised training for carers includes material on the neurobiology of trauma and brain development, and a suite of helpful responses to trauma-based behaviours.

Also unique to the program is the operation of an effective Care Team that includes key professionals and the carers in processes that foster a shared approach to the care of the child. Care Teams are resourced to include a therapeutic specialist, a social worker or psychologist who has expertise in reparative therapeutic work with children and young people, and a case manager, who is a foster care social worker employed by the partner agency. Both positions are informed to offer a more intensive response than is the case in generalist programs, with an agreement that they carry reduced caseloads. Other professionals in the team are determined by the child’s needs and may include other health, medical and education professionals involved with the child. The purpose of the Care Team is to inform and support the therapeutic relationship between the carer and the child. Each of the program partners subscribe to clear guidelines outlining roles and responsibilities to ensure that children and young people experience a highly coordinated, “wrap around” treatment and care.

Conceptualising Complex Trauma in Children

A new theoretical framework for understanding complex trauma in children was proposed more than a decade ago (Cook et al. 2005), which identified the limitations of a diagnosis of posttraumatic stress disorder (PTSD) for those children who had experienced abuse and neglect. Put simply, this framework highlighted the importance of considering the developmental implications for the child who has been affected by trauma and ensuring that intervention responses capture this assessment. The framework proposed was based on clinical expertise and a comprehensive literature review suggesting seven distinct domains of impairment observed in children who have experienced complex trauma. They are: Attachment, biology, affect regulation, dissociation, behavioural regulation, cognition and self-concept (Cook et al. 2005, p. 392).

This framework built on seminal theories of attachment and attachment disruption (Bowlby 1988), emerging knowledge in the areas of the neurobiology of relationship (Perry and Pollard 1998; Perry 2002, 2006), and the documented implication for children’s brains of exposure to persistent trauma (Teicher et al. 2002; Heim and Nemeroff 2001; McLean 2016). Complex trauma theory has profound implications for intervention with children in care. This is because complex trauma occurs in the context of a relationship that was intended to be secure and trustworthy (Perry 2006). As such, intervention approaches that stabilise children would need to be primarily “relational” as a way of promoting connectedness and the capacity for children to form secure attachments again. Such relational-based approaches are seen as those most likely to enable children to build strengths and reduce the impact of trauma on their development (Cook et al. 2005). Another clear implication for a trauma-informed approach is that it enables a rethinking of what individualised services should be provided to children with complex traumas.

McLaughlin et al. (2014) argue that our increasing knowledge in the relationship between neuro-psychological development and trauma may lead us to design interventionist programs that address specific stress pathways for children with trauma. A diagrammatic representation of the implications for children’s development and the consequential implications for healing can be seen in Fig. 1. This diagram highlights the interrelatedness of trauma, attachment and development for children as a core tenet of trauma theory (Cook et al. 2005; Kolk et al. 2005; Perry and Pollard 1998; Perry 2006,). It shows that focusing on the child’s capacity to form a lasting, trusting relationship minimises the impact of trauma and helps facilitate development of healthy relationships.

Fig. 1.

Conceptualising the implications of complex trauma for children

The Australian Policy Context for Out-of-Home Care

Australian child protection services target those children and young people at risk of being abused, neglected or harmed, or whose families are unable or unwilling to protect them (AIFS 2018). Statutory child protection services are the responsibility of seven state and territory governments, with legislation in each state and territory governing the way child protection services are provided.

In common with many other countries, the number of children in OOHC in Australia has grown at an alarming rate over the last 15 to 20 years, and has almost tripled from just over 14,000 in 1997 to 43,399 in 2015–16, with children entering OOHC at a younger age and remaining longer (AIHW 2017). There are also a growing number of children and young people in care with complex, intense and trauma-related needs often resulting from severe abuse and neglect (Higgins and Katz 2008). Aboriginal and Torres Strait Islander children are significantly overrepresented in the out-of-home care system. These children and young people account for less than 5% of all Australian children and young people, but account for almost 35% of the OOHC population. Aboriginal and Torres Strait Islander children are over 9.5 times more likely to be in OOHC than non-Indigenous children (AIHW 2017).

In an effort to prevent children from entering the residential care system, some Australian states have imported foster care programs designed in the USA, such as the Oregon model (formerly MTFC) and Children and Residential Experiences (CARE) program, as a way to deal with the crisis. The results of their effectiveness are contentious, with some research finding that young people who had committed offences and were subsequently placed in MTFC foster care reduced their offending behaviour, but that this effect was not sustained beyond the time they were in foster care (Biehal et al. 2012). This indicated that prosocial behaviour had not been “internalised”. One of the few studies employing a randomised trial also found that the MTFC model did not provide outcomes for a group of young people at risk that were superior to those of the region’s standard foster care (Green et al. 2014). Further research is required to investigate interventions and systems of care that may result in lasting change for vulnerable children.

The Role of Trauma Literacy in Developing Policy in Australia

Australian States and Territories appear to be making efforts to incorporate trauma literacy, theory and research into policy and programs supporting children and young people in OOHC. What follows is a snapshot of program documentation across states and territories reflecting these efforts. In the Australian Capital Territory (ACT), for example, the Step Up for Our Kids Strategy (2016) described the reformed service “as a therapeutic, trauma-informed service system with the child or young person at the centre” (p. 18). Similarly, in 2016 the New South Wales Government launched a framework for therapeutic out-of-home care with the following declaration:

Children and young people in OOHC have often experienced trauma, abuse, neglect or are faced with severe adversity before being placed into care. Therapeutic Care is a beneficial framework that addresses the needs of children and young people in OOHC and has the potential to improve their long-term outcomes (New South Wales Government 2016, p. 1).

The government of Western Australia, through their Out-of-Home Care Strategy (2015) advises that:

All children entering out-of-home care have experienced some form of trauma. Whether it is before birth; in their early years; or by the simple fact they are no longer living with their family-of-origin. At base, out-of-home care arrangements are to provide an environment for safe healing from this trauma (p. 18).

The Queensland Government (2013), through its child protection inquiry, found that, “Care facilities should no longer be places where children are simply housed; instead there is a consensus that the child’s placement must serve a therapeutic purpose.” Similarly, the Children in State Care Commission of Inquiry in South Australia stated, “Therapeutic services are giving priority attention to a more assertive response to the therapeutic needs of children and young people [and as such, they are committing] to support foster carers to provide effective and responsive parenting” (South Australian Government 2008, p. 354). The Victorian Government Child Development and Trauma Guide states:

There has been an explosion of knowledge in regard to the detrimental impact of neglect and child abuse trauma on the developing child, and particularly on the neurological development of infants. It is critical to have a good working knowledge of this growing evidence base so that we can be more helpful to families and child focussed (Victorian Government 2015).

The case for change identified in the various cited reports is evidence that there is a difference between regular foster care and therapeutic foster care. In the latter, the carer does not merely provide for a child’s material and social needs but also actively works with the child or young person to shift the way they process and express emotion.

Research Design and Methodology

This paper is drawn from a broader study that aimed to establish whether a relationship-focused, trauma-informed intervention, which forms the basis of an Australian therapeutic foster care program called Treatment and Care for Kids (TrACK), was effective in creating stability for traumatised children. Furthermore, the study sought to examine whether the intervention positively impacted on the children’s projected life trajectory. As established, the TrACK program fosters children and young people who have experienced severe trauma, exhibited complex behaviour, have extensive histories of placement disruption and emotional dysregulation, and due to the complexity of their trauma needs are considered “unfosterable”. A key goal of the program is to create stability for these children by forming a care environment that is matched to unique needs and is experienced as therapeutic by the child. The program is designed as a long-term placement and therapeutic option for children for whom adoption is not an option and where there are no suitable extended family members to offer care.

The evaluation of the program sought to answer the following two questions:

1. Is TrACK an effective program to create stability in the following four domains?

• Placement stability

• Education

• Peer relationships

• Self/Arousal-regulation

• 2.Does TrACK positively impact on children’s projected life trajectory?

We settled on these four domains as they were highlighted in literature as being the most measureable indicators of progress for a child living with trauma. The evaluation used a mixed method approach incorporating a qualitative and quantitative design. Quantitative data was collected through client files from two agencies spanning 18 years, while qualitative data was collected through in-depth individual interviews with foster care leavers as well as through focus group discussions with the Care Team, which comprised therapeutic specialists, foster care social work staff, agency managers and the carers.

We interviewed participants in a style often described as a “conversation with a purpose” (Smith et al. 2009). However, purposeful questions were centered on measuring progress on the four domains of our study, which, as stated above, are placement stability, educational outcomes, peer relationships and arousal regulation. We encouraged participants to tell their own stories on their own terms, and so, for the most part, the interviews were participant led. We considered the participants as the experiential experts that should be given most of the “airtime” to communicate their stories without feeling as if they were following a script. We asked questions that sought to uncover the subjective experience of being fostered through a therapeutic foster care program and in what ways (if any) the program was able to help them achieve progress in the four aforementioned domains.

The 4-Phase Research Design Process (Data Collection and Analysis)

First, we conducted a thorough review of international scholarship in the area. This was completed to identify contemporary peer-reviewed research pertaining to child abuse, neglect and the complex trauma experienced by children as a result. It also sought to identify an evidence base for treatment and care approaches for children removed from home under these circumstances. Secondly, we collected the data directly and indirectly from client files. All available files were sought by the research team in order to develop a “conceptual map” of the 48 children and young people who had been placed in the program from 2002 to 2017. Informed by the literature review, file data was used to identify, as far as possible, the nature and number of ACEs prior to the program referral, as well as the number of placements that children and young people had experienced prior to placement in the program.

Thirdly, we conducted in-depth individual interviews with the young adults who had been fostered through the program, as well as focus group discussions with the primary carers of the children with a view to learn about the outcomes for the children and young people in their care. Another focus group discussion was conducted with Care Team professionals including therapeutic specialists, foster care workers and managers. The interviews with former clients, carers and the professionals in the Care Team provided in-depth detail on the personal and structural challenges of providing care to children with complex needs.

Analysis of the Data

The final stage was analysing the data. This involved analysing the extent to which TrACK’s therapeutic foster care impacts on developmental outcomes for children and young people who have experienced severe trauma within the four aforementioned domains. Based on the stage-by-stage Model of Thematic Analysis described by Braun and Clarke (2006), work in the analysis phase specifically involved a series of tasks outlined below.

First, we familiarised ourselves with the data set. We read and re-read transcriptions, reviewing and “reading the data in an active way—searching for meanings and patterns” (Braun and Clarke 2006, p. 87). Secondly, we worked methodically to develop an initial list of codes, aligning them with data extracts. We were cognisant of the advice of Braun and Clarke (2006), in this task, to look for as many patterns as possible in order to retain context as far as possible. We asked ourselves, “What patterns are emerging from each of the four domains that we are exploring?”

Thirdly, we clustered the developed patterns together using the thematic mapping process to reflect and review the “story so far”. This involved returning to the detailed data extracts identified earlier and reviewing the alignment between those extracts selected, the codes and the themes. Finally, we defined and refined themes and sub-themes, with a view to confirm a “coherent and internally consistent account, with accompanying narrative” (Braun and Clarke 2006, p. 92). We were confident by the end of this task that a rich interpretive analysis of the data set had been produced.

Results

Forty-eight children who had experienced the program over an 18-year period were studied. They comprised 28 males and 20 females, with 32 being former clients and 16 current clients. Most children and young people (defined as people up to 18 years of age) were of Anglo-Australian origin, with only two Indigenous clients and two clients who had a Vietnamese father. Almost half of the children (n = 19) were referred directly from a residential care setting while the others came from other home-based care settings.

The cohort of children studied had experienced a high level of instability prior to placement in this program. Twenty-nine children had experienced more than three out-of-home care placements prior to entering the program and fifteen children had lived in more than six out-of-home care placements. Seven of those children had been placed more than ten times.

Data from the files showed that almost all children who were school age were identified as struggling and falling behind socially and academically compared to their peers of similar age. They also struggled with social interaction, with the majority not having any friends or any significant peer relationships. A therapeutic specialist that we interviewed reported that one child who had experienced extreme sexual exploitation and assault from infancy, was noted to be overly compliant and wary of adults and had not developed a sense of speech, temperament or mannerisms of children his age.

The single most compelling result emerging from this study is that the children, who had experienced many placements and years of threat and deprivation, were usually able to achieve stability. The results show that in spite of significant histories of instability, children placed in this program almost always remained there in the long term. The client files showed that of all the 32 clients who have aged out of the program, only six experienced a placement disruption as the reason for exiting the program. The majority of former clients who have left the program did so in a planned way (n = 26). All 16 children currently placed in the program were found to be highly stable with their length of stay ranging from 13 months to more than eight years. See Table 1 for a summary of client ages and durations of stay in the program. This stability is noted within the Australian policy context where adoption is rarely used, as it an order that requires parental consent. Foster care, in the TrACK context is not seen as temporary care; and in fact is the most lasting form of care available to this cohort in Australia given that kinship care was not available to them. The young people placed were each legally under the guardianship of the State, with a case planning goal to stabilise and maintain them in the long term in the TrACK program.

Table 1.

The age of entry and stability trajectory for each of the 48 previous and current clients of the program

ID	Gender	Age	1st Age of Entry to care	TrACK Entry	TrACK Exit	Duration in TrACK
1	M	23y 11 m	7y 8 m	Jul-03	Sep-06	3y 2 m
2	M	27y 11 m	3y 8 m	Jul-03	Jan-07	3y 6 m
3	F	30y 10 m	6y 7 m	Jul-03	Dec-04	1y 5 m
4	M	22y 11 m	7y 11 m	Sep-03	Nov-12	9y 2 m
5	F	16y 11 m	1y 8 m	Oct-06	Nov-13	7y 1 m
6	F	24y 8 m	10y 5 m	Jul-03	Feb-11	6y 9 m
7	M	19y 9 m	4y 0 m	Aug-04	Nov-09	5y 3 m
8	M	27y 8 m	11y01 m	Jul-03	Jun-07	3y 11 m
9	M	23y 3 m	7y 3 m	Feb-05	Feb-10	5y
10	F	17y 3 m	2 m	Feb-06	Mar-13	7y 1 m
11	M	24y 2 m	7y 11 m	Feb-06	Aug-11	4y 6 m
12	F	23y 1 m	7 m	Nov-05	Mar-08	2y 4 m
13	F	24y 3 m	9y	Feb-06	Jul-11	4y 5 m
14	F	18y 9 m	7y 6 m	Oct-06	Feb-10	3y 4 m
15	M	20y 1 m	8 m	Feb-04	Dec-10	6y 8 m
16	M	22y 8 m	7 m	May-11	Oct-12	1y 5 m
17	M	10y 2 m	2y 11 m	Jul-11	Mar-12	8 m
18	M	9y 3 m	1y 11 m	Jul-11	Mar-12	8 m
19	F	18y 7 m	1y 2 m	Jan-11	Oct-11	9 m
20	F	8y 2 m	10 m	Nov-11	May-12	6 m
21	F	21y 6 m	6y 8 m	Jan-13	Apr-14	1y 3 m
22	M	21y 6 m	6y 8 m	Sep-13	Apr-14	7 m
23	M	17y 9 m	11y	Dec-11	Apr-12	5 m
24	M	19y 5 m	12y 5 m	Aug-13	Apr-14	8 m
25	M	16y 10 m	8y 10 m	Jul-11	Jun-13	1y 11 m
26	F	7y 8 m	2y 1 m	Jul-14	Feb-16	1y 7 m
27	F	22y 4 m	4y 8 m	Jul-11	Jun-13	1y 11 m
28	M	20y 6 m	10y 5 m	Jan-13	Dec-14	1y 11 m
29	M	18y 11 m	7y 9 m	Jul-08	Nov-16	8y 4 m
30	M	18y 7 m	9y 2 m	Oct-10	Mar-17	6y 5 m
31	M	15y 1 m	5y 7 m	Oct-10	Current	7y
32	F	17y 5 m	6y 4 m	Jul-09	Current	8y 3 m
33	F	9y 5 m	5 m	May-13	Current	4y 5 m
34	M	11y 2 m	8 m	Nov-14	Current	2y 11 m
35	F	9y 7 m	7 m	Nov-14	Current	2y 11 m
36	F	14y 2 m	2y 6 m	Jan-13	Current	4y 9 m
37	F	12y 9 m	2y 1 m	Jan-13	Current	4y 9 m
38	M	8y 3 m	2y 7 m	Apr-14	Current	3y 6 m
39	F	9y 8 m	5y 9 m	Feb-14	Current	3y 8 m
40	M	11y 1 m	3y 9 m	Apr-14	Current	3y 6 m
41	M	15y 6 m	6y 9 m	Jan-09	Current	8y 9 m
42	F	11y 5 m	1 m	Sep-14	Current	3y 1 m
43	M	12y 3 m	2y 4 m	Apr-14	Current	3y 6 m

Discussion

Here, we integrate the stability results emerging from the study. We present and discuss the two dominant strategies of therapeutic intervention that emerged from the analysis of the findings. We propose that these two key “relationship-focused” and “trauma-informed” strategies that form the TrACK program have made a difference in the lives of severely traumatised children.

Strategy 1: Moving Children from Adversity to Stability

All children entering this program had experienced extreme forms of threat and deprivation throughout infancy and in early childhood. The elongated episodes of abuse and neglect at home led to statutory intervention upon which these children were taken into the out-of-home care system. Similar to what is reported in literature for children in OOHC, the children and young people entering TrACK had experienced a period of continued instability where they were moved from one foster home to another due to placement breakdowns (Chambers et al. 2018; Koh et al. 2014; Rock et al. 2013; James 2004). This led to disconnection from family, culture, school and community supports, and functioned to cement the lack of trust that they were already experiencing.

Placement breakdowns occur largely because of children and young people presenting with complex trauma-based behaviors that are highly challenging to foster carers (Newton et al. 2000; Octoman et al. 2014; James 2004). Children who were placed in this program, not surprisingly, demonstrated a range of highly problematic and complex behaviors. Most commonly, their carers and professionals reported and described the children as highly dysregulated and prone to aggressive and violent outbursts and explosive reactions to direction. This took the form of attacking carers with objects and weapons (such as knives), kicking and punching, yelling and swearing at them, throwing furniture and breaking windows at home and at school, and generally severe defiant and oppositional behavior. Other relatively common behaviors noted were stealing, hoarding or a need to control food, sexually aggressive behaviours toward peers and carers (such as public masturbation, sexual grinding on carers laps, taking off clothes suggestively in front of others and using sexually explicit language), enuresis, encopresis and sleep disturbance including nightmares and night terrors. If the original traumas that lead to these complex and problematic behaviors are not addressed on time, foster care leavers often transit from the care system to a life characterised by chronic difficulties (Curry and Abrams 2015; Jonson-Reid and Barth 2000; Mendes et al. 2014; Philip and Pamela 2016; Reilly 2003).

However, upon entering the program, the children’s healing and stability is prioritised. Their relationship with the carer family is nurtured and becomes a secure base for them. The prioritisation of the child’s safety and security is based on attachment theories, which suggest that creation of a sense of belonging to a family has therapeutic effect for traumatised children. This approach stresses five dimensions of caregiving, the first four of which were identified by Ainsworth in 1969 as important ingredients for secure attachment. They include availability, which assists the child in developing trust; sensitivity, which pertains to helping a child or young person manage their feelings; acceptance, which is a core criterion for helping a child build their self-esteem; and cooperation, which allows the child to feel that they are a part of the family and providing a child a sense of identity.

After listening to the reflections of the Care Team as well as the former clients that we interviewed, we concluded that due to the developing sense of stability, children in the program were able to stay in or return to school, attending full time, and develop hobbies and interests that mirror the values of their carer family. Data from the client files also showed that the majority of the children fostered through the program successfully age out of care but remain securely based as a member of the family, with a lasting sense of being “claimed” and belonging to the family.

One carer gave an example of how their child moved from instability to stability, and reflected on the impact of this secure attachment to their once-very dysregulated child:

You never know what you are going to experience each morning. It can be calm or crazy violent. This child has hurt me…. The constant unpredictability creates enormous anxiety and an unreliable employee. He has enormous disappointments, is very aggressive, can be very violent, very needy, and needs me for everything.…Since I am the one he has formed the attachment with, I have to be all things to him: counsellor,, mum, teacher, therapist, taxi driver, friend, protector.…[But] I know therapeutic care works for [him] because he can now read and write, he can sit in a classroom and participate, he can be very loving, talks to me about his fears, his life, his anger. He has a great vocabulary. When he is worried about doing something bad he can tell me about it. He might still do it, but he starts off trying not to. He can behave [better] for longer and longer periods of time.

Alan Schore’s (2012) theory enables an understanding of this reflection by the carer. He suggests that the critical ingredient for creating stability for children relies less on what the therapist and/or the carer says or does, and more on how they choose to be, particularly when the child is very dysregulated. What is important is the co-creation of an attachment communication bond between the child and their carer. Creating stability is about seeing the child and not just their trauma, and making deliberate effort to recreate worth and wholeness within a child. It is about knowing that the child chooses the carer and that the carer chooses them, and both are committed to the healing relationship regardless of its complexity.

To be stable therefore means that the child must feel completely assured that the foster family will never abandon them, reject them, re-traumatise them, hurt them or withdraw their affection from them regardless of how slow or complex their healing journey is. Drawing too from Hughes’s Dyadic Developmental Psychotherapy (DDP) model, which is “characterized by a strong therapeutic alliance, empathy and unconditional positive regards,” the focus is placed on stabilising the child through therapy and the relationship. Hughes et al. (2015) argue that stabilising a child should be guided by the PACE model, which allows Playful connections, Acceptance of the child’s inner world, cultivating Curiosity about the meaning underpinning behavior, and having Empathy for the child’s emotional state (PACE).

TrACK recognises that stabilising and healing a child who has experienced severe trauma is as confusing as it is complex. As such, when a traumatised child experiences or remembers something afflictive from a previous trauma while in the relationship with a therapeutic carer, that memory (however negative or traumatic) is paired with the positive experience of being seen, accepted, cared about, and made sense of. As Schore (2003) and van der Kolk (2003) argue, the pairing of acceptance with old trauma, repeated often enough, modifies the old circuits and they are returned to explicit or even implicit memory, and are transformed over time.

Strategy 2: Moving Children from Stability to Integration

The second strategy shows how children fostered through the TrACK program moved even more securely from instability to stability to integration. Integration is the penultimate stage that indicates a child has successfully healed, not only their physical and emotional wounds, but also feels wholesome in their soul and spirit. The final stage is the “integration of integration”, which occurs when children are able to experience love, develop trust and be integrated within a family system to which they (can) fully belong.

Understanding Integration

Daniel Siegel’s (2012, 2015) work on the developing mind provides a critical perspective in understanding the intricacies of interpersonal neurobiology (IPNB). He argues that social experiences shape who children become by influencing how their brains function. This neural integration shows the connectedness between brain, mind and relationships, and signifies that our “whole self” materialises from our experiences with others—especially our significant others. Our external world, and the experiences it fosters, impacts how the nervous system develops, especially in our early childhood years when there is little verbal or emotional functioning. Siegel and McCall (2009) states that “integration catalyses the emergence of a state of continued health and well-being… [and] generally occurs when a system remains balanced [with] a synthesis of stability and change, adaptively developing through time” (p. 3). Our emotions help us to make sense of our experiences, and, as such, if a child’s experiences are negative, abusive and neglectful; their dominant emotions are often in a constant state of arousal or dysregulation.

Children who have experienced adversity (such as those we studied) need to develop a sense of safety and earned attachment (Schore 2009) before they can learn how they should respond to both internal and external stressors. This secure attachment can lead to integration, which is “the central mechanism by which health is created in the mind, brain and body and in relationships…and is at the heart of positive emotion, and creates the foundation for resilience and well-being” (Siegel and McCall 2009, p. 8). There are nine dimensions of integration outlined by Siegel (2012), and among them is the integration of consciousness, which helps (children) to stabilise (their) minds. There is also the narrative integration which helps children to make sense and meaning of one’s life stories and experiences. This is “the weaving [together] of the facts and felt experiences of our lives into coherent stories that make sense of our inner and outer.” The highest form of integration one can achieve is “transpirational” integration. This is the integration of integration, involving a person’s deep sense of belonging and the connection to something beyond the self. It is the “expansive feeling of being part of a much larger whole, a connection to the essence of being human and to all of humanity, to the precious rhythms of the global pulse of life” (Siegel and McCall 2009). The overall message in Siegel’s integration domains is that an increased sense of integration raises the level of positive emotions whereas a decrease in integration fosters negative emotions.

We interviewed one of the young adults who had successfully aged out of care. We enquired about the aspect of the program that was most beneficial to him, and what helped him to recover from the trauma he had encountered as a child and achieve integration. He reflected clearly:

I got a lot of support and love.... [In the future] I want the residential units to go and [they should] put all the kids in the TrACK program, to help kids, like what happened to us. I reckon they would benefit more from [this] program than the residential units…because they are still lost in the residential units, and probably not loved, and that's why most of them end up not like us.

As this young man reflects, integration is facilitated and punctuated by love. To be loved deeply and unconditionally is central to recovery, and to integration to the community, as it instils in children a sense of worthiness and wholeness. It reminds them that they are good, and hence lovable. The “most valuable gift that a child can receive is free; it’s simply a [caregiver’s] love, time and support, …[and] science is now showing why [babies] brains need love more than anything else” (Winston and Chicot 2016, p. 13). Love, as we define it, is not just a simple emotion which reflects positive affection to the child, but a deep sense of care, concern and connectedness to the child. It is the deliberate effort to create a “loving space” centered on discovering the child, accepting the child’s vulnerabilities, providing comfort and constantly nurturing the relational space between the carer and the wounded child. Love holds, it grounds, and it secures the child into experiencing an environment that is conducive to developing trust, regulation and emotional stability. This leads to the “integration of integration”, and is characterised by a person’s sense of belonging and connecting to something beyond the self.

How Integration Manifests in Children: The Relationship and the Journey to Belonging

The journey to safety, stability, nurturing and integration for children is not without its complexities. We observed that there were still a number of children who continued to struggle with giving and receiving love; however, the majority showed a developing ability to express affection within their foster families. Their way of showing and accepting love varied and can be categorised as non-conventional as it involved simple things like looking at their carer’s eyes when talking to them and accepting contact through touch. As Hughes et al. (2015, p. 148) say, it’s a matter of love and “it’s a matter of trust.”

We asked carers how they showed love to their foster children and whether they could tell if their child was able to receive love from them. One of the carers said that this was the easiest way for her to measure progress for the child she was fostering:

Yeah…we sing songs about me, about how he loves that I am his mum, [that] I am the best mum, and that he loves me. So my success for him is that, you know, he can love me and we can talk, you know…this is awesome for a kid who couldn’t read and write.

A core component of the TrACK program is the relationship between child and their carer. It is within this context that a therapeutic milieu is established and intervention takes place. A child will only feel safe to explore their curiosity and playfulness in the context of a loving and secure relationship. Another carer stated that they loved their foster children just as much as they loved their own children:

I love my little fella, like when I was sick that I thought I wouldn’t—maybe couldn’t continue with him just because I was so sick; I just bawled and bawled and bawled.

The other carer reported that her child’s loving nature had developed significantly since they started developing a relationship:

So my child is in Grade 5 now, and although he has no friends either, he can read, he can write, and he has a great vocabulary. He has no social skills at all. [However,] he is very, very loving to me and has learned to believe in that and trust it.

Another way that children were able to move from stability to integration is by having a sense of belonging; a place to call home; a state of permanence. Schofield and Beek (2009, p. 19) state that having “unconditional family membership can provide anchorage and the reassurance of practical and emotional solidarity and support through life.” Having a family to call their own is key in providing children with resources that lead to developing positive identities and outcomes, and as such are more likely to feel worthy of being part of a community.

This study shows that when carers and the foster children build a relationship that is based on a sense of permanence, there is often a long-term and explicit commitment to each other beyond the official end of the foster care—when the child reaches 18 years of age. To illustrate, one carer said that he loved his foster boys so dearly that he invited them to live with him and his partner for life. That way, their (foster) sons knew that they always had a home—and they could come and go as they pleased as they matured into young men with their individual interests. The carer said that he always made an effort to talk to his sons in the future tense to show them that he would always be a part of their life:

Well, one of the strategies [which works] for us is to [always] to talk to the children in the long term; you know, I talked to…[our foster son] when he was 14 about how I’m going to teach him how to drive [when he is older]…and he knows he is welcome to stay here for the rest of his life.

The other carer said when she travels overseas she leaves her son in charge and responsible for the house—because that is his home as well:

I have been caring for 15 years. I have a young man with the TrACK program, and he is 23 and still lives with me…. He looks after our house when I go home to see my parents overseas…. He cooks, he is a clean child, he is not good socially, but you know, he is fighting. And I will [always] be there for him. He has a home and he knows that.

Figure 2 concludes our analysis and represents a six-level “journey of trust” which summarises how the sense of belonging and being loved enough to be “claimed” by family is a key element of healing and integration. Based on the study findings and the work of Baylin and Hughes (2016) and Siegel (2012), we have proposed a new step to the existing model in the journey to “belonging”. In the journey to “belonging” and to integration, the child is “claimed” as a member of the family.

Fig. 2.

The journey to “belonging” and “claiming” of the child

Conclusion

Based on these results and our analysis, it is our view that it is possible to achieve outcomes of safety, stability and integration even for the most severely traumatised and vulnerable children in society. The study shows evidence of a therapeutic foster care program that is undoing the trauma of children through the nurturing of the “healing relationship” and the “claiming” of the child. The healing relationship can alter the trajectory of children whose adult lives would likely have been characterised by various social, financial and psychological difficulties.

Care that is truly therapeutic can help in “stabilising the children’s stress response system, reconfiguring their baseline arousal levels, integrating their memory functioning and building connections with the important network of adults in their life” (Australian Childhood Foundation, 2017). This study shows that the application of an evidence-informed theoretical framework enables a “comprehensive understanding of interpersonal neurobiology, child development, and attachment” (Australian Childhood Foundation 2017). Children in therapeutic care showed significant improvements in the domains of placement stability, educational outcomes, arousal and self-regulation, formation of healthy relationships and, ultimately, in their overall life trajectory.

Funding

The evaluation was supported by a grant from the Victorian Department of Health and Human Services to Australian Childhood Foundation.

Compliance with Ethical Standards

Conflict of Interest

No conflict of interest declared.

Ethical Standards and Informed Consent

This study was approved by Southern Cross University and Anglicare Victoria Human Research Ethics boards. The university’s approval number is ECN-17-153 while the Anglicare reference number is 2017–90.