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

ABSTRACT

The article reviews practical experiences and theoretical reflections from the Dutch child and youth care sector on the provision of care for families with multiple problems. Emphasis is laid upon the complex relations between socioeconomic and psychosocial problems, and subsequent issues that may arise in arranging child and youth care. Furthermore, the current state of discussion in program development for the target group in the Netherlands is introduced. The originally English concept of families with multiple problems has been used only modestly in German-speaking countries. This is remarkable from an international 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 for the transnational discourse about child and youth care services for families with multiple problems.

KEYWORDS:

• family preservation
• poverty
• social exclusion
• home-based interventions
• international comparison

The originally Anglo-American concept “multi-problem families” has been used for more than two decades in the Dutch child and youth care 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, Grietens & Ghesquière, 2008; Steketee & Vandenbrouke, 2010; van der Steege, 2010) and programs were developed and/or modified specially to meet their needs in Dutch child and youth care practice (Netherlands Youth Institute, 2014b).

In a cross-national literature search on “multi-problem families” we found that the concept has been applied only sporadically in German child and youth care literature, thus far, which from a Dutch point of view is striking. 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 by us 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, as the following quote illustrates:

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.¹ (p. 74)

A primary notion expressed in this quote is that child and youth care interventions in families need a strong focus on the actual or potential strengths and (coping) skills of the client system (i.e. resource orientation, rather than being problem based and deficit-oriented). Secondly, emphasis is laid on analyses and intervention strategies that specifically include the macro level of social policies and society. Intractable factors, like for example, economic hardship, single parenthood, or chronic health problems, and their cumulative experience in life situations defined as poverty and marked by social exclusion, can have a significant impact on the long-term prospects of child and youth care interventions. Signalling them in practice and analysing them through research is considered 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. These two principles—(1) providing care based the client capabilities and resources, and (2) allowing for advocacy in social conflicts—can be seen as two core principles of the discipline of Social pedagogy in Germany (Kleipoedszus, 2011; see also Coussée, Bradt, Roose, & Bouverne-De Bie, 2010).

The conclusion of the quote, which also 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 problems, in particular the complexity of interactions between socioeconomic and psychosocial problems, which are essential to the phenomenon of “multiple problems,” as we will outline in the following. Therefore, in in this article, 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 Labor 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 article is to expand the understanding of the complex connections between problems within the family system (cf. Characteristics of Families, below) and the difficulties these families experience within the child and youth care system (cf. Problems in Arranging Support, below). In conclusion this justifies a closer look of lessons learned from international research and practical experiences from the Dutch child and youth care. We hope this article will contribute to the critical examination of the phenomenon from an international perspective and help to tailor child and youth care services to meet the needs of families in complex life situations.

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 distinguished as developmental lines of social work in the Netherlands, portrayed via the changes in terminology and practice (Baartman & Dijkstra, 1986).

The process of segregation in the Netherlands described interventions in which individuals or whole families were relocated to designated areas or institutions in which their everyday life was observable, highly organized and tightly structured, mainly through manual labor, in order to re-educate the so-called antisocial [Dutch: de onmaatschappelijken] (van Wel, 1992). Semantics of this period, in the Netherlands approximately lasting till the mid-1960s, emphasized the family's social deficits and need for educational correction, with only minimal attention to socio-economic causes. In the following period “the descriptive hierarchy was reversed so that economic weakness became the focus of attention. Antisocials would be redefined as an extremely impoverished subset of the economically weak” (van Wel 1992, p. 153). This shift in perspective, mainly influenced by critical sociological analyses, allowed for a pluralized understanding of what constituted social norms, and interventional efforts shifted towards community oriented services that aimed at equalizing social opportunities for deprived families. From the mid-1980s onwards a third general shift in approaching families through social work interventions could be observed in the Netherlands, which was inspired from insights of Family Therapy research. Not only societal factors needed to be accounted for in social work interventions, but also the relationships in the family system, which were seen as a main source for individuals to solve or cope with problem situations (Baartman & Dijkstra, 1986). Similar 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. But lately critical debates about family based welfare interventions had also emerged (again) in Great Britain, which centred around the so-called Family Intervention Projects (Flint, 2012; Garrett, 2007; Nixon, 2007) and implications of related policy changes (Churchill, 2013; Hayden & Jenkins, 2013; Morris, 2011; Murray & Barnes, 2010). 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 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—the 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. (1993, p. 42)²

In the above 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. Problems these families experience include 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 (Bodden & Deković, 2010; Holwerda, Reijneveld, & Jansen, 2014; Mehlkopf, 2008b). 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. An analysis of 120 child and youth care files 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 the records and statements made by the 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 distinguishes other families from families in multi-problem situations, it is their ability to solve problems in a persistent way (Dallos, Neale, & Strouthos, 1997; Spratt, 2011; Zinko, Meijer, & Oppenoorth, 1991).

A fourth characteristic is according to Ghesquière (1993) the chronic nature of the problem(s), such that 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, 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 (OECD, 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, Caspi, Moffitt, Polo-Tomás, & Taylor, 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.

Problems in arranging support

The second group of problems, after the severity and extent of the problems these families experience (see Characteristics of Families, above), is the difficulty in arranging 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, van der Goot, & Jansen, 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). Furthermore, fluctuations in problem intensity and the phenomenon of chronicity, especially with health related problems, need to be generally considered in intervention designs to prevent a “revolving door effect” (i.e., repeated relapse and care re-entry) (Boddy, Statham, Warwick, Hollingworth, & Spencer, 2012).

The person of the professional as an essential element in service delivery is often not included specifically in program 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, De Jong, & Zeelen, 2011). The personal qualities of the care workers 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 in the 1950s, and in the Netherlands in the 1980s, several programs 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, Ryan, Choi, & Testa, 2006; McCartt Hess, McGowan, & Botsko, 2000; Sousa & Rodrigues, 2012; Thoburn, Cooper, Brandon, & Connolly, 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 programs 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, namely, the difficulties in providing adequate support, especially in cases of care avoidance or so-called 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 emerged in the Netherlands: the effectiveness of intervention, the duration of the care services, the degree of voluntariness, the coordination of support, and financing.

Research on the effectiveness of care

According to a recent systematic review by Holwerda et al. (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 group of an intervention program. They conclude that for most interventions 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 (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 (cf. Problems in Arranging Support, above), other studies also raise concern about the sustainability of effects of short-term interventions, which indicates a possible need for flexible support over longer periods of time (Al, Stams, van der Laan, & Asscher, 2011; Berry, Cash, & Brook, 2000; 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).

Crisis intervention versus 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 programs, 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, Cooper, Brandon, & Connolly, 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 versus 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 (cf. Problems in Arranging Support, above). Compulsory participation 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 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 Family intervention Projects in Great Britain and historical lines of intervention development in the Netherlands (see Services for Families in Multi-problem Situations, above) both tie into this point of discussion.

Coordination of support versus 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 responsibility 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 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 versus 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 (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, programs 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 wellbeing, and reduce further dependency on their services. The primary characteristic 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).

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 (see Characteristics of Families, above); secondly, with regard to institutional barriers and care avoidance in child protection (see Problems Arranging Care, above).

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 multicomponent 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 programs are found that directly target care avoiding families in child protection (see Families in Multi-problem Situations, above).

In the development of Child and Youth Care programs for these families in the Netherlands, five major points of discussion can be distinguished:

1.	the effectiveness of care
2.	the duration of support
3.	the degree of voluntariness
4.	the type of funding, and
5.	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 gain new insights or critically appraise diversity (Boddy, Smith, & Statham, 2011). Thus, for example, with regard to the developments in family support in Germany, two of the five overarching themes can also identified: the type of funding and coordination 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 coordination and organization of family support are sought in Germany mainly in the discussion on legal classifications (Findt, 2010, p. 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 five 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 formulation of clear goals and eventual stopping rules, as well as routinely monitoring 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 wellbeing (Whittaker & Maluccio, 2002). It is also very short-sighted if one assumes the subsequent involvement of 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 intervention 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.

Notes

1. Translation by the authors of this article.

2. Translation by the authors of this article.