“Pepleri Ravikodu oli mulle teine kodu. Alati mulle olemas.”
Noor (kaks aastat pärast ravikodus viibimist)
ANALYSIS OF THE SERVICE
We use the Children’s Overall Performance Assessment Scale (CGAS) to assess performance, which we score on a team-by-team basis at least twice, – when the child arrives and at the end of the service; we use descriptive assessment to assess children’s performance. At the beginning of the school year or upon arrival at the service, the team of the health care home prepares an individual action plan for each child, in which the suitability and achievement of the set goals are assessed in the middle and at the end of the school year.
When evaluating performance, we analyse the individual characteristics of each child and each specific case separately. We can consider it to be an achievement when a young person goes to acquire higher education years after their stay in a nursing home. However, it can also be considered an achievement when the child is away from a violent home environment five days a week during the period of stay with us. Given the specificities of the age and development of the children in the service, the effectiveness of the stay in the centre may be immediate or it can be effective several years later when the young person is able to internalize the experience of the milieu therapy centre.
The shorter the time a child stays in a milieu therapy centre, the lower the performance. The more complex and longer-lasting the child’s problem, the longer it takes for the changes to take place and consolidate.
AREAS OF CHILD EVALUATION
Physicality
– the age-appropriateness of the child’s physical development
– strengths/weaknesses/peculiarities in physical development
– own body perception (does the child like his/her body)
– the compatibility of body language with other expressions
– the enjoyment of sports and skills
– relationship to one’s sexuality, knowledge of needs, its expression in an adequate way
– control of locomotor skills (fine and gross motor skills)
Communication skills
– responding to new situations
– ability to make contact with adults, peers, younger people
– ability to maintain a relationship
– ability to be alone
– ability to empathize and help – in various ways and situations
– ability to communicate in a group
– jealousy and the situation in which it arises
– differentiation between formal and actual contact skills
Emotions
– ability/courage to adequately express joy, anger, fear and sadness
– ability/courage to express intimacy
– ability/courage to show interest in another person
– ability to behave in difficult situations
– losing and winning skills
– ability to express frustration
– provocative behaviour or state of fright
– ability to express one’s feelings adequately in changed situations
– ability to use fantasy
– the presence of a sense of humour
– sleeping skills
– mental pain prevention patterns
School/work
– joy/hatred for studying/working
– relationship with teacher/supervisor
– relationship with fellow students/colleagues
– compliance with agreements, and their conditions
– cognitive abilities
– wishes and plans
Interests
– interests at home
– participation in events outside their home
– desire to be with other people
– pleasure to test oneself in new situations
– special skills/talent
Family
– description of family and internal communication patterns
– wishes/hopes for the future
– family myths/ideology/patterns
– events uniting the family
– genogram
Out-of-family network
– friends/acquaintances
– involvement with different groups
– professional network
Self-image
– ability to assess one’s own abilities
– ability to assess one’s own learning needs
– ability to assess one’s own future possibilities
– ability to evaluate one’s own place/role in the family
– network strength assessment skills
– ability to evaluate the relationship with others
– ability to manage one’s future life
– ability to postpone one’s needs adequately
– ability to use one’s “trading skills”
Milieu therapy centre
– relationship with peers in a group
– ability to use adult assistance
– reacting to rules/routines/”common sense”
– what happens in conflict situations
– ability to apply what has been learned in psychotherapeutic sessions
– compliance with agreements, relationship with money, relationship with authority
STATISTICAL ANALYSIS
From the autumn of 2014 until today (8 years), Pepleri Milieu Therapy Centre has provided services to 30 children, including 20 girls and 10 boys aged 10-19. Most of the children have been referred to the service by a child psychiatrist, as well as by the employees of the municipal child protection service. All children have previously been treated in the child psychiatric ward (Tartu and Tallinn), most of them have been diagnosed and treated. In the case of both boys and girls, we have dealt with complex and difficult problems (compound psychiatric diagnoses, abuse, the inability of parents to cope with the situation, etc.). Based on diagnoses, the majority of cases are PTSD (22 children, 73% of children), mood disorders/depression (18 children, 60%), attachment (7 children, 23%), eating disorder (6 children, 20%). All children have 2 or more (up to 6) diagnoses at a time, which illustrates the complexity of the problems.
In addition to the above-mentioned diagnoses, children are also burdened with various other life-crippling problems. Of the children who stayed in Pepleri Milieu Therapy Centre between 2014-2020, 26 children (87%) have had a pronounced and often years-long school failure, 23 children (77%) have had severe difficulties with self-hygiene, and 20 children (67%) have experienced self-harming behaviour (cutting, suicidal thoughts and actions). However, it is particularly shocking that 25 children (83%) have experienced abuse (mental, physical, neglect) and 10 children (33%) have experienced sexual abuse, of which only 1 child had been previously diagnosed.
Almost half of the girls have been sexually abused, either as incest or by a stranger; boys have predominantly PTSD and affection disorders. The average length of service in the therapeutic centre has been 2 years, in some more severe cases also 3-4 years.
Close co-operation was established with parents, local governments, the rehabilitation team, the police, the orphanage and other network members.
Despite the complexity and difficulty of the stories, a positive result has been achieved for all children (they have been able to finish middle school, continued their education, either in secondary school or vocational school, start a family and become a parent, etc.). Those, who had been hospitalised in the past, managed to achieve a stable situation where hospital treatment was no longer needed. Following their stay in the therapy centre young people learn to cope with traumatising childhood experiences and are better integrated into daily life.
In 20% of the cases where no significant progress was made, it was exclusively due to the team’s failure to involve the parents in meaningful cooperation (deprivation of parental rights, parents with a serious criminal background or a severe mental disorder); in three cases children continued their education in Maarjamaa Hariduskolleegium, in two cases the service was terminated at the request of the parent, in one case the child needed long-term inpatient treatment (deep anorexia and self-harm).
Based on the CGAS (Children’s Global Assessment Scale), we assess the overall well-being of children after they arrive at Pepleri Milieu Therapy Centre (up to one month) and at the end of the service. The difference between each child’s arrival and departure evaluation score provides a rate of personal change that is one component of the performance evaluation, along with the child’s and parent’s feedback on the impact of the time spent in the centre.
Upon arrival, the average overall coping score for boys was 29.5 (min 10 and max 45), for girls 30.9 (min 9 and max 48), and the average arrival score for boys and girls was 30.2.
Upon leaving, the average overall coping score for boys was 51.6 (min 31 and max 70), for girls 56.6 (min 15 and max 85), and the average leaving score for boys and girls was 54.1.
Assessment of the change in personal general coping on the basis of CGAS.
Boys’ overall coping improved by an average of 22.2 points (minimum change 6, highest 43), while girls improved by an average of 25.6 points (minimum change 5, maximum 50).
Personal overall coping improved by an average of 23.9 points for the 27 children (boys and girls combined) in Pepler’s Milieu Therapy Centre in 2014-2021. All children improved in general coping.
In order to assess the persistence of positive changes, it would be necessary to conduct a new assessment and survey of children and their parents in the care home, for example, three years, five years, ten years after the end of the service.
CGAS CHILDREN'S GLOBAL ASSESSMENT SCALE
100-91: Doing very well
90-81: Doing well
80-71: Doing all right – little damage
70-61: Some problems – only one area
60-51: Some noticeable problems – in more than one area
50-41: Obvious problems – moderate damage in most areas or severe damage in one area
40-31: Serious problems – severe damage in several area and inability to function in one area
30-21: Severe problems – unable to function in almost all area
20-11: Very severe damage – Substantial safety oversight required
0-10: Extremely impaired – Continuous monitoring required for security