Family factors influencing out-of-home placement decisions

Improving the transition process to independent living for adolescents with profound intellectual disabilities. Experiences of parents and employees

Background

The transition process from the family home to independent living for young adults with profound intellectual disability (PID) becomes delayed. Those families face challenges that exceed those of typical families such as higher objective and subjective burden, more frequent psychological distress and lower social support. The aim of this study was to explore the collaboration process between parents and employees and identify factors that improve the transition with less burden.

Methods

A descriptive qualitative study was undertaken with 18 persons (9 parents and 9 employees) interviewed individually and in groups. In accordance with the municipality’s guidelines, families with a child with PID should apply for housing, when the child turns 16. The purpose is to ensure interdisciplinary collaboration, information flow and coordinated services according to family’s needs. The main question in the interviews was ‘What was your experience with cooperation in the transition process, and what would you do to improve this process?’ The interviews were analysed with a thematic approach using systematic text condensation.

Results

The parents experienced a lack of general information about the ‘housing waiting list’, level of services, and the plan for time of moving from the family home, and how to choose where and whom to live with. Parents described an unsustainable burden of care during the waiting period, and a family crisis caused the allocation of an apartment in a group house. Employees shared challenges to meet families’ wishes, as there were too few group homes. They experienced good collaboration with families and said they offered respite care, due to reduce parents’ burden of care. Employees experienced that PID adolescents developed skills, mastery and degrees of independence after completing a residency at the Folk High School.

Conclusions

To improve the transition process from family home to independent living for young adults with PID, the informants highlighted some factors to reduce the burden of care on families: 1) Systematic follow-up program for families to observe their needs at an early stage; 2) More available group houses; 3) Information about the housing priorities of the services and; 4) Educational preparation programs for families.

Does cannabidiol reduce severe behavioural problems in children with intellectual disability? Study protocol for a pilot single-site phase I/II randomised placebo controlled trial

INTRODUCTION

Severe behavioural problems (SBPs) are a common contributor to morbidity and reduced quality of life in children with intellectual disability (ID). Current medication treatment for SBP is associated with a high risk of side effects. Innovative and safe interventions are urgently needed. Anecdotal reports and preliminary research suggest that medicinal cannabis may be effective in managing SBP in children with developmental disabilities. In particular, cannabidiol (CBD) may be a plausible and safe alternative to current medications. Families who are in urgent need of solutions are seeking cannabis for their ID children with SBP. However there is no evidence from randomised controlled trials to support the use of CBD for SBP. This pilot study aims to investigate the feasibility of conducting a randomised placebo-controlled trial of CBD to improve SBP in children with ID.

METHODS AND ANALYSIS

This is a single-site, double-blind, parallel-group, randomised, placebo-controlled pilot study of 10 participants comparing 98% CBD oil with placebo in reducing SBP in children aged 8-16 years with ID. Eligible participants will be randomised 1:1 to receive either CBD 20 mg/kg/day or placebo for 8 weeks. Data will be collected regarding the feasibility and acceptability of all study components, including recruitment, drop-out rate, study visit attendance, protocol adherence and the time burden of parent questionnaires. Safety outcomes and adverse events will be recorded. All data will be reported using descriptive statistics. These data will inform the design of a full scale randomised controlled trial to evaluate the efficacy of CBD in this patient group.

ETHICS AND DISSEMINATION

This protocol has received ethics approval from the Royal Children's Hospital ethics committee (Human Research Ethics Committee no. 38236). Results will be disseminated through peer-reviewed journals, professional networks, conferences and social media.

TRIAL REGISTRATION NUMBER

ACTRN12618001852246.

Maternal Factors Associated With the Healthcare Utilization of Technology-Dependent Infants Following NICU Discharge

This study examined the relationship of mothers' psychological well-being (depressive symptoms, posttraumatic stress symptoms) and resourcefulness with their technology-dependent infants' healthcare utilization (rehospitalization, emergency department [ED] visits) following discharge from the neonatal intensive care unit (NICU). This descriptive, correlational study was conducted at a large Midwest level 4 NICU in the United States. Mothers (n = 19) with a technology-dependent infant (eg, supplemental oxygen, feeding tubes) to be discharged home from the NICU within 2 to 3 weeks were interviewed face-to-face using standardized instruments. Infant rehospitalization and ED visit data were collected from the electronic medical record (EMR) for the first 3 months following the infant's discharge. Analyses included descriptive statistics and negative binomial regression. A majority of infants (72.2%) required at least 1 hospitalization; 33% required at least one ED visit. Mothers' age and resourcefulness were significant predictors of ED visits while only resourcefulness predicted rehospitalizations. Neither depressive symptoms nor posttraumatic stress symptoms significantly predicted healthcare utilization. Maternal resourcefulness was the only main variable that significantly predicted both ED visits and hospitalizations and one of the few modifiable factors that could assist mothers with successfully coping with the complexity of caring for a technology-dependent infant. Future research should focus on interventions to enhance mothers' resourcefulness prior to their technology-dependent infant's NICU discharge.

Sleep disturbance in family caregivers of children who depend on medical technology

OBJECTIVES

Family caregivers of children who depend on medical technology (CMT) provide highly skilled care up to 24 hours per day. Sleep disruption places family caregivers at risk for poor health and related outcomes that threaten their long-term caregiving capacity. Few studies exist that have measured sleep in family caregivers, and most have relied entirely on subjective measures.

METHODS

In a prospective cohort study, family caregivers of CMT (n=42) and caregivers of healthy children (n=43) were recruited. Actigraphy data and a concurrent sleep diary were collected for 6 days/7 nights. Measures of sleep quality, depression, sleepiness, fatigue and quality of life were also administered.

RESULTS

Family caregivers of CMT averaged fewer hours of sleep per night (mean (SD)) (6.56 ± 1.4 vs 7.21 ± 0.6, p=0.02) of poorer quality (7.75 ± 2.9 vs 5.45 ± 2.8, p<0.01) than the control group. Three times as many family caregivers of CMT scored in the range for significant depressive symptomatology (12(33%) vs 4(10%), p=0.01) and experienced excessive daytime sleepiness (16(38%) vs 5(12%), p<0.01). Fatigue was also more problematic among family caregivers of CMT (22.12 ± 9.1 vs 17.44 ± 9.0, p=0.02).

CONCLUSIONS

Family caregivers of CMT are at risk of acute and chronic sleep deprivation, psychological distress and impaired daytime function that may threaten their capacity for sustained caregiving. Family caregivers of CMT may be important targets for screening for sleep disorders and the development of novel sleep-promoting interventions.

Experiences and needs of carers of Aboriginal children with a disability: a qualitative study

Background

Australian parents/carers of a person with a disability experience higher rates of depression, more financial stress, and are twice as likely to be in poor physical health than the general population. Aboriginal and Torres Strait Islander peoples experience worse health, social and economic outcomes than other Australians, and those with a disability face ‘double disadvantage’. This study aimed to better understand the experiences and needs of parents/carers/families of Aboriginal children with a disability.

Methods

Semi-structured in-depth interviews were conducted with parents or primary carers of Aboriginal children aged zero-eight with disability. Interviews were analysed using thematic analysis.

Results

Nineteen women (sixteen mothers and three grandmothers) were interviewed. More than half were lone carers (without a partner or spouse). Participants described their experiences, including challenges and facilitators, to providing and accessing care, impacts on their health and wellbeing, and associated economic and non-economic costs of caregiving. Financial strain and social isolation was particularly prominent for lone carers.

Conclusions

Tailoring services to the needs of carers of Aboriginal children with a disability means supporting kinship caregiving, facilitating engagement with other Aboriginal families, and streamlining services and systems to mitigate costs. The experiences described by our participants depict an intersection of race, socio-economic status, gender, disability, and caregiving. Services and funding initiatives should incorporate such intersecting determinants in planning and delivery of holistic care.

Talking with caregivers of children living in the community with ventricular assist devices

A VAD is a mechanical pump used to support the functioning of a failing heart. As a pediatric therapy, a VAD is used as a temporary solution for poor heart function, a bridge to transplantation or recovery, or a destination therapy. The goal of this qualitative study was to explore the perspectives of family and professional caregivers of children who are supported by VADs in outpatient settings. Semi-structured interviews were conducted with 22 caregivers of school-aged children discharged home on VAD support. Interviews were transcribed, and data were analyzed using qualitative content analysis. Caregivers identified issues facing children on VAD support in the contexts of home, school, and other childhood places including being physically connected to a device; experiencing changes; living a medical life; negotiating restrictions; cost of care; family, kinship, and community; and, present and future living. While a child with a VAD may have much in common with other medically complex children, the technological complications and risks of living with a VAD are uniquely identified by caregivers as an issue, especially when considering the way that children with a VAD are connected to their device-implanted yet exterior, mobile yet restricted, and autonomous yet dependent.

Relationships Between Caregiver Characteristics and Health-Related Quality of Life Among Youth with Spinal Cord Injury

Background: Past research has found a relationship between the mental health of parental caregivers and their children with spinal cord injury (SCI), but little is known about how other aspects of caregiver health and functioning impact health-related quality of life (HRQOL) of youth. Objective: The purpose of this study was to explore the importance of caregiver mental health, physical health, burden, and problem-solving skills in relation to children's physical and psychosocial HRQOL. Methods: Forty youths with SCI ages 7 to 17 years completed the PedsQL^TM; primary caregivers completed standardized measures of mental and physical health, burden, and problem solving. We evaluated 2 hierarchical linear regression models predicting children's physical and psychosocial HRQOL. Results: The 40 youths were an average of 11.48 years (SD = 3.21), 62.5% were male, and 80% Caucasian. They had been injured an average of 6.90 years (SD = 3.92); 75% had paraplegia, and 61.5% had complete injuries. Most caregivers were mothers (85%), were married (60%), and had at least some college education (87.5%). Univariate analyses revealed that caregiver problem solving alone was related to children's physical HRQOL, and caregiver mental health, burden, and problem solving were related to children's psychosocial HRQOL. Regression analyses controlling for child age and injury level revealed effective caregiver problem solving (P < .01) was significantly related to greater child physical (Model R² = 0.440) and psychosocial (Model R² = 0.547) HRQOL. Conclusions: Although relationships should be explored longitudinally with larger samples, results indicate caregiver problem solving may be a reasonable target for intervention to improve HRQOL among youth with SCI.

Out-of-home placement for children and adolescents with disabilities

The vast majority of children and youth with chronic and complex health conditions who also have intellectual and developmental disabilities are cared for in their homes. Social, legal, policy, and medical changes through the years have allowed for an increase in needed support within the community. However, there continues to be a relatively small group of children who live in various types of congregate care settings. This clinical report describes these settings and the care and services that are provided in them. The report also discusses reasons families choose out-of-home placement for their children, barriers to placement, and potential effects of this decision on family members. We examine the pediatrician's role in caring for children with severe intellectual and developmental disabilities and complex medical problems in the context of responding to parental inquiries about out-of-home placement and understanding factors affecting these types of decisions. Common medical problems and care issues for children residing outside the family home are reviewed. Variations in state and federal regulations, challenges in understanding local systems, and access to services are also discussed.

Parental adaptation to out-of-home placement of a child with severe or profound developmental disabilities

Utilizing grounded theory qualitative research methods, a model was developed for describing parental adaptation after voluntary placement of a child with severe or profound developmental disabilities in out-of-home care. Interviews of parents from 20 families were analyzed. Parents' cognitive appraisals of placement outcomes were classified as either inducing emotional stress (i.e., guilt, sadness, fear and worry, anger and frustration, and uncertainty) or relief. Parental appraisals of responses to placement by children, extended family, and friends were identified as factors affecting the parents' adaptation to placement. The primary coping methods used by parents to decrease emotional stress and increase relief consisted of reappraisals regarding the necessity of placement, involvement in the child's life, psychotherapy, and the passage of time.

The balancing act: meeting the needs of all children including an adolescent with disabilities

BACKGROUND

The aim of this study was to explore parents' experiences and strategies used when meeting the needs of all their children, including an adolescent with disabilities.

MATERIALS AND METHODS

A qualitative study design was employed. The study was conducted in two phases. (i) Secondary analysis of ecocultural interviews with 12 parent-carers of more than one child, including an adolescent (10-21 years) with intellectual disabilities. (ii) In-depth, semi-structured interviews with a sub-sample (n = 4) of parent-carers. Data was analysed using Strauss & Corbin's (1998) constant comparative method.

RESULTS

Parents balanced their children's needs through a combination of strategies driven by their goals, beliefs and values. Parents found this very challenging. They were always conscious of the needs of all of their children, although they could not necessarily meet all their children's needs equally. Strategies that attended to all children simultaneously were preferred by most parents, but could not always be used. Parents, at times, used strategies that prioritized the needs of the adolescent with disabilities or siblings.

CONCLUSIONS

Findings add to knowledge on what families of adolescents with disabilities do day to day and specifically reveal how these parents meet the needs of their children. Practitioners, together with disability and mainstream services and systems, need to recognize parents' goals, beliefs and values and the needs of the adolescent with disabilities. This will effectively aid the adolescent with disabilities, their siblings, parents and the whole of family life.

Home care of children and youth with complex health care needs and technology dependencies

Children and youth with complex medical issues, especially those with technology dependencies, experience frequent and often lengthy hospitalizations. Hospital discharges for these children can be a complicated process that requires a deliberate, multistep approach. In addition to successful discharges to home, it is essential that pediatric providers develop and implement an interdisciplinary and coordinated plan of care that addresses the child's ongoing health care needs. The goal is to ensure that each child remains healthy, thrives, and obtains optimal medical home and developmental supports that promote ongoing care at home and minimize recurrent hospitalizations. This clinical report presents an approach to discharging the child with complex medical needs with technology dependencies from hospital to home and then continually addressing the needs of the child and family in the home environment.

Review: the development of family quality of life concepts and measures

Historically, intervention programmes in intellectual and developmental disabilities have targeted the individual's special needs independent of the family and environmental context. This trend has been changing over the past two decades. This paper presents a literature review on changing trends in family support and the development of family quality of life (FQOL) and intellectual disability from a construct to a theory. The evolution of research in quality of life from the perspective of the individual with the disability to the family is described. A description of the development of FQOL measures is included, specifically an introduction and comparison of the two leading comprehensive initiatives on measuring FQOL - international FQOL project and the FQOL initiative of the Beach Center on Disability, in the USA. This paper provides the conceptual background and context to the other papers presented in this special issue, which focus on FQOL measurement in specific contexts.

Psychological well-being of caregivers of children with intellectual disabilities: using parental stress as a mediating factor

Parental stress has been identified as a major affecter of caregivers' psychological well-being and a risk increaser for unwillingly placing children with disabilities in the care of others. Recognition of effective means to ease caregiving burdens must guide policymaking and will help to provide better and tailored support and intervention for the children. This study aims to characterize caregivers of children with intellectual disabilities who are about to seek outside support and care and to identify the conditions under which psychological well-being and parental stress are affected using parental stress as a mediating factor. We found that parental stress and the child's depressive feelings strongly affected psychological well-being. We also found an indirect relation of restricted caregiver social activities through parental stress. To protect psychological well-being of caregivers, support services should address depressive feelings among children with intellectual disabilities, facilitate caregivers' social activity, and reduce stress.

The Home and Caregiving: Rethinking Space and its Meaning

Occupational therapists are routinely engaged in the homes of their clients with disabilities, providing consultation on the use and modification of space to improve functional independence. The meaning of home space is currently underexplored. This study describes the meaning and use of home space for mothers who are primary caregivers for a child or adolescent with disabilities and high support needs. This article reports data from two empirical studies of mothers of children and adolescents with disabilities. In-depth interviews were conducted with 80 mothers across the two studies. Interview transcripts were analyzed with a grounded theory approach. Access around the home for a family member with disabilities allowed mothers to combine caring with other home management activities. However, preventing access or excluding the family member with a disability from some areas of the home enabled the mothers to resist the medicalization of their homes and create a personal space for themselves. Full access to the home for the child with disabilities was rarely a desirable outcome. Decisions about the home and how it should be modified to improve function become more complex when the needs of family members are taken into account. Meaning ascribed to space within the home is integral to how the space is used and whether a family member with a disability is included or excluded from the space. For occupational therapists, the meaning that clients and their families ascribe to various spaces within the home is as important as the use of space.

Comparative study on self-perceived health of parents of children with autism spectrum disorders and parents of non-disabled children in Croatia

AIM

To assess self-perceived health of parents of children with autism spectrum disorders (ASD) in comparison with those of parents of non-disabled children.

METHODS

A total of 350 parents participated in the study: 178 parents of children with ASD (71% response rate) and 172 parents of non-disabled children matched by age, education, and place of living. Parents' self-perceived health was assessed using the Croatian version of the health status questionnaire SF-36, while socio-demographic information, chronic medical conditions, and needs were assessed by a general questionnaire.

RESULTS

For all dimensions of health, except physical health, parents of children with ASD had significantly poorer self-perceived health and reported significantly more deteriorated health in the last year than the control group (P<0.001). They also reported more psychological disorders (11% vs 4.3%), which was the largest difference in specified chronic medical conditions. Hundred twenty six (71%) parents of children with ASD thought that enhancing different policy measures (economic, social, educational) could advance their and their children's health and well-being.

CONCLUSION

Parents of children with ASD had poorer health than the control group in all components, except physical health. Because parents are the main providers of support for children with ASD, preserving parents' good health and well-being is a precondition for an optimal care for children. Therefore, current system for treating children with ASD in Croatia should also include permanent improvement of parents' health and well-being.

'I don't know how we coped before': a study of respite care for children in the home and hospice

AIM AND OBJECTIVE

To describe the experiences of families, whose children have life-limiting and life-threatening conditions and who have complex healthcare needs, of receiving respite care at home or in a hospice.

BACKGROUND

Respite provision is an extremely important service in assisting families to cope with the extra stresses and problems of coping with children with complex healthcare needs. There are different issues when the venue is home or a hospice.

DESIGN

Semi-structured interviews were carried out with families of children with complex healthcare needs, receiving respite care at home or in a hospice.

METHODS

A convenience sample of 11 families was interviewed using an interview schedule, exploring their experiences of the service and their views on the service.

RESULTS

The areas of concern identified as significant to all the families were referral to respite service, service organisation, communication, relinquishing control to respite carers and satisfaction with service.

CONCLUSION

Within the provision of respite care, there needs to be more overt referral systems and criteria, negotiation of appropriate roles, continuity of care, regular assessment of need and acknowledgement of the difficulty, which parents have in relinquishing control to respite carers.

RELEVANCE TO CLINICAL PRACTICE

High-quality respite care for families involves more than just organising a respite session. Healthcare professionals organising and providing care could manage a service more effectively, if taking the above issues into consideration.

The health of caregivers for children with disabilities: caregiver perspectives

BACKGROUND

There are an estimated 5.9 million children with severe disabilities in the USA, and most of them are cared for at home by their parents and families. Indirect evidence suggests that poor caregiver health may contribute to recurrent hospitalizations and out-of-home placements for children with chronic conditions and disabilities. Greater knowledge of caregiver health-related needs would allow for the improvement of existing services and the development of new strategies to sustain caregivers in their vital roles. This study explores caregiver perspectives of the health implications of long-term informal caregiving for children with disabilities.

METHODS

Forty parents/caregivers of children with disabilities residing in urban, suburban and rural regions of Utah completed questionnaires and participated in focus groups that explored their feelings regarding their current physical and emotional health and the factors that they viewed as either impairing or promoting their health. The sessions were audiotaped and transcribed. Summary statistics were generated for the questionnaire responses. Focus group content was analysed according to emerging themes and patterns in clusters of information.

RESULTS

The caregiving experience was captured by five themes: (i) stress of caregiving; (ii) negative impact on caregiver health; (iii) sharing the burden; (iv) worry about the future; and (v) caregiver coping strategies. Forty-one per cent of the caregivers reported that their health had worsened over the past year, and attributed these changes to a lack of time, a lack of control and decreased psychosocial energy.

CONCLUSIONS

Caregivers of children with disabilities describe negative physical, emotional and functional health consequences of long-term, informal caregiving. They have important insights regarding those aspects of caregiving that have positive and negative influences on their health. Interventions that address these issues may have the potential to positively impact caregiver health.

Families challenged by and accommodating to the adolescent years

BACKGROUND

Informed by Ecocultural theory, this study explores the challenges that families caring for an adolescent with disability face and strategies they apply to sustain a meaningful family routine during the adolescent years.

METHODS

In-depth Ecocultural interviews were conducted with 20 families caring for an adolescent (aged 10-21 years) with severe disabilities, including intellectual disability. Transcripts were analysed using a constant comparative approach. Two types of family level challenges were differentiated--internal and external factors impacting on daily family life.

RESULTS

Two themes representing this distinction between internal and external family challenges are presented in detail. Across both younger adolescent (aged 10-14 years) and older adolescent (aged 16-20 years) groups, families were first challenged by changing family roles and relationships (an internal factor). In response, families used three strategies: dividing up family time, protecting some members from too much involvement and engaging others in family activities. Families were also challenged by service discontinuity (an external factor). Accommodation strategies included advocacy, coordinating multiple services and forfeiting a desired alternative.

CONCLUSIONS

Family routine in the adolescent years is dynamic rather than static, simultaneously challenged by internal and external factors. Families use multiple strategies to accommodate these challenges, which are underpinned by their beliefs, values and resources. Professionals working with families caring for an adolescent with disability need to be aware of these in order to support families effectively to sustain a meaningful family routine during the adolescent years.

Decision-making of Chinese caregivers for adult out-of-home placement

BACKGROUND

In the light of the existence of lengthy waiting lists for out-of-home placements, this study examines the factors affecting the decision to apply or not to apply for this facility in a city traditionally characterized by a cultural and policy emphasis on family responsibility and by relatively low levels of welfare commitment to residential services.

METHOD

A sample of 321 people responsible for providing care for adults with moderate to severe intellectual disability (ID) from 22 service units of seven non-governmental organizations in Hong Kong was surveyed by means of a structured questionnaire.

RESULTS

The non-application group reported better emotional ties with the people with ID and greater confidence in their caregiving skills, but also tended to be caring for more challenging people with poorer health and higher or more frequent levels of self-harm behaviour than the application group who exhibited higher levels of worry and fear. Discriminant analysis successfully predicted 80% of non-application cases, while logistic regression revealed that decline in perceived competence to care, absence of other health problems and at least one parent of the client having long-term illness were better predictors of the decision to apply than handicap-specific characteristics of the people with ID themselves.

CONCLUSION

The implications of this finding are discussed, and consideration given to the possibility of developing policies designed to strengthen and treasure family values while not detracting from the importance of providing proper community support.

Out-of-home placement of children with intellectual disability: Israeli-born parents vs. new immigrants from the ex-USSR

Although the policy of deinstitutionalization encourages parents to raise a child with development disability at home, professionals are becoming increasingly aware of these parents' care-giving roles. Immigrant parents from the ex-USSR who have children with developmental disabilities are potential clients for placement, but to date, the tendency in Israel to out-of-home placement by immigrant parents, compared with Israeli-born parents, has not been studied. The placement variables were examined as a function of place of birth, emotional stress and social support. The sample was 100 parents who have children aged 6-21 years with mild to moderate mental retardation (according to the American Association on Mental Retardation definition) who live at home. Fifty parents were immigrants (arrived in Israel after 1990) and 50 were Israeli-born. They live in the region of Haifa and the north of Israel. The following measurements were carried out: (1) Demographic Questionnaire for data such as place of birth, age, socioeconomic status, etc., (2) Questionnaire of Resources and Stress, (3) Family Support Scale and (4) Out-of-Home Placement Questionnaire. The results showed that parents' readiness to apply for out-of-home placement proved to be related to their stress level and child's age, regardless of their origin (immigrants or Israeli-born) and regardless of social support resources. The older the children with mental retardation and the higher the stress levels felt by their parents, the higher was these parents' potential to apply for out-of-home placement. Immigrant parents tended to report a significantly higher level of stress than Israeli-born parents. No difference was found in the social support resources available to both research groups. Immigrant parents' stress level was higher as the child's mental retardation level was more moderate and their time in Israel was longer. Stress level among Israeli-born parents was higher among those who were religious, were of lower socioeconomic status and/or when, in addition to the mental retardation, the child suffered from other medical problems. In conclusion, families with children with mental retardation should be referred to services in an integrative way, regardless of the origin of the children's parents. Professionals must increase their own awareness of parents' level of stress and its impact on their readiness to apply for out-of-home placement. Recommendations for practical work and for future researches are made.

Dilemmas in the provision of own-home respite support for parents of young children with complex health care needs: evidence from an evaluation

Dilemmas in the provision of own-home respite support for parents of young children with complex health care needs: evidence from an evaluation Aims. The aim of this article is to present some of the results of a qualitative evaluation of a United Kingdom (UK) nurse-led, home-based, respite service for the families of children under the age of five with complex health care needs. Background. Advances in neonatal medical and nursing care have contributed to a growth in the number of children who survive low birth weight, birth trauma, and various congenital anomalies. Many of these children are likely to have long-term care needs which will require innovative nursing responses. Of particular importance is the need for parental respite, given the added demands of caring for very ill children at home. Methods. A parent-centred, follow-up evaluation, using in-depth qualitative interviews with parents in 18 families consecutively referred to the Children's Outreach Service between April and December 1997. Findings. This evaluation reveals the sometimes mixed reactions of parents to this innovative service, and the equivocal evidence about its role in contributing to family well-being. We discuss, from the perspective of parents using the service, some of the dilemmas and problems in the provision of home-based respite support to this client group. In particular, we explore the diverse ways in which families talk about their need for respite support and point to the need for flexibility in this kind of service provision if these support needs are to be met. Conclusion. We conclude by discussing the practice implications of our evaluation for those planning similar services.