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Thursday, August 26, 2010

If we always do it that way.....

The National Survey of Child and Adolescent Well being in the USA (No. 16) has shown some distressing data on the effectiveness of child protection interventions ( ). The one that really struck me:

"Parenting services. The leading CWS service provided for biological families was some kind of parenting intervention. A full 94% of counties delivered parent training to families with identified need, but the most frequently used programs failed to adhere to evidence-based approaches (Hurlburt, Barth, Leslie, Landsverk, & McCrae, 2007)"

I have heard other researchers talk about the use of interventions for which there is little evidence that it impacts the family behaviors (example is Dr. Harriet MacMillan from McMaster University in Hamilton, Ont.) Perhaps the main reason why this keeps happening is related to lack of better alternatives that have shown effectiveness over the long term (although research has shown some possible directions. Another feature is budgets that may limit exposure to effective programming that tends to be more intense and expensive.

Too often research has shown that case plans follow formulas either because that's all that is available or that's just how we do it.

This research bulletin is worth a read (doesn't take long) but it really helps to again see that the level of needs in maltreatment families are high and we may not be meeting them successfully judging by the outcomes.

Saturday, August 21, 2010

The Christian Lee Case - a detailed review

Christian Lee – DOB:
Date of Death: September 4 2007
Christian Lee (CBC Photo)

Christian Lee was a six year old boy, the only child of Peter Lee and his estranged wife, Yong Sun (Sunny) Park. He would be murdered by his father on September 4 2007 along with his mother as well as his maternal grandparents. Peter Lee would also kill himself as part of this family massacre.
The British Columbia Representative for Children and Youth completed a review of how matters were handled with this family’s case where Sunny had reported that she was afraid of her husband. In the Executive Summary, the report on his death notes:
Prior to committing the murders, Peter Lee was banned from the family home and had
no job. He was facing charges for confining and threatening a young man, and for deliberately causing harm to his wife by crashing the family vehicle.

Five weeks prior, Peter Lee, 38, and Sunny Park, 32, had been involved in a car crash in the Greater Victoria region, where they lived and worked. Police learned from Sunny that she believed the crash was intentional. As a result of the crash, she had a fractured arm and serious injuries to her face. Sunny was told that recovery would take up to a year. She told police she had been a victim of her husband’s violent behaviour for many years and that she was extremely concerned for her safety. She thought her husband was going to kill her. She began initiating divorce proceedings with a lawyer.(p.1)

That there were clear concerns of domestic violence is noted to have been a primary concern of this case. The police appeared to have been sufficiently concerned that they believed the risk of some further domestic violence was real. The report goes on to note:

As a result of the car crash, Peter was charged with dangerous driving causing bodily harm and unlawfully causing bodily harm to Sunny. He was under a court order, which prohibited him from contacting Sunny Park, from visiting the family home, from visiting the family’s downtown restaurant, and from possessing explosive substances or weapons, such as knives. He was not prohibited from contacting Christian.

Police felt that he posed a serious threat to his wife and were concerned enough about Peter’s release on bail that they contacted the Ministry of Children and Family Development (MCFD). This prompted the ministry’s first involvement with Christian and his family. The police had been called to the home for a domestic dispute in 2003, and although police records indicate the ministry was notified, no record was found of this at the ministry.(p.1)

Inter agency communication break downs have been found to be a significant factor in many of the inquiries regarding deaths of children. This has been true in Canada, the United Kingdom and other Anglophone jurisdictions. Many of these inquiries have been critical of these as information not flowing between agencies causes decisions to be made that are contrary to the protection of children. CPS decision making is based upon imperfect information in virtually all cases. This is made worse, however, when valuable data that could improve the decision making is withheld (rarely consciously) or is sent along ineffectively.

The Representative’s investigation into Christian’s death describes how three systems
worked independently of each other, and how this affected Christian’s safety because
of lost opportunities for effective intervention. (p.3)

The report states further,” Consistent with the overall theme of this report it is important to note that all the information gathered in this section was not known to all relevant officials at all times, including Crown Counsel” (p.21).

In this case, the Representative is critical of this lack of coordination

Domestic violence cases are particularly difficult as offenders are often disrespectful of court orders prohibiting contact. Yet CPS can determine that, from a risk perspective, if the individual who constitutes the risk is out of the home and there is another adult caring for the child, that adult may be able to protect the child from harm. This is not an unusual case decision. The report on Christian’s death notes:

MCFD took the approach that because Christian was with his mother and his father was not living at home, the boy was safe from physical harm. Ministry staff concluded his mother was willing and able to protect him. While this approach reflects the way our child protection legislation is structured, it does not allow for a full recognition of the dynamics at play in domestic violence cases. Christian was not safe because his mother was not safe. She was an immigrant depending on her abusive husband to explain the social service and legal systems in British Columbia, and she had limited confidence in her ability to express herself in English.(p.2)

Cultural issues are at play. Immigrants to a country may well not be sufficiently independent or aware of their rights or services to support them. Immigrant women may be particularly vulnerable as they can be isolated, highly dependent on their husbands who have more contact in the broader community and, depending on the culture, may struggle with controlling behaviors from the originating culture. Asserting their right to safety, such as through safety planning, can be so foreign that following through is challenging. Imagine being fearful while also struggling to communicate that in a crisis where English is not your native language.

An area that may create cultural misunderstanding is a belief that when an immigrant has been in Canada for quite some time, as Sunny had been since the late 1990’s that they will have assimilated. This is an assumption that can prove quite erroneous. There are a number of factors that can impair assimilation such as:

·         Limitations with language;
·         Strong ties within the particular cultural community which preserve traditional ways;
·         Family processes that are sustained also sustaining traditional positions for immigrant women making it hard to establish an independent position within the larger community.

In Sunny’s case, she was seen as a successful business person working in a restaurant business with her husband and her sister with private investors backing it up. This could be seen as giving an impression of independence when one apparently did not exist. Only by taking time to assess what is going on, building a relationship with a client and coming to see just how the client fits into their environment can we come to see what are the real strengths versus those that might appear to exist. Thus, it is possible to engage in planning with an immigrant client that appears to be clear but is poorly understood by the client.

Plans also need to be developed based upon an understanding of the needs, including the risks that may be present, bearing in mind that we never truly understand the depths of the risk. In addition, risk assessment is prone to include both false positives and negatives. These are lessons to ensure that risk assessments are seen for what they are, but they are still a useful tool. Without assessment, planning is the proverbial shot in the dark. In the Christian Lee case, this would appear to be part of the problem.

The ministry and police each independently discussed safety planning with Sunny Park, but a comprehensive safety plan was not developed nor was there a rigorous assessment of the risk posed by Peter Lee. (p.2)

There were strong indicators that there were serious concerns indeed. Peter Lee was no longer working with his wife. Even more important, there is a record of domestic violence. Next there is a relevant criminal record:
At the time of the murders, Peter was subject to two bail orders – the first arising from charges of uttering threats and unlawful confinement stemming from an incident in July 2006 involving a young man, and the second arising from a car crash in July 2007. (p. 12).

The Representative reviews in detail the chronology of events prior to the murder. What is apparent in that is the ineffective communication between police and CPS:

MCFD’s After Hours office receives and responds to child protection reports outside of regular business hours. On Aug. 3, 2007, the After Hours office was called by a senior Victoria Police Department officer. The officer alerted After Hours staff that Peter had been released on bail the previous day. Peter had been arrested on July 31, 2007, and held in custody. He was charged with dangerous driving causing bodily harm, and unlawfully causing bodily harm to Sunny. The investigating officers believed he posed a serious threat to his wife and her family. The police officer wanted this information entered into MCFD’s child protection system in case the ministry had further involvement with the family. (p.13)

The report also notes on the same page:
The police officer reported that the conditions of Peter’s release included a no-contact condition with Sunny, and no-go conditions to the family residence and restaurant. He noted that Peter had no job, no residence, and was destitute. The police officer believed that he might try to make contact with his son Christian, who was not part of the no contact order.

Additional background information about the family was also provided by the police officer to the After Hours social worker. Peter, Sunny, Christian, Sunny’s parents and her sister had been living in a house in Oak Bay. The couple’s business and financial interests had been signed over to Sunny. Although there was a long history of domestic violence, this had not been reported to police and Peter had never before been charged in that regard. It appeared that Sunny had been the sole target of violence and that Christian had not been the direct victim of any physical abuse

It is easy to see how CPS might view that the risk is to the mother as opposed to the child. This is flawed thinking as it creates a false barrier between the parent and the child. What good does it do to assume the child is safe if the parent is at risk? Does that not, by definition, mean that the child can only be viewed as safe if away from the parent at risk? How then can there be any planning that would leave a child in the care of such a parent unless that parent too can be protected?
In this case, there are three systems operating with the family but not in a coordinated fashion. They are criminal law / justice; family law and CPS. They were not working in tandem.
This police officer’s report to After Hours was the only direct contact between the ministry and the Victoria Police Department about this family, between Aug. 3, 2007 and the date of the murders. (p.16)

The report identifies other communication problems beyond child welfare such as between various police forces within the region. The practice point is that various bodies are often involved with CPS families. As is seen time and again in these cases, communication between them is poor leading to gaps in knowledge and thus action.
There can also be problems with history either being ignored or not known because of problems with records. This too is a problem seen in other cases:
Police records indicate that in 2003 Victoria police responded to a domestic violence call at the family home and called MCFD to report it. However, there is no mention of the call from police in ministry records.(p.18)

There were also prior criminal involvements which, if part of a coordinated assessment picture, would have helped police and social workers to better assess the risk. In addition, the police had information about prior domestic violence episodes.
The report goes on to describe the history of domestic violence that had occurred in this family. Domestic violence typically occurs in silence and this may be even more so in immigrant families.  In an interview with one of the police forces, Sunny offers a detailed history of such violence offering details that have not been known before outside the family but offered an alarming pattern of violence once known.
Sunny described intimidation and emotional and psychological abuse. She said that Peter had pressured her to have sex against her wishes on numerous occasions. She said that he had threatened to kill her and to kill himself. The report to Crown Counsel expressly records:

PARK states that LEE insists that they stay together and has threatened her in the past that if PARK ever tried to pursue a divorce he would kill her or both of them. PARK never made a complaint to police as she fears for her life and believed that if she had tried to make a complaint LEE would seriously harm her or worse kill her.

Sunny said the violence escalated in the months after she told Peter that she wanted to end their marriage. She believed that he would kill her if she pursued a divorce. She was afraid that if Peter was released, the situation would get much worse. Sunny also told police that Peter had told her that he would rather die than have a divorce and that he would kill everybody and then kill himself. (p. 17)

This again raises another point where assessment might have been seen as urgent. The literature on domestic violence tells us that there are men who cannot let go. If they cannot have their family then they cannot live without them. They will not share them and they will not lose them. These can be dangerous people for sure. Was Peter Lee such a person? That he killed his family suggests so. Assessment may have identified him as such.
Another system was also at play in this case – private therapy. While involvement had not been extensive, it was revealing but not necessarily available to the public systems. This again represents a communication barrier.

According to the therapists, Peter was there to save the marriage, while Sunny wanted the marriage to be over. Sunny said that she had tried to leave many times, but Peter had always convinced her to stay. During the session, the issue of violence quickly came out. Peter did not deny that he had been abusive. He acknowledged each incident that Sunny brought up, apologized, and said he had been stupid. His behaviour was respectful and although he was expressing his emotions, he remained very much under control. (p.19)

However, the private therapist lacked detailed information and involvement occurs only weeks before the murders take place. There would be some minor follow up with the therapist but bit appears to be fairly limited in nature. Peter did not follow through despite the therapist attempting to engage him
The report then brings us to a crucial point for learning from this case. CPS officials receive the police report just under a month before the murders. It is a very difficult scenario for social workers – how important is this case versus others? Is there imminent risk? Is the child protected? Like many similar situations, the question becomes what more should we know and how can we gather it?
In assessing the report, the team noted that MCFD had no prior contact with Sunny or Peter.They wondered how this could be the case. The report from the police officer noted a long history of domestic violence, yet the ministry had no documented reports about the family.

At the intake meeting, the team decided to first gather more information about the circumstances. They decided to meet with Christian’s parents and request the police records to further assess the situation. At this point, the team knew about the history of
domestic violence, and there was no information to indicate that Christian had been the direct victim of any physical abuse.

The file was assigned to an experienced social worker. The social worker left a phone message for Sunny that same day. She also requested records from the Victoria Police Department pertaining to the car collision, and records of any other police involvement and any relevant information regarding criminal activity, occurrences and/or criminal records for Christian’s father and mother.

The next day, Aug. 8, 2007, the social worker received a phone call from Sunny, who said that she and Christian were staying with family in Vancouver. She said that Peter had been abusing her over the previous seven years and that the situation was getting worse, particularly after she decided to get a divorce. She told the social worker that she believed he had deliberately caused the car crash in an attempt to injure her.
The social worker understood that there was a restraining order in place, and she suggested that Sunny get Christian’s name added as a ‘no-contact’ person. Sunny stated that she was planning to return to Victoria on Aug. 13, 2007. The social worker decided to wait for Christian and his mother to return, in order to further assess the family. The social worker asked Sunny to call when she returned to Victoria.(p.23).

From this it would not be hard for an experienced worker to feel that the criminal justice system as well as the mother herself were combining to take steps to keep the child safe. The social worker proceeds to gather information from the police forces involved. A little under 3 weeks prior to the murders, the social worker is asked by the bail supervisor:

.. for an opinion as to whether Christian should be added to the order. The social worker replied that she was not in a position to comment on whether Christian was safe because the ministry needed to meet with his mother and get more information in order to assess the child’s safety. The social worker had not at that time met Sunny.(p.24)

The criminal justice system would continue to attempt to contain Peter Lee and Sunny would remain afraid of him. Largely that system will focus on Sunny but does have some worries about contact between Peter and Christian. The bail supervisor requests this but the criminal justice system determines that there are no reasonable grounds to do so.
By August 20, now only a few weeks before the murder, Sunny is overtly afraid of her husband describing this fear to representatives of the criminal justice system as well as to CPS. The report notes:
Also on Aug. 20, 2007 – 17 days after the report first came in to the ministry and 13 days after the social worker was assigned to assess the family – the social worker conducted a home visit. Christian was at the front door when she arrived. During the meeting, he went in and out of the living room until his mother told him to go to his grandmother. He was not separately interviewed by the social worker. The meeting lasted more than three hours.

Sunny described her husband as being very controlling and manipulative. She said he had a bad temper and had broken furniture in fits of rage that had been witnessed by Christian, her father and her sister. She said Christian had seen her and Peter fighting throughout the previous years.(p.26)

Given the ever increasing caseloads facing CPS, the response time by the social worker may, in fact, have been reasonable if not a reflection of pragmatic reality. There may be jurisdictions that might even suggest that this was pretty good. However, denying the child a voice by not interviewing him is to withdraw from a legitimate source of information but to also neuter his capacity for meaningful participation in his own life.
The social worker does what many would do in the situation, consider the risks and determine how services in the community might benefit. This forms part of the safety planning but the social worker engages in a presumption – not an uncommon one frankly – that the client is capable of ensuring follow through with the plan with a third party – in this case her lawyer:
The social worker talked again with her about having Christian’s name added to the no contact order. The social worker was confident that Sunny would review these referrals with her lawyer the following day. The social worker believed that the lawyer would assist her with follow-up and with getting Christian’s name added to the no-contact order. The social worker also talked to Sunny about organizing supervised visits between Christian and his father.(p.26)

At what point are such assumptions valid? When can we have confidence in the client’s capacity and / or motivation to follow through? Many social workers can tell stories of clients agreeing to plans that they then do not complete or even begin.
The social worker advised the mother that if Christian were exposed to further domestic violence or if he were in his father’s sole care, the ministry would need to reassess his safety and consider taking more intrusive measures. She explained to Sunny that she had the authority to remove a child, but considers other measures first. This alarmed Sunny, and was reported to Peter by Sunny’s sister. The next day Peter phoned the social worker and expressed concern about this possibility.(p.26)

The onus is, in essence, then placed on the mother to protect or face loss of her child. Could she have done that when she was herself so afraid that her husband might harm her?  But quite importantly, there is the notation that Peter calls the next day – how does Peter know about the possibility of apprehension? This can be an example of the apparent contradictions in a case – Sunny, allegedly afraid of Peter, might well be the source of the information to Peter. These contradictions should be considered the norm in CPS cases – not the exception.

The mother offers a further contradiction to the social worker:
Sunny said she felt safe because her parents and sister were living in the home with her. She had changed the locks and the alarm code in the home. She did not believe that Peter would come to her house, and said she would call the police or the ministry if anything happened.(p.26)

She gives to the social worker an apparent statement that safety could be maintained. It is tempting to take these statements at their face value. Was the statement reasonable? Well, with the strength of hindsight, no.
Given that the social worker did conclude that the mother could protect, she discussed the case with her team leader “…from the perspective that the child’s safety was secured through the safety of his mother. They concluded that the mother was protecting Christian. They decided that the most appropriate response to the report was to proceed with referring the mother to community services.” (p.27)

What had not occurred was a coordination of information amongst the various systems involved, along with an assessment of Peter, to determine if, when all the available data was seen from a coordinated perspective, the conclusion that the mother could protect was a reasonable one.

The social worker was going on vacation from Aug. 24 to Sept. 4, 2007. The social worker’s plan was to check in with Sunny again after her vacation, and then close the file. (p.26)

The CPS also begins to see this matter as a custody issue between parents who are divorcing – another not uncommon perception when alleged CPS matters arise in the course of couples separating. Of course, the research tells us that in domestic violence cases, risks tend to increase during separation divorce processes.
The report also states:
The same day, Aug. 28, 2007, MCFD received a response to its request for Sunny’s and Peter’s records from the Oak Bay Police Department. This contained information about Sunny providing a statement after the car crash on July 31, 2007, the domestic dispute call of July 19, 2007, a call from Peter on Feb. 2, 2007 when he suspected someone was prowling around their Oak Bay house, and a 2004 incident when the Oak Bay police spoke with Peter about a group of intoxicated students causing a public disturbance.

These records arrived when the social worker was on vacation and they were not reviewed by anyone at the ministry in her absence.

During the four weeks that the ministry was involved with the family, the file remained assigned to one social worker. The supervision was covered by two different acting team leaders and one permanent team leader. For one week, the social worker assigned to the file was also acting as the team leader. The ministry had no further contact with Christian’s family.(pp.29-30).

Although it may well be that the social worker was not told this and that the family law specialist may have been, Sunny raises a very important red flag.

She had also begun to feel that Christian may be in danger because she learned that Peter had been trying to arrange visits with Christian through an intermediary. Peter had told Christian these visits were secret and he should not tell his mother about them. (p.28)

Peter appears to be taking steps to ally Christian and to seek access in a way that engages his son in secrets held between them. This is a clear risk signal. She tells her lawyer further crucial information but it appears that this was not known to CPS:
She believed Peter had a compulsive disorder, and noted that he had a problem with gambling and had treatment for a drinking problem five or six years earlier. Sunny described a history of Peter hitting her and breaking things. She said Peter had not been allowing her to speak. (p.28)

This raises concerns about what stress Peter might be under and his capacity to manage that stress. The lawyer offers crucial advice although it is not clear how she was to implement it:
The lawyer advised Sunny that although an application for a restraining order would be made, it alone could not protect her. Sunny was told she would need a safety plan, and that in her case that meant she absolutely should not return to the family home. The lawyer discussed the risks, and what they were based on. These included Peter’s familiarity with knives and other weapons, gained from his military background, and Sunny’s stated concern for her safety, as well as her parents’ and Christian’s well-being. (p.28)

Following her meeting with the lawyer, Peter calls Sunny’s lawyer’s office making it clear that he knew she had been there. This is something that he had also done with a dentist. This is a further red flag of stalking behaviors.
The Victoria Times-Colonist newspaper reports that the inquest was told that Sunny was clear with the police about her fears. Their story on January 18, 2010 states:
The interview with Ms. Park, played at the start of the inquest, showed her heavily bandaged after Mr. Lee drove the family car into a utility pole, which she said was an attempt to kill her.
She calmly predicted that her husband would “kill everyone” if she proceeded with a divorce. She chronicled years of escalating abuse, sometimes in front of the couple's young son, Christian Lee.
“He said, ‘I'll kill everybody, I'll kill myself,' like that, if I divorce him,” Ms. Park said.
The Victoria police officers who interviewed Ms. Park, her sister, and Mr. Lee, who was facing domestic assault charges, believed he should not be released on bail, but they were unable to persuade Crown counsel that they had enough evidence to hold him.
Mr. Lee was released, and on Sept. 4, 2007, just hours before his son was to begin Grade 1, he broke into the home and murdered Christian, Ms. Park and her parents, Kum Lea Chun and Moon Kyu Park.
An area of concern that became evident in both the Representatives report and the inquest is that there was a lack of coordination between the various parties. As a result, many of the flags that can be seen in this case outline did not get viewed in a coordinated fashion. Various parties held aspects of the data. There was also an apparent lack of training identified around domestic violence issues. Consider the impact of uncoordinated information along with what information was available coming to the attention of those not properly trained to appreciate the value of the data. Therefore, it is not surprising that the Representative states as a conclusions:
The lack of a system-wide domestic violence response across criminal law, child welfare and family justice sectors, and the absence of a thorough and fully informed assessment of the risk of harm and lethality posed by Peter Lee placed Christian Lee and Sunny Park in grave danger without an adequate safety plan.(p.33)

There were many signals throughout this family’s relatively brief involvement with the various systems that said Peter Lee was a risk to his family. The most obvious ones include:
·         An apparent attempt to kill Sunny through a motor vehicle accident;
·         Threats that he could not be without his family;
·         Stalking behaviors;
·         Failure to adhere to the court orders;
·         A history of abusive behaviors;
·         Failure to follow through with things such as therapy; and
·         A loss of employment and financial status.
These alone should have signaled real concern that Sunny and Christian were in danger. These, properly assessed would have signaled to criminal, legal and child protection that risk was very present and that the mother, a particular target of the risk, could not then protect Christian. Research helps us to see that men with the apparent profile of Peter are prone to thinking that they cannot handle the losses of family to which they are so emotionally and egotistically defined.
It is not clear that legislation in various jurisdictions will directly include domestic violence in the home as the basis for intervention. Of course, there are so many reasons for child protection to get involved in a family and there remains the challenge of resources that can assist – can families be better identified? Can they be properly assessed? Are the resources accessible? Is the client capable of using the resources? These are case challenges that many workers face. If we are truly going to help families, however, these are the very challenges that we need to address. Just using legislative intervention, such as apprehension or threats of apprehension, are not the solution in these cases. Getting real interventions that create change are needed but limited resources (including case worker time) are a frequent block to real changes in a family.
In this case, Peter Lee required proper, timely assessment before he was allowed out of jail. Does the criminal justice system understand this? How is the family protected if they do not? The Coroner’s Inquest jury understood this. They recommended:
- risk assessments be conducted before someone is released on bail;
- stricter bail conditions, particularly for people who cannot provide a fixed address;
- education and advertising campaigns against domestic violence; and
- advocacy services for both victims and abusers. (Globe and Mail, January 19, 2010)

These recommendations and the details of this case help us to see that child protection is not the sole territory of the child welfare services. Rather, they encompass a variety of systems – child welfare, police, criminal and family law, therapists – as identified in the case. There are others as well, in particular the various aspects of the health care system. When one group believes they have ownership, then children will be unprotected who ought to be otherwise. While it is true that the legislative framework will give the statutory ownership to child welfare, the real ownership les with society of which all of these systems are its representatives.
The political system is supposedly society’s leaders in developing the legal framework from which all of this activity is to take place. Too often they are driven more by the appearance of doing something as opposed to actually making the types of systemic change that will make real differences in how services are delivered.
In the Christian Lee case, government has so far made some promising statements but these have not been backed up with any significant resources. A review of child protection death cases sees that government will often make lofty statements about system changes but they seem incapable of achieving the wide spread changes that will diminish risk because families act more responsibly or systems can react in a preventative rather than crisis response mode. Arguably, we may not know how to do the latter effectively. There are precious few models to draw upon as examples.
Indeed, solutions may lie outside of the direct child protection system. What difference might have existed if police were able to act upon their concerns, get the appropriate legal restraints as well as help Sunny to be in safe housing away from the risk of Peter breaking into her home and killing his family?
The question we must face, if politicians, managers and policy makers keep coming up with new responses following these cases, why do they still occur? We might need to accept that no level of policy structure will ultimately stop deaths from occurring. The responses and changes that are brought into place may reflect the particular needs of a given case but not of the general issues that may exist in broader society.
What this work does do is help us to see that service delivery can improve how and what it does. Society, on the other hand, may need to address the complexities that create people and situations leading to the deaths of children.
Politicians are well meaning but typically driven by an agenda that has more to do with balancing re-election with the agenda that is politically astute. There is often a leadership vacuum to try to address the systemic changes that child protection needs.

Friday, August 20, 2010

Child Sexual Abuse - Hidden stories

One of the biggest challenges in working in child protection is the knowledge that the cases you see represent only a portion of what is out there. Sure, there are cases that are exaggerated, fabricated, over emphasized - but they are not the majority. Most cases are legitimate and in need of intervention.

Child sexual abuse is one of those areas where getting the story told is challenging. This is partly because the abuser holds such power over the victim. The victims are often voiceless because if they tell, then they believe that something very bad will happen in the family. After all, this is what the abuser has told them.

Some commentary out of Scotland lends credence to the view that most child sexual abuse remains hidden. Here is the link to the story (copy the link into your browser)  

Child Protection Interview - Auroville

I had the opportunity to speak with Auroville Radio about child protection. Here is the link to the interview (copy the address into your browser). 


Sunday, August 15, 2010

Justice delayed

A recent study in the United Kingdom talks about long delays by the courts in determining child protection cases. This is a problem that is not unique to England. Research has spoken about this problem before. For the child, this is not only justice delayed but life delayed.
The child is left in limbo not knowing what the probable future holds. This creates loyalty binds - should the child hold out hope for the return to family or should the child begin to attach to a foster family (yet other research shows that children in care may face as many as 7 changes in care placements). There are other very profound challenges for a child who faces long delays in court processes. These include:

  1. changes in schools - multiple and during times when it is socially awkward. It also interrupts learning and the child may well wonder why they should bother given that another school lies just over the horizon.
  2. Loss of friends as they move about - again - why bother working at making friends
  3. Poor academic achievement as things like learning disabilities or gaps will be missed as teachers don't have the child in the classroom long enough to really understand the child
  4. Ambivalence about life - what matters and doesn't matter
  5. Changes in social workers - as the case drags on, social workers move on
  6. Behavior problems that are getting worse as there is a lack of stability in school and households to really address them - this has led some writers to feel that this is one of the reasons that so many children in care are on psychiatric medication.
If our system is child centered, one might ask how this can be left to occur. But we are also trying to balance the rights of parents to have their case heard and possibly appealed. The latter might lead to a re-trial - all of which might be appropriate - but it is hard to explain this to a child who simply waits.

A dialogue should be happening (and in some places is) about ways to change this. It will be interesting to see what the Munro commission in England comes up with that might alter the system so that decisions affecting children can be made expeditiously and truly focused on what the child needs.

Saturday, August 14, 2010

Some key elements of good child protection

Those of us who have worked in the field for a while, talk about the need for good prevention programming and building a good relationship with the client. We are too frequently in a responsive position where we must try and pick up the pieces long after the damage is done. Intervention comes too late.

In the United Kingdom, Ofsted has looked at what makes for good child protection. They have identified some key conclusions:

"The main characteristics of the best performing authorities show:
  1. consistency in practice that is driving real improvement of local services;
  2. a clear focus on the children and young people who need support most and on their progress and development
  3. a deep understanding of local children, families and communities" (p.5)

They identified some other key elements:
  1. a broad view of what children's services are that is shared amongst various agencies with a mandate to help children and their families;
  2. they paid attention to outcomes to see what was working
  3. there was a focus on closing the gap between vulnerable children and those things that allow children to be successful
  4. stability was sought for the children who were in out of home care
  5. there was close familiarity with programs and what was happening in them by those responsible for them - strong management and strong leadership
  6. they looked at what was going well as what was not and responded to that which was not going well - and responded in a timely manner
  7. helped staff to see where strengths and deficiencies existed within the system and afforded opportunities for addressing the deficiencies

The report gives some good case examples so that you can see how these ideals exist in action. You can find the full report at 


Tuesday, August 10, 2010

A child dies - do we over react

There is a growing body of research that suggests when a major catastophe occurs in child protection, it will be followed by an over reaction - the system and those in it seek to protect themselves. If a child dies, an increase in foster care placements follows. This has been seen in several locations such as in Britain and the USA. BBC reports that just such a trend is occuring in Britain now following the death of Baby Peter.

Reseach from Cahpin Hill in the United States tells us that foster care often fails to deliver a good outcome overthe long run often because the resources needed to support a successful outcome are lacking.

There are claerly cases where sustaining a child in tehfamily is not possible but a child's death should not take the profession away from good case work to risk management - yet that is what happens. Risk management approaches are not about good case management.

Here is a report from BBC this week

A sharp increase in the number of children being taken into care following the death of Peter Connelly, known as Baby Peter, is putting increasing pressure on foster carers, figures seen by Newsnight show. Liz MacKean meets those affected.


Michele Sutcliffe's home is, as ever, busy and noisy. Her two young boys charge about their Cheshire garden with their football.

Standing in goal is Jeff Fletcher, one of the many young people raised by Michele and her husband during the 14 years they have been foster carers.

When stable and living with someone you can worry about yourself and get on with your own life

"Things have deteriorated in recent years," Michele tells me.

It has got worse because of the growing pressure to find suitable placements for children in need.

Even while having their own two boys, the Sutcliffes continued to provide a home and haven for teenagers - some of them very troubled.

But Michele explains how she has taken care of children she would never have taken in had she been given more information about them.

"We have had placements... where it's apparent very quickly they're mismatched - and my own children are then at risk due to the nature of these children," she says.

I ask Michele why she had not been given a full picture, and she explains how her local authority is "desperate to place children" and that "they've got little choice and few options".

A report from the Fostering Network , called Bursting at the Seams due to be published on Thursday will show how desperate some local authorities have become to meet a growing demand for their fostering services.

The foster care system is the United Kingdom is under tremendous strain at the moment
A third need to find homes for an additional 50 children. Two thirds have asked foster carers to take in children outside those for which they are officially approved.

The 2007 death of Peter Connelly in north London despite being seen regularly by child care professionals has seen social workers more inclined to recommend children are taken away from problem parents.

In the last year, this has led to a 34% rise in children being taken into care in England, putting the system under increasing strain.

Robert Tapsfield, from the Fostering Network, argues this is more likely to lead to inappropriate placements.

"When children don't find the right family for them it's more likely to break down, and that's when things start to go wrong," he says.
The foster care system is the United Kingdom is under tremendous strain at the moment."

Jeff Fletcher, who's now 25, believes his own experience shows why long-term foster placements are so vital. He now has a child of his own and puts his current stability down to the six years he spent with the Sutcliffes.
It's very difficult to say no, because you wonder where that young person's going to go to if you don't take them

"The upset of leaving home was bad enough," he says. "If you have to move around it's another rejection... when stable and living with someone you can worry about yourself and get on with your own life."

In Aberaeron, North Wales, 15-year-old Leon has also benefitted from his foster placement. He works as a sous chef, and admits he would probably have "ended up going into crime and stuff" had he not found a stable placement.

"I used to be shy, kept myself to myself. But now I've come out of my shell," he says.
And Caroline March, who has looked after Leon for six years, says turning a child down can be hard.

"It's very difficult to say no, because you wonder where that young person's going to go to if you don't take them," she says. "And you know you have that ability to work with them - every child has something to work with."

Foster carers provide sanctuary to around 75% of all children in care.

Foster carers fears that the growing pressure will turn carers away and put others off at a time when they are more needed than ever.

Wednesday, August 4, 2010

Relationships are vital but why aren't they working

Recent research has affirmed what many social workers have known for years. The relationship between the worker and the client is the most crucial element of effective case work – including in child protection. Certainly there are clients who make the relationship very difficult as they resist working with anyone connected to child protection. In a few cases, this can be a severe enough resistance that intervention cannot work and the child cannot be protected within the family. As well, there are parents whose behaviors are so dangerous that, even when they engage with services, cannot be with their children until real change is well underway. However, for the vast majority of cases, a good working relationship with a case worker is vital to supporting their change efforts that are genuinely motivated to make their parenting better.

Telling people what to do and how to do it is not typically effective. Complex families in particular are often so stuck in their ways that they cannot trust the worker to begin with and will see prescriptive efforts as just another example of people in authority interfering in their lives. It talks time to get into these families in ways that cause them to believe that the worker really is trying to support something worthwhile. Remember that for many of these families, what we see as going wrong is both normal and likely inter-generational. Even if the family feels that what they are doing isn’t working very well. It may be so normal that they lack the capacity to see that it can be any different because it has been that way in the family for so long – and not just in a nuclear family sense but in the broad extended family.

Where some of the reasons for poor family function are also ecological, the family may feel that change is something that is so remote a possibility that they can see no reason to try to do something different. Consider the housing project full of families struggling with the economic realities of life, surrounded by crime, violence, substance use. In other words, they are surviving in an environment that they can afford to be in but may not want to be and without the means to live elsewhere. The social influences are massive and beyond the direct control of the family.

And then along comes what they believe is little miss goody two shoes from another world telling them what they need to do – it feels like a Martian arriving from some other world. Without the relationship, how can the family be expected to take anything seriously?

We tell the parents that they need to react to their child differently, calmer with more nurturing behavior. Yet, these are behaviors that are foreign. The majority of abusing parents themselves grew up in environments that created disorganized attachments in which nurturance, support, emotional regulation were typically unseen. A social worker coming in with power to tell parents should therefore not surprisingly result in anger, resistance, and other features of a power struggle.

To overcome this takes time – something that budget oriented management approaches make difficult. It may well take weeks to achieve even the beginning of a relationship and many months before real change is occurring. This is long term work that is further complicated by the reality that the sooner we intervene in a child’s life the better. Neuroscience and attachment research tell us that the neural networks of relationship are strongly in place from within the pregnancy to about three years. These attachment patterns have lifelong implications for how well we relate to others and manage our own emotions. Indeed, most of the parents we will work with have disorganized attachment – thus the intergenerational nature of child protection work.

We are torn between needing to get in early, do intense relationship building and then model different ways to parent in families with high levels of resistance and complexity while at the same time needing to show results to budget oriented mangerialism. However, that may not be the biggest hurdle but it may be the work environment itself. If relationship building is so crucial to this work, then the workers need to stay around. Yet, we are seeing high turnover rates in child protection throughout the Western world.

If I am the resistant client, I probably know enough about the system to know that you will go away to be replaced by some other worker, wet behind the ears, that I can also outlast. This is one of the reasons why we see files being re-opened time and again. Families may even show some progress from file opening to file opening but cannot sustain it because the interventions have not been intense and long enough to overcome the attachment patterns, for example.

If we cannot keep workers, how can we expect these families to trust us? The relationships just aren’t there.

As in all of these posts, there is so much to discuss and no post is really thorough enough to cover it all – but hopefully it is stimulating the kind of thinking that our profession needs for a healthy debate about where we are going.

An excellent review of some of these issues can be found in the recently published book out of the United Kingdom:

Barlow, J. & Scott, J. (2010). Safeguarding in the 21st century – where to now. Dartington: Research in Practice.

Tuesday, August 3, 2010

Saskatchewan review talks big reform

CBC news is carrying a story that a review of the Saskatchewan child protection system has identified problems so big that the system needs a complete rebuild. There are many calls for systemic restructuring in child protection throughout the western world. I look forward to redaing the report in Sask but a word of caution. Child protection may not be working in the western world in many but not all cases because we have the mandate confused. Further, as a society, we may not be willing to pay for a good system that can do the folloiwng well:

1. assist families where the parents are not good enough to get interventions that will help get there;
2. prevent child abuse and neglect through family and community interventions;
3. protect children from parents who are not good enough and can't get there.

These are expensive goals that require a budgetary committment over the long term. Are we, as a society, willing to pay. We say we want these things (few would argue to keep children being abused) but we also don't want to pay more taxes and people often feel that prevention programs and lower level interventions are inteference in families by the state. Such conundrums!

This is further complicated by a social work profession that may well be running scared in many places. The fear that there might be another death on their caseload that will lead to the kind of public villification that Sharon Shoesmith experienced in England following the death of Baby P. When things go wrong the public wants a scapegoat and there is usually a social worker who can be found.

We don't want kids to die but we may not be willing to build the kidn of system where that becomes less possible. It will never be completely avoidable.

Saskatchewan's recommendations will be fascinating and one hopes that it can offer ideas that go beyond the blame culture that has been the hallmark of the many, many reports that precede it.

Here is the CBC story:

July 30, 2010

Child welfare needs overhaul: study chair

By CBC News

Saskatchewan's child welfare system is performing so poorly it needs a complete overhaul, according to the chairman of a panel studying the situation.

Saskatchewan's child welfare system is performing so poorly it needs a complete overhaul, according to the chairman of a panel studying the situation.

Bob Pringle told CBC News on Friday that his evaluation of the current state of affairs reveals a system that is so broken it cannot, in his view, get any worse.

The provincial government asked Pringle to study the system after concerns were raised by Saskatchewan's children's advocate about foster care. In 2009 the advocate identified a number of problems, especially overcrowding of foster homes.

Pringle and three other panel members have been talking with hundreds of people, gathering input for a report. He said issues with foster care are just the tip of the iceberg when it comes to child welfare in the province and he will recommend a complete restructuring of the system.

"This is, in my personal view, the first true window of opportunity for major restructuring that I've seen in my 35 years," Pringle told CBC News, referring to his long career with social service agencies in Saskatoon. "These are long term problems which took a long time to get in this mess.

"Timing is often the key thing in [creating] new policy initiatives," he added, saying the climate was right for change "because the situation cannot get any worse."

He said First Nations groups in Saskatchewan need to be involved in decision-making about child-welfare policies.

Pringle added that other social service initiatives also need attention, including addictions counselling, affordable housing and parenting classes. Addressing needs in those areas could prevent a lot of problems with children, he said.

Pringle said the final report of the child welfare review panel will be delivered to the minister responsible by Oct. 1.