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Monday, July 25, 2011

Mental Health and Child Protection

A new report from Australia helps to highlight the connection between mental health issues and child protection. This is an important topic, as anyone working directly with cases will know how frequently the connection exists. The report is titled, "Keeping the child in mind: Child protection practice and parental mental health" makes an important point - It is not the presence of the mental illness that matters but the impact that it has on parenting. Practitioners will know that there are many cases where parents with mental illness still manage to provide at least good enough parenting. The same can be said with those suffering chronic physical illnesses.

As well, practitioners must also pay attention to what supports exist that can remediate the impact of the illness.

The authors sum up the parenting point quite well stating, "Parental diagnosis of mental illness alone is not sufficient to cause problems for the child and family. Rather, it is how the illness affects the parent’s behaviour and familial relationships that may cause risk to a child. The age of onset, severity and duration of the parents’ mental illness, the degree of stress in the family resulting from the parents’ illness, and most importantly, the extent to which the parents’ symptoms interfere with positive parenting, such as their ability to show interest in their children, all influence the level of risk." (p.10).

A fundamental question is what is the impact on the child in areas such as attachment, development and their own mental health. Will they be required to assume responsibilities beyond their capacity which may also include looking after the ill parent?

Mental health may also be episodic meaning that children can have experiences that vacillate between rather good parenting to neglectful or abusive. Their world may be quite unpredictable. This illustrates the need for good assessment and attempts to ensure parents are connected to ongoing services. Their insight might be impaired by the mental health issues resulting in challenges with cooperation between the parent and child protection.

The implications for parenting capacity assessments are noted on p. 12, "In their view, parenting capacity assessments need to be comprehensive and based on:
• an acknowledgement of the family’s strengths
• child-parent observations in natural settings over a period of time, recognising the often episodic nature of mental illness
• linkage of specific qualities and functional aspects of parental behaviour with protective or risk factors for the child
• a multi-method, multi-source approach that includes, where possible, information from mental health professionals who are familiar with the parent’s mental health status."

A good assessment matters as mental health issues, which include substance abuse, require treatment that is a good match with the parent and the issues. Resource availability can, of course, limit the best choices but understanding what they should be helps to develop the best plan. These can be challenging cases to work when the mental illness is at its height as resistance and poor insight are common. This is partially why so many of these cases result in some period of time in foster care for the children. Good resources and supports that reduce the frequency and intensity of the symptoms will reduce entry into foster care - a benefit for the children! Of course, that requires parental willingness which may be its own challenge.

This research highlights the specific challenges of Borderline Personality Disorder as one illness that presents often in child protection populations. "Recent research has emphasised the relationship between borderline personality disorder and early childhood trauma and adversity and suggests that the core features associated with this disorder will have an immediate impact on parenting, compromising the promotion of attachment security and healthy child development. Parents with borderline personality are ‘high risk’ parents, who, as this study has demonstrated, are likely to be over-represented in child protection services. Children of mothers with borderline personality disorder present with various clinical syndromes and types of emotional disturbance (Newman and Stevenson 2005:386). There are significant community and public health implications if the needs of these parents remain unaddressed – borderline personality disorder can impact on parenting and on the child over time and across generations.'(p.44). Treatment can often be long and resources limited for BPD patients.

The report also highlights the need for inter agency cooperation - a theme that we have seen often in child death inquiries, for example.


Jeffrey, H., Rogers, N. & Hirte, C. (2011). Keeping the child in mind: child protection practice and parental mental health. South Australia: Department of Families and Communities. Downloaded 2011/06/25 from

Thursday, July 21, 2011

Supporting visits between parents and children in foster care

Research has been telling us that children have a much higher chance of returning to parental care when there are frequent high quality visits with their parents. This is good news for the goals of family preservation and reunification. There is now a very useful, short guide to helping make those visits effective. It was published in April 2011: Family Visitation in Child Welfare Helping Children Cope with Separation while in Foster Care. This US publication has widespread value despite a few references to US legislation. The report highlights its purpose:

"Research shows (Weintraub, 2008) that children who have regular, frequent contact with their family while in foster care experience:
• A greater likelihood of reunification
• Shorter stays in out-of-home care
• Increased chances that the reunification will be lasting
• Overall improved emotional well being and positive adjustment to placement
In order to make the most of visits, families need to be prepared for the purpose of visits, what is expected during visits and how visits may change over time in length and frequency."

It provides practical steps to make these visits effective and shows how they can change to increase usefulness over time. The report can be accessed at:

Wednesday, July 20, 2011

Notes on soon to be published research

The journal Children and Youth Services Review has several articles forthcoming that are of clinical importance in child protection.

Daniel has an article, "Fostering cultural development: Foster parents’ perspectives" which is a qualitative review done with a small group of foster parents in two Canadian provinces. It looks at trans racial foster care. This is quite important as there is a shortage of non-caucasian foster homes while there is a far greater representation of non-caucasian children, particularly Aboriginal children, in foster care. She concludes, "The core theme that emerged, based on my interpretation of 9 participants responses, was that foster parents were ‘fostering cultural development’ in their homes as well as their respective communities." While the study is small, it is a look at an under studies issue in Canada.

In another study forthcoming in this journal, Grant and her colleagues will publish "Maternal substance abuse and disrupted parenting: Distinguishing mothers who keep their children from those who do not". This is such an important topic as substance abuse issues are so prevalent in child protection populations. They note, "Mothers who have substance abuse disorders typically have psychosocial characteristics that put them at risk for poor or disrupted parenting, including experiences of early childhood neglect and abuse." Reunification efforts with this population can be challenging. "A significant body of research has examined the role of service delivery in family reunification among mothers who have substance abuse problems, and confirms the benefits of comprehensive, multidisciplinary, and accessible services being available and tailored to the mothers’ needs." Multi agency cooperation is key to successful intervention.

Too often I have seen efforts made with one parent the focus (typically the mother) with little attention paid to a partner, particularly if that partner is a part time member of the family unit or not the biological father. This research notes, "...for mothers who completed inpatient treatment the odds of reunification were increased if they also had a partner who was supportive of them staying clean and sober." This research also notes the complex nature of substance base issues and the need to match services with those needs which include such things as mental health services, housing and health needs.

In another Canadian study, Guibord and colleagues from the University of Ottawa wrote, "Risk and protective factors for depression and substance use in an adolescent child welfare sample". The abstract of the article nicely outlines their conclusions and really emphasizes how important caregiver relationships are. "Results from logistic regressions indicated that adolescent females were at higher risk of experiencing depression than males, and increasing age was associated with increased risk for substance use. Turning to protective factors, results indicated that the greater the perceived quality of the youth–caregiver relationship, the lower the risk for mental health difficulties (i.e., depression, substance use). Moreover, participation in extracurricular activities appeared to protect youth against depression or substance use. Results imply that the youth–caregiver relationship and involvement in extracurricular activities are important areas to consider to promote the well-being of maltreated youth in out-of-home care." In essence, creating something stable and approximating a typical developmental trajectory matters. The converse implication is that multiple unstable placements are likely to be high risk for youth.

I was also fascinated with another study given work that I do with adolescents with substance dependency problems and their families. Hornberger and Smith have an article upcoming, "Family involvement in adolescent substance abuse treatment and recovery: What do we know? What lies ahead?" They conclude "amily involvement should be an essential part of intake, treatment, and recovery planning, as well as the foundation for effective parent–professional partnerships." I would go further based on my own research that is about to be published in Procedia in which I note that families also need treatment to help with the impact of substance abuse problems on family functioning. I particularly like Hornbereger and Smith's conclusion "The goal of family involvement is not only to involve families in the treatment process, but also to develop collaborative partnerships that bring the expertise, resources, and experiences of families and professionals together. Such collaborative partnerships are necessary to help adolescents and their families not only understand the disease of addiction but engage in treatment, sustain recovery, and heal from the impact of substance abuse. In treatment, when families and professionals work together in the best interests of the adolescent and impacted family members, positive outcomes occur. When there is increased family involvement, family members have greater owner- ship of the treatment plan, which in turn increases their motivation and participation, and thereby improves outcomes."

In yet another important piece of research to be published, Jones looks at foster care youth in the 3 years after moving to adulthood. She notes " Factors which facilitated successful adaptations were: a period of transitional residence after foster care, good support systems including family and former social workers, and a commitment to further education." This emphasizes other research that transitional supports are so needed. Given that children growing up in biological homes require support to adulthood why would we think it would be any different for foster children who typically face greater odds.

Good research helps us to have better clinical interventions. These articles add to our knowledge.

Thursday, July 7, 2011

Faulty Thinking affects kinship placement

A case in the UK has demonstrated the risks associated with using the wrong criteria to determine what is in the best interests of children. In this case, an assessor determined that children should not be placed with extended family as a move to a northerly area of the UK would be a difficult transition for the children. The factor? Growing up in the south meant that they would have a different accent. A BBC report stated, "But they were put into care after a social worker "feared their southern accents would leave them isolated". Fortunately, the aunt fought the decision in court and the children are now with her.

This case illustrates that, as we make decisions about the needs of children, we should be well grounded in what really matters. If a kinship placement is available, and it is a good enough placement, then it should be considered a high probability for use. Research does tell us that kinship placements are a good support for children as they send a strong message about the role of family.

One legitimate consideration that this case might need is how and when the biological mother was going to have contact with the children if that is appropriate. That may not over ride the kinship placement in many cases but it is an example of the factors that need to be included in planning for kinship placements. There are other factors as well. An example is whether kinship can work with child protection to focus on the needs of the children and not get enmeshed with the parents sabotaging the child protection actions. Yet, the majority if kinship carers, who will struggle with the divided loyalty between the relative parent and the children, will work with CPS for the sake of the children.

As I have talked about in an earlier blog, grandparents are a strong force in caring for children. In addition, we now see that informal care arrangements use kinship a great deal of the time - extended family helps out parents who are struggling. That has been going on for generations and represents a normal familial response. We should not suggest that the presence of child protection should be a barrier in using such normal connections when they are available.

The aunt in this case should be congratulated for standing up for her niece and nephew. Let us use the lesson to ensure that the right factors are upper most in assessors minds as they make recommendations for children.

A study just published in the British Journal of Social Work also tells us that the voice of the child matters, although one wonders why this is news. The author states, "Also, there is a repeated failure amongst professionals to pay sufficient attention to what children and young people may be saying about their own needs and experiences." In my experience, in kinship matters, children will typically seek to be with family.

The BBC story can be found at

Sunday, July 3, 2011

Collateral Interviews Really Matter!

Mary Ellen Turpel-Lafond, the Representative for Children and Youth in British Columbia on Canada’s west coast begins her report Isolated and Invisible: When Children with Special Needs are Seen but Not Seen with the poignant summary of why her office would see the topic as needing special focus:

“This investigation focuses on the critical injury of a 15-year-old girl with special needs. The investigation began after this developmentally disabled girl was found alone with her dead mother. Neighbours, concerned that they hadn’t seen the girl and her mother for many days, looked through a front window and saw the girl on the floor beside the body of her mother. The mother had been deceased for an undetermined length of time, possibly seven days.” The girl in this story, not named, suffered from Down’s syndrome. Her life would intersect with various government ministries. She would be failed too often. Her story teaches us more about the kinds of direct service activities that better serve vulnerable populations.

This girl would require supports for her complex needs starting right at birth. She was apparently not an easy child to parent. This is also one of those cases where efforts were made to get good programming into place. The mother did not have a good record of following through, it seems. She did get her daughter on medication and this helped with behavioral concerns.

However, the mother would also experience her own health demands. This limited her capacity to work placing very significant financial demands on the family unit. The mother would also lose her care due to an accident creating isolation as neither she nor her daughter could get around easily. Disconnect from supports occurred.

The family came to the attention of child protection with accusations of abuse along with the mother’s own problems with alcohol and prescription drug abuse being raised. An investigation would cause the girl to be returned to the mother’s care with concerns not being validated.

Child protection will come under criticism for what is a too often seen problem in critiques of the system – a failure to gather appropriate collateral data. On p.19 of the report, it notes:

“On June 2, 2010, the MCFD child protection report was concluded and the file was closed. The child protection social worker closed the file without consulting with the respite caregiver, any medical professionals involved with the family, the behavioural support worker or the police who investigated the April 2010 motor vehicle accident.” However, there would be further investigations and opportunities for intervention. The report details those steps including an apparent incongruence between what child protection did and the level of risk that they apparently noted.

The report contains a timeline on pp26-27 that shows the many involvements without this child being properly protected.

The Representative concludes on p. 29:

“his vulnerable girl’s needs were not adequately addressed throughout the period covered by this investigation. There was no assessment of her situation as a child with special needs requiring a range of health, education and social supports for positive development. She was not safe. She was left with compromised hearing and physical mobility, in an impoverished environment and primarily cared for by a severely ill and challenged mother. This girl was invisible. If there had been an assessment and a plan in place to ensure high visibility, the harm caused to this girl by being left with her deceased mother would likely have been prevented. “

A lesson that should be taken from this case is the importance of collateral data. It is these various sources that afford an opportunity to garner information that is being withheld by a family or, on the other hand, to corroborate what is being told.

Collateral checking will also help to identify who is working with the family. This creates the opportunity for more coordinated case planning and delivery. The Representative has avoided the trap of laying blame on the workers and focuses instead on the systemic issues. Here too, however, she has managed to avoid the trap of suggesting grand schemes. She is to be congratulated. Instead shoe observes:

“t would be easy to blame the front-line workers who did have contact with this child and her mother. Although standards were not met, that would take us in the wrong direction, and would not address the central issue. The systems they work in failed, and these systems must improve. They must focus on the children and the supports and services they need. Not grand schemes of reorganization or governance, but solid, cost-effective, accountable programs that improve outcomes for vulnerable children. We need clarity about who does what, and we need programs that require child protection social workers, special needs workers, therapists, physicians and teachers to work together effectively with the child as the focus. “ (p.46)

We have seen this need for coordination in many case reviews. It is a lesson taught repeatedly but often not applied.

If interested in the full report, it is available at

Friday, July 1, 2011

Shaken Baby Syndrome - Very New and Important Research

Following the recent story on Frontline and NPR in the USA in which the medical diagnosis of shaken baby syndrome was reviewed and questioned, new research is lending credibility to the conclusion that children can die from shaking. But, not the way that we have been led to believe. Fortunately, the new research may well assist child protection investigators and assessors as it more clearly identifies how a child can die from shaking.

This should also be good news for those who seek to exonerate those they believe were convicted wrongly. This new research should assist in sorting out what are truly SBS cases versus those that might be the result of other causes (the Frontline / NPR program clearly shows there are many other possible explanations).

The new research is summed up on the NPR website "A team of researchers who conducted autopsies on 35 babies in Miami, Dallas and Calgary, Alberta, report that when children die after being violently shaken, they die of neck injuries and not from brain trauma." The research will need to be replicated for sure. In addition, the authors of the research note that the mechanism for this autopsy procedure is not easy. However, when there is so much at stake in these cases, the extra steps seem worthwhile as way to determine if a crime has been committed; should someone be charged; if child protection should be concerned about other children in the home - just to name the obvious.

If you wish to read the NPR report, it can be found at