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Saturday, December 31, 2011

The Poverty Narrative

A recent story in the Huffungton Post suggests that a majority of children are in foster care for reasons largely connected to poverty. The focus is on the notion that children are being neglected because parents cannot afford to meet the needs of the children. The article also suggests a series of other somewhat nefarious intrusions by child protective services in the United States.

Poverty and child protection have been issues that have been linked for decades. There would be little doubt that the poor have a long history of over representation in child protection systems. Indeed, if one looks at the early roots of this work, it was the friendly visitor who would come to help the less fortunate. Yet, there are also early cases of horrific abuse that also stood out.

Critics, such as the author of this Huffington Post article talk about how the media focuses on the high profile, emotional stories that tug at the public's anger and causes politicians to become enraged. I agree that these are typically the stories that get the media attention and rarely does the media talk about the cases where child welfare has kept families together; offered services that reunified families that needed intervention; helped parents get sober and then raise their children.  The media doesn't like those stories very much - they don't garner the attention.

One has to wonder why the critics do not slam the media for the attention on the stories that push politicians to over react and then thrust child protection to be more intrusive.

The question of poverty though remains crucial. It is easy to blame child protection for being intrusive when not asking society at large why they remain so unwilling to solve the problems of poverty. Why are we so unwilling might be linked to our unwillingness to pay the taxes. It might also be because we have seen such failed efforts at the "welfare" state in places like the United Kingdom.

Economic policies that continue to create greater divides between the wealthy and the poor will only add to the child protection system needs.

As the world economy gets worse, there will be greater pressures on child protection systems. More children will come into care because of poverty related issues.  This can be seen in a tragic case in Greece reported in the Sydney Morning Herald where a family struck down by economics sought the placement of some of their children.

There are also public policies that will ensure more children come into care. In Canada, we are seeing the introduction of new crime legislation that will result in more people going to jail. This will have many negative consequences on Canadian society that will include parents not being able to look after children or families sliding into poverty as the bread winner goes to jail. I am certainly not supporting crime, but one must consider the downstream impacts of legislation.

There are no easy solutions for child protection who act as society's clean up scheme when we are unwilling to collectively address the core issues that exist. I agree with the author of the Huffington Post article that children are, in many cases, not better off in foster care. But children will end up there if we are not going to address the larger systemic issues.

As the Lilly Manning story shows, the solutions can be as bad or worse than the original problems.

However, I must take exception to the author of the Huffington Post story that social workers, lawyers and judges live with a master narrative of parents as brutal, devious and monstrous. This may be his experience but it is not mine. Yes, I have met those parents - the ones who do brutally abuse their children or the ones whose addiction is so profound that the children are significantly neglected or the parent who sexually abuses their children. But mainly I have met parents who try to sort their way through poverty or other adverse events in life. I have met lawyers, judges, social workers who believe strongly that finding ways to support families and keep them together is the preferred solution. This is not to suggest that mistakes are  not made - but it is to suggest that, at least in my experience, that the master narrative that he suggests is not so pervasive.

Monday, December 26, 2011

Foster Children and Psychotropic Medications

There have been several high profile media reports on the high use of psychotropic drugs being used with foster children.  Thus, a study by the Government Accountability Office (GAO), an office of the United States government, has provided a useful look at the practices in 5 US states. As seen in the media reports, they find that foster children are indeed prescribed drugs at rates significantly in excess of non-foster children. They have not succumbed to hyperbolae however and note that children in foster care can also present with much higher mental health issues. Yet, they also challenge the practices that they have found, particularly when children are being prescribed high doses or high numbers of drugs.

One crucial issue that has often been missed in the debate is that the problem is not restricted to foster children. As they state:

According  to   our  experts,  no  evidence  supports  the  concomitant  use  of  five  or  more   psychotropic  drugs  in  adults  or  children,  yet  hundreds  of  both  foster  and   nonfoster  children  were  prescribed  such  a  medication  regimen.  Similarly,   thousands  of  foster  and  nonfoster  children  were  prescribed  doses   exceeding  maximum  levels  cited  in  guidelines  based  on  FDA-­approved   drug  labels,  which  our  experts  said  increases  the  potential  for  adverse   side  effects,  and  does  not  typically  increase  the  efficacy  of  the  drugs  to   any  significant  extent.14  Further,  foster  and  nonfoster  children  under  1   year  old  were  prescribed  psychotropic  drugs,  which  our  experts  said  have   no  established  use  for  mental  health  conditions  in  infants  and  could  result   in  serious  adverse  effects. (p.7)

In other words, there are significant reasons to be concerned about the ways in which these medications are being used with children in general. There is no doubt, however, that the foster child population is receiving these medications at a much higher rate. When asking why, the GAO notes:

These  factors  included  the  greater  exposure  to  trauma  before  entering   state  care,  frequent  changes  in  foster  placements,  and  varying  state   oversight  policies.  However,  our  literature  search  identified  a  relatively   small  number  of  studies  that  have  been  conducted  to  determine  to  what   extent  each  of  these  factors  contributes  to  higher  prescription  rates,  or   whether  additional  factors  are  involved. (p.10)

One of the more concerning aspects is that medication is being prescribed because child protection has apparently not found ways to sustain stable foster care placements. Unlike issues such as pre-foster care trauma, placement is an issue which might often be better managed. Multiple changes in where children live, lead to greater emotional angst, re-occuring abandonment and loss and an inability for symptoms arising from trauma to settle. Rather than treat with medications, other solutions might be appropriate that would include greater emphasis on placement stability, better efforts to sustain children within family systems and faster decisions for permanency for children (be that back to family, kinship care or other long term placements such as adoption). Placement instability may be one of the most damaging experiences for children. If you have no regular place to call home, then you also have no persistent safe haven possible.

The American Academy of Child and Adolescent Psychiatrists (AACAP) recommends that there be a clear consent process for children in foster care that includes clarity on who can consent to treatment and that this be based on a clear understanding of diagnosis and what, why and how medications are being used. They also recommend that child protection have a consultation process so that cases are carefully managed and monitored.

This report raises some thoughtful ways through which good case management can occur emphasizing that those who manage these issues be well informed about what is happening with each case and why. They also recommend that child protection and caregivers be kept informed about what medications are being used and the positive and negative implications.


Dr. Peter Breggin, a noted psychiatrist and commentator on psychiatric medications has written an op-ed piece that also considers the GAO report.

Wednesday, December 21, 2011

When Parents are Incarcerated

In Canada, 2012 will see the implementation of a new crime bill that will substantially increase the number of people going to jail. More crimes will be subject to mandatory minimum sentences. There is virtually no professional group that has supported this legislation be it social workers, criminologists, lawyers, psychologists or medical practitioners.  There has been much debate about the impact on society that has included the high probability that increased incarceration rates will, in the long term, actually increase crime rates. Those placed in jail tend to become increasingly alienated from society and become more connected to criminal activity patterns.

This is all occurring in an environment where Canada's crime rates have been falling. The rehabilitation focus has largely been working.

One area that has not received as much attention is what happens to children when parents are incarcerated. The implications of this issue are what will happen to the next generation when the parental one is sent to jail. A book edited by Eddy and Poehlman shows that the outcome is poor. Published about 1 year ago the book concludes that the children "are more likely to experience learning difficulties, poor health, and substance abuse, and eventually be incarcerated themselves."

This creates a burden on the society that goes far beyond the costs of the justice system. Family bonds are broken; more children will end up in foster or alternate care; educational systems will see costs rise; medical and mental health systems will need to support more children. It is typically lower income children who will be most impacted and parental incarceration tends to worsen their situation. 

For these children, they will tend to have less stable living situations which leads to instability in school placements and social relationships. They become impoverished in a multitude of ways that many will never recover from. For these children, parental incarceration makes their world worse. They have not committed a crime but they will pay a huge price for the crime that their parent did commit. Thus, putting the parent in jail should truly be the result of that person being a significant risk to society. Otherwise, why would we as a society seek to pay such long terms costs? These children are the hidden victims of Canada's new crime bill. They should not be hidden yet there has been virtually no discussion about them.

For the child the parent is gone. How can they truly have a relationship that is meaningful through the bars of a prison?

Thursday, December 15, 2011

We already know the reasons for child deaths

Rarely would I juts copy an article to put in a blog, but a thoughtful op-ed piece written by Marlene Huff who chairs the Kentucky Chapter of the National Association of Social Workers raises some thoughts that deserve attention. She states:

Eighteen children died as a result of abuse or neglect in fiscal year 2011 compared to 33 deaths the previous year, 29 in fiscal year 2009 and 31 in fiscal year 2008.

Now, the commissioner of the state Department for Community Based Services has resigned during a debate about record reviews of deceased children that may have nothing to contribute to a discussion about the death of children.

Social workers, though not all employees of the department, are graduates of accredited schools of social work and are bound by a social work code of ethics that strictly prohibits the release of client information as well as those associated with the client even after the client has died.

In this case, the social work principle of confidentiality flies directly in the face of the journalistic principle indicating that the public has a right to know all.

The governor's mandate to release the records of those children killed by their caregivers in 2011 would have forced the commissioner, in essence, to act in direct opposition to her professional values and ethics.
Social workers (even those appointed to the position of commissioner) who violate the code are to be reported to the State Board of Social Work for review and action leading to a variety of possible negative actions against the violator's license.

Might we find in those record the answers necessary to end all child fatalities suffered at the hand of caregivers?

Sadly, I predict that this will not happen. We may, indeed, find an employee (social worker or not) to blame, a policy that is not consistently enforced or a sharp decline in fiscal resources that needs to be addressed.
In fact, I am sure this type of information is contained in the records of those deceased children whose confidentiality social workers are ethically bound to protect.

We, the public, through our resource allocations and decisions about which people among us are worthy and which are not, have a role to play in the death of those children.

We have allowed the department's already-meager budget to be cut to unspeakably low levels, allowed the case loads of social workers to increase to the point that even a supremely talented and educated social worker struggles with the sheer volume of the work, and we have only begun to discuss the needs of vulnerable children after 18 of them have died.

It seems to me that we decided long ago that Kentucky's children were not deserving of the best resources the state could offer.

I can predict the review of those records will lead to findings that are already known to us but left unaddressed.

Children die in Kentucky because of poverty. Social workers work with children and families that, two years ago, were operating on the "just" system — just enough food to get to the first of the month, just enough gas to go to the doctor, just enough coal to get through the winter.

Those same Kentucky families, barely functioning before the economic crisis, collapsed afterwards. Rates of drug and alcohol abuse rose dramatically, jobs were lost, mental-health problems increased, and families became isolated in their poverty and suffering. When families collapse, children suffer.
As the deaths of those children are reviewed and their confidentiality is shattered like a fragile vase, we need to take responsibility for our failure of those same children as well as the department. We allow Kentucky's children to live in squalor, deal with hunger as best they can, and be subjected to angry, out-of-control individuals who comprise the only family ever known to them.

We have financially starved the department to the point that it cannot protect the children in Kentucky without some of them being killed. Is this good enough? I think not. I wonder what the department could do for Kentucky's children if it was supported by the public, legislature and the media instead of breaking the confidentiality promised to those children prior to their death?

The reasons for their death, as well as the way to prevent additional deaths, are right in front of us already

Read more:

Sunday, December 11, 2011

Exaggerating, Lying, Stealing Children?

Two stories that appeared in newspapers thousands of miles and continents away present a disturbing picture of how some families have experienced child protection. To what extent they are or are not accurate is difficult to tell. They do present, though, an image of child protection that should cause some serious reflection.

The first appeared in the San Jose Crime Examiner in California. This article suggests that children are badly treated in foster care and refers to the ABC news report I wrote about recently. In dramatic prose, the author goes on to suggest:

Oftentimes, a parent will be investigated by a child welfare agency under a false report or when a mandated reported from school, the hospital, or daycare against a parent. This often sets in motion a set of events that is not only traumatic and terrifying for the child, but also traumatic and terrifying for the family.
The first and often wrong response is to violate the family’s civil rights, and remove the child from the home oftentimes without a warrant, court order, or validated reason. Then they will kidnap, hide, and continue to abuse the child into submission by interviewing, confusing, and twisting the situation to make it fit their view of things.
If the child is adoptable, they will find a home where adoptive parents are waiting and the social workers will promise that they can adopt this child as soon as they terminate the parental rights, without fully investigating the initial claims of abuse. Oftentimes, courts refuse to listen to the parents and punish and sanction them needlessly, all while placing gag orders to cover up these crimes. There are plenty of cases nationwide to prove this is so.

This is certainly not my experience with most social workers and other mental health professionals. In general, I have found that they genuinely seek to find a solution for the child that is in the best interest of that child. Regrettably, there have been cases where I believe that the professional has not been honest but these moments have very much been the exception and not the rule. This is the opposite of what the California article suggests.

Certainly, there is economic pressure on child protection systems which undermines the ability of social workers to do a top notch job. Case loads are too high and the funds needed to properly support families are scarce and shrinking. Society seems unwilling to pay for the child protection system it should have.

A story coming out of the United Kingdom in the Express suggests that social workers are under pressure to exaggerate details of a case. This allows cases to have higher levels of intervention and helps child protection authorities to reduce the risks of having another Peter Connolly case which saw a very high profile death.

These stories also remind us of the very difficult balance between supporting families so that children can continue within them and protecting children from harm that arises in some families.  Critics of child protection also miss the responsibility of the family to provide at least a good enough environment for their children.

It is worth considering the criticisms in these stories as a way to reflect upon what is good practice.

Monday, December 5, 2011

Medicating Foster Kids

First PBS' Frontline did a story in 2001 on how some children are over medicated to address mental health issues. Recently, ABC with Diane Sawyer revisited the topic. Both stories should help us to focus on some essential questions when managing children involved with child protection who present with behavioural and / or  mental health problems:

  1. Have we properly considered the traumas and other life experiences that the child has faced? This would include the trauma of coming into care. Few of us adapt well to being forced into a new environment. The move away from family to foster care can also be layered upon neglect, abuse, maltreatment or other losses and traumas the child has faced.
  2. Have we considered the best therapy that might be available for the problem the child presents with? Often it may include some medication but most evidence based research says that children need multi-model therapy to really change long patterns.
  3. Are we seeking the fastest intervention (medication) as opposed to the intervention that may have the longest positive impact?

In addition, we might consider the pressures that social workers, physicians and others who care for these children are under. Resources rarely match need so quick fix solutions are easier to administer.

There is often a lack of consideration to the pharmaceutical industry that works hard at creating a demand for the drugs. 

This discussion about the use of medication should form part of a larger discussion about the effectiveness of interventions with families. The New York Times reports that economic pressures may cut funding to programs found to be effective in working with families. Given the growing economic turmoil in Europe and elsewhere, pressures mount on program funding. But if we wish fewer children in foster care, then these in-home programs that are talked about in the New York Times article are needed. Otherwise, more children will come into care which in turn will increase the need for medications as the resources to support the children will also be limited.

Society gets the child protection system that it is willing to pay for. 

As well, if we are going to be successful with interventions, we should ensure we target them where the need exists. This may, at times, cause us to reconsider some families that may benefit from interventions other than removing children - even in case of addiction. As research reported in the Australian Sunday Morning Herald notes, multigenerational impacts may not be avoided as children tend to drift back to the addicted mothers. Solving the problem is more likely to be bettered focused on the mother wherever possible. Removing children permanently is hard to accomplish successfully, particularly with older children.

Thus, one might sum up these possibly disparate news stories by saying:

  • Treat comprehensively and when medication is needed for children, do it as part of a lager therapeutic effort;
  • Help families stay together wherever possible as medication is not likely going to help a kid with the grief and loss of being taken away from families
  • Use evidenced based approaches that show many families can be helped
  • Allow yourself to see how a family can be sustained even when the presenting problems have historically meant separation (such as in addiction cases).