Child Death Reviews - An American imperative?

Youth Today is reporting on a recommendation from a US Federal Commission that:

wants the states to examine all child abuse and neglect fatalities from the past five years as part of a national strategy to end such deaths.

The notion is interesting. Trying to understand what has gone wrong in the past is often seen as a way to help prevent further deaths. Looking into deaths has become common in many countries. For example:

• Serious Case Reviews in the UK are used as a way to find leanings from deaths that might help the child protection system do a better job protecting children
• Large scale formal public reviews are used by politicians to look into high profile cases. In Canada, there has been the Phoenix Sinclair review which published its report in 2015 after months of public hearings. Another example is the Victoria Climbe case in the UK.
• The Jeffrey Baldwin case saw a high profile Coroner's Inquiry which received national media attention.
• There are inquiries by agencies that represent children and youth such as the Child and Youth Advocate in Alberta which this week issued a report on the death of Lily. These reviews offer an independent lens on what might have gone wrong.

There are other methods as well such as aggregate reviews by third parties along with internal reviews. The latter are not typically made public. The advantage of many review processes is that they are public allowing citizens to feel that there is a sense of accountability.

There are downsides however. There is somehow a feeling that all deaths can be prevented. That is not the case as it is not possible to predict with any certainity who will or will not kill a child. There is also the negative impact that these stories have in child protection practice. In particular is the impact on worker's decision making - they tend towards bringing more children into care in order to not be the worker with the next case on the front page. That may not serve children well.

The recommendation in the United States may not be the best use of resources. There are literally hundreds of inquiries in the western world that show oft repeating patterns of practice errors that contribute to poor outcomes for children. A better use of resources might have been to analyze and learn from those inquires. A next step might be to set up a way to use that knowledge while also setting up methodologies to learn from new cases. Going back over a 5 year period will use a lot of resources and be unlikely to yield information that is different from the existing knowledge base.

By using existing data, there has been an opportunity to reframe how child protection is delivered. This is an opportunity missed. Doing it differently has more promise than spending time looking backward especially when a large database of such learning already exists.

Learning from the deaths of children

Children die when involved with child protection systems. It is inevitable that some children will die as it is impossible to predict which parent is going to kill a child. However, there are several behaviours by social workers that can reduce the risks. This poster represents some of the most important themes that we have found in our research of Canadian published case reviews.

There are a few I would like to highlight:

1. Supervision really matters - when a front line worker gets good supervision we have another set of informed eyes talking about the case. The supervisor gets to ask questions about missing data, why case plans are structured the way they are and to offer ideas and suggestions about what might be done. Remember that a large number of front line workers have less than 5 years experience. Supervision matters.
2. The child is the reason the case exists - it is not hard to get distracted by the needs of the parent. This can be particularly true in cases where there is a conflict through the court system. Indeed, in a recent case I was involved in, I experienced counsel for the parents as being strongly focused on what was best for the parent but disguised in questions that made it seem about the child. Our task is to bring the case back to what serves the child.
3. Being open to the unimaginable - case workers do not like to think that the parent or caregiver that they are working with would kill the child - but if we are open to that as a possibility then we ask better questions and consider the data more thoroughly.
4. Front line social workers are generalists - they often lack specialist training in the complex issues that child protection work brings. This can range from mental health to addictions to inter personal violence to FASD and so on. BUT, the front line worker does need to know how to get at experts who can aid them in understanding the case. These experts also need to learn how to talk to front line workers in ways that make the issue clear.
5. One assessment at the beginning is not the end of assessment - assessment is an ongoing process. Things change in cases and so should the social workers understanding of the case.
6. If the child is at the centre of the case - see the child - see the child frequently.
7. History does matter - it tells us a lot - what have been the problems in the past and how successful were interventions; how are things different now that may yield strengths or ongoing deficits; is there a pattern that needs to be considered and so on.
8. The new partner is a risk - they need to be met and assessed. 

One of the big lessons for us is how important it is to talk to students about these issues - but talk with students inter professionally. Child protection requires an ability to work across professions - medical, psychology, social work, criminal justice, law - and be able to do so with a grounding in what protecting a child is all about. Inter professional communication has been a problem at the heart of many cases.

There are also cultural implications to our research which I will review in the next posting.

I do want to leave with this message as well - case reviews where things have gone wrong need to be done at the front line - but not in a way that is hanging people out to dry but rather in using the case to enhance learning and improve practice. That helps to reduce the risks of the death for children involved with child protection.

Phoenix Sinclair Report recommendations go over all too familiar ground

The inquiry headed by Justice Ted Hughes into the death of Phoenix Sinclair has now issues its report. It turned out to be the most expensive inquiry in Manitoba's history but it covers territory that is all too familiar. Mistakes by social workers that should never have been made in a system that ought to have prevented the death. This is part of a long line of inquiries that reach very similar conclusions.

The full report can be read here.

Phoenix Sinclair

The report does make some very valuable suggestions such as all child protection workers should be trained social workers who are registered with the Manitoba social work association; case loads be kept manageable; records be well maintained; better communication with others involved including when transferring a case; the system be more transparent and that more effort be put into prevention.

The big idea that Hughes came up with is that child protection requires a national conversation. He suggests that the issue belongs on the agenda of the next Premier's conference which the Manitoba premier has asked be done. The notion of a cross country conversation makes a great deal of sense. I recently attended a roundtable on child protection here in Alberta which was organized by Human Services Minister Manmeet Bhullar. In his opening comments, the Minister noted that there have been over 50 reports on child protection problems across Canada. I have read them. They have a numbing familiarity raising problems about caseloads, funding, the decision making environment, poor communication between agencies, poor record keeping, the need for better training, missing cues and so on.

What so many reports do not address is the very human nature of child protection work. Social workers are rarely invited into families. Most often, they arrive because there has been an allegation of abuse or neglect which requires investigation. Families are very understandably defensive and sometimes downright resistant. This is so much an issue that last year Siobhan Laird wrote a text on managing conflict, hostility and aggression in child protection. It is in that environment that a worker must try to determine the safety and risks for a child.

The information is always (and I use that word very consciously) incomplete. No social worker ever knows everything that is relevant. Thus, the decision making is done with an information set that is changing constantly. Decisions often need to be revisited. There is no way (again I use that phrase consciously) that a worker can predict with absolute certainty the risks. There is probability. We are still faced with the fact that the best predictor of future behaviour is past behaviour in the absence of a compelling story of change.

Part of the challenge with child protection is that there is an expectation of perfection. There is a zero tolerance in the public's mind regarding a death of a children. But there is a reality that no system anywhere can guarantee that. We do have an obligation to provide the best system we can and to really understand how we can reduce risks.

There is also an obligation by society at large to fund prevention which is best done by poverty reduction. The majority of children brought to child protection attention are related to neglect - which is very strongly rooted in poverty. Reducing poverty reduces children in care which increases the attention that can be paid to the higher risk cases.

Daniel Pelka: The power of parental evasion and deceit

There has already been much written about the murder of Daniel Pelka. I obtained the sentencing remarks of Mrs. Justice Cox when she imposes a 30 year minimum. She reviews the evidence in her 6 page statement. It is gruesome reading. Within it, are a few powerful lessons about how this case has been evolving. The Serious Case Review which is likely to be published next month will add more details.

The urine stained mattress; the door of the room Daniel was kept in with interior handle removed and a

model of how emaciated he was at death

Yet, some of what Justice Cox has to say reminds practitioners of just how duplicitous parents can be, particularly when they are engaged in a campaign of torture as was happening in this case. The decision outlines how the mother and step father lied, avoided contact with authorities. When they did have contact, they created stories that were just plausible enough.

These caregivers, step father Mariusz Krezolek and mother Magdelan Luczak, if they can be called that, picked on Daniel as opposed to the other children making him the targeted child. Justice Cox seems perplexed at this but it is not an uncommon phenomena. She also notes that the siblings were coached to tell the story that the parents wanted told. These combined efforts made piercing the veil to find the truth difficult. Certainly there were signs that the Seroius Case Review will probably highlight.

Parents who engage in this behavior are more difficult to work with, and even get any meaningful connection in the first place. They may be amongst the hardest population to gain any significant relationship with, much less progress.

Mariusz Krezolek, the step father,  testifying before Mrs. Justice Cox

Some examples from Justice Cox's decision:

Both of you constructed a careful and wholly untruthful account that Daniel had a serious eating disorder and learning difficulties, which he may have inherited and for which he was receiving medical treatment. This account was deliberately designed to prevent interference by school, medical and welfare personnel, and to perpetuate the brutality being meted out to him. You instructed and encouraged Daniel’s older [sibling] to tell lies to the authorities if she were asked any questions about what was happening at home.  (p.3)

I am in no doubt that, before you made that call, you had deliberately planned the detailed lies you would tell in an attempt to deceive the authorities and save your own skin. That plan was put into action even in the call to the emergency operator. 

Before your arrest you made concerted efforts to remove evidence by deleting the computer search history, attempting to tidy the house and concealing the stained mattress from the box room. You lied persistently when you were interviewed by the police. (p.4)

Both of you carried out a deliberate and cynical deception of teaching, welfare and medical personnel, which was designed to conceal what was happening, to prevent any help being provided for Daniel and to enable you to continue your ill treatment of him without interference. You instructed and encouraged Daniel’s older [sibling] to tell lies to anyone in authority about what was happening at home. 

Once you became aware that Daniel had stopped breathing, you made a concerted and deliberate attempt to deceive the authorities from the outset, and to seek to remove evidence of your involvement in Daniel’s abuse and death. (p. 5) 

The media has also noted that the mother kept Daniel away from medical care, missing appointments and avoiding contact.

There are deficiencies in how people did respond to what was before them. But, in my view, we must also bear in mind that parents can put up significant barriers to accessing children. We must not be daunted by the barriers but, rather, be prepared to challenge. Having an empathic mind in child protection is important, but so is having a curious one where you challenge the data before you - ask whether it makes sense? Does the explanation intuitively seem to explain or is it off?

I raise the notion of intuition because, at times, it is paying attention to our gut feeling that can cause us to ask further probing questions.

This is a case where there were opportunities to ask - the paediatrician who saw Daniel shortly before his death; school officials who saw many signs of concern (bruises, stealing food, eating large quantities when he could get food, rummaging for food in garbage cans, declining attendance). A curious mind might well have probed beyond the parental explanations. Assembling even the school data might have caused one to say, "There is just too much going on here." Yet, the mother suggested that there were problems and that she was getting help from a doctor. Just the kind of response that assures an observer that the issues are known and being taken care of.

It will be easy to point fingers in this case. I hope that those considering it will not lose sight of the power of parental evasion and deceit which can be very effective in keeping inquiring eyes away.

Child Abuse Hospitalizations

A study published this week in the American journal Paediatrics has a look at the issue of children who are abused and end up in hospital. This might be seen as a the more probably serious end of the abuse spectrum, although as a a clinician I do see families where they have abused children and avoided getting the child treated. The study did not look at children with suspicious injuries, only those who were coded as abused.

As in most studies of child abuse, it is the youngest children at highest risk. In this case, children under a year were seen as most vulnerable.  Science Daily notes that the study concluded:

They found 4,569 children were hospitalized in the U.S. in 2006 due to serious abuse; 300 of these children died. Children in their first year of life were at highest risk, of being hospitalized, making up 58.2 per 100,000 children in this age group.

The study found the incidence rate to be higher than Sudden Infant Death Syndrome. They also found that there was a correlation between this physical abuse and poverty, although one must bear in mind that the poor have fewer options when it comes to accessing medical services. Thus, that may have brought them more to light.

This study is valuable in that it helps us to see the incidence rate but also a way to think about the rate in comparison to other serious disorders that affect children.

The study will be published in the March 2012 issue of Paediatrics.

Some thoughts on reforming child protection

 This is the major content of a speech I gave February 3, 2012 on reconsidering child protection: 

THANK YOU FOR THE OPPORTUNITY TO SPEAK WITH YOU TONIGHT. IN PARTICULAR, I AM HONOURED TO NOT ONLY BE ASKED BUT ALSO THAT YOU ARE WILLING TO GIVE UP A FRIDAY EVENING.

I AM GLAD YOU ARE HERE BECAUSE I WANT TO ENGAGE YOU IN A CONVERSATION THAT IS NOT NEW BUT IS NEITHER LOUD ENOUGH NOR BROAD ENOUGH. I ALSO WANT TO CHALLENGE YOUR THINKING AND RAISE SOME QUESTIONS THAT MAY HAVE PROBLEMATIC ANSWERS. I ALSO WANT TO INVITE YOU TO A TRADITIONAL CORE VALUE OF SOCIAL WORK – ADVOCACY FOR CHANGE.

TONIGHT, I WANT TO SPEND SOME TIME TALKING ABOUT SOME CORE PROBLEMS WITH CHILD PROTECTION SYSTEMS. THE THESIS I PUT OUT TO YOU THIS EVENING IS THAT WE, AS A COLLECTIVE SOCIETY, ARE UNWILLING AND EVEN PERHAPS, INCAPABLE OF HAVING A SYSTEM THAT CAN BE TRULY SUCCESSFUL IN CREATING CHANGE IN SOCIETY. THAT INCAPACITY IS ROOTED IN THE UNWILLINGNESS.

RATHER, CHILD PROTECTION HAS BECOME THE ORGANIZATION THAT CLEANS UP MESSES THAT SOCIETY DOES NOT WANT TO ACKNOWLEDGE EXISTS. FURTHER, WHEN THOSE MESSES BECOME PUBLIC, TYPICALLY AS SENSATIONAL STORIES IN THE MEDIA, WE COLLECTIVELY BECOME OUTRAGED.

REGRETTABLY, THAT OUTRAGE IS NOT ABOUT WHAT HAPPENED PER SE, BUT RATHER THAT IT WAS NOT PREVENTED FROM HAPPENING. IT IS AN OUTRAGE THAT THE UNSEEN BECOMES THE SEEN.

CONSIDER TWO RECENT CASES IN ALBERTA. IN THE PAST FEW WEEKS, WE HAVE SEEN MEDIA COVERAGE OF A 13 YEAR OLD FOSTER CHILD WHO IS ALLEGED TO HAVE SEXUALLY ABUSED YOUNGER CHILDREN IN THE FOSTER HOME. WHAT HAS BEEN FASCINATING ABOUT THAT COVERAGE HAS BEEN THE APPARENT SHOCK THAT A CHILD OF THIS AGE COULD DO THIS. THEN COMES THE OUTCRY THAT THE FOSTER HOME, THE CHILD PROTECTION SYSTEM DID NOT PROPERLY SUPERVISE OR CONTROL THIS BOY.

THIS CASE HELPS US TO SEE HOW NAÏVE THE PUBLIC REALLY IS ABOUT THE COMPLEX CASES THAT CHILD PROTECTION SYSTEMS WORK WITH. RESEARCH ON CHILDREN WHO SEXUALLY ABUSE TELLS US SEVERAL KEY MESSAGES THAT THE MEDIA MISSES:

1.    MOST OF THESE CHILDREN ARE THEMSELVES VICTIMS OF ABUSE.

2.    MOST CHILDREN WHO SEXUALLY ABUSE ARE TREATABLE.

3.    MEDIA COVERAGE AND PUBLIC REACTION ARE FOCUSED ON THE APPROXIMATELY 5% OF THESE OFFENDING CHILDREN WHO WILL GO ON TO BECOME LONG TERM CONCERNS. AMERICAN DATA SHOWS THAT 85-95% OF YOUTH WHO SEXUALLY OFFEND WILL NEVER BE RE-ARRESTED. WHILE THAT DOES NOT MEAN THAT THAT ENTIRE GROUP DID NOT RE-OFFEND (THUS JUST NOT BEING CAUGHT), IT TELLS US THAT THE VAST MAJORITY ARE NOT RE-OFFENDING. THE SMALLER NUMBER REPRESENTS THOSE WHO ARE LONG TERM OFFENDERS.

THE NATURE OF SEXUAL ABUSE, AS WE HAVE SEEN IN THE VERY HIGH PROFILE CASE OF THE FOOTBALL COACH , MR. SANDUSKY, WHO HAS YET TO BE CONVICTED, TELLS US THAT THESE BEHAVIORS TYPICALLY OCCUR IN SECRET. IT MAY TAKE EITHER YEARS FOR CHILDREN WHO ARE VICTIMS TO TELL, EVEN WHEN THE OFFENDER IS ANOTHER CHILD. THE PERPETRATORS TYPICALLY KNOW THAT WHAT THEY ARE DOING IS WRONG AND THUS, EVEN YOUTH OFFENDERS, WILL TAKE PRECAUTIONS TO KEEP THE BEHAVIOR SECRET.

THE YOUTH VICTIMS ALSO HAVE A TENDENCY TO KEEP THE SECRET FOR A VARIETY OF REASONS THAT INCLUDE SHAME, GUILT, INNOCENCE, LIKING THE ATTENTION AND THREATS FROM THE PERPETRATOR.

MEDIA ATTACKS SEEM TO SUGGEST THAT, NONE THE LESS, CHILD PROTECTION SHOULD HAVE BEEN ABLE TO SEE WHAT WAS GOING ON. HOWEVER, THIS CASE ALSO ILLUSTRATES THAT THOSE WHO HOLD POSITIONS OF POWER CAN BEHAVE IN WAYS THAT GET IGNORED, MINIMIZED OR EXPLAINED. WE SAW THIS WITH THE MULTIPLE ABUSES THAT HAVE OCCURRED IN THE CHURCH SYSTEMS.

ANOTHER RECENT CASE IN ALBERTA IS THE DEATH OF ELIZABETH VALASQUEZ. IN THIS CASE, THE PROVINCE OF ALBERTA LAUNCHED A REVIEW AND CONCLUDED THAT MORE COULD HAVE BEEN DONE TO PROTECT THIS CHILD.  ONE ISSUE THAT RECEIVED SCANT ATTENTION IN THE MEDIA, HAS BEEN THE SILOS OF INFORMATION THAT EXIST BETWEEN AGENCIES MAKING IT HARDER FOR CHILD PROTECTION TO KNOW WHAT IS GOING ON.

IN MY OWN CLINICAL EXPERIENCE, I HAVE BEEN RUNNING ACROSS CASES, MORE FREQUENTLY THAN I WISH, WHERE, EVEN WITH INFORMED CONSENT FROM THE CLIENT, THE AGENCY IS REFUSING RELEASE OF INFORMATION.

IN MY RESEARCH ON OVER 600 CASES OF CHILDREN WHO HAVE DIED WHILE INVOLVED IN THE CHILD PROTECTION SYSTEMS OF CANADA, U.S.A., NEW ZEALAND, AUSTRALIA AND THE UNITED KINGDOM, VIRTUALLY ALL CASES HAVE RESULTED IN A RETROSPECTIVE ANALYSIS IN WHICH SOCIAL WORKERS COULD HAVE DONE SOMETHING BETTER. I WOULD PARENTHETICALLY NOTE, THAT INFORMATION SILOS HAVE BEEN A THEME IN A LARGE NUMBER OF THESE CASES.

BUT THE REALITY IS THAT, CASES ARE SO COMPLEX , INVOLVING MULTITUDES OF FACTORS, VARYING QUALITIES OF INFORMATION, DATA THAT IS OFTEN HELD IN DIFFERENT SYSTEMS AS WELL AS RESISTANCE FROM FAMILIES, THAT ERRORS ARE ALMOST ASSURED. WHEN LOOKING BACKWARDS HOWEVER, THERE WILL BE A DESIRE THAT CASES ARE DONE CORRECTLY AND THAT THE CHILD’S DEATH SHOULD HAVE BEEN PREVENTED. WHAT IS OFTEN MISSING IS AN UNDERSTANDING THAT ERRORS ARE GOING TO HAPPEN AND THAT NO CHILD PROTECTION SYSTEM IS CAPABLE OF AVOIDING THEM ALL. THIS ALSO MEANS THAT CHILDREN WILL DIE WHO ARE KNOWN TO CHILD PROTECTION SYSTEMS. IN THE MEDIA FRENZY, IT WILL BE FORGOTTEN THAT THE VAST MAJORITY OF CASES HAVE REASONABLY GOOD OUTCOMES.

PERFECTION IS UNATTAINABLE. WHEN YOU BOARD AN AIRPLANE, YOU KNOW THAT THERE IS SOME SMALL CHANCE THAT THE PLANE WILL CRASH – BUT IT RARELY DOES. YOU KNOW WHEN YOU GO FOR SURGERY, YOU MIGHT DIE – BUT IT RARELY OCCURS. EVEN COMING HERE TONIGHT, THERE WAS AN INHERENT RISK THAT YOU COULD GET INTO AN ACCIDENT – BUT THAT RARELY OCCURS ON A STATISTICAL BASIS. WHY THEN SHOULD WE EXPECT CHILD PROTECTION TO NOT ALSO HAVE A STATISTICAL RISK OF FAILURE WHICH MIGHT INCLUDE THE DEATH OF A CHILD?

SO WHY ARE THESE HIGH PROFILE ERRORS OCCURRING? THE REASONS ARE COMPLEX AND INCLUDE, AMONGST OTHERS:

1.    NOT ALL WHO KILL CHILDREN CAN BE PREDICTED. IN FACT, OUR CAPACITY TO ACCURATELY PREDICT VIOLENT BEHAVIOR IS RELATIVELY POOR.  EVEN ON AN ACTUARIAL BASIS, WE WILL STILL GET ONLY MODERATELY STRONG CAPACITY TO PREDICT BASED ON PROBABILITY. WHAT THIS MEANS IS THAT, EVEN IN THE BEST CIRCUMSTANCES, WE WILL GET IT WRONG AT LEAST SOME OF THE TIME. WE WILL CLASSIFY AN INDIVIDUAL AS LOW RISK WHO WILL THEN GO ON TO SEXUALLY ABUSE, PHYSICALLY ABUSE OR KILL A CHILD.

2.    THERE ARE FAMILIES WHO GO OUT OF THEIR WAY TO AVOID THE SCRUTINY OF CHILD WELFARE – THEY WILL LIE, THEY WILL MISREPRESENT OR THEY WILL DISCONNECT OR WILL BE TRANSIENT. IN SOME CASES THEY WILL ENGAGE IN DISGUISED COMPLIANCE. THIS MAKES IT VERY HARD FOR A SOCIAL WORKER TO KNOW WHAT IS REALLY GOING ON. AS WE SAW, FOR EXAMPLE WITH THE TURNER CHILD IN NEW BRUNSWICK, SOME PARENTS ARE HARD TO FOLLOW AND TRACK.

AS WE HAVE SEEN IN THE SHAFIA MURDER CASE IN CANADA, THIS PAST WEEKEND THE GLOBE AND MAIL OPINED THAT CHILD PROTECTION IN QUEBEC MAY HAVE BEEN ABLE TO SAVE THOSE GIRLS FROM BEING MURDERED. IS THAT REAL? I DON’T KNOW BUT IT IS A POWERFUL MESSAGE FROM THE MEDIA TO THE PUBLIC OF CANADA. MOST INTERESTING IN THE CRITICISM WAS THE SUGGESTION THAT THE SOCIAL WORKERS WERE TOO DEFERENTIAL TO CULTURE. QUEBEC CHILD PROTECTION AUTHORITIES HAVE NOW SAID THAT THEY WERE ILL PREPARED TO CONTEMPLATE THE NATURE OF THE RISK THAT EXISTED IN THIS TYPE OF CASE. THUS, IN A WORLD WHERE MIGRATION IS THE NORM, CHILD PROTECTION MUST SOMEHOW ADAPT TO THE MYRIAD OF CULTURAL REALITIES THAT MAY BE IN CONFLICT WITH WHAT HAVE COME TO BE KNOWN AS “CANADIAN STANDARDS”.  THE DIRECTOR OF THE CHILD PROTECTION AGENCY THAT HANDLED THE SHAFIA CASE STATED EARLIER THIS WEEK:

“I think it's a failing that we share with the rest of Canadians, in terms of not having the consciousness of how extreme some of these behaviours are,” Ms. Bérard said. “We think they're so far away and will never come home, but they are actually home right now in our own country, and we have to deal with them.” (GLOBE AND MAIL)

IN ANOTHER COMMENT, THIS ONE FROM Homa

Arjomand, a transitional support counsellor in Toronto and the founder of the International Campaign Against Sharia Court in Canada STATED:

"The greater success will come when social workers, children's aid workers, police, teachers and all crisis workers start to care more about the individual crying out for help, rather than for the culture of the parents or the husband," Arjomand said.

"We must stop training counsellors to be culturally sensitive," she said. "Instead, we need to hear the victims, listen to them and treat them equally with any other Canadian woman or child exposed to violence." (CALGARY HERALD)

3.    SOME ABUSE IS UNPREDICTABLE BECAUSE CHILD PROTECTION DOES NOT KNOW THE INFORMATION. THERE CAN BE A NEW PARTNER WHO IS QUIETLY BROUGHT INTO THE HOUSEHOLD WHO THEN GOES ON TO ABUSE AND / OR KILL THE CHILD. CHILD PROTECTION WILL NEVER KNOW EVERYTHING.

BUT WE MUST ALSO ACCEPT THAT CHILD PROTECTION, AS A HUMAN SYSTEM, WILL MAKE MISTAKES. IN AN ENVIRONMENT WHEN THE MEDIA WILL INTENSELY SCRUTINIZE ERRORS AND POLITICIANS MAY GO ON TO SEEK A SACRIFICIAL LAMB TO LET GO, THERE IS MUCH FEAR ABOUT OPENLY TALKING ABOUT THE ERRORS.

IN THE CASE OF BABY PETER IN THE U.K., A HORRIBLE DEATH, THE MEDIA BEGAN A FRENZY ABOUT THE FAILURES OF CHILD PROTECTION AUTHORITIES PAINTING THE SYSTEM AS GROSSLY INCOMPETENT. THE POLITICIANS OF THE DAY, FOUND THEIR SACRIFICIAL LAMB IN THE FORM OF THE SUPERVISOR, SHARON SHOESMITH. SHE WOULD BECOME VILIFIED IN THE MEDIA, AND THIS IS NOT AN UNDERSTATEMENT. SHE WAS FIRED ALTHOUGH WOULD ULTIMATELY WIN A COURT CASE AS A RESULT OF THAT FIRING BEING UNFAIR AND UNLAWFUL.

WHEN THESE CASES OCCUR, POLITICIANS TYPICALLY RESPOND WITH SOME SORT OF PROMISE THAT IT WILL NEVER HAPPEN AGAIN ON THEIR WATCH. THEY SPEAK OF DOING EVERYTHING THAT THEY CAN TO ENSURE IT WILL NEVER HAPPEN AGAIN. IT IS A PROMISE THAT CANNOT BE KEPT BECAUSE THERE WILL BE ANOTHER DEATH. AS HARRY FERGUSON, ANOTHER BRITISH RESEARCHER NOTES, THERE IS A KEY ASSUMPTION IN SUCH PROMISES, “THAT IT IS POSSIBLE FOR SOCIAL WORK INTERVENTION TO PROTECT ALL CHILDREN FROM ABUSE AND, ULTIMATELY, DEATH. YET THIS IDEA IS QUESTIONABLE AND IS IN FACT QUITE NEW…”

REVIEWS OF SOCIAL WORKER ACTIONS HAVE BECOME POLITICIZED AND MAY BE ON THE VERGE OF BEING LITIGIOUS IN NATURE.

WHEN SOCIAL WORKERS SEE THEIR COLLEAGUES BEING ATTACKED AND POLITICIANS SEEKING TO COVER THEMSELVES, THERE WILL BE AN OBVIOUS DESIRE TO AVOID HAVING YOUR OWN MISTAKES KNOWN. THUS, IT IS HARD TO CREATE AN ENVIRONMENT WHERE MISTAKES CAN BE USED AS A METHOD TO BETTER LEARN HOW TO DO CHILD PROTECTION. AS SOME RECENT CASES IN THE U.S.A. HAVE SHOWN, THERE IS ALSO THE GROWING RISK THAT SOCIAL WORKERS ARE BEING HELD PERSONALLY LIABLE FOR THE DEATH. IN NEW YORK A SUPERVISOR AND A CASE WORKER HAVE BEEN CRIMINALLY CHARGED IN RELATION TO THE DEATH OF MARCHELLA PIERCE. THE NOTION IS THAT, IF THEY HAD DONE THEIR JOB PROPERLY, THE CHILD WOULD HAVE LIVED.

IN THE UNITED KINGDOM WE SEE A SETTLEMENT REPORTED BY COMMUNITY CARE FROM A CHILD PROTECTION AGENCY IN ESSEX FOR ALMOST $1.5 MILLION TO FOUR SIBLINGS WHO WERE NOT PROTECTED FROM PARENTAL ABUSE.

CHILD PROTECTION SYSTEMS ARE BECOMING, INDEED MAY HAVE ALREADY BECOME, RISK AVERSIVE. GIVEN THE PRICE THAT A HIGH PROFILE MISTAKE CAN BRING, THIS IS NOT SURPRISING.

I AM HOPEFUL THAT THE RECENT STEPS IN ALBERTA TO ESTABLISH THE CHILDREN’S ADVOCATES OFFICE AS AN INDEPENDENT BODY WILL LEAD TO THOUGHTFUL INQUIRIES ABOUT HOW TO DO BETTER AND NOT AS PLATFORMS FOR BLAME.

THIS LEADS ME TO WHAT I THINK IS REALLY THE CORE ISSUE WITH CHILD PROTECTION AND THAT IS THE FAILURE OF SOCIETY TO REALLY WANT TO ADDRESS THREE CRUCIAL ISSUES:

1.    A SIGNIFICANT NUMBER OF CASES ARE THE RESULT OF POVERTY AND OTHER SYSTEMIC ISSUES WITHIN SOCIETY. A RECENT PUBLICATION FROM THE NATIONAL COUNCIL OF WELFARE PRESENTS DATA THAT TELLS US, THAT A MERE 2% INCREASE IN THE GST IN CANADA WOULD PROVIDE THE MONEY NEEDED TO CORRECT POVERTY IN CANADA. WHY, AS A NATION, WOULD WE NOT SEEK TO DO THAT? LET US NOT FORGET THAT POVERTY COSTS US. FOR EXAMPLE, JUST A WEEK OR SO AGO, THE CANADIAN CENTRE FOR POLICY ALTERNATIVES NOTED THAT NEW BRUNSWICK PAYS 7%  OF ITS GDP TO POVERTY RELATED COSTS.

POVERTY IS BECOMING A MORE PERVASIVE ISSUE THROUGHOUT THE WESTERN ECONOMIES. WE HAVE SEEN CRISIS IN THE UNITED STATES, EUROPE AND VARIOUS PARTS OF CANADA, ALTHOUGH WE HAVE BEEN SHIELDED MORE THAN MOST. IF ONE IS PREPARED TO ACCEPT THAT POVERTY CAN LEAD TO FAMILY CRISIS, THEN ONE IS ALSO FACED WITH THE POSSIBILITY THAT SUCH STRESSORS WILL LEAD TO MORE FAMILIES SUFFERING PARENTING DEPLETIONS. THIS WILL BRING MORE FAMILIES TO THE ATTENTION OF CHILD PROTECTION. SOME OF THOSE FAMILIES ARE BROUGHT THERE BY MERELY BEING UNABLE TO FUND SOME OF THE BASIC NECESSITIES. IS THIS NEGLECT? THERE ARE CERTAINLY THOSE WHO WOULD SUGGEST SO. ONE OF THE STERNEST CRITICS OF CHILD PROTECTION IS AN AMERICAN GROUP CALLED THE NATIONAL COALITION FOR CHILD PROTECTION REFORM. IN MY MIND, THEY OFTEN WRITE FROM A SENSATIONALISTIC AND JOURNALISTIC PERSPECTIVE. YET, THEY ARE WISE IN NOTING THAT POVERTY IS OFTEN GETTING MIXED UP AS A CHILD PROTECTION ISSUE WHEN IT MIGHT BETTER BE THOUGHT OF AS AN ISSUE OF SOCIETY’S UNWILLINGNESS TO PROTECT THOSE WHO HAVE FALLEN PREY TO THE FORCES IN THE WORLD THAT ARE FAR BEYOND THEIR INDIVIDUAL CONTROL. YET, WE SO OFTEN EXPECT THEM TO SOLVE THE PROBLEM ON THEIR OWN.

YET, IN A BOOK RELEASED JUST THIS WEEK, CHARLES MURRAY ARGUES THAT WE ARE FACING A CULTURAL DIVIDE THAT IS MUCH MORE POWERFUL THAN THE ECONOMIC ONE THAT DIVIDES RICH AND POOR. THERE IS A FRAGMENTATION OF SOCIAL STRUCTURE THAT CREATES A SET OF REALITIES WHERE PROBLEMS THAT WE KNOW CREATE MORE NEGATIVE OUTCOMES ARE BECOMING TOO MUCH THE NORM – HIGH STRESS SINGLE PARENTHOOD AND UNEMPLOYMENT THAT DETACHES PEOPLE FROM MEANINGFUL PURPOSE. FAMILY LIFE IS IMPACTED AND CHILDREN WILL PAY DISPROPORTIONATELY. IT IS A PRICE THAT WILL BE PAID IN BOTH THE PRESENT GENERATION BUT, AS WE HAVE SEEN IN THE U.K., FOR GENERATIONS THAT FOLLOW.

IN HER EXCELLENT BOOK PROBATION AND SOCIAL WORK ON TRIAL,  WENDY FITZGIBBON MAKES NOTE THAT ANOTHER OUTCOME OF THE ECONOMIC CRISIS HAS BEEN THE FRAGMENTING OF COMMUNITY. WHERE, IN THE PAST, COMMUNITY SOUGHT TO LOOK AFTER THOSE AROUND THEM, THAT IS NOW FAR LESS COMMON. PEOPLE ARE TRANSIENT, HOMES ARE VACANT, AND PEOPLE SEEK REFUGE FROM A WORLD INCREASINGLY SEEN AS UNSAFE BY DETACHING AND HIDING WITHIN THEIR HOMES. A FAMILY IN TROUBLE IS LESS ABLE TO REACH OUT FOR HELP FROM THOSE AROUND THEM. THEY ARE LEFT ISOLATED WITHIN THEIR COMMUNITY. ISOLATION INCREASES A SENSE OF POWERLESSNESS – THE FEELING THAT YOU ARE ALONE IN THAT SINKING SHIP. THIS, IN TURN, DEPLETES PERSONAL RESOURCES LEAVING LESS AVAILABLE FOR THE TRIALS AND TRIBULATIONS OF PARENTING.

YET, IF MONEY WERE THE SOLUTION ALONE, THEN MANY OF SOCIETIES PROBLEMS WOULD HAVE BEEN SOLVED. IT IS DEEPER THAN THAT.

2.    WE HAVE HISTORIC PATTERNS THAT CHILD PROTECTION IS FOCUSED ON POPULATIONS THAT ARE MARGINALIZED FOR REASONS BEYOND POVERTY. AS THE NATIONAL COLLABORATIVE CENTRE FOR ABORIGINAL HEALTH NOTES:

     “THE 2003 CANADIAN INCIDENCE STUDY OF REPORTED CHILD ABUSE AND NEGLECT (CIS-2003) FOUND THAT ABORIGINAL CHILDREN WERE 2.5 TIMES AS LIKELY TO HAVE A “SUBSTANTIATED” REPORT OF MALTREATMENT IN THE CHILD WELFARE SYSTEM, AN OVERALL POPULATION RATE OF 49 PER 1000 CHILDREN IN COMPARISON TO 19.8 PER 1000 NON-ABORIGINAL CHILDREN.”

IN OTHER WORDS, WE HAVE YET TO RIGHT THE LONG STANDING PROBLEMS OF CANADA’S ABORIGINAL POLICIES OF THE LAST CENTURY.

CANADA IS NOT ALONE IN MARGINALIZED POPULATIONS BEING OVER REPRESENTED IN CHILD PROTECTION SYSTEMS. THIS IS TRUE IN THE UNITED STATES, AUSTRALIA, NEW ZEALAND AND THE UNITED KINGDOM. WE SHOULD CERTAINLY ASK WHY? IS IT BECAUSE WE ARE LEAST WILLING TO SUPPORT THE WEAKEST PARTS OF SOCIETY? IS IT BECAUSE WE BELIEVE THAT SOCIETY WILL ALWAYS HAVE THE VULNERABLE AND THAT IS JUST THE WAY IT IS? IS IT BECAUSE A CULTURE OF GREED HAS PERMEATED OUR SOCIETY MAKING US LESS WILLING TO WORRY ABOUT THOSE PEOPLE WHO DO NOT FORM PART OF OUR MAINSTREAM?

REGARDLESS OF WHY, CHILD WELFARE IS LEFT TO PICK UP THOSE PIECES. WHICH LEADS TO THE THIRD PROBLEM.

3.    CHILD PROTECTION IS BEING ASKED TO REPAIR DAMAGE FROM PUBLIC POLICY ERRORS, POVERTY AND MARGINALIZATION OF VULNERABLE POPULATIONS. THEY DO SO ON A FAMILY BY FAMILY BASIS WHILE SOCIETY FAILS TO ADDRESS THE MAJOR OVERARCHING PROBLEMS.

WE NEED TO ACCEPT THAT POVERTY, WHILE CREATING STRESSORS IN FAMILIES, IS NOT, IN AND OF ITSELF THE ISSUE. THERE ARE MANY WHO HAVE BEEN RAISED IN POVERTY WITHIN NURTURING AND CARING FAMILIES. IT IS THE MORE CHALLENGING PATTERNS IN OUR SOCIETY OF ADDICTION, ALCOHOLISM, DOMESTIC VIOLENCE, ABUSE AND SEXUAL TRAUMA THAT ARE MORE AT THE CENTRE OF WHAT NEEDS TO CHANGE. IF WE CHANGE THOSE PATTERNS THEN THE HEALTH AND SAFETY OF CHILDREN WILL BE THE DIRECT BY PRODUCTS.

AS AN ASIDE NOTE, WE SPEND BILLIONS TRYING TO ERADICATE THE DRUG PROBLEM BY ADDRESSING THE SUPPLY SIDE – GROWING, MANUFACTURING AND DISTRIBUTION AND RELATIVELY LITTLE ON THE DEMAND SIDE – THE USERS. IMAGINE, IF THE WAR ON DRUGS HAD THEIR BUDGETS SHIFTED TO PREVENTION AND REHABILITATION. THIS WOULD BENEFIT CHILDREN!

AS A SOCIETY, WE ARE ALSO FAILING TO PROVIDE THE FUNDS NEEDED FOR CHILD PROTECTION TO REALLY DO WHAT MUST BE DONE. CORRECTIVE CHILD PROTECTION IS EXPENSIVE. FURTHER, MOST OF THE REWARDS WILL COME IN THE NEXT GENERATION, NOT BY THE NEXT ELECTION. THUS, THE BUDGETS NEEDED TO SUPPORT THIS LONG TERM SOCIETAL CHANGE ARE NOT EASILY SOLD TO THE ELECTORATE. IN ESSENCE, THE MESSAGE WOULD NEED TO BE, “I WANT YOU TO PAY SIGNIFICANT FUNDS FOR A CHILD PROTECTION SYSTEM THAT WILL REALLY PAY OF IN THE GENERATIONS OF YOUR CHILDREN AND GRANDCHILDREN.” THAT IS A HARD SELL.

WE KNOW FROM QUITE EXTENSIVE LONG TERM RESEARCH IN THE U.S.A. AND THE U.K., THAT CHILDREN WHO ARE RAISED IN THE FOSTER CARE SYSTEM HAVE SIGNIFICANTLY POORER LIFE OUTCOMES THAN CHILDREN RAISED EVEN IN MARGINALLY GOOD ENOUGH HOMES.

LEGISLATION IN MANY JURISDICTIONS SEEKS TO PRESERVE THE FAMILY UNIT. THE RESEARCH I HAVE JUST REFERRED TO SUGGEST THAT IS A GOOD GOAL. BUT TO MAKE THE GOAL TRULY EFFECTIVE, WE NEED TO INVEST IN INTENSIVE, LONGER TERM RESOURCES TO CHANGE HOW VULNERABLE AND HIGHER RISK PARENTS ENGAGE THE ROLE OF PARENTING. RESEARCH DONE HERE IN CANADA THROUGH MCMASTER UNIVERSITY SHOWS THAT MOST OF OUR SHORT TERM EFFORTS DO NOT YIELD LONG TERM BENEFITS. YET, WE KEEP DOING THESE SORTS OF THINGS OVER AND OVER BECAUSE WE DO NOT HAVE THE FUNDS TO PROGRAM LONG TERM FAMILY SUPPORTS THAT WOULD KEEP FAMILIES TOGETHER. BUT IT IS PRECISELY THOSE KINDS OF EFFORTS THAT ARE NEEDED TO GET TO THE LONG TERM SOLUTIONS IN THE REDUCTION OF SUBSTANCE DEPENDENCY, DOMESTIC VIOLENCE AND THE OTHER ISSUES I REFERRED TO A FEW MOMENTS AGO.

OTHER RESEARCH HAS SHOWN THAT MANY MORE FAMILIES CAN BE PRESERVED IF WE ARE WILLING TO FUND THESE LONGER TERM EFFORTS. FOR EXAMPLE, ONE OF THE CRUCIAL FACTORS THAT HAS BEEN SHOWN TO BE EFFECTIVE IS TO ALLOW CASE LOADS TO BE AT A LOWER LEVEL THAN TYPICALLY SEEN SO THAT THE SOCIAL WORKER CAN TAKE THE TIME TO ACTUALLY BUILD A TRUSTING, WORKING RELATIONSHIP WITH A FAMILY. IT IS IN THAT WAY THAT REAL CHANGE CAN BE ENGAGED AS OPPOSED TO CRISIS INTERVENTION OR SYMPTOM REDUCTION. THAT AGAIN, MEANS INVESTING IN CHILD PROTECTION WAITING FOR THE PAY OFF SOME TIME DOWN THE ROAD.

BUT THE FAMILY PRESERVATION AGENDA IS WORKING IN MOST INSTANCES. THE ONTARIO INCIDENCE STUDY, 2008, SUGGESTS THAT NO MORE THAN 1:5 CHILDREN WITH SUBSTANTIATED MALTREATMENT WILL BE REMOVED FROM THE HOME. THIS IS A STATISTIC THAT RUNS COUNTER TO WHAT THE CRITICS OF CHILD WELFARE WOULD HAVE YOU BELIEVE.

RESEARCH DONE BY OFSTED, A BRITISH ORGANIZATION, HAS SHOWN 8 SIGNIFICANT FACTORS THAT SOCIAL WORKERS CAN DO THAT WILL MAKE A DIFFERENCE AND HELP TO BUILD ON FAMILY PRESERVATION:

•   USE APPROACHES WHICH BUILD ON FAMILY STRENGTHS;

•   BE PERSISTENT, RELIABLE AND FLEXIBLE AND BE RESPONSIVE;

•   OFFER OPEN AND HONEST COMMUNICATION INCLUDING WHAT IS AND IS NOT ACCEPTABLE BEHAVIOR;

•   USE AN APPROACH WHICH VALUES FAMILY MEMBERS, REALLY LISTEN TO THEM, RESPECT WHAT THEY HAVE TO SAY AND UNDERSTAND THEIR PERSPECTIVE;

•   BE CLEAR ABOUT EXPECTATIONS AND WHAT NEEDS TO BE DONE AND THE CONSEQUENCES OF NOT ACHIEVING THE CHANGES;

•   IDENTIFY AND ADDRESS THE NEEDS OF ALL FAMILY MEMBERS;

•   WORK WITH THE FAMILY, ALONG SIDE THEM, WITH A CLEAR PLAN TO SUSTAIN CHANGE BEYOND THE INVOLVEMENT OF CHILD PROTECTION.

IN SOCIAL WORK, WE HAVE A LONG TRADITION OF SEEING FAMILIES AS HAVING A PLACE IN AN ENVIRONMENT, A SYSTEM AND EXISTING WITH STRENGTHS CAN BE BUILT UPON. THE MANAGERIALISM OR BEAURACRATIZATION OF SOCIAL WORK DIMINISHES THOSE TRADITIONS MEANING THAT FOLLOWING PROCEDURE AND TICKING THE RIGHT BOXES HAS MORE REAL MEANING THAN DOES THE RELATIONSHIP WITH THE CLIENT. THIS IS A PROBLEM THAT ARISES WHEN RISK AVERSION OCCURS. GOOD CASE MANAGEMENT MEANS TAKING INFORMED RISKS THAT LEAD TO CHANGE. IT MAY ALSO LEAD TO FAILURE AT TIMES.

AS YOU CAN READILY SEE, THIS REQUIRES TIME FOR PROPER CASE WORK. IT WOULD ALSO ALLOW US TO SEE THOSE FAMILIES THAT TRULY ARE SUSTAINABLE – BUT NOT ALL FAMILIES ARE. SOME CHILDREN DO NEED TO COME INTO CARE. BUT, IT IS MORE PROBABLE THAT IT WILL BE THE RIGHT KIDS COMING INTO CARE.

THIS WOULD ALLOW US TO FOCUS MORE INTENSIVE EFFORTS ON THOSE CHILDREN WHO DO NEED TO BE IN ALTERNATE CARE AS NO CHILD PROTECTION SYSTEM WILL BE ABLE TO PRESERVE ALL FAMILY UNITS.

A RECENT REVIEW BY WALSH AND MATTINGLY NOTES THAT CHILDREN IN FOSTER CARE ARE 16 TIMES MORE LIKELY TO RECEIVE A PSYCHIATRIC DIAGNOSIS THAN CHILDREN NOT IN FOSTER CARE. THEY ARE ALSO 8 TIMES MORE LIKELY TO BE TAKING PSYCHOTROPIC MEDICATIONS.  THE MEDIA HAS PAID MUCH ATTENTION TO THIS SUCH AS THE RECENT INVESTIGATIVE REPORT IN THE USA BY THE PBS PROGRAM FRONTLINE AND ANOTHER BY ABC NEWS WITH DIANE SAWYER. WHAT THESE AND SIMILAR PROGRAMS OFTEN MISS IS THAT THIS IS A TROUBLED POPULATION AND THUS, THE RISKS OF MENTAL HEALTH AND EMOTIONAL HEALTH PROBLEMS WILL BE MUCH HIGHER. BUT AGAIN, THEY MISS THAT A REAL PART OF THE SOLUTION WILL BE TO BETTER SUPPORT CHILDREN IN FOSTER CARE WITH THREE KEY ELEMENTS:

1.    STABILITY OF PLACEMENT

2.    STABILITY OF SOCIAL WORKER WHO CAN BUILD A REAL RELATIONSHIP WITH THE CHILD (THIS TOO REQUIRES INVESTMENT IN CHILD PROTECTION SO THAT BURNOUT AND STAFF TURNOVER ARE REDUCED) AND

3.    MORE INTENSIVE SUPPORTS THAT PERMIT THESE CHILDREN TO WORK THROUGH THE ISSUES THAT BROUGHT THEM INTO CARE. THESE INCLUDE THE REALITIES THAT THEY HAVE BEEN THE VICTIMS PARENTAL NEGLECT OR ABUSE BUT HAVE ALSO LOST IMPORTANT ATTACHMENT FIGURES IN THEIR LIFE. LET US NOT FORGET THAT THE VAST MAJORITY OF CHILDREN IN CARE SEEK TO BELONG TO FAMILY – AND TYPICALLY BIOLOGICAL FAMILY. THIS IS TRUE EVEN WHEN THEY HAVE BEEN ABUSED.

WE MUST ALSO FOCUS ON EARLY INTERVENTION. RESEARCH PUBLISHED JUST LAST MONTH BY LUTTMAN AND FARMER, SUMMED UP OUR KNOWLEDGE OF NEGLECT BY STATING THAT “NEGLECT HAS A NEGATIVE IMPACT ON DEVELOPMENTAL OUTCOMES FOR CHILDREN, INCLUDING SERIOUS LONG TERM EFFECTS ON CHILDREN’S COGNITIVE, SOCIO-EMOTIONAL AND BEHAVIORAL DEVELOPMENT, HEALTH AND EARLY ATTACHMENT AND THE EFFECTS APPEAR TO BE CUMULATIVE.” THEY FOUND IN THEIR RESEARCH THAT THE VAST MAJORITY OF NEGLECTED CHILDREN WERE SUBJECT TO MALTREATMENT AS WELL.

THIS RESEARCH AND A MUCH LARGER BODY OF WORK SHOWS THAT, OUR FAILURE TO ADDRESS THE CAUSATIVE ISSUES IS COSTING US FOR GENERATIONS. WE NEED ONLY TO LOOK AT THE ABORIGINAL COMMUNITY IN CANADA TO KNOW WHAT DAMAGE IN ONE GENERATION COSTS US IN SUBSEQUENT GENERATIONS.

MY THOUGHTS MIGHT BE SEEN AS RADICAL STUFF, BECAUSE IT ASKS FOR A THOROUGH RECONSIDERATION OF HOW WE FUND AND OPERATE CHILD PROTECTION. I SUGGEST THAT THE MOTIVATION FOR THAT IS VERY LOW. MY CALL IS FOR US TO BEGIN, AS A PROFESSION, A PUBLIC DIALOGUE ABOUT CHILD PROTECTION AND WHAT TRULY NEEDS TO HAPPEN. WE HAVE BEEN SILENT TOO LONG AND THE PUBLIC REALLY DOES NOT UNDERSTAND. WE HAVE LEFT IT TO THE MEDIA TO COMMUNICATE OUR MESSAGE AND THEY GENERALLY ONLY DO IT WHEN WE FAIL.

IF WE DO NOT CREATE THE CHANGE, THE NATURAL OUTCOME IS THAT CHILDREN WILL NOT BE PROTECTED WELL. CHILDREN WILL END UP IN FOSTER CARE THAT WOULD BE BETTER OFF IN FAMILIES BUT THE RESOURCES NEEDED WILL NOT BE THERE. A CHILD WILL AGAIN DIE AND THE MEDIA WILL AGAIN SEEK TO FIND THE CULPRIT.

HIGH PROFILE CASES THAT ARE COVERED BY THE MEDIA COST SOCIETY IN SOME VERY EXPENSIVE WAYS, HOWEVER. THESE CASES OFTEN LEAD TO WORKERS WANTING TO ENSURE THAT SUCH A CASE DOES NOT HAPPEN ON THEIR CASELOAD SO THAT THEY BECOME OVERLY CAUTIOUS. IN THOSE SITUATIONS, CHILD PROTECTION WILL OVER APPREHEND. BUT WHO CAN THEN BLAME THE WORKERS WHEN ERRORS ARE SEEN NOT AS LEARNING OPPORTUNITIES BUT AS BLAMING OPPORTUNITIES.

AS I NOTED EARLIER, THERE IS A RISK AVERSION WITHIN CHILD PROTECTION BUT TRYING TO KEEP HIGHER RISK FAMILIES TOGETHER, WHICH AS I HAVE NOTED IS OF BENEFIT TO A MULTITUDE OF CHILDREN, REQUIRES TAKING RISKS. TAKING THE RISK THAT APPARENT CHANGES ARE REAL; THAT CHANGE CAN BE SUSTAINED; THE PARENTS WILL UTILIZE THE NEW TECHNIQUES THAT THEY HAVE BEEN TAUGHT AND, AS A RESULT, THE FAMILY SITUATION WILL BE AT LEAST, GOOD ENOUGH. BUT THAT RISK WILL NOT ALWAYS HAVE A POSITIVE OUTCOME.

WHAT MIGHT BE DISCOURAGING IS THAT THESE ARE ISSUES THAT HAVE BEEN TALKED ABOUT FOR SOME TIME. DOUGLAS BESHAROV, WRITING FOR THE LEGAL COMMUNITY IN 1994 NOTED THAT HIGH PROFILE MEDIA CASES LEAD TO OVER REACTION AND MORE CHILDREN COMING INTO CARE. IF WE ARE NOT PREPARED TO USE ERRORS AS LEARNING OPPORTUNITIES BUT RATHER AS EVIDENCE THAT CHILDREN ARE NOT BEING PROTECTED THEN WE WILL CONTINUE TO SEE THESE KINDS OF REACTIONS.

ONE WAY THAT SOME POLITICIANS TRY TO GET THIS APPARENT NO-WIN STORY OFF THEIR PLATE IS TO PRIVATIZE CHILD PROTECTION SERVICES. RESULTS THUS FAR ARE NOT THAT ENCOURAGING. CASE OUTCOMES DO NOT APPEAR TO BE BETTER, STAFF TURNOVER IS STILL A PROBLEM AND COSTS DO NOT APPEAR TO BE LESS. THE SOLUTIONS ARE NOT ABOUT WHO DELIVERS THE SERVICE BUT HOW AND WHAT IS DELIVERED.  PRIVATIZATION DIVERTS AWAY FROM THE DISCUSSION THAT REALLY NEEDS TO HAPPEN.

THE OTHER MAJOR CHALLENGE OF LOOKING AT IMPROVEMENTS IN THE SYSTEM IS THAT WE FOCUS ON WHAT GOES WRONG AS OPPOSED TO WHAT GOES RIGHT. ERRORS ARE WINDOWS INTO IMPROVING THE SYSTEM BUT SO IS EXAMINATION OF THE THINGS THAT GO WELL – WE NEED TO ASK WHY SUCCESS OCCURS AND SEEK TO REPLICATE MORE OF THAT.

I WANT TO EMPHASIZE THAT, HAVING BEEN IN AND AROUND CHILD PROTECTION SYSTEMS FOR ABOUT 3 DECADES, I BELIEVE THAT WORKERS ARE TRYING TO DO THEIR BEST WITH THE RESOURCES THAT THEY HAVE AVAILABLE. AS A SOCIETY, WE ARE NOT WILLING TO DO WHAT IS REALLY NEEDED, HOWEVER, AND WE WILL CONTINUE TO ASK CHILD PROTECTION TO SERVE AS SOCIETY’S CLEAN UP CREW.

I KNOW THAT THERE ARE FAMILIES WHO ARE BETTER OFF BECAUSE OF CHILD PROTECTION. I HAVE MET THEM! I KNOW THAT THERE ARE CHILDREN WHO ARE ALIVE TODAY BECAUSE OF CHILD PROTECTION. I HAVE WORKED WITH THEM! I KNOW THAT IN MOST CASES, THINGS GET BETTER BUT UNTIL WE ARE WILLING TO ADDRESS THESE CORE MATTERS, AS A SOCIETY, THINGS WILL NOT BE GETTING BETTER AS THEY SHOULD. NOT ENOUGH GOOD WILL HAPPEN TO ENOUGH FAMILIES. WE AS A PROFESSION NEED TO CELEBRATE OUR SUCCESSES BUT WE ALSO NEED TO DEMAND OF OUR SOCIETY, THROUGH OUR POLITICIANS, THE RESOURCES TO CHANGE WHAT OCCURS IN SOCIETY – THOSE ISSUES OF DOMESTIC VIOLENCE, SUBSTANCE DEPENDENCY, ABUSE AND NEGLECT – BECAUSE THOSE ARE THE CHANGES THAT REALLY PROTECT CHILDREN AND PRESERVE FAMILIES. LET US RAISE OUR VOICES SO THAT DIALOGUE OCCURS. TO NOT DO SO IS TO TRULY TO FAIL CHILDREN.

THANK YOU.