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.

Jeffrey Baldwin: A thematic analysis of media coverage and implications for social work practice

ABSTRACT

Jeffery Baldwin died in 2002 in the care of his maternal grandparents. The case received intense media attention at various times over an almost eight-year period. Along with other public documents, the media coverage permits an analysis of the practice errors by Child Protection Services that are related to the failure to protect Jeffrey. Nine key themes emerged around core child protection practices: opening a file; the role of prior knowledge; issues related to assessment; knowing the child and their needs; the role of culture; case supervision; the child as the client; the enmeshment of child abuse; and the role of stability and healing. This analysis offers key lessons to be learned from such cases.

This article has been published in Child Care in Practice

Paige is a distressing story

The story of how a British Columbia First Nations girl was let down by child protection authorities has been documented in a report by the province's Representative for Children and Youth. It is a hard read. Page after page, you are left wondering how social workers decided to make the decisions they did - leaving this vulnerable child in care situations that were clearly risky; believing that interventions would work when there was little evidence that they would; failing to see the child. As the report notes on p.5, "Professional standards of care were not upheld in how Paige was treated."

This is a child who was subject to maltreatment throughout her life - from infancy to early adulthood when she would die. In some ways, looking back, you can see that she was destined to die early given the amount of maltreatment in her life. She experienced a number of adverse life experiences (ACEs). The ACE research project shows convincingly, that people who experience three or more of these events, have a dramatically higher rate of illness, addiction, mental illness and early death. Based on what is written in the report, her score may have well been in the range of 6.

It didn't have to be that way. Early intervention could have made a difference in terms of both the quality of her life and its duration. She need not have ended up in the Downtown Eastside of Vancouver - one of the most social disadvantaged communities in Canada.

Having researched hundreds of reports like Paige, I am struck by the similarities of repeating problems including (but certainly not limited to):

• being too optimistic that change will occur thus minimizing or not seeing the ongoing and growing risk factors;
• failing to see that repeated efforts at change are not making a difference;
• not putting the needs of the child as the most significant priority;
• failing to coordinate information available from a variety of sources;
• failing to look for the permanent solution believing that being with biological parents was somehow preferable; 
• creating instability through multiple moves and placements;
• failing to follow up on case plans;
• having poor case supervision;
• not really knowing the file;
• not completing needed risk assessments;
• not understanding the nature of addiction.

The Representative's report states on p. 6:

This is a child who should have been permanently removed from her mother’s care at an early age. She was the subject of no less than 30 child protection reports during her 19 years, involving allegations of domestic violence, neglect and abandonment. Her mother was actively using alcohol and drugs and there were no signs of that behaviour abating. Paige was repeatedly returned to her mother by the Ministry of Children and Family Development (MCFD) despite glaring and unavoidable evidence that this was not a healthy, nurturing or safe environment for any child and wasn’t ever likely to be.

As a result, Paige’s life was a case study in chaos. By the time she was 16, she had moved no less than 40 times, between residences with her mother, foster homes, temporary placements and shelters. After her mother moved them to the DTES in September 2009, Paige lived with her in toxic environments and moved another 50 times, living in various homeless shelters, safe houses, youth detox centres, couch-surfing scenarios, foster homes and a number of Single Room Occupancy (SRO) hotels.

As I noted, I have read quite literally hundreds of these reports from Canada, Australia, the USA, England, Ireland, Scotland --- the themes are painfully consistent. So why is that?

Often we think of systemic problems - poor resourcing, over worked social workers, funding problems, weak supervision of front line managers. These are all true. As a profession, however, we must start to look at the quality of care that we are providing. Ultimately, we are responsible for what we do with a client.

We also need to look at the education social workers receive. How well are we preparing students for the real world challenges of managing cases like Paige? We also need to look at politicians for honest leadership that is backed up with funding, resources and the sense that child protection is a priority as opposed to a service to keep the sad stories in check. Political leadership also recognizes that there are problems which child protection cannot solve - poverty, crime in communities and so on.

As a society, we need to have a longer attention span to these issues. Stories like page hit the headlines, people shake their heads and wonder how such a tragedy could occur, politicians nod and speak of change and then……… nothing. The story fades while the media seeks out the next big tragedy to talk about. The themes are telling about tragedy not about actual real change. When society really pays attention, things might change because then the politicians can expect to be held accountable.

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.