Assessing risk in child protection - but what risk?

When one thinks of assessing risk in child protection, one might automatically think about risk to a child. Is the child safe? If not, what needs to be done? Should the child be left with parents or removed? If there are immediate risks, can they be mitigated. These are all important risk questions.

However, there are two other facets of risk that are often not spoken about but can play very crucial roles in assessing risk in a family - risk to the social worker and risk to the agency. Both of these risks are by products of the outrage that occurs when a child is seriously harmed or killed while child protection is involved. There have been a myriad of high profile cases in Canada, Australia, New Zealand, the UK, Ireland, the United States and elsewhere. Here in Canada, we are awaiting the release of the Hughes Inquiry into the death of Phoenix Sinclair. It is expected to be released early in 2014. Based on prior inquiries that Justice Hughes has done in other provinces, one can expect a thorough report that will make for grim reading. It is these types of reports that are needed but also create a fear response - who wants to have the next high profile case in the media after all.

Phoenix Sinclair

For the social worker, this means that each case decision is also influenced by the risk to the social worker. What is likely to happen if this decision turns out to be riskier and problems occur? When this pressure exists within the decision making process, then there develops a tendency at self protection. This leads to more conservative decision making where getting more intrusive with a family seems like the best path.

So too for the agency or the team managers who do not want to be the next team under public scrutiny. 

Thus, the decisions around what a child needs are influenced by matters that have really nothing to do with the risks to the child.

Some attempts have been made to influence this decision making process by introducing programs such as Signs of Safety. This looks to a family's strengths that can be utilized and enhanced. The goal is to reduce the number of children living away from home. It does require that the agency take more risks that enhancement can occur. The early research tends to be promising. But it does require that the agency be able to tolerate the higher risks. Even more important, is for the politicians to be able to accept the risks.

When things go wrong, politicians have zero tolerance for errors even though errors under any program are inevitable. Child protection decision making is done in a reality of partial information that is almost constantly changing. It is politically difficult to defend the imperfections of decision making when the public is outraged.

There are also factors that child protection cannot solve particularly poverty, crime in neighbourhoods, family breakdowns and unemployment - even those increase risks. Politicians can create social policies that do reduce those risks - but cannot eliminate them.

Thus, while we want social workers to be the best they can at the work they do, no matter how well budgets are managed and case loads are kept low, there will still be errors and fatalities - albeit fewer. This is a very hard argument to sell as a politician but it is reality.

Readers might also find this comparative work between the UK and Belgium of interest

Also of interest will be this blog from Chris Mills in the UK.

What supports sexual abuse disclosure?

In 2011, I had the privilege of delivering the annual lecture sponsored by the Tulir Centre for the Prevention and Healing of Child Sexual Abuse. They are located in Chennai, India. I was speaking on the sexual abuse by a sibling or juvenile. An individual in the audience found it hard to believe that the majority of victims are not disclosing the abuse almost immediately after it happens. I was reminded of this upon reading a newly published study in the Journal of Interpersonal Violence. McElvaney, Greene & Hogan have raised a number of very fascinating points. The article is well worth a read including their literature review in the introduction.

These researchers helped to identify that there may be a difference in the data from studies that have been done on a prosecution sample (where there has been disclosure in some way) and in studies where there has not been the involvement of the criminal justice system. They note that in research studies, there is a substantial group who has never told prior to being asked in the study - this ranged from 19% up to 47%. Silence is real.

The longer the delay in telling, the harder it may be to seek help. Further, given the link between child sexual abuse and subsequent traumatization through sexual assault and abuse, it may be even harder as trauma builds upon trauma.  There are many barriers to disclosure which the authors identify including shame, guilt, the risk to the family or the perpetrator and fear of reactions by others. I was particularly interested in the notion of the victim needed to weigh the consequences of a disclosure creating a pressure cooker effect - the wish to tell and the wish to keep it secret. This is a wonderful insight that serves as a useful reminder that disclosure is often an extremely challenging decision.

These authors found 5 themes from they qualitative research with both victims and parents:

1. The fear of not being believed although those fears often turned out to be unfounded once the disclosure was made;
2. Being asked is a way in which disclosure occurs.There were also those in the study who felt that someone (an adult) must have known it was happening;
3. Shame and Self Blame was another theme;
4. Fear and concerns for self and others - for example the fear that a disclosure would break up the family or that the victim would be unsafe or get int trouble; and
5. Peer influence in that first disclosures often happened to a peer.

There is a need to be aware of these barriers when working with those who may have been abused. As the researchers noted, many parents were "incredulous" when the child disclosed. It was not something that was meant to happen in their own family. 

A child who has yet to disclose may have some or all of these barriers in place - each one of them being quite powerful in and of themselves. Imagine the impact of several at once.

In my own work, I have seen time and time again, various disclosures simply because I have asked. This research affirms that. 

An already hurt and wounded child does not want to spread the pain - hurt the family; cause a family member to be gone; create more vulnerability as well as the fear of retaliation. One feature that may be useful in creating disclosure, beyond creating safety for the child, is to ensure that the perpetrator does not hurt others. Thus, disclosure can protect siblings or other children. This seemed to matter. But, of course, little will occur if the child believes that disclosure will create a further lack of safety.

Reference:

McElvaney, R., Greene, S. & Hogan, D. (2013). To tell or not to tell? Factors influencing young people's informal disclosures of child sexual abuse. Journal of Interpersonal Violence, published online 27 November 2013. http://dx.doi.org//10.1177/0886260513506281 

Marchella Pierce Convictions of social workers

This past week, two social workers (although they are not licensed social workers) plead guilty to misdemeanours related to the death of Marchella Pierce. Damon T. Adams, a caseworker in New York and his supervisor Chereece Bell had originally been charged with criminally negligent homicide. There have not been many instances where social workers have been charged with the death of a child on their caseload.  The mother and grandmother have been charged with the murder of the child.

The caseworker, Damo Adams, plead guilty to falsifying business records, official misconduct and endangering the welfare of a child. Chereece Bell plead guilty to endangering the welfare of a child and a disorderly conduct violation.

In child protection, there is a real need to build relationships with families. This is how you are able to better ascertain what is happening to risk factors and what can be done to monitor and mitigate those factors. In this case, it appears that Mr. Aadams was not attending home visits as he was to do and then apparently falsified the records. That can certainly be seen as a failure of child protection. Even if the caseload was high and the demands too great, the records should not be falsified, rather, they should reflect the truth - there was too much on the plate to get it all done.

Damon Adams and Chereece Bell

Child protection often faces work loads that can challenge what needs to get accomplished. Yet the ethics of the profession demand that truthful efforts and reporting occur.

There is less clarity on the role of Ms. Bell who is being held accountable for not catching the failures of her supervisee. 

The danger here is that there is now less room to admit errors. The case suggests systemic problems but how do those can spoken about when the risks of the criminal process hangs out there. Yet, I am also struck that there should be accountability for those charged with child protection. But there can be no valid expectation that children will not die at the hands of their parents. What worries me is the "what if" that lies under this case - If the Mr. Adams had been more diligent then the child might be alive? If Ms. Bell had done a better job of supervising then the child might be alive? These are dangerous suppositions when the present understanding is that the child died due to the actions of family.

What this case can help us to understand is that doing the job right does matter but we cannot predict the outcome - some parents will kill their children no matter how good the casework. But it also tells us that the system should be subject to scrutiny so that the systemic weaknesses can be spotted and addressed.

It is doubtful that either of these social workers will do child protection again. Yet I cannot wonder what both of them would have learned from this process that might make them far more vigilant and astute. As Ms, Bell noted in an interview, what about all the other cases where things went well and she saved a child or helped a family? 

Accountability does matter but we must also look at the environment in which child protection is done - high caseloads, limited resources and some of the most high risk families who can be very challenging to engage and work with. Errors will happen. I fear that the lesson taken here is that if you make a mistake, you may face criminal charges. Maybe the lesson should be around ensuring appropriate resources exist.

Marchella Pierce

When it happens in your own family

A couple of recent discussions with social workers reminds me that, despite our profession, it is possible to have family become involved with child protection systems (CPS). This is a cause for embarrassment if colleagues become aware of the family connection. However, there is also the need to find a way to deal with this reality. In my discussions, a few themes came out strongly.

1. Being a family member means you are not the professional - no matter how much experience you have, you cannot be the family advisor on a child protection case. You will not know the case or the reasons why CPS is involved and why they are taking the actions that they are. Thus, you are a family member and not a social worker.

2. That being said, you can then act as a family member offering appropriate support.

3. As a social worker, we often learn to turn our emotions down. We keep a degree of professional detachment. When we start to see the "facts" of a case, that turns on. What we need to turn on is our personal emotions that allow us to be a member of a family.

4. We are not the confidant of the social work professionals who may turn to us to act as a go between - after all, they might say, we understand what needs to be done - could we explain it to the family? Well no, we can't. That places us in an untenable position of walking a bridge between the social workers and the family. It's not our role.

5. We are also therefore, not the advocates for the family. The best advocates are those who are not in the family system. Therefore, you should not be attending meetings in such a role.

6. We also need boundaries. We tell our clients this all the time - this is a point in which to heed our own advice.

7. Trying to be a social worker in your own family system means that you are likely to alienate colleagues and family members alike.

There are things you can do. You can be a family member who supports, acts as a shoulder to lean on if appropriate and listen. You can use your skills at reflective listening to help family members process. You can also point people to the sorts of resources that can professionally assist. Most importantly, you can also feel. There may be other ideas but knowing when to step back from the social work role with your own family system is important.

Hamzah Khan - a powerful child death that has so much to teach us

A Serious Case Review was published this past wee into the death in the UK of Hamzah Khan. She was profoundly neglect and when police entered the home, the partially rotted corpse was found. This is a disturbing case from several perspectives - a very unhealthy mother who was in no position to raise a child is a theme at the core of the this case.

The National Society for the Protection of Cruelty to Children (NSPCC) in the UK summarized the SCR stating that the issues include:

Maternal history of: alcohol dependency; depression; social isolation; domestic abuse; and reluctance to engage with services. Issues identified include: invisibility of children to education and health services; failure to take into account the impact of domestic abuse on children; absence of enquiry into the cultural and religious complexity of the family;  insufficient significance given to disclosure by adolescents; lack of professional curiosity; insufficient interagency cooperation. Themes for learning include: cognitive influence and human biases; viewing incidents in isolation and failing to identify patterns that represent harm to children; and tools for effective sharing and analysis of information.

These are powerful lessons indeed. The Daily Mirror noted that it was a neighbourhood police officer responding to a neighbour's complaint who ultimately led to the discovery. The police officer was persistent - a behaviour that should be considered essential for those working in the areas of child abuse and domestic violence.  The Daily Mirror also quotes the SCR author stating:

Very sadly, I cannot give assurances that a tragedy like this will never happen again in our country - as we can’t control or predict the behaviour of all parents, the vast majority of whom are doing their very best to care for their children.

The reality is just that. Even the best of child protection systems will not prevent all deaths for quite a variety of reasons. These include that we cannot see into every house. As well, there are clients who feign cooperation but do not actually follow through with interventions. Then there are the cases where the parent behaves unpredictably or the interventions simply don't work.

Another SCR was published this past week in the UK that reminds us that domestic violence is intricalty connected to child abuse. Perhaps more importantly, is the reminder that these issues are not unique to the more disadvantaged populations. Child protection and other professions can develop a bias when approaching a family that is more advantaged and can have the appearance of success. The facts of the case need to be considered. As the NSPCC noted:

the need to remember that child abuse crosses all class and gender boundaries and to consider the potential impact of bias on evaluations

These cases remind us that errors can repeat themselves. Followers of this blog will see some familiar themes. Thus, we must continue these conversations and do so widely creating a broad reminder of what good practice can look like. 

Aging out

The question of children who grow up in the foster or group care system has been a haunting one. The answers are too often discouraging. Long term research continues to tell us that these youth are more likely to end up homeless, poor, mentally ill, involved in the criminal justice system and be parents of children far too early. There are of course, exceptions. Many of us who have worked in or around the child protection system know the exceptions.

I have had former foster and group care youth in my classes at university. I have met some who have managed to create careers in the trades. This is partially because of good planning and caring adults who saw these youths into adulthood.

Increasingly we are seeing that young people from all sorts of family situations are taking longer to transition into adulthood. They stay at home longer, they take longer to establish themselves in careers and they will have a harder time affording their own house. Even those who come from relatively advantaged environments face these challenges. Those who have grown up in care face much greater obstacles as their support systems are often weaker.

Making the point is a video which is making the rounds.  Aging out

You Tube has many other such videos.

In an environment where the income gaps between the rich and the rest (the famous 1%), the pressures on the most vulnerable will grow. Those in foster and group care are amongst the most vulnerable. We must challenge the policy makers to recognize this and create programs that do bridge the transition as strongly as possible. Many jurisdictions are trying to tackle the problem with a variety of creative programs. More options are needed. Perhaps one discussion worth having is, that if society as a whole sees more kids staying at home longer into adulthood, why would we not expect that this vulnerable population will not also require such supports which significant extension of foster care would create? It's a tough question in environments where governments are into austerity. But what does it cost us to have these youth unsuccessful and placing demands on our health care and justice systems?

Fortunately, we are seeing fewer children in group or institutional care in Canada as seen in the following charts from the Canadian Incidence Study:

These help us to realize that policy changes can shift what happens, although the data also tells us that the rate of involvement with child protection in Canada is growing. The growth of kinship care may mean that there are more family members who will be there for the child over the long term. 

American data is also quite informative about what happens to kids as they come into care:

Some UK data adds to the debate:

The point, of course, is that we need to have the debate. What we have now is not working that well whether we are talking Canada, the USA or the UK.

Depression in parents really does matter

In an editorial review in Psychological Medicine, Psychogiou & Parry have managed to capture the essence of our current understanding of the effects of depression on parenting and implications for children. They note that these implications may also exist for some other conditions such as anxiety, ADHD and Borderline Personality.

Some of the highlights of the article note:

* Parents with low positive affect interact less with their children;
* Parents high on negative affect tend to be intrusive or excessively critical;
* Depressed mothers may show  poorer emotion-regulation strategies;
*They may lower parenting motivation;
* Mothers and fathers with post partum depression may not interact as well with their infants and may, as a result, not build some of the brain circuitry that play a key role in a parent's motivation to be responsive and involved caregivers;
* Rumination in parents affects motivation but it may be more so with fathers;
* Depressed parents may also have lower cognitive flexibility to deal with the demands of parenting.

The authors also note that contextual or environmental factors that a parent operates within also are important. This would include marital conflict, single parenthood or socio-economic realities.

This review certainly brings increased credence to the need to ensure that we are intervening with depressed parents quickly and effectively so that their emotional awareness, regulation and interactions can be encouraged towards a child development lens.

In another recent report, Lewandowski and colleagues note how important the self esteem and resiliency of a child is in buffering the effects of depressed parents. Thus, our interventions need to look beyond the parents to also ensure that we are focused on what the child needs to build internal strengths. Parenting is bi-directional and thus, both parts of the interactional equation, parent and child, should be the focus of attention.

Properly treated, the vast majority of cases of depression respond positively to intervention. These recent publications help us to see that they are useful ways to think about avoiding the need for child protection involvement when other health care systems can see the problem and act quickly and effectively.

References:

Lewandowski, R.E., Verdel, H., Wickramartne, P., Warner, V., Mancini, A. & Weissmann, M. (2013).  Predictors of positive outcomes in off spring of depressed and non-depressed parents across 20 years. Journal of Child and Family Studies, early view, doi: 10.1007/s10826-013-9732-3

Psychogiou, L. & Parry, E. (2013). Why do depressed individuals have difficulties in their parenting role? Psychological Medicine, early view. doi: 10.1017/S0033291713001931

As a result of the comment below, I am adding a link to their rather excellent info graphic