Willful Blindness

Margaret Heffernen's book Willful Blindness was published this past week. In it, there are lesson for those who work in and around child protection. Indeed, there are lessons for any of us who work in the mental health fields, criminal justice, business, physical health and just being in a relationship.

As I read her book, I was deeply reminded of the death of Logan Marr just over 10 years ago - a needless death in which I suspect that, like many other child protection deaths, the workers were suffering from a form of Willful Blindness. This happens when a child protection team forms a view on a case which is then becomes the common view of the team. It is hard to stand up with a different and perhaps unpopular view suggesting that the common view may be wrong. In Logan Marr, there appeared to be a view that her mother was not capable and that the former child welfare worker who was now the foster mother was. This would be tragically wrong. You can see the fixed view in the e-mails sent from the case manager that are reported in the Frontline story on the case.

You can see Willful Blindness in the Victoria Climbe case as well. Here, the common view that developed was that this was a housing case and one where the aunt needed to go back to France. This caused various people to be blind to what was quite observable if they were willing to look.

One wonders if Willful Blindness might also have been an issue in the Jeffrey Baldwin case where a decision seems to have been made that the grandmother who would starve Jeffrey to death was a better caregiver than the parents and that was the end of it.

It is difficult to decide to look beyond the commonly held belief. It can result in a worker being seen as a troublemaker who dissents - not a team player. It can disrupt already accepted case plans. It can result in more work. It can buck the view of management and affect promotions and careers. The less powerful a person might be within a hierarchy or the more that an individual has to lose by dissenting, the easier that Willful Blindness really can be.

Willful Blindness also allows us to develop our own view and then go onto believe that what we have decided is right! Why then question our own decisions; our own capacity to analyze a case and draw appropriate case plans from that analysis?

In essence, we need to cure the blindness to recognize that we never have all the data. With that, we can then give ourselves permission to re-consider. But going up against the established view of the team or the agency - that can be very difficult indeed.

Interesting USA Data on foster care usage

Childtrends databank has provided some new American data on foster care trends. They place the data in context helping us to see its importance. It also helps us to see that this is largely a troubled population. There is a foster care narrative that all foster care is bad and that kinship care is better. Let's look first at the American data:

"Because of their history, children in foster care are more likely than other children to exhibit high levels of behavioral and emotional problems. They are also more likely to be suspended or expelled from school and to exhibit low levels of school engagement and involvement with extracurricular activities. Children in foster care are also more likely to have received mental health services in the past year, to have a limiting physical, learning, or mental health condition, or to be in poor or fair health.1 One study found that almost 60 percent of young children (ages 2 months to two years) in foster care were at a high risk for a developmental delay or neurological impairment.2

Youth who “age out” of foster care instead of returning home may face challenges to making a successful transition to adulthood. According to the only national study of youth aging out of foster care, 38 percent had emotional problems, 50 percent had used illegal drugs, and 25 percent were involved with the legal system. Preparation for further education and career was also a problem for these young people. Only 48 percent of foster youth who had “aged out” of the system had graduated from high school at the time of discharge, and only 54 percent had graduated from high school two to four years after discharge. As adults, children who spent long periods of time in multiple foster care homes were more likely than other children to encounter problems such as unemployment, homelessness, and incarceration, as well as to experience early pregnancy.3,4"

The report adds:

"In 2009, nearly half (48 percent) of all foster children lived in homes of non-relatives. Nearly a quarter (24 percent) lived in foster homes with relatives—often known as “kinship care.” Sixteen percent of foster children lived in group homes or institutions, four percent lived in pre-adoptive families, and the rest lived in other types of facilities (based on preliminary estimates)."

A study published this past week, shows that there are pluses and minuses to being in foster care and also in kinship care. It also highlights the needs to better support kinship care. To do this may increase the benefits of kinship care and decrease the negative outcomes of children who cannot live in their biological parental homes. ScienceDaily on February 7, 2011 summed up the research:

"Children placed with a relative after being removed from their home for maltreatment have fewer behavioral and social skills problems than children in foster care, but may have a higher risk for substance use and pregnancy as teenagers, according to a report in the February issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. These relatives -- known as kinship caregivers -- appear more likely to be single, unemployed, older, and live in poorer households, yet receive fewer support services than do foster caregivers....

Kinship caregivers were more likely than foster parents to have a low socioeconomic status -- they were four times more likely not to have graduated high school and three times more likely to have an annual household income of less than $20,000. However, they were less than half as likely as foster parents to receive any form of financial support, about four times less likely to receive any form of parent training and seven times less likely to have peer support groups or respite care.

At the three-year follow-up, children in kinship care were more likely to be with a permanent caregiver than were children in foster care (71 percent vs. 56.4 percent). They also had 0.6 times the risk of behavioral and social skills problems and half the risk of using outpatient mental health services or taking psychotropic medications. However, adolescents in kinship care had seven times the risk of pregnancy (12.6 percent vs. 1.9 percent) and twice the risk of substance abuse (34.6 percent vs. 16.9 percent).

"Our findings indicate that kinship caregivers need greater support services," the authors write. "The findings also indicate that kinship care may be associated with a reduced risk of ongoing behavioral and social skills problems and decreased use of mental health therapy and psychotropic medications. Conversely, adolescents in kinship care have higher odds of reported substance use and pregnancy. These findings suggest that increased supervision and monitoring of the kinship environment and increased caregiver support services are urgently needed to improve outcomes of children in kinship care."

The value of kinship care for children is significant. It allows them to sustain connection with family ensuring a greater sense of belonging. There appears to be lower risks for multiple placements as well allowing for greater stability in neighborhood, school and peer connections. By supporting these families, you can create the greater stability and perhaps also offset some of the economic issues. Clearly some of the negative outcomes require addressing if we are to truly make kinship care an overall better choice. Of course, not all kinship opportunities are better when the original problems that brought child protection in are systemic to the larger family system but that is certainly not always the case.

Note: the foster care data can be found at http://www.childtrendsdatabank.org/?q=node/199

Mental Disorders in Children

When we talk about child protection issues, we see that there are high frequencies of mental disorders in children within that population. It is helpful to see the average rates of disorders in children as that gives us a base of comparison. In the USA, the National Institute of Mental Health has published data that helps us to see the "average" rate of mental health issues within the general population of children.

Describing this data, they state:
The Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES) includes prevalence data for children ages 8 to 15; a slightly younger age range than the data from the NCS-A chart above. These data show that approximately 13 percent of children ages 8 to 15 had a diagnosable mental disorder within the previous year. The most common disorder among this age group is attention-deficit/hyperactivity disorder (ADHD), which affects 8.5 percent of this population. This is followed by mood disorders broadly at 3.7 percent, and major depressive disorder specifically at 2.7 percent.

The Child Welfare Master Narrative – Is it for real?

Fraidin (2010) has recently published a review that looks at confidentiality laws and the master narrative of child welfare. He argues that the master narrative of child welfare is about abusive parents who are meting out untold harm on children who must be protected. He states, “In short, the master narrative of child welfare depicts foster care as a haven for “child victims” savagely brutalized by “deviant” “monstrous” parents.” (pp2-3). He correctly points out that the vast majority of children in foster care in the USA (and likely the Western world) are there for neglect as opposed to abuse.

He suggests that policy ought not to be built around this master narrative as it is essentially incorrect – most children in child protection systems are not in need of protection from physically abusive parents or guardians. He is equally correct in pointing out that foster care is not always a better alternative and that there have been children harmed by foster parents.

Regrettably, Fraidin does not see that he too is engaging in a master narrative approach by focusing on foster care as generally unsafe and harmful. This is a story line that is often picked up by critics of child protection. This master narrative suggests that foster care system is largely one where children are harmed and that children will be better off with their biological parents. He cites research by Doyle (2007) which looked at a large cohort of children in foster care (excluding abused children) who, fared poorer in a number of important measures versus those left in biological homes. This research has been replicated elsewhere. The point is valid.

However, other researchers have shown that there are policies that can be adopted which better support educational attainment and subsequent employment and social well being. If adopted, these policies might well alter Doyle’s conclusions (see for example, Dworsky & Courtney, 2010). In other words, if we better support the transition to adulthood then more foster children are likely to be successful. We certainly see that children within families are in need of such support. So is the problem one of foster care per se or one of better managing the needs of the children in care?

Fraidin, in his article, cites cases where children would have likely have seen greater success if appropriate supports were in place or followed through.
He then wanders into another master narrative of the child protection critique which is that family preservation is the golden idol against which all child protection efforts should be judged. The question might better be posed – are we bringing the right kids into care? This requires us to assess whether we are using child protection for the purposes intended or, is society using child protection because it does not wish to address the real underlying issues. These include:

• The willingness to address widespread poverty which underlies so much of the neglect cases. If we are not willing as a society to alter the economic paradigms, then children end up in care because poverty creates the social landscape that leads to child protection interventions. It is quite true that children are neglected as parents struggle to get enough food on the table or a roof over the heads of children.

• Health care access is a major concern in many countries including the United States. Much improvement could be made in that area that would reduce the demands on child protection systems. Parents who can be healthier because they have the care needed will do a better job with caring for their children.

• Aboriginal families across North America are still struggling to recover healthy parenting capacity. Multi generation losses in this area occurred because of residential schools. Getting effective supports will reduce neglect and demand for child protection services.

• Early intervention services reduce the need for child protection. They support parents as they enter the role. They help them adapt to the needs of their children and to relate with them in ways that allow the parent to be good enough (See for example the very powerful study by Allen, 2011).

Fraidin also raises the issues of how the media covers tragic stories where children die who are being or have been monitored by child protection. The public is obviously upset and major tragedies that receive widespread coverage can lead to increased apprehension rates. His criticism of this is valid. But he fails to see the real point which is that we are asking child protection to be too many things. The issues noted above need to be addressed (and funded) if we want to create a world where child protection can focus on the cases that really matter. Is society will to pay for these prevention services? So far, the answer is, not really.
What Fraidin does not address is how those tragedies can be useful in increasing the debates about:

• The willingness to fund effective intervention, poverty reduction and health care programs;

• The need to decide what child protection is there to do – which cases should they be focusing on?

• The need to consider how, as a society, we are defining neglect. Are we using definitions that are much too broad (thus capturing too many families)? And are we doing so because the other programs that should be working are not there or are underfunded?

• Are we willing to talk about tax payer dollars being made available at times when economies are struggling and increasing neglect caseloads?

On p, 12, Fraidin refers to the child protection master story also bringing in government malfunction when children die. But government is malfunctioning and children are suffering because of it. This is a management issue but it is even more an issue of how resources are being allocated to which problems.

As someone who has spent many years working with child protection cases, I find that Fraidin’s global criticism of the master narrative creating belief systems that impact lawyers, judges and social workers to be biased against parents, refusing to consider their perspective or their wants and hopes. He offers no critical research to support this. If we rely on anecdotal stories then I can equally point to very caring lawyers, judges and social workers who seek to find ways to support families and sustain the family unit. Indeed, I see clinicians and researchers struggling very hard at finding ways to effectively intervene with the problems that clinically disrupt families. What judges, lawyers and social workers cannot do is change the societal commitments to funding these very interventions that can positively impact families caught up in neglect.

I am pleased that Fraidin has raised the debate yet I am also significantly disappointed that he has framed it.

References:
Allen, G. (2011). Early intervention: The next steps. An Independent report to Her Majesty’s Government. London.

Dworsky, A. & Courtney, M.E. (2010). Does Extending Foster Care beyond Age 18 Promote Postsecondary Educational Attainment? Issue Brief. Chapin Hall at the University of Chicago. Downloaded 2011/02/05 at http://www.chapinhall.org/research/brief/does-extending-foster-care-beyond-age-18-promote-postsecondary-educational-attainment

Fraidin, M.I. (2010). Stories told and untold: Confidentiality laws and the master narrative of child welfare. Georgetown Law Review, 63, p.1-60.

The role of medication with foster children

Research in the past has shown that mental health issues are a major concern with children in foster care. Given the circumstances that surround the entry into foster care for most children, that is not surprising. When children have experienced neglect, maltreatment, abuse or been exposed to domestic violence,they may well feel depressed, anxious or oppositional. Various forms of therapy have proven helpful including attachment therapy, play and expressive art therapies, cognitive behavioral therapy and mentoring to name a few. Of course, each case is different.

A program I recently attended on adolesecnt depression, showed that relaxation therapies where highly beneficial and much more so than medication. Interpersonal training, relaxation and social skills training were all found to be superior to medication. (http://www.research4children.com/admin/contentx/default.cfm?PageId=89243) See for example slide 26 of that presentation.

A recent PBS program, Need to Know, has looked at the over use of medication with foster children. Of concern is something that I see clinically quite often not only with foster children but also with teenagers getting into drug abuse - a long list of diganosis all of which are getting medicated. The PBS program highlights this. You can watch it online at http://video.pbs.org/video/1726725895 It is the first 20 minutes of the program.

The issue is further highlighted by research on the questionable use of atypical antipsychotics. Researchg at Stanford University and the University of Chicago shows this quite clearly.A summary of the research shows, "Many prescriptions for the top-selling class of drugs, known as atypical antipsychotic medications, lack strong evidence that the drugs will actually help, a study by researchers at the Stanford University School of Medicine and University of Chicago has found. Yet, drugs in this class may cause such serious effects as weight gain, diabetes and heart disease, and cost Americans billions of dollars." http://www.sciencedaily.com/releases/2011/01/110107094900.htm

Medication is a faster fix for foster children. I am actually not against medication because I have seen it make a real difference in the lives of some kids. The problem is that it has become the quick fix as opposed to it being considered as part of an overall treatment plan when it makes sense to include it there.

The issues are complex and giving meidcation will not solve them. They mask symptoms or alleviate them without addressing what lies below. Even when medication is used, research has shown that it is most effective when combined with other therapies. That requires more intense case work for child protection workers already facing high work loads.

Privatization

We start 2011 off with a scary initiative in Nebraska - the privatization of child welfare. State social workers will have only initial responsibility for cases. The profit motive now enters child protection.
In Canada, we saw profit motive in an odd way - government providing funds to operate residnetial schools for aboriginal children. There was a fixed budget that needed to be operated within. That saw poor food. limited resources and disasterous outcomes.
No doubt there will be many who will note that jails in both the USA and the UK are operated successfuly by the private sector.
This is a curious mpral dilemma that should be watched very carefully.

http://www.nptelegraph.com/articles/2011/01/01/news/40001202.txt

The Aboriginal lesson in child protection

Two recent reports on child protection have highlighted the ongoing issue of Aborginal children in the child protection system in Canada. The reports, one in Alberta and the other in Saskatchewan, show that between 7-8 out of 10 children in they systems are related to the Aboriginal communities. This is despite the fact that Aboriginals make up only about 15% of the Canadian population. Why then such disparities?

It is the legacy of bad policy that, as a society, we thought had been good policy. Through the residential schools Canada set out to eradicate the Aboriginal intending to assimilate their children into the dominant white society.

Father Joseph Hugonnard, principal, with staff and aboriginal students of the Industrial School, May 1885, Fort Qu'Appelle, Sask (O.B. Buell/Library and Archives Canada/PA-118765).

Perhaps no quote illustrates the poilcy better than this one: “I want to get rid of the Indian problem. I do not think as a matter of fact, that the country ought to continuously protect a class of people who are able to stand alone… Our objective is to continue until there is not a single Indian in Canada that has not been absorbed into the body politic and there is no Indian question, and no Indian Department, that is the whole object of this Bill.” Dr. Duncan Campbell Scott - 1920

It is this policy that led around 150,000 Aboroginal children into the training and residential schools from the late 1800s to the late 1990s. Thousands died, most were abused, underfed and forced to live in a culture that was foreign while their own culture was oppressed.

Today, in child protection, we have the legacy which is why there are so many children involved with child care. There were generations raised in these schools who lacked any role mdoelling about how to be a parent or even a successful, nurturing adult. Such essentials as how to love, how to raise a child, how to build a child up, how to run a family were all lessons missing. The reservation system often robbed people of the chance to support a family and the schools typically failed at work training. It will take generations to fix this damage.

Not surprisingly, substance abuse and mental health problems are also a major part of the legacy which further damages the parenting capacity. Add to this entrenched poverty as a further consequence and you can see why there are so many Aboriginal famileis and why neglect is the major issue. It is hard to do what you have never been trained to do - parent effectively.

If we are to repair the damage, then Aboriginal communities are going to need to be supported in a multi-generational healing process. Yes, children need protection but families need support, healing and opportunities to learn how to parent. As a society we need to come to grips with this. The Alberta and Saskatchewan reports both highlight this crucial and complex issue.