Depressed Mothers in the child welfare system

Kohl, Kagotho and Dixon have just published a rather interesting piece of research regarding depressed mother's parenting. They looked at a child protection population. As they note, women are more likely to experience depression as compared to men. Further, those referred to a child protection system will more likely have cumulative stressors that may add to the problems. Women are more likely to be the caregivers in child welfare families and depression is a common concern. Depression has also been found to have a relationship with dysfunctional parenting.

These researchers looked at 92 sampling units across 36 states in the USA. The sample was robust with 5501 children. The families were followed for 36 months and comprised those where the children spent no more than 5% of time in an out of home placement. Thus, while this is a child welfare population, it is one where family preservation is occurring. This might suggest that the population is less severe than might other samples be, but it also afforded the researchers a chance to see what unfold with parenting when the parent stays in that active role. Given the focus of the research, the mother also needed to be the primary caregiver, but could be biological, adoptive or step mother.

The results showed some surprising conclusions, the most important being that it did not replicate the previously seen conclusion that there is a connection between depression and harsh parenting. However, it did increase from 9% to 14% over the course of the study. That is a statistically significant increase. Even so, harsh parenting was a rare event. This is an important result.

The connection between neglectful and emotionally abusive parenting was found. The latter grew over time which is of course, rather concerning. As these authors note,

These high rates of ongoing emotional maltreatment after a CPS referral are a concern, given the long-term adverse consequences of experiencing this type of maltreatment in child- hood. Emotional maltreatment has been found to be an important contributor of psychological adjustment in young adulthood, with higher levels of emotional maltreatment being associated with poorer outcomes (Miller-Perrin, Perrin, & Kocur, 2009).(p.223). 

In their discussion about the implications of their work for clinical practice, the authors note that parents in child protection system are much less likely to receive mental health services as opposed to the overall population. That is worrisome given the implications for these families. This result comes from the USA and may vary across jurisdictions. None the less, it is an acute reminder that assessing for mental health concerns remains a priority in child protection populations. Getting mental health services in place may well serve to increase family preservation outcomes and also reduce such parenting practices as emotional abuse and neglect.

This research underlies the value of good assessment and then connection to needed services.

Reference:

Kohl, P.L., Kagotho, J.N. & Dixon, D. (2011). Parenting practices among depressed women in the child welfare system. Social Work Research, 35, (4), 215-225.

Creating a sense of "Hardiness"

An interesting piece of research has been published this month in the American Journal of Family Therapy. It looks at men and women in relationships who are also survivors of abuse in childhood. The work by  Sandberg, Feldhousen and Busby had a sample of 338 females and 296 males, which is a robust size.

they defined hardiness as a sense of control or influence in one's life especially when faced with adversity. They also acknowledge that previous research has identified that abuse in a person's life can have long term implications. Depression and substance abuse can also serve to negatively moderate the influence of abuse in childhood and, in term, negatively impact parenting. They also note that the quality of the adult relationship between the parenting partners can negatively or positively mediate. In other words, a strong and positive husband and wife relationship can reduce the negative impact of childhood abuse on the survivor's parenting behaviours. This, of course, adds to the building literature that helps us to see that not all people abused in childhood will necessarily go on to be abusive in adulthood.

The implications for practice in child protection are valuable. Building self efficacy and resiliency in a parent increases their hardiness. This, in turn, improves the way in which they can engage parenting. Further, increasing the quality of the couple's relationship will increase the hardiness and again benefit parenting.

It is not a surprise then that it is also important to address issues such as depression in parents as this can impact the hardiness of the individual. This too, then, will have a probable negative impact on parenting. Depression and hardiness, the authors state, have a bi-drectional relationship.

They also noted some gender differences which may help when working with survivors of childhood abuse. Females will benefit from a strengths based approach as opposed to one with a problem base. When working with men, they note:

 "When working with men, clinicians should note that these results suggest childhood trauma, particularly sexual abuse, is correlated with feeling depressed and a weakened sense of hardiness. Clinicians must recognize that overtly addressing this type of abuse may be very difficult for men struggling against gender stereotypes, and as a result patience and persistence will likely be needed" (p.88).

This is valuable research and helps us to see how we can create strength in parents who have been the victims of abuse in their own childhoods.

Reference: Sandberg, J.S., Feldhousen, E.B. & Busby, D.M. (2011). The impact of childhood abuse on women's and men's perceived parenting: Implications for practice. American Journal of Family Therapy, 40 (1), 74-91. DOI: 10.1080/01926187.2011.566827

What happens to children placed in care?

This is the essential question that a new UK study posed. American research previously referred to on this blog has suggested poorer life trajectories. Thus, the British study adds more to the picture. There were 431individuals who, at age 30, provided details on what had occurred in their life trajectory. The report notes that "Compared with cohort members with no public care history, a greater proportion...from public care were from poorer socio-economic background, single motherhood and were underweight at birth." There was also a larger minority representation, particularly blacks. This is not an unexpected result given the long history of poor and minority populations within child protection systems throughout the western countries.

However, for those children admitted to foster care earlier and younger, the outcomes are more favourable. Non foster care outcomes, such as residential care, are less favourable. Pre-care characteristics could not full explain the differences. One vital conclusion is the quality of staff in residential group care really does seem to matter.

Some of the key findings in this research include:

• longer stays in care tended towards poorer outcomes;
• placement instability was also related to poorer outcomes;
• care systems are typically not able to offer all of the supports and roles that a family offers;
• a single, stable and caring long term placement generally leads to better outcomes and, not surprisingly, unstable placements and frequent placement changes lead to poorer outcomes;
• one-off placement, even short term, may have long term negative implications if that placement was a traumatic process for the child, if that admission was mishandled;
• older age at placement is also related to poorer outcomes;
• placement prior to age 1 did not seem to have the poorer outcomes which may challenge some of the assumptions of attachment theory according to the authors;
• Adverse events of the first year appear to be overcome-able by longer term subsequent positive events.

They also postulate that pre-placement negative events and the effects of placement may be countered by providing good support to a family such that the family environment is much improved for the child upon return. They also note that it is important to support the family changing while the child is out but also offering specific services to support the child. If, upon return home, the family life is one of continuing adversity for the child, then longer term outcomes may well continue to be poorer.

This research has real implications for clinical practice. Perhaps the most vital lessons are that the child protection system continues to be one that is most likely to serve the poor, disadvantaged and minority populations. The life circumstances of these populations are such that they are more likely to come to the attention of CPS. Society, which has the power to solve many of these complex problems seems unwilling to do so. A recent report in Canada from the National Council of Welfare presents data that tells us that a 2% increase in the goods and services tax, with proceeds targeted to poverty reduction, could provide the funds needed to eliminate poverty. It is highly improbable that this would happen. Such policy options exist but instead, we are going to see governments avoid such solutions meaning that CPS will continue to end up dealing with the implications of poverty and its related challenges.

Child protection is a clean up service, in some respects, for the problems that larger society does not wish to effectively address. Yet child protection will also face criticisms at three crucial points: when a child known to child protection dies; when a child is wrongly apprehended and when child protection remains over involved in disadvantaged populations creating an image of focusing upon them.

Reference:

Dregan, A. & Guilford, M. (2011). Foster care, residential care and public care placement patterns are associated with adult life trajectories: Population-based cohort study. Social Psychiatry and Psychiatric Epidemiology, In Press. DOI 10.1007/s00127-011-0458-5.

The Poverty Narrative

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

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

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

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

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

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

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

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

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

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

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

Foster Children and Psychotropic Medications

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

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

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

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

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

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

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

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

UPDATE:

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

When Parents are Incarcerated

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

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

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

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

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

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

We already know the reasons for child deaths

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

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

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

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

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

The governor's mandate to release the records of those children killed by their caregivers in 2011 would have forced the commissioner, in essence, to act in direct opposition to her professional values and ethics.

  

Social workers (even those appointed to the position of commissioner) who violate the code are to be reported to the State Board of Social Work for review and action leading to a variety of possible negative actions against the violator's license.

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

Sadly, I predict that this will not happen. We may, indeed, find an employee (social worker or not) to blame, a policy that is not consistently enforced or a sharp decline in fiscal resources that needs to be addressed.

    

In fact, I am sure this type of information is contained in the records of those deceased children whose confidentiality social workers are ethically bound to protect.

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

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

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

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

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

Those same Kentucky families, barely functioning before the economic crisis, collapsed afterwards. Rates of drug and alcohol abuse rose dramatically, jobs were lost, mental-health problems increased, and families became isolated in their poverty and suffering. When families collapse, children suffer.

 

As the deaths of those children are reviewed and their confidentiality is shattered like a fragile vase, we need to take responsibility for our failure of those same children as well as the department. We allow Kentucky's children to live in squalor, deal with hunger as best they can, and be subjected to angry, out-of-control individuals who comprise the only family ever known to them.

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

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

Read more: http://www.kentucky.com/2011/12/14/1993899/we-already-know-the-reasons-for.html#ixzz1gcCHyQif