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

Kaenu Williams and Marchella Pierce - some common territory in their tragic deaths

By chance, the Serious Case Review (SCR) into the death of Keanu Williams in Birmingham, UK and the grand jury deliberations regarding the death of Marchella Pierce in Brooklyn, NY were published in the same week. Also by chance, are some common themes. For any of us connected to the world of child protection, both reports are disturbing not only in their details but also in the familiarity of the concerns that they raise.

Injuries to Keanu Williams

The injuries to Keanu were extensive as the above illustration shows. The mother had prior history with child welfare as a child in need as well as with her other children. Prior history is something that is seen in many cases, although certainly not all. But the all too familiar aspects of the case were, as the SCR notes "...various agencies involved had collectively failed to prevent Keanu's death as they missed a significant number of opportunities to intervene and take action" (p.6).  The SCR concludes that the death could not have been predicted.  This is a point that many media have noted. But, also on p. 6, the SCR goes on to state,

However, in view of the background history of Rebecca Shuttleworth and the older Siblings including the lifestyle and parenting capacity of Rebecca Shuttleworth and the vulnerability of Keanu in Rebecca Shuttleworth’s care; it could have been predicted that Keanu was likely to suffer significant harm and should have been subject of a Child Protection Plan on at least two occasions to address issues of neglect and physical harm.

In other words, had the various agencies and authorities been paying attention, communicating with each other and giving priority to the child, the outcome may well have been different. As the SCR notes on p. 8, there had been a lack of focus on the children of this mother. The SCR found themes that have been repeated often in these kinds of reviews:

A number of the issues which have arisen in this Review are also familiar themes in Serious Case Reviews nationally, such as: poor communications between and within agencies, a lack of analysis of information as well as a lack of professional curiosity in questioning the information, a lack of confidence among professionals in challenging parents and other professionals, short comings in recording systems and practice, professional over optimism rather than to ‘respectfully disbelieve’ and dealing with events as one off episodes often referred to as the ‘start again syndrome’.

The start again syndrome is dangerous. There is no other way to put it. It is a way to ignore history. Something that a child protection agency does at its peril. In Canada, we are experiencing the brutal inquest into the death of Jeffery Baldwin where the child protection authorities failed to read their own files to see that the grandmother who starved Jeffery to death had been previously convicted of child abuse.

As the Keanu Williams SCR notes, it is the business of child protection to stay focused on the child's journey. But to do so requires the time to be so focused. This brings us to the Marchella Pierce case where the former case worker and the case work supervisor are both facing charges in her death.

Amongst other things, the Brooklyn Grand Jury notes that the workers faced a system that had failed before. But, case loads are high. Problems have been identified and not corrected. Now, rather than the system being held accountable, there is a risk that the people working in the system will be the scapegoats. We have seen that before as well with the Baby Peter case in the UK where Sharon Shoesmith was vilified in the media.

Marchella Pierce

Workers faced with high caseloads will make mistakes and the clients, children and their families will suffer as a result. Should we hold the caseworkers liable or should we be having a discussion about whether or not society should be held accountable by failing to fund child protection at a rate needed? Or by not funding the kind of prevention services needed?

There is also the ugly truth that, no matter what we do, some parents will kill their children.

In my research, I have catalogued about 900 cases where children have died when child protection was involved. I have missed many cases I am sure, Each week, I add to the list. But each week I see a repetition of the systemic issues such as these.There is no easy solution. We need to continue to highlight these cases putting pressure on governments to properly fund both prevention and reaction services.

What if the war on drugs was failing?

What if we were to come to the conclusion that the war on drugs has been a failure? What if we were to link that war to increased violence in communities? What if, despite the war on drugs, they have become more potent and less expensive? These are the conclusions of research done by the International Centre for Science in Drug Policy (Disclosure: I am a recent member).

The answer to these questions raises significant concern for the child protection systems. If indeed, the war on drugs has failed, then we must conclude that the billions of dollars being spent in interdiction are not being spent wisely. These monies may indeed not be reducing the demand for drugs and are not assisting those that have become drug dependent.  It may also mean that too many families have been disrupted as interdiction leads to high levels of incarceration (particularly in the United States) for individuals who have been in possession of small amounts of drugs or have been at the lower end of the drug dealing enterprise.  For children, this has meant reduced family cohesion, a parent in jail, increased financial strain in the family and possibly placement in care outside the family.

What perhaps may be missing is a focus on rehabilitation via seeing the person who is abusing or dependent on drugs as having a medical disease. A large volume of research supports that addiction is just that – a disease. Indeed, the Canadian and American societies on Addiction Medicine have taken a stand that addiction is a primary disease. What other medical condition do we treat as a crime in the way that we treat addiction?

What the body of research leads us to is that the financial resources should be redirected to health interventions. The research also leads us to a discussion about the role that gover

nment should play in the marketplace. We need a better discussion about whether government should retail marijuana, for example, in the way that it retails alcohol.  

Where I live, in Calgary Canada, not a single day goes by that I do not walk down a main street smelling someone using marijuana. It is now prevalent. Access is easy.

The ICSDP research notes:

 The study authors conclude that there is a need to re-examine metrics of drug strategy effectiveness, which currently place a disproportionate emphasis on seizures as a marker of reducing drug supply rather than reducing problematic drug use. For example, rather than using indicators of the quantity of drugs seized, which appear to be unrelated to actual supply, governments could assess the effectiveness of their drug policies by employing indicators of drug-related harm such as the number of overdoses, the rate of blood-borne disease transmission (e.g., HIV and hepatitis C) among people who use drugs, or emergency room mentions of drugs.  

Children in the child protection system will benefit from greater family cohesion if a health approach is taken. We can reduce the costs of child protection by focusing community efforts on treating. This is not an easy discussion but when the evidence keeps mounting that the present approach is not working, it is needed discussion.

Richard Dawkins just has it wrong

Speaking in an interview with Times magazine, author Richard Dawkins stated:

‘Just as we don’t look back at the 18th and 19th centuries and condemn people for racism in the same way as we would condemn a modern person for racism, I look back a few decades to my childhood and see things like caning, like mild paedophilia, and can’t find it in me to condemn it by the same standards as I or anyone would today.’

At one level, it is perhaps easy to see the merits in Dawkins argument - times change and so do standards of what is and is not acceptable. Yet, he suggests that what took place 50 or 60 years ago represented such a different standard that sexual and physical abuse should be seen as indicative of the times.

Richard Dawkins

The Sovereign Independent goes on:

In a new autobiography Professor Dawkins told how a master at his Salisbury prep school had pulled him on to his knee and put his hand inside his shorts’, adding that other boys had been molested by the same teacher.

While he said that he had found the episode ‘extremely disagreeable’ he wrote: ‘I don’t think he did any of us any lasting damage.’

Those of us who work in and around child protection have worked with enough parents from that age to know that they live with the haunting memories of the abuse from those times. In my view, Dawkins minimizes the impact but also creates a patina of acceptance for what took place. Consider the following:

• In Mount Cashel orphanage in St. John's, Newfoundland where state wards were routinely physically and sexually abused by the Christian Brother's of Ireland. This occurred through the 1950's;
• How about the literally hundreds of victims of Jimmy Savile in the UK;
• In Canada, there were several churches involved in the residential schools where Aboriginal children were stripped of their identity and dignity through neglect, physical and sexual abuse;

These are but three high profile cases amongst thousands that could be added to the list. But most importantly, Dawkins fails to see that what he is describing is the abuse of power by a teacher who is engaged in grooming a child towards greater sexual involvement. In his case, it may have stopped for any number of reasons. One can almost be certain that the teacher he speaks of has other victims, some of whom would have been less fortunate than Dawkins.

The clinical research tells us that those who use their position of authority to take sexual advantage of a minor, typically have several victims. In order to help reduce this type of sexual abuse, we need to educate children about both protecting themselves and being open about advances that may occur. As a society, we also must respond to those who do offend. Seeing it as Dawkins describes it is dangerous as it dismisses the importance of the offence.

Dawkins says that he got over it - maybe he had a good support network; had resiliency; had a way to compartmentalize the event - but for millions of others, these sorts of events have created life long damage that has impacted their lives in multiple ways.

In essence, he has become the apologist for the abusers. That is the most dangerous aspect of his thinking.

Coincidentally, some rather poignant research was published in Frontiers in Psychaitry:

Child sexual abuse (CSA) occurs frequently in society to children aged between 2 and 17. It is significantly more common in girls than boys, with the peak age for CSA occurring when girls are aged 13–17. Many children experience multiple episodes of CSA, as well as having high rates of other victimizations (such as physical assaults). One of the problems for current research in CSA is different definitions of what this means, and no recent review has clearly differentiated more severe forms of CSA, and how commonly this is disclosed. In general we suggest there are four types of behavior that should be included as CSA, namely (1) non-contact, (2) genital touching, (3) attempted vaginal and anal penetrative acts, and (4) vaginal and anal penetrative acts. Evidence suggests that CSA involving types (2), (3), and (4) is more likely to have significant long-term outcomes, and thus can be considered has having higher-impact. From the research to date approximately 15% of girls aged 2–17 experience higher-impact CSA (with most studies suggesting that between 12 and 18% of girls experience higher-impact CSA). Approximately 6% of boys experience higher-impact CSA (with most studies suggesting that between 5 and 8% experience higher-impact CSA). The data also suggests that in over 95% of cases the CSA is never disclosed to authorities. Thus, CSA is frequent but often not identified, and occurs “below the surface” in the vast majority of higher-impact cases. 

This research emphasizes the long term impact of sexual abuse in most cases.

Reference for research

Martin, E.K. & Silverstone, P.h. (2013). How much child sexual abuse is "below the surface" and can we help adults identify it early? Frontiers in Psychiatry. published online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711274/

 

Are we making progress with sexual abusers of children?

There is likely no topic that can stir a highly charged debate like the one around sexual abusers of children. I am careful to not use the word pedophile as the broad descriptor as they are a subset of the sexual abusers of children. A pedophile has a sexual orientation to children whereas not all sexual abusers have that.

None the less, there is a major abhorrence of sexual abusers in our society. There is a strong sentiment against them that might be summed up as, "Throw them in jail and toss the key away." The research, however, offers a somewhat different view.

There is not doubt that sexual abuse is prevalent. It is estimated that up to 20% of women and around 8% of men report that they have been abused prior to age 18. There are some highly visible examples such as with the Catholic Church, Jerry Sandusky, the former UPenn coach, the Boy Scouts of America, Jimmy Savile in the UK, all coming to mind.

As well, the long term consequences of sexual abuse are significant in both physical and mental health. Some victims of sexual abuse will also go on to become perpetrators.

With all that in mind, I was fascinated to see research published by Langstrom et al., in The British Medical Journal. It looked at the data on preventing sexual abusers of children from reoffending. Overall, they did not find that there was significant research to conclude that many interventions have an evidence base to support that they are effective. There is simply a significant need for well designed research to help answer the question. This was a rather disappointing conclusion.

There were a few points in the article that merit specific mention:

1. The observed rate of re-offence for sexual abusers of children is low. One study with a sample size of 9,603 found only 12.7% re-offended after 5 years. Yearly hazard rates are less than 3%;
2. Treating all sex offenders alike is dangerous. By low risk offenders with high risk offenders we create a significant concern of increasing the risk level of the low risk offender - a contamination effect;
3. Even keeping low risk offenders in long term therapy may increase their risk;
4. The Risk, Needs and Responsivity principle is important - offenders should be matched with treatment that matches their level of risk; the specific treatment needs of the client and their responsivity to intervention.

To be as effective as we can be with sexual abusers of children, we need to understand more, but also be sure to apply what we do know. Policy should be driven by the research. There is no taking away the pain of sexual abuse. Effective intervention with offenders is one of the tools we need. We have yet to develop effective prevention tools that reduce the frequency of sexual abuse. As the authors note, rates of abuse have not differed substantially in recent decades (although regional variations exist).

Reference:

Langstrom, N., Enebrink, P., Laure, E., Lindblom, J., Werko, S. & Hanson, K. (2013). Preventing sexual abusers of children from reoffending: Systemic review of medical and psychological interventions. The British Medical Journal, 347, f4630.  http://doi.org/10.1136/bmj.f4630

Access to children after Termination of Parenting Rights

When courts terminate parental rights (TPR), the prevailing wisdom has been that the connection between the parents and the children will typically be severed. Exceptions might occur when the children are placed in kinship homes with extended family who may offer some connection. This is often the case as TPR is usually a last resort that has followed a variety of efforts to help parents change. After all, the goal of most legislation is to try and sustain families through a variety of family preservation programs.

TPR is often associated with unmanageable or unmanaged mental health, addictions or family violence as well as chronic neglect. Quicker efforts to TPR can occur in cases of serious physical harm or sexual abuse. Thus, the prevailing wisdom associated with no contact with biological family has made some sense.

Yet, there are situations where contact may make sense. When extended family is willing to act in the role of primary caretaker while accepting that the biological parent has significant limitations that preclude acting as caregiver, then contact can be managed. Extended family keeps the child safe and looked after while also allowing the child some level of relationship with the parent.

There are also cases where the parent, later on, takes steps to address the problems. What then of a parent who sustains sobriety later?

In this day of social media, it is much easier for children to find their biological roots. Searching in Facebook, Google, Linkedin and so on can yield connections. Children often want to know their roots and go looking. I have seen this in several cases.

Then there is the reality of small towns and rural areas. I recall a case where the foster home was only a few blocks away - inevitable in the small community. The child exercised the "right" to see the parent by just walking down the street. In that case, counselling to help the child understand the risks while also managing the relationship was the best solution.

It may be different when the child is an infant or toddler, but it becomes much more problematic with older children. This is a challenging discussion but it is one that we need as the new ways for children and parents to find each other demands that we rethink.

Child protection industry conspiracy

Having your parental rights to a child terminated must be a traumatic experience. Whether the parent has intentionally abused a child, suffered from serious mental health issues or intractable addictions, there is a permanent hole in the parent's life when a child is lost to them. Even parents who have children removed on a temporary basis, still get up in the morning and see the place where the child used to sleep and feel the loss. Taking a child into care is a step that impacts all involved.

However, there is also a belief amongst some that child protection workers are somehow rewarded with removals and the subsequent adoption of children. Some theorists argue that funding formulas, such as those in the USA, support states taking children into care as opposed to leaving children in families and then trying to improve the family situation.

An example of this thinking can be found in a YouTube video Documentary on the Child Protection Industry. It is not that well done, but it certainly illustrates the thinking.

Critics are able to point to some high profile cases where child protection really did get it wrong. An example is the death of Logan Marr. She was placed in foster care. The foster mother, who was also a former child protection worker, was subsequently convicted of killing Logan. The PBS program Frontline has done a documentary on the case.

Logan Marr

There are many other cases where errors have led to high profile media reports. Like any system, a child protection system is going to get it wrong at times. The challenge of course, is that the price of errors can be high. At the same time, little pubic attention is given to the multitude of cases where things go well and sometimes, brilliantly. Little media time is given to the child who is alive and well today because of CPS interventions.

Child protection workers are constantly walking the line between protecting a child and preserving a family unit. Most child protection legislation seeks to have this balance tip towards family preservation. The appropriate standard for a parent to keep raising the child is not perfection or even being close to it. The standard is good enough.

As my colleague Sandra Engstrom and I are noting in an article we are preparing for publication:

Budd, Clark & Connell (2011) identiCied three domains that they concluded formed elements of minimally adequate parenting. These include:

• meeting the physical needs of the child including the provision of a stable and safe home environment as well as meeting such things as medical and dental needs;
  
• providing for the cognitive and developmental needs; and
  
• addressing and responding to emotional needs including affection and sensitivity, appropriate discipline in order to promote positive behavior (p. 105).

 These same authors also suggest that issues of fit between parent and child form part of minimal parenting capacity. These include child factors such as the developmental stage of the child and the presence of any special needs. Can the parents meet both the needs of the child as well as their own needs? These authors further note that environmental considerations come into play such as culture, socioeconomic status and interpersonal stressors (p. 105). 

However, to suggest that child protection workers, in general, seek to remove children in order to meet the needs of adopting parents, as the above noted documentary suggests, is not supported in any credible research I have been able to find. No doubt, there are some outlier cases where this may appear to have occurred, but there simply is not the evidence to suggest that this is a goal of child protection. Yet, those who have been affected by CPS can well feel aggrieved and seek to shift blame.

My research focuses on child protection errors - cases where they indeed got it wrong and children have suffered. Yes, there are definitely cases of practice errors - Logan Marr is one of those cases. Many errors occur, however, due to systemic problems such as high case loads and insufficient funding of CPS and the intervention systems that can help families.

Social work needs to keep working on the practice errors. Like any system, engineering, aviation, medicine, the profession must learn from its errors. That is essential.

Allegations of conspiracy to take children in order to support adoptions as well as the employment of social workers and other allied mental health professions does little to advance an understanding of the errors. Yet, within their criticisms can be found some powerful areas for discussion as well as an understanding of the deep pain that parents feel who lose their children.