Ethical Responses for Vulnerable Children and Families

1
Ethical Responses for Vulnerable Children and
Families

• Dr Leah Bromfield
• Manager
• National Child Protection Clearinghouse

2
The ACCFPP Conference 2008

• In explaining the theme for this conference, the
  organisers state
• As debates continue within the child and family
  welfare system about the effectiveness of
  strategies to support vulnerable children, the
  professions are instead struggling to reconcile
  the need for appropriate supportive relationships
  with clients against ever increasing compliance
  bureaucracy

3
What does it mean to be ethically responsive?

• Integrity
• Respect
• Partnership
• Empowerment
• Empathy

• Forensically astute
• Childs best interests
• Meeting needs
• Timely
• Quality

• For me, it conjures concepts such as

4
Overview

• Child and family protection systems
• Evaluation evidence-informed policy and practice
• Intervening early in the life of the problem
• The right service at the right time
• Child and family protection practice
• Risk assessments and risk aversion
• Engaging families

5

• Ethically responsive policy and practice is
  evidence-informed

6
Ethically responsive services

• Ethically responsive services
• Do no harm
• Provide high quality services
• Improve outcomes for children and families
• The best way to achieve this is through
  evidence-informed policy and practice

7
Good ideas dont always result in good outcomes

• Personal safety programs for children
• Theory Increasing childrens knowledge about
  concepts such as good touch-bad touch will help
  prevent child sexual abuse
• Evaluations show mixed results
• Some success - increased disclosure
• No evidence that personal safety programs prevent
  a child from experiencing child sexual abuse
• May have unintended consequences (gt anxiety)

8
NCPC Audit of prevention programs

• Audit of all Australian child abuse prevention
  programs
• Research undertaken in 1999
• Prevention programs classified according to
  target group
• Children (Personal Safety)
• Families (Parenting Education Home Visiting
  Family Preservation)
• Community (Community Education)
• Many programs (n 1762)
• Majority had some form of evaluation - mainly
  process
• Insufficient evidence base to determine what
  works

Tomison Poole, 2000
9
Child abuse prevention programs A review of the
evidence

• Reviewed evaluations of child abuse prevention
  programs to find out what works
• Australian and international research
• Outcome evaluations only
• 52 published evaluations identified with search
  criteria
• Only 5 of 52 evaluations identified were for
  Australian programs

Richardson et al., 2005
10
Evidence-informed policy practice

• Evaluation is essential to determine if a program
  works
• Can explain why some programs work and others do
  not
• Limited pool of money for child welfare programs
• Growing demand for programs to be evaluated to
  secure ongoing funding
• Abused and neglected children are among the most
  vulnerable in our community
• Vital that interventions are accountable, that
  they actually work and that they do no further
  harm

Holzer et al., 2006
11
Essential elements of a rigorous evaluation

• Impact and/or outcome measures
• Impact - direct effect of a program according to
  its aims and objectives
• Outcome - assumptions underlying the direct aims
  of the program
• Pre- and post-test design (change?)
• Comparison group (better than nothing?)
• Follow-up (long-term effects change?)

Holzer et al., 2006
12
Implications

• There is a critical need for rigorous program
  evaluations to show
• programs that are effective in improving client
  outcomes
• core components of effective programs
• Is there evidence that the program
• does no harm?
• improves outcomes for children and families?
• Can you provide a plausible theoretical and
  empirical rationale for the program?

13

• Ethically responsive service systems intervene
  early in the life of the problem with the aim of
  preventing children from being harmed and family
  problems becoming entrenched

14
Case Study

• This case study illustrates a pattern of chronic
  maltreatment and the cumulative effects if
  maltreatment persists
• 22 notifications 4 substantiations over 8yrs
• Underlying issue in majority of notifications
• poor parenting capacity
• psychological maltreatment by mother

Bromfield, Gillingham Higgins (2007)
15
Case Study

• Notifications fell into 5 groups of 2-3
  notifications per group
• The notifications within each group were all
  essentially regarding the same set of concerns
• Physical abuse
• Emotional abuse (esp. verbal abuse and rejection)
• Exposure to family violence
• Neglect

Bromfield, Gillingham Higgins (2007)
16
What is cumulative harm?

• Cumulative harm may be caused by an accumulation
  of a single adverse circumstance or event, or by
  multiple different circumstances and events
• The unremitting daily impact of these experiences
  on the child can be profound and exponential, and
  diminish a childs sense of safety, stability and
  wellbeing

Bromfield Miller (2007)
17
Notification One05-Oct-1994 to 06-Oct-1994

• Grandparent saw mother kick walker with 8mth old
  son, Jarrod sitting in it. Pulled Jarrod up off
  couch by one arm. Mother no diagnosed mental
  illness, but severe mood swings and previous
  psychiatric care. Mother receiving support from
  MCHN and FS
• Outcome Insufficient info to warrant
  involvement, especially given involvement of
  local support agency.

Bromfield, Gillingham Higgins (2007)
18
Cumulative harm analysis

• No previous child protection involvement for this
  or any other child in mothers care. Does not
  reach threshold for involvement

Bromfield, Gillingham Higgins (2007)
19
Notification Three04-May-1995 to 05-May-1995

• Aunt alleging loud verbal arguments in front of
  15mth old Jarrod, Father punches walls, Mother
  verbally abusive of Jarrod and is becoming
  increasingly aggressive towards him. Mother
  giving Jarrod stronger doses of prescribed
  medication to get him to sleep. Family Support
  Worker only sees parents in office.
• Outcome Notification raising similar issues also
  received from Grandparents.

Bromfield, Gillingham Higgins (2007)
20
Cumulative harm analysis

• No previous child protection involvement for this
  or any other child in mothers care. Does not
  reach threshold for involvement
• 3rd notification for same issues. 2 different
  notifiers. Increasing verbal and physical
  aggression towards child.

Bromfield, Gillingham Higgins (2007)
21
Notification Eleven15-Oct-1997 to 15-Oct-1997

• Notification from worker at Family Welfare
  Agency. Mother came into service requesting a
  washing machine (note parents now separated).
• While at the agency Mother continually yelled at
  3 year old Jarrod for misbehaviour. In workers
  opinion, child was not behaving inappropriately.
• Worker told Mother that yelling at child was not
  acceptable. Mother verbally abusive towards
  worker and left.
• Outcome Assessed no protective concerns

Bromfield, Gillingham Higgins (2007)
22
Cumulative harm analysis

• No previous child protection involvement for this
  or any other child in mothers care. Does not
  reach threshold for involvement
• 3rd notification for same issues. 2 different
  notifiers. Increasing verbal and physical
  aggression towards child.
• 11th not. for same issues from 7 different
  sources. 2 prior substantiations. Professional
  notifier. Behaviour observed in public parental
  behaviour in private?

Bromfield, Gillingham Higgins (2007)
23
Cumulative harm analysis

• One month laterGP stated 3 year old Jarrod was
  severely traumatised following overnight access
  with mother and further contact with mother
  should not be permitted

Bromfield, Gillingham Higgins (2007)
24
Systemic barriers to recognising cumulative harm

• Research, policy and practice treat maltreatment
  as an isolated event
• Because each involvement treated as a discrete
  event
• Information not accumulated from one report to
  the next
• Information lost over time
• Assumption that problems presented in previous
  involvements are resolved at case closure
• Files are not scrutinised for pattern of chronic
  maltreatment and cumulative harm

Bromfield, Gillingham Higgins (2007)
25
Implications for policy

• Recognise and address systemic barriers to
  identifying cumulative harm
• Intervene early in the life of the problem to
  help prevent
• children from being harmed
• family problems becoming entrenched
• families subsequently requiring child protection
  services

26
Implications for practice

• Unlikely to receive a report explicitly due to
  cumulative harm
• The majority of children who experience
  maltreatment experience
• multiple incidents and
• multiple types
• Need to be alert to possibility of cumulative
  harm in all reports

Bromfield Miller (2007)
27
Indicators of cumulative harm in the case history

• Be alert if there are
• Multiple reports
• Previous substantiations
• Multiple sources alleging similar problems
• Reports from professionals
• Evidence of children not meeting developmental
  milestones
• Allegations of inappropriate parenting in public

Bromfield, Gillingham Higgins (2007)
28

• Ethically responsive service systems provide the
  right service at the right time

29
Changing social context

• Internationally, developments over the past 30
  years have resulted in very high demand on child
  protection services
• Key developments have included
• Increased public awareness of child maltreatment
  and its effects
• Broadened scope of what constitutes child
  protection
• Changing thresholds for interventions

Bromfield Holzer, 2008
30
Ethically responsive service system

• One of the critical challenges for creating an
  ethically responsive service system is creating
  pathways to services for families in need that
  do not require them to first be referred to child
  protection services

Bromfield Holzer, 2008
31
Child protection and families in need

• High numbers of notifications
• Large administrative burden for processing these
• Total reports comprise relatively small number of
  children who need a child protection response
• Only 1 in 5 notifications are substantiated
  (approx.)
• Majority of families reported are in need and
  likely to be re-referred if no preventive action
  is taken

Bromfield Holzer, 2008
32
External
Public Health Approach
Bromfield Holzer, 2008
33

• Ethically responsive child and family protection
  practitioners put children at the centre of
  assessments

34
Risk assessment and risk aversion

• Risk, rather than being a neutral term to
  describe statistical probability, is value-laden
  and implies heightened risk
• Risk to children is considered to be measurable
  and manageable.
• Implication - harm to children both can and
  should be prevented
• If not, then someone is to blame

Bromfield Holzer, 2008
35
Risk assessment and risk aversion

• Negative media attention when the wrong
  decision is perceived to have been made
• In response to negative attention, process of
  assessments, as well as general child protection
  practices, have become increasingly risk-averse

Bromfield Holzer, 2008
36
Risk assessment and risk aversion

• Risk assessment in child protection involves an
  additional un-stated dimension - risk to the
  individual or organisation of making the wrong
  decision
• High-profile child death reviews and the media
  response to them have reinforced increasingly
  risk-averse practice in recent years

Bromfield Holzer, 2008
37
Implication for policy and practice

• Critical challenge, in a highly politicised
  context, is maintaining sight of the childs best
  interests as the central issue in assessing risk

Bromfield Holzer, 2008
38

• Ethically responsive child and family protection
  practitioners engage families to meet their needs

39
Practice in a statutory environment

• Child protection practitioners work in a
  statutory environment in which
• they must comply with their obligations under
  legislation and
• with agency policy and practice directives

40
Autonomy over relationships

• Due to the proceduralised nature of child
  protection, staff have limited autonomy
• However, they still have a large degree of
  autonomy in their relationships with children and
  families and in the way in which they choose to
  engage them

Connolly, 2007 in Bromfield, 2008
41
Importance of relationships

• Relative contribution of different factors in
  psychotherapy outcomes showed
• therapeutic relationship contributed to 30 of
  change
• compared with only 15 contribution for the
  specific intervention technique
• Suggests relationships between practitioners and
  families may have a greater impact on outcomes
  than the structure of the service systems

Scott, 2007 in Bromfield, 2008
42
Changing organisational culture

• In my PhD research, I concluded that
• Organisational culture change may need to occur
  along with a re-clarification of the role of
  statutory child protection services to address
  the preoccupation with risk management that
  appeared to preclude practitioners from engaging
  with families

Bromfield, 2005
43
Role of individual practitiones

• Need to encourage and acknowledge the difference
  individual practitioners can make from the ground
  up through relationships based on
• Empathy
• Respect
• Genuineness, and
• Optimism

Scott, 2007 in Bromfield, 2008
44
Implications for practice

• Challenge is for practitioners to reflect on the
  most effective way to engage their clients
• Individuals have the power to make a difference
• Harness the power of therapeutic relationships to
  assist families to change

45
Conclusion

• Ethically responsive child and family protection
  services
• Are evidence-informed
• Intervene early in the life of the problem
• Enable families to access the right service at
  the right time
• Ethically responsive child and family protection
  practitioners
• Put children at the centre of assessments
• Engage families to meet their needs

46
National Child Protection Clearinghouse

• Australian Institute of Family Studies
• Level 20, 485 La Trobe Street Melbourne
• 03 9214 7888
• www.aifs.gov.au/nch
• This presentation can be downloaded
  fromwww.aifs.gov.au/nch/pubs/presentations/diary
  

47
References

• Bromfield, L.M. (2008). Editorial. Child Abuse
  Prevention Newsletter, 16(1), pp.1-2.
• Bromfield, L. M. (2005). Chronic Child
  Maltreatment in an Australian Statutory Child
  Protection Sample. Unpublished PhD thesis, Deakin
  University, Geelong.
• Bromfield, L. M., Higgins, D. J. (2005).
  Chronic and isolated maltreatment in a child
  protection sample. Family Matters, 70(38-45).

48
References

• Bromfield, L.M., Holzer, P.J. (2008).
  Australian Institute of Family Studies Submission
  to the Special Commission of Inquiry into Child
  Protection in NSW. Melbourne Australian
  Institute of Family Studies. Available from
  www.aifs.gov.au/nch/pubs/submissions
• Bromfield, L. M., Miller, R. (2007). Specialist
  Practice Guide Cumulative Harm. Melbourne
  Victorian Government Department of Human
  Services, available from www.aifs.gov.au/nch/resea
  rch/menu.html

49
References

• Bromfield, L. M., Gillingham, P., Higgins, D.J.
  (2007). Cumulative harm and chronic child
  maltreatment. Developing Practice, 19, 34-42.
• Holzer, P. J., Higgins, J., Bromfield, L. M.,
  Richardson, N., Higgins, D. J. (2006). The
  effectiveness of parent education and home
  visiting child maltreatment prevention programs.
  Child Abuse Prevention Issues, 24.

50
References

• Richardson, N., Higgins, D. J., Bromfield, L.
  M. (2005). Making the right choices about child
  protection Programs and services. Paper
  presented at the Healthy Solutions for Children
  Making the Right Choice, 10th National Conference
  of the Association for the Welfare of Child
  Health.
• Tomison, A., Poole, L. (2000). Preventing child
  abuse and neglect Findings from an Australian
  audit of prevention programs. Melbourne,
  Australia Australian Institute of Family
  Studies.