MULTIDISCIPLINARY WORKING IN CASES OF NEGLECT: MECHANICS OR GARDENING? JAN HORWATH PROFESSOR OF...

MULTIDISCIPLINARY WORKING IN CASES OF

NEGLECT: MECHANICS OR GARDENING?

JAN HORWATHPROFESSOR OF CHILD WELFARE

J.Horwath@sheffield.ac.uk

NEGLECT: THE NEGLECT: THE REALITYREALITY

• Most common reason for multidisciplinary child protection plan

• Act of omission?• Focus on physical needs and safety issues• Key antecedent - relationship between

primary carer and child• Variations in interpretation • Association with poverty• Marginalised, vulnerable groups

• Interventions: parenting changes or reoccurrence of neglect? (Macmillan et al., 2009; Tanaka et al., 2010)

• Facing major, potentially intractable personal and socio-economic problems

• Dealing with erratic and unexpected behaviour

• Working with verbal and physical violence and aggression

• Pros and cons to every decision

• Increasing levels of economic disadvantage

• Watch my back culture

• Significant changes to public sector services and diverse range of new providers

• Era of austerity

THE WORKING CONTEXT

NEGLECT THRESHOLDS

Out of home placements

Years child exposed to on-going neglect

Threshold for s17

Universal services

Early support

SERVICE PROVISION

EVENT: THE PRESENTING

PROBLEM

PATTERN: PAST RESPONSES

NEEDS AND COGNITIONS: ABILITY AND MOTIVATIONS

QUICK FIX

PROBLEM RECURS

FIELD REVIEW ‘…….the things that matter most are a healthy pregnancy, good maternal mental health, secure bonding with the child, love and responsiveness of parents along with clear boundaries as well as opportunities for a child’s cognitive, language, social and emotional development’

PREVENTING OCCURRENCE THROUGH UNIVERSAL

SERVICES: BARRIERS TO EARLY RECOGNITION

• Pre-birth focus on drugs not the 4 ‘Ds’

• Able to manage initially

• Perceptions of ‘good enough’ parenting

• Failing to identify particularly vulnerable children

• Societal neglect

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Families unlikely to make direct explicit approaches:• May articulate anxieties

• Aware of impact of substance misuse

• Children may self-report via creative approaches

Indirect approaches:• Signs and indicators

• Issue re perceptions of need(Daniels et al 2009)

SIGNALLING NEED FOR ASSISTANCE?

FAMILIES FITTING SERVICES?

• Failure to research family perspectives on support

• Lack of focus on fathers and other care-givers

• Failure to assess parenting style• Focus on skill development• Limited concrete resources(Daniel et al., 2009; Zolotor & Runyan, 2006; Brandon et al., 2008)

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KENNEDY REVIEW - FROM MINUS NINE MONTHS: HOW CHILDREN’S SERVICES SHOULD BE SHAPED FROM CONCEPTION• focus on getting policy right

• additional paediatric training for GPs

• shift investment towards health services for children

• Integrate policy: a unified, holistic approach to children’s health and wellbeing

• link services for children to an identified funding stream.

• re-focus on prevention, early intervention and wider well-being

• joint train to a common curriculum.

PROVISION OF ADDITIONAL

SUPPORT• Direct interventions to enhance existing or potential relationships

• Support groups to learn about parenting

• Informal helpers from community

• Using trained volunteers e.g. Home Start

• Social skills and parent training

• Use of mobile phones (Gaudin, 1993; Burke Lefever et al., 2008))

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HOME VISITING PROGRAMMES

(FNPP)• Targets young first-time mothers

• Intensive home support from pregnancy to 2yrs

• Appear to reduce incidents of neglect

• Key:• Relationship with worker

• Intensity and quality

• On-going involvement(MacMillan et al., 2009; Barnes et al., 2009)

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MAKING REFERRALS: WHO IS MOST IMPORTANT?

•Bad for me

•I can do better than the system

•Not reportable

•Cover my back

Zelleman 1990. Horwath 2005

Confusion regarding thresholdsShort-term and reactiveIgnoring past historyAbsence of risk assessment Roles and responsibilities not clearLack of focus on all individual childrenFocus on mothersLack of awareness of implications of learning disabilities

(Kirklees SGB Oct 2010)

COMMON FINDINGS FROM SCRs:

ASSESSMENT AND PLANNING

PLANNING FOR CHANGE

•Assessment: seeing the error of one’s ways?

•Child protection planning meeting: this is how you put it right

•Child protection plan: we’ll support you - but not forever?

•Re-referral: oh dear let’s start again

© The University of Sheffield not to be reproduced without permission

‘..parents tended to avoid agencies, but agencies also appear to avoid or rebuff parents. Evidence of this rebuttal was seen through offering a succession of workers, closing the case, losing files or key information, by re-assessing, referring on, or through initiating and then dropping court proceedings…the end result is a failure to engage with the parents’ fundamental problems in parenting and the children’s experience of direct or indirect harm’.

(Brandon et al. 2008, p72)

WORKING WITH NEGLECT

• Service provision not always based on needs of child

• Lack of clarity regarding outcomes

• Putting square pegs into round holes

• Measuring improvements in terms of need for court intervention

(Kirklees SGB Oct 2010)

COMMON FINDINGS FROM SCRs:

INTERVENTIONS

• Parents of older children receive less support

• Older children receive more types of support but insufficient intensity and duration

• Lack of specialist help for parents linked to poorer outcomes for children

• Services not suited to severity of problems and sustaining changes in parenting

(Farmer and Lutman 2010)

CASE MANAGEMENT AND OUTCOMES

• Difficulty engaging carers

• Being overly cautious about care proceedings (28% left too long in unsatisfactory conditions)

• Inappropriate use of another chance

• Plans made during care proceedings did not work out in 62% of cases

• Proactive case management in 25% of cases

(Farmer and Lutman 2010)

CASE MANAGEMENT AND OUTCOMES

OUT OF HOME PLACEMENT

• Regular periods of planned ‘respite’ care can be beneficial

• Oscillation between home and care results in poor wellbeing

• Over 6 at time of placement greatest risk of placement instability

• Neglected children in stable placements better outcomes than those returned home

(Farmer and Lutman, 2010; Wade et al., 2010)

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MAINTAINING A FOCUS ON THE

CHILD• Failure to identify the child’s experience

• Tends to be based on views of others

• Considered difficult to engage

• Practitioners lack skills and time

• Lack of innovative approaches to assessment and intervention e.g. peer-support interventions

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ACHIEVING EFFECTIVE

OUTCOMES FOR CHILDREN

IDENTIFIED ISSUES: CAUSES OF CONCERN

‘PROCESS’ OBJECTIVES

‘OUTCOME’ GOALS

WHAT DO WE NEED TO DO AND WHY?

WHAT INDICATORS CAN WE USE TO MEASURE OUTCOMES?

ASSESSING ENGAGEMENT IN CHANGE PROCESS:

PARENTS & PROFESSIONALS

Talk the talk &

walk the walk

Talk the talk: surface static

Walk the walk:

disguised complianceWalk away:

disengageme

ntCommitment to meeting the needs of the child

Effort

high

low

lowhigh

Horwath Copyright 2009

THE KEY TO SUCCESS

The service user 40% Relationship with worker 30%Method of intervention 15%Verbalised confidence of service user 15%(McKeown 2000)

Horwath Copyright 2009

WHAT IS REQUIRED OF WORKERS: THE 4

‘Cs’•Collaboration

•Consistency

•Containment

•Contingency(Morrison 2009)

SERVICES: WHAT WORKS?

•Sufficient dosage (frequency and intensity)

•Sufficient breadth (for parent, child and parent-child)

•Sufficient duration (length of time provided)

(Gilligan 2009)

EFFECTIVE INTERVENTIONS?

•Intensive family support•Multi-systemic therapy•Video interaction guidance

WHAT WORKS?

We need to stop thinking like

mechanics and to start acting like

gardeners(Adapted from Senge)