Child abuse and neglect

Child Abuse and Neglect

The following describes a case study scenario in which I am an experienced, protective services worker about to do the first home visit with a new family. It goes on to speculate what might happen, the families reactions, cultural variations and engagement tools and recommendations.

Crosson-Tower, C. (2010). Understanding Child Abuse and Neglect Eighth Edition. Boston: Pearson Education Inc.

Huston, A.C. (Ed.). (2003). Children in poverty: Child development and public policy. Cambridge, MA: Cambridge University Press.

Jones, E.D. (2004). The North Lawndale Family Support Initiative: Findings from the interim process evaluation. Chicago, IL: National Center on Child Abuse Prevention Research Report.

Pelton, L.H. (2008). Child abuse and neglect: The myth of classlessness. American Journal of Orthopsychiatry, 48, 608-617.

While many service bureaucracies focus on a single family member as the client or patient, my site visits suggested that the needs of children in particular (and probably other family members as well) may be impossible to solve, and perhaps even to diagnose, if a program's focus is on the individual child rather than the family. In fact, programs may need to learn a great deal about the family as a whole if they are to diagnose and solve the problems of children. At the simplest level, an example is a problem for a baby that is caused by interaction between a teen mother and her own mother, the baby's grandmother: [One caseworker:] "Most of the grandparents will tell them, "Don't hold the baby, you're going to spoil it." . . I spend a lot of time trying to talk to grandparents." [Another caseworker:] "[You] have to go back to the grandparents. These kids [the teens] -- all they hear is 'You're stupid. I didn't do it that way.' So after a while they figure, 'If I touch this baby, it's wrong.' So, 'Here, momma, take it' (Jones, 2004, pg. 44).

Two examples are shown below, to illustrate more fully the way in which children's needs are nested in a family context and intimately connected with the parents' and other family members' own personal well-being. The first example comes from Oklahoma's Integrated Family Services (IFS) System, which serves multiproblem families:

A seven-year-old boy came to the attention of a school principal because of both physical and emotional health problems. The boy had long been prone to seizures and self-destructive behavior and was just starting to threaten other children. When the principal called us, he found that IFS was already working with the family because the mother was on AFDC and herself had multiple problems. I (IFS worker) called a meeting of all of the agencies who had contact with the family to talk about the child's needs. As a result, the boy was admitted and sent to a diagnostic center for several months of testing and treatment; the mother received needed services such as mental health treatment and literacy training; and the Child Protective Services worker changed her mind about the possible outcomes for the case and concluded that the mother had the potential to be an adequate parent (Huston, 2003. pg 117).

In this example, the needs of the child turned out to be related to the needs of the mother -- and, perhaps more important for the service delivery system, part of the solution to the child's needs lay in providing services to the mother so that she could help him. According to my colleague IFS case worker, "What the child really [may] need is a mother who can cope" (Herr, et al. 1999. pg 2). In the second example, in which meeting a child's needs again depends on an adult's well-being, serving the child depends critically on the service deliverer's relationship with the adult. The illustration comes from a one of my home visits:

I made a home visit to a young (18-year-old) mother who had suffered physical and sexual abuse as a child. During the visit, the I picked up and played with the young woman's 8-month-old child and observed how the child responded. Then she asked the mother a specific question about her experience with the child: Did she ever feel as though she were "climbing the walls" and just had to get out of the house when the baby was crying? The young woman said yes, and the case manager asked what she did at such times: Was there anyone she could leave the child with so that she could go on a walk? The teen responded that either she left the baby with her friend downstairs and went for a walk, or she put the child in the crib, closed the door partway, and went into another room. I seemed satisfied with these responses, and she later told the interviewer that, while she has no reason to suspect any abuse or neglect in this case, she realizes that the teen is somewhat unstable and under great stress, so she likes to keep close watch on what is going on (Pelton, 2008. Pg 609).

In this example, my key contribution to the child's well-being comes through my attention to and friendship with the mother. Only the case manager's strong personal relationship with the teen enabled her to keep a constant eye on the case while not being perceived by the teenager as intrusive, only the strong relationship permitted her diagnosis that the child was doing fine, and only the relationship permitted her to provide preventive services in the form of low-key advice. These links between a child's needs and the well-being of the family as a whole reinforce the conclusion that effective family service deliverers need a trusting relationship with the family and an ability to reach out across systems (Crosson, 2010; pg 12). In particular, the links between child and family well-being suggest that serving children in multiproblem families requires that the service deliverer know both child and family well and be able to reach out across the service system to help all family members.

2.) We shall now discuss the three types of preventions with examples.

References:

Crosson-Tower, C. (2010). Understanding Child Abuse and Neglect Eighth Edition. Boston: Pearson Education Inc.

Herr, T., Halpern, R., & Conrad, A. (1999). Changing what counts: Rethinking the journey our of welfare. Evanston, IL: Northwestern University, Center for Urban Affairs and Policy Research.

Wolock, L, & Horowitz, B. (October 1984). Child maltreatment as a social problem: The neglect of neglect. American Journal of Orthopsychiatry, 54, 530-543.

Huston, A.C. (Ed.). (2003). Children in poverty: Child development and public policy. Cambridge, MA: Cambridge University Press.

Jones, E.D. (2004). The North Lawndale Family Support Initiative: Findings from the interim process evaluation. Chicago, IL: National Center on Child Abuse Prevention Research Report.

Many of the "preventive services" offered by the sites (Wolock, 1984. Pg. 535) parenting education and support for parents' ability to nurture their children-occur not through formal services but through the relationship between the family and the case manager. Essentially, neglect is about omission, a breakdown to meet the critical developmental needs of a child for nutrition, housing, medical care and education (Crosson-Tower, 2010. p. 68). However, several of the sites also provide more formal services, such as support groups, classes, or workshops. For example, all three of the teen parent programs provide teen support groups that touch on parenting issues as well as other topics such as self-esteem, health and nutrition, and family planning. In addition to knowledge about parenting, these programs generally emphasize providing mothers with the warmth and support that they are seen to need in order to be warm and supportive, in turn, to their children. Some of the programs also emphasize the actual practice of new attitudes and skills in interacting with children (Herr, et al. 1999. Pg 6). For example, in the TASA Next Step program, teen parent support groups are paired with on-site child care, and the sessions are planned so that mothers meet without their children for the first portion of the visit and with the children for the second.

What exactly does it mean to serve children through this case management relationship? What does the relationship offer besides referral to specific, functional services like those already discussed? More generally, the family-oriented case managers in the site programs serve children by:

1

Keeping an eye on children themselves and helping families gauge how their children are doing;

2

Providing parents with support and friendship, assistance in improving important family relationships and in dealing differently with their children, and information about parenting or children;

3

Providing friendship, support, and role models for a child directly; and encouraging other service deliverers to respond more effectively to a child's needs.

Prevention occurs at three levels: primary prevention activities that are directed to the population at large, secondary prevention efforts that target families judged to be at risk of child abuse and/or neglect, and tertiary prevention focusing on families in which abuse already has occurred and steps must be taken to prevent a recurrence. Child physical abuse is only one form of family violence, and one of many forms of oppression that are underpinned by inequality. In 1999 Herr & Conrad identified a number of areas of activity as particularly appropriate for primary prevention of physical abuse. Tackling the effects of poverty, or enabling parents to cope with them, are key components of many primary prevention interventions.

While it is particularly difficult to demonstrate the cost-effectiveness of primary preventive strategies, this problem eases as we target interventions at those most at risk of developing particular problems. Essentially this is the rationale for screening groups at high risk within health services. Of course, the benefit of this approach depends on our ability to accurately identify those at risk, and to be able to provide effective preventive services. Our improved, as yet imperfect knowledge, of some of the factors which interact to increase the risk of child abuse and neglect, affords an opportunity to design interventions which, at least conceptually, have a chance of effecting change in areas over which we have some influence.

This is one reason for placing an emphasis on secondary prevention. Others include: (i) our limited success with post-maltreatment interventions (tertiary prevention) means it remains preferable to Endeavour to pre-empt the development of problems. This also maximizes the chances of good developmental outcomes for children (Jones, 2004. Pg 12). Children in poverty: Child development and public policy. Cambridge, MA: Cambridge University Press.; (ii) in some circumstances this can be done without reference to child protection services, thereby maintaining the positive emphasis on child and family well-being that makes primary prevention such an attractive option; (iii) we now have some promising indicators that some interventions can affect the changes we are seeking, and reduce the incidence of child maltreatment. Not surprisingly, we again encounter some problems in this literature. Whilst we may be better able to identify some individuals and groups as being at risk of maltreatment, it seems that as we move into the areas of secondary and tertiary prevention problems arise in relation to the families recruited to the studies. Distinctions between those 'at risk' and those who are deemed to have in fact physically or psychologically mistreated their children can become rather blurred, particularly as one moves away from physical injury per se. Many studies feature 'mixed' samples rather than samples which fall wholly into an 'at risk' or 'abusive' category, not least because many studies rely on referrals to and from child protection agencies where the categorization of families is often a difficult professional judgment (Huston, 2003-page 12). The technical challenges of conducting research in this field may make these problems difficult to avoid, but again it means that one has to be cautious in interpreting the results.

In several programs, case managers struggle to bring together their role in relation to a single client, such as a teen mother or a school age child, with their role in relation to the family as a whole. In these successful examples, case managers reported integrating those roles to see the child in a family context rather than advocating for one family member against another, but not all experiences were as successful. In addition, case managers operated with quite different levels of training in child development and family functioning; again, the examples illustrated in this paper show what is possible with training and, in several cases, expert backup support.

3. The following discusses the societal changes that should be made to protect children in the twenty-first century.

References:

Crosson-Tower, C. (2010). Understanding Child Abuse and Neglect Eighth Edition. Boston: Pearson Education Inc.

Jones, E.D. (2004). The North Lawndale Family Support Initiative: Findings from the interim process evaluation. Chicago, IL: National Center on Child Abuse Prevention Research Report.

Wolock, L, & Horowitz, B. (October 1984). Child maltreatment as a social problem: The neglect of neglect. American Journal of Orthopsychiatry, 54, 530-543.

Children who are growing up in poverty or other kinds of need are likely to come into contact with other large public agencies besides the welfare system (Crosson, 2010. Pg 206): the public schools, community health clinics or city hospitals, and, perhaps, sadly, the state's child protective services agency. What are the implications of the findings presented here for the other large public agencies that see poor children and families? To put the question slightly differently, what principles would we apply to each system if we wanted to create a coherent network of services to children? While this study was not designed to investigate other service systems in any detail, the research sites do suggest several intriguing speculations. First, other agencies besides the welfare department can and should consider what it means to be two-generational. As the research sites and the evidence of other researchers suggest, family needs are often intertwined, whereas the services offered by many of the large systems are limited to a single family member (Jones, 2004. Pg 11). A number of program examples from the site visits and other sources illustrate what it means for service providers other than the welfare department to be two-generational in their focus:

The PACE program in Kentucky, with its combination of adult literacy and preschool education operates within the public schools. In addition to offering two-generational services to families that are directly enrolled in PACE, the program director sees PACE as a vehicle for changing the thinking of the public schools toward a greater inclusion of parents and other family members.

Child protective services workers in several of the research sites found that working with intensive case managers helped them appreciate the demands on parents that made it difficult for the latter, in turn, to respond to the needs of the child. This insight lies behind a variety of family support and family preservation programs now being deployed as part of the child welfare services continuum in a number of states. The aim of these programs is to offer services to both parent and child to improve family functioning and enable the child to stay in the home (Wolock, 1984. 541). Visiting nurse programs enable health care providers to see parents and children together and serve the whole family. Maternal and child health clinics with other collocated services also offer the opportunity to meet the needs of several family members.

In several locations in New England, Head Start programs are planning or already operating programs jointly with education and training programs for mothers on welfare. These programs include cooperative projects with vocational high schools and with a community training agency. The ways in which welfare agencies have overcome these barriers may well offer insights to other agencies (Jones, 2004). For example, welfare agencies at the successful sites have overcome the limitations of their initial mandate by developing a clear and sustainable mission that makes dear why services to children and families are part of the welfare agency's job. In order to expand services, schools, health clinics, and child protective services agencies may similarly need to articulate connections between an initial, narrower mission and the broader, family-centered mission that they would like to achieve (Crosson, 2010. Pg 16). Thus, schools may conclude that they cannot teach children without a collaborative relationship with parents, that they cannot teach children without addressing the problems that keep them from being ready to learn, or that they cannot teach teen mothers effectively without addressing their roles as parents as well as students. Child protective services agencies may conclude that functions such as enhancing family stability and averting foster care are more effective over the long run than providing after-the-fact treatment.