child abuse case in Ireland where a child had died of wilful neglect (Western Health Board 1996) and Nadya’s (2002) Australian study of community nurses’ reporting behaviours when they encounter child abuse both illustrate that nurses experience a sense that their opinions are neither valued nor taken seriously, and in the latter study, this acted to deter them from activating the child protection system. Faughey (1997) makes an argument based on her Irish study that although public health nurses share corporate responsibility under child care legislation, the high threshold of entry into the child protection system means that not only do families not get a service, but also public health nurses lose credibility in their eyes when their assessment of need does not result in an intervention. In areas where child protection social workers are the gate-keepers of family support services, this can be a crucial issue. Research in Ireland and the UK has also shown that the ambivalence felt by teachers in relation to the reporting of suspected child neglect is influenced by their sense that no response or feedback will be forthcoming, based on past experience (Baginsky 2000; Briggs 1997; Kelly 1997). A group of school principals inter-viewed by Berry (2003) were extremely vociferous in their expression of frus-tration at the poor communication from statutory child protection social work services in relation to children they had referred. In an earlier study on the role of secondary schools in supporting pupils who had been victims of child sexual abuse, Bradshaw (2000) points out that ‘teachers feel insignificant and under-valued by health board professionals’ (p.94), a factor that undermines their willingness to collaborate in child protection work.
Effective interventions with children and families where
nature due to the constraints imposed by their agency function. At the same time, there are many examples of programmes conducted within communities by non-statutory social workers, community-based nurses, schools prog-rammes and family support services that have been highly effective with cases of neglect, once families have been linked with them. Community-based nurses who have access to universal populations of children and families are ideally placed to intervene with vulnerable children and families. One of the best-known programmes in Ireland is the Community Mothers’ Programme, managed by public health nurses in Dublin, which has been evaluated and found to achieve significant improvements in children’s health and diet, and mothers’ parenting skills and self-esteem following their involvement in the programme (Johnson 1999; Johnson et al. 2000; Molloy 2002). Programmes based in early years settings, schools, family support projects and commu-nity-based youth projects have been evaluated and found to produce evidence of considerable progress with families where neglect has been a problem (Buckley 2002; Holt, Manners and Gilligan 2002; McKeown 2000). Berry et al. (2003) cite many examples of positively evaluated home-based programmes delivered in the USA by nurses and other multidisciplinary service providers, aimed at enhancing child health and safety as well as interpersonal relationships in neglectful families.
Further afield, a very effective and carefully evaluated programme in New Zealand, called Social Workers in Schools, capitalizes on the opportunities provided by schools to intervene with vulnerable children over a period and offers a good example of the usefulness of early intervention before problems become complex (Department of Child Youth and Family 2002). The impor-tant role played by teachers in both observing potential or actual abuse and at the same time developing resilience and improving the quality of life for many children has been highlighted by Gilligan (1998). A review of Irish research on child protection and welfare practice demonstrates the skill and commitment of a range of practitioners including public health nurses, early years workers, family support workers, youth workers and community-based child care workers in responding to and intervening with actual and potential child neglect (Buckley 2002). Box 7.2 gives a case example of intervention in a case of ‘failure to thrive’ (Faughey 1996, cited in Buckley 2000) which demon-strates task-focused intervention by a public health nurse in which effectiveness is easily measurable because of the clear links between aims, process and outcomes. This case had been initially referred by the public health nursing service to the statutory child protection team because of serious concern over the child’s delayed development and high number of hospitalizations, but no action was taken in response to the referral.
Interestingly, while the public health nurse in this example emphasized that progress was achieved not simply through her own interventions but in combination with the work conducted within the multidisciplinary network,
she had encountered considerable difficulty in communicating with the other professionals involved in the case, either through their unavailability or apparent lack of interest. However, on the positive side, she suggested that similar interventions could provide exciting opportunities for public health nurses to engage in direct work with multiproblem families and avoid the pro-liferation of specialist referrals that often have a disempowering and marginalizing effect on families.
Box 7.2 Case example: failure to thrive
In this case example, a public health nurse designed, carried out and eval-uated a specific intervention in a case of non-organic failure to thrive, a condition where a young child’s physical development is observably delayed with no obvious organic cause. In this case, there was a suspicion that the failure to thrive was linked with neglect. The child, here called Joanne, was eleven months old and well below her expected rate of devel-opment. Joanne lived with her mother who had suffered from depression, had been a problem drug user, was taking care of five children with little support from her partner and was socially isolated from her family.
The public health nurse assessed Joanne’s family composition, their financial position, background, the health of Joanne’s mother, the family’s social support, the child’s own history and development, her relationship with her mother and her feeding habits and patterns. On the basis of her assessment, the public health nurse designed a programme to be carried out over ten weeks, involving the family, herself and a commu-nity child care worker. The intervention was aimed at:
· increasing Joanne’s weight above the third centile
· improving the parent–child interaction during feeding
· correcting the delay in Joanne’s gross motor, fine motor and language development
· empowering the mother and raising her self-esteem.
The nurse, as key worker, outlined individual action plans designed to address target behaviours and problems and achieve desired results, iden-tifying specific goals and proposed actions to be taken in relation to each of the difficulties identified. For example, she linked Joanne’s lack of interest in food and poor appetite to a combination of factors, including her mother’s depression and apathy, the fact that she was not sitting where she could see her mother and the way that she was not included in family mealtimes. Other areas targeted were the lack of routine and
stimu-One of the key elements identified in the success of some of these projects described above is the relationship that is developed between the workers and families (Buckley 2002; Department of Child Youth and Family 2002;
McKeown 2000). An important aspect of this is that practitioners in these services are seen as ‘friendly’ by families to whom the ‘heavy’ image of statutory social workers is a source of threat. However regrettable the latter, it now appears to be a fact of life that continues to pervade child protection and welfare work. There also appears to be a significant difficulty in merging differ-ent intervdiffer-entions satisfactorily with the child protection social work service, and in receiving feedback, support and acknowledgement. Yet, as we now know, child neglect can be as dangerous and critical as any other form of abuse in terms of risk to children’s immediate safety and long-term well-being and
lation, Joanne’s insecure attachment to her mother, the mother’s sense of being overwhelmed by caregiving and the relationship problems between the mother and her (non-resident) partner. Many of the ameliorative strategies involved other personnel, including the commu-nity welfare officer, the commucommu-nity care child care worker, general practi-tioner, addiction counsellor, staff in the day nursery and the paediatrician.
The public health nurse’s own contribution to the multidisciplinary plan of intervention was to visit weekly with the aims of tackling feeding in a constructive way, providing information, listening to the mother’s concerns and positively reinforcing any changes that were observable.
She also kept a diary in which she recorded events that affected the family, any changes, the content of each visit and observations of the mother–child interaction.
Although the mother and her partner were initially reluctant to par-ticipate, the nurse managed to engage them in the process. Using a stan-dardized measure, she was able to demonstrate that the previously identi-fied goals were being achieved in relation to Joanne’s gross and fine motor development, and the mother–child relationship. Ultimately, Joanne became far less insecure and her interaction with her mother became more positive and began to include smiles and laughter. Joanne displayed a new capacity to explore independently and seek comfort from her mother when she was upset, all illustrating a healthier attach-ment. Noticeable improvements were observable in relation to the mother’s mental health and her interest in the programme. Goals in relation to Joanne’s language, weight and feeding and the parents’ rela-tionship had been partially reached, which is understandable within the
must be taken seriously (Bonner, Crow and Logue 1999; Bridge Childcare Consultancy 1995; Fitzgerald 1998). If the statutory system is not the most appropriate channel for bringing direct assistance to families, it cannot abrogate its responsibility; it must still ensure that child neglect is addressed, albeit by services outside the statutory system, and assume accountability over the process by developing clear contracting arrangements with whatever agency is carrying out the task.
Many metaphors are used to describe the formal process of child protec-tion. It has been described as a fishing net, where only certain-sized fish survive. Another striking illustration has been offered by Thorpe (1997) and adapted by Ferguson and O’Reilly (2001) in the shape of a funnel, demonstrat-ing the filterdemonstrat-ing process that is normally applied to child protection cases, and showing how a number of families are moved out of the system by the time a decision for intervention or allocation is made. I would propose a further exten-sion of that illustration, turning the funnel into an eggtimer shape, the lower half illustrating the range of services which are available to families and are known to be effective where child neglect is a problem, but which are accessible only by service users who have qualified for them by squeezing through the narrow middle part, which could be said to represent the gate-keeping function of the child protection system.
The challenge is clearly to find a way of eliminating the isthmus that divides the two phases of the process described above and broadening out the filtering process thereby responding to families where neglect is a problem, whilst making sure that services are neither fragmented nor duplicated, but joined up by their accountability to an over-arching authority.
What we now know from research and evaluations of existing policies and practices clearly demonstrates that the statutory child protection social workers system has difficulty in addressing the problem of child neglect. This is attrib-utable in part to the sort of screening and gate-keeping practices operated by them which tend to prioritize incidents of child abuse that have a more
Filtering
Service provision
Childabuse
Figure 7.1 The ‘eggtimer’ model of filtering
dramatic and urgent manifestation. It also appears that the ‘heavy’ image of statutory social workers does not lend itself to the approach required by families where neglect is a problem. It is clear, as this chapter has already dem-onstrated, that many significant interventions are already being made into families where neglect is a problem, by a range of multidisciplinary services.
While the independence and non-threatening nature of these services undoubtedly facilitates their capacity to engage with families, it is important that they see themselves as part of a network interlinked in various ways, accountable to and supported by the statutory system responsible for oversee-ing a comprehensive response to vulnerable children and families. The next section will offer some pointers towards the accomplishment of this goal.
Messages from research
· Multidisciplinary involvement in child neglect is a concept laced with assumptions and is open to many interpretations.
· Unproblematic co-operation and communication is idealistic.
· Child protection guidelines and frameworks for assessment tend to be social work driven and are built on the presumption that social workers can elicit the required amount of co-operation from relevant disciplines.
· The majority of referrals of suspected child abuse to statutory agencies concern neglect, and the majority of these are filtered out at an early stage.
· Child neglect is traditionally accorded low priority in the continuum of child abuse – many reasons are given to explain this
phenomenon, mainly attributing the trend to a combination of the complexity of neglect and pessimism of practitioners.
· Social workers can be ‘shy’ about drawing explicitly on theory, whereas their counterparts in other professions operate a more empiricist style of assessment drawing on quantifiable evidence.
· Nurses and teachers can be reluctant to refer cases of neglect to social work because of anticipated lack of response.
· Community-based nurses are ideally placed to intervene with vulnerable children and families.
· Home and community-based programmes have produced evidence of considerable progress with families where neglect has been a problem.
Implications for practice
One of the principal advantages of multidisciplinary work is that it takes into account the interplay of various factors in a child’s life. It also provides families with options, which increases the likelihood of their identifying an acceptable intervention. Reinforcement of the same messages by different agencies gives confidence to service users and improves working relationships between services and service users. Crucially, however, interventions into cases of child neglect must be co-ordinated at an authoritative level. The objective is to provide a range of multidisciplinary interventions that are appropriate, effective and non-threatening, but which are at the same time, accountable to and sup-ported by the system that is statutorily obliged to ensure that concerns about children’s safety and welfare are satisfactorily addressed. In order to achieve this, a number of messages for practice suggest themselves, at management and front-line levels.
Implementation of an assessment framework that is multidisciplinary in nature
The most logical place to situate the basis for multidisciplinary work is at assessment. Though each profession working with children tends to operate a framework for assessment that elicits information appropriate to each profes-sional perspective, the concept of multidisciplinary assessment of child neglect is strongly associated with a statutory social work led process. However, speech and language therapists, teachers, health visitors, community-based nurses, early years workers and a host of other professional service providers are probably more likely to witness first-hand evidence of child neglect, and for the many reasons cited above, may find it unsatisfactory to refer their concerns to the child protection social work service. There is a need for an assessment framework that is formally established within a local team or sector and that permits assessments to be carried out by a range of professionals but, impor-tantly, ensures that they are co-ordinated and recognized at a level which has the mandate to allocate resources and which will ‘log’ the concern in a system where it immediately becomes accountable and auditable. Consultation and support as well as regular communication will have to flow between disciplines in order for this process to work effectively, and it will not be sufficient to assume that each service can manage child neglect on its own. This will require a significant change of approach for many agencies and organizations and is not something that can be undertaken without considerable self-challenging by individual professions and service managers. While the substantial content of a framework for assessment is important, the process by which it is imple-mented and operated will determine its capacity to reach its full potential.
Management
The Climbié report (Lord Laming 2003) has been very strong in its insistence that managers assume more accountability for the range of interventions being carried out at front-line level, and must actually acquaint themselves with the detail of routine work by consulting files and holding regular reviews. Effective multidisciplinary work will be achieved when this accountability, with concur-rent levels of support, is extended to all agencies and professionals in regular contact with vulnerable children. Lord Laming made a biting criticism of the gap that he perceived to exist between front-line services and management in the Victoria Climbié case, and called for the establishment of ‘a clear line of responsibility, from top to bottom, without doubt or ambiguity about who is responsible at every level for the wellbeing of vulnerable children’ (p. 6). The Climbié inquiry suggested a four-tier structure emanating from a Children and Families Board at central government level in England. It may be possible to situate at some point in this configuration a means of co-ordinating services to neglected children in some way that makes them visible and accountable.
Training
Much has been written about the benefits of inter agency and interprofessional training as a means of promoting multidisciplinary work (Buckley 2003b;
Charles and Hendry 2001; Horwath and Morrison 1999). While there is cer-tainly evidence to indicate that it is one of the most effective ways of breaching barriers and promoting understanding, particularly of each other’s professional roles, as Horwath and Morrison (1999) point out, caution must be exercised about over-optimistic expectations of the potential for training to sustain interagency and interprofessional relationships.
Interprofessional training on child neglect needs to cover substantive issues, such as causative factors, short and long-term effects of neglect and evidence about effective interventions. It must inform participants about each other’s roles but, importantly, it must focus on the dynamics of inter agency relationships and actively promote team working or one of the main benefits will be lost. One of the most useful inter agency models is where the training is delivered by a multidisciplinary peer group of trained trainers, who are likely to have more credibility with colleagues than an external consortium (Buckley 2003b).
Information management
One of the most commonly recognized impediments to multidisciplinary working is failure of communication. In the absence of a good data manage-ment system, practitioners can find themselves in the dangerous position of
acting in ignorance of vital information about a child or family, particularly concerning the patterns or trends that are so significant in child neglect. Dupli-cation of information can exist, for example, in the records of public health nurses, psychologists, public health doctors, speech and language therapists and family support workers and yet be inaccessible to the different members of the professional network who are engaged in work with the same children and families. This type of practice is not only time-wasting and inefficient, but increases the sense of hopelessness and confusion that already exists in neglect-ful families. Parents in need of help and support are far less likely to have confi-dence in professionals who mirror their own chaos and disorganization.
Password or otherwise protected access to data by appropriate professionals and managers is fundamental to good multidisciplinary practice, and should be a universal commodity.
Commitment to promoting multidisciplinary work by focusing on the process and developing links
There must be a strong commitment from senior management in all organiza-tions providing services to vulnerable children to promote collaborative work.
If this is absent, staff in less senior posts will be unable to either represent their organizations or carry any mandate for co-operation. Organizations could usefully appoint a link person to promote inter agency co-operation, or develop some strategy to maintain partnerships/links between agencies or dis-ciplines in an overall sense. Whatever process is implemented, it is vital to understand and acknowledge that co-operative multidisciplinary working rela-tionships will not develop without active facilitation. Consistent and regular efforts should be made to maintain partnerships with agencies that have been contracted to do work so that roles and mutual expectations are negotiated, agreed and reviewed. Contracting obligations need to be absolutely clear so that ‘cherry picking’ by non-statutory agencies, a practice that was noted in Irish research (Buckley 2003a), is not an option.
Good practice
In front-line work, consistent adherence to basic norms of good practice could make a significant difference to the quality of working relationships. An example is the matter of feedback; as this chapter has demonstrated, the experi-ence of lack of response and feedback from statutory agencies to referrers acts as a deterrent to collaboration. Mundane as it sounds, staff should always respond to phone calls and other forms of contact as soon as possible and give feedback to other relevant professionals about the nature of their work with a given family, particularly any changes in the circumstances or work plan.
Proactive communication is relatively easily achieved by regular exchanges of information regarding, for example, changes of staff, locations and new policies, and can pave the way for more complicated negotiations by establish-ing positive relationships on a consistent basis.
Overcoming obstacles in contact and communication
Certain staff may have heavy workloads or inflexible working arrangements that limit their availability for meetings or discussions, teachers and police being two examples. This can be addressed by identifying one point of contact for referral and receipt of information in order to ensure that it is managed care-fully and efficiently. Nominating specific personnel between whom informa-tion can be shared, and agreeing the most appropriate contact times and means of communication can overcome potential frustration and slippage. It is impor-tant to have arrangements that will endure beyond staff changes, therefore this practice should become firmly enshrined in local strategies.
Norms about the exchange of information
Despite assumptions to the contrary, it cannot be assumed that all organizations providing services to children and families have a shared understanding about confidentiality. Therefore protocols must be agreed regarding the nature and extent of information to be shared in different circumstances, together with the necessary consents to be obtained. While the requirement to share information if child abuse is suspected is generally understood, the question of sharing information about the type of need or vulnerability often associated with child neglect is more sensitive and requires careful consideration. Child-centered-ness, clarity about the rationale for communicating information and assurances about the uses to which information will be put should help to determine the necessary protocols.
Promoting multidisciplinary work at the front line
Most of the literature on promoting inter agency and multidisciplinary work focuses rather broadly on actions to be taken by management, but individual practitioners also carry a level of responsibility. For example, they should famil-iarize themselves with the roles of other professionals within and outside their own organizations so that they are aware of the optional services available to families. They should also ensure that they understand the responsibilities, policies and procedures of their own and others’ professions and organizations, and should make it their business to be aware of the nature of any agreements between their profession, department and organization and any others.