Not all child deaths or injuries through abuse and neglect are predictable and preventable (Sinclair and Bullock 2002) but in cases where they are, competent and timely professional involvement can make the necessary difference. Whilst neglect demands efficient multiprofessional work, the evidence from practice and serious case reviews indicates that many professionals find it a difficult issue to address effectively (Bridge Childcare Consultancy 1995; Bridge Childcare Development Service 1999, 2001; Macdonald 2001; Munro 1996;
Reder and Duncan 1999; Reder et al. 1993).
Multidisciplinary work and communication
The vast majority of case reviews (in the UK and beyond) point to a lack of multiprofessional dialogue that is crucial in the complex area of child protec-tion. This can be caused by:
· failure to recognize and thus share important information (Sanders, Colton and Roberts 1999)
· tension or conflict in the communication (Reder and Duncan 1999;
Sanders et al. 1999)
· fear of breaking rules of confidentiality.
In cases of child neglect where the sharing of information is crucial at a rela-tively low threshold, maximizing dialogue is important. Clear communication can avoid misunderstandings arising between professionals. This is an issue that was widespread in the Climbié case and Lord Laming commented exten-sively on the need for improvements to the exchange of information. Two quotes used in the report that evidence this point are:
I cannot account for the way other people interpreted what I said. It was not the way I would have liked it to be interpreted. (Dr Ruby Schwartz) I do not think it was until I had read and re-read this letter that I appreciated quite the depth of misunderstanding. (Dr Mary Rossiter)
Children suffering from chronic neglect and emotional abuse come from families with complex needs. It is entirely unrealistic to believe that social workers alone can assess and intervene successfully with these families on an ongoing basis. For example, in some cases, particularly those involving mental health, the lack of shared expertise between adult and child care professionals has seriously inhibited the assessment of risk. A review of child death inquiries, concerning parental psychiatric illness and fatal child abuse, by Falkov (1996) highlighted this.
Decision-making
Decision-making in child protection is a very complex process and has signifi-cant impact on the lives of children and families. Practitioners bring their knowledge, practice wisdom and professional judgement to assessments of risk and subsequent decision-making. This is influenced by the legal and policy frameworks/guidelines and the resources available. The impediments to decision-making identified in the literature are:
· Knowledge: Serious case reviews have repeatedly highlighted alerting evidence not being recognized as such (Bridge Childcare
Development Service 2001; Newham Area Child Protection Committee 2002). This is proportional to the level of skill,
experience and training that staff have, or have access to in order to undertake their duties competently.
· Personal beliefs and values: Personal beliefs and values strongly influence professional judgement and reasoning in child protection work (Jones 1993; Macdonald 2001). In the case of Victoria Climbié there is evidence that her regimented behaviour in front of her great aunt was interpreted as being ‘cultural’ as she was from the Ivory Coast rather than due to her being deeply frightened. In a serious case review of a little girl with moderate to severe learning difficulties, her neglect was thought to be because of the stress
caused by her complex needs rather than the possibility of the reverse being considered (Bridge Childcare Development Service 1999). See Box 9.1 for a case example. Racism and prejudice are also powerful inhibitors to good practice.
In neglect and emotional abuse in particular, where risk may be less extreme or immediate, personal values, beliefs and intuition play a much greater part and can lead to bias and errors in decision-making.
Box 9.1 Case study
Girl Two and her twin were the youngest of six children who were living with their mother, father and/or stepfather at the point when Girl Two was removed from home in August 1997. The family had been known to several agencies for a very long time.
Her removal followed a visit by a social worker two days earlier. The Serious Case Review report comments ( Bridge Childcare Development Service 1999, p.2), ‘In her case recording, the social worker reports that mother was cleaning the house, while Girl Two’s twin brother was playing outside with no shoes on; Girl Two was in her bedroom asking for milk and trying to get out; the doorway into Girl Two’s bedroom was obstructed by three boards nailed across it, to a height of approximately four feet six inches, and there was also a board nailed across the window;
there was no bed, the mattress being on the floor, and no carpet; the room smelled of urine…the bedroom was a downstairs lobby area. There was no light bulb… There was no carpet on the floor; it was covered by lino tiles and appeared very dirty…there appeared to be nothing else in the room. Photographs taken by Gwent police on 14 August show that parts of the house were reasonably well maintained and furnished’ (p.2).
All of the children in this family at various stages in their lives were assessed as having developmental delay (some global), learning difficul-ties and serious speech difficuldifficul-ties. In Girl Two’s case health services had gone to considerable lengths to try to establish the cause of her develop-mental delay and learning difficulties.
Each of the three main agencies (health, social services and educa-tion) held a great deal of information about the past history of the family (and the extended family) that was not brought together either within each agency or across organizations until 1997. This meant that no one professional had oversight of this case and each professional was dealing with a very small percentage of the information available on the family.
There were over 173 different professionals involved with Girl Two’s
Bias and errors in decision-making
Human psychological processes affect decision-making in child protection. We tend to form judgements in line with evidence that is readily available (Mac-donald 2001; Reder and Duncan 1999) and approach problems of categoriza-tion on the basis of simple resemblance between different cases with similar features. These particular factors, particularly when combined with selective perception and emotional commitment, can distort professional judgement and contrive to persuade practitioners that child abuse exists when it does not, or the other way round (Macdonald 2001; Sheldon 1987).
There is strong evidence from serious case reviews that once practitioners have formulated a hypothesis they are reluctant to change their mind in spite of information to the contrary being available (Bridge Childcare Consultancy 1995; Munro 1996, 1999). This is not surprising since the psychological liter-ature confirms that we tend to pay more attention to evidence that supports our beliefs rather than challenges them (Kahneman, Slovic and Tversky 1990).
Reviewing decisions and in fact changing one’s mind is a sign of good not bad practice (Munro 1996, 2002). Mistakes which were at first ‘unavoidable’
because of lack of information become ‘avoidable’ as more information joins the system.
Repeatedly, serious case reviews emphasize the importance of a good assessment that includes historical information and frequent multiprofessional reviews to stop ‘drift’. Yet Macdonald (2001) indicates that a completed assess-ment is still likely to be an exception rather than the norm in case files. Similarly Sanders et al. (1999) found in their review of 21 serious case reviews under-taken in Wales between 1991 and 1996, that assessments were either not undertaken or were insufficiently structured to be useful as a basis for planning.
Child protection conferences have been seen as one way to hypothesize and take decisions relating to risk in a multiprofessional forum. However, Kelly and Milner (1996, 2000) in a rigorous analysis of case conference minutes extracted from child death inquiry reports found strong indications that the original perceptions of a family constructed by the individual decision-maker and the subsequent management of the case are likely to be supported, main-tained and endorsed in ‘group decisions’ within the conference forum and this persists even in the face of contrary evidence. This is supported by Munro (2002). Group pressure for conformity ensures that the initial dominant
family, and this was considered an under-estimate as many of the teachers could not be identified. These features are not limited to this case (Bridge Childcare Development Service 1999).
position in the group will emerge as the group choice. The child protection conference is not then necessarily a forum where previous decisions are chal-lenged or reviewed and in chronic cases of emotional abuse and neglect there is often no one serious event that may act as a trigger to re-evaluate the original hypothesis. This lack of very immediate danger also raises the probability of
‘drift’ as cases may not hit agency thresholds, thus professionals mentally cate-gorize the case as relatively ‘safe’ in relation to others where issues of risk are defined in more tangible terms.
Case complexity
As the introductory section highlights, neglectful families have a multiplicity and complexity of needs. Reder and Duncan (1999) describe a process of ‘as-sessment paralysis’ in which the focus of professional attention on a parent or carer’s mental health diagnosis takes over the whole case, rather than looking at the effects of the parent’s behaviour on the child. Although Reder and Duncan use this term specifically when referring to parents with mental health problems, this could apply to other areas of assessment. The important factor is that there is a danger in the needs of the parent becoming the point of focus, and this then becoming the context for all decisions relating to intervention, with other relevant factors relating to the child not given sufficient attention.
‘Paralysis’ can also result because of poor training, lack of confidence, lack of credibility and an over-reliance on the opinion of other professionals (Skinner 2002). Professionals can experience an overwhelming sense of need within the family. Invariably the practical needs are the easiest to identify and the danger is that the case goes down a path of intervention that does not tackle the fundamental reasons for the problems.