Buckley (in Chapter Seven) points out that there is some ambiguity and confu-sion as to the nature of interdisciplinary assessment. This chapter explores certain aspects of this process in the context of the current system in England and Wales. The English Framework for the Assessment of Children in Need and their Families (Department of Health 2000) marked an important stage in the devel-opment of policy in an area of work in which all are agreed that interdisciplin-ary co-operation is a prerequisite for effective practice. There have been some
contentious aspects of its implementation and the materials designed to support it. (The issues are not explored here.) Nonetheless, the basic building blocks of the assessment process, epitomized in the familiar ‘triangle’ (Figure 6.1), is a sound working tool to ensure all relevant considerations are taken into account. It is of particular value in cases where neglect is a major feature since, almost by definition, such families exhibit a range of difficulties across many dimensions of family life.
The ‘framework’ document stresses that:
effective collaborative work between staff and different disciplines and agencies assessing children in need and their families requires a common language to understand the needs of children, shared values about what is in a child’s best interests and a joint commitment to improving the outcome for children. (Preface p.x)
However, Chapter Five, entitled ‘Roles and Responsibilities in Inter-agency Assessment of Children in Need’ (my italics) refers only to agencies, not to the different disciplines (as in the preface). The chapter emphasizes the responsibil-ity of various professionals in the assessment process but says virtually nothing about the distinctive nature of the contributions which the different profession-als are expected to make. So far as I am aware, there has not been significant research into the content of assessment records and the contribution of
differ-CHI LD’S
DEVEL OPM
ENTAL NEEDS
FAMILY & ENVIRONMENTAL FACTORS PARE
NTING CAPAC
ITY CHILD
Safeguarding
&
promoting welfare
Ensuring safety Basic care
Emotional warmth Stimulation
Guidance & boundaries Stability
Social presentation Emotional &
behavioural development EducationHealth
Self-care skills
Familyhistor y
&functioning Widerfamily Hou
sing Employment Income Fam
ily’s social integr ation Comm
unit y resour
ces
Assessment Framework
Identity Family & social
relationships
Figure 6.1 The Department of Health (2000) assessment triangle
ent disciplines to it. It remains to be seen, therefore, if the speculation which follows is borne out by empirical work.
The English Green Paper Every Child Matters (Chief Secretary to the Treasury 2003) has proposed changes to ensure that, at least at a basic level, there is a common assessment framework for professionals to use based on a common data base. ‘The aim is for core information to follow the child between services to reduce duplication’ (p.51). This assessment is to be designed as a rel-atively simple tool, suitable for use by a wide range of workers. This marks a first step towards more effective communication but in cases of serious neglect, on which this chapter is focused, the complex issues raised by the Assessment Framework as a multidisciplinary tool will necessitate more radical and more sophisticated consideration.
The role of social workers
The official guidance is unambiguous in giving social services the lead respon-sibility for the completion of assessment for children in need. In practice, this means responsibility for the co-ordination of information provided by others as well as by themselves. The guidance does not, however, identify the distinctive professional contribution which such social workers can make, in addition to the co-ordination of other people’s work.
Implicit in much of what is written about social services is that a designated social worker will carry out the direct assessment of parenting capacity and of
‘family or environmental factors’, even if others are involved. Similarly, the guidance in ‘communicating with children’ seems to assume that the social worker will have a duty to ‘see, observe, talk to, and engage in activities’ with children (Department of Health 2000).
Although these responsibilities apply generally, they have particular signif-icance in cases of neglect. Yet there are unresolved doubts and ambiguities in the social work role. First of all, constant references to the gathering of ‘infor-mation’ on many dimensions does not ensure that workers will be able to inte-grate it into a coherent theoretical framework, thus making sense of the data.
Second, there are two elements in the process which may need specific atten-tion. These are, first, the factors outside the immediate family and, second, direct communication with children.
Since the Assessment Framework was published in 2000, it seems that the bottom line of the assessment ‘triangle’, ‘family and environmental factors’ may have received less attention. This may have been partly a simple visual problem – the subcategories on the bottom line are more difficult to read! But it may also reflect the ebb and flow of professional interest in aspects of users’ lives.
The first five subheadings are:
· Community resources
· Family’s social integration
· Income
· Employment
· Housing.
It is hard to imagine issues more important in the assessment of neglectful families than these five. For example, their ‘social pariah’ status in some neigh-bourhoods (‘the neighbours from hell’) is an extremely destructive element in some situations; aggressive interactions breed paranoia. They also make allega-tions of child maltreatment from neighbours more likely. These are very diffi-cult for professionals to assess. Are they malicious or well founded? Similarly, the material problems arising from debt, unemployment and poor housing are all too familiar.
It seems clear that social workers are likely to be best placed to consider these issues. It is also clear that, if such matters are not considered in depth, a crucial dimension of holistic assessment is weakened. As was pointed out in my earlier work (Stevenson 1998a, pp.20–27), it is not enough to note that such parents may be at, or below, the poverty line. The question is why this is so, and what impact it is having on family life. For example, the existence of unpayable debts may so reduce weekly income that there cannot be adequate nutrition for the children.
The last two subcategories of the ‘bottom line’ of the triangle are ‘wider family’ and ‘family history and functioning’. Indeed, these two are indivisible.
History may be alive in the present, perhaps members of the extended family living just down the road, for better or for worse, so far as the family is con-cerned! Again, the social worker in the assessment team is the most likely to have access to this part of the family story, which may be critical in understand-ing the dynamics and evolvunderstand-ing possible strategies for intervention. It seems, therefore, that social workers, whatever else they do, should ensure that, in all cases of neglect, these dimensions are thoroughly probed.
The second important role for the social worker to consider in the assess-ment process concerns the children within the neglectful family. There will be other expert contributions, of course, such as those from paediatricians, health visitors and teachers. There may be professionals called in specifically, perhaps in the context of the courts, such as psychologists or child psychiatrists.
However, social workers who visit such families, often over a substantial period of time, are in an important, perhaps unique, position to observe ordinary inter-actions between adults and children and between children. These may be dif-ferent from encounters with other professionals and cast fresh light on aspects
of the dynamics. Social workers may be able, in a less formal, more everyday, environment, to notice individual children and to talk, perhaps through play, to them. They are sometimes overlooked in the chaotic interactions so characteris-tic in such families. There is something in the way that neglectful families often present themselves, in crisis and in turbulence, that may make it particularly dif-ficult to follow through the assessment of each child.
More generally, it is apparent that there is a lack of professional confidence in assessment skills, combined with resentment at being perceived as
‘second-class citizens’ by some other disciplines, especially in the eyes of the courts. There is justified anger at the way Guardians ad litum are accorded status denied to the local authority social worker (who may be, after all, the same person a few years later). If the role in assessment is seen as only drawing together other people’s words of wisdom, this may perpetuate feelings of inad-equacy.
Health care professionals
Thus far, we have concentrated upon the aspects of the ‘lead role’ of the social worker in the assessment process. There is also, however, a complex and prob-lematic issue in relation to the role of health care professionals in cases of serious neglect. There is ample evidence from serious case reviews, of which
‘Paul’ (Bridge Childcare Consultancy 1995) is perhaps best known, that neglectful families have often subverted the best efforts of health professionals to provide care. In the case of Paul, no fewer than thirteen health professionals and agencies were involved. More recently, my own experience, in relation to a review involving children with learning disabilities, has brought home to me the complex physical health needs many such children have. Similar problems in Scotland in co-ordinating health information are noted by Daniel (in press).
The underlying reasons for the difficulties experienced in seeking to provide for the health needs of neglected children are not difficult to find. Yet, overcoming them has so far proved intractable. Neglectful parents, especially those with a number of children near in age, often have difficulty meeting the diverse health needs of their children. Characteristically, they do not keep appointments. It is common for the children to have a range of health-related problems, some of which may in themselves have been caused or exacerbated by parental mismanagement. Thus, there may be a downward spiral, in which children become more ill, ‘poorly’ and difficult to manage, and parents more desperate to avoid blame.
The families tend to be involved with a number of health professionals situated in various agencies: different hospitals, different outpatient depart-ments; primary health care teams; a range of community health services, includ-ing those for schools, and so on. There can be a large number of individual practitioners with some direct responsibility. Some children have relatively
minor problems, such as squints or (in Down’s Syndrome) weak ankles; others have more serious and potentially grave problems, such as speech delay, which can adversely affect the child’s future career at school. Health professionals have distinct identities and very different roles, and often have little or no contact with each other. Furthermore, they may not have shared governance.
The present system is meant to ensure that the general practitioner will receive notification of hospital outpatients’ appointments, including ‘did not attend’ notes (DNAs). But there is little to suggest that such information is followed up or collected in any systematic way. Sadly these ‘DNAs’ often only rise to the surface when a serious case review is undertaken. In any case, contact with health professionals is not restricted to such formalized appointments.
It would seem imperative to devise a method within the framework of health agencies by which such information could be systematically brought together and its cumulative significance assessed. Even the bare facts of atten-dance and non-attenatten-dance at health appointments over (say) the course of a year would be invaluable. Leaving aside the obvious value of the health infor-mation per se, it would give important indications of the parents’ capacity to handle the problems. The neglect of children’s health needs can be a key factor in overall assessment. (See also Chapter Thirteen for a discussion of the health needs of disabled children.)
Every Child Matters (Chief Secretary to the Treasury 2003) proposes an ambitious programme to improve information collection and sharing (p.52). A
‘local information hub’ is suggested which would ensure that every authority has a comprehensive list of basic details about all children in their area. The aim would be to ensure that concerns about their well-being and safety would be flagged up. Whilst this should prevent the grosser failures of communication, it does not address the difficulties of sharing information about neglected children and their health needs which require more detailed attention. (The ‘in-formation hub’ (p.54) presented in diagrammatic form does not even list hospi-tals as a relevant agency!)
There are, however, other recommendations which could have a bearing in the better co-ordination of information. One proposes the creation of Chil-dren’s Trusts (p.72), the second identification of lead professionals, where children are known to more than one specialist agency (p.51), and the third integration of professionals through multidisciplinary teams (p.51). The impli-cations are far reaching and cannot be explained here except in relation to sus-tained intervention which is discussed later.
The discussion above has been selective; it refers only to a few dimensions of the vital process of interdisciplinary assessment. There is a case for exploring each element in turn. The role of schools more generally in the assessment of neglected children is of particular importance. Every Child Matters, in the pro-posals for bringing together educational and social services for children, opens
up the possibility of very significant improvements in the crucial relationship between the school and social services in care for seriously neglected children.
Questions for practice
· What ‘content analysis’ of completed assessments has there been? If none, why not? Such an analysis could provide evidence as to whether the three sides of the ‘triangle’ are each being tackled in the appropriate depth and whether these different dimensions were adequately integrated. Such practice research could form part of regular audit and would have many uses in training.
· Content analysis might also be used to assess the relative weight given to the contribution of different disciplines and to consider whether that seems appropriate. It could lead to a helpful debate between the disciplines and to greater awareness of the usefulness of particular inputs to the whole.
· What steps can and should be taken by senior managers to increase appropriate confidence in the value of the part played by social workers? This is likely to be a two-way process; there is a need to enhance their skills but also to emphasize to other disciplines, perhaps particularly the lawyers and the judiciary, the distinctive, perhaps unique, value of their contribution.
· How can health professionals begin to collect systematically the health information available to them in their own systems,
specifically the practical details of attendance or non-attendance at appointments, clinics, etc? In the event of this revealing serious concerns about the children’s well-being, how should this be used to feed into the overall family assessment? Is this best done in the context of the primary health care team? How can evolving technology help?
· For children from the age of four or five, the schools can play a critical part in ensuring that health needs are noted and that the links between schools and health services are close. For children with special needs who attend special schools, such links are often well managed. It is less clear whether children from neglectful families who are not at special schools, but who nonetheless may have diverse unmet needs, are generally well served. Anecdotal evidence suggests it is patchy.