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A Public Health Approach to Child Protection Professor Dorothy Scott

History of Child Protection. First wave

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A Public Health Approach to Child Protection Professor Dorothy Scott

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    1. A Public Health Approach to Child Protection Professor Dorothy Scott The mission of our Centre is to enhance the life opportunities for children in Australia who are at risk of child abuse and neglect, which we aim to achieve through three strands: research and strategic evaluation professional education and workforce development advocacy (especially in the policy domain). Our overarching framework is a public health approach to child protection and the conceptual foundations of our work are based on our knowledge of: Research utilisation in policy and practice domains Diffusion of innovation The mission of our Centre is to enhance the life opportunities for children in Australia who are at risk of child abuse and neglect, which we aim to achieve through three strands: research and strategic evaluation professional education and workforce development advocacy (especially in the policy domain). Our overarching framework is a public health approach to child protection and the conceptual foundations of our work are based on our knowledge of: Research utilisation in policy and practice domains Diffusion of innovation

    2. Research and policy are fine words but let us start with the images of some children to remind us why we are here. These are Australian Aboriginal children. This is the face of my nations child protection shame. Aboriginal children are 9 times more likely to be in State care than other Australian children. There are also very high rates in some Aboriginal communities of Foetal alcohol syndrome Non-organic failure to thrive Exposure to domestic violence Sexual abuse This picture speaks to me about this. It also speaks to me about the legacy of past removalist policies in which children of mixed Aboriginal and European descent were brutally taken from their families and placed in institutions or white foster families, and for which a national apology has now been made by our Prime Minister. This image also speaks to me of the joy, the beauty and the resilience of children whatever their colour or creed. Research and policy are fine words but let us start with the images of some children to remind us why we are here. These are Australian Aboriginal children. This is the face of my nations child protection shame. Aboriginal children are 9 times more likely to be in State care than other Australian children. There are also very high rates in some Aboriginal communities of Foetal alcohol syndrome Non-organic failure to thrive Exposure to domestic violence Sexual abuse This picture speaks to me about this. It also speaks to me about the legacy of past removalist policies in which children of mixed Aboriginal and European descent were brutally taken from their families and placed in institutions or white foster families, and for which a national apology has now been made by our Prime Minister. This image also speaks to me of the joy, the beauty and the resilience of children whatever their colour or creed.

    3. This image could speak to us of social inequality these would seem to be affluent Anglo-Celtic children. But this image also reminds us that all children are unique each seeing the world and seeing us through a different lens, and that children of all social classes may suffer beneath the surface of their smiles. Recent research on young adults reports on their childhood experiences of abuse and neglect suggest that the social class differences may actually be significantly less than the picture which emerges from using data from our child protection services. This image could speak to us of social inequality these would seem to be affluent Anglo-Celtic children. But this image also reminds us that all children are unique each seeing the world and seeing us through a different lens, and that children of all social classes may suffer beneath the surface of their smiles. Recent research on young adults reports on their childhood experiences of abuse and neglect suggest that the social class differences may actually be significantly less than the picture which emerges from using data from our child protection services.

    4. History of Child Protection First wave late nineteenth century child rescue movement for destitute and neglected children, with the State assuming a guardian role. Second wave 1960s battered baby syndrome and 1980s child sexual abuse, leading to forensic models and risk assessment emphasis, with the State assuming a screening/surveillance role. Third wave? twenty-first century public health and whole of government approach, with State assuming a responsive regulation role? Let us reflect on our history for it gives us a unique perspective on our current policy dilemmas. The first wave in the history of child protection responded to the plight of destitute and neglected children and pushed for the State to play a role in their care and protection, often in collaboration with the Church. We are now aware that the past institutionalisation of children could inflict great harm. The second wave of the child protection movement uncovered the hidden problems of physical and sexual abuse, and led to policies that strengthened the role of the State in attempting to identify children at risk of child abuse and neglect. This has proved to be very difficult given that there are no reliable risk assessment instruments and those instruments which exist have very high false positive rates that is they catch many children in the net, only a few of whom would have actually been abused. Also, in the past generation or two there has been a massive widening in the definitions of child maltreatment so that what was once not seen as child maltreatment- physical discipline, leaving children in the care of older children, exposing children to domestic violence, children not attending school etc, is now seen as such. We are thus in some parts of the world now seeing the limits of the capacity of the State to respond to the scale of the problem as it is come to be defined. These demand management pressure may help to give way to a third wave in the child protection movements leading us to grasp the opportunities for prevention the challenge we have not yet fully embraced. The growing body of knowledge in a field called prevention science, and the emergence of powerful data linkage, may also help contribute to a third wave in the history of child protection which is population based. History carries painful lessons for us that despite our good intentions, our interventions can harm children. History also affirms how far we have come. For example in just a generation I see the recognising of childrens rights and hearing their voices, the lifting of the lid on problems such as child sexual abuse and domestic violence, and our greatly increased understanding of early brain development and the psycho-social conditions which impair parenting capacity, as tremendous achievements. Let us reflect on our history for it gives us a unique perspective on our current policy dilemmas. The first wave in the history of child protection responded to the plight of destitute and neglected children and pushed for the State to play a role in their care and protection, often in collaboration with the Church. We are now aware that the past institutionalisation of children could inflict great harm. The second wave of the child protection movement uncovered the hidden problems of physical and sexual abuse, and led to policies that strengthened the role of the State in attempting to identify children at risk of child abuse and neglect. This has proved to be very difficult given that there are no reliable risk assessment instruments and those instruments which exist have very high false positive rates that is they catch many children in the net, only a few of whom would have actually been abused. Also, in the past generation or two there has been a massive widening in the definitions of child maltreatment so that what was once not seen as child maltreatment- physical discipline, leaving children in the care of older children, exposing children to domestic violence, children not attending school etc, is now seen as such. We are thus in some parts of the world now seeing the limits of the capacity of the State to respond to the scale of the problem as it is come to be defined. These demand management pressure may help to give way to a third wave in the child protection movements leading us to grasp the opportunities for prevention the challenge we have not yet fully embraced. The growing body of knowledge in a field called prevention science, and the emergence of powerful data linkage, may also help contribute to a third wave in the history of child protection which is population based. History carries painful lessons for us that despite our good intentions, our interventions can harm children. History also affirms how far we have come. For example in just a generation I see the recognising of childrens rights and hearing their voices, the lifting of the lid on problems such as child sexual abuse and domestic violence, and our greatly increased understanding of early brain development and the psycho-social conditions which impair parenting capacity, as tremendous achievements.

    5. We need to rethink policy because: The prevalence and long term effects of child abuse are so serious (The Lancet 2009 Special Issue). The current cure of removing children is harming many children (Doyle, 2007; Rubin et al 2007). 3. Demand has outstripped the capacity of child protection systems. I believe that we are at a crossroad in child protection policy and that we have no choice but to rethink our direction. I shall assume that we are familiar with the evidence that child abuse and neglect is a serious problem both in relation to its prevalence and its effects and say no more about this. The recent special issue of The Lancet provides excellent papers which review these issues. As there is little evidence to show that we can reverse the effects of child abuse and neglect, prevention is paramount. I will elaborate on the second and third propositions in my argument. I believe that we are at a crossroad in child protection policy and that we have no choice but to rethink our direction. I shall assume that we are familiar with the evidence that child abuse and neglect is a serious problem both in relation to its prevalence and its effects and say no more about this. The recent special issue of The Lancet provides excellent papers which review these issues. As there is little evidence to show that we can reverse the effects of child abuse and neglect, prevention is paramount. I will elaborate on the second and third propositions in my argument.

    6. Child rescue can hurt children In the US Rubin, OReilly, Luan & Localio (2007) followed 729 children for first 18 months in foster care and found a high level of placement instability. This was strongly associated with a childs behavioural problems at 18 months, regardless of the level of behavioural problems on entering care. The risk of iatrogenic emotional abuse is thus very significant in placing children. Until very recently we have not been able to differentiate the harm done children prior to coming into care and the harm done by being in care. Two very recent US studies have done this. How generalisable their findings are is yet to be determined but given the pervasive problem of placement instability in many foster care systems in the world, the Rubin, OReilly and Localio study poses the possibility that we are inflicting psychological harm on a large number of children by bringing them into care. I have compared it with bringing sick children into a hospital with rampant antibiotic resistant infection. There are occasions when it is justified to do this only, however, if we are confident that the harm to which a child is exposed at home will be greater, and if we have excluded other interventions which can pose less risk than removing a child from their home. This argument may not hold in systems where: there is a low level of child removal; a low level of placement instability; or where for the small minority of children whose prospects of reunification are clearly unviable from very early on and where there are good prospects of a permanent substitute family. However, there are few foster care dependent systems in the world without a serious problem of multiple placements, and as far as I am aware attempts to reduce placement instability have had limited success. Until very recently we have not been able to differentiate the harm done children prior to coming into care and the harm done by being in care. Two very recent US studies have done this. How generalisable their findings are is yet to be determined but given the pervasive problem of placement instability in many foster care systems in the world, the Rubin, OReilly and Localio study poses the possibility that we are inflicting psychological harm on a large number of children by bringing them into care. I have compared it with bringing sick children into a hospital with rampant antibiotic resistant infection. There are occasions when it is justified to do this only, however, if we are confident that the harm to which a child is exposed at home will be greater, and if we have excluded other interventions which can pose less risk than removing a child from their home. This argument may not hold in systems where: there is a low level of child removal; a low level of placement instability; or where for the small minority of children whose prospects of reunification are clearly unviable from very early on and where there are good prospects of a permanent substitute family. However, there are few foster care dependent systems in the world without a serious problem of multiple placements, and as far as I am aware attempts to reduce placement instability have had limited success.

    7. Data linkage study of 45,000 Illinois child protection cases. Compared children at similar risk level where some were placed in foster care and others remained at home. School aged children on margin of placement had lower adult arrest rates, lower teen pregnancy rates and better employment when remaining at home. Doyle, National Bureau of Economic Research, 2007 Child rescue can hurt children Given the ethical and legal barriers to randomised controlled trials in which children at similar level of risk are removed from their families and others not, Doyles data linkage study provides valuable insights which are usually only possible from RCTs. The study is not without controversy and a couple of studies do not justify major change but they provide sobering reflection. Doyle followed up a huge cohort of children who were referred to child protection services in Illinois when they were of school age. Cases were randomly allocated to child protection workers, some of whom were more interventionist than others, and so it was possible to compare the outcomes for those children of a similar level of risk where some remained with their families and others were placed in foster care. Outcomes for school aged children on the margins of placement the grey cases, were better if they remained at home, regardless of whether the family received services, in terms of adult arrest rates, teenage pregnancy and employment. This may not be true in countries with a very low rate of placing children as there may be fewer borderline or grey cases, in those situations. It is unknown whether the outcomes are better or worse for children who enter care below school age. Given the ethical and legal barriers to randomised controlled trials in which children at similar level of risk are removed from their families and others not, Doyles data linkage study provides valuable insights which are usually only possible from RCTs. The study is not without controversy and a couple of studies do not justify major change but they provide sobering reflection. Doyle followed up a huge cohort of children who were referred to child protection services in Illinois when they were of school age. Cases were randomly allocated to child protection workers, some of whom were more interventionist than others, and so it was possible to compare the outcomes for those children of a similar level of risk where some remained with their families and others were placed in foster care. Outcomes for school aged children on the margins of placement the grey cases, were better if they remained at home, regardless of whether the family received services, in terms of adult arrest rates, teenage pregnancy and employment. This may not be true in countries with a very low rate of placing children as there may be fewer borderline or grey cases, in those situations. It is unknown whether the outcomes are better or worse for children who enter care below school age.

    8. Unsustainable systems Identify and notify policies (eg mandatory reporting laws) were an appropriate response to dealing with a relatively small number of serious cases of child physical and sexual abuse. Such policies, now applied to an ever widening range of child protection concerns (emotional abuse and neglect comprising at least two thirds of notifications), has completely overloaded child protection systems. My third proposition is that current systems based on a narrow focus of identify and notify are unsustainable. The most extreme form of identify and notify is found in those jurisdictions with extensive mandatory reporting laws which require a wide range of professionals to report suspected child abuse or neglect, or even children they see as at risk, to statutory authorities, or face criminal penalties. Such laws are symbolically appealing (we are taking child abuse seriously) but in a risk averse culture, this leads to defensive practice and the child protection system, despite injections of greater and greater funds, often diverted from other child welfare areas, can only respond to a small minority of referrals. Such a scenario does not require mandatory reporting as a risk averse culture can also be created by sensational media coverage of child deaths attributable to child protection failures as seen in New Zealand following extensive publicity in which social workers in a centralised intake service were punished and publicly pilloried for failing to forward what would appear to have been a low risk case to a regional office for investigation. Child protection systems and cultures based on identify and notify create a system where there is enormous frustration for referrers and child protection workers resulting from the large gap between the low threshold for making a notification or referral and the higher threshold for initiating statutory intervention. It also means that looking for the child at serious risk is like looking for the needle in the haystack and such cases are increasingly like to be overlooked, prematurely closed and superficially assessed in order to move on to the next case. Like an overloaded casualty department in a hospital, this then becomes a dangerous place for a child in serious trouble to be. Such a child welfare system is akin to a health system based only on hospitals and no GPs, where all suspected cases must report to the emergency room or casualty department. The main goal of such a child protection system thus becomes screening for risk rather than reducing risk. Such system are in contrast to those common in western Europe where the statutory child protection service is relatively small and there is a larger infrastructure of universal services which work with troubled children and families. Let me share with you some excellent supporting evidence on this from Australia.My third proposition is that current systems based on a narrow focus of identify and notify are unsustainable. The most extreme form of identify and notify is found in those jurisdictions with extensive mandatory reporting laws which require a wide range of professionals to report suspected child abuse or neglect, or even children they see as at risk, to statutory authorities, or face criminal penalties. Such laws are symbolically appealing (we are taking child abuse seriously) but in a risk averse culture, this leads to defensive practice and the child protection system, despite injections of greater and greater funds, often diverted from other child welfare areas, can only respond to a small minority of referrals. Such a scenario does not require mandatory reporting as a risk averse culture can also be created by sensational media coverage of child deaths attributable to child protection failures as seen in New Zealand following extensive publicity in which social workers in a centralised intake service were punished and publicly pilloried for failing to forward what would appear to have been a low risk case to a regional office for investigation. Child protection systems and cultures based on identify and notify create a system where there is enormous frustration for referrers and child protection workers resulting from the large gap between the low threshold for making a notification or referral and the higher threshold for initiating statutory intervention. It also means that looking for the child at serious risk is like looking for the needle in the haystack and such cases are increasingly like to be overlooked, prematurely closed and superficially assessed in order to move on to the next case. Like an overloaded casualty department in a hospital, this then becomes a dangerous place for a child in serious trouble to be. Such a child welfare system is akin to a health system based only on hospitals and no GPs, where all suspected cases must report to the emergency room or casualty department. The main goal of such a child protection system thus becomes screening for risk rather than reducing risk. Such system are in contrast to those common in western Europe where the statutory child protection service is relatively small and there is a larger infrastructure of universal services which work with troubled children and families. Let me share with you some excellent supporting evidence on this from Australia.

    9. South Australian birth cohort study All babies born in South Australia in 1991, 1998 and 2002 were tracked (Hirte et al 2008) 22.5% (one in 4.5 children) of the 1991 cohort had been notified to child protection authorities by age 16 Allegations of physical abuse and neglect were most common, and 5.6% of 1991 cohort (1 in 4 of the notifications) were substantiated. The trend for 1998 and 2002 cohorts was even more dramatic From data mining child protection information systems, and data linkage across sectors such as health, education and social services, we can now know a lot more about what is happening in our child protection systems. SA has one of the strongest mandatory reporting legislative frameworks in the world. This SA tracking study followed birth cohorts in 1991, 1998 and 2002 and identified how many of these children were notified to statutory child protection services for the 1991 cohort they were tracked up to the age of 16. These are the key findings comparable to Cleveland Ohio where one in 2 African American children and one in 5 white children is the subject of a child protection referral or notification by the age of 18. No child protection system can function safely under such pressure.From data mining child protection information systems, and data linkage across sectors such as health, education and social services, we can now know a lot more about what is happening in our child protection systems. SA has one of the strongest mandatory reporting legislative frameworks in the world. This SA tracking study followed birth cohorts in 1991, 1998 and 2002 and identified how many of these children were notified to statutory child protection services for the 1991 cohort they were tracked up to the age of 16. These are the key findings comparable to Cleveland Ohio where one in 2 African American children and one in 5 white children is the subject of a child protection referral or notification by the age of 18. No child protection system can function safely under such pressure.

    10. This graph shows the alarming trajectory of notifications: for example, of the 1991 birth cohort, 10% were notified by age 7, of the 1998 cohort 10% had been notified by age 4, and of the 2002 birth cohort, 10% had been notified by 2.5 years, so it is very likely that more than 1 in 4.5 children in the 1998 and 2002 birth cohorts will be notified by age 16. Only a minority of these cases are investigated, with approximately 20% of notifications being substantiated as cases of maltreatment (substantiation is the belief by a child protection workers that the suspicion of child abuse or neglect has substance it is not as stringent as the criteria used to place a child on a register in the UK system or to initiate statutory intervention). Mandatory reporting of suspected child abuse and neglect was extended in 1993 in SA (and again in 2007 so that it now includes volunteers in sporting clubs, Sunday schools etc), as this was associated with a marked increase in referrals. The system is so overwhelmed with notifications that it cannot respond to most referrals. Paradoxically, any child who dies is much more likely to have been known to child protection services than in jurisdictions with a lower notification rate. This leads to more frequent media and political controversy which fuels more notifications (excellent NZ data showing the direct impact of media coverage on reports of alleged abuse) and further demoralises the service providers and exacerbates recruitment and retention problems. This is a classic negative feedback loop. This graph shows the alarming trajectory of notifications: for example, of the 1991 birth cohort, 10% were notified by age 7, of the 1998 cohort 10% had been notified by age 4, and of the 2002 birth cohort, 10% had been notified by 2.5 years, so it is very likely that more than 1 in 4.5 children in the 1998 and 2002 birth cohorts will be notified by age 16. Only a minority of these cases are investigated, with approximately 20% of notifications being substantiated as cases of maltreatment (substantiation is the belief by a child protection workers that the suspicion of child abuse or neglect has substance it is not as stringent as the criteria used to place a child on a register in the UK system or to initiate statutory intervention). Mandatory reporting of suspected child abuse and neglect was extended in 1993 in SA (and again in 2007 so that it now includes volunteers in sporting clubs, Sunday schools etc), as this was associated with a marked increase in referrals. The system is so overwhelmed with notifications that it cannot respond to most referrals. Paradoxically, any child who dies is much more likely to have been known to child protection services than in jurisdictions with a lower notification rate. This leads to more frequent media and political controversy which fuels more notifications (excellent NZ data showing the direct impact of media coverage on reports of alleged abuse) and further demoralises the service providers and exacerbates recruitment and retention problems. This is a classic negative feedback loop.

    11. By the end of the twentieth century in most English speaking countries the State is now trying to perform two roles with escalating demand pressures in relation to both. Being guardian or in loco parentis for the children whom the State deems in need of this. Screening a vast number of families for suspected child abuse and neglect In relation to the former, national figures for Australia show that the number of children in out of home care on audit day (June 30) in the years 1999-2008 has more than doubled in a decade. This figure does not include the number of children who came into care in a given year only those in care on June 30 so it is an underestimate of the total population of children in State care in any given year, especially in those jurisdictions where large numbers of children enter care for short periods of time. It should also be noted that in some jurisdictions, the rise in the number of children in care over time is more strongly associated with more children remaining in care than with more children entering care, although both factors may operate. Australia is highly dependent on foster care and there is an increasing shortfall in the number of foster care placements. This is therefore a clearly unsustainable trajectory, and given concerns about the effects on many children of being in unstable foster care, is deeply concerning. By the end of the twentieth century in most English speaking countries the State is now trying to perform two roles with escalating demand pressures in relation to both. Being guardian or in loco parentis for the children whom the State deems in need of this. Screening a vast number of families for suspected child abuse and neglect In relation to the former, national figures for Australia show that the number of children in out of home care on audit day (June 30) in the years 1999-2008 has more than doubled in a decade. This figure does not include the number of children who came into care in a given year only those in care on June 30 so it is an underestimate of the total population of children in State care in any given year, especially in those jurisdictions where large numbers of children enter care for short periods of time. It should also be noted that in some jurisdictions, the rise in the number of children in care over time is more strongly associated with more children remaining in care than with more children entering care, although both factors may operate. Australia is highly dependent on foster care and there is an increasing shortfall in the number of foster care placements. This is therefore a clearly unsustainable trajectory, and given concerns about the effects on many children of being in unstable foster care, is deeply concerning.

    12. What is very interesting to note are the major inter-jurisdictional differences in Australia which in relation to children in care are consistent and comparable. These provide us with valuable case studies in relation to the impact of different child protection policies. NSW has the highest level of notifications per annum (greater number annually than the rest of Australia put together) and the highest rate of children in State care so it is under extreme pressure in relation to both functions of the State. It had 8.4 children per 1000 in care on June 30, 2008. The State with the lowest is Victoria with 4.2 children per 1000 in 2008 (ie half the NSW rate). But a decade earlier, both jurisdictions had similar levels eg between 3 and 3.5 children per 1000 in care, so the difference is most unlikely to be due to demographic factors. It is very likely it is due to different legislative and policy factors. Over the past decade NSW vigorously pursued strong identify and notify policies while Victoria has pursued strong diversionary or differential response strategies. The key characteristics of the NSW system are: severe penalties for not reporting suspected child abuse if a mandated reporter; a broad range of professions and occupations are mandated; mandatory reporting covered at risk of harm (not serious harm as in Victoria) in relation to all forms of child maltreatment; a large centralised intake system like a giant call centre rather than referral locally or regionally to a child protection service; little alternative dispute resolution; weak universal health visitor services and limited NGO family support and family preservation services. In comparison, Victoria has: limited mandatory reporting (physical and sexual abuse only and a limited number of professions mandated); an alternative to notification referral to a regional NGO funded to respond to children in need; a strong infrastructure of health visitor and NGO early intervention services as well as intensive family services where placement risk if high; and strong and compulsory alternative dispute resolution processes before proceeding to the Childrens Court. Following a high level Commission of Inquiry in 2008, NSW child protection legislation and policy is now changing to: increase the threshold for a notification to significant harm; and enable mandated notifiers the option of dealing with their concerns via local community service centres. But it is very hard to bring about a shift in a systems culture after it has worked in this way for a long time, especially in an increasingly risk averse environment in which people and agencies are driven to shift risk rather than share risk. What is very interesting to note are the major inter-jurisdictional differences in Australia which in relation to children in care are consistent and comparable. These provide us with valuable case studies in relation to the impact of different child protection policies. NSW has the highest level of notifications per annum (greater number annually than the rest of Australia put together) and the highest rate of children in State care so it is under extreme pressure in relation to both functions of the State. It had 8.4 children per 1000 in care on June 30, 2008. The State with the lowest is Victoria with 4.2 children per 1000 in 2008 (ie half the NSW rate). But a decade earlier, both jurisdictions had similar levels eg between 3 and 3.5 children per 1000 in care, so the difference is most unlikely to be due to demographic factors. It is very likely it is due to different legislative and policy factors. Over the past decade NSW vigorously pursued strong identify and notify policies while Victoria has pursued strong diversionary or differential response strategies. The key characteristics of the NSW system are: severe penalties for not reporting suspected child abuse if a mandated reporter; a broad range of professions and occupations are mandated; mandatory reporting covered at risk of harm (not serious harm as in Victoria) in relation to all forms of child maltreatment; a large centralised intake system like a giant call centre rather than referral locally or regionally to a child protection service; little alternative dispute resolution; weak universal health visitor services and limited NGO family support and family preservation services. In comparison, Victoria has: limited mandatory reporting (physical and sexual abuse only and a limited number of professions mandated); an alternative to notification referral to a regional NGO funded to respond to children in need; a strong infrastructure of health visitor and NGO early intervention services as well as intensive family services where placement risk if high; and strong and compulsory alternative dispute resolution processes before proceeding to the Childrens Court. Following a high level Commission of Inquiry in 2008, NSW child protection legislation and policy is now changing to: increase the threshold for a notification to significant harm; and enable mandated notifiers the option of dealing with their concerns via local community service centres. But it is very hard to bring about a shift in a systems culture after it has worked in this way for a long time, especially in an increasingly risk averse environment in which people and agencies are driven to shift risk rather than share risk.

    13. In order to give some sense of other countries in relation to the number of children per 1000 in out of home care, these data may be useful, but should be used with caution eg the US data disguises the very high level of forced adoptions that occur in some parts of the US after a child has been in foster care for 18 months. I have calculated the Scottish figure after removing those Looked After Children who are at home with their parents. I would still like to check the figure for Wales in case it also includes children at home with their parents. This is not a league table. Whether it is good or bad to have a higher or lower level of children in care depends on a range of other social indicators and on how harmful or helpful it may be to be in care in that system. In order to give some sense of other countries in relation to the number of children per 1000 in out of home care, these data may be useful, but should be used with caution eg the US data disguises the very high level of forced adoptions that occur in some parts of the US after a child has been in foster care for 18 months. I have calculated the Scottish figure after removing those Looked After Children who are at home with their parents. I would still like to check the figure for Wales in case it also includes children at home with their parents. This is not a league table. Whether it is good or bad to have a higher or lower level of children in care depends on a range of other social indicators and on how harmful or helpful it may be to be in care in that system.

    14. Who are these families? There is now compelling evidence that families whose children are involved with statutory child protection services have multiple and complex needs, and that the level of complexity increases across the spectrum from referral to placement in out of home care. So, what do we know about the families of children involved with child protection systems? Data mining of electronic child protection case records is yielding rich information on the characteristics of the families, and how they compare across the spectrum from those who are notified/referred, substantiated, placed on court orders and those who are placed in care. This is very important if we are to consider possible points of prevention, early intervention and remedial intervention. While Australian data is better in this respect than most other jurisdictions, it is not routinely and consistently collected across the different States and Territories. I am therefore now going to use data from one off studies conducted across 3 States to create a profile of the parental characteristics in child protection cases across the spectrum from notification to admission to care, and then explore the implications of this. Where we do have consistent data within a jurisdiction, it supports the case of increasing complexity and multiplicity of parental problems as one moves across this spectrum of intervention, as one would expect. So, what do we know about the families of children involved with child protection systems? Data mining of electronic child protection case records is yielding rich information on the characteristics of the families, and how they compare across the spectrum from those who are notified/referred, substantiated, placed on court orders and those who are placed in care. This is very important if we are to consider possible points of prevention, early intervention and remedial intervention. While Australian data is better in this respect than most other jurisdictions, it is not routinely and consistently collected across the different States and Territories. I am therefore now going to use data from one off studies conducted across 3 States to create a profile of the parental characteristics in child protection cases across the spectrum from notification to admission to care, and then explore the implications of this. Where we do have consistent data within a jurisdiction, it supports the case of increasing complexity and multiplicity of parental problems as one moves across this spectrum of intervention, as one would expect.

    15. New South Wales The most common issues known in relation to reports to child protection services in 2005-06: Domestic violence 32.0% Drug and alcohol 20.4% Drug issues only 11.6% Alcohol issues only 10.3% (DoCS, 2007) If we look at the NSW data on notifications we see the significance of factors such as domestic violence and substance abuse. It may be an underestimate as in many cases those making notifications to the statutory child protection call centre eg teachers, would not be in a position to know about such parental factors.If we look at the NSW data on notifications we see the significance of factors such as domestic violence and substance abuse. It may be an underestimate as in many cases those making notifications to the statutory child protection call centre eg teachers, would not be in a position to know about such parental factors.

    16. Victoria In 2000-01 substantiated cases of child maltreatment (mostly neglect and emotional abuse): Domestic violence 52% Illicit drug Abuse 33% Alcohol abuse 31% Psychiatric Disability 19% (sums to more than 100% due to many parents having more than one characteristic) If we look at Victorian data on substantiated cases of suspected child abuse and neglect, we see that such the incidence of such parental factors is higher. If we look at Victorian data on substantiated cases of suspected child abuse and neglect, we see that such the incidence of such parental factors is higher.

    17. South Australia In a sample of 99 children first entering care in 2006, parental substance dependence was known in 75 cases, and these cases also had much higher incidence of : Mental health problems (65.3%) Domestic violence (69.3%) Homelessness (28%) (Jeffreys, Hirte, Rogers &Wilson, 2009) If we then look at children coming into care for the first time, we find those characteristics are even more common, and that they are closely interrelated, with parental substance dependence being the overriding issue, and with these families also having a higher level of domestic violence, mental health problems and homelessness than the families where parental substance dependence was not present or known. For children re-entering care, the picture may even be more serious in relation to parental problems. The majority of children coming into care in Australia, as elsewhere, have parents with more than one of these characteristics. So the essential challenge in preventing children coming into care, and successfully reuniting children in care with their families, is understanding and responding effectively to these multiple and complex needs which seriously impair parenting capacity.If we then look at children coming into care for the first time, we find those characteristics are even more common, and that they are closely interrelated, with parental substance dependence being the overriding issue, and with these families also having a higher level of domestic violence, mental health problems and homelessness than the families where parental substance dependence was not present or known. For children re-entering care, the picture may even be more serious in relation to parental problems. The majority of children coming into care in Australia, as elsewhere, have parents with more than one of these characteristics. So the essential challenge in preventing children coming into care, and successfully reuniting children in care with their families, is understanding and responding effectively to these multiple and complex needs which seriously impair parenting capacity.

    18. Where to from here? So what can we do? So what can we do?

    19. Some have argued for a responsive regulation approach to be adopted in child protection policy. This is similar to a differential response system in which cases are triaged as children in need compared with children who require a statutory child protection intervention. In a differential response system which depends on statutory risk assessment to determine if the case is a child in need or a child protection case, there are still vast resources tied up in triage processes, and referral for those screened out of child protection intervention is problematic, both in terms of the familys acceptance of a referral and the limited resources provided to serve these cases. We need to go beyond the responsive regulation and differential response models, and think in population terms. Some have argued for a responsive regulation approach to be adopted in child protection policy. This is similar to a differential response system in which cases are triaged as children in need compared with children who require a statutory child protection intervention. In a differential response system which depends on statutory risk assessment to determine if the case is a child in need or a child protection case, there are still vast resources tied up in triage processes, and referral for those screened out of child protection intervention is problematic, both in terms of the familys acceptance of a referral and the limited resources provided to serve these cases. We need to go beyond the responsive regulation and differential response models, and think in population terms.

    20. Focus on populations as entities Requires knowledge of the prevalence (actual extent) of a condition not just incidence (eg number of reported cases). Requires measurement of changes over time on the basis of prevalence measures or proxy measures Depends on epidemiology as a core discipline and good data linkage systems A public health approach to child abuse and neglect, like a public health approach to diabetes, heart disease or skin cancer, is based on whole populations, not just the clinical population seen in medical services. It requires good prevalence data on a condition, not just good incidence data (number of reports or diagnosed cases). What might be useful prevalence measures for child maltreatment? We need a range of indicators which balance out the strengths and weaknesses of each measure, and are likely to capture different dimensions of child maltreatment and different levels of severity, and which are robust over time and within and across jurisdictions. For example: Child maltreatment related deaths (but low numbers means that trends cannot be easily identifiable) and neglect related deaths (eg avoidable fatal accidents, failure to seek medical treatment for an infant suffering from a chest infection who is also suffering from failure to thrive) are often under-identified as neglect related deaths. Homicide data is more reliable. Rates of low birth weight, foetal alcohol syndrome, faltering weight/non organic FTT useful if there is a universal paediatric surveillance service Supervisory neglect (eg admissions to hospitals of infants with injuries relating to ingestions, falls and burns; or school non-attendance for primary school aged children) Retrospective child self-report re sexual abuse, emotional abuse or physical abuse problematic re what is understood to constitute these forms of abuse, unwillingness to report abuse etc Data linkage is becoming an increasingly powerful tool in providing such measures. The broad social indicators relating the childrens health, literacy etc are useful as a backdrop but will not necessarily capture the well-being of the most disadvantaged minority of children which could fall as the overall well-being of children rises. A public health approach to child abuse and neglect, like a public health approach to diabetes, heart disease or skin cancer, is based on whole populations, not just the clinical population seen in medical services. It requires good prevalence data on a condition, not just good incidence data (number of reports or diagnosed cases). What might be useful prevalence measures for child maltreatment? We need a range of indicators which balance out the strengths and weaknesses of each measure, and are likely to capture different dimensions of child maltreatment and different levels of severity, and which are robust over time and within and across jurisdictions. For example: Child maltreatment related deaths (but low numbers means that trends cannot be easily identifiable) and neglect related deaths (eg avoidable fatal accidents, failure to seek medical treatment for an infant suffering from a chest infection who is also suffering from failure to thrive) are often under-identified as neglect related deaths. Homicide data is more reliable. Rates of low birth weight, foetal alcohol syndrome, faltering weight/non organic FTT useful if there is a universal paediatric surveillance service Supervisory neglect (eg admissions to hospitals of infants with injuries relating to ingestions, falls and burns; or school non-attendance for primary school aged children) Retrospective child self-report re sexual abuse, emotional abuse or physical abuse problematic re what is understood to constitute these forms of abuse, unwillingness to report abuse etc Data linkage is becoming an increasingly powerful tool in providing such measures. The broad social indicators relating the childrens health, literacy etc are useful as a backdrop but will not necessarily capture the well-being of the most disadvantaged minority of children which could fall as the overall well-being of children rises.

    21. A public health approach requires an understanding of: Classification, diagnosis, prevalence and incidence Aetiological research risk and protective factors, causal mechanisms, and outcomes Intervention and evaluation research what works for whom in what settings Effectiveness of implementation and dissemination efforts A public health approach to child abuse and neglect needs more than prevalence data. It also needs to draw on epidemiological research to understand the causal pathways which lead to child abuse and neglect, and what may be effective in intervening in these pathways. Such knowledge also needs to be disseminated and utilised. The gap between what we know and we do is probably greater than the gap between what we know and what we dont know so research utilisation is a major element.A public health approach to child abuse and neglect needs more than prevalence data. It also needs to draw on epidemiological research to understand the causal pathways which lead to child abuse and neglect, and what may be effective in intervening in these pathways. Such knowledge also needs to be disseminated and utilised. The gap between what we know and we do is probably greater than the gap between what we know and what we dont know so research utilisation is a major element.

    22. Supervisory Neglect Fatalities and injuries to young children (eg ingestions, burns, drowning) successfully addressed in 1960s-1990s by an integrated population based approach: Legislation to reduce exposure to risk (labelling of poisons, inflammable nightwear, pool fences) New technologies to reduce risk (eg tamper-proof medications, plugs in electric sockets) Social marketing to change caregiving norms Given that the different types of maltreatment are so interrelated and have similar causal pathways (child sexual abuse being somewhat different in this respect), it may not be that useful to tackle them separately. In fact, there is strong evidence from Durlaks meta-analysis on prevention that tackling the common set of underlying risk and protective factors in relation to a whole range of problems such as child maltreatment, low birth weight, school failure, teenage pregnancy, juvenile crime etc. is much more effective than problem specific strategies. Reframing the challenge in this broader context also leads to a much stronger justification in terms of cost effectiveness given the huge cumulative costs of this range of problems. However, it is easier to illustrate a public health or population based approach by examining it in relation to specific problems such as supervisory neglect. In relation to the accident prevention field, there is also a superb track record in population based approaches to addressing injuries to children where parental vigilance or supervisory neglect is a major facto, to lead us to be confident that this can work. The history of accident prevention illustrates the potential for population based strategies, but there is unmet potential to apply more targetted interventions at sub-populations with the highest levels of childhood injuries relating to supervisory neglect. Sub-populations could be based on geographical area or sub-groups at greater risk (eg parents with an intellectual disability). Given that the different types of maltreatment are so interrelated and have similar causal pathways (child sexual abuse being somewhat different in this respect), it may not be that useful to tackle them separately. In fact, there is strong evidence from Durlaks meta-analysis on prevention that tackling the common set of underlying risk and protective factors in relation to a whole range of problems such as child maltreatment, low birth weight, school failure, teenage pregnancy, juvenile crime etc. is much more effective than problem specific strategies. Reframing the challenge in this broader context also leads to a much stronger justification in terms of cost effectiveness given the huge cumulative costs of this range of problems. However, it is easier to illustrate a public health or population based approach by examining it in relation to specific problems such as supervisory neglect. In relation to the accident prevention field, there is also a superb track record in population based approaches to addressing injuries to children where parental vigilance or supervisory neglect is a major facto, to lead us to be confident that this can work. The history of accident prevention illustrates the potential for population based strategies, but there is unmet potential to apply more targetted interventions at sub-populations with the highest levels of childhood injuries relating to supervisory neglect. Sub-populations could be based on geographical area or sub-groups at greater risk (eg parents with an intellectual disability).

    23. Building on this Use hospital admission data for 0-1 years re ingestions, burns and falls breakdown to areas and implement localised keep our kids safe campaign Primary eg local papers, schools Secondary eg GPs, health visitors Tertiary eg case based intervention In South Australia we are exploring with epidemiologists if it would be possible to develop targeted interventions down to the district/neighbourhood level using hospital admission data to identify those locations with higher levels of such parental vigilance related infant injuries. Such interventions could range from social marketing via local shops/local newspaper items/messages on milk cartons etc through to opportunistic interventions by health visitors and GPs in specific districts and to supportive public health nurse intervention for families where injuries had occurred in order to reduce the rate of further injuries. In South Australia we are exploring with epidemiologists if it would be possible to develop targeted interventions down to the district/neighbourhood level using hospital admission data to identify those locations with higher levels of such parental vigilance related infant injuries. Such interventions could range from social marketing via local shops/local newspaper items/messages on milk cartons etc through to opportunistic interventions by health visitors and GPs in specific districts and to supportive public health nurse intervention for families where injuries had occurred in order to reduce the rate of further injuries.

    24. Child sexual abuse (Smallbone, Marshall & Wortley, 2008) Defining child sexual abuse and identifying prevalence (retrospective surveys) An integrated theory Biological foundations Developmental influences Ecosystemic factors Situational factors Targets for intervention: offenders, victims, situations, communities Smallbone et al have also approached child sexual abuse from such a perspective. Here the challenge with prevalence data is that they are retrospective dependent on young people and adults responding to surveys about childhood experiences. Some have argued that there has been a decline in the prevalence of child sexual abuse, other studies suggest a stable picture over many years. It is hard to distinguish the factors which may be responsible for this. Smallbone et al have also approached child sexual abuse from such a perspective. Here the challenge with prevalence data is that they are retrospective dependent on young people and adults responding to surveys about childhood experiences. Some have argued that there has been a decline in the prevalence of child sexual abuse, other studies suggest a stable picture over many years. It is hard to distinguish the factors which may be responsible for this.

    25. What do we NOT mean by a public health approach? It does not mean going soft on abuse It does not make children responsible for behaviour change or prevention It is not solely about primary prevention or health promotion It doesnt mean it is a health authoritys job It does not mean we cant act until we have complete understanding The term public health may not convey well what we mean by this approach. These are some of the misconceptions we have encountered in using public health language. There may be better terminology we can use. A common misconception is that a public health approach to child maltreatment is about health services. If we consider skin cancer as an example one can see that strategies such as tackling the hole in the ozone layer is not about health services similarly the most important approaches to controlling infectious diseases are not about medical services but are about sanitation and clean water. The range of possible interventions in relation to preventing child abuse and neglect is very broad and needs to be mapped out in relation to risk and protective factors and the context specific opportunities to intervene early in the causal pathways. The term public health may not convey well what we mean by this approach. These are some of the misconceptions we have encountered in using public health language. There may be better terminology we can use. A common misconception is that a public health approach to child maltreatment is about health services. If we consider skin cancer as an example one can see that strategies such as tackling the hole in the ozone layer is not about health services similarly the most important approaches to controlling infectious diseases are not about medical services but are about sanitation and clean water. The range of possible interventions in relation to preventing child abuse and neglect is very broad and needs to be mapped out in relation to risk and protective factors and the context specific opportunities to intervene early in the causal pathways.

    26. Underlying social determinants Need to target strategies to reduce risk factors and enhance protective factors Poverty (risk) Parental substance misuse (risk) Mental illness (risk) Parent-child attachment (protective) Spacing between births (protective) Social capital and social support (protective) Here are some of the common risk and protective factors or social determinants for different type of child abuse and neglect, as well as a broad range of other problems such as low birth weight, child mental health, school failure, etc. From the epidemiological research of Michael Rutter, we also know that there is a synergistic or multiplier effect of risk factors. So we need to tackle these risk factors at a population level. We must also target protective factors in our strategies. For example, communities with low SES but high social capital have lower levels of child maltreatment. There are some promising indications from holistic community development strategies. If it takes a village to raise a child, then what might it take to rebuild the village? Here are some of the common risk and protective factors or social determinants for different type of child abuse and neglect, as well as a broad range of other problems such as low birth weight, child mental health, school failure, etc. From the epidemiological research of Michael Rutter, we also know that there is a synergistic or multiplier effect of risk factors. So we need to tackle these risk factors at a population level. We must also target protective factors in our strategies. For example, communities with low SES but high social capital have lower levels of child maltreatment. There are some promising indications from holistic community development strategies. If it takes a village to raise a child, then what might it take to rebuild the village?

    27. Example of reducing a risk factor Parental alcohol abuse is very prevalent -13.2% of Australian children live in households with at least one binge drinking adult (Dawe et al 2008), and it is a major contributory factors in all forms of child abuse and neglect, with over 50% of children entering State care having at least one parent with an alcohol problem (Jeffreys et al 2009). Lets look at just one risk factor and one protective factor as examples. A full matrix of how one might do this will all the relevant risk and protective factors is beyond the scope of this presentation so it is important to realise that these are just two examples of the many dozens of risk and protective factors which could be tackled. Some factors are more important than others. For example, alcohol abuse is the single largest problem in the history of child welfare in English speaking countries if one looks at case records going back to the 1890s. Its importance stems from 5 features: Alcohol abuse is highly prevalent Alcohol abuse is highly tolerated Parental alcohol abuse is strongly associated with all forms of child abuse and neglect Alcohol dependence is hard to treat Once parental alcohol abuse is identified, it may be too late for children (eg FAS). Like any health condition (eg diabetes) with features of high prevalence, serious effects and poor prognosis, we cannot rely only on clinical services it needs a population approach.Lets look at just one risk factor and one protective factor as examples. A full matrix of how one might do this will all the relevant risk and protective factors is beyond the scope of this presentation so it is important to realise that these are just two examples of the many dozens of risk and protective factors which could be tackled. Some factors are more important than others. For example, alcohol abuse is the single largest problem in the history of child welfare in English speaking countries if one looks at case records going back to the 1890s. Its importance stems from 5 features: Alcohol abuse is highly prevalent Alcohol abuse is highly tolerated Parental alcohol abuse is strongly associated with all forms of child abuse and neglect Alcohol dependence is hard to treat Once parental alcohol abuse is identified, it may be too late for children (eg FAS). Like any health condition (eg diabetes) with features of high prevalence, serious effects and poor prognosis, we cannot rely only on clinical services it needs a population approach.

    28. Parental alcohol abuse Primary prevention volumetric taxing, periodic steep price increases, advertising bans, social marketing campaigns, reduced availability of high alcohol products Secondary Prevention Ante-natal screening/referral, GP intervention Tertiary Prevention Specialist treatment, under court order if necessary where there are child protection concerns (eg special drug courts). So what would that look like for parental alcohol abuse? Primary prevention evidence-based measures include: volumetric taxing; periodic sharp price increases; advertising restrictions; and reduced availability via licensing laws. We need to understand the demand as well as the supply factors in relation to alcohol abuse. We also need to know how effective social marketing or health promotion campaigns carrying the message alcohol and children dont mix can be. In some societies eg Sweden, there is government control of the alcohol industry and much higher social disapproval of parental drunkenness and under age drinking. If we were able to follow the Scandinavian lead in shifting attitudinal and behavioural norms in English speaking countries in relation to drink driving, why cant we do the same in relation to children? At the secondary prevention level, there are windows of opportunity for early diagnosis and referral that pregnancy presents for all substance misuse, including nicotine, alcohol and other drugs. There have been encouraging results on ante-natal intervention to reduce smoking and midwives have shown that they are able to engage women and refer them to smoking cessation programs. Can midwives play a similar role in relation to a range of risk factors in pregnancy alcohol, DV, mental illness etc? At the tertiary level, how can a whole range of service providers from GPs to child protection workers, help parents get into treatment services. And how can treatment services think child and think family in the way they work with parents and their children?So what would that look like for parental alcohol abuse? Primary prevention evidence-based measures include: volumetric taxing; periodic sharp price increases; advertising restrictions; and reduced availability via licensing laws. We need to understand the demand as well as the supply factors in relation to alcohol abuse. We also need to know how effective social marketing or health promotion campaigns carrying the message alcohol and children dont mix can be. In some societies eg Sweden, there is government control of the alcohol industry and much higher social disapproval of parental drunkenness and under age drinking. If we were able to follow the Scandinavian lead in shifting attitudinal and behavioural norms in English speaking countries in relation to drink driving, why cant we do the same in relation to children? At the secondary prevention level, there are windows of opportunity for early diagnosis and referral that pregnancy presents for all substance misuse, including nicotine, alcohol and other drugs. There have been encouraging results on ante-natal intervention to reduce smoking and midwives have shown that they are able to engage women and refer them to smoking cessation programs. Can midwives play a similar role in relation to a range of risk factors in pregnancy alcohol, DV, mental illness etc? At the tertiary level, how can a whole range of service providers from GPs to child protection workers, help parents get into treatment services. And how can treatment services think child and think family in the way they work with parents and their children?

    29. Example of Strengthening a Protective Factor Parent attachment to a child is a strong protective factor in relation to child abuse and neglect, and motivates parents to protect and care for children. A childs capacity for attachment is central to good peer relations and moral development. Attachment is governed by complex bio-psycho-social mechanisms. Parent-child attachment is a useful protective factor to examine because it is a powerful protective factor and because it is so central to healthy emotional development and the future capacity of the child to nurture their children. But how amenable is such a complex bio-psycho-social process with a sensitive period or developmental window of opportunity, open to modification? Parent-child attachment is a useful protective factor to examine because it is a powerful protective factor and because it is so central to healthy emotional development and the future capacity of the child to nurture their children. But how amenable is such a complex bio-psycho-social process with a sensitive period or developmental window of opportunity, open to modification?

    30. Intervening to enhance parent-child attachment Primary Prevention Promote breastfeeding; use ultrasound consultations purposively; paid parental leave; reduce disruptions to attachment. Secondary Prevention Attachment based intervention with at risk parent-infant dyads (eg nurse home visiting) Tertiary Prevention Specialised therapy for attachment disorders Recent research is encouraging: - breastfeeding is a protective factor in relation to maternal physical abuse of children a large data linkage study in Qld tracked women who had given birth and compared child protection records for physical abuse in the years that followed in both breastfeeding and non BF groups. The BF group, controlled for other factors, had lower rates of physical abuse. The nature of the causal relationship is not clear (stronger attachment might predispose mother to breastfeed) but the researchers raise the possibility that the hormone oxytocin which is involved in lactation, may enhance mother-infant attachment. If this is so, then in time might we see the use of hormonal interventions to enhance attachment especially where this is impaired? Ultrasound consultations with attention to individualising and visualising the baby have also been shown to enhance maternal attachment to infants post birth. Both of these findings have implications for ante natal and postnatal services. There are also secondary and tertiary prevention strategies. In relation to specialised therapy, it is possible to deliver these from universal service platforms such as child care centres or nurseries, not just in child and adolescent mental health services. Recent research is encouraging: - breastfeeding is a protective factor in relation to maternal physical abuse of children a large data linkage study in Qld tracked women who had given birth and compared child protection records for physical abuse in the years that followed in both breastfeeding and non BF groups. The BF group, controlled for other factors, had lower rates of physical abuse. The nature of the causal relationship is not clear (stronger attachment might predispose mother to breastfeed) but the researchers raise the possibility that the hormone oxytocin which is involved in lactation, may enhance mother-infant attachment. If this is so, then in time might we see the use of hormonal interventions to enhance attachment especially where this is impaired? Ultrasound consultations with attention to individualising and visualising the baby have also been shown to enhance maternal attachment to infants post birth. Both of these findings have implications for ante natal and postnatal services. There are also secondary and tertiary prevention strategies. In relation to specialised therapy, it is possible to deliver these from universal service platforms such as child care centres or nurseries, not just in child and adolescent mental health services.

    31. In addition to population based strategies, what might a service system based on primary, secondary and tertiary prevention ideas look like? In relation to universal and targeted child and family services ante natal, health visitor, early childhood education and care, schools - how much room is there to maximise their capacity to reduce the risk factors associated with child abuse and neglect? Which services in these fields have shown a capacity to reach the desperate as well as the deprived? Under what conditions have they been successful? Schools have enormous potential to also provide therapeutic support to very vulnerable children. In relation to specialist services, we need to build their capacity to think child and think family, and provide more holistic responses to families with multiple and complex needs. This requires changing single input based on categorical funding models as well as integrated policy and major workforce development strategies. For some families, child protection services may be the first to know agencies in relation to parental problems such as substance dependence and homelessness so their capacity to assess, engage and refer to specialist services needs to be enhanced. In addition to population based strategies, what might a service system based on primary, secondary and tertiary prevention ideas look like? In relation to universal and targeted child and family services ante natal, health visitor, early childhood education and care, schools - how much room is there to maximise their capacity to reduce the risk factors associated with child abuse and neglect? Which services in these fields have shown a capacity to reach the desperate as well as the deprived? Under what conditions have they been successful? Schools have enormous potential to also provide therapeutic support to very vulnerable children. In relation to specialist services, we need to build their capacity to think child and think family, and provide more holistic responses to families with multiple and complex needs. This requires changing single input based on categorical funding models as well as integrated policy and major workforce development strategies. For some families, child protection services may be the first to know agencies in relation to parental problems such as substance dependence and homelessness so their capacity to assess, engage and refer to specialist services needs to be enhanced.

    32. Service System Reform Strategies Build capacity within both child and adult sectors for child and family sensitive practice. Build bridges between sectors. Enhance organisational culture and climate. Strengthen relationship-based practice. There is a 4 pronged approach to service system reform and some of this will be familiar to you as recent initiatives in the UK have emphasised some of these strategies. There is a 4 pronged approach to service system reform and some of this will be familiar to you as recent initiatives in the UK have emphasised some of these strategies.

    33. Building Capacity to think child, think family in all services and sectors 1. Broadening universal child-focussed services so that they are family centred eg. Health visitor services, early childhood education and care services, primary schools 2. Broadening targetted adult-focussed services so they are family centred eg Drug and alcohol, corrections, family violence, mental health, disability, homelessness, refugee services etc This is a major challenge but there are encouraging examples of how it can be done in every one of these fields. We need to analyse and evaluate how it can be achieved and then systematically explore the conditions under which these exemplary models can be scaled up and embedded in sustainable ways across a whole service sector. This is a major challenge but there are encouraging examples of how it can be done in every one of these fields. We need to analyse and evaluate how it can be achieved and then systematically explore the conditions under which these exemplary models can be scaled up and embedded in sustainable ways across a whole service sector.

    34. Think Family Core Elements No wrong door (contact with any service offers an open door to joined up support) Look at the whole family (services take into account family circumstances and adult services consider clients as parents) Build on family strengths (relationship and strength based engagement) Provide support tailored to need (not one size fits all) The English Social Exclusion Taskforce Think Family initiative, articulates the core principles for family centred service delivery very well. The English Social Exclusion Taskforce Think Family initiative, articulates the core principles for family centred service delivery very well.

    35. This is a visual representation of how we need to think child and think parent regardless of whether we are working in a so called child or adult service. But lets not leave out the Dads like this picture does, or does it?? This is a visual representation of how we need to think child and think parent regardless of whether we are working in a so called child or adult service. But lets not leave out the Dads like this picture does, or does it??

    36. There are 3 levels to tackling this type of large scale service re-engineeering: the practitioner values, knowledge and skills necessary to provide holistic family centred practice - the organisational conditions which support such practice - the policy conditions which support organisations to support such practiceThere are 3 levels to tackling this type of large scale service re-engineeering: the practitioner values, knowledge and skills necessary to provide holistic family centred practice - the organisational conditions which support such practice - the policy conditions which support organisations to support such practice

    37. Role definition: narrow to broad 1. core role only (its not my concern) 2. core role plus assessment of other needs, leading to referral (its a concern but someone elses job refer on) 3. other needs incidental but unavoidable (not my core role but I have to do it) 4. other needs intrinsic part of core role (its part and parcel of my job) We need to get a critical mass of the service providers in every sector from level 1 to level 4. This cannot happen overnight but it has been achieved in some professions and can be done if there is a strong workforce development strategy in place.We need to get a critical mass of the service providers in every sector from level 1 to level 4. This cannot happen overnight but it has been achieved in some professions and can be done if there is a strong workforce development strategy in place.

    38. Organisational Factors Reasonable size of caseload Mission led Broad performance indicators Enable practitioner flexiblity Supportive supervisory style Positive culture and climate Organisational factors which facilitate such a shift in practice include these. High quality leadership is thus vital.Organisational factors which facilitate such a shift in practice include these. High quality leadership is thus vital.

    39. Enhancing organisational climate and culture Recent research on child protection services has identified organisational culture and climate as more significant than inter-agency collaboration in service quality (Hemmelgarn, Glisson & James 2006). This has profound implications for leadership in both child protection and related sectors. Too little attention has been paid to organisational culture and climate. We now have strong research showing that this is critical in child protection and is likely to be so in other human services where high turnover and low morale are common.Too little attention has been paid to organisational culture and climate. We now have strong research showing that this is critical in child protection and is likely to be so in other human services where high turnover and low morale are common.

    40. Policy Context Factors Reduce legal constraints such as mandatory reporting Reduce single input services based on categorical funding Common cross portfolio priorities Outcome not output funding Strong centralised reform drivers Good cost-effectiveness data The legal and policy environment needs to be support of whole of government approaches. The legal and policy environment needs to be support of whole of government approaches.

    41. Building Bridges Between Sectors Working across agency and sectoral boundaries is challenging at five levels inter-organisational Intra-organisational Inter-professional Inter-personal Intra-psychic Inter-sectoral collaboration is important and to do this we need to confront the very real and multiple challenges to collaboration, and build service networks based on trust. This requires constant hard work as collaboration poses a threat to organisational autonomy and in itself is resource intensive. Under conditions of chronic resource scarcity and functional inter-dependence, inter-organisational tensions are therefore completely normal. The challenge is to ensure that the conflict is constructive, not destructive. Inter-sectoral collaboration is important and to do this we need to confront the very real and multiple challenges to collaboration, and build service networks based on trust. This requires constant hard work as collaboration poses a threat to organisational autonomy and in itself is resource intensive. Under conditions of chronic resource scarcity and functional inter-dependence, inter-organisational tensions are therefore completely normal. The challenge is to ensure that the conflict is constructive, not destructive.

    42. Relationship Based Practice Successful engagement of families with multiple and complex needs requires high quality, ethical relationship-based practice. Empathy Respect Genuineness Optimism Ultimately at the coalface of practice, families must be effectively engaged if we are to reduce the risk factors and enhance the protective factors in relation to child maltreatment. It is therefore timely to revisit relationship based practice and how this can co-exist with the judicious use of authority in those family situations in which this is a necessary lever of engagement. We thus need a marriage between the art and craft and the science of therapeutic interventions with families with multiple and complex needs.Ultimately at the coalface of practice, families must be effectively engaged if we are to reduce the risk factors and enhance the protective factors in relation to child maltreatment. It is therefore timely to revisit relationship based practice and how this can co-exist with the judicious use of authority in those family situations in which this is a necessary lever of engagement. We thus need a marriage between the art and craft and the science of therapeutic interventions with families with multiple and complex needs.

    43. What we know about the therapeutic relationship A meta-analysis of the psychotherapy effectiveness literature identifies a positive therapeutic relationship as very significant. For families with multiple and complex needs this is very likely to be even more so. This is certainly what both parents and children tell us. So, how in all we do in our services do we: Reduce situational stressors Enhance relationship based practice Nurture hope Utilise interventions for which there is supporting evidenceA meta-analysis of the psychotherapy effectiveness literature identifies a positive therapeutic relationship as very significant. For families with multiple and complex needs this is very likely to be even more so. This is certainly what both parents and children tell us. So, how in all we do in our services do we: Reduce situational stressors Enhance relationship based practice Nurture hope Utilise interventions for which there is supporting evidence

    44. Lancet editorial, 2003 Maltreatment is one of the biggest paediatric public-health challenges, yet any research activity is dwarfed by work on more established childhood ills (Editorial 2003, 443) Historically, shifts in child protection policy and practice have not been based on a rigorous knowledge base such as that which underpins health policy, but on child abuse death inquiries which only focus on the last link or two in a long causal pathway, not on root cause analysis. It is not surprising that they usually provide poor policy directions and in many instances have had a counter-productive effect on child protection services, making them more hierarchical and proceduralised and intensifying demoralisation and staff turnover. This editorial in The Lancet refers to child maltreatment as a public health challenge yet it has not been considered as such and our research agenda has been far too narrow to provide the necessary knowledge base to tackle child abuse and neglect at a population level. Historically, shifts in child protection policy and practice have not been based on a rigorous knowledge base such as that which underpins health policy, but on child abuse death inquiries which only focus on the last link or two in a long causal pathway, not on root cause analysis. It is not surprising that they usually provide poor policy directions and in many instances have had a counter-productive effect on child protection services, making them more hierarchical and proceduralised and intensifying demoralisation and staff turnover. This editorial in The Lancet refers to child maltreatment as a public health challenge yet it has not been considered as such and our research agenda has been far too narrow to provide the necessary knowledge base to tackle child abuse and neglect at a population level.

    45. and sustaining our hope that change is possible Sustaining our hope that change is possible may be the greatest challenge in the transition to a third wave in the history of child protection, as despair begins to set in among some of our systems. What will help us do this transcends knowledge, and includes our evolutionary endowment to cherish children, not just our own children, but all children. Sustaining our hope that change is possible may be the greatest challenge in the transition to a third wave in the history of child protection, as despair begins to set in among some of our systems. What will help us do this transcends knowledge, and includes our evolutionary endowment to cherish children, not just our own children, but all children.

    46. References Cabinet Office Social Exclusion Task Force (2008), Think Family: a literature review of whole family approaches, London. Dawe, S. et al (2006) Drug Use in the Family: impacts and implications for children. Australian National Council on Drugs Doyle, (2007) Child Protection and Child Outcomes: Measuring the Effects of Foster Care American Economic Review, 97(5). December : 1583-1610. Graycar, A. (2006) Public Policy: Core Business and By-Products, Public Administration Today, July-September, pp.6-1 McCaughey, J. et al, (1977) Who Cares? Family Problems, Community Links and Helping Services, Melbourne, Sun Books Middlebrooks, J.S, Audage N.C., The Effects of Childhood Stress on Health Across the Lifespan. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2007

    47. References (continued) Rubin, D., OReilly, A., Luan, X., & Localio, R. (2007) The impact of placement instability on behavioral well-being for children in foster care, Pediatrics, 119: 336-344. ODonnell, M., Scott, D. & Stanley, F. (2008) Child abuse and neglect is it time for a public health approach? Aust & NZ Journal of Public Health, 32,4,325-330 Scott, D, (1992) Reaching vulnerable populations: framework for primary service provision, American Journal of Orthopsychiatry, 62,332-341 Useful website: http://www.cabinetoffice.gov.uk/social_exclusion_task_force/families_at_risk.aspx

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