An internet search using the term “most common medical errors,” suggests that misdiagnosis heads the list of the top five. An incorrect diagnosis can result in unnecessary or harmful treatment. It also means that the patient’s true illness won’t be treated right away, if at all, prolonging the patient’s suffering. In the worst-case scenario, the patient may die.
The term diagnosis is not common to the child protection lexicon, where the preferred nomenclature is “assessment.” Generally, some assessments in child protection cases are classificatory: substantiation determinations of the validity of abuse or neglect allegations, risk assessments intended to classify families according to the likelihood of future repeat maltreatment, or safety assessments intended to determine the likelihood of serious harm or death from repeat maltreatment.
Other assessments are explanatory — for example, family assessments intended to explain why a child is at risk of future abuse or neglect or is unsafe so that relevant interventions can be initiated to mitigate associated risk and safety factors. Since family assessments are used to determine the course of treatment for families in which child abuse or neglect has been determined, they are probably the best more parallel to medical diagnoses.
An internet search using the term “mis-assessment in CPS cases” found nothing. And that speaks to a big problem in this field: We have yet to reach an agreement on clinical guidelines as to what to assess and how to accurately assess it.
In the world of medicine, millions of patients each year are misdiagnosed, despite a medical team’s best efforts to divine the problem. But the profession has developed clear standards of care that help to differentiate a good-faith error from what is commonly known as malpractice, the failure to properly arrive at a conclusion and treatment protocol.
Just like misdiagnosing a patient, mis-assessing a family poses real threats to both parents and children. It can lead to no intervention where one is badly needed, or over-intervention unwarranted by the family and child’s circumstances. Over-inclusion in child welfare subjects the family to unwarranted trauma and expenditure of time and limited family resources. Under-inclusion means that maltreatment may continue. At stake is the reality that a family can permanently lose custody of its children, children lose their parents, or that children may be severely traumatized if not suffer continuing physical and emotional harm, or even die.
Mis-assessment runs the risk that contributing factors and underlying conditions are not accurately recognized and that families may be referred to services unlikely to bring about the changes needed to prevent repeat abuse or neglect, or not given needed services at all.
Both classificatory and explanatory assessments are critical core processes in child protection interventions. So how accurate are these assessments? And to back up even further: What determines whether an assessment is accurate?
Our answers to these questions in the realm of child safety continue to be insufficient. Robert Horowitz, formerly of the American Bar Association, once commented that child welfare professionals don’t need to be concerned about malpractice lawsuits due to the reality that standards of care for CPS practice have not been adequately defined. And I believe he is correct.
There are three principal assessments performed by CPS. First, did maltreatment occur? This is determined by the legal definitions of child abuse and neglect.
Second: What is the extent of risk of further maltreatment possibly leading to serious harm or death? This is largely determined by a range of risk and safety assessment protocols.
And third: What explains a child’s maltreatment and safety? Presumably this is achieved by research which has determined the factors influencing maltreatment in families and what interventions are likely to be successful in ameliorating these factors.
Our coherent movement through that course is stymied early on by the lack of agreement on simply what constitutes maltreatment and what does not.
Decades ago, the National Research Council conducted an exhaustive review of the child abuse and neglect research which was published in “Understanding Child Abuse and Neglect.” The council offered the following commentary:
Since no single risk factor has been identified that provides a necessary or sufficient cause of child maltreatment, etiological models of child maltreatment have evolved from isolated cause-and-effect models to approaches that consider the combination of individual, familial, environmental, and social or cultural risk factors that may contribute to child maltreatment. The phenomenon of child abuse and neglect has thus been moved away from a theoretical framework of an individual disorder or psychological disturbance, toward a focus on extreme disturbances of childrearing, often part of the context of other serious family problem such as substance abuse or mental illness.
In other words, child abuse and neglect more likely results from the interaction of multiple risk factors than from any single risk factor. This complexity in turn complicates both types of assessment and subsequent case planning. Most service providers are designed to treat a single risk factor — substance abuse, mental health or domestic violence for example — rather than the interaction effects of multiple factors.
To some extent, this explains the evolution of a case management model in which case managers are expected to coordinate and integrate the treatment effects of multiple providers. In reality, most case managers are trained and expected to monitor service participation and the treatment outcomes from a singularly focused provider. This is not the same thing.
Consequently, it leaves open the possibility for a host of assessment errors and consequences. These include a failure to:
- Identify the right mix of underlying conditions and contributing factors in each unique family situation.
- Connect the family to the right or effective service providers. This can lead to engagement with services unlikely to address the conditions needed for a family to get the return of its children or achieve successful case closure.
- Fully understand how the various underlying family conditions and contributing factors interact and thus how service providers must integrate their efforts rather than just act in isolation of each other.
- Identify necessary protective factors and their role in mitigating threats of harm in the future. Weakened or missing protective factors must be strengthened or developed. The focus cannot be only on reducing the virility of threats of harm.
Unless these and other failures are prevented, families will not succeed, and children may lose their family connections for life.
Diane Redleaf has written extensively about the harm accruing to families due to the vague legal definitions of neglect suggesting there is considerable mis-assessment of actual neglect. Much discussion continues about the efficacy of various risk assessment methods and which methods should be accepted as efficacious enough to be preferred practice. As well, no safety protocols have been validated. Lastly, to my knowledge, there are not broadly accepted “standards of care” for assessing families in which maltreatment is occurring.
As mentioned, medical misdiagnoses can occur in good faith, or as a result of malpractice. And the same is true of the assessment process in child protection.
But without more clearly established standards of care, we lack the proper guidelines to parse between those two buckets. We lump good-faith mistakes in with incompetence, shrug, and lean on the rhetorical talking point that every case is unique.
And absent standards of care for clinical assessment, the field is ripe for the possibility of conclusions that are not well supported by research on the etiology of child maltreatment or the clinical effectiveness of various related interventions. The potential for harm seems evident to me.