Developing an Effective Response to Multi-type Child Maltreatment
Remarkably, after more than 50 years since the creation of the current U.S. child protection system public child welfare agencies are largely unprepared conceptually or organizationally to meet the challenge of the most damaging type of child maltreatment, i.e., the combination of chronic neglect with physical and/or sexual abuse, and emotional abuse and neglect as well.
In this commentary, I refer to multitype child maltreatment as “chronic maltreatment.” The psychologist, Steven Gold refers to childhood histories of multitype maltreatment as “prolonged child abuse trauma.” It is questionable whether U.S. child welfare systems are sufficiently motivated to find effective responses to chronic multitype maltreatment, in part because of the lack of public concern with emotional harm and developmental damage to children resulting from growing up with pervasive and chronic neglect and abuse.
Some child advocates believe that social justice requires a narrower standard for CPS intervention and for child removal, one focused on imminent threat of physical harm. In addition, understaffed child welfare agencies are typically forced to focus on imminent threats to child safety, whatever their policy frameworks may say.
How can child protection programs, not to mention some child welfare scholars, be so off the mark in their understanding of chronic multitype child maltreatment and its effects on children? There has been a persistent tendency in CPS policy and procedural frameworks and among developers of therapeutic programs to treat physical abuse, sexual abuse, neglect and emotional maltreatment as discrete entities with different dynamics. Different theoretical frameworks and different CPS and law enforcement responses recapitulate the history of modern child protection systems:
- A concern with severe physical abuse conceptualized as “battered child syndrome” in the 1960s followed by
- the discovery and “outing” of child sexual abuse in the 1970s, accompanied by
- decades of the “neglect of neglect” both in training programs and child welfare scholarship.
It is only during the past 10 to 15 years that child neglect has received the amount of attention bestowed on physical abuse and sexual abuse for decades. Federal and state administrative data bases continue to compartmentalize types of child maltreatment in a way that emphasizes their differences and disguises their frequent co- occurrence.
The idea that children are maltreated in discrete ways, i.e., either physically abused, sexually abused or neglected, is often false. Anthony Loman’s study of more than 33,000 families with CPS reports tracked for five years in the late 1990s found that of 4,242 families initially reported for ‘unmet physical needs’ 748 were subsequently reported for alleged sexual abuse, 59 for severe physical abuse, 1,039 for less serious physical abuse, as well as almost 3,900 for either unmet physical needs or lack of supervision. Only 28% of subsequent reports for families initially reported for ‘unmet physical needs’ matched the initial report. Loman also found that of the 3,570 families initially reported for alleged sexual abuse, almost half had another CPS report within 5 years, and only one- fifth of these subsequent reports were for sexual abuse. Almost 70% of families with more than one CPS report did not have alleged maltreatment histories that could be neatly categorized under one type of maltreatment.
In their study, “Child Neglect and the Broader Context of Child Victimization,” Heather Turner, et al. discuss data from two waves (2011, 2014) of the National Survey of Children’s Exposure to Violence in which 7,852 children, ages 2-17, were either interviewed by phone, or their caregiver was interviewed. These researchers distinguished physical neglect from supervisory neglect. The survey included questions regarding physical and sexual abuse, neglect and eight other types of victimization, e.g., assault and sexual abuse by peers and witnessing of interpersonal violence (IPV).
The authors comment: “Of particular note was the strong relationship between physical neglect and sexual abuse, with any physical neglect associated with 9.07 times the risk of sexual abuse,” compared to children without reported neglect. “Any physical neglect increased the relative risk of physical abuse by 5.28 times and emotional abuse by 3.5 times. Similarly, any supervisory neglect was strongly associated with sexual abuse (4.7 times increased risk) and to sexual victimization by an adult non-caregiver (7.5 ties increased risk) compared to children without reported supervisory neglect.”
Turner and her co-authors comment: “exposure to physical and supervisory neglect is strongly linked to increased risk for other types of maltreatment and other forms of non-maltreatment victimization.” The authors assert that “the exact reasons for these particular associations are not entirely evident,” but opine that “the linkages between neglect and risk of sexual victimization by adults (both family and nonfamily) suggest the need for practitioners to pay particular attention to the possibility of these types of serious exposures among neglected youth.” This study found that neglected adolescents were as at much risk of multiple types of victimization as younger children.
Chronic neglect and chronic maltreatment
Chronic multitype maltreatment develops out of chronic neglect which is pervasive across child care domains, e.g., inadequate care of basic physical needs, lack of supervision, medical or dental neglect, deprivation of nurturance. There have been outstanding studies of chronic neglect and chronic maltreatment published by Loman, Melissa Jonson-Reid, Brett Drake, Diana English, Diane DePanfilis, Mark Chaffin and others. These studies describe characteristics of families with extensive CPS histories:
- Parents have one or more chronically relapsing conditions, often co-occurring substance abuse and mood disorders, and often recurrent IPV as well.
- Parents are poor, often severely poor, with incomes less than half the federal poverty standard.
- The first and second CPS reports allege incidents of neglect, but allegations of other types of maltreatment begin to appear in subsequent CPS reports.
- Parents often take a preschool child to an emergency room due to extreme out of control behavior, including “meltdowns.”
- School-age children and parents are engaged in extreme parent-child conflict, and parents have often lost authority and control of the behavior of school age children.
- Deprivation of nurturance, i.e., emotionally responsive parenting, in early childhood leads to difficulties with executive functioning and emotion regulation.
- Children have elevated rates of chronic illness and disability and higher rates of all-cause mortality due to compromised immune systems. (“The Science of Neglect” from Harvard’s Center for the Developing Child).
As informative and invaluable as this research is, it does not do justice to the experience of CPS caseworkers who often encounter demoralized, hopeless/helpless parents initially resistant to offers of help, filthy homes with health hazards, young children who engage in non-stop attention-getting behaviors or are apathetic, and parents who may be alienated from their extended families. Inexperienced caseworkers are often shocked by the condition of homes and wonder how families can live in such squalor, though they may prudently refrain from verbalizing these reactions to their supervisor.
Even experienced caseworkers who review a multivolume case record may feel defeated before they begin working with parents, especially if a family has already received every service the agency has to offer and is resistant to any or all assistance. However, Jonson-Reid has cautioned against assuming that chronically referred families have already received and failed to benefit from services. Many families referred to CPS several times for low-level neglect often receive no services until there is a perceived immediate safety threat, by which time the opportunity for effective early intervention has been lost. In our experience, these cases are often close out as “low risk,” “unfounded” or “child is safe, no safety threat.”
These clueless investigative findings and assessments are enabled by a focus on incidents alleged in the most recent CPS report rather than a focus on a pattern of alleged maltreatment reflected in multiple reports.
In addition, CPS programs that define child safety in terms of presence or absence of ‘present danger’ cannot possibly adequately assess safety issues in families engaged in chronic maltreatment.
On Nov. 1, The Las Cruces Sun News published a story regarding a
police response to the report of a 2-year-old child without pants wandering alone. When (with the help of a neighbor) the police located where the child lived, they found a 15-year-old girl supervising two of her five younger siblings while the mother took the older children to school. The apartment had no phone, heat, or electricity.
“While at the apartment [the police officers] said they realized this was not just the case of a 15-year-old having lost sight of her two younger siblings while the mother was out,” the story says. “Later, a CPS investigator told a Las Cruces Police detective they’d received 52 calls for service,” including multiple allegations of neglect, abandonment and drug use. After being removed from the home, the 15-year-old reported that the mother’s boyfriend had sexually molested her several times in past years, until the mother discovered the abuse and forced him to leave the home. Police subsequently found sexually explicit photos of the 15-year-old on the boyfriend’s phone. The 15-year-old “said she was sole caretaker of her five siblings,” as the mother spent her days allegedly job seeking. The 15-year-old had dropped out of school to care for her siblings.
A key element of this story is that police officers quickly recognized what CPS caseworkers had failed to recognize after 52 CPS reports and dozens of investigations, i.e., that these children had been neglected and abused in multiple ways for years. Police officers could recognize chronic maltreatment of children despite – or possibly because of – lack of training or child welfare experience. Perhaps they had not become desensitized to the home conditions they observed as CPS caseworkers may become desensitized after extensive contact with chronically neglectful families.
Contrast the officers’ response to a possible CPS response: return the 2- year-old to the care of her 15-year-old sister and then talk with the mother regarding the need for better supervision, while hopefully finding resources to turn on the heat and electricity, but ignoring the history of 52 prior reports. The case might be quickly closed with a note in the record, “child was in the care of her 15-year-old sister while mother looked for work, no ongoing safety threat.” There is no practice framework that can be effectively implemented when entire CPS programs engage in denial of chronic maltreatment and the harm it does to children.
Guidelines for intervention
Chronic maltreatment develops out of chronic neglect which, in turn, grows out of situational neglect and sporadic neglect. Much of the neglect reported to CPS initially is not chronic, which presents an opportunity to prevent the development of chronic neglect through early intervention services. Even modest levels of poverty-related services and/or financial benefits, and skill-based parenting programs have the potential to prevent chronic neglect when they are provided in a timely way. However, once chronic neglect becomes an embedded part of family life, poverty-related services and brief parent education programs will usually not be sufficient to stop the downward spiral into chronic maltreatment. Chronic neglect is marked by the erosion or collapse of social norms around parenting resulting from chronically relapsing conditions. Once parents have egregiously violated widely accepted social norms that guide parenting practices, e.g., “preschool children should be supervised at all times,” without consequences these norms are difficult to restore. Chronic neglect is far more than “just poverty,” and chronic maltreatment is usually far more damaging to children than chronic neglect.
A goal of public policy should be to ensure that a CPS investigation is never the first or only outreach to a parent receiving publicly funded substance abuse or mental health treatment. Public health departments should be funded to reach out to parents with offers of child care and with information regarding early child development, and with emotional support. Family support services should be provided at the time of the first or second CPS report rather than waiting until a child is deemed “unsafe.” Therapeutic day treatment childcare programs should be available to infants and toddlers and their parents with or without CPS involvement. Currently, many CPS interventions are too little, too late to protect the lives of infants and toddlers. Delaying services until a young child is assessed to be at risk of imminent harm endangers the lives of children in chronically referring families.
No later than the third screened in CPS report families should be referred to a specialized multidisciplinary case management team when:
- CPS reports contain allegations of pervasive child neglect, i.e., neglect cross several child care domains such as basic care, supervision, deprivation of nurturance, or when reports contain allegations of multitype maltreatment; or
- When CPS reports allege parental substance abuse, mental illness, recurrent DV, or severe cognitive impairments of parents, or
- When a child in the family has a disability, severe developmental delay, or has a chronic illness.
Public human services systems should be administratively reorganized to create 4- to 5-person case management teams consisting of a CPS caseworker, substance abuse assessment specialist, a mental health therapist, a public health nurse and parent advocate. These professionals should be co-located and together share responsibility for 20 to 25 families. Currently, CPS programs lack the expertise needed to help chronically maltreating families, and a single caseworker is often quickly defeated by the overwhelming needs of children and parents.
These case management teams must be allowed to keep families open for services for at least a year, and often longer when a parent is chronically mentally ill or has a severe cognitive impairment. In their 2011 study of service outcomes for chronically neglecting families in Oklahoma, Chaffin, et al. comment:
“We would suggest that the episodic and reactive service model characterizing traditional child welfare services may be a mismatch with the trajectories increasingly observed among families who are chronically in the system. Episodic service models presume that once a condition, (i.e., maltreatment) is detected, a rehabilitative treatment for that condition can be applied and then the treatment is done.”
However, authors continue, “Episodic and reactive service models are better suited to acute conditions but are a mismatch with chronic conditions. Chronic care models more often rely on proactive, lower intensity, longer term approaches that emphasize monitoring, maintenance, stepped care or harm reduction,” though “None of these alternative chronic care approaches are a particularly good fit within the child welfare system as it is currently constructed.”
The main challenge to developing a more effective response to chronic neglect and chronic maltreatment is not the lack of evidence-based programs that can be delivered within child welfare as it is currently organized. Rather, it is that current administrative structures and assumptions about what constitute effective services stand in the way of adapting to the challenges of families with chronically relapsing conditions, often co-occurring, and children with disabilities, severe developmental delay and chronic illness. No brief, time-limited evidence-based program will be adequate to this challenge. This is a message many policymakers and child welfare managers will not want to hear, but it is where discussions of a more effective practice model for chronically referring families should begin.
Chaffin, et al, found that 10-20% of chronically neglectful parents (they did not distinguish between chronic neglect and chronic maltreatment) substantially benefited from home-based family preservation services. The researchers challenge the idea that there is a well-defined category of “untreatable” chronically neglecting families. The concept of “untreatable family” refers to the current state of knowledge, not to the intractable characteristics of families. Many medical conditions were once untreatable, e.g., pneumonia, until an effective treatment was discovered. The same is true of seemingly intractable social conditions such as community violence.
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