1. Fragile Families: Handle with Care Emeritus Professor Dorothy Scott

2. Inquiries and...reform?
The Protecting Victoria’s Vulnerable Children Inquiry (2012) is the most recent in a long line. Such inquiries do not necessarily lead to reform. Some do more harm, especially those with narrow terms of reference and undertaken in reaction to a highly politicised child protection tragedy. This Inquiry was not hindered by these factors. Time will tell whether it leads to action which will protect Victoria’s vulnerable children.

3. The knowledge gap
“Maltreatment is one of the biggest paediatric public-health challenges, yet any research activity is dwarfed by work on more established childhood ills.” The Lancet Editorial 2003, p. 443

4. Key Foci of Recommendations
Prevention
Early Intervention
Statutory child protection services
Aboriginal children and young people
The law and the courts
Workforce Development
System governance

5. How might we take the first step?
So what can we do? 5

6. Prevention
Child abuse and neglect cannot be solved solely by services. It requires population-based measures to tackle the key social determinants, including reducing risk factors such as parental alcohol misuse, and strengthening protective factors such as parent-child attachment and social support. Social marketing targeting harsh physical discipline, family violence and supervisory neglect is also worth trying and evaluating.

7. Parental Alcohol Misuse
13.2% of children in Australia live with at least one adult who regularly binge drinks (Dawe, 2006), and is the single largest contributing factor to children coming into out-of-home care.
Effective population based strategies include volumetric taxing, restricted advertising, licensing reform, and social marketing to change social norms

8. Parent-Child Attachment
In utero – using ultrasound as an opportunity to individualise the foetus
avoiding threats to ante-natal attachment
Promotion of breastfeeding
Paid parental leave
Reducing separations in first year of life
Evidence-informed “clinical” interventions with vulnerable parent-infant dyads offered from universal service platforms

9. Social Support
first time parent groups via maternal and child health and playgroups
tailored groups for young mothers, cultural/linguistic groups, women who have post-natal depression
facilitated playgroups
individualised befriending programs

10. MCH related recommendations
“The increased investment in MCH and Enhanced MCH should focus on:
Enhanced support to families whose unborn babies are assessed as vulnerable to abuse or neglect, especially as a result of pre-birth reports to child protection.
A more intensive program of outreach to families of vulnerable children who do not attend MCH checks, particularly in the first 12 months of life.”

11. Why do we need reform?
The prevalence and long term effects of child abuse are so serious (The Lancet 2009 Special Issue).
2. Demand has outstripped the capacity of child protection systems to respond, placing the most vulnerable children in jeopardy.
3. The current “cure” of removing children is likely to be harming many children (Doyle, 2007; Rubin et al 2007).
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.

12. Australian prevalence estimates
Child physical abuse: 5-10% of adults
Penetrative child sexual abuse: 4-8% of males and 7-12% of females
Witnessing domestic violence: 12-23%
(Price-Robertson, Bromfield & Vassallo, 2010)
What we do know is that child abuse is a big problem but it is very difficult to estimate its true extent. These are some carefully considered estimates drawing on a range of surveys on what adults report having experienced as children, or in the case of the last estimate, what is currently the situation in their household.

13. Long-term effects
Impairment of early brain development through neglect and witnessing violence
Higher incidence of adult health and mental health problems
Higher incidence of adolescent and adult substance misuse and offences
Greater risk of inter-generational child abuse and neglect
There is a lot of evidence on the effects of child abuse. The most recent advances in this area have come from the neurosciences identifying the serious harm neglect and witnessing violence can inflict on a young child’s developing brain, reducing the capacity to learn, and causing chronic high anxiety, akin to post-traumatic stress disorder. Professor Fraser Mustard, a SA Thinker in Residence, helped increase the awareness of this important research.

14. Demand greatly outstrips capacity
Based on current reporting rates, one in five Victorian children will be notified to statutory child protection services by the age of 18. A small minority of these are “substantiated”, and an even smaller proportion proceed to statutory intervention. No child protection system can cope with such demand pressures. It increases the likelihood that children at greatest risk will receive inadequate assessment and protection.

15. The out of home care challenges are enormous
The out of home care challenges are enormous. This slide illustrates the large increase in the number of children in care in Australia on June 30 each year -
37,058 children on June 30, 2011, double that of a decade ago. It significantly underestimates the number of children in care at any time during a given year. All States and
Territories are heading in the same direction although the trend is less marked in Victoria and is more marked in NSW. SA sits in the middle of this pattern.
The major reason is not that more children are coming into care but that those in care are staying longer. – in some jurisdictions fewer children are now entering care each year The longer a child is in care the greater the exposure to the serious psychological risks associated with multiple placements. Some groups, eg Aboriginal children and children of parents with substance misuse problems, are less likely than others to return home.
Nationally, Aboriginal children are 10 times over-represented.
In some jurisdictions more foster families leave the system than enter it each year. While there has been a marked trend toward more kinship care, with fewer foster placements than we need and limited options within extended families, we are now seeing the increased use of residential care. Overall this is very poor quality care and very costly. Escalating costs(eg SA residential care is $221,232 per child pa, totalling $55.3m pa)
Children in care have very poor health and educational outcomes. It is difficult to differentiate the contribution to this from the adversity experienced prior to coming into care and that experienced following coming into care in relation to Australian research but there are some US studies which highlight the risks associated with being in out-of-home care.

16. Removal carries long-term risks
A 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 the margin of placement who remained at home had lower adult arrest rates, lower teen pregnancy rates and better employment than those placed in foster care.
Doyle, National Bureau of Economic Research, 2007
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, Doyle’s 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.

17. Parental characteristics of children in out-of-home care, 2007
Parental substance abuse %
Domestic Violence %
Parental mental health problems 62.6%
Delfabbro, Kettler, McCormick & Fernandez (2012), The nature and predictors of reunification in Australian out-of-home care, AIFS Conference, Melbourne.

18. Single input services for families with multiple and complex needs???
We have a service system largely organised around single input services based on categorical funding. Families with multiple and complex needs often end up involved with a large number of organisations and in a revolving door of referrals and fragmented care. Engagement of parents remains a major challenge, and relationship-based practice is greatly diminished.

19. The challenge…
“The challenge of ending child abuse is the challenge of breaking the link between adults’ problems and children’s pain.” (UNICEF, A League Table of Child Maltreatment Deaths in Rich Nations, 2008)
Children are in care because the capacity of their parents to care for them, or protect them from others, is seriously compromised by a range of common problems.

20. A wider role for adult services
“The Government should enhance its capacity to identify and respond to vulnerable children and young people by providing funding to support specialist adult services to develop family-sensitive practices, commencing with an audit of practices of adult specialist services that identify and respond to the needs of any children of parents being treated, prioritising drug and alcohol services.” Recommendation 15.
Cummins,P.,Scott, D. & Scales, B. (2012) Report of the Protecting Victoria’s Vulnerable Children Inquiry

21. And MCH services?
Have we enabled our MCH workforce to acquire the necessary competencies in parenting in the context of alcohol and other drugs, mental health, family violence and intellectual disability? Overall, I would say that MCH has made great gains in relation to parental mental health and family violence, but less so in relation to alcohol and other drugs and intellectual disability.

22. What about collaboration?
If we were to do an audit of the way in which services work together to address the adult problems linked to children’s pain, what might we find? While MCH is now much better linked with a range of child and family services, there is a long way to go generally in children’s services and adult specialist services working effectively together.

23. Child Protection Intervention
Families
at risk of
violence
Disability
Correctional services
Homelessness services
Drug and alcohol services
Mental Health
IServices
Children in need
of placement
Child Protection Intervention
Universal Prevention for all Children/Families
Targeted Prevention and Intervention for Vulnerable Families
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, 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? 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.

24. Moving from “it’s not my concern” to “it’s part and parcel of my job”
1. ‘core role only’ (‘it’s not my concern’)
2. ‘core role plus assessment of ‘other needs’, leading to referral’ (‘it’s a concern but someone else’s 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 (‘it’s 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, and favourable organisational and policy conditions.

25. This is the logo of the Adelaide Women’s and Children’s Hospital – it is a lovely symbol for how we need to ‘think child and think parent’ regardless of whether we are working in a so called child or adult service. But let’s not leave out the Dads like this picture does, or does it??

26. Organisational Setting
Three levels of service reform
Policy Context
Organisational Setting
Service Providers
There are 3 levels to tackling this type of large scale service reform:
– the practitioner values, knowledge and skills necessary to provide evidence-informed, family centred practice
- the organisational conditions which support such practice
- the policy and funding conditions which enable organisations to embed such practice

27. The triangle of values, knowledge and skills
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, and favourable organisational and policy conditions.

28. Values for working with vulnerable families: ERGO
Empathy Respect Genuineness Optimism

29. What we know about ‘the therapeutic relationship’
30%
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 evidence
40%
15%
15%
From The Handbook of Psychology Integration by
M.J. Lambert, 1992, P97.

30. Relationship-based Practice
In relationship-based practice with vulnerable families, we are the instrument of our own work. How do we care for and fine tune this instrument so we are able to convey the empathy, respect, genuineness and optimism required? How do we share our practice wisdom? What sustains us in our work with families?
Clinical supervision is an important vehicle for looking after self, sharing practice wisdom and sustaining practitioners in their work with vulnerable families. In a clinical group supervision session for MCHNs I recently facilitated in Knox, each person spoke from her heart about her journey to become a maternal and child health nurse. It was a privilege to witness this. They also spoke about the stresses of their work, and the challenges of its increasing proceduralisation. But most of all they described the joy and deep satisfaction of knowing how they were supporting parents to form a family and laying the foundation for the baby to become someone who could love and be loved. They were honest that in tough times it could sometimes be ‘just a job’ but mostly it was profession to which they were proud to belong. And sometimes it was a vocation.  

31. …a vocation which sustains us in working with vulnerable families
It has been said that vocation is where the heart’s desire meets the world’s need. That is the essence of maternal and child health nursing.
What will help us do this transcends knowledge, and includes our evolutionary endowment to cherish children, not just our own children, but all children.

32. References
Dawe, S. et al (2006) Drug Use in the Family: impacts and implications for children. Australian National Council on Drugs Delfabbro, P., Kettler, L. McCormick, & Fernandez, E. (2012), The nature and predictors of reunification in Australian out-of-home care, AIFS Conference, Melbourne. Doyle, (2007) “Child Protection and Child Outcomes: Measuring the Effects of Foster Care” American Economic Review, 97(5). December : Rubin, D., O’Reilly, A., Luan, X., & Localio, R. (2007) The impact of placement instability on behavioral well-being for children in foster care, Pediatrics, 119: O’Donnell, 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, Price-Robertson, R., Bromfield ,L.& Vassallo , S. (2010) What is the prevalence of child abuse and neglect in Australia? A review of the evidence. AIFS conference, Melbourne. Scott, D, (1992) Reaching vulnerable populations: framework for primary service provision, American Journal of Orthopsychiatry, 62, Scott, D. (2009) Think Child, Think Family, Family Matters, 81:37-42.

33. University of South Australia
Emeritus Professor Dorothy Scott Australian Centre for Child Protection
University of South Australia