Wednesday, June 8, 2016

To prevent child abuse: replace the “public health approach” with a social justice approach

Consider two approaches to working with troubled children and families.
Approach #1 is embodied in a paragraph from a column in which the author cites what she sees as barriers to working with children in foster care:
“When foster parents said they could not, and our overworked paraprofessionals were unavailable, I had to take my clients to the doctor, dentist, therapist and for family visits. I spent as much as 10 hours a week driving and I logged as many as 300 miles per month. I don’t see how it makes sense for a person with a master’s degree in social work to serve as a paid driver.”
Approach #2 comes from Lisbeth Schorr’s bookCommon Purpose. It focuses on keeping children out of foster care:
“A [Homebuilders] therapist told of appearing at the front door of a family in crisis, to be greeted by a mother’s declaration that the one thing she didn’t need was one more social worker telling her what to do. What she needed, she said, was to get her house cleaned up.”
“The Homebuilders therapist … responded by asking the mother if she wanted to start with the kitchen. After working together for an hour, the two women were able to talk about the out-of-control teenager who had set off the family’s difficulty. It was an unorthodox way of forging what the mental health professionals call a therapeutic alliance, but it worked!”
Though they deal with two different points in the process, the mindset in the first example has dominated our approach to child welfare. So no one should be surprised that neither prevention nor foster care has worked too well.
We can do a lot better. But even now, our wretched approach to prevention beats throwing more children into foster care.
Sean Hughes, who has written a number of columns on finance reform points to a 2015 study by the Children’s Data Network (CDN) showing that 60 percent of infants “reported” as being maltreated – meaning only that someone picked up a phone and called a hotline – are reported again within five years, suggesting that leaving those children in their homes was unsafe.

But even assuming results from this one study are typical, they tell us nothing. That’s because, as Prof. Emily Keddell of New Zealand’s University of Otago explains, “child abuse” is such a broad, vague concept, so prone to whim, prejudice and agency practice patterns, that reporting and even substantiation are meaningless measures. If an infant’s poverty is confused with neglect and a few years later that child still is poor, it’s hardly a shock that the infant will be reported as “neglected” once again.

The same CDN study found that 90 percent of reported cases receive no follow-up. That’s probably because most of the reports were false. But even in so-called “substantiated” cases, it’s been estimated that only 40 percent get any kind of follow-up.

One can’t say “prevention” is failing where prevention was never tried.

What Can We Do Instead?

What are the alternatives to a failed approach to prevention?

One is to give up and consign even more children to foster care. But 150 years of experience suggests that doesn’t work well.
Consider two studies, from 2007 and 2008, of more than 15,000 children in typical child welfare cases. They compare children placed in foster care to comparably maltreated children left in their own homes. The results aren’t even close.

Children left in their own homes are far less likely to become pregnant, far less likely to wind up in the juvenile justice system, far less likely to commit crimes as young adults and far more likely to hold onto a job than comparably maltreated children placed in foster care.

But what about drug abuse? Don’t we have to take children from those parents?
In 1998, University of Florida researchers published a study of two groups of infants born with cocaine in their systems. One group was placed in foster care, the other with birth mothers able to care for them. After six months, the babies were tested using all the usual measures of infant development: rolling over, sitting up, reaching out.
Consistently, the children placed with their birth mothers did better. For the foster children, being taken from their mothers was more toxic than the cocaine.
The way these studies were conducted also makes it impossible for foster-care apologists to use their usual excuse for dreadful foster care outcomes: the one where they claim it must have been because of what those terrible parents did before we “rescued” their children.
And of course, all this is before we even reach the issue of the highrates of abuse in foster care.

Foster-care apologists also like to claim the outcomes wouldn’t be so rotten if we just “fixed” foster care. 

But another study in 2005, which found only 20 percent of former foster youths do well in later life, came up with a mathematical model in which they estimated how much better the outcomes would be if foster care were made perfect.

The answer: 22.2 percent.
So if you could fix every problem in foster care – and that’s worth doing, because some children really do need to be removed from their homes – it would still churn out walking wounded three times out of five instead of four times out of five. The only real way to fix foster care is to have less of it.
This does not mean the only alternatives for vulnerable children have to be a bad prevention system and a worse foster care system. We can build a better system if we insist on one fundamental change: Whatever we do has to be for the families, and not for ourselves. Our current system is designed more to make the helpers feel good than to actually provide help.

Medicalizing Social Problems

This is rooted in our American habit of medicalizing our social problems, an approach that helps primarily the helpers and lets the rest of us off the hook for poverty itself.

When Reagan budget cuts led to a resurgence of hunger and homelessness, we rushed to blame it on “mental illness.” Gun violence out of control? Never mind the guns; it’s a mental health problem! We approach “child abuse” the same way.
Nineteenth century “child savers,” as they proudly called themselves, deemed the poor to be genetically inferior. Twenty-first century child savers view them as psychologically inferior.
As Barbara Nelson documents in her book Making an Issue of Child Abuse, when Sen. Walter Mondale wanted to pass what became the Child Abuse Prevention and Treatment Act, he had to pretend that poverty was not an issue in order to avoid a veto by President Nixon.

Nelson writes that the “medical model” fits the quintessential American view of all social problems: “Individually rooted, described as an illness, and solvable by occasional doses of therapeutic conversation.”
And sure enough, the so-called “Commission to Eliminate Child Abuse and Neglect Fatalities” tells us over and over that we need a “public health approach” to child abuse. The result is a prevention regime built around “counseling” and “parent education” that actually can make things worse.

Take an impoverished single mother who starts to feel sad because she is holding down two dead-end jobs and sleeping with the lights on to try to keep the rats from coming out at night and biting her children in the only housing she can afford. She may be diagnosed with “apathy-futility syndrome” – I’m not making that term up – and forced to schlep downtown to counseling sessions and parent education classes, when what she really needs is a better job so she can afford a better place to live and get a little rest.

Malcolm Bush explained why this happens in his book, Families in Distress:
“The recognition that the troubled family inhabits a context that is relevant to its problems suggests the possibility that the solution involves some humble tasks … This possibility is at odds with professional status. Professional status is not necessary for humble tasks … Changing the psyche was a grand task, and while the elaboration of theories past their practical benefit would not help families in trouble, it would allow social workers to hold up their heads in the professional meeting or the academic seminar.”
If that sounds familiar, it may be because Molly McGrath Tierney, director of the Baltimore City Department of Social Services, recently offered a similar take.

So we wind up with social workers who see driving children as a waste of time instead of a wonderful opportunity to talk to those children and find out how to help fix their real problems.
Doing this while actually helping clean a house works even better. So it’s no wonder that IntensiveFamily Preservation Services programs that follow the Homebuilders model are among the very few child welfare interventions for any purpose that gain high marks from the California Evidence-Based Clearinghouse for Child Welfare.

So, how do we fix prevention? By replacing the “public health approach” with a social justice approach. We don’t have to wipe out poverty to significantly reduce child abuse, just ameliorate its worst effects.
§  Since three separate studies have found that 30 percent of America’s foster children could be home right now if their families just had decent housing, make housing a core “preventive service.”
§  Since another common reason for child removal is “lack of supervision,” get serious about providing child care for impoverished working families.
§  Give caseworkers access to “flex funds,” one-shot infusions of cash to help families get through crises – it’s a key part of the highly successful child welfare reform in Alabama. Or just give poor families a little more money every year.
§  Get serious about drug treatment – because it’s extremely difficult to take a swing at “bad mothers” without the blow landing on their children.
§  Tailor every intervention to the needs of a particular family, as in this example provided by Karl Dennis, the father of “wraparound.”
§  Provide high-quality defense counsel for families, like this, so they can craft alternatives to the failed cookie-cutter “service plans” often offered by child welfare agencies.

And when there really is a need to combine hard services with counseling and parent education, do it while driving, or better yet, do what that Homebuilders worker did: Start with the kitchen.