• By Dartington SRU
  • Posted on Friday 01st April, 2011

Child protection: The shape of things to come?

There was a glimpse of the future of child protection services on the opening day of the Society for Research on Child Development (SRCD) conference in Montreal, Canada yesterday. Ways of going to families before problems occur and seeking evidence that it meets those who need it most have been tested by Ken Dodge and colleagues from Duke University, North Carolina in the US, and partner organisations.For the most part, child protection services currently wait for families who may be maltreating their children to knock on their door for extra help or are referred for extra help by other agencies. This is then followed by a lot of discussion among professionals about whether or not the child has been abused. The results of this analysis are usually inconclusive. Most families get little in the way of useful support but a few lose their children to foster or residential care.Instead of waiting for possible maltreatment or for someone to go to the agency, these modern child protection services are seeking to prevent the problem by going to the family home. It’s a simple but radical change.Two programs were described in four presentations by the Duke team. Durham Connects is a universal health visiting program comprising one to three home visits, a health assessment and connection to local resources.Healthy Families Durham is a targeted health visiting program based on the proven model Healthy Families America. It is delivered to low income, first time, high risk, young mothers. HFD is provided to mothers who typically are 16 years or younger, have been maltreated themselves or have symptoms of depression or anxiety.HFD is provided by professional social workers who used several core curricula, but especially Parents as Teachers, with added modules to address major risks such as violence and substance misuse.Sophisticated evaluations of both programs are underway. The presentations at Montreal focused on engagement, screening and retention of families.The word "universal" has different meanings depending on the context in which it is used. Universal health visiting in the UK, for example, means that every new mother has some contact with a health visitor by law. In the US, mothers have to be recruited to universal programs. Failure to get sufficient numbers onto the program risks losing the community-wide effects promised by these public health style approaches.Speaking to the conference, Shelley Alonso-Marsden gave the engagement levels for the 1,130 births that took place in the first nine months of Durham Connects. Four in five new mothers scheduled a visit, and nearly nine in ten of those who did turned up. Overall engagement rates are running at about 69 per cent.Consistent with other studies, it is the ethnic minority mothers, especially those from African American and Latin American backgrounds, who are most likely to participate and complete home visits. The challenge in the USA, at least, is reaching white low income mothers.Mothers are showing up because they feel they need help and like what is in offer. So how can this fit with statutory responsibilities to identify and respond to child protection?Karen O’Donnell described the screening tool developed for the North Carolina work. It fits into a structure in which health visitors celebrate birth and parenthood, conduct the standard health assessments that new mothers love. The trick in the Durham Connects approach is to weave the hard questions into an ordinary relationship between professional and client. Twelve factors across four domains -parental health, care of infant, home safety and parental well-being- are threaded into an informal discussion. The nurses are trained to use a script, but they do not deliver it by rote and there is no sign of a check-list.Tested with 1,679 home visits over 16 month period, O’Donnell reported an 85 per cent adherence to the protocol. The approach seemed to hold up for the highest risk areas like shaken baby, domestic violence, maternal post-partum depression and substance use.The point of screening is to pick those mothers who need extra help. Katie Rosenbalm described the Healthy Families Durham program being offered to 150 low income, first time mothers, the youngest of whom was 13 at the time of her child’s birth. The evaluation is comparing different doses of HFD with services as usual.Rosenbalm was able to report a reasonable pay off for the strong retention strategies adopted by the HFD team. Nearly six in ten of families offered support were still engaged after a year, completing on average about 21 meetings with their social worker.Particularly encouraging was the finding that it was those at highest risk of child maltreatment, for example, those with high levels of inter-parental violence, who were the most likely to engage.Parents know when they are in trouble and they will take help, advice and support if it is offered to them in the right way.All of this work is experimental. By design, its effectiveness in reducing child maltreatment is not known. But Dodge and his team will find out and they have reason to be optimistic. The greatest impact on child protection so far uncovered has come from health visiting programs like David Old’s Nurse Family Partnership.The approach taken stands in stark relief from the orthodoxy in child protection. Duke’s work is about prevention, not reaction. The team are evaluating the impact of their work, routine child protection is guessing.There is, however, one point of overlap between the old and the new. Both are concentrated on poor children. The real breakthrough will come when these experiments are taken to scale, not just for mothers in impoverished communities, but for all mothers, rich and poor.[See also: Michael Little's blog entry on Prevention Action]

Back to Archives