Failure to Track Risk is a Fatal Flaw in Child Protection

The vast majority of children served by child protection agencies are served while remaining in their own families. It is very rare that they are fatally injured while being served. Yet each time a fatality does occur on an open intact family case, critics argue that these efforts risk children’s lives.

Is this actually true? The public, emotional following a fatality, frequently shouts, “Yes!” But the available data suggests no. According to Child Maltreatment 2017, 37 states reporting data on fatalities with a prior contact reported a total of 1,108 maltreatment fatalities – with 90 of those children having had a prior victim contact.

Twenty-eight states reported data on child abuse or neglect fatality victims who received prior family preservation services. Of the 904 fatalities reported by these states, 28 had received family preservation services within the past five years.

We assert that the true problem is the flawed lens through which many systems view risk and safety. Noted safety scientist David Woods once observed that “our responsibility is to create foresight about the changing nature of risk before anything goes wrong.”

The phrase “changing nature of risk” is critically important in understanding the safety of children remaining in the custody and care of their parents. We have to acknowledge in practice that the family dynamics we see early in a case are constantly in motion due to later actions and events, and failure to learn about these changes is an invitation for tragedy. With intact families, the risk is that caregivers can become overwhelmed and subsequently engage in unsafe parenting practices.

We propose that Erik Hollnagel’s “resilience potentials,” as described in Safety-II in Practice, can be built into child welfare systems in order to offer a better approach to managing safety. He defines resilience as the ability to “adjust performance to the conditions and function as required under expected and unexpected conditions alike.”

Hollnagel lists four potentials as necessary for resilient performance. They are:

  • The potential to respond to regular and irregular changes, disturbances and opportunities by activating prepared actions, adjusting the current mode of functioning or by creating new ways of doing things.
  • The potential to monitor, knowing what to look for or being able to monitor that which affects or could affect the organization’s performance in the near term.
  • The potential to learn, knowing what has happened or being able to learn from experiences.
  • The potential to anticipate, knowing what to expect or being able to anticipate developments further into the future.

Caseworkers must be able to recognize the “changing nature of risk” and respond before a tragedy occurs. Probabilistic risk models employed by many child protection agencies, such as actuarial risk assessments and predictive analytics, offer methods for addressing triage decisions at the front end by estimating the likelihood of a recurrence of maltreatment, mostly within a general timeframe of one to two years. Consensus-based safety assessment instruments help with immediate safety actions such as child removal.

These models help agencies decide who to serve, but at the same time depend significantly on historical data that does not change with time. They only offer a fixed picture of risk and safety drawn at a point in time and in the context of the currently alleged maltreatment. So while they may be helpful in deciding which families can stay together, they are not helpful later in telling us if changing circumstances now challenge that decision.

The ongoing assessment of the safety of a child in an intact family arrangement necessarily must take into account the daily, if not hourly, ebb and flow of caregiver behavior and conditions that may mean danger to a child. Maltreating families are often chaotic and unstable, and do not present the kind of stable environment in which probabilistic risk models work best. Safety projections must be revised and updated frequently as caregiver’s resilient capacity can change with elevated stressors. This requires the potential to monitor, learn, anticipate and respond before an adverse outcome occurs.

There are a number of practices that may help lower the risk of an adverse outcome in an intact family case. Here are a few we would suggest:

  • Work with an intact family should begin with a family team meeting that includes consideration of what must go right and what could go wrong. Once enumerated, how will fluctuations be monitored?
  • Monitoring contacts must be frequent enough to be sensitive to the variable and sudden fluctuations in threats of harm or caregiver resilience, probably no less than weekly face-to-face contact with family members and electronic or telephone contacts with providers.
  • The focus of monitoring contacts must be on changes in the frequency and intensity of threats of harm and improvements or deterioration in caregiver resilience in the face of danger. Providers must report on what they have learned about caregivers’ status and progress in both realms, not simply on compliance with appointments.
  • The fact that nothing has gone wrong is not by itself evidence that everything is going right. Safety science has shown that plan continuation based on the hubris of prior success is often a major factor in tragedies.
  • Changes that signal a drift toward failure must be communicated to caregivers and caregivers should be engaged in planning a response.

Two critical factors in continually assessing safety in intact family service cases are actively monitoring and recognizing dynamic changes in the nature of risk and safety and avoiding the assumption that past success guarantees future success as a basis for plan continuation.

The inability to completely control caregiver behavior has inherent risks that cannot be denied. Building resilience potentials into the child protection agency offers strategies for further minimizing risk of child fatalities while on the agency’s watch.

Tom Morton is the former president of the Child Welfare Institute, and former director of the Clark County Department of Family Services in Nevada. Jess McDonald is the former child welfare director for the state of Illinois.

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