The Personal Security of Children Demands Bold System Reform
In this article, we argue for a new approach to child welfare—one that replaces existing child protection systems beset by scandals and tragedies with broad-scale system re-alignment that places public health prevention and early intervention at the forefront of efforts to engage, support, and empower families. We explain that the ‘rescue and removal’ orientation that drives policies and practices in contemporary child welfare and child protection systems is deeply flawed in its orientation, lacking in its evidence of effectiveness, and fiscally unsustainable. We point to differential response as one attempt to reform child welfare systems from within, but note that the changes DR brings, while promising, are insufficient to achieve what is required to eradicate child maltreatment and bring about a more just and sustainable practice of promoting the welfare of children. Here, we also share some emerging and encouraging initiatives from around the globe to illustrate the promise of prevention and early intervention approaches—what we call beacons of hope. For the sake of all children, it is time think boldly about the potential that exists in broad-scale, systemic and cross-sectoral reform that fully and unabashedly embraces universal and primary prevention as a means to ensure children’s right to personal security.
KeywordsChild maltreatment prevention Child protective services Child welfare Reform Public health
Despite important inroads in child welfare and child protection, it is generally understood that these systems are failing in their mission to protect children from harm. In our edited book on public health approaches for protecting children (Lonne et al. 2019), we noted that this failure is not a matter of bad intent, but a reflection of a statutory-led system that is overwhelmed and in disarray. Regrettably, our systems are plagued by tragedies, scandals, and failures that sap public and political faith in the institutions we trust to keep vulnerable children free from harm.
Our goal when intervening in the private lives of families should be to ensure children’s rights to personal security by providing families with the basic supports they need to care for and nurture their own. In child welfare systems as they are, this goal is rarely achieved. The rescue and removal orientation that drives policies and practices in child welfare is problematic because services are provided only after problems materialize and the risk of harm to children has reached a point where interventions are required by law. Featherstone and her colleagues (2018) posited that ‘‘while the toxic embrace of risk aversion, audit, and responsibilisation has been consistently challenged, we still operate in a context where need is understood through a risk lens, and responsibility continues to be conflated with conscious (p. 12)’’. Not only are statutory interventions necessarily intrusive, they are also punitive and deeply stigmatizing.
As concerning, there have been few robust studies showing that children served by child welfare systems actually benefit from the services they receive (Albright et al. 2019). As noted by Albright et al. (2019), ‘‘there is no culture of measuring quality or long-term outcomes in the various sectors of CPS worldwide, nor have there been outcomes-based evaluation of CPS systems, despite previous calls for such work’’ (p. 2). This lack of robust evaluation of system effects and outcomes is both puzzling and deeply troubling.
Fortunately, prevention in public health offers an alternative based in prior successes of population-based initiatives that have led to profound advancements such as cleaner water, better sanitation, reduction in childhood dental caries, safer roads, and eradication of communicable disease via immunizations. Nonetheless, our protection systems seem stubbornly to resist adopting this prevention framework as a way to get ahead of what most experts view as one of the most controllable threats to the health and safety of children. Why these systems seem stuck in state interventions at the tertiary level rather than moving upstream and tackling the factors that give rise to the persistence of child maltreatment is as puzzling as the absence of child outcome data.
The neglect of children, the most prevalent form of child maltreatment, is as preventable as the more ‘‘visible’’ forms of physical and sexual abuse. Indeed, neglect remains ‘the big kid on the block’ for many jurisdictions1 and groups, such as Indigenous peoples, people of colour, and families with disability and mental health concerns, who are over-represented in statutory systems. For these groups, neglect is one of the primary targets of our contemporary protection interventions. The continued rise in notifications and substantiations in many Anglophone countries can be used as evidence that the current systems are wrongly targeted, ineffectual, and unsustainable.
So, what can—and should—be done to bring about the systemic, broad-scale change of child welfare systems that is so desperately needed?
Reform the System from Within?
Calls to reform the child welfare system have grown increasingly louder and more insistent in recent years. In response, there have been attempts to change the system from within, as with differential response (DR), also known as dual track or alternative response (AR), that was introduced in the 1990s as an alternative to a traditional investigatory process.2 Many U.S. states have since adopted DR as a model albeit in various forms and iterations but with the same or similar intent (Fluke et al. 2019).
DR is used in other countries, although the work in not necessarily done by statutory child protection departments, as in the USA. For example, in Australia, there is an increasing use and integration of community-based services that provide voluntary assistance and referral to universal and secondary services. The aim is to link families in need to timely help within their local communities without the involvement in a tertiary child protection system investigation.
The idea of DR and other similar models is to lessen the stigma, fear, and stress of formal investigations by allowing families to access services voluntarily and without a formal determination of abuse or neglect. Although not viewed as a replacement for traditional investigations, DR shifts the emphasis from intervening with families solely to address concerns about child safety to engaging and supporting families as a way to lessen risk for future harm (Schene 2005). It is a subtle but potentially important distinction, because the goal of DR is to provide services to families before crises arise, thereby increasing the likelihood of better child outcomes.
While promising in theory, evaluations of DR have been decidedly mixed. In one study conducted in the USA, Piper (2016) compared re-reports to child welfare among families in alternative (DR) response and traditional response tracks of child welfare agencies across 13 states that had implemented DR by 2012. She found that, among a number of states within certain years, there were no differences at all in rates of re-reports when alternative and traditional tracks were compared. In other U.S. states, it appeared that when families were assigned to alternative tracks at very high rates, re-reports were actually more likely in those tracks than in traditional tracks. She concluded that DR must only be implemented with awareness of the tendency for results to turn negative when rates of assignment to alternative tracks exceed about a third of all reported cases.
Others offer a more favourable assessment of DR/AR effects. For example, Fluke et al. (2019) found that counties with higher AR utilization had lower rates of re-reports to child welfare agencies than those with lower utilization rates. In fact, they found that a 1% increase in AR utilization was associated with a 3% decrease in re-reports (p. 133).
Lisa Merkel-Holguin and colleagues’ (2019) recent examination concluded that DR was ‘‘an effective alternative to a one-pathway system’’ (p. 193). Taken overall, they determined that evaluations of DR show it improves child safety, strengthens family engagement, and reduces follow-up costs when compared to traditional investigation approaches. Describing DR as a promising alternative to traditional investigatory approaches, the California Evidence-Based Clearinghouse for Child Welfare, concluded that “anti-DR proponents, pro-DR advocates, and independent researchers have ‘dialogued’ past one another” (p. 186).
Other considerations relevant to the assessment of DR are its influence on the nature of the broader child welfare service system response, including access points, service availability, and scope. In that DR shifts casework practice away from incident-focused assessment to a broader assessment of background issues and challenges experienced by families, there is more potential in the model for proactive engagement with families and interventions tailored to their specific needs. If it comes down to a choice between (a) keeping traditional assessment practices and practice/case management frameworks, referral, and engagement processes as they are or (b) moving to a framework more like DR, which offers more flexibility and tailored interventions, then, of course, the latter is the better alternative. But, is it sufficient? We believe not.
One of the major challenges with DR and other like models is that they come as incremental reforms to systems that remain entrenched in a risk mitigation model. Our position is that, if the goal is to produce sustained, positive effects on the well-being of children and families, broad-scale and systemic reform of child welfare and child protection systems is required. It may even be time to think of a new integrated prevention system, distinct from the statutory child protection system, that positions primary and universal prevention services centrally.
We have previously argued that, while DR may bring about certain short-term gains, such as greater flexibility and better access to services for more families, services available to families still remain embedded in systems that are mostly reactive and poorly resourced, and which are locked into child protection interventions through legal, policy, and contractual obligations. Fundamental to our position is the belief that any system that prioritizes tertiary interventions over prevention and early intervention will likely not succeed because services come too late, often well after problems have become resistant to change. Indeed, we are of the mind that broad-scale and systemic reform is perhaps the only sustainable path forward.
The Public Health Model of Child Maltreatment Prevention
As we have discussed in earlier publications on this topic, the best hope we have of improving the lives of vulnerable children at risk of abuse and neglect is to fully engage a public health prevention framework that focuses on promoting safe, supportive, and caring environments and developing a continuum of services based on the concept of blended prevention and proportionate universalism (see Herrenkohl et al. 2015; Higgins et al. 2019; Sanders et al. 2018).
In a blended prevention model, interventions are implemented at three levels: primary, secondary, and tertiary (or sometimes referred to as universal, selective, and indicated) with all three elements being critical. However, a well-balanced system has primary prevention and universal services as the largest component. If successfully implemented, primary prevention services will shift the risk profile positively for an entire community, meaning that fewer children and families will need more intensive secondary or tertiary services (Herrenkohl 2019; Herrenkohl et al. 2015; Higgins et al. 2019). In addition, by engaging families earlier, services will be experienced as less punitive and less stigmatizing and will provide more timely responses to the pressing issues they face.
The public health model has several core components and employs a cyclical approach. Firstly, the problem is defined and the magnitude of the problem is identified. Research is used to identify the causes, the risk, and protective factors associated with these causal issues, and the mechanism by which the factors lead to the problem outcome of maltreatment. Research is again used to design and test interventions. Interventions are implemented and evaluated, and the surveillance data that defined and measured the magnitude of the problem is used to measure differences and impacts from the interventions, bringing the model back to the beginning.
Universal interventions are directed at whole populations, regardless of the presence of risk or protective factors. In a child welfare context, these could include public awareness or primary prevention education campaigns focused on risk mitigation and protective behaviours, income support, or even legislation action against corporal punishment. Secondary or targeted interventions are focused on groups of people at higher risk for maltreatment. These interventions are targeted at ameliorating risk factors to prevent maltreatment and include respite care for vulnerable families, alcohol or substance use services, and voluntary parenting support or parent training.
Finally, tertiary or indicated interventions are, as they suggest, intensive—and therefore necessarily more intrusive. Families receiving such interventions are at the highest-end of the risk continuum, and the goal is to minimize the harm caused to children, while also working to prevent recurrence and the deepening entrenchment of difficulties with the family. These interventions include trauma-based therapy, child removal and out-of-home care, mandatory reporting legislation, mandatory treatment for parenting deficiencies (such as parenting skills, anger management, and substance misuse), and community shelters to escape family violence (see for example, Scott et al. 2016).
Typically, the child welfare system focuses on tertiary responses and, thus, it misses opportunities to engage lower risk families before targeted interventions become necessary. Often, the universal or primary-prevention support services are the responsibilities of sectors outside of child welfare, such education or primary health, but even these systems are poorly equipped to support the broad and diverse needs of families who can benefit from preventions services (Herrenkohl 2019). Moving the focus away from a child protection (tertiary) response to a proactive child-wellbeing prevention support system will require engagement of these other sectors, and, together, they must (re)focus on primary and secondary interventions.
The Task Ahead
Public health prevention in child welfare has been a topic of discussion for many years, yet efforts to bring about broad-scale systemic reform have progressed at a slow, and some would say a glacial, rate. We argue that this has in large part been the result of previous reforms that tinkered at the edges of the foundational aspects of the child protection model. Reform, often stemming from formal inquiries, has hitherto been largely a reactive agenda to gross system failures.
We argue for broad-scale system reconfiguration that fully embraces a prevention orientation, thereby shifting the dominant discourses of judgmental rescue and removal to the promotion of child well-being and empowerment of families. What is required is a new vision for understanding and operationalizing public health prevention strategies that redress the inequity in the social determinants of child well-being by moving services upstream and broadening the focus to include families at the lower and mid-levels of the risk continuum.
We are under no illusions about the enormity of the reforms required to achieve this goal. It will entail a wholesale de-escalation of existing forensic child protection practices and an institutional, cross-sectoral reconfiguration that shifts how and when families are engaged and served. Struggling families and communities are in need of help to change their often desperate situations tied to the ravages of poverty and enduring inequities that long been implicated as causes of child maltreatment (Klevens and Metzler 2019).
Beacons of Hope
Because of the generally slow progress with introducing public health prevention approaches, relatively few good examples of the concept currently exist. Yet, several case studies illustrate the promise and potential of a model based in part on prevention and early intervention. For example, Canavan et al. (2019) described an effort in the Republic of Ireland to advance a programme called ‘Development and Mainstreaming Programme for Prevention, Partnership, and Family Support (PPFS).’ The programme was the result of a partnership among The Atlantic Philanthropies, the Department of Children and Youth Affairs (DCYA), an independent agency overseeing child protection and child welfare services (Tusla), and the National University of Ireland (NUI), Galway.
The Irish model came out of identified systemic failures and consists of a set of integrated institutional arrangements to address the poor social and economic environments that place children and families in vulnerable situations. There is a strong emphasis upon partnership in both organizational and practice relationships and a focus upon investment in community and voluntary services, as well as a move away from predominant investigatory interventions. As one example, the Meithal is a traditional process that enlists neighbours and other members of a community in an easy and collaborative guidance and helping process that facilitates access to cross-agency support and services. There are numerous strengths of the model, including a focus on population-level strategies (e.g. parenting support) to improve the health and well-being of children, as well as a reliance on evidence-based approaches and data-driven strategies for quality improvement.
Elsewhere, some jurisdictions have embraced alternative approaches to system reform in seeking to alter their approaches to protect children, as in Alberta Canada where the gross over-representation of Indigenous children was a driving issue in the recognition for change (see Barraclough et al. 2019; Duthie et al. 2019). The Their Futures Matter integrated system redesign in NSW Australia3 has embraced public health approaches to address the poor outcomes for families and children (especially those in out-of-home care) and enable earlier help to be provided by primary and secondary services. The Strong Communities programme in South Carolina, another example, used community mobilization strategies to provide informal supports to families through shared norms of care that the whole community used to help them with their caring responsibilities.
Importantly, these innovations have embraced the centrality of true partnership and the sharing of power among those with a stake in children’s safety and well-being. Broad-scale reform entails altered institutional relationships. Also important is the goal of moving policy and practice to become culturally aware through processes and initiatives that recognize the historical and contemporary impacts of colonization of Indigenous peoples and the inter-generational impacts of trauma. Broad-scale reform entails altered relationships with service users and those communities who have to this point been the target of destructive child protection policies and their outcomes.
To achieve children’s right to personal safety and security, we need to stop trying to just work backwards from statutory interventions when harm has occurred, or risks are already high (and circumstances likely to be entrenched and harder to shift). Instead, we have to think in reverse and work from the ground up to develop population-wide supports for all children and their families. It is only from this starting point that effective strategies can be implemented to ramp-up services to a greater intensity when circumstances of individual children and families require it.
Public health approaches to prevention of child maltreatment emphasize promotion of safe, stable, and nurturing environments for all children (Centers for Disease Control and Prevention 2014), rather than directing services to the highest need groups. This requires starting with the agencies that already have universal service delivery platforms in place (schools, early childhood services, primary health clinics, and maternal and child health services), and build on these. In schools, it is possible to embed tiered strategies of support that start with universal programs (Herrenkohl 2019; Herrenkohl et al. 2019a, b). Although not yet active in the prevention of child maltreatment per se, schools are settings where efforts can be made to both nurture child development and provide families with access to needed health and social services (Brooks 2006; Oakes et al. 2017).
A new approach would mean getting to families and children earlier to address their "needs’’ rather than asking parents ‘Why aren’t you doing a better job of parenting?’, there is space to inquire; ‘‘What can be done to support you better in raising your children?’’
The implications of upending the current system are manifold: we need to stop offering our ‘expertise’ too late—when it is not welcomed, and start offering services earlier, and in more places where it can be taken up voluntarily. This involves collaboration across service silos, shifting (and sharing) responsibilities, and letting go of the empires that have been built to support the behemoth that statutory service systems have become. It also means questioning some of the drivers of statutory system referrals (including the expansion of mandatory reporters and the range of concerns about which they are required to report) and replacing these with a culture of service provision earlier in the continuum of vulnerability and need.
Here we have outlined the child protection system outcomes that result in often poor system outcomes that do not align with children’s rights to personal security, are blaming and punitive toward parents, and do not meet with societal expectations for preventing maltreatment. The system we have established is beset by scandals and tragedies, with reform agendas that are driven by reactive inquiries. We have argued that rather than tinkering with a broken set of policies, practices, and institutional arrangements, we need instead to have a bolder approach toward broad-scale system re-alignment that places public health prevention and earlier intervention centre stage. We have shared some emerging and encouraging initiatives from around the globe. With courage, conviction, and vision, it is possible to mobilize public health approaches as the first line of support for children and families, and provide the timely, accessible help that make children’s right to personal security a reality.
For example, in 2017, three-quarters of children identified as maltreated in the USA were neglected (see https://www.acf.hhs.gov/sites/default/files/cb/cm2017.pdf
See for example the Children’s Bureau 2011 literature review of differential response http://www.ucdenver.edu/academics/colleges/medicalschool/departments/pediatrics/subs/can/DR/qicdr/General%20Resources/QIC-DR_Lit_Review%20version%20%202.pdf
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
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