REFLECTIONS AND DISCUSSION
Better recognition of neglected children
The review suggests that there is better recognition of children in Scotland who are experiencing neglect. While identification of children is a good thing practitioners were clear that this needed to be matched with services able to offer the appropriate level of help to all the children being identified. It is not helpful for children if improvements in recognition are undermined by reductions in the quality of response.
In order to plan and resource services it is important to know the genuine size of the problem. Information-sharing between agencies for the purposes of individual case management has been improving, but there is still a long way to go in improving information sharing for the purposes of service planning. There are a variety of information recording systems in use across Scotland. There are developments taking place to introduce data linkage systems. It is recognised at a national level that better use should be made of administrative data and that there is a need for more linkage and aggregation across data-sets to establish the scale of problems children face and plan services to help them (McGhee et al., 2011). In order to understand better the scale of the problem of neglect it would appear to be a crucial first step to link the SCRA data, especially (but not only) on children referred because of lack of parental care with data from local authorities about children referred because of concerns about neglect. Currently we do not know the extent of the overlap between these groups. It would also help to link information about adults receiving services for mental health and substance misuse problems with information about their children. In order to understand better the impact of neglect upon children it would then be helpful to link the routinely collected data about health and education with this aggregated data set. McGhee et al. (2011) found there to be a gap in routinely collected information about services delivered to children, but such that there is collected by all services should also be linked to begin to build a picture of intervention.
The strategic move towards earlier intervention and a more integrated approach
The GIRFEC framework is now being implemented, although this is taking time, particularly in large urban areas where services are not always geographically co-terminus and some change regularly according to their funding stability. The aim is to ensure that help is made available earlier and in a more accessible way, with all local services deciding collaboratively with parents and, if appropriate, children about what they can offer.
The GIRFEC system has the potential to work well, as long as it is adequately resourced to enable provision of support services across the spectrum from earlier intervention to intensive help. This is particularly important during the transition stages of GIRFEC implementation.
It is anticipated that the shift of emphasis, where possible, towards a less stigmatising delivery of support and interventions by health and education service staff as outlined by the GIRFEC model, should widen the options for families by the provision of support without invoking compulsory measures of care. Child protection systems can fit within the new system and work towards being less adversarial and investigative, although clearly there will be some families who struggle to co-operate or make the necessary changes to ensure 'good enough' parenting even with the most supportive approaches. Integrated approaches, where the forensic investigative approaches are embedded within broader service responses, are optimal for situations of child neglect because of the extent to which the risks flow from the damage caused by unmet needs. For this reason, separate 'family support' and 'child protection' pathways are not helpful for neglect; instead they should both be seen as stages on the one pathway. Effective family support is protection, effective protection is supportive.
Integration, such that a protective network of support is created from all disciplines working together, should help reduce the prevailing discourse about thresholds. The issue of thresholds seems to be associated with confusion about whether the focus should be on:
1. the severity of the neglect and associated harm to the child or
2. the likelihood of the parents being able to accept help and make changes without the need for compulsory measures.
It is not surprising that when practitioners encounter severe neglect they seek the structure of forensic investigation and/or compulsory measures of care.
They act as a 'marker' of severity and of practitioner concern to galvanise action. However, in cases where parents are willing to accept help and work with practitioners, even where neglect is severe, compulsory measures may not be required, as long as there is a structured framework within which that support is provided with clear agreement about what is to change, by when and what will happen if it does not.
There are real concerns about whether early intervention will draw more families into the net than can be adequately supported and whether children at high risk of immediate harm may be obscured.
One issue that perhaps needs further development is the refinement of what 'early' means. 'Early' can mean early in the stage of the problem - whatever the child's age. In some contexts 'early' means that help is provided quickly once the need is identified - but this may not be early in the actual stage of the problem, it may be that practitioners just have not been aware of the child until something triggers their attention. When a child is encountered who appears to be experiencing some signs of neglect that is not very severe there are several possible scenarios. First, looking back, this may a family where:
- the care has, until recently, been good, but something has changed to dip levels of care
- the care has always been characterised by less severe levels of neglect
- there has been very severe neglect, but something has changed to improve the care.
Then looking forward this may be a family where, without any formal support:
- the care is on a downward trajectory and will become very severe neglect
- the care will stay the same
- the care will improve.
When factoring in the impact of intervention Horwath and Morrison's model (2001) for exploring capacity and willingness to change remains the most helpful for assessing parental motivation to change and to change within a quick enough timeframe to match the child's developmental trajectory. It can also help with deciding whether compulsory measures may be required. The model comprises two dimensions - one of levels of effort and one of levels of commitment. When these are combined there are four possible categories:
1. 'genuine commitment' where parents make good efforts to change and show commitment to improving their parenting for the benefit of the children, here there is unlikely to be a requirement for compulsory measures
2. 'tokenism' where parents express commitment to change, but for a range of possible reasons do not put in actual effort to change and here there may be need for compulsory measures, although the parents may be able to accept that the care is not good enough
3. 'compliance imitation' or 'approval seeking' where there can be high effort to make changes (perhaps sporadically) but the commitment to sustained change is not demonstrated. There may not be a requirement for compulsory measures if, perhaps, the parents are able to come to an acceptance that the child requires alternative care or that there is an ongoing need for extensive additional support for the child within the home
4. 'dissent' or 'avoidance' where there is a combination of low effort and low commitment, and where compulsory measures are highly likely to be required.
Given the individual variability and complexity of children's circumstances, it may be better to accept that for every situation there will need to be assessment, discussion with the family and negotiation between professionals in order to establish the level of unmet need, the associated risk of harm and the extent of real opportunity for change without the need for compulsory measures, or indeed with compulsory measures.
Improving outcomes and evaluation of outcomes
There are many examples of emerging practice across Scotland which can and should be shared across areas through vehicles such as the Scottish Child Protection Committee fora.
More evidence about intervention is available, and the voluntary sector, in particular, has been building evidence about the most effective approaches. Intervention should build comprehensive packages of support that are clear, focused and address the issues at each ecological level. The provision of direct support for children is of especial value and intervention has to include attention to the processes underlying service use and change. It can hinge on the quality of the relationship between practitioner and parent and, or child. And for a long time we have known that intervention to support neglected children has to be provided on a long-term, not episodic basis. In summary, intervention needs to be concrete, comprehensive, sustained and brokered by good relationships (Daniel et al., 2011). Farmer and Lutman (2010) emphasise the need for intervention to be proactive throughout; and the evaluation of the trial Family Drug and Alcohol Court (FDAC) also supports the need for authoritative practice (Harwin et al., 2011).
There is, also, considerable effort being put into finding ways to measure the effectiveness of intervention by recording information that can be used to gauge outcomes. This is, again, something that could be tackled at a national and more strategic level so that wheels do not have to be re-invented in each area.
This review has gone some way towards examining the scale of neglect in Scotland, and we heard of high levels of concern from professionals about neglected children and their capacity to help them all.
We do what we can better, but what we can't do grows.
Focus group respondent
At the same time, this in-depth look at policy and practice in Scotland suggests that we have huge potential to take a lead in the UK with our practice response to neglected children. There is clear recognition that neglect is damaging to children across all disciplines and professions and there are considerable efforts going into supporting individual children and into developing more effective frameworks for multi-disciplinary practice and evaluating outcomes. This would appear to be a good time to bring together the learning from across Scotland and to create an integrated approach within the GIRFEC structure.
The review highlights some priorities in relation to the three original review questions.
1. Develop a co-ordinated national and local data collection, management and linkage strategy, building on existing pockets of good practice, that would:
- support a better understanding of the prevalence of actual or potential neglect
- underpin the planning of preventive and responsive services
- provide the foundation for gauging outcomes for children.
2. Synthesise the learning from different areas developing different models of multi-agency responses to neglect within the overarching GIRFEC framework to:
- identify examples of effective co-ordination of universal and targeted services that incorporate early intervention and appropriate responses to risk of harm
- identify examples of effective thresholds
- support the development of integrated pathways to support for neglected children and their families.
3. Draw together the learning from the range of services being developed to address neglect with the evidence from the literature on effective intervention to:
- share learning about how to develop responsive and authoritative service models that address the needs of children and their parents
- identify examples of promising practice that can be rolled out across Scotland
- synthesise learning about how to embed measures at the outset that can be used to track outcomes for children and families.
Email: Philip Raines