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Effective practice to protect children living in highly resistant families Lorraine Hansom, Sector Specialist 1
Effective practice to protect children living in highly resistant families
Lorraine Hansom, Sector Specialist
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• To explore key messages from national research & learning from local reviews
• Develop working awareness & understanding• Develop skills & confidence in making decisions
and achieving change• Understand staff care & safety issues• Consultation on SSCB practice guidance• For parents & children to more readily engage
in interventions to change entrenched behaviour
Aims & Objectives
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• Recent high profile child protection cases have raised concerns about some extremely ‘resistant’ families who do not change despite intervention
• Research and practice suggest that most parents who maltreat their children do not fall into this group
• There is a need to better understand resistance and how these families can be helped
Why is this important?
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• Serious case review NS10Working with hostile or highly resistant families can deflect social workers and other professionals from focussing upon the needs of children in such families
• Learning review5 agencies 34 families 44% inadequate safeguarding arrangements
These families present resistance early within universal services. Lack of engagement / take up of support usually leads to closure / discharge = a missed opportunity to intervene early
Local Evidence
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• Safeguarding Knowledge Review 1 “Effective Practice to protect children living in “highly resistant” families”
• Safeguarding briefing 1 “Effective Interventions for complex families where there are concerns about, or evidence of, a child suffering significant harm”
• Safeguarding briefing 2 “What are the key questions for audit of child protection systems and decision-making?”
• Safeguarding briefing 3 “The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information?”
• These can all be downloaded from www.c4eo.org.uk
C4EO Evidence base
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1. What are the circumstances, characteristics and prevalence of families that are resistant to change?
2.2. What challenges to practice do resistance, and What challenges to practice do resistance, and the underlying characteristics and the underlying characteristics and circumstances, raise?circumstances, raise?
3. What services, treatments and interventions are effective for families that are resistant to change?
Rebecca Fauth, Helena Jelicic, Diane Hart and Sheryl Burton,NCBProfessor David Shemmings,University of Kent
Knowledge Review
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• ‘Highly resistant’ families are a subpopulation that does not get much specific attention in research
• Thus, we mined existing literature on:
– families with ‘multiple’ or ‘complex’ problems
– maltreatment recurrence
– serious case reviews
– practitioners’ and parents’ perceptions of effectiveness
• Used this literature to infer relevant information about the most challenging families.
The review evidence base
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What is resistance?
Denial/AvoidanceAmbivalence
Unresponsiveness to treatment
(Disguised Compliance)
Violence/Hostility(Confrontation)
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• No evidence on prevalence of ‘highly resistant’ families per se
• Recurrence rates vary significantly between studies due to differences in study design (i.e., 25-69 per cent)
• 2005-2007 analysis of serious case reviews revealed that 75 per cent of families were characterised as ‘uncooperative’, which included hostility, avoidance, disguised compliance and/or ambivalence.
Prevalence
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Think about the ‘reluctant’ families with whom you are working where it is hard to achieve change
• Precisely what was the behaviour that made you think they were reluctant / resistant?
• When did it happen?
• Why do you think it happened?
Exercise
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Beware! These are associations.
They are not causes and nor are they reliable indicators
Key circumstances associated with recurrence:• Families’ history of abuse, particularly substantiated and
repeated prior reports, one of the most consistent and strongest factors– Possibility of labelling and further scrutiny of these
families?
Circumstances and characteristics
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• Multiple, simultaneous problems– Domestic violence, substance misuse, mental health
problems in combination are a stronger predictor of recurrence than each alone
– Criminal activity, lack of financial resources, low social support
• Lack of timely services and assessments• Child characteristics associated with being hard to help:
premature, disabled, teenagers, those returning home from care
Circumstances and characteristics
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Parental attitudes• US study using parent-reported and observed
parent-child interactions found that abusive parents’ reports of their children’s behaviours were more negative than that observed by the researchers
– Suggests the need for more observations of parent-child interactions
– Many studies do not differentiate between mothers and fathers; indeed ‘parenting’ is used when focus is solely on mothers.
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• Fear of consequences
• Stigma and mistrust
• Actual experience of receiving services
Barriers faced by families
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• Parents who are aware that behaviours are damaging but are reluctant to give them up will conceal difficulties, e.g.– Addiction– Relationships with perpetrators
• Parents who fear that their children will be taken away from them will minimise issues e.g.– Domestic violence– Mental ill health
Fear of consequences
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• Parents who are discriminated against e.g.– Black and Ethnic Minority groups– Disabled parents
• Communities who consider it stigmatising to seek state help
• People who have experienced coercive state power in the past
• Parents who hold strong views about physical punishment or child compliance
• Parents who appear to be coping well but have low tolerance of stress
Stigma and Mistrust
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• Parents who were in care themselves
• Parents whose earlier experience of receiving services has involved:
– Services which they didn’t find helpful
– Power being taken from them
• Workers being judgemental, rude, not understanding
Experience of services
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2. What challenges to practice do 2. What challenges to practice do resistance, and the underlying resistance, and the underlying characteristics and circumstances, characteristics and circumstances, raise?raise?Challenges relating to familiesChallenges relating to familiesChallenges relating to practitionersChallenges relating to practitioners Challenges related to agencies Challenges related to agencies
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• Practitioners are able to describe behaviours and circumstances that pose challenges to their practice including:
– Inability to contact parents
– Families’ lack of motivation/commitment
– Families that are in constant crisis
– Violence
• But, they lacked confidence distinguishing between families’ active engagement in treatment vs. false compliance.
Challenges related to familiesChallenges related to families
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• When working with complex families, practitioners sometimes become overly optimistic
– Focus too much on small improvements rather than considering families’ full histories
• Practitioners need to ensure they:
– Are willing to make critical judgements
– Do not underestimate harm to children
– Do not develop ‘fixed views’ of families that are not updated in light of contrary evidence
Challenges related to practitionersChallenges related to practitioners
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• Practitioners involved in complex cases may lose focus on children when:– Parents’ needs eclipse needs of children
– Parents turn the focus away from maltreatment allegations
– Parents make it difficult for practitioners to see children alone
– Practitioners do not have sufficient experience/training to help parents understand how their behaviour is harmful to children
• Men, grandparents and siblings are often left out of equation.
Challenges related to practitionersChallenges related to practitioners
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Practitioners need to ensure they are not:– Unwilling to make critical judgements– Underestimating harm to children– Developing ‘fixed views’ of families that are not updated
in light of contrary evidence– Allowing their own anxieties to lead them to behave
negatively towards families– Failing to involve families fully
BehavioursBehaviours for practitioners to for practitioners to avoidavoid
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• Agency policies may encourage practitioners to create a (false) dichotomy between ‘in need’ and ‘at risk’ of harm
– Comprehensive assessments and services targeted at children deemed to be suffering or being likely to suffer significant harm
• Practitioners feel pressured to close cases quickly and balance heavy caseloads
• Practitioners frustrated with long waits for or lack of available specialist services.
Challenges related to agenciesChallenges related to agencies
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• Poor information sharing and analysis within and across agencies:
– Ofsted review indicated that individual agencies did not have complete information on families’ histories
– Confusion regarding data protection/information sharing
– Assessments were not sufficiently in-depth for decision-making
– Varying thresholds for classifying significant harm
– Sheer number of agencies involved
• Child- and adult-focused practitioners may have different priorities.
Challenges related to multi-agency workingChallenges related to multi-agency working
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• What practitioners perceive as resistance may be parents’ lack of satisfaction with services
• Parents identified some negative traits they associated with practitioners including judgemental, cold, one-sided and insincere
• Parents did not always receive the help they asked for
– Sought out informal sources of support
• Parents expressed frustration that they weren’t involved in assessments and interventions.
Parents’ perspectivesParents’ perspectives
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• Are you prepared? Plans & strategies?
• Could you have aggravated the situation? Is the hostility a response to frustration?
• Does the person need to complain?
• Is behaviour deliberately threatening / obstructive?
• Is the person aware of impact having on you? Is s/he so used to aggression that doesn’t appreciate impact?
• Is your discomfort disproportionate to what has been said/done?
• Taking personally where hostility is aimed at agency?
Making sense of responsesMaking sense of responses
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3. What services, treatments and intervention are effective for families that are resistant to change?
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3 aspects:
• Interventions
• Interpersonal factors
• Assessment
What makes a difference?
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• No studies examine effective services for ‘resistant’ or complex families
• A few studies look at impacts of various programmes to prevent recurrence including:– Intensive Family Preservation Services (IFPS) –
provide a range of intensive, short-term services in the home
– Multi-component – provide a package of services directed at identified problems
– Parent training – teach parenting strategies and help parents improve skills.
Research on effectiveness
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• Long term continuity (as opposed to episodic services)
• Centre-based delivery integrating targeted with universal services
• Preceding or following intensive services with lower-intensity ones (allowing families to re-enter of their own volition if stresses re-occur)
• Services from specialist adult workers
Research on effectiveness
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Child protection system is a powerful tool– Practitioners should harness this power in a positive,
non-coercive manner– Parents’ response depends on an honest
acknowledgement of power differential– Honesty and transparency are important– Workers need the ability to combine support and
control
Social workers and partners must be prepared to ask direct questions on more than one occasion about the impact of adult behaviours on the child
Engaging complex families
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• What worked Multi-agency approach
Shared work plan
Agreement about outcomes needing to be achieved
Information sharing
Right services at the right time
• What didn’t workPoor communication between agencies
Families dividing agencies
Discharge from services - ‘revolving door’
Unannounced visits
Engaging complex familiesSSCB Learning Review
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• Empathy and established relationships skills such as active listening and demonstrable respect are necessary practitioner behaviours– But need to be balanced with healthy dose of
scepticism– Evidence suggests that many practitioners display a
confrontational style
• Active involvement, with as much power as possible given to families
• Experienced, skilled, persistent & resilient staff (SSCB Learning review)
Engaging complex familiesInterpersonal factors
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Practitioner Tips: Written Contracts
Consider drawing up a written contract with the family specifying:
a) Exactly what behaviour is not acceptable e.g. raising of voice, swearing, threatening etc.
b) Spelling out that this will be taken into account in any risk assessment of the child/young person
c) Clearly explaining the consequences of continued poor behaviour on their part- this could include undertaking joint visits, seeing them only at the office; or for statutory agencies initiating action to consider the removal of the child.
Engaging complex familieswritten contracts
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• Cannot underestimate the importance of good, in-depth assessments
• Assessments should not be ‘one-off’ snapshots of families’ behaviours, but should include:
– Observations – particularly, parent-child interactions
– Understanding of families’ histories
– Inclusion of the whole family unit
• Assessments should be sustained to ensure cases do not lose momentum
• The collection of information needs to be coordinated across practitioners.
Effective assessments
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• Assessments weakened by hostility of family – deflected practitioners from focussing on needs of young person
• Practitioners assessments must be evolving pieces of work that can be developed and changed as new information comes to light.
• Importance of information sharing systems across agencies
Effective assessments Local Learning Points
“There is an urgent need to review practitioners’ tendency to rely almost exclusively on interviewing parents about their parenting skills...Attention needs to be paid to observing parent-child dynamics in order to assess caregivers actually parenting, as distinct from describing how they parent...Convincing evidence exists to show that simulating sensitive parenting is very hard to sustain. But to accomplish such a shift in emphasis it is likely that specific observational techniques, such as understanding and recognising disorganised attachment behaviour, will need to be acquired by practitioners”
Observation
• If you feel threatened, what is it like for the child?• Impact of hostility on the child:
oDe-sensitised to violenceoLearnt to appease and minimiseoSimply too frightened to tell
•Have you seen the child? Seen them alone? Listened to them? Understood their views?•What might the child have been feeling as the door closed behind you?
Focus on the Child
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Think of 5 questions which would help you (or someone you supervise) to assess the impact that resistance or
hostility could be having on your work
Please write down your agreed set of questions
Group exercise
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Implications for practice
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• “It is only when skilled and committed workers have time to spend time with and empathise with these parents that it becomes possible to understand when important information or serious problems are being concealed and more intrusive measures to protect the child are needed.
• In these cases, to ensure that the child’s welfare remains the paramount consideration, the role of an equally skilled and knowledgeable casework supervisor becomes even more vital”
The role of supervision
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• Most evidence mentions the importance of management & supervision, few lessons on what works
• Circumstances where good supervision is essential include when practitioners:
– Are overwhelmed/lacking confidence
– Experience violence
– Are acting out their own strong emotions
• A safe but challenging space to guard against rigid adherence to a particular view, or jumping from one theory to another without resolution
– Learning culture; dialectic mindset: playing the devil’s advocate; bring in a fresh pair of eyes
Effective supervision
Effective SupervisionSupervisors need to be able to
• Stand back to ensure that they have oversight of a case• Use processes for regular review and follow-up• Give practitioners a sense of direction• Keep them on track, including reviewing whether the current approach is working• Maintain a clear record of decision-making
Effective SupervisionQuestions supervisors should ask practitioners
What are your assumptions about the family and where is the hard evidence to support them?At what points have you changed your assessment of the situation?Would you have acted differently if this information had come from another source?What alternative explanations / goals might have existed?What factors led you to the chosen option?Might there be other explanations?How might others describe and explain what is going on?Can you picture what life is like for this child?Does your original hypothesis still make sense?Do you need to change your view?Which case are you most worried about and why?Which case are you least worried about and why?
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• Critical role of managers• Stereotypical assumptions
– Males present higher levels of risk– Male workers less likely to be intimidated
• Culture of denial, minimising, ‘part of the job’• Impact of violence or abuse on identity / self-
image• Worker takes on role of family mediator
Staff Care & Safety
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Staff Care & SafetyPractitioner Tips: Keeping yourself safe
• Acquaint yourself with your agreed agency procedures e.g. there may be a requirement to ensure the police are informed of certain situations.
• Don’t go unprepared: be aware of the situation and the likely response• Don’t make assumptions that previously non-hostile situations will
always be so• Don’t put yourself in a potentially violent situation. Feel safe and in
control at all times• Get out if it is getting threateningIf an incident occurs:• Try to stay calm and in control of your feelings• Make a judgement of whether to stay or leave without delay• Contact your manager immediately• Follow your agency’s post-incident procedures including recording.
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Staff Care & SafetyTop Tips for Managers• Keep Health & Safety regularly on agenda of team meetings• Ensure H&S is on all new employee inductions• Ensure staff have the confidence to speak to you about concerns
relating to families• Prioritise case supervisions and do not cancel• Ensure you have a monitoring system for home visits• Analyse and regularly update team training• Ensure everyone knows how to respond in an emergency• Empower staff to take charge of situations, be confident in their
actions• Recognise individual dynamics, acknowledge impact on individuals• Pay attention to staff safety when allocating workloads• Be aware what is happening in local communities
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• Risk management
• Violence to Staff policies
• Case auditing
• Learning reviews
• Performance Management
• Use of ‘near miss’ or serious incident investigations
Using Management Processes
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• The importance of this area of work• Underpinning knowledge • Challenges to practice• Skills and ‘what works’ – effective practice• Importance of assessments• Focus on child, observations & triangulation• Joint working• Trust and empowerment• Need for good supervision and staff care
Final Summary
Challenge or opportunity?• Implications must be considered within current
policy context• Crisis of confidence in the system …• At a time of increased referrals, fewer resources
and less national guidance• BUT Munro review provides opportunity to
refocus on content rather than process • Review findings fit well within this approach –
rediscovering professional judgement
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Where next?
• As a result of the learning you have undertaken, what do you intend to do differently?
• What support will you need?
• How will you know if you have been successful?
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Evaluation
THANK YOU
And Finally…..
