Investigating child maltreatment in out-of-home care: Barriers to effective decision-making
Introduction
In September 2002, there were an estimated 532,000 children in out-of-home care in the United States (U.S. Department of Health and Human Services, March 2004). When children are placed in out-of-home care, public authorities have an obligation to ensure that they are safer in out-of-home care than they would have been at home (The Pew Commission on Foster Care, 2004). Federal legislation underscores this obligation. The Adoption and Safe Families Act (ASFA) affirms that the safety of children is the paramount concern that must guide all child welfare services. ASFA states explicitly that child safety is the paramount consideration in decision-making regarding service provision, placement, and permanency planning for children (U.S. Department of Health and Human Services, 2000). In fact, one of the core outcomes mandated by ASFA is that child welfare agencies will reduce the incidence of abuse and neglect of children in foster care, and the Department of Health and Human Services has set a national standard that no more than 0.57% of children in care will be the subject of substantiated or indicated maltreatment by a foster parent or facility staff member (U.S. Department of Health and Human Services, 2004).
In spite of the increased emphasis on the safety of children in out-of-home care, only 66% of the states with available data in 2001 met the national standard (U.S. Department of Health and Human Services, 2004). Among the 38 states that provided sufficient data for comparison, the percentage of children in out-of-home care who were victims of maltreatment by foster parents or facility staff in 2001 ranged from 0.02 to 1.62 with a median of 0.47.
Attempts to reduce the maltreatment of children in out-of-home care may be hampered by a limited knowledge base. Research on the maltreatment of children in foster care is in its formative stages, with limitations in terms of research design and statistics (Benedict et al., 1996, Zuravin et al., 1993). The literature that exists suggests that maltreatment in foster care emerges from the interaction of factors from three domains: agency practices, foster child psychological and physical characteristics, and foster parent and home characteristics (Carbino, 1992, Ryan et al., 1987, Zuravin et al., 1993). Speculation about factors from each of the three domains has produced a list of what are believed to be salient variables, including: stresses such as acute and chronic illness of foster family members; economic difficulties; marital difficulties; and emotional/psychological problems. Agency factors include inadequate pre- and in-service training of foster parents; licensing and re-licensing of marginally adequate foster homes; overcrowding of homes with children; and inadequate monitoring of homes (Zuravin et al., 1993).
According to federal policies, child welfare agencies should have specialized procedures for responding to and investigating reports of child abuse or neglect by foster parents or child care staff (Carbino, 1991, Nunno & Motz, 1988). Federal regulations that implemented P.L. 93–247, the Child Abuse Prevention and Treatment Act (CAPTA), call for states to have “a statute or administrative procedure requiring that when a report of known or suspected child abuse or neglect involves the acts or omissions of the agency, institution, or facility to which the report would ordinarily be made, a different properly constituted authority must receive and investigate the report and take appropriate protective and corrective action” (CAPTA Federal Regulations, 1985). Research has echoed this position, pointing to knowledge gaps and role conflict as potential barriers to effective responses to the maltreatment of children in out-of-home care.
Based on their knowledge of child protective services (CPS) training programs, Nunno & Motz (1988) suggest that the skills necessary for the successful completion of an investigation of child maltreatment in out-of-home care are beyond the expertise of many CPS workers with experience in familial maltreatment. Workers may lack knowledge in relevant areas, including proper and approved restraint techniques; crisis de-escalation in institutional settings; psychological, medical, and pharmacological treatment of psychological or psychiatric disorders; and the development of institutional corrective action plans (Nunno & Motz, 1988).
Role conflict may challenge the ability of CPS personnel to intervene effectively in instances of out-of-home maltreatment, as well. CPS or foster care personnel charged with dual roles of investigation and support may not feel comfortable providing supportive services to foster parents and child care staff while the investigation is proceeding (Carbino, 1991). When regular caseworkers are charged with conducting the investigation, there may be a conflict of interest as they may have existing working relationships with foster parents or child care staff and may not want to lose an out-of-home placement resource if the results of the investigation prove to be substantiated (Nunno & Motz, 1988).
The decision-making processes required of personnel investigating out-of-home child maltreatment may differ in important ways from those of CPS or regular foster care workers. Investigations of out-of-home abuse require decision-making that involves consideration of the potential culpability of the agency, supervisor, and staff members, and the possible need for corrective action or the revocation of licenses.
Though a number of researchers have investigated decision-making processes related to substantiation and placement (post-substantiation), there is a sparse literature on the decision-making processes related to investigating alleged reports of child maltreatment in foster care or other out-of-home placements. The purpose of this paper is to explore barriers to effective decision-making in response to reports of child abuse and neglect in these settings. Based on the results of a study of the quality of investigations of alleged maltreatment in out-of-home care settings (DePanfilis, 2003), this paper explores factors that may have led to faulty decision-making in four decision categories: (1) placement in foster homes with prior substantiated child abuse and neglect; (2) findings of new reports of child maltreatment; (3) evaluation of child safety after a report of child maltreatment; and (4) licensure and corrective action.
Section snippets
Literature review
An exhaustive search of the literature on decision-making focused on locating prior research on these four categories of decisions made by workers in child welfare agencies. Researchers began studying decision-making in child welfare in the 1950s and this work continues today. As a whole, studies of decision-making highlight the fallibility of clinical judgment (Gleeson, 1987) and unavoidable pitfalls of the decision-making process (Benbenishty & Chen, 2003, Gambrill, 1997), particularly in the
Method
This secondary analysis of a cross-sectional archival case review was designed to assess the quality of decision-making related to required investigative procedures and explore the possible barriers to decision-making when original decisions were judged to be inappropriate. The aim of the original study (DePanfilis, 2003) was to evaluate a representative sample of New Jersey Division of Youth and Family Services (DYFS) Institutional Abuse Investigation Unit (IAIU) files to determine the degree
Faulty decisions
Brief reviews of the four areas of faulty decisions are identified, followed by an analysis of the barriers to good decision-making that may explain each of these decisions. It is recognized that decisions do not occur in a vacuum and that certain faulty decisions (e.g., finding decision) may lead to other faculty decisions (failure to remove a child from an unsafe out-of-home care setting). The main purpose of exploring possible explanations for the errors in decision-making is that it may
Discussion
This paper was based on a secondary analysis of a study of the quality of investigations of child abuse and neglect reports in out-of-home care as recorded in archival records of these investigations. Experts were involved in assessing the quality of key decisions in response to a random sample of investigation reports in one state. Because significant errors in decision-making were identified in four key areas, we looked to possible ways to explain these results. Since there was no prior
Recommendations
Gambrill's (1997) barriers to problem-solving framework allowed us to organize data into fruitful problem barrier domains, and seem promising for use in future studies of faulty decision-making. If barriers identified in this study are confirmed by future research, the mitigation of these barriers could inform child welfare reforms. For example, to enhance task environment, workers could be provided more resources to yield adequate caseloads, and supervisors' skills could be enhanced through
Acknowledgements
The study that is the subject of this paper was partially supported by Children's Rights. Portions of this paper were presented at the International Symposium on Decision-making in Child Welfare, University of California, Berkeley, December 4, 2003. The authors thank case readers Debra Linsenmeyer and Gisele Ferretto for their substantial contributions to this study.
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