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Cross-recidivism and Chronic Maltreatment

(Originally published September 2021)

Every public child welfare agency has cases of families with 20–50 (or more) CPS reports, both screened in and screened out, beginning when children were infants or toddlers and continuing into adolescence. These cases typically have the following characteristics:

Initial CPS reports contain a wide range of neglect allegations, often minor, but by the third or fourth report contain allegations of physical abuse and/or sexual abuse and emotional abuse or neglect as well. Allegations of multiple types of maltreatment increase as the number of CPS reports increase.
Caregivers have co-occurring substance abuse and mental health conditions, e.g., depression, and often other debilitating conditions such as severe cognitive impairments, frequently combined with domestic violence.
The families are poor, often severely poor, leading to episodic homelessness and unmet needs for medical and dental care.
By the time children enter school, CPS reports contain information regarding parent-child conflict which intensifies as children become older.
Parents sometimes take their child to a hospital emergency room during a child’s “meltdown.”
Children in the family have severe developmental delays and early onset mental health conditions and have difficulty in school, both academically and socially.
Youth, 12-17, often spend much of their adolescence in congregate care or institutional care due to combinations of maltreatment, juvenile justice offenses or chronic mental illness.

Some families have received every service a child welfare agency has to offer, while others may have received no services. Melissa Jonson-Reid, a distinguished scholar who has done outstanding studies on chronically referring families, cautions against the assumption that families with multiple CPS reports must have received - and failed to benefit - from services. Nevertheless, I have encountered cases in which families were resistant to all services and fed up with (in their view) unwarranted CPS interference with their parenting practices. Parents may have repeatedly failed to complete substance abuse treatment programs; and often have given up on the idea that any treatment program can help them.

Child welfare staff are often at a loss for what to do about families with double digit CPS reports who are resistant to services; or have exhausted agency services without apparent benefit when (in their view) they lack statutory grounds for involuntary out of-home placement; or when a child was placed in foster care after a prior CPS report only to “bounce” from home to home while their behavior problems worsened.

I suspect child welfare staff would sometimes prefer to ignore CPS reports when they believe their agency has nothing useful to offer parents or children; but mandated reporters, neighbors and family members usually continue to make reports on children clearly growing up with child maltreatment as a way of life. Communities will not let child welfare agencies “off the hook” for chronically maltreated children; nor should they.

This is a frustrating situation for all concerned, including mandated reporters who cannot fathom CPS inaction in these cases, and for child welfare staff who may feel defeated merely by reading a voluminous case record of multiple investigations and ineffectual service plans. Child welfare staff whose hopeless/ helpless response to chronically maltreating families mimics the hopeless/ helpless feelings of parents regarding their afflictions cannot possibly implement effective case plans. Some persons who have made CPS reports may wonder why CPS programs are even funded if they can do nothing about pervasive child maltreatment that has gone on for years with devastating consequences for child development, and with no end in sight.

What can be done ?

First and most importantly, child welfare agencies can be better supported in legal statutes and better prepared conceptually to recognize indicators of chronic maltreatment before there are double digit CPS reports on a family. Every family with 20-50 (or more) CPS reports once had 2-4 reports at a time when multiple types of maltreatment were not an embedded feature of family life. As a rule, earlier interventions will be more effective. It is possible that crisis-oriented FPS services, or skill based parenting programs and/or poverty related services would help some families if delivered in a timely way, but not after substance abuse, chronic mental illness and DV have shaped parenting practices.

To recognize and offer help to families at elevated risk of chronic maltreatment following the first few reports, CPS caseworkers must be as concerned with:

(a) the cumulative developmental harms of child maltreatment (especially chronic neglect) as with immediate safety threats,

(b) the effects of a pattern of emotional maltreatment on children as with physical abuse/neglect,

(c) a pattern of maltreatment reflected in a history of CPS reports as with the most recent serious incident of maltreatment.

Any CPS report that contains allegations of neglect and physical abuse or sexual abuse should be “red flagged” for special attention. Some families with multiple reports have entered a new terrain of child maltreatment.

State child welfare systems which (a) lack an explicit definition of emotional abuse and neglect in statute, (b) employ a safety framework that conflates safety threats with danger, (c) require evidence of physical harm or immediate threat of physical harm for out-of-home placement, (d) ignore developmental harm, and (e) only fund brief family support services are not prepared to effectively intervene in chronic maltreatment.

It should not be surprising that these agencies are struggling to find effective responses to chronic maltreatment within their current policy and practice framework. In effect, they have conceptually blocked their workforce from providing timely family support services with a focus on early child development; and are challenged to cope with a severely troubled adolescent population difficult to help or stabilize in any type of care arrangement.

Pulling together case management teams

The single most important change child welfare agencies could make to develop more effective responses to families with double digit CPS reports would be to organize multi-disciplinary case management teams modeled on teams that existed in Oregon two decades ago. In this model, a CPS caseworker, substance abuse treatment specialist, mental health therapist and parent advocate were co-located and shared responsibility for 20-25 chronically referring families. These teams included experienced, knowledgeable professionals with varied expertise who met daily to divide up tasks, and to provide mutual support and opportunities for brainstorming. These teams (Oregon had several) were financed with family preservation services funding, which was gradually reduced over several years, cuts that eventually led to their demise. These teams had high morale and a confidence in their ability to help chronically referring families which I have yet to encounter in any other state.

Case management teams are necessary to sustain the morale of professionals in daily contact with demoralized parents and their children. There is no way that CPS caseworkers required to meet the daunting challenges in chronic maltreatment without daily emotional support and concrete assistance can cope with chronic maltreatment. The cases are too complex, with too many urgent demands for one caseworker to manage. Every large and medium sized office needs to develop (with the participation of other community agencies) at least one case management team for chronically referring families. These teams can be funded through a combination of several federal funding streams and through joint planning with other state and local agencies.

Developing engagement skills

Chronic maltreatment is the troubled sibling of chronic neglect, and shares the same characteristics and dynamics:

Co-occurring substance abuse and mental health problems are common, the rule rather than the exception.
Social norms around parenting have eroded or collapsed; anything is possible regarding the parenting of children in some of these families.
Chronically relapsing conditions combined with poverty have led to a loss of self-efficacy, i.e., to a loss of a parent’s confidence in her/his ability to cope with challenges; or perform basic tasks necessary for survival.

If there is a difference in the psychological underpinnings of chronic neglect and chronic maltreatment, it is in the frequency and severity of traumatic experiences, both in childhood and in exposure to violence among young parents (Cort, et al, 2011). Chronic maltreatment is a result of histories of untreated chronic or complex trauma compounded by multiple adversities, both psychological and social. Parents’ capacities for intimate nurturing relationships with children or other adults have been severely damaged by their early histories. There is no quick fix or skill-based evidence based parenting program that can remedy these deficits. More is required.

Initially it is not difficult for caseworkers to figure out the services parents need; they have co-occurring substance abuse and mental health conditions that require intensive treatment, often accompanied by DV. The main difficulty caseworkers face is motivating parents to enter and complete treatment programs in which they have little or no confidence. Caseworker engagement skills are challenged from the first contact with parents who present as apathetic or dejected, with stubborn pushback to any offer of help.

The main rule of engagement practice (Social Work 101) is “join to need,” a rule that applies to all ages, all IQs. Caseworkers skilled at engagement can quickly determine parents’ needs (as parents perceive them), e.g., for concrete poverty related services, or to be “heard,” or for simple kindness, or for help in coping with their child’s behavior, or for meaning and purpose over and above survival. Skilled engagement practice places a premium on emotional intelligence. Engagement skills cannot be learned through classroom lectures or brief training programs; skill development requires practice and coaching. “Joining to need” is the first step in forming a supportive relationship with parents, if not by the caseworker, then by a professional or informal helper.

It is only through a therapeutic relationship that people with long histories of trauma can come to feel safe and cared for, and to develop the courage to reconnect with others. In Trauma and Recovery, Judith Herman asserts:

“Helplessness and isolation are the core experiences of psychological trauma. Empowerment and reconnection are the core experiences of recovery.” (p. 197)

Sobriety and the reduction of symptoms of psychological distress are means to empowerment, reconnection, and renewed confidence of a parent in their capacity to cope with the challenges of parenting. They are not ends in themselves, and not adequate grounds (in and of themselves) for reunification.

Who can be helped?

I have done training on chronic neglect and chronic maltreatment for twenty years. In past years, I cautioned child welfare staff against the tendency to engage in moralistic judgments of parents, urging instead that caseworkers substitute curiosity for judgment, e.g., by stepping back and asking the question, “how did this family come to be in this condition?” Recently, I am sometimes inclined to caution caseworkers and supervisors against viewing families through ideological blinders that minimize the harm of chronic maltreatment and the extent of parents’ functional impairments. Both perspectives remain relevant to meet the difficult challenge of seeing chronically maltreating parents as they are, while offering help to the maximum extent possible.

There are differences among chronically maltreating parents that make it easier or more difficult to provide effective services:
the extent and severity of parents’ mental health problems, including psychiatric conditions, varies greatly.
parents differ in their ability to separate their needs from their children’s needs, and to engage in harm reduction behaviors during drug binges.
parents’ capacity to form and maintain supportive relationships with professionals or informal helpers varies from A to Z.
parents’ capacity to nurture children when they are clean and sober varies enormously.
the extent to which parents have developed a pattern of parenting practices which are cruel, humiliating or dehumanizing is highly variable.
some parents have extended family members willing and able to offer concrete support (such as child-care), while others have alienated their entire extended families.

Parents with less serious and less chronic mental health conditions able to form a therapeutic relationship with a professional or informal helper; and who can distinguish their needs from their children’s needs; and who already have the capacity to nurture a child when clean and sober have the best prognosis. Other parents can sometimes benefit from treatment programs through skilled and persistent outreach, but over longer periods of time and only after many therapeutic setbacks.

Foster care guidelines in chronic maltreatment

There should be one set of placement guidelines for children, 0-5, and another set of guidelines for children, 6-17. Foster care is a dissected system with different risks, potential benefits, and outcomes for these two age groups.

Infants and toddlers are more physically vulnerable (by far) than older children. Some infants have compromised birth outcomes and chronic physical ailments that require consistent, dependable care. CPS assessments in these cases should zero in on parental capacity and motivation to meet their children’s special needs. Voluntary family support services should be offered from birth in these cases, ideally prior to a CPS report. If early intervention services are not available, family support services, including child-care and respite care on demand, should be available from the first CPS report. CPS agencies should not wait until a young child is assessed to be in immediate danger before offering services to a family.

When a chronically maltreated child, 0-5, is assessed by a CPS caseworker to be in danger, the child should be placed with a relative or in foster care unless there is a residential treatment program that can take both the mother and her baby; or unless the mother and child have access to a supportive community living arrangement (e.g., the Lummi Sche’lang’en Village ). In-home safety plans should not be used to control safety threats for children, 0-3, given the lack of research on in-home safety planning, the inadequate resources to support these plans and the extreme physical vulnerability of these children.

Parenting practices that involve deliberate cruelty or a pattern of humiliation or dehumanization of a child should be viewed as a safety threat, regardless of the extent of inflicted physical injury.

Children and youth, 6-17, are less likely to be seriously physically injured by child maltreatment; but more likely to be sexually abused and to have severe behavior problems resulting from a long history of child maltreatment. There is often strong community pressure to place behaviorally troubled children in foster care or residential care, absent physical danger, due to the havoc these youth create in school settings and neighborhoods, and/or because they are clearly on the path to incarceration.

Child welfare agencies have a poor track record of providing therapeutic care for these youth, who may be moved from kinship care to non-kin foster care or residential care facility, while being given cocktails of psychotropic drugs which are often more harmful than the abuse or neglect that led to their entry into care. Child welfare agencies should not give in to community pressure to place these youth in foster care or residential care unless they have a therapeutic resource in which they have confidence, e.g., a relative, therapeutic foster home or residential care program with a good reputation for helping behaviorally troubled youth. In the absence of a therapeutic placement resource, child welfare agencies should at least “do no harm.”

Some sexually abused children and adolescents or other maltreated youth must occasionally be placed in foster care to protect their physical safety, though many safety threats to adolescents can be resolved without lengthy foster placements, or any foster placement. Most child welfare agencies make an intensive effort to find relative caregivers for these children.

References

Cort, N., Toth, S., Cerulli, C. & Rogash, F., “Maternal Intergenerational Transmission of Childhood Multiple Maltreatment,” Journal of Aggression, Maltreatment and Trauma , Vol. 20, #1, 2011.

Jonson-Reid, M., Drake, B. & Stahlschmidt, M., “Cross-type recidivism among child maltreatment victims and perpetrators,” Child Abuse and Neglect, 27, 2003.

Jonson-Reid, M., Emery, E., Drake, B. & Stahlschmidt, M., “Understanding Chronically Reported Families,” Child Maltreatment 15 (4), 2010.

Loman, L.A., “Families Frequently Encountered by Child Protective Services: A Report on Chronic Child Abuse and Neglect,” Institute for Applied Research, St Louis, Mo., 2006.

©Dee Wilson

www.deewilsoncon.com

deewilson13@aol.com