CHAPTER
8
Multidisciplinary
Assessment: The Core of Effective Practice
As we
have seen, the problems associated with child abuse and
neglect can be complex. Not only can abused or neglected
children exhibit serious emotional and developmental impairments,
their parents may also struggle with alcohol and drug dependencies,
emotional disorders, lack of attachment with their children,
and deficiencies in parenting skills and knowledge. Also,
the physical signs of child abuse - bruises, broken bones,
and other more subtle signs of non-accidental injuries -
often require experienced medical experts to detect and
confirm as abuse-related. These situations are often
so complex that no single professional or discipline should
have the burden of assessing a family's full needs and developing
a service plan to address them.
All
cases of abuse and neglect can benefit from a multidisciplinary
team approach to medical diagnosis, assessment, investigation,
and treatment. Studies show that in the most serious cases,
sound clinical and prosecutorial outcomes are optimized
when they are the result of comprehensive, up-front assessments
of child victims, joint investigations, quality forensic
interviewing techniques, and limitations in the number of
child witness interviews.
Multidisciplinary
teams are convened to assess a variety of issues including:
medical evaluation, the extent of trauma inflicted on the
child, the child's overall diagnostic and treatment needs,
the indications for prosecution, the non-offending parent's
position, and whether the offender is acknowledging or minimizing
the abusive behavior. There is a growing consensus that
the implications of placement decisions are so critical
to the child that no one individual should have absolute
discretion in this area. Teams can pool the collective wisdom
and experience of their members and make sound judgments
about contacts between offending parents and their children.
In court-involved
cases, the use of teams provides greater likelihood that
the abused child will have input into decisions concerning
their needs. For example, one jurisdiction uses a written
questionnaire to assist in determining parent offender/child
victim contact after sexual abuse has been disclosed. It
asks simply, "Are the child's needs being put forth first?"
This child-centered approach ensures that children's needs
are considered over potentially competing agency agendas
or individual ideologies.[152]
Generically,
Multidisciplinary Child Protection Teams (CPTs) are comprised
of professionals from the medical, mental health, child
welfare, and legal disciplines. The Teams are convened to
evaluate the child's condition and safety and to implement
a service plan to address the needs of the child and family.
A typical
Team assessment includes a physical, psychosocial, and developmental
evaluation of the child, as well as an assessment of the
family's ability to function and provide a safe environment.
The Team's first priority is to ensure the safety of the
child. This could mean a recommendation to remove the child
from the family or to provide a range of family services
so that the child may remain safely at home. Trained legal
professionals on the team determine if a crime has been
committed and identify appropriate legal remedies available
to protect the child from further harm.
The
potential benefits of Multidisciplinary Child Protection
Teams are numerous. They not only improve the quality of
assessments, treatment plans, and services for abused and
neglected children; parents, families, communities, and
the child welfare system benefit as well. Research shows
that multidisciplinary CPTs:
- Increase collaboration and cooperation among agencies;
- Broaden perspectives of involved professionals;
- Increase the number of reviewed cases;
- Decrease the number of cases that "fall through the
cracks."
In
addition, a study conducted by the California Attorney General's
Office concluded that the quality assessments provided through
the multidisciplinary approach expedite the legal process
by decreasing the number of child interviews while increasing
the findings of evidence of abuse.[153] Quality assessments,
therefore, improve the probability of a successful prosecution
in cases of sexual and serious physical abuse.
Teams
have a number of potential benefits for communities, as
well. These include: promoting community awareness and action
with respect to abuse and neglect; increasing an understanding
of community strengths and weaknesses; and, developing additional
services and resources at the local and state levels.
Assessments
can be best provided by permanent, community-based multidisciplinary
teams that function under a statewide system that is itself
based on consistent principles of practice and accountability.
The following section describes such a system.
Child
Protection Teams of Florida
The
longest-standing and most successful system of child protection
teams is in Florida. The enactment of Florida's child protection
law in the early 1970's, and the substantial increases in
reports of suspected child maltreatment that followed, prompted
the state to create a system of diagnostic and treatment
services for children and families who came to the state's
attention through these reports.[154]
Under
Florida statutes, child protective investigators were required
to determine the cause of harm or threatened harm for each
child, as well as the nature and extent of all injuries
from abuse and neglect.[155] Child abuse investigators,
however, were unable to access the resources necessary for
such determinations. As a result, the Florida Department
of Human Resources (DHRS), within which Child Protective
Services is located, developed a method to provide specialized
medical services to aid investigators in this responsibility.
In 1978 the first Child Protection Team (CPT) was established
in Jacksonville, Florida.[156]
This
pilot program involved a team of child and family experts
and an appointed pediatrician with a specialty in abuse
and neglect. Together they provided comprehensive assessments,
more accurate diagnoses, and appropriate treatment plans
for affected children and families. The success of this
team, funded through legislative appropriation, led to the
development of CPTs in each of Florida's 15 districts that
operate under the Department of Health.
Child
sexual abuse reports dramatically increased in the early
years of the CPTs operation. Soon CPTs, originally established
to evaluate physical abuse and neglect, became specialized
in the medical examinations of sexually abused children
and the evaluation of sexual abuse accusations. This led
to the awareness that many other sexually abused children
did not have access to appropriate treatment and services.
Thus, in 1984, the legislature funded child protective services
to develop Florida's Sexual Abuse Treatment Program (SATP),
a model intervention and treatment plan for child sexual
abuse victims and their families that now also operates
through funding by the Department of Health.
Although
collaboration exists between the CPTs and SATPs, each program
has a unique purpose and offers distinctive treatment options.[157]
CPTs are prime examples of high functioning public/private
partnerships. They are community-based and function independently
as non-profit organizations, providing consultative services
to Florida's state child protection agency. Teams are funded
by state allocations which support core services, including
interviews, case coordination, medical evaluations, psychosocial
assessments, psychological assessments, expert testimony,
and training.[158]
Children
who have been reported to Florida's abuse hotline and have
been accepted by Child Protective Services for assessment
meet the criteria for CPT services. These usually include
physically abused, sexually abused, or medically neglected
children.
Currently,
there are 23 teams that provide services 24 hours a day,
seven days a week, in all areas of the state, as well as
satellite locations for those teams serving large geographic
regions.
CPTs
function under the direction of a pediatrician with expertise
in child abuse and neglect who serves as the medical director.
Other consultant pediatricians work for the team either
on a fee-for-service or contract basis. Some teams have
Advanced Registered Nurse Practitioners (ARNP) that practice
with a consultant pediatrician.
A Team
Coordinator, usually a social worker or nurse, is responsible
for the coordination of daily activities and supervision
of social work. The Team also has Case Coordinators, who
conduct individual casework and assessment activities. CPTs
are actively involved in training other professionals to
identify abuse.
CPTs
have a licensed psychologist and a consulting attorney,
either on staff or on contract. Depending on the particular
case, other staff members may include school personnel,
representatives from community agencies working with the
child and family, or an attorney representing the state.
Across Florida, current CPT staff include 133 physicians
and ARNPs, 212 social workers as case coordinators, 14 nurses
as case coordinators, 46 psychologists, and 18 consulting
attorneys.[159]
Many
CPTs are now located within the more recently established
Children's Advocacy Centers and function in accordance with
the National Standards of Children's Advocacy Centers. (A
general description of CACs follows.) Though child welfare
and child health professionals in Florida launched this
system over twenty years ago, it has continued to evolve
to meet newly identified needs. For example, when Florida
recognized the need to reach rural areas with a shortage
of trained professionals, they initiated a "telemedicine
program." This program has significantly reduced the number
of children needing transportation for evaluation, and has
increased successful court actions by improving the medical
expertise of local health professionals.[160]
Another
example of how CPTs have evolved relates to the state's
aggressive recruitment and training strategies for physicians.
All medical personnel participating on these CPTs must complete
a required training curriculum. The training encompasses
classroom training and a requirement that the physician
in training work with an experienced professional mentor
prior to being deemed sufficiently experienced to evaluate
and treat child abuse cases.
This
basic training is supplemented with widely attended regional
trainings held twice a year where medical staff consult
with their colleagues on complex or unusually cases and
learn about the latest advances in the field. These trainings
are offered at no cost to the physician.
Consumer and Professional Responses to Florida's Program
Annual
surveys conducted by the Children's Medical Service division
of the Florida Department of Health have consistently
found that the majority of children and families involved
with Child Protection Teams are very satisfied with the
quality of team services. Eighty-seven percent (87%) of
participants rated the quality of team services "excellent
or good."[161] Satisfaction among mandated reporters who
interface with the teams was even higher.[162]
The
role of Florida's CPTs in reducing subsequent child deaths
from abuse and neglect is noteworthy. Data show that only
three of the many thousands of children assessed by the
Teams later died from abuse or neglect. (In one case,
Child Protective Services did not follow the Team's recommendation
that the child not be returned home.) In contrast, 68
child deaths occurred among children served by Child Protective
Services who were not referred to the Teams.[163]
Florida's
Child Protection Team Program provides assessments and
evaluations by permanent community-based multidisciplinary
child protection teams that function under a statewide
system based on consistent principles of practice and
accountability. The longevity and success of this child
protection program makes it an exemplary model for evaluation
and study by other states committed to implementing approaches
that work.
By
working creatively to identify multiple funding streams,
CPTs in Florida have demonstrated that fiscal cost need
not be barriers to quality assessments for abused, neglected
and traumatized children. Florida CPT's provided 19,142
children and their families with assessments in Fiscal
Year 1997-98, at an average cost of $436 per assessment.[164]
Massachusetts
Teams
Currently,
in the state there are different multidisciplinary team
approaches operating in response to cases of child abuse
and neglect - Sexual Abuse Investigative Network Teams (SAIN
Teams), Children's Advocacy Centers (CACs), hospital-based
Child Protection Teams (CPTs), and Multidisciplinary Assessment
Teams (MDATs). The quality and availability of the teams
vary widely across the state. They also differ greatly with
respect to their specific goals, functions, structures and
membership.
Overall,
these teams do not make up a statewide, coordinated system
with uniform standards and accountability to identify, assess,
and treat child abuse victims as they enter the child protection
agency. The existence of this basic infrastructure, however,
makes it possible to envision the development of an effective,
truly coordinated, statewide system.
Some
counties are working to develop better coordination among
their local teams, and legislation is pending to address
the need for statewide Children's Advocacy Centers and to
expand hospital-based Child Protection Teams. These important
efforts and the recommendations described below could significantly
upgrade Massachusetts' child protection response and result
in more effective investigation, evaluation and treatment
planning for children and families.
In describing
the various teams operating in Massachusetts, there are
a number of issues that are fundamental to the future functioning
of all of them.
 |
Confidentiality
Since multidisciplinary teams are specifically designed
to cross professional barriers, issues of confidentiality
among professionals who participate on these various
teams must be formally addressed. |
|
Training
Multidisciplinary teams must be supported through ongoing
training programs aimed at enhancing professional skills,
clarifying team roles, and supporting good team dynamics. |
|
Decisions
by the Courts
The assessments and recommendations made by multidisciplinary
teams must be routinely shared with the courts as they
formulate decisions on a range of service and placement
issues involving abused and neglected children. This
will better ensure decision making that is in children's
best interests. |
|
Services
Adequate funding of current effective services and the
development of specific family supports and treatment
options identified by the various teams are essential
to the Teams' ability to develop and implement service
plans that effectively meet the needs of children and
their families. |
Sexual
Abuse Investigative Network Teams [SAIN TEAMS]
The
Sexual Abuse Investigation Network (SAIN) program was developed
in the early 1980's by DSS, District Attorney's Offices,
and law enforcement, in an attempt to create a multidisciplinary
approach to the investigation and assessment of child sexual
abuse cases.
The
complex nature of sexual abuse cases requires that various
professionals be involved with the child and the family
during investigations. In past years, the increased number
of involved professionals often resulted in multiple interviews
of children. To avoid the potential negative impact of multiple
interviews, professionals developed the investigative process
used by SAIN teams. It minimizes trauma for children and
provides a more structured, systematic response.
The
first SAIN teams in Massachusetts began in Springfield in
the early 1980s.[165] By 1998, SAIN teams had been implemented
in each of the 11 judicial districts of the state.[166]
Most SAIN teams do provide support to investigators and
to families. However, the main focus of these teams is interviewing
child victims of sexual, and, in some counties, physical
abuse. Even though there is no standardized model for this
process, the interview procedure has been found to be similar
across sites.[167]
Each
SAIN team has a team coordinator responsible for scheduling
team meetings, managing the SAIN process, assisting in the
sharing of information, and functioning as a resource for
other team members. Most teams have a separate forensic
interviewer.
Teams
consist of professionals from the District Attorney's Office,
police, and child protective services. While professional
disciplines within the team vary across counties, each team
is typically comprised of a DSS investigator/supervisor,
Assistant District Attorney, a Victim Witness Advocate,
a professional from law enforcement, and a child interviewer.
When needed, a physician is consulted regarding medical
evidence, and some counties have mental health professionals
that may consult with the team.
In cases
of alleged abuse, pre-interview meetings are held to orient
the team, plan the interview, and, if appropriate, gather
information from parents. The child interview usually lasts
from thirty to sixty minutes. The interview is typically
carried out in a small, comfortable room with a one-way
mirror. It may also be videotaped depending on the needs
of the team. The one-way mirror and videotaped interview
are essential, for they decrease the likelihood of the child
having to be interviewed more than once.
Specialized
interviewers with training and experience in child interviewing,
forensics, and child safety conduct the majority of interviews.
Other members of the team may occasionally conduct an interview
if, for example, they have a better relationship with a
child or are better "match" with a child, in terms of gender,
culture, or style of interviewing.[168]
Cases
that are eligible for SAIN services differ from team to
team. Many teams have tried to create a written set of criteria
to clarify what constitutes an appropriate referral. However,
these criteria are not always written clearly and many are
subject to interpretation. One frequent criterion is a required
disclosure by the child or clear medical evidence that sexual
abuse occurred. But it is very difficult to determine objectively
what constitutes a disclosure, and even more taxing to understand
the definition of "clear medical evidence."
DSS
is the primary referral source for SAIN cases and participation
is voluntary, based on parental consent. At present, DSS
is attempting to standardize the criteria and is conducting
a statewide survey and developing a reporting protocol.
Massachusetts
SAIN teams clearly demonstrate many benefits.[169] SAIN
teams:
- reduce the number of child interviews;
- reduce or eliminate inconsistencies resulting from
multiple interviews;
- increase the consistency and clarity of investigation
for families;
- help families access additional services;
- increase the overall quality of interviews and investigations;
- enable investigators to gather evidence more thoroughly
because of information sharing;
- increase the tracking of cases;
- increase understanding of other service systems through
training and mentoring programs.
These
specialized teams could logically evolve into full-scale
multidisciplinary assessment teams whose role would extend
beyond the forensic interview. Today, several former SAIN
teams have, in fact, evolved into full-scale Children's
Advocacy Centers (described more fully below). Within this
model, children who have been referred because of allegations
of serious physical abuse or neglect have the advantage
of a forensic, clinical, and medical assessment, as well
as follow-up clinical support and case management. The trend
to evolve SAIN teams into a statewide system of Children's
Advocacy Centers must be supported and encouraged.
Children's
Advocacy Centers [CACs]
The
National Children's Advocacy Center (CAC) Model was first
developed in Huntsville, Alabama in 1985. This model was
designed as a multidisciplinary program independent of the
major state agencies involved in child abuse investigations.[170]
It is similar in purposes to other multidisciplinary approaches,
such as the Florida Child Protection Teams and the Massachusetts
SAIN teams described above that have expanded their role.
The
purpose of the Children's Advocacy Center model is:
- To facilitate collaborative investigations of suspected
child abuse;
- To decrease the trauma associated with multiple interviews
of the child; and,
- To provide supplementary services to abused children
and their families.[171]
The
response to child abuse allegations includes forensic interviews,
medical evaluation and referral for therapeutic intervention,
victim support and advocacy, case review and case tracking.
These components may be provided by the CAC staff or by
other members of the multidisciplinary team.
Ideally,
CACs are governed by a non-profit board of directors and
are located in independent physical facilities where interviews
are conducted in specially designed child-friendly environments.[172]
Unlike SAIN teams that limit their interventions to child
victims of alleged abuse, CACs have been designed to extend
their services to non-offending family members of the alleged
victim. While SAIN teams were created to deal specifically
with sexual abuse, CACs are involved in serious physical
abuse and neglect, as well.
The
core staff of a CAC typically consists of a coordinator,
mental health consultant and trained volunteers who assist
in the day-to-day operations of the center.[173] CAC staff
is also involved in the coordination of the teams, and in
providing follow-up and coordination of training for the
team members.
The
Nation Children's Alliance, a non-profit organization committed
to the establishment and improvement of Children's Advocacy
Centers, has identified the following components necessary
for full membership in the Alliance.
- A child-appropriate facility
- Organizational capacity
- Cultural competency and diversity
- Forensic Interviews
- Multidisciplinary Teams that include members from:
- law enforcement
- child protective services
- prosecution
- mental health
- victim advocacy
- Children's Advocacy Center
CACs
are designed to accommodate the special needs of the community
and in this way, each CAC is unique, with varying components.
CACs that seek full-membership in the Alliance work towards
implementing all of the required components listed above.
Within this range of diversity, however, all programs share
a common philosophy:[174]
|
Child
abuse is recognized as a community problem. No single
agency, individual, or discipline possesses the required
knowledge, skills, or resources to provide comprehensive
assistance to abused children and their families. |
|
Interventions
in child abuse cases must be sensitive to the needs
of abused children and their families and these needs
must be addressed in a respectful environment. |
|
Collaboration
among the various disciplines that comprise the child
protection system will result in a more thorough understanding
of cases, and in the most appropriate responses available. |
Children
involved in allegations of sexual abuse, serious physical
abuse, or siblings of children who have died from abuse,
are eligible for CAC services. Though DSS is the primary
referral source for CAC cases in Massachusetts, referrals
are also made by other agencies, including police, hospitals,
mental health agencies, and school departments.[175]
There
are several advantages to the CAC design according to the
Final Report of the Multidisciplinary Task Force convened
in 1995 by DSS to review models of multidisciplinary team
practice.[176] By creating a child-friendly environment
located in a site not associated with any one agency, CACs
create a less traumatic atmosphere for the child. This setting
also minimizes family members' negative impressions of the
child protection system and provides them with a single
point of entry to services provided by various systems involved
with the CAC.
The
CAC's ability to provide a coordinated and collaborative
response is founded on interagency agreements and so its
success depends on each agency's continued ability and willingness
to participate and meet commitments. Another factor that
affects the CAC's success is its ability to acquire adequate
funding for its site and for the provision of services.[177]
In 1994,
the Suffolk County Task Force began designing the first
Children's Advocacy Center in Massachusetts to replace its
existing SAIN team.[178] In addition to Suffolk County,
there are established centers in Middlesex, Hampden, and
Berkshire Counties. Centers are under way in Norfolk, Plymouth,
Franklin-Hampshire and Barnstable Counties. Some existing
SAIN Teams, such as the one in Essex County, have now expanded
their teams to include physical abuse.
Referrals
to these multidisciplinary teams have increased dramatically
over the past decade, a clear indication of the need for
expanded capabilities within these centers.
Hospital-based
Child Protection Teams (CPTs)
Hospitals
and emergency rooms are frequently the first to identify
children who have been the victims of physical abuse, sexual
abuse and serious neglect. Since the 1970s, hospitals have
understood the need to establish internal systems to address
the various needs of these children and their families.Hospital-based
Child Protection Teams were initially established to bring
together medical specialists and hospital social workers
to develop appropriate responses to these cases. State child
protective workers became regular members of some of these
teams and all worked together to contribute to an appropriate
service and treatment plan. In Massachusetts, the earliest
CPTs in hospitals were developed at Boston City Hospital
and at Children's Hospital in the late 1960s.
A recent
survey conducted by Massachusetts Citizens for Children
of recognized experts in child abuse found that statewide
there are fewer than ten physicians who identify themselves
or are recognized by their peers as experts in child abuse
and neglect.[179] It is alarming that in a state recognized
as a leading center for expert pediatric medical care, the
number of trained child abuse specialists is so low. In
contrast, through its statewide, comprehensive system of
Child Protection Teams, Florida and its courts recognize
133 such experts while its population base is only one-third
larger than Massachusetts.
Hospital
emergency room staff, family practitioners, pediatricians,
and other specialists treating children are literally lifelines
for children who present with injuries and symptoms resulting
from abuse and neglect. Failure to recognize non-accidental
injuries and to report suspected child abuse cases has cut
the lifelines of too many Massachusetts children who are
sent home only to return to hospitals dead, dying, or seriously
injured.
The
major reason for the failure to attract physicians to this
important work is economic. Currently hospital-based CPTs
operate on woefully inadequate budgets. These multidisciplinary
teams generate very little income for the hospital, and
in today's fiscal environment, hospitals are not inclined
to underwrite budgets for the teams to the degree needed.
In contrast
to Florida, the state legislature has appropriated no funds
for this activity, and DSS has no funds within its budget
to support this. Consequently, the medical component of
most reported cases of child maltreatment is omitted. There
are no Fellowships at any Massachusetts hospitals to train
the next generation of child abuse specialists. Currently,
of the six pediatric specialists in Massachusetts, one is
over 65 years of age, one is in his late 50s, and the rest
can only do this work on a part-time basis. Also, no support
for organized research about child maltreatment exists,
despite the fact that over 100,000 cases are reported each
year.
The
shortage of child abuse experts within medical settings
is further compounded by a lack of formal supports for new
physicians coming into this field. Without it, physicians
interested in child abuse quickly become overwhelmed and
discouraged. For example, at Baystate Medical Center in
Springfield a resident physician who developed expertise
in this area soon became inundated with referrals. During
this physician's tenure of less than a year, referrals from
various departments in the hospital increased dramatically.
Without an adequate number of other child abuse specialists
to help evaluate cases, the physician eventually left the
specialty, physically overwhelmed and emotionally drained.[180]
Clearly,
physicians need a structured support network they can turn
to for consultation around complex cases and where they
can gain the emotional support they require. Massachusetts
must move quickly to establish and fund a statewide system
of hospital-based Child Protection Teams and support the
development of a statewide training and fellowship program
that would aggressively sponsor, recruit and support physicians
to work in this vital area.
Teaching
hospitals for children have been shortchanged under federal
policies for underwriting the training of physicians. Graduate
programs for medical doctors are subsidized primarily through
the Medicare health care program for the elderly. Since
pediatric centers treat young children, they receive few
benefits.[181] For example, the average independent children's
hospital receives about $400 federal dollars per resident
physician while the average adult hospital receives $87,000
per resident.[182]
All
pediatric hospitals in Massachusetts are attempting to cut
costs and improve fund-raising in response to huge fiscal
losses.[183] This situation could be turned around through
a $285 million dollar proposal in Congress to fund children's
hospitals. This critical federal aid would allow hospitals
such as the Floating Hospital for Children, Massachusetts
General Hospital for Children, the Pediatric Department
of Boston Medical Center, Children's Hospital, and others
across the state to move beyond their current level of service,
and expand critical help for abused and neglected children.
Multidisciplinary
Assessment Teams [MDATS]
The
MDATs are Massachusetts' most recently implemented type
of multidisciplinary teams, and are convened by the Department
of Social Services. Initially piloted in January 1997, MDATs
are currently operational in the 28 DSS Area Offices.[184]
Their stated purpose in 1997 was to:
- Collect comprehensive clinical information and improve
understanding of the family and its needs;
- Work directly with the family and child and develop
recommendations to serve as the basis for a relevant and
appropriate service plan; and,
- Facilitate referrals to community-based services and
communication between DSS and community agencies. (Note:
This precedes implementation of Family Based Services
Treatment Teams within DSS that began in 1999.)
Long-term
goals of MDATs as described by DSS are to improve DSS decision-making
early in the case, reduce the time a case remains open,
decrease the number of children in out-of-home and multiple
placements, reduce the rate of families re-entering the
protective service system, and encourage community-based
providers to participate more actively with DSS in serving
children and at-risk families.
MDATs in Theory
In
theory, each MDAT is assigned a DSS team convener, who
is responsible for scheduling and organizing meetings,
facilitating Team discussions, distributing case materials,
and preparing final assessment reports.[185]
Teams
are ideally composed of standing members who meet on a
regular basis and represent a variety of disciplines.
Core DSS members may include a Team Convener, Social Worker,
Assessment Unit Supervisor, and Domestic Violence Specialist.
External members might include, a Substance Abuse Specialist,
Mental Health/Trauma Specialist, and a Pediatrician or
health care practitioner.[186]
In
addition to its core members, MDATs can seek assistance
from other community specialists in specific cases, e.g.
a dentist might participate in a case involving serious
dental neglect. Team members are meant to play an active
rather than consultative role in assessing families and
facilitating services.
During
the Initial Investigation/Assessment phase of the case,
the MDAT could be called upon to serve:
- Children with 6 "highs" on the Risk Factor Matrix
who are living at home;
- Children with 10 "unknowns" on the Matrix at the
conclusion of the investigation;
- Families whose cases are closed and then re-opened
within 6 months; or
- Sexual abuse cases, or those involving juvenile sex
offenders.
The
"highs" and "unknowns" described above are derived from
the Risk Factor Matrix used by DSS social workers to determine
if a child is at risk.[187] Questions on the matrix are
divided into categories: Child Characteristics, Child/Caretaker
Relationship, and Caretaker Characteristics. For each
question, the social worker making the assessment evaluates
the child's status as no risk, low risk, moderate risk,
high risk, or unknown risk. Once the level of risk has
been assigned for each question, the social worker determines
the overall level of risk, and, if necessary, refers the
child to services.
Cases
involving MDATs at the Ongoing Case Management phase might
include:
- Children with multiple placements (over 3 placements
within 6 months);
- Families who have multiple 51As filed;
- Children re-entering care after a return home within
6 months; or
- Cases that are chronically "stuck."
MDATs in Practice
While
the theoretical premise of MDATs is appealing, an evaluation
of currently operating MDATs demonstrates that many are
still striving to fulfill their envisioned goals. When
MDATs were originally implemented, a five-stage evaluation
was planned to monitor the development, progress, outcomes,
and impact of these Teams. The most recent analysis of
this evaluation, entitled "Phase Two" was written in November
1998 and provides insight into how the MDATs were functioning
after one year of operation.[188] Responses to anonymous
surveys developed and distributed by DSS and completed
by Team members, highlighted benefits, as well as areas
that needed development.
Sixty
five percent of respondents had been on their team for
at least 10 months.[189] Although this percentage indicates
length of membership, it does not demonstrate the quality
or level of active participation of each member. In other
words, it does not distinguish between those members who
regularly and consistently attend meetings and those who
do not.
Consistent
with our discussion above about the lack of pediatric
child abuse specialists, the evaluation revealed that
few physicians or other health experts were members of
MDATs.[190] Lack of funding has been cited as the reason.
Although in a few instances, local MDATS have chosen to
use flexible funds to support the participation of key
medical representatives, there is currently no statewide
mechanism in place to fund medical professionals for these
teams. Given that most cases reviewed by the MDATs involve
moderately to severe abuse or neglect with medical implications,
the lack of input from specialized health experts with
experience in diagnosing and treating child maltreatment
is alarming.
Benefits
cited by team members during the evaluation include increased
collaboration among a variety of experts, increased collaboration
between DSS and service agencies, and increased availability
of flexible funds needed to provide creative services
to families. Criticisms of the MDATs were that the amount
of time required to participate was significant and more
than had been anticipated. Many professionals cannot remain
on teams where compensation does not adequately match
the time and resources necessary for their attendance.
Also, 51 percent felt they received too little follow-up
information on the cases reviewed.
Half
of the "Phase Two" survey respondents indicated that they
rarely or never saw the child and family being discussed.[191]
Since the quality of any review is highly influenced by
direct contact with the family and child in question,
some argue that the MDATs are mostly consultative to the
DSS social worker and do not conduct true "assessments."
A
recent DSS survey of the kinds of cases being reviewed
by ten MDATs makes it clear that a majority of cases being
referred have been in the system for some time. These
include: families with complex, interacting problems,
e.g. domestic violence, substance abuse, serious mental
illness; children with multiple 51A reports; children
with multiple placements within a short period of time;
children re-entering care within 6 months of returning
home; and, chronically "stuck" cases. Though there is
certainly value to providing input on difficult cases,
it appears that the original purpose of the teams to review
cases "up-front" and early is not its prime focus.
The
need to conduct quality multidisciplinary assessments
at the earliest stages of a case is a theme that
has been consistently promoted by MCC since its Settlement
Agreement with DSS in the mid-80s. As part of their separate
investigations into the functioning of DSS, both the Senate
and the House Committees on Post Audit and Oversight have
embraced the notion of multidisciplinary teams and assessments.[192]
A
central recommendation of the 1993 Governor's Commission
Report on Foster Care[193] called for "front-loading"
the system, that is, to focus the bulk of resources at
the front end of the system when cases are just entering
and a quality assessment of the child's and family's needs
are essential. The rationale is that if cases are properly
assessed and addressed early on, they will likely move
through and away from the system faster, benefiting the
child, family, and the state agency. Such early and comprehensive
assessments, it is argued, would minimize poor decision-making
that may contribute to cases being "stuck" and those cases
that revolve in and out of the system. The need for quality
multidisciplinary assessment conducted early on in a case
was a prominent recommendation reiterated throughout the
Summit's recent proceedings.
MDATs and Family Based Services Treatment Teams (FBSTs)
In
1999, DSS began to implement a Family Based Services model
combining multidisciplinary practice and family strengthening
principles within a managed care system. In this model,
established child welfare agencies compete to serve as
the Family Based Service Lead Agency in their particular
area of the state. Through local FBS Treatment Teams,
Lead Agencies provide services to DSS clients from an
array of local services. Increased family input in choosing
appropriate services, and increased use of community supports
for families are key to this program. Local, culturally
competent experts in child development, substance abuse
and other clinical issues can be made available to the
network.
Currently,
every DSS Area Office utilizes Family Based Services.
Open DSS cases are served, as well as cases involving
Children In Need of Services (CHINS) referred by the courts.
According
to DSS, the roles of these two evolving team models is
differentiated in the following way:
- MDATs provide a better understanding of a family
and their issues resulting in a comprehensive clinical
assessment, whereas
- FBS Treatment Teams provide a family-centered treatment
plan following a completed assessment, as well as
access to wrap-around services.[194]
These
models represent the beginnings of an infrastructure within
DSS based on family support principles and multidisciplinary
practice. Their development should be supported. However,
as these team models evolve, a clearer distinction should
be made between the development of a service plan and
its subsequent implementation. MDATs are better positioned
to assess the child and family, and based on their assessments,
to develop a detailed treatment plan. FBS Teams
can best implement the treatment plan by creatively
utilizing community contacts and flexible funding.
Dividing
the roles of these two teams in such a way has important
benefits for children and families. The clinical composition
of a fully developed MDAT ensures that the treatment plan
is tailored to the specific needs identified in the clinical
assessment. The MDATs are also not constrained by managed
care considerations as they develop treatment plans. In
contrast, FBSTs are more limited in their clinical expertise
and by their very design are meant to function as agents
of the managed care system. This has direct implications
for families and the types of services they receive.
For
example, an MDAT recommendation could include providing
parent aide services to a neglectful mother. Parent aide
services by design are based on the development of a relationship
between the parent aide and the parent and may take from
three to six months to establish. Important gains are
often made in the period after the relationship is formed
and trust has been built. If an FBS Treatment Team accepts
the MDAT's recommendation for this specific service but
limits the duration to three months, it will negate the
basic philosophy of this lay therapy approach, thus rendering
the entire intervention ineffective.
Recommended
treatment plans that are not implemented in full, or services
that are provided for a shorter duration than recommended
can have dire consequences: service plans fail, parents
working in good faith to improve their care taking skills
are further stressed, state dollars are wasted, and children
remain at risk.
Currently,
many workers are reluctant to bring a case to the MDATs
because they will need to present it a second time to
an FBS Treatment Team in order to obtain services for
their clients. Their clients may also have to meet with
both teams. This is an inefficient use of limited caseworker
resources and discourages families from participating
in what they see as a redundant process.
While
the functions of these two teams should be distinct and
clear, information sharing and coordination between them
is essential. Identifying a representative of the FBS
Treatment Team to serve as a core member of each MDAT
and to act as a liaison would be an ideal way to achieve
this.
Family Support Teams
As
discussed earlier, DSS cases identified as low risk, cases
screened out without any investigation, or those found
not to be substantiated after investigation could benefit
from Family Support Teams that could coordinate family
conferencing and "assessments" at the local level. Family
Support Teams that include community-based social workers
and other child and family service providers assist the
family in identifying local supports that could reduce
stresses and improve family life. In this model, parents
play a key role in identifying their needs and the supports
that would be most helpful in addressing them. Some local
DSS offices are introducing the concept of Family Support
Teams through "Community Connections," their community-based
partnership program. A further description of this program
is included in Chapter 16.
Multidisciplinary
Assessments and the Courts
The
impact of quality assessments on the handling of child abuse
cases by the courts can be significant because these assessments
are seen as highly reliable and accurate. For example, Florida
CPT cases referred to the courts have an 89 percent rate
of conviction or pleas, while the rate of non-teamed cases
is only 69 percent. This higher rate reflects the CPTs'
ability to properly send only the most appropriate cases
to the court for its review, thus reducing court costs.
In addition, data show that Florida courts order 94 percent
of recommendations made by CPTs, whereas only 53 percent
of services are ordered when recommended by child protective
service workers without the benefit of a team assessment.[195]
It is
clear that the quality of judges' decisions in complex matters
involving children and families is inextricably tied to
the quality of the information they receive. Massachusetts
courts and the children they serve could benefit greatly
from assessments and recommendations made by multidisciplinary
teams. A discussion of this proposal is found in Chapter
13, "Abused/Neglected Children and the Courts."
RECOMMENDATIONS
Children's
Advocacy Centers
- Enact legislation to support a statewide system
of Children's Advocacy Centers.
To provide comprehensive and coordinated assessments of
children and families involved in serious cases of child
abuse and neglect, a statewide system of Children's Advocacy
Centers must be established and funded. These Centers
should be located in every county and in sub-county sites
based on population and the distribution of child abuse
and neglect cases.
- Include relevant disciplines within CACs.
Assessments conducted through CACs should involve all
relevant disciplines including: health, mental health,
DSS, the District Attorneys, law enforcement, victim advocates,
as well as, family violence specialists, educators, and
others when indicated. Quality forensic interviewing by
trained law enforcement or mental health professionals
should be a core component of CACs. Medical evaluations
by pediatricians or nurses trained in child abuse and
neglect diagnosis and treatment should also be a core
component of the CAC system. Development of statewide
emergency response protocols for after-hours assessments
should also be developed.
- Reflect local community preferences when locating
sites for CACs.
Though the National Alliance Standards promote the location
of CACs as independent, non-profit entities governed by
community boards, they also state that CAC location should
reflect the preferences of the community. Some CACs operate
under the auspices of a District Attorney's Office or
as a specialized unit within or on the grounds of a hospital.
Drawbacks associated with these settings, however, may
include too narrow a focus on cases involving prosecution
and the high overhead costs associated with hospital sites.
Decisions about CAC location should be determined jointly
through a process involving law enforcement, medical,
child protection, and community leaders. A major goal
is to ensure a setting that will provide clients with
the greatest level of comfort.
- Standardize referral criteria to the CACs.
CAC legislation must define the specific types of cases
that should be referred to the CACs for assessment and
referral to treatment. Cases involving the courts and
other serious cases of abuse and neglect should be the
prime focus of the CACs. Referrals from the child protection
agency and law enforcement should conform to these standardized
referral criteria.
- Provide case management, review, data collection,
tracking and outcome measures within CACs.
In addition to the function of assessing cases, CACs must
provide case management and case tracking services or
coordinate this function with other identified agencies.
In addition, periodic case reviews and evaluation of outcome
measures are essential to ensure effective response to
child abuse victims.
- Develop training protocols.
The CACs should work in conjunction with the Departments
of Social Services, the District Attorneys, boards of
registration, and other accrediting bodies, to develop
training protocols for all relevant disciplines, for example,
law enforcement and forensic interviewers engaged in investigating
cases of child abuse and neglect. The CACs and hospital-based
Child Protection Teams should join in coordinating and
providing training for other relevant disciplines, e.g.
social workers and mental health professionals.
Hospital-Based
Child Protection Teams
- Enact legislation to support a statewide system
of hospital-based Child Protection Teams.
These CPTs should be established initially within medical
teaching institutions located regionally across the state.
Each CPT should include core staff including, at a minimum,
a pediatrician, a psychologist, and a social worker who
are trained to medically evaluate and treat children who
have been abused and their families. Consultation on a
24-hour availability to other hospitals in the region
ands to other rural medical sites would also be included.
- Create and fund a statewide medical training program
to recruit, train and support pediatricians, nurses and
other relevant medical providers to become child abuse
and neglect specialists.
In addition to training medical personnel, the hospital-based
Child Protection Teams should join with the CACs in coordinating
training for other relevant disciplines e.g. mental health
professionals, social services staff, law enforcement
personnel, teachers, and other human service workers.
Furthermore, Fellowships in Child Maltreatment must be
established within the CPTs and supported with state funds
to replenish the dwindling supply of child abuse specialists
in Massachusetts.
Multidisciplinary
Assessment Teams (MDATs)
- Ensure quality and effectiveness of MDATs within
DSS.
Core standards for MDAT composition and team member participation
should be implemented to improve quality assessments,
decision-making, and service planning for children and
families. Each family deserves the right to a quality,
comprehensive review of their case.
- Include professionals with a wide range of competencies
to serve on MDATs and provide a mechanism for reimbursement
of selected specialists.
MDATs could be improved by increasing the number of disciplines
represented on each team, particularly medical and educational
experts. A funding mechanism must be developed to ensure
the participation of these core members and other specialists
when needed.
- Conduct assessments when cases are first
opened.
MDAT resources should be focused more on "front-end" assessment
of cases, than on cases that are "stuck" in the system.
Bringing in MDATs at the onset of a case could improve
service plans, assist DSS in making decisions regarding
removal of children from their homes, and, over time,
improve outcomes for children and families.
- Define the role of Family Based Service Treatment
Teams to implement service plans developed by the MDATs
and based on MDATs assessments.
Clinical assessments and treatment planning are two functions
that should be vested in the MDATs. The FBS Treatment
Teams' role should be to implement the service plan creatively
through community contacts and flexible funding.
- Identify a representative of the Family Based Services
Treatment Team to serve as a core member on each MDAT.
In order to facilitate information sharing, avoid redundancy
and coordinate treatment planning and implementation,
a liaison from the FBS Treatment Team should serve as
a core member of the MDAT.
- Include families and their advocates in MDAT meetings
whenever possible.
Involving families proactively in decision making about
their children's future should be a core goal of each
review. Families are often best able to identify their
needs and the range of services that would best meet them.
Family support principles that respect family input and
that work to reduce or eliminate adversarial relations
should be embraced at all levels of child protective services.
- Provide Team Members with regular and ongoing training.
DSS should provide ongoing multidisciplinary training
opportunities for MDAT members, including psychosocial
implications of abuse and neglect, medical consequences,
and the effects of abuse and trauma on school behavior
and performance. Team Conveners should be brought together
regularly to share information and address barriers to
good team functioning. Strategies to resolve contradictory
opinions of participating professionals must be developed.
Return
to Top
Section
III: Protecting Our Children:
|
