What do serious case reviews achieve?

Although there had been some earlier public inquiries, the inquiry into the death of 7 year old Maria Colwell in 1973[1] was a critical episode in the history of child protection in the UK. It was this inquiry that led to the formalisation of inter-agency child protection procedures, the establishment of Area Child Protection Committees, and the creation of a child protection register. It also sparked off a long line of public inquiries into serious and fatal maltreatment, more recently superseded by statutory Serious Case Reviews (SCRs) carried out by Local Safeguarding Children Boards (LSCBs). The public outcries over the deaths of Victoria Climbié and Peter Connelly highlighted the fact that, in spite of all the time and resource spent on these reviews, the problems of severe child abuse have not gone away. This begs the question of whether we have truly learnt anything from the reviews and whether anything has changed as a result

All Systems Go

Just like nature and life, my work is made up of many smaller parts working synergeticly in order to function properly. The systems I use are increasingly more complex, involving layers of interacting information competing for attention, giving rise to emergent qualities that could not exist without the interaction. Paraxial imaging and emergent shapes could not exist without the systems or the chromophobic choices

Developing effective child death review : a study of ‘early starter’ child death overview panels in England

Aim This qualitative study of a small number of child death overview panels aimed to observe and describe their experience in implementing new child death review processes, and making prevention recommendations. Methods Nine sites reflecting a geographic and demographic spread were selected from Local Safeguarding Children Boards across England. Data were collected through a combination of questionnaires, interviews, structured observations, and evaluation of documents. Data were subjected to qualitative analysis. Results Data analysis revealed a number of themes within two overarching domains: the systems and structures in place to support the process; and the process and function of the panels. The data emphasised the importance of child death review being a multidisciplinary process involving senior professionals; that the process was resource and time intensive; that effective review requires both quantitative and qualitative information, and is best achieved through a structured analytic framework; and that the focus should be on learning lessons, not on trying to apportion blame. In 17 of the 24 cases discussed by the panels, issues were raised that may have indicated preventable factors. A number of examples of recommendations relating to injury prevention were observed including public awareness campaigns, community safety initiatives, training of professionals, development of protocols, and lobbying of politicians. Conclusions The results of this study have helped to inform the subsequent establishment of child death overview panels across England. To operate effectively, panels need a clear remit and purpose, robust structures and processes, and committed personnel. A multiagency approach contributes to a broader understanding of and response to children’s deaths

Systematic review of interventions for the secondary prevention and treatment of emotional abuse of children by primary carers

Background Emotional abuse (or psychological maltreatment, as it is more commonly called in the US) is an inadequately researched and poorly understood concept, despite increasing awareness about the harm it can cause to children‟s lives. Although it unifies and underpins all types of maltreatment it also occurs alone and when it does, tends to elude detection and intervention. There have to date been no systematic reviews of the literature on the secondary prevention and treatment involving the parents or primary carers of emotionally abused children. Objective The objective of the review was to identify studies that evaluate the effectiveness of interventions in the secondary prevention and treatment of child emotional abuse involving the parents or primary carers of children aged 0 – 19 years. Methods Studies were included if they involved any intervention which was directed at emotionally abusive parenting and that measured change in (i) emotional unavailability (ii) negative attributions (i.e. that involve the parent attributing negative intentions, beliefs or attitudes toward the child); (iii) developmentally inappropriate interactions; (iv) lack of recognition of children‟s boundaries; (v) inconsistency of parenting role; (vi) missocialisation or consistent failure to promote the child‟s social adaptation. The primary outcomes evaluated involved proxy measures of a range of parent, family and child outcomes including parental psychopathology, parenting attitudes and practices, family functioning and/or child behaviour and the child‟s development and adaptation. . A broad search strategy was developed in order to identify as many relevant studies as possible. An electronic search of a wide range of databases was carried about. No study type was excluded. The search was augmented by direct contact with academics and practitioners known in this field. The search included studies written in English, Spanish, French and German. Studies were included if the intervention was described, and the impact on at least one indicator of emotional abuse was assessed. Included studies were critically appraised by two reviewers using standard criteria. Data were extracted using a standard proforma, and a qualitative synthesis of results was carried out. Results The initial search yielded 4248 publications of potential interest. Of these, 175 were obtained for possible inclusion or as background material. A total of 21 studies of 18 interventions, met all the inclusion criteria. A further 43 studies were relevant, but did not meet all of the inclusion criteria. Studies were organised according to the type of emotional abuse targeted: emotionally abusive parenting; parents of infants with faltering growth; missocialisation: parenting interventions with substance-abusing mothers. Twelve included studies had quantitative designs. Of these, 6 comprised randomised controlled trials; 1 comprised a follow-up of a randomised controlled trial; 2 were controlled studies; and 3 had one-group pre- and post-designs. The remaining 9 were case studies. Included studies involved a wide range of interventions. The 8 studies for parents which address emotionally abusive parenting (rejection, misattribution, parent-child role reversal and anger management) involved evaluations of cognitive-behavioural training (CBT), behavioural training and parent-infant psychotherapy. Two further case studies involved cognitive-behavioural training, mentalisation and family-based therapy. The 9 interventions with parents of infants with faltering growth evaluated CBT, behavioural training, parent infant psychotherapy and interaction guidance; lay home visitors, and a range of therapeutic options based on the diagnostic condition of the parents. The 3 studies of interventions for substance abusing mothers evaluated a relational psychotherapy group for mothers, and a residential treatment for substance abuse with a parenting component. The sample sizes for quantitative studies were small and ranged from 17 to 98 participants. Ten interventions involved mothers alone, while a further 11 included fathers, either at the outset or at a later stage, and in 3 cases extended family members. Interventions for emotionally abusing parents The findings from the 8 included studies evaluating CBT, psychotherapy, and behavioural approaches suggest that group-based CBT may be an effective means of intervening with this group of parents, although it cannot currently be recommended with parents experiencing symptoms of severe psychopathology. While one comparative study showed a psychotherapeutic intervention to be more effective than a CBT focused intervention, the outcomes measured in this study (i.e. parent and child representations) favoured the former. Behavioural case work involving the use of problem-solving techniques may also have a role to play with some parents, although further research is still needed. Interventions to enhance parental sensitivity The findings from a systematic review of 81 interventions that aimed at enhancing parental sensitivity and / or infant attachment found strong evidence that short term (less than 16 sessions) interventions, with a behavioural focus and aimed exclusively at enhancing maternal sensitivity were also most effective in enhancing infant attachment security. This supports the notion of a causal role of sensitivity in shaping attachment. Interventions that included fathers as well as mothers showed higher effect sizes but results are tentative since they are based on a small number of small scale trials. Parental behaviours associated with faltering growth Nine studies evaluated a range of interventions with parents of babies with faltering growth including interaction guidance, home visiting; parent-child psychotherapy, behavioural casework and multi-component interventions. The findings show that interaction guidance and parent-infant psychotherapy may be potentially effective means of working with this group of clients along with behavioural casework, but that further research is needed before these can be recommended. Missocialisation: Parenting interventions for substance-abusing parents 5 studies (one of which was a 6-month follow-up) evaluated interventions for substance abusing mothers, including a relational psychotherapy group and a residential treatment for substance abusing adults with a parenting component. The findings show that initial gains made in the former were not sustained at 6-months and few benefits from residential intervention. Conclusions Emotional abuse is a complex issue resulting in part from learned behaviours, psychopathology and/or unmet emotional needs in the parents, and often compounded by factors in the families‟ immediate and wider social environment. As such, a „one-approach-fits-all‟ is unlikely to lead to sustained change. The evidence base is weak, but suggests that some caregivers respond well to cognitive behavioural therapy. However, the characteristics that define these parents are not clear. There is currently no evidence to support the use of this intervention alone in the treatment of severely emotionally abusive parents. Some of the evidence suggests that a certain form of emotional abuse (for example, highly negative parent affect, which may be expressed as frightened and frightening behaviours in the parent) stemming from unresolved trauma and loss, is less amenable to CBT. There is some evidence that interaction guidance and psychotherapeutic approaches can generate change in parents with more severe psychopathology. Further research is urgently needed to evaluate the benefits of both psychotherapeutic and cognitive behavioural interventions, including those which take the form of family therapy, with parents at the more severe end of the spectrum, with fathers, and with older children. There is also a need to gain further understanding about which forms of emotional abuse respond best to different treatments

Child protection procedures in emergency departments

Background: Emergency departments (EDs) may be the first point at which children who have been subject to abuse or neglect come into contact with professionals who are able to act for their protection. In order to ascertain current procedures for identifying and managing child abuse, we conducted a survey of EDs in England and Northern Ireland. Methods: Questionnaires were sent to the lead professionals in a random sample of 81 EDs in England and 20 in Northern Ireland. Departments were asked to provide copies of their procedures for child protection. These were analysed qualitatively using a structured template. Results: A total of 74 questionnaires were returned. 91.3% of departments had written protocols for child protection. Of these, 27 provided copies of their protocols for analysis. Factors judged to improve the practical usefulness of protocols included: those that were brief; were specific to the department; incorporated both medical and nursing management; included relevant contact details; included a single page flow chart which could be accessed separately. 25/71 (35.2%) departments reported that they used a checklist to highlight concerns. The most common factors on the checklists included an inconsistent history or one which did not match the examination; frequent attendances; delay in presentation; or concerns about the child’s appearance or behaviour, or the parent–child interaction. Conclusions: There is a lack of consistency in the approach to identifying and responding to child abuse in EDs. Drawing on the results of this survey, we are able to suggest good practice guidelines for the management of suspected child abuse in EDs. Minimum standards could improve management and facilitate clinical audit and relevant training

Investigating sudden unexpected deaths in infancy and childhood and caring for bereaved families : an integrated multiagency approach

The sudden unexpected death of an infant or child is one of the worst events to happen to any family. Bereaved parents expect and should receive appropriate, thorough, and sensitive investigations to identify the medical causes of such deaths. As a result, several parallel needs must be fulfilled. Firstly, the needs of the family must be recognised—including the need for information and support. Further, there is the need to identify any underlying medical causes of death that may have genetic or public health implications; the need for a thorough forensic investigation to exclude unnatural causes of death; and the need to protect siblings and subsequent children. Alongside this, families need to be protected from false or inappropriate accusations. Limitations in the present coronial system have led to delays or failures to detect deaths caused by relatives, carers, or health professionals. Several recent, highly publicised trials have highlighted the possibilities of parents facing such accusations. As a result of this the whole process of death certification has come under intense scrutiny. We review the medical, forensic, and sociological literature on the optimal investigation and care of families after the sudden death of a child. We describe the implementation in the former county of Avon of a structured multiagency approach and the potential benefits for families and professionals