How effective is the multidisciplinary approach? A follow-up study

The multidisciplinary approach to diagnose, evaluate, and plan the treatment of victims of child abuse and neglect has been widely advocated and adopted by hospitals and community-based protective service teams. Despite the increasing prevalence of this approach, few if any studies have looked at its effectiveness. In the current study the effectiveness of the multidisciplinary approach was assessed by looking at the number of recommended services obtained by a sample of 180 children one year after evaluation by a multidisciplinary team. The results indicate that a large percentage of services recommended by the multidisciplinary team were obtained. This compares with the very low probability of service acquisition reported in samples of abuse and neglected children identified by CPS teams but not having access to a multidisciplinary evaluation. The multidisciplinary team plays a central role in acquiring the services needed to reduce the deficits and sequelae suffered by the victims of child abuse and neglect.     

Hospital-based multidisciplinary teams can prevent unnecessary child abuse reports and out-of-home placements

OBJECTIVE: To determine how often and for what reasons a hospital-based multidisciplinary child abuse team concluded that a report of alleged or suspected child abuse was unnecessary in young children with fractures. METHODS: A retrospective review was completed of all children less than 12 months of age who, because of fractures, were referred to the hospital multidisciplinary child abuse team for consultation regarding the need to consider child abuse. RESULTS: The team received 99 consultations, reported 92 (93%) children as alleged or possible victims of physical abuse, and did not report 7 (7%). Age at presentation of those who were reported was 4.2 months compared to 3.0 months in the non-reported group. The average number of fractures in the reported group was 2.9 (SD 3.53) compared to 3.4 (SD 4.6) in the non-reported group. Factors that led to cases not being reported included: (a) a trauma history consistent with the fracture (n=4), (b) a diagnosis of bone fragility secondary to genetic, nutritional or medical therapy etiologies (n=2), and (c) iatrogenic fracture (n=1). CONCLUSIONS: Seven percent of the children less than 12 months of age and with at least one fracture referred to the multidisciplinary team for evaluation of possible child abuse were not reported as alleged or suspected physical abuse. The involvement of the hospital multidisciplinary child abuse team may have prevented unnecessary investigation by the county social services agency and/or police, and possible out-of-home temporary placement.     

Formative evaluation of a collaborative community-based child abuse prevention project

OBJECTIVE: Together for Kids is a child abuse prevention project that serves children and families in two neighboring communities in a mid-sized Canadian city. The project, a collaborative endeavor of various agencies in the health, social services, and law enforcement sectors, focuses on preventing child abuse and neglect through family support and programming. This article presents the results of a formative evaluation of the project focusing on client and team member views on project implementation. METHOD: The evaluation strategy was primarily qualitative. In-person interviews following a semi-structured format were conducted with 17 clients and 10 team members by an external evaluator. In addition a review of all client records was conducted. RESULTS: The community-based approach, the multidisciplinary composition of the team, the ability to seek services when needed, the immediacy of the response time and the availability of support during stressful times were all aspects of the project that clients found beneficial. The most beneficial aspect of the project, however, was the informal support received from team members who were accepting, non-threatening, and non-judgmental. Team members found the collaborative approach made access to services easier for clients, particularly for those who were more socially isolated. CONCLUSIONS: Multidisciplinary, community-based models of service delivery contribute to a more effective and compassionate response to vulnerable families. Attention to the variables identified as important aspects of the project from the clients' perspective in this evaluation may assist others in developing similar programs.     

Client evaluation of a consultation team on crimes against children

OBJECTIVE: Cases of child abuse filed in court as crimes against children represent a small percentage of the total numbers of children maltreated. However, studying crimes of maltreatment against children is important for individual victims and their families, and for theory and policy in order to assure that these cases are managed as well as possible. Forensic consultation teams can perform several functions related to child abuse crimes: provide multidisciplinary expertise in the evaluation of maltreatment cases, offer a method for allocating resources between cases managed by the criminal justice and child protection systems, and provide important research and teaching opportunities. This study reviews the role played by multidisciplinary team consultations based on the perception of client professionals whose agencies pay for an outside consulting forensic team. METHOD: Professionals referring to a forensic team for consultative assistance were asked to evaluate the service during telephone interviews, responding to both structured and unstructured questions. RESULTS: Responding professionals (N= 18) stated that the team increased their confidence that the approach being taken to a case was correct (94%), that missing expertise was provided (100%), that progress was made in cases that might otherwise not have been made (55%), and that ambiguity was reduced (in 83% of referred cases). Using the team sometimes caused delays. Some delays were unacceptable administrative delays while others were considered necessary to assure completeness of the evaluation. CONCLUSION: The use of the team did not result in resolution of all of the cases referred, but referral to the team consistently provided closure for referring professionals. In one-third of the cases studied, if it had not been for the START consultation the cases would not have proceeded to an appropriate criminal or civil resolution.     

Child abuse treatment and follow-up: Can the pediatrician help improve outcome?

The pediatric role in the management of child abuse and neglect has been largely limited to detecting and reporting cases, with little involvement in long-term treatment and follow-up. A review of published clinical experience indicates that customary protective services' “treatment” strategies are all too often ineffective at preventing reabuse, improving child health and developmental status, and improving family functioning. When foster care is used as a treatment modality, children run the added risk of never returning home, nor being freed for adoption, and they may suffer the emotional harm of repeated foster placements. This situation is likely to worsen, in the light of recent cutbacks in social service programs, at a time of rising reports of maltreatment. The pediatrician is widely recognized as an expert in children's health and development, and he can effectively use his position to influence the management of cases and thereby the outcome, by actively participating in treatment decision making and providing close follow-up in a limited but important way. In order to do this, he must first become acquainted with the effects of maltreatment upon children's health and development and with the general principles and available modalities of treatment. He must be sympathetic and supportive of the difficult role of the protective service worker who must make treatment decisions. His role is to assist the worker by making medical resources available in order to adequately define the child's needs and the capacity of the family to meet those needs. Essential to answering these questions is the availability of a child development clinic and mental health resources. After ensuring that the child and family are thoroughly assessed and the treatment plan tailored to the child's and family's needs, the pediatrician provides continual longitudinal follow-up, monitoring the child's health and developmental status. If the child is placed in foster care, the physician observes the child's adjustment and provides advice and consultative assistance when needed to help foster parents manage health, developmental or behavior problems. Periodically he also meets with the natural family to keep them informed about their children's health and development and to ensure they are making good use of treatment. Finally, he communicates closely with the child protective service worker and participates in interdisciplinary staff meetings to review and evaluate treatment progress in the hopes of shortening the time needed to make decisions regarding placement.     

A USA national survey of program services provided by child advocacy centers

OBJECTIVE: Child Advocacy Centers (CACs) are designed to improve the community collaborative response to child sexual abuse and the criminal justice processing of child sexual abuse cases. CACs, in existence for 16 years, now have standards for membership developed by the National Children's Alliance (NCA) that include nine core components. And yet no systematic examination of the CAC model exists. The purpose of this paper was to assess the variations within these core components as they exist in the field. METHOD: Using a stratified random sampling design, 117 CAC directors were interviewed using a semi-structured interview that was based on the NCA's standards for membership. The eight core components of the CAC model examined in this study include: a child-friendly facility, a multidisciplinary team, an investigative child interview, a medical examination of the child, provision of mental health services, victim advocacy, case review, and case tracking. RESULTS: Results reveal the CAC model has been widely adopted by both member and nonmember centers, although variations in implementation exist. CONCLUSIONS: Future developments in the CAC model must include evaluation of the model.     

The escalation and maintenance of child abuse: A cybernetic model

A cybernetic model of child abuse is presented as a contribution to the theoretical literature on child abuse. The child's role in his or her own abuse is stressed; interaction between caretaker and child is emphasized. While the origins of abuse are discussed, the focus of the paper is on the maintenance and escalation of the pattern of abusive interaction. The author proposes to explain this pattern-maintenance through the application of Gregory Bateson's concept of schismogenesis, or regenerative feedback, a concept derived from cybernetics and family systems theory. Suggestions for intervention in this process are discussed in the conclusion.     

Child extrafamilial sexual abuse: predicting parent and child functioning

Objective: This study evaluated the emotional and behavioral adjustment of parents and children within 3 months and 1 year after the discovery of child extrafamilial sexual abuse.Method: Ninety-two case parents (63 mothers, 29 fathers) and 56 children were compared to a nonclinical comparison group of 136 parents (74 mothers, 62 fathers) and 75 children. Parent adjustment was assessed using self-report measures while child functioning was assessed using a combination of child-, parent- and teacher-report measures.Results: Mothers, fathers and sexually abused children experienced clinically significant effects both initially and at 12 months post-disclosure. Children’s perceptions of self-blame and guilt for the abuse and the extent of traumatization predicted their self-reported symtomatology at 3 months and 1 year post-disclosure. Child age and gender also significantly contributed to the prediction of many of the child outcome measures. No abuse-related variable was related to any child self-report measure. Mothers’ satisfaction in the parenting role, perceived support and intrusive symptoms predicted their initial emotional functioning. Avoidant symptoms, child’s internalizing behavior and mothers’ initial emotional functioning were significant predictors of longer-term emotional functioning.Conclusions: Results emphasize the need to address children’s abuse-related attributions and underscore the need to expand our focus beyond the child victims to the traumatized families.     

Patterns of interactions in multidisciplinary child protection teams in New Jersey

OBJECTIVE: The objective of this study was to gain an understanding of how multidisciplinary team members in child protection worked together within the team, meeting to provide assessments of, and services to, children and families. METHOD: Fifteen multidisciplinary child-protection teams in New Jersey were observed during one meeting of each team. The interaction among team members was recorded and analyzed using a structured observation method, Bales' Interaction Process Analysis. RESULTS: There was a wide variation in participation among team members, with some contributing nothing to the meeting and others contributing a great deal. In some teams, participation by members was more equal than others. Some professional groups and agencies contributed very little to any meeting while others contributed a great deal to many meetings. CONCLUSIONS: Professionals are members of multidisciplinary teams because they are expected to contribute to the investigation of child maltreatment cases and to the planning for further work with cases. However, the findings from this study suggest that there is a considerable degree of inequality in levels of participation in multidisciplinary meetings. It is particularly noticeable that staff from the prosecutor's offices participate in every meeting and either the agency as a whole or individual members of it dominate many of the meetings.     

Treating abused children: Some clinical and research aspects of work carried out by the national advisory centre of the National Society for the Prevention of Cruelty to Children in the United Kingdom

A study of the initial phase of intensive work with families indicated that whilst outreach techniques had dramatically reduced physical injury there was long-term distortion in the child's relationship with mother (parent) less amenable to change. The most recent phase of work has concentrated on direct treatment for the abused child, using a multidisciplinary team that includes a play specialist and child psychotherapist in addition to the social workers involved. Out of a total number of 66 children seen between April 1977 and December 1979 it was alarming to find that almost all were emotionally disturbed; even if the abuse did not reoccur they remained with considerable problems. The study highlights the degree of emotional disturbance suffered by these abused children and how they can be helped by focusing on their particular treatment needs. It is important to assess all children in the family situation and not to miss the quiet, depressed, withdrawn child who might not have been the subject of the initial referral. In some instances the needs of the child may outweigh those of the family and the focus of treatment must be on the child.     

Centers for disease control and the epidemiology of violence

Violence is a major cause of morbidity and mortality in the United States. The Center for Health Promotion and Education, the Centers for Disease Control (CDC) has begun to apply epidemiologic techniques to study the problems of child abuse, child homicide, homicide, and suicide. CDC's involvement in these areas has evolved in association with significant shifts in emphasis in public health policy and planning, from areas of acute and infectious diseases to areas of chronic diseases and premature mortality. We have recently addressed the problems of reporting biases and definitional variability in regard to child abuse and have characterized child homicide in the United States. We are currently epedemiologically investigating the underrecording of child homicide in this country. Our future work will include delineation and evaluation of programs to prevent violence toward children and examination of the relationship between intrafamilial violence and extrafamilial, noncrime related violence.     

Treatment of parents who abuse their children: A literature review and implications for professionals

This article contains a review of the current treatment approaches to child abuse in terms of the following models: psychopathological, sociological, social-situational, family systems and social learning. The psychopathological model of child abuse emphasizes direct services. The services provided may consist of individual, group and lay treatment, volunteer companions, and self-help groups. The sociological model's approach to intervention emphasizes the need for wide-ranging changes in social values and structures. The socio-situational model's approach to treatment is based upon the assumption that the cause of child abuse lies not in the individual, but in the social situation, which may, in turn, be maintaining abusive patterns of behavior. The family systems approach to treatment resembles that of the socio-situational model in that it too emphasizes changing the family's pattern of interaction and behaviors. Finally, the social learning approach to treatment involves the identification of behavioral goals, specific techniques for achieving these goals, and the use of social reinforcers to facilitate this process. Data indicate that parents who abuse their children face multiple social and psychological difficulties. It has been suggested that the reason why treatment programs have not prodoced significant results in treating parents who abuse their children is that they focus on only one of the factors that operate to produce child abuse, i.e., lack of child management skills, marital dissatisfaction, or vocation or interpersonal skills dissatisfaction. It is logical that a treatment approach to abuse must view the problem as multi-determined and services should be structured in such a manner. Thus, the comprehensive treatment program should consist of the following; (1) Child Management Program; (2) Marital Enrichment Program; (3) Vocational Skills Enrichment Program; (4) Interpersonal Skills Enrichment Program. Programs to accomplish the acquisition of requisite skills in each of the four areas of emphasis are chosen from the technology of applied behavioral analysis. Each of the four program components is reviewed along with the rationale for a comprehensive program delivered through a behavioral group work approach. The article concludes with a discussion of the implementation and evaluation of the program.     

Law enforcement officers as investigators and therapists in child sexual abuse: A training model

Law enforcement officers, often the first professionals to come in contact with a victim of child sexual abuse, can either increase or decrease the traumatic impact on the child and the family at the time of disclosure. The model for a training program for police officers in handling cases of child sexual abuse outlined in this paper is divided into three sections. The first part is directed towards theoretical issues involved in this problem, including an explanation of the history and background of sexual abuse of children by adults and of the difference in the dynamics of extra- and intrafamilial sexual abuse. The second part consists of a detailed explanation of different types of sex offenses and of standard physical examinations of sexual abuse victims. Graded slides of physical trauma geared towards wound identification are paired with relaxation exercises. The third section focuses on special considerations when interviewing sexually abused children. The difference between interviewing and interrogation, specific questioning techniques, and the use of videotape is explained. Each part of this training procedure is followed by a question and answer period and small group discussions for the purpose of encouraging disclosure and better understanding of the officers' personal reactions to cases of child sexual abuse.     

The school: Liberator or censurer?

The community is faced with an increasing number of children suffering from social and emotional difficulties. As all children attend school, this is a highly suitable place to examine possible means of identifying and helping children suffering from social and emotional difficulties. For the last 20 years most schools have lagged in their adjustment to the full range of needs of students. They act as a censurer by: domination of academic requirements causing many to fail; failure to meet the expressed needs of children; inadequate teacher training; too little help given to children and often too late; uncoordinated assistance within the school or with community agencies; and by not reducing peer abuse. The school can play a significant role in child development, but for the child with adjustment difficulties coherent assistance is rarely offered. The school can liberate by: recognition of the needs of non-academic children; recognition of the affective needs of all; providing affective training for selected teachers; giving appropriate curriculum time for a programme in personal growth and social relationships; by developing a multidisciplinary community agency which interacts with the school. A model is proposed outlining how effective intervention will break and prevent the cycle of abusive behaviour. This programme proceeds sequentially through each grade. Basically it is one of effective student group interaction in the presence of a specially selected and trained group leader. Such a programme contributes to change in school philosophy, and increases the possibility of the child becoming a more adequate adult/parent. Negative emotional effects of bureaucracy and the Australian school institution on children are discussed. This paper looks critically at schools, outlines some ways in which such abuse is manifested and discusses how the schools can become factors in healing as well as preventing abuse.     

Child abuse: The role of a consultant psychiatrist in a specialist institution

This paper is based on the experience of a consultant psychiatrist in a child abuse agency. Working with abusing families produces high levels of anxiety in the staff and conflicts over role are particularly strongly felt. These processes, as they affected the consultant psychiatrist and a staff group, were used to try to understand the anxiety and conflicts of the client families. The split between consultant and psychiatrist, between caregiver and authority figure, between parent and child, had to be acknowledged and accepted before the staff could work more effectively. Abusing families benefit from the range of skills offered by a multidisciplinary team. But the stresses for individual staff members working with these emotional, damaged, demanding, difficult families, can at times appear to be increased by the multidisciplinary team with its diversity of views. In the light of experience so far, it seems that work on the conflicts and anxiety needs to be part of a continuing process of staff development. Some of the difficulties for the consultant psychiatrist in such an institution are also discussed.     

Child abuse and neglect in Greece: Sociomedical aspects

Fifty-four abused and neglected children have been referred to our multidisciplinary team for assessment and treatment. There were many more boys than girls (36 vs 18) and the mean age was 3.3 years. Half of the children were admitted for medical reasons and abuse or neglect were secondary findings. The medical findings included bruises and fractures, head injuries, knife wounds, and failure to thrive. The children's main characteristics were: “difficult children,” unwanted pregnancies, difficult pregnancies and deliveries and half of them were separated from their mothers during the first months of life due to illness. The families were characteristic of multiproblem families of low social level. Almost all parents were young when married and half were unemployed or had unsteady employment. In most cases the parents were socially isolated and had poor relations with their families of origin. Most mothers and half of the fathers had an unhappy childhood while almost half of the mothers had a psychiatric problem. In general, our findings were in accordance with those described in other nations. Nevertheless, there were some characteristics which seem to be of relevance within the Greek ethnic and cultural context. The legal problems as well as those pertaining to child protection are discussed.     

Characteristics of abusive parents: A look at self-esteem

Low self-esteem has often been cited in the child abuse literature as a characteristic of abusive parents. However, most of these references have been based on individual case studies and practitioner reports rather than explicitly designed inquiries that attempt to control bias associated with clinical observations. Data for this study were derived from a broader exploratory research project conducted within the states of Arkansas, Louisiana, and Texas. As part of the project, a total of 111 abusive parents were administered the Tennessee Self Concept Scale (TSCS). The TSCS score profiles for this group are examined along with a discussion of the implications of the findings for intervention services. The profiles permit a comparison between abusive parents' self-concepts, a group of normal self-concepts, and a group drawn from a mental hospital population. The departure of the abusive parents' self-concepts from the normal group and the apparent greater similarity to self-concepts of mental patients suggest a lengthier and more involved treatment than may have been formerly thought.     

A selective study of child mortality

Identification of children's deaths from abuse and neglect is a complex process, thus no one individual should have the sole responsibility for this identification. A team could best carry out the comprehensive, interdisciplinary investigation and evaluation that the process requires.While at the present time, prevention of child abuse is a high priority item; before we invest large sums of public and private money and manpower in a variety of supportive services, some fundamental issues need to be addressed. We ought to do a more thorough job of trying to find out how many infants and children are dying of abuse. Second, we ought to open our minds to the fact that even more children are dying of neglect. When we do a better job of identifying these tragic phenomena, we will also be arriving at better preventive methods.We cannot prevent what we know so little about.