Removal of babies at birth and the moral distress of midwives.

BACKGROUND: Midwives and nurses appear vulnerable to moral distress when caring for women whose babies are removed at birth. They may experience professional dissatisfaction and their relationships with women, families and colleagues may be compromised. The impact of moral distress may manifest as anger, guilt, frustration, anxiety and a desire to give up their profession. While there has been much attention exploring the concept of moral distress in midwifery, this is the first study to explore its association in this context. AIM: This article explores midwives' experiences of moral distress when providing care to women whose babies were removed at birth and gives valuable insight into an issue nurses and midwives encounter in their profession. METHODS: Four mothers and eight midwives took part in this research. Narrative inquiry incorporating photo-elicitation techniques was used to generate data; mothers were interviewed face to face and midwives through focus groups. The images and audio data were collected, transcribed and analysed for emerging themes. For the purpose of this article, only the midwives' stories are reported. This research received a favourable ethical opinion from the University of Surrey Ethics committee. ETHICAL CONSIDERATIONS: This study received a favourable ethical approval from a higher education institutes ethics committee. RESULTS: Midwives who care for women whose babies are removed at birth report it as one of the most distressing areas of contemporary clinical practice. Furthermore, they report feelings of guilt, helplessness and betrayal of the midwife-mother relationship. Many of the midwives in this study state that these experiences stay with them for a long time, far more than more joyful aspects of their role. CONCLUSION: Midwives experience moral distress. Support systems, education and training must be available to them if we are to reduce the long-term impact upon them, alleviate their distress and prevent them from leaving the profession.

An intervention that increases parental sensitivity in families referred to Child Protective Services also changes toddlers' parasympathetic regulation.

Experiencing maltreatment in early childhood predicts poor parasympathetic regulation, characterized by low baseline parasympathetic activity and strong withdrawal of parasympathetic influence in response to tasks. The Promoting First Relationships® (PFR) program improves parental sensitivity toward young children in families identified as maltreating. Using a subsample from a randomized control trial, we examined whether parental participation in PFR had lasting effects on toddlers' parasympathetic regulation, as measured by respiratory sinus arrhythmia (RSA), relative to a resource and referral control condition. In addition, we examined whether parental sensitive and responsive behavior mediated or moderated associations between parent treatment group and children's RSA. More than 6 months after completing treatment, 29 families in the PFR condition and 30 families in the control condition were visited at home, and toddlers' RSA was assessed at baseline and during five moderately challenging tasks. Groups did not differ in baseline RSA, but differed in RSA reactivity to the tasks. Across tasks, toddlers of parents in the control condition manifested significantly larger RSA decreases than toddlers of parents in the PFR condition. Parental behavior showed divergent associations with RSA change for toddlers of parents in the PFR versus control condition, with PFR treatment predicting RSA change ranging from small decreases to increases in toddlers of parents who showed the most sensitive, responsive behavior in the 6 months following treatment. This preliminary study showed that the same intervention that improved parenting also improved toddlers' parasympathetic regulation in response to everyday activities, warranting further experimental investigation.

Early Involvement of the Child Protection Team in the Care of Injured Infants in a Pediatric Emergency Department.

BACKGROUND: Physical abuse is a significant cause of infant morbidity and mortality. Early detection in the emergency department (ED) is crucial. OBJECTIVE: We describe the impact of a clinical pathway focused on early involvement of the child protection team (CPT) and social work (SW) team for infants presenting to a pediatric emergency department with an injury concerning for abuse. METHODS: The pathway lists 10 injuries associated with abuse in infants and directs consultation of the CPT and SW. It was implemented at a single site on April 1, 2014. Seasonally matched data were collected 12 months before and after implementation on all children < 12 months of age with a qualifying injury. Demographics, CPT and SW consults, referral to Child Protective Services, diagnostic studies, and ultimate determination of abuse by the CPT were collected. RESULTS: Implementation of the pathway was associated with an increase in consultation of the CPT from 17% to 47% (p < 0.001) and SW from 33% to 52% (p < 0.001). CPT and SW consultations were obtained more frequently for those on public compared to private insurance prior to implementation but not after (CPT: odds ratio [OR] 4.32; p = 0.046; 95% confidence interval [CI] 1.03-18.15; SW: OR 3.23, p = 0.034; 95% CI 1.09-9.74). Diagnostic testing increased in the post-pathway period. There was no difference in the detection of abusive injury or number of missed cases. CONCLUSIONS: These findings suggest that this clinical pathway was successful in increasing involvement of the CPT and SW teams and reducing socioeconomic disparity in the evaluation of infants with injuries concerning for abuse.

Beyond and around mandatory reporting in nursing practice: Interrupting a series of deferrals.

Nurses are well positioned to contribute to child protection efforts but are underutilised. This paper describes a critical discursive analysis of nursing responses to child neglect and abuse (CN&A) in British Columbia, Canada. Legal and practice guidelines were analysed alongside nurse interview texts, offering a glimpse into how nurses prevent CN&A in their everyday practice with families. Results show how the primacy of mandatory reporting to child protection authorities coordinates a series of deferrals and how nurses engage with and interrupt these deferrals in everyday practice. Nurses' relational approaches are essential to gain access to the private sphere of the family to assess, plan, elicit cooperation with interventions and monitor the situation. They considered reporting to be one among many possible responses. This study highlights how nursing contributions to prevention are largely overlooked and points to the potential for a more significant role for nurses in a public health approach to child protection.

Teacher Outcomes from the Second Step Child Protection Unit: Moderating Roles of Prior Preparedness, and Treatment Acceptability.

Teachers play a critical role in child sexual abuse (CSA) prevention and intervention efforts. We examined the impact of the Second Step Child Protection Unit (CPU) on improving teacher awareness, attitudes, and teacher-student relations for 161 teachers. Teacher baseline scores and treatment acceptability were examined as moderators. Structural equation modeling (SEM) revealed a significant effect of the CPU on teachers' awareness, attitudes, and teacher-student relations, particularly for teachers with lower prior knowledge, attitudes, and student relationships. Teachers' acceptability of the CPU also moderated outcomes, where a higher level of acceptability of CSA interventions was associated with an increase in outcomes.

CAN ATTACHMENT INFORM DECISION-MAKING IN CHILD PROTECTION AND FORENSIC SETTINGS?

The historic publication of the "consensus statement" on not using the "D/disorganized" category in the infant Strange Situation (M. Ainsworth, M. Blehar, E. Waters, & S. Wall, 1978) for case-specific child protection work (P. Granqvist et al., 2017) opens the door for a broader discussion of different branches of attachment theory and different attachment classificatory systems applied to infants, young children, and their parents. We agree with the consensus authors that Strange Situation classifications alone, regardless of coding method, are insufficient for decision-making. The authors, however, have acknowledged that the Dynamic-Maturational Model of Attachment and Adaptation (DMM; Crittenden, 2016) offers a different perspective on classifying Strange Situations. The DMM is a branch of attachment theory that expands the Ainsworth A and C classifications across the life span to reflect the complex attachment strategies that some individuals use in dangerous contexts. We contrast the DMM to the D classification, both for the Strange Situation for infants and its adaptation for young children and also for the Adult Attachment Interview (AAI; C. George, N. Kaplan, & M. Main, 1984-1996) for their parents. We initiate a scientific dialogue by addressing three points: (a) "Attachment" does not imply or require a model that includes a D/disorganization category nor is the D/disorganized category the only clinical expansion of Mary Ainsworth's (1978) original work; (b) the DMM method for classifying Strange Situations may be better attuned to parental inadequacy and child protection than is the D/disorganized category; and (c) with attention to guidelines, DMM classifications from the Strange Situation with both infants and preschool-aged children can be used in a case-specific manner in both treatment and forensic settings. The same is true for other DMM assessments of attachment, including the AAI. We close by suggesting steps that could further understanding and application of Ainsworth's great accomplishment: individual differences in attachment relationships.

Medical social work practice in child protection in China: A multiple case study in Shanghai hospitals.

With the rapid development of the child welfare system in China over recent years, medical social work has been increasingly involved in providing child protection services in several hospitals in Shanghai. Focusing on five cases in this paper, the exploratory study aims to present a critical overview of current practices and effects of medical social work for child protection, based on a critical analysis of the multidimensional role of social work practitioners engaged in the provision of child protection services as well as potential challenges. Implications and suggestions for future improvements of China's child protection system are also discussed.

Voices in the wilderness: Co-location meeting the needs of children in protective care.

OBJECTIVE: To explore how access to a family medicine clinic co-locating with the Children's Aid Society (CAS) of Hamilton in Ontario helped meet the unique needs of children in care. DESIGN: Qualitative research using semistructured face-to-face and telephone interviews. SETTING: The CAS of Hamilton. PARTICIPANTS: Nineteen foster parents. METHODS: Stakeholders were invited to participate with flyers posted in the clinic, notices that were mailed to foster parents, personal invitations that were distributed during clinic visits, and an internal memo that was distributed to the CAS staff. Informed consent and assent where appropriate was obtained before an interview was started. Interviews were audiorecorded when and where feasible, transcribed, and subsequently underwent inductive, thematic analysis. Common themes evolved by consensus. MAIN FINDINGS: Foster parents valued the family medicine clinic co-locating with the CAS. The co-location helped children in care to know that there were others in similar circumstances. Foster parents learned from and shared parenting skills with one another, which resulted in developing confidence in the care they provided. The clinic became a neutral place for children in care, foster parents, and birth parents. The clinic team gathered the children's complete health records and was responsible for sharing this information when appropriate. CONCLUSION: Access to a family medicine clinic designed specifically for children in care that co-located with the CAS enhanced not only the planning, management, and evaluation of care, but also provided a consistency that was not found in other parts of the children's lives; this helped generate trusting relationships over time. The co-location provided a strong spoke in the circle of care.

Typologies of Post-divorce Coparenting and Parental Well-Being, Parenting Quality and Children's Psychological Adjustment.

The aim of this study was to identify post-divorce coparenting profiles and examine whether these profiles differentiate between levels of parents' well-being, parenting practices, and children's psychological problems. Cluster analysis was conducted with Portuguese heterosexual divorced parents (N = 314) to yield distinct post-divorce coparenting patterns. Clusters were based on parents' self-reported coparenting relationship assessed along four dimensions: agreement, exposure to conflict, undermining/support, and division of labor. A three cluster solution was found and replicated. Parents in the high-conflict coparenting group exhibited significantly lower life satisfaction, as well as significantly higher divorce-related negative affect and inconsistent parenting than parents in undermining and cooperative coparenting clusters. The cooperative coparenting group reported higher levels of positive family functioning and lower externalizing and internalizing problems in their children. These results suggested that a positive coparenting alliance may be a protective factor for individual and family outcomes after parental divorce.

[Growing up under adversity in Germany : Design and methods of a developmental study on risk and protective mechanisms in families with diverse psychosocial risk]. / Aufwachsen unter familiärer Belastung in Deutschland : Design und Methoden einer entwicklungspsychologischen Studie zu Risiko- und Schutzmechanismen bei Familien mit unterschiedlicher psychosozialer Belastung.

Family adversity comprises many risk factors for parents and children. The German early intervention approach Frühe Hilfen aims at providing enduring, effective, and scientifically validated prevention and intervention for effective child protection against those risks. The study on risk and protective mechanisms in the development of families with diverse psychosocial risks aims at identifying those mechanisms that cause and stabilize or moderate and diminish maltreatment and neglect, as well as cognitive, social, and emotional developmental deviations in risk families, specifically in the current German social and child protection system. The study examines the development of competence and early behavior problems in a sample of infants and toddlers and the interaction quality with their caregivers by applying a longitudinal sequential-cohort design. The assessments include developmental tests, systematic observations, and questionnaire data. First results suggest stable risk group membership and moderate stability of single risk factors.

[Child maltreatment and new morbidity in pediatrics : Consequences for early child support and child protective interventions]. / Kindesmisshandlung und neue Morbidität in der Pädiatrie : Konsequenzen für Frühe Hilfen und Kinderschutzmaßnahmen.

The effects of child maltreatment on children's chronic health conditions have become more visible during recent years. This is true for mental health problems as well as some chronic physical conditions, both summarized as new morbidity within pediatrics. As several Bradford Hill criteria (criteria from epidemiology for the determination of the causal nature of a statistical association) are met, the likely causal nature of underlying associations is discussed. Early family support may have the potential to modify such associations, although empirical evidence is lacking. At least for attachment-based interventions with foster carerers after child maltreatment, positive effects on child HPA axis dysregulation have been demonstrated.

Factors Associated with Child Removal Among American Indian and Alaska Native People in an Alcohol Intervention Study.

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.

Prevention of Substance Use Disorders.

Methods to prevent substance use disorders (SUDs) act on the individual risk factors for addiction. Most adults with SUD initiated substance use during their teenage years, so preventive interventions during adolescence are critical. Antisubstance use messaging, routine screening, and pathways for referral to treatment can be extended into all settings whereby trusted adults interact with adolescents such as sports, mentoring programs, child protective services, and juvenile justice settings. Pediatric primary care is an ideal place to incorporate preventive counseling and screening for substance use. Evidence-based technologic interventions for primary, secondary, and tertiary prevention are needed.

Factors associated with the decision of a French hospital to report child abuse to judicial rather than administrative authorities.

OBJECTIVES: Two independent sectors manage the child protection system in France: judicial and administrative protection. The choice between judicial or administrative reporting depends on the seriousness of the case. The goal of this study was to determine the characteristics associated with the decision in a French pediatric hospital to report child abuse to judicial instead of administrative authorities. METHODS: A retrospective study was conducted. Participants were all the children (n=83) who were admitted from 2017 to 2018 to the emergency department (ED) and the general ward of a pediatric university hospital in France, and were reported for suspicion of child abuse by the professional teams. The children who were suspected victims of sexual abuse were excluded. Multivariate logistic regressions were used. RESULTS: A total of 47 children were reported to judicial authorities, and 36 to administrative authorities. Their median age was 7 years. Suspicion of physical abuse (odds ratio [OR]: 21.2; 95% confidence interval [CI]: 4.5-99.1), cases reported by the pediatric ward team (OR: 9.1; 95% CI: 1.9-43.6), adult person different from parents who accompanied the child to the ED (OR: 5.8; 95% CI: 1.2-28.6), and perception of parental behavior as inappropriate and non-cooperative (OR: 6.6; 95% CI: 1.4-29.6) were associated with a higher risk of the case being reported to judicial authorities. Data were often unavailable for parental health issues, history of child abuse, and intimate partner violence. CONCLUSION: Some factors associated with the choice of report type were most likely quite subjective. Better documentation and standardization are needed.

Child abuse and neglect in a pediatric emergency department: epidemiology and outcome.

INTRODUCTION: Managing child abuse and neglect in pediatric emergency departments (PEDs) is difficult because of the complexity of screening and the prolonged care process. This study's main objective was to measure the child protection activity in a PED. METHODS: A retrospective, single-center study was conducted in the PED of the Lille University Hospital from 16 September∫2017 to 11 February 2019. All patients who required a social evaluation by the PED staff were included. Children admitted at first to the PED but for whom social management was exclusively performed by other units were not included. The whole population was analyzed first and then by type of abuse. The primary endpoint was the rate of patients who needed social management in the PED. The length of stay in the PED, the number of reports for investigation by child protective services, and reports to a judge were secondary assessment criteria. RESULTS: The study involved 245 patients (median age, 5 years; interquartile range [IQR], 2-13; boys, 49%), accounting for 0.6% of the PED visits. The main reasons for visiting the PED were somatic complaints (31%), sexual assault (23%), and behavioral disorders (20%). The median length of care in the PED was 5 h (IQR, 3-13). Thirty-three percent of the patients were monitored in the short-stay unit of the PED; 78% returned home. The main social measures taken were reports to child protective services (34%) and reports to a judge (24%); 51% of the patients required further actions by the PED physician after discharge. CONCLUSION: Management of child abuse in the PED is important and time-consuming. A hospital team specialized in child protection is essential for the initial care and monitoring of child victims.

Effectiveness of child protection practice models: a systematic review.

BACKGROUND: Attempts to improve child protection outcomes by implementing social work practice models embedded in a particular theory and practice approach, have increased internationally over the past decade. OBJECTIVE: To assess the evidence of the effectiveness of child protection practice models in improving outcomes for children and families. PARTICIPANTS AND SETTING: Children < 18 years and their families involved in child protection services. METHODS: A systematic review was conducted to synthesize evidence regarding the effectiveness of child protection practice models. Systematic searches across 10 electronic databases and grey literature were conducted to identify quasi-experimental studies minimally. Included studies were critically appraised and the findings summarized narratively. RESULTS: Five papers, representing six studies, focusing on three practice models (Solution-Based Casework; Signs of Safety; and Reclaiming Social Work) met the inclusion criteria. All studies applied a quasi-experimental design. Overall, the quality of the evidence was rated as being poor, with studies suffering from a risk of selection bias, small sample sizes and short-term follow up. CONCLUSIONS: Despite the popularity of practice models, the evidence base for their effectiveness is still limited. The results suggest that high-quality studies are urgently needed to evaluate the impact of practice models in improving the outcomes of child-protection-involved families. The findings also illustrate the difficulties of conducting high-quality outcome evaluations in children's social care, and these challenges and future directions for research, are discussed. PROSPERO registration number: CRD42018111918.

Health and public health approach to ending child abuse and neglect.

The 30th anniversary of the United Nations Convention on the Rights of the Child provides an opportunity to reflect on whether the approaches to date in dealing with child abuse and neglect (CAN) have been successful. Initial responsibility in most countries to address CAN has been given to Child Protective Services Agencies. Recently, there have been calls for CPS to take a Public Health Approach in their practice. This paper discusses the potential positive and unintended problems that such a shift in approach might entail.

Using Child Protective Services Case Record Data to Quantify Family-Level Severity of Adversity Types, Poly-victimization, and Poly-deprivation.

BACKGROUND: Child protective services (CPS) case records contain a vast amount of narrative information that is underutilized for estimating risk, conceptualizing family needs, and planning for services. OBJECTIVE: The current study applied a novel method for quantifying family-level severity of maltreatment and non-maltreatment-related adversity types to narrative information reflecting a family's full CPS history. PARTICIPANTS AND SETTING: Cases were randomly sampled (N = 100) from two regions of Connecticut that were referred over a specified 6-month period. METHODS: De-identified data were extracted through comprehensive chart review of electronic and paper case records. The Yale-Vermont Adversity in Childhood Scale (Y-VACS; Holbrook et al., 2015) was used to quantify adversity severity across a range of intrafamilial and extrafamilial experiences. RESULTS: Several family-level adversity severity ratings were associated with administrative data on allegations and investigative outcomes. Poly-victimization (ß = .47, p < .001) and poly-deprivation (ß = .25, p = .005) significantly predicted total allegation types and total substantiation types (ß = .30, p = .002; ß = .26, p = .008, respectively) across the case history. Poly-victimization significantly predicted the presence of a new allegation within 12 months of the index report, OR = 1.72, SE = .25, p = .027. CONCLUSIONS: Findings support the feasibility of a novel method that uses narrative case record information to quantify severity of maltreatment and non-maltreatment-related adversity types, as well as cumulative measures of threat- and deprivation-based adversities at the family level. Implications for utilizing case record data to inform CPS intervention are discussed.

Promising observational instruments of parent-child (0-12 years) interaction within the child protection system: A systematic review.

BACKGROUND: Parent-child interaction (PCI) is considered a critical environmental factor that affects child development. In the field of child and family intervention, assessment of caregiver-child interaction has great relevance for decision-making. OBJECTIVE: The aim of this study is to report the results of a systematic review of the best observational instruments to assess the quality of PCI, taking into account the most advanced protocols. METHODS: Firstly, one search was conducted to identify eligible observational instruments, and a second search was conducted to identify studies reporting on the psychometric properties of the instruments previously identified. To assess and rate the quality of the psychometric properties of the tools, the COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) checklist was applied. RESULTS: The nine PCI observational tools selected (with category B - promising) are widely used by researchers and clinicians across different stages of childhood. The Keys to Interactive Parenting Scale (2-71 months) obtained the highest rating. CONCLUSIONS: The most reported and robust psychometric property was inter-rater reliability, but validity evidence is understudied. This systematic review can help clinicians keep up-to-date, provide evidence for policymakers to judge risks and benefits of health care behaviors, as well as assess the evaluation programs in child abuse and neglect context.

Benefit-cost analysis of Promoting First Relationships®: Implications of victim benefits assumptions for return on investment.

BACKGROUND: Child abuse and neglect (CAN) cost United States society $136 billion to $428 billion annually. Preventive interventions that reduce CAN may improve people's lives and generate economic benefits to society, but their magnitude is likely to vary greatly with assumptions about victim costs avoided through intervention. OBJECTIVE: We examined the implications of different assumptions about avoided victim costs in a benefit-cost analysis of Promoting First Relationships® (PFR), a 10-session attachment and strengths-based home visiting intervention. PARTICIPANTS AND SETTING: Participants were 247 child protection-involved but intact families in Washington State randomized to receive PFR (n = 124) or resource and referral (n = 123). METHODS: We monetized intervention effects on out-of-home placements and implicit effects on CAN and calculated net present values under three scenarios: (1) benefits from avoided system costs, (2) additional benefits from avoided tangible victim costs, and (3) additional benefits from avoided tangible and intangible quality-of-life victim costs. For scenarios 2 and 3, we varied the CAN effect size and estimated the effect size at which PFR was reliably cost beneficial. RESULTS: PFR's societal net benefit ranged from $1 (scenario 1) to $5514 - $25,562 (scenario 2) and $7004 - $32,072 (scenario 3) (2014 USD). In scenarios 2 and 3, PFR was reliably cost beneficial at a CAN effect size of approximately -0.25. CONCLUSIONS: PFR is cost beneficial assuming tangible victim costs are avoided by PFR. Research into the long-term health and economic consequences of reducing CAN in at-risk populations would contribute to comprehensive, accurate benefits models.