Explaining and Preventing Chronic Maltreatment
(Originally published in February 2016)
Children and parents with several (5 or more) CPS reports are almost always referred for multiple types of child maltreatment, often beginning with allegations of neglect for babies and toddlers and then including allegations of sexual abuse, physical abuse and/or emotional abuse as children become older. In possibly the best published study of cross-type recidivism, Jonson-Reid, et al (2003) found that virtually all children with initial reports of physical abuse, sexual abuse or emotional abuse who had five or more reports in a 54 month period (4.5 years) were alleged to experienced cross-type maltreatment; and more than 80% of children alleged to have been neglected in their first CPS report and then re-reported at least four times were also alleged to have been abused in some way, sometimes in multiple ways. Cross-type recidivism was so pervasive among families sometimes referred to by scholars as “frequently encountered” by CPS or “chronically reported” that Jonson-Reid and her co-authors maintain that for these families “pure” types of maltreatment appear to be essentially non-existent.”
Jonson-Reid’s, et al, study includes several other important findings that shed light on the distinctive characteristics of families with cross-type recidivism:
• One half to two-thirds of the almost 40,000 parents in the sample from Missouri had only one CPS report, depending on the type of maltreatment alleged in the initial report.
• A substantial percentage of families with only two CPS reports in 54 months were alleged to have engaged in only one type of maltreatment, usually neglect.
• Children and parents with initial neglect reports were far more likely to have been re-reported than children and parents reported for some type of abuse (six times more likely than
children initially reported for sexual abuse, twice as likely as children initially reported for physical abuse).
• Neglect was the most common type of allegation in the second CPS report regardless of the type of maltreatment alleged in the initial report.
• The likelihood of allegations of physical abuse increased and the likelihood of neglect allegations decreased by a small percentage for each year of a child’s increasing age.
• By the time children and parents had 3 or more CPS re-reports, the cross-recidivism pattern of maltreatment was usually firmly established, even for families initially reported for neglect.
In chronically referring families, early CPS reports usually contain allegations of neglect of young children followed by allegations of physical abuse, sexual abuse and emotional abuse as children in these families become older. Antony Loman’s outstanding study, Families Frequently Encountered by Child Protective Services (2006) found that allegations of maltreatment involving parent-child conflict were common in CPS referrals on school age children in families with 5 or more CPS reports. Jonson-Reid’s, et al, (2010) study of chronically referring families found that emergency room visits related to children’s mental health problems were a strong predictor of subsequent CPS reports. One explanation of cross-type recidivism suggested by these referral patterns is that chronic neglect which begins when children are infants and toddlers results in externalizing behavior problems which, in turn, provokes harsh physical punishment of children by parents who lack the skills to cope with oppositional behavior and “meltdowns”.
There is another explanation of a pattern of early neglect of young children followed by chronic maltreatment that includes both chronic neglect and one or more types of abuse, i.e., physical, sexual, emotional, that draws on an understanding of how mood disorders and/or substance abuse gradually undermine the capacity to parent. In this formulation, mood disorders – including depression – and substance abuse make it difficult or impossible for parents to provide the consistent care of basic needs, including emotional needs, of young children. Neglecting parents with chronically relapsing conditions are likely to have difficulties developing and maintaining a consistent structure of child care that includes feeding, bathing, supervision, sleep routines and the responsive 'Serve and Return' interactions on which normal early brain development depends. Difficulties in providing consistent basic care are followed by reduced impulse control and compromised ability to focus and problem solve. Eventually, parenting standards of all types erode or collapse under the pressure of chronically relapsing conditions such as depression and substance abuse (often co-occurring) and poverty. In extreme cases, the collapse of parenting standards includes a cognitive component in which caregivers have ceased to care that they are harming children, and sometimes have become hopeless/helpless about their living conditions and future prospects.
According to this hypothesis, the process of personal and family breakdown leading eventually to chronic child maltreatment proceeds in stages: difficulty in maintaining essential structures of child care (and often self care), i.e., a deterioration in dependable behavior, is followed by impaired thinking and executive functioning, including increasing lack of impulse control, which evolves into destructive alterations in feeling, valuing and caring. This is a painful process to witness or experience as a family member; and fortunately, not every substance abusing or chronically depressed person is afflicted by it to the same degree.
In its initial stages, parents often engage in “work around” harm reduction behaviors during periods when they are incapacitated, engaged in binges or unable to provide adequate care for children for whatever reason. Some of these parents may have extended family members or friends to depend on for child care, at least to some extent. However, impaired thinking and reduced impulse control usually results in incidents that alienate, frighten or infuriate intimate partners, family members and friends, as well as reducing consistent use of harm reduction behaviors. Weird, scary and objectionable behaviors become more common as the willingness and ability to consider possible consequences for anti-social behavior is reduced. When impaired thinking and impulse control is combined with destructive alterations in values and feelings for others, parents may become capable of the abusive practices that occur in the small number of cases in which children are systematically beaten, starved and sometimes tortured in horrifying ways, or pervasively neglected both physically and emotionally.
My view is that patterns of chronic maltreatment involving both pervasive neglect and one or more types of abuse develops gradually through parent-child conflict, insecure or disorganized attachments resulting from early neglect, the inability of caregivers to cope with children's mental health problems or physical disabilities and deterioration in parents' self-efficacy resulting from mental health conditions and family violence, combined with poverty. However, chronically referring families vary widely in their patterns of maltreatment and in the factors which lead to family breakdown. Consider Anthony Loman's comparison of families he refers to as frequently encountered (FE) and non-FE families:
Parental substance abuse 41% 21%
Mentally ill adult in family 7% 2%
Domestic Violence 34% 18%
Emotionally disturbed child 24% 13%
Disabled child 24% 13%
Rates of substance abuse, adult mental illness, domestic violence, children's mental health problems and physical disabilities were 2-3 times higher in FE and non-FE families in Loman's study, but there was no one single factor which was present in more than 41% of families. Based on Loman's study, chronic maltreatment is not the result of one or two factors, but rather appears to result from the combination of increased child care burdens associated with children's mental health conditions and/or disabilities and conditions which lead to a gradual deterioration in parents' behavior, thinking, valuing and caring. Because chronic maltreatment does not usually appear fully developed at the time of the initial CPS report on a family, there is often an opportunity to intervene to stop the destructive breakdown in caregivers' functioning and in children's development and relationships with parents; but only if CPS caseworkers and other helping professionals are able to recognize the early stages of chronic maltreatment and have policy frameworks and resources to offer a range of supports when services are most likely to be effective.
Guidelines for Case Planning
It is important for caseworkers and other professionals who work with children and parents with open CPS cases to keep in mind that many, probably most, of these children have not been chronically neglected and abused in multiple ways over a period of months or years. Loman's study of frequently encountered families found that about one-fifth of families with screened-in CPS reports had five or more reports within 5 years, and most of these reports were not substantiated. Nevertheless, Loman found that each CPS report, whether substantiated or not, significantly increased the likelihood of a future substantiated report. Loman recommends that child welfare agencies view CPS reports as “occasions of assistance” to help families with a wide range of needs, beginning with poverty related concrete needs, but also including assessment and treatment for chronically relapsing substance abuse/ mental health disorders and family violence and with a focus on improving parent child interactions. The key to more effective treatments/services is usually persistent and skilled engagement of parents in helping efforts and in earlier interventions, not in the creation of new services that have yet to be discovered.
Jonson-Reid, et al, (2010) found that less than a quarter of families in the study sample with multiple CPS reports had received services at each “stage”, that is, after the second report but before the third report, etc.. This study also found that both family centered services and children's mental health services significantly reduced the likelihood of future reports. Jonson-Reid and her co-authors comment that “any thought that chronic families should not receive services because “we've tried before and it didn't work” should be abandoned.”
CPS programs also need a different understanding of child safety in their work with chronically referring families. Currently, many child welfare agencies view “Unsafe” to mean “in danger”, i.e., at risk of imminent harm. However, much of the harm done to children in
chronically maltreating families is gradual and cumulative, not immediate physical harm. Many of the CPS reports of chronically maltreated children are likely to be for low level neglect that may not meet agencies' eligibility standards for services. If CPS agencies lack an understanding of the dynamics of chronic maltreatment and how it affects children's health and development, especially when combined with other adversities such as substance abuse and family violence, there is no chance that child welfare agencies will do a better job of protecting children in these families.
Reflections on Extreme Cases
In the many neglect trainings I've done during the past decade I've often heard from child welfare caseworkers and supervisors about families with 20, 30, 40, 50 or more CPS reports. Caseworkers and supervisors are often baffled about what to do for children and parents in these families and uncertain about where even to start in helping families with co-occurring substance abuse and mental health disorders, long histories of family violence, severe poverty, criminal records, disabled and/or emotionally disturbed children and other problems as well. It is not helpful to lecture caseworkers and supervisors responsible for child protection in these families about the folly of waiting for double digit CPS reports before engaging parents in service plans which will almost certainly be too little too late. I offer the following suggestions with the hope that caseworkers and community professionals will not give up on the children and youth in families with multiple CPS reports despite the temptation to do so:
1. Every community should develop at least one case planning team that includes representatives from child welfare, medicine, substance abuse assessment and treatment, mental health, DV, public health, early childhood education, school and parent advocates. These agencies should develop a collaborative structure for comprehensive assessment of both children and parents. These assessments should focus on describing in-depth the health, mental health and development of all family members.
2. Family search should look for extended family members who can be helpful to children and parents in a variety of ways. In the absence of extended family members, experienced foster parents can be utilized for
respite care, or in some cases for out-of-home placements.
3. Parent advocates should help impoverished parents to establish eligibility for public benefits. Persistent skilled outreach to parents and children will often be required. Parents and children should also be offered the opportunity for recreational activities and for civic engagement.
4. In case planning for and with multi-problem families, start somewhere but not everywhere. Services should occur in sequence, rather than all at once.
5. Court structure should be used as needed but not routinely; every effort should be made to work with families on a voluntary basis.
6. Community teams should use extreme caution in making placement recommendations for emotionally troubled school age children; lacking potentially therapeutic placements at least “do no harm” by placing children and youth in non-nurturing homes or residential facilities unless a child's physical safety is immediately threatened. However, for babies and other preschool children extreme deprivation of emotionally responsive care should be viewed as grounds for immediate out-of-home placement, hopefully with extended family members. Deliberate cruelty and torture of children, systematic deprivation of food and water, corruption and exploitation of children should not be tolerated, even for a single day.
7. Child welfare managers should scale back expectations. In many of these families with 20-60 CPS reports, there is no program or set of services likely to quickly prevent additional reports, but there is almost always a way to help children and parents in small and large ways.
Caseworkers should forget about the child welfare agency's performance indicators and do the good that can be done.
Jonson-Reid, M., Drake, B., Chung, S. & Way, I., “Cross-type recidivism among child maltreatment victims and perpetrators,” Child Abuse and Neglect, 27, 2003.
Jonson-Reid, M., Emery, C., Drake, B. & Stahlschmidt, M.J., “Understanding chronically reported families,” Child Maltreatment,
15, (4), 2010.
Loman, L.A., Families Frequently Encountered by Child Protective Services, Institute for Applied Research, St. Louis, Missouri, 2006.