Updates from Child Welfare Policy & Practice Blogs:

Cross-systems Collaboration for Crossover Youth: Resources for Professionals

Guest blog post written by Wendy Haight, PhD, and Minhae Cho, MSW, Doctoral student, in partnership with the Center for Advanced Studies in Child Welfare.

“Crossover youth” refers to youth who have experienced some form of maltreatment and also engaged in delinquency (Stewart, Lutz, & Herz, 2010). Research increasingly points to the importance of designing comprehensive, integrated approaches for crossover youth. Such approaches typically involve multi-system collaborations, minimally between child welfare and juvenile justice professionals, but also law enforcement, education, behavioral health, and court personnel (Herz et al., 2012). Multi-system collaboration can reduce unnecessary detention of foster youth who are arrested for misdemeanors and less serious felonies; more comprehensively address their needs, for example, through coordinated case planning and supervision; and may reduce recidivism (Herz & Fontaine, 2012; Herz & Ryan, 2008a; Herz & Ryan, 2008b).

The Crossover Youth Practice Model (CYPM) was developed in collaboration between the Georgetown University Center for Juvenile Justice Reform (CJJR) and Casey Family Programs (Stewart et al., 2010). This intervention targets multiple ecological levels to minimize the involvement of maltreated youth in the juvenile justice system. Cross-system collaboration in CYPM aims to identify crossover youth as early as possible and provide existing services earlier and in a more individualized manner. Youth and family engagement also is fundamental to the CYPM. Family members meet with child welfare and juvenile justice system workers to explore how they can work together at all phases of the CYPM. At the time of this writing, the CYPM has been implemented in 96 counties in 21 states.

The CYPM implementation consists of three phases. Phase I focuses on arrest, identification of crossover youth, and decisions regarding detention and charges. Phase II centers on dual-system case assessment and planning after a youth is formally involved in both systems and Phase III focuses on on¬-going case management and planning for case closure. A number of internal evaluations report positive outcomes of the CYPM including less recidivism and restrictive care, and more diverted dispositions.

In a two-year long, ethnographic study about professionals’ experiences of CYPM implementation in five Midwestern counties (Haight, Bidwell, Marshall, & Khatiwoda, 2014), professionals consistently described structural changes involving improved service provision to youth and families, and procedures and legal mandates for sharing information across departments. Professionals also described positive changes in their ability to promptly identify youth who cross over. A social worker described recent changes in her collaboration with a juvenile in probation:

“I have a kid in lock-up right now who wants to meet me. And, I called (juvenile probation officer) yesterday saying, “Let’s go out and meet this kid together…” And, we are at every court hearing together. Even if it’s just my stuff, I will invite him and he will do…likewise… And, we’re consulting together at meetings about our kids …and trying to do joint recommendations and we always sit together up front so the judge can address us both and I think it’s made it a much more unified process than in the past…” (p. 94).

Professionals also reported positive changes in psychosocial processes during the implementation of the CYPM. A county attorney commented on the impact of psychosocial changes on practice:

“I firmly believe that having more information about kids is going to permit us to make better decisions for our kids and our families….[Now] we will share data. … lots of kids, particularly younger kids, they will come in on…[an] offense and, all of a sudden, you understand that there’s a whole history of how the kid got there. And, there’s been all this social service involvement … at least from the delinquency side, you get a vastly better understanding of what’s happening in the family system” (p. 95).

An external evaluation of the CYPM is consistent with professionals’ perceptions that the CYPM improves outcomes for youth. In an external evaluation of the CYPM using state-level data, Haight and colleagues (2016) examined recidivism rates among crossover youth as an outcome of the Crossover Youth Practice Model (CYPM) in Oak County (pseudonym), an urban county in a Midwestern state. They used a quasi-experimental, post-test only design with independent historical and contemporaneous comparison samples from Oak County and 6 neighboring counties that shared a border with Oak County. They linked state-level data from the State Court Information System with the Child Protection Administrative Data and the Automated Report Student System. Youth receiving CYPM services were less likely to reoffend over a one-year period than youth in the comparison groups receiving “services as usual” even when controlling for location, time and other key covariates.

Despite the positive structural changes and outcomes for crossover youth, multi-system collaborations are challenging because each system has its own complexities, terminology, expectations and sometimes conflicting responses to youth. Within the juvenile justice system, youth often are seen as perpetrators and services are intended to remediate delinquent behaviors, in part, to protect public safety, respond to the needs of victims, and prevent recidivism. In the child welfare system, youth are typically seen as victims in need of protection and nurturing. These differing perspectives can result in tensions between systems in how youth and families are engaged and how services are provided that can challenge cross-systems collaboration.

Lessons learned from the professionals implementing the CYPM and outcomes for crossover youth provide insight into how cross-system collaboration leads to better services targeting crossover youth through cultural systems change efforts. Social workers educated in the use of ecological systems models are in particularly strong positions to provide leadership within implementation teams. Interdisciplinary implementation teams including professionals with backgrounds in law and policy, as well as those with clinical backgrounds, also can help to ensure that mutually reinforcing changes occur at multiple systems levels.

For more information on crossover youth and existing practices for this population, refer to a recent Minn-LInK brief detailing this model and two new learning modules: An Outcome Evaluation of the Crossover Youth Practice Model (CYPM) in Oak County, Minnesota and Crossover Youth in a Developmental, Ecological Framework.

Our fact sheet contains additional information, and keep an eye out for our Twitter and Facebook  posts that will be shared over the next several days.

References

Center for Juvenile Justice Reform. (2014). The Crossover Youth Practice Model (CYPM): An abbreviated guide. Retrieved from https://csgjusticecenter.org/youth/publications/the-crossover-youth-practice-model-cypm-an-abbreviated-guide/

Herz, D., Lee, P., Lutz, L., Stewart, M., Tuell, J., & Wiig, J. (2012). Addressing the needs of multi-system youth: Strengthening the connection between child welfare and juvenile justice. Retrieved from http://cjjr.georgetown.edu/wp-content/uploads/2015/03/MultiSystemYouth_March2012.pdf

Herz, D. C., & Fontaine, A. M. (2012). Final data report for the Crossover Youth Practice Model in King County, Washington. Georgetown University, Center for Juvenile Justice Reform. Retrieved from http://www.modelsforchange.net/publications/466/Final_Data_Report_for_the_Crossover_Youth_Practice_Model_in_King_County_Washington__20102011_Cases.pdf.

Herz, D. C., & Ryan, J. P. (2008a). Building multisystem approaches in child welfare and juvenile justice. Bridging Two Worlds: Youth Involved in the Child Welfare and Juvenile Justice Systems: A Policy Guide for Improving Outcomes, 27-113.

Herz, D. C., & Ryan, J. P. (2008b). Exploring the characteristics and outcomes of 241.1 youth crossing over from dependency to delinquency in Los Angeles County. Center for Families, Children & the Courts Research Update, 1-13.

Haight, W., Bidwell, L., Choi, W. S., & Cho, M. (2016). An evaluation of the Crossover Youth Practice Model (CYPM): Recidivism outcomes for maltreated youth involved in the juvenile justice system. Children and Youth Services Review, 65, 78-85.

Haight, W., Bidwell, L., Marshall, J. & Khatiwoda, P. (2014). Implementing the crossover youth practice model in diverse contexts: Child welfare and juvenile justice professionals’ experiences of multisystem collaborations. Children and Youth Services Review, 39, 91-100.

Stewart, M., Lutz, L., & Herz, D. H. (2010). Crossover Youth Practice Model. Washington, D.C.: Center for Juvenile Justice Reform, Georgetown Public Policy Institute.

2017 Legislative Session Begins

Minnesota’s 2017 legislative session began on January 3 with a number of new legislators and a Republican majority in both houses. This year begins a new two-year biennium session, in which the legislature sets the budget for the state for the next two years. And it marks a return to the Capitol, after the majority of the extensive repairs and renovations that closed the building for the past year have been completed.

The second year of the biennium is generally focused on passing a bonding bill, allocating funds for special projects like road construction, maintaining and constructing buildings, and last year, legislators failed to reach an agreement on their bonding bill. Governor Dayton has introduced a $1.5 billion bonding bill this session, which he’s dubbing his Jobs Bill, for the legislature’s consideration.

The November 2016 budget forecast, which is used to determine a preliminary budget target for the two-year budget cycle, projects a $1.4 billion positive balance. A portion of those funds must be placed in reserves, according to state statute, but the remaining funds can be used to increase spending or decrease taxes, or a combination of both. Additional information is available through Minnesota Budget Project  The updated February budget forecast will be used to determine the final figures to set the budget for the biennium.

Committee meetings to date have primarily focused on reports from state agencies to get new committee members acquainted with the agencies’ roles and responsibilities, and their current needs. We will be tracking bills this session on our website  and blogging with updates when bills of significance to the child welfare field are introduced and make their way through the legislative process.

Also keep an eye on the CASCW Facebook and Twitter.

At the annual Minnesota Council of Nonprofits’ Session Lineup event in St. Paul, we heard from Lieutenant Governor Tina Smith, Senate Minority Leader Tom Bakk (D), Deputy Majority Leader Senator Michelle Benson (R), House Deputy Minority Leader Rena Moran (D) and House Speaker Tony Albright (R). The need to continue to fund high-quality early childhood education was highlighted by most of these leaders. There is also talk of tax relief for low income and working families.

Representative Albright was asked about his interests in child protection reform efforts. He said he’d like to coordinate activities between counties and the Department of Human Services (DHS). There will be a lot of competition for funds in the budget this year, but he said that when “people are trying to take care of their kids and don’t fall through the cracks, that’s a very very high priority that the state should undertake and make sure it’s taken care of, not just minimally, but… adequately.”

The Legislative Task Force on Child Protection is expected to continue as the legislature and DHS continue to process and implement key provisions set forth by the Governor’s Task Force on the Protection of Children in 2014. The composition of the task force, with Senator Sheran and Representative Mullery no longer in office, will change, but we have not yet heard who will fill those openings. There have been no meeting dates set for 2017, but we will continue to monitor the work of this task force and share information as it becomes available.

Progress on the task force’s oversight of the review and implementation of the 93 recommendations is documented in a spreadsheet, including some notes on timeline for completion, responsible parties for action, and references to relevant statute.

According to this document, slated for 2017 legislation is a clarification of the definitions of “medical neglect,” “threatened injury” and “investigation.” There are also plans to expand the training system for child protection workers and supervisors, renew the commitment for DHS to conduct Child and Family Service Reviews (CSFR) for counties and tribes, and update the SSIS system used by workers to maintain electronic case files for families and children being served by the child protection system. Further plans for this year’s session according to the spreadsheet include increased funding for greater DHS oversight of county and tribal child protection agencies, and for improved data gathering during the intake and screening process.

Coming up is the annual Minnesota Council of Nonprofits Children and Youth Issues Briefing, held at the Intercontinental St. Paul Riverfront, on January 27 at 8:30 AM. Registration is open for this free event.
We will be attending, and will share what we learn following that event.

Moral Injury and Child Welfare

Guest blog post written by Erin Sugrue, MPP, MSW, LICSW, and Wendy Haight, PhD, School of Social Work, University of Minnesota, in partnership with the Center for Advanced Studies in Child Welfare.

The Case of Brandon

12-year-old Brandon was receiving counseling for Post Traumatic Stress Disorder (PTSD) following his placement in foster care. Brandon’s parents had become addicted to methamphetamine three years before and as their disease rapidly progressed, Brandon and his younger siblings were physically and sexually abused and exposed to adults’ interpersonal violence. He adjusted to foster care and responded well to cognitive behavior therapy approaches that addressed symptoms of trauma. He remained deeply troubled, however, over an incident that had occurred two years earlier involving his grandfather, whom he loved and respected, and who had provided shelter and nurturance to Brandon and his siblings, especially during family crises. On this occasion, Brandon’s parents, who were seeking drugs, instructed him to break into his grandfather’s store to steal money. Brandon continued to struggle with a deep sense of betrayal that his parents would tell him to steal, and equally troubling feelings of guilt and shame that he, in fact, had stolen from his grandfather. Though Brandon’s case worker was pleased by his adjustment to foster care and positive response to cognitive behavior therapy, his persistent emotional distress over a number of incidents including the one involving his grandfather, suggested that this child’s struggles went beyond the anxiety responses typical of PTSD. Brandon may also have been struggling with moral injury.

Moral Injury

Moral injury refers to the lasting psychological, spiritual and social impact of one’s own or others’ actions that transgress deeply held moral beliefs and expectations (see Litz et al., 2009; Shay, 1994). Shay (1994), for instance, suggests that a caregiver’s betrayal of the moral order through physical or sexual abuse or neglect impacts the character of the vulnerable child through a disruption of a sense of safety, trustworthiness, reliability and competence within the family. In Brandon’s case, he was not only the victim of abuse by the adults responsible for his protection, he witnessed and failed to protect his younger siblings from abuse, and he perpetrated a moral transgression against his beloved grandfather.

Moral injury is a relatively new term. The experience, however, has been described since ancient times, as when Homer wrote of Achilles’ experiences of social withdrawal, indignity, violent rage and severing of emotional bonds as the result of Agamemnon’s violations of commonly understood social and moral values in the Illiad nearly 3,000 years ago. The use of the term moral injury began when psychiatrists providing services to Vietnam combat veterans began to recognize that many were suffering from a type of persistent distress that was not being captured by the DSM diagnosis of PTSD (Gray et al., 2012; Shay, 2014), or resolved by interventions for PTSD (Gray et al., 2012; Litz et al., 2009; Nieuwsma et al., 2015). By definition, PTSD involves a traumatic threat to one’s own or loved one’s physical safety and results in symptoms of anxiety (American Psychiatric Association, 2013).

In contrast, moral injury occurs when a high stakes event contradicts one’s deeply held moral framework. In other words, when there is a troubling mismatch between the individual’s core moral beliefs and the event (Boudreau, 2011; Dombo, Gray, & Early, 2013; Meagher, 2014). This mismatch leads to a “breakdown in global meaning” (Currier, Holland, Rojas-Flores, Herrera, & Foy, 2015a, p. 26) or “threat to the integrity of one’s internal moral schema” (Dombo et al., 2013, p.200). It is this lack of meaning, not threat to physical safety (Currier, Holland, & Mallot, 2015c), that contributes to individuals’ guilt, shame, rage, depression, (Dombo, et al., 2013; Kopacz, Simons, & Chitapong, 2015; Litz et al., 2009; Shay, 1994) and loss of confidence in their own or others’ “motivation or capacity to behave in a just and ethical manner” (Drescher et al., 2011, p. 9).

Moral Injury & Child Welfare

Somewhat surprisingly, moral injury has received very limited attention in the social work literature (but see Dombo et al., 2013). Yet the impact of moral injury may play a significant role in increasing the vulnerability of a wide range of the profession’s clients as well as its practitioners. Some parents involved with the child welfare system may experience moral injury due to harm they (or others) inflicted on their children while they were under the influence of substances or experiencing mental health issues. They also may have experienced moral injury from their own experiences of child maltreatment or intimate partner violence, or due to their failure to provide basic necessities to their children as a result of poverty. Children like Brandon also may present with moral injury, for example, due to the violation of trust while experiencing abuse or neglect, actions they take for survival, and exposure to parents’ violence or violation of other social norms. Parents, children and child welfare professionals all may experience harm within social systems they are expected to, and which are charged with, providing assistance to struggling families.

Addressing Moral Injury

The literature on moral injury has only been emerging over the past 10-15 years, thus information about how to address moral injury is limited. However, the following interventions and strategies show promise:

• Acceptance & Commitment Therapy (Nieuwsma et al., 2015)
• Adaptive Disclosure (Gray et al., 2012)
• Prolonged Exposure Therapy (Paul et al., 2014)
• Pastoral care (Moyo, 2015)

Current research suggests that moral injuries can heal via therapeutic inventions which provide for meaning-making, self-forgiveness, acceptance, and a recommitment to personal values (Currier et al., 2015a, Currier et al., 2015b, Ferrajao & Oliveria, 2016; 2015; Gray et al., 2012).

Looking Ahead

There is a need for more research into moral injury across the field of social work, and particularly in high-stakes, morally challenging contexts like child welfare. Social work researchers and practitioners may identify possibilities for future research on moral injury based on the level of their practice lens (micro-mezzo-macro) and specific areas of expertise. Social workers concerned with micro-level issues, for instance, may focus on issues of moral transgressions committed by parents while they are experiencing altered mental states due to substance abuse or mental illness.  For example, if a mother left her two young children alone for days while she was on a meth binge, how does she integrate the reality of her transgressions, once she is in recovery, with her identity as mother and how does this viewpoint impact her ability to re-engage as a parent and help her children heal? Social workers concerned with macro-level issues, for instance, might focus on ways that the child welfare system, with its structures, processes, policies, and practices, results in moral transgressions against families, children, and professionals involved in the system. In such complex contexts, individuals may have overlapping experiences of perpetrator, victim and bystander of moral injury; there may be compounding influences of PTSD, medical illness, poverty and infrastructure problems; and family, community and culture may be shaped and distorted over time. The need is great for policy and organizational systems innovations that lead to more just and ethical systems, thereby decreasing the risk of moral injury.

To learn more about moral injury, you can view our Moral Injury Learning Module and download a Moral Injury Fact Sheet.

Also, keep an eye out for our Twitter and Facebook posts over the next week, as we will share various resources pertaining to moral injury.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Arlington, VA: American Psychiatric Publishing.

Boudreau, T. (2011). The morally injured. The Massachusetts Review, 52(3/4), 746-763.

Bowman, M. (1997). Individual differences in posttraumatic response: Problems with the adversity-distress connection. Mahway, NJ: Lawrence Erlbaum.

Buechner, B.D. (2014). Contextual mentoring of student veterans: A communication perspective. (Doctoral dissertation).  Available from ProQuest Dissertations and Theses #3615729.

Currier, J. M., Holland, J. M., Rojas-Flores, L., Herrera, S., & Foy, D. (2015a) Morally
injurious experiences and meaning in Salvadorian teachers exposed to violence. Psychological Trauma: Theory, Research, Practice, and Policy, 7(1), 24-33.

Currier, J.M., Holland, J.M., Drescher, K., & Foy, D. (2015b).  Initial psychometric evaluation of the Moral Injury Questionnaire-Military Version.  Clinical Psychology & Psychotherapy, 22(1), 54-63.

Currier, J.M., Holland, J.M., & Malott, J. (2015c). Moral injury, meaning making, and mental  health in returning veterans.  Journal of Clinical Psychology, 71(3), 229-240.

Dombo, E. A., Gray, C., & Early, B. P. (2013). The trauma of moral injury: Beyond the battlefield. Journal of Religion & Spirituality in Social Work: Social Thought, 32(3), 197-210.

Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 20(10), 1-6.

Ferrajao, P.C. & Oliveira, R.A. (2016).  Portuguese war veterans: Moral injury and factors related to recovery from PTSD. Qualitative Health Research, 26(2), 204-214.

Ferrajao, P.C. & Oliveira, R.A. (2015). From self-integration in personal schemas of morally experiences to self-awareness of mental states: A qualitative study among a sample of Portuguese war veterans. Traumatology, 21(1), 22-31.

Ferrajao, P.C. & Oliveira, R.A. (2014). Self-awareness of mental states, self-integration of personal schemas, perceived social support, posttraumatic and depression levels, and moral injury: A mixed-method study among Portuguese war veterans. Traumatology, 20(4), 277-285.

Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing,A, Maglione, M., Lang, A.J., & Litz, B.T. (2012).  Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43, 407-415.

Kopacz, M.S., Simons, K.V., Chitaphong, K. (2015). Moral injury: An emerging clinical construct with implications for social work education.  Journal of Religion & Spirituality in Social Work: Social Thought, 34(3), 252-264.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706.

Moyo, H. (2015). Pastoral care in the healing of moral injury: a case of the Zimbabwe National Liberation War veterans.  HTS Teologiese Studies/Theological Studies, 71(2), 1-11.

Nieuwsma, J.A., Walser, R.D., Farnsworth, J.K., Drescher, K.D., Meador, K.G., & Nash, W.P. (2015). Possibilities within Acceptance and Commitment Therapy for approaching moral injury. Current Psychiatry Reviews, 11, 193-206.

Paul, L.A., Gros, D.F., Strachan, M., Worsham, G., Foa, E.B. & Acierno, R. (2014).  Prolonged exposure for guilt and shame in a veteran of Operation Iraqi Freedom.  American Journal of Psychotherapy, 68(3), 277-286.

Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182-191.

Low Health & Mental Health Literacy in Asian American Immigrant Families: Implications on Children’s Health and Mental Health Equity

Guest blog post written by Hee Yun Lee, PhD & Raiza Beltran, MPH,  School of Social Work, University of Minnesota, in partnership with the Center for Advanced Studies in Child Welfare.

According to the U.S. Census, from 1990 to 2013, the U.S. immigrant population doubled to 4.3 million, comprising thirteen percent of the total U.S. population. With this unprecedented growth, the population of children with immigrant parents or who are immigrants themselves also increased within the same decades. Today, approximately one of out of four children in the U.S. lives in immigrant households. Despite a lack of reliable data on the number of immigrants currently in the child welfare system, experts acknowledge that child welfare workers may see an increase in the number of immigrant children, or children with immigrant parents, needing their services.

However, immigrant families face multiple challenges that may reduce their ability to work well with child welfare workers. Among these potential barriers are low health literacy and low mental health literacy. Health literacy is defined as the “Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” while mental health literacy is the “knowledge and beliefs about mental disorders which aid their recognition, management or prevention.” Immigrants, particularly those with limited English proficiency skills, were found to have low health literacy and certain immigrants, Asian Americans in particular, were found to have low mental health literacy. Previous research also points to a relationship between poor parental health literacy and poor child health outcomes. Therefore, it is imperative that child welfare workers are aware of health and mental health literacy, especially when working with immigrant families. Child welfare workers can empower clients identified with low health literacy by linking them to services that can improve their functional health literacy, communicative/interactive health literacy, and critical health literacy.

For more information and resources on health literacy in Asian Immigrant families, check out our fact sheet.

Also, keep an eye out over the next week for our social media campaign, which includes daily Twitter and Facebook posts about this topic.

Resource List

• Jimenez, M. E., Barg, F. K., Guevara, J. P., Gerdes, M., & Fiks, A. G. (2013). The impact of parental health literacy on the early intervention referral process. Journal of Health Care for the Poor and Underserved, 24(3), 1053–1062. doi:10.1353/hpu.2013.0141
• Johnson, M. A. (2007). The social ecology of acculturation: Implications for child welfare services to children of immigrants. Children and Youth Services Review, 29(11), 1426–1438. doi:10.1016/j.childyouth.2007.06.002
• Jorm, A. F. (2012). Mental health literacy: empowering the community to take action for better mental health. The American Psychologist, 67(3), 231–43. doi:10.1037/a0025957
• Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483), U.S. Department of Education. Washington, D.C.: National Center for Education Statistics.
• Lee, H. Y., Lytle, K., Yang, P. N., & Lum, T. (2010). Mental health literacy in Hmong and Cambodian elderly refugees: a barrier to understanding, recognizing, and responding to depression. International Journal of Aging & Human Development, 71(4), 323–344. doi:10.2190/AG.71.4.d
• Porr, C., Drummond, J., & Richter, S. (2006). Health Literacy as an Empowerment Tool for Low-Income Mothers. Family & Community Health, 29(4), 328–335. doi:10.1097/00003727-200610000-00011
• Rajendran, K., & Chemtob, C. M. (2010). Factors associated with service use among immigrants in the child welfare system. Evaluation and Program Planning, 33(3), 317–323. doi:10.1016/j.evalprogplan.2009.06.017
• Ratzan, S. C. & Parker, R. M. (2000). Introduction. In C. R. Selden, M. Zorn, R. M. Ratzan (Eds.), National library of medicine current bibliographies in medicine: Health Literacy (pp. v-vi). NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.
• Yin, H. S., Dreyer, B. P., Vivar, K. L., MacFarland, S., Van Schaick, L., & Mendelsohn, A. L. (2012). Perceived barriers to care and attitudes towards shared decision-making among low socioeconomic status parents: Role of health literacy. Academic Pediatrics, 12(2), 117–124. doi:10.1016/j.acap.2012.01.001

Law Enforcement’s Role in Removals & Defining Substantial Child Endangerment

Updates on the Legislative Task Force on Child Protection

The Legislative Task Force on Child Protection met on September 28, 2016, to continue seeking input and monitoring progress of the recommendations set forth by the recommendations of the Governor’s Task Force on Child Protection.

KSTP reporter Katherine Johnson was there to observe the discussion, and a story aired on the 5pm news that evening.

Several members of the Governor’s Task Force were called on to provide information about the intentions and ongoing support and concern for the implementation process of their recommendations. The four members, Dr. Lisa Hollensteiner, Dr. Mark Hudson, Michelle Zehnder-Fischer, and Rich Gehrman, expressed their interest in continuing their involvement in the ongoing work to incorporate their recommendations into practice. They also acknowledged there is more work to be done to address funding shortages, racial disparities in out-of-home placement and DHS oversight to ensure more consistent practice across the state.

Law Enforcement’s Role in Removing Children from Home

Joshua Lego, a St. Paul Police Department Commander with the Family and Sexual Violence Unit, testified before the task force to describe how investigations are conducted in cooperation with the county attorney’s office and child protection. He said that the department’s use of “immediate protective control,” in which they must remove a child from a home due to imminent danger, is rare. Generally, removals are due to neglect and law enforcement and child protection staff are able to work together at the home to arrange for a placement, with child protection staff most frequently transporting the child to the placement.

Senator Sheran asked whether the Commander believed that child protection staff could intervene and remove a child from a home without law enforcement present, except in those rare imminent danger situations. The concern is that the impression on the child can have lasting consequences for their views of law enforcement in general. Lego responded that he sees the value of having law enforcement in attendance at the time of removal, and that they have dedicated staff and capacity in their unit to respond to cases in which removal of a child from their home is likely. They could consider wearing plain clothes or a softer uniform than the typical police uniform with a belt and weapon.

Senator Rosen observed that they didn’t ask a social worker to weigh in on whether they would prefer to have responsibility for child removals in non-emergency situations. She said that she understands how difficult it is to make the decision to remove children from their homes, and believes it’s important to ensure that officers and workers involved with these cases have access to supportive resources for their own mental health when needed.

The Commander said that he sees their role as a “peace officer” and officers make every effort to engage with the children in a supportive, non-threatening manner. Rarely would a child be transported to a police station upon removal from the home. Only if the child was under arrest would he or she be taken to the station. If they’re removed due to abuse or neglect, they’ll be transported directly to a placement.

Substantial Child Endangerment

Prior to the task force meeting, Senator Sheran convened a meeting with community stakeholders that serve communities of color.  The meeting largely focused on experiences and concerns related to how people of color are treated in the child protection system and to discuss the work being done to add language in statute to clarify substantial child endangerment. Key provisions being proposed to be introduced in the next legislative session include:

• Adding an “imminent danger” definition to the substantial child endangerment statute, which was previously in Minnesota Rule.
• Adding a definition of abandonment: “when the child is under the age of three and has been deserted by a parent under circumstances that show an intent not to return to care for the child, unless another person has physical custody of the child pursuant to an order, designation or appointment under chapter 257, 257B, 257C, 518 or 524, or pursuant to a mutual agreement with the parent.”
• Adding to neglect definition (not substantial child endangerment) to include: “failure by a parent to contact a child on a regular basis with no demonstrated consistent interest in the child’s well-being, when reasonably able to do so, unless another person has physical custody of the child pursuant to an order, designation, or appointment under chapter 257, 257B, 257C, 518 or 524, or pursuant to a mutual agreement with the parent
• Defining “bruise” to mean “an area of discolored skin caused by a blow or impact that ruptures underlying blood vessels.”
• Adding provisions to define physical abuse of a child “under the age of six that causes injury to the face, head, back or abdomen; under the age of three that causes bruising to the buttocks, or under the age of one or a nonmobile child that causes injury

Discussion on these proposed changes centered around concerns that the definition of neglect fails to include informal caregiver arrangements, which is especially common in families of color. DHS staff said that they can create guidance around the use of “regular basis” in the neglect definition (see above). The hope is that this will allow for cultural considerations and create consistency across agencies when considering whether a parent has made efforts to maintain a relationship with a child who is being cared for by a family member or friend temporarily due to the parent’s inability to provide adequate care during that time.

DHS Implementation of Governor’s Task Force Recommendations

Jim Koppel, Assistant Commissioner, Children and Family Services, DHS, provided an update on the work DHS is doing to implement recommendations of the Governor’s Task Force. He clarified that the screening guidelines that they rolled out in January is guidance, and not statute, so counties do not necessarily have to follow it. An updated version of the screening guidance is being finalized now to send to counties shortly.

Koppel continued that we need to build a system that is balanced, so that cases aren’t unnecessarily screened in, but perhaps invest more in the state prevention program – Parent Support Outreach Program in order to provide support to families that have need for services but do not require intervention.

DHS would like to establish a clear practice standard for county child protection agencies, and serve more as an active supervisor, acknowledging that there are inconsistencies in practice, and that counties could benefit from additional support and guidance. DHS welcomes a system created by the legislature, said Koppel, to provide independent oversight of DHS and serve as a feedback loop for practice issues.

Senator Hayden asked about which states have an ombudsman for child protection. In Minnesota, the Office of the Ombudsperson for Families has four ombudspersons that work with four different communities of color. As independent government officials, they advocate for families and ensure that government and government regulated agencies have fair, reasonable, and appropriate practices. The four ombudspersons collaborate with the Indian Affairs Council, the Chicano-Latino Affairs Council, the Council on Black Minnesotans, and the Council on Asian-Pacific Minnesotans.

Senator Mullery asked whether there were general guidelines for minimum services available to families. It’s acknowledged that services exist to support families in the child protection system needing guidance. Of particular need across the state is additional trauma-informed services, but also many other types of services to meet the various needs of families. Mullery wondered whether there was a disconnect between what families need versus what is available to them, and if their needs for services aren’t being met, how are we helping those families and children while they are under the guidance of the child protection system.

Several people also gave public testimony detailing challenges they’ve personally faced while involved with child protection agencies in Minnesota.

CEHD Policy Breakfast: Minnesota’s Child Protection System: Working Toward More Effective Data-Based Decision Making

Panel: Dr. Kristine Piescher, Director of Research and Evaluation, CASCW; Jamie Sorenson, Director of Child Safety and Permanency Division, Department of Human Services; and Ron Kresha, Minnesota House of Representatives
Moderator: Dr. Traci LaLiberte, Executive Director, CASCW

The College of Education and Human Development (CEHD) hosts a policy breakfast each Fall and Spring on a timely topic. The topic this fall was the use of data for decision-making in Minnesota’s child protection system.

Jean Quam, Dean of CEHD, introduced the moderator, Traci LaLiberte, who reflected on the increase in media coverage on child protection in Minnesota since 2014, when a young child named Eric Dean died. As the media began to pay closer attention to our child welfare system a series of events occurred, beginning with the Governor’s Task Force on Child Protection, which developed 93 recommendations . Four separate work groups began studying the recommendations and developing practice changes in the form of new guidelines for counties, legislative action, and planning for reforming the Minnesota Child Welfare Training System.

KSTP recently featured a news report focusing on the need for increased access to and use of data in child protection, which included a discussion of caseload sizes, and the connection to data that could make decision-making easier for workers. This media story set the tone for the panel discussion which was framed around a greater emphasis on incorporating data into the decision-making process for Minnesota’s Child Protection System.

Jamie Sorenson began the discussion by explaining that the current data dashboard used in the child protection systems across the state is aligned with required federal data measures. The public can access information, which has been converted to Tableau format for better analysis and a more user-friendly dashboard display. The Data Unit in the DHS Child Safety and Permanency Division looks at how quickly workers see a child, the length of time children stay in foster care, and whether they achieve permanency.

The Minnesota SACWIS system is called Social Service Information System (SSIS). This system has been in place a long time. Caseworkers enter data into the system, and DHS extracts it to determine how they’re complying with federal performance measures. This data is not accessible in real time, but instead requires uploads at intervals. We want an accessible, robust, and real time data system to look at reports and ongoing case management. There’s a general mistrust in the data, due to issues with accuracy and completion. It’s largely case-level data, as that’s what the system was developed to be used for.

How does tribal data interface in the system? Some tribal agencies, like the Prairie Island Mdewakanton and Shakopee Mdewakanton Sioux, have their own data system for child protection cases. The White Earth Nation and Leech Lake Band of Ojibwe enter data into SSIS, and Red Lake Nation inputs some into SSIS. Therefore, some tribal data is included in the DHS annual child welfare report, but not all. To find information for American Indian children in the system, we want to continue to receive data and increase the amount of data being shared by tribes who administer their own child protection agencies.

SSIS wasn’t intended to be used for research purposes, but the data is used for that purpose now. The data wasn’t collected for research purposes, rather for practice-level decision making. When we tap the data for research and evaluation we need to look at the workers’ measures rather than develop research measures. In doing this, we can effectively analyze the information and draw conclusions about trends and performance improvement strategies.

Case-level data doesn’t contain deeper measures of child well-being to perform refined analysis, predictive analytics , or a broader perspective of what’s happening in families. Additionally, data systems exist in silos. SSIS and DHS’ data systems capture a lot of service systems, including child care assistance, child protection, and children’s mental health, but linkages between these systems are challenging.

Data about children and families is housed in DHS, Minnesota Department of Education, and Minnesota Department of Health and it can be hard to compile and extract data across systems. Minn-LiNK crosses data from all three areas to better understand child well-being and the effectiveness of programs and policies in Minnesota across agencies.

Do we have the right data and are we using the data in a way that’s helpful?

Rep. Kresha responded that he believes we have the right data, but that it’s tucked in so many places that it’s hard to access. “We would like to see more collaboration to share data across systems, but we need to address people’s fears for data privacy. DHS and MDE don’t currently share information easily, but maybe we haven’t given them the right tools, “ Kresha said. Children who are served by the DHS system go to school; MDE can benefit from information collected by DHS to provide adequate school support. Kresha continued, “We need to use and share data that’s beneficial to kids and not be afraid that we’ll label them.”

Jamie Sorenson added that he would like to better understand our problem statement on the use of data across systems and work toward identifying the solution.

Sorenson continued that key players should be able to share information using a shared database, but the matrix of federal legislation like CAPTA contain regulations that we can’t upset or we would jeopardize our funding stream. Additionally, we have a matrix of laws around confidentiality, as well as ethical considerations and informed consent. Shared information also may impact workers’ willingness to input information into the system.

Dr. Piescher explained that there is an interoperability between systems – educators and child welfare professionals need to share some information in order to get children the services that they need. Minnesota has been a leader in research with cross-systems data. The Center for Advanced Studies in Child Welfare has had an agreement since 2003 to access data about children in families in several systems to answer questions that can’t be answered in their own systems, such as the achievement gap for children in child protection. Security and confidentiality issues are the primary priority. Questions remain that once we have systems set up to share data, who will be allowed access to that information?

Rep. Kresha stated he would never advocate for a teacher to have access to all data, but some pieces that would be useful to them in understanding needs. Educators state they could pay more attention to special needs of children if they had more information about child protection history for families, for example.

Legislatively, data is often interpreted inaccurately , both by advocates and legislators. It is imperative that we have a group of legislators that understand how to properly interpret data and make informed decisions. Too often, admits Rep. Kresha, legislators use data in the wrong way to push their bills and make stronger points.

Dr. LaLiberte explained that from a research standpoint, you can use data to prove your point in many ways. We can ask a question and then see what the data tells us, but we cannot go into a study with the intention of showing a particular desired outcome. It’s a misuse of data to seek data to simply prove your point. The onus is on researchers to properly interpret data conclusions, but also on practitioners to be honest about findings when they share information about data.

Sharing data can make people nervous, but it’s how we use and interpret it. There’s a growing movement to push the use of predictive analytics in child protection. New Jersey and California use predictive analytics to guide policy and practice in child welfare. New Jersey also uses it to look at which families we can anticipate would be in the greatest crisis and facing the greatest safety threats. They don’t want to use this in a way to profile families. However, they can identify trends, such as families who have been assigned more than ten caseworkers, combined with risk factors and safety threats, to assess cases monthly and provide a different type of intervention.

Is this a direction we should go in Minnesota?

Jamie Sorenson stated that in terms of risk measures, some Minnesota counties use a Structured Decision Making (SDM) tool to identify risks of recurring maltreatment. We could apply that tool more widely and consistently in Minnesota. When we see fatalities and near-fatalities in children, sometimes that’s the first time the child is identified by the system, but other times they had been referred to the system previously. We can also do a “social autopsy” to determine the risk factors that may help identify potential for serious future harm, more than is being done currently. However, predictive analytics do not replace highly trained and skilled social workers and supervisors. Social workers and supervisors still need to use their professional judgment to determine how to proceed in every individual case. When we identify a child at risk, what do we need to do to make that child safe?

Dr. Piescher said that she agrees and emphasized that everyone assesses risk, whether they use a standardized tool or previous experience. Predictive analytics is important and is becoming more popular. However, when is it appropriate and for what purposes? To determine how to allocate resources? Level of intervention?

Rep. Kresha said that when we look at data, we are looking at what contributes to a given situation. It is important that we have enough faith in the data to use it to change policy. We know all these factors. We can move big levers at the policy level. Whatever decision we are going to make, we hope that we see a reduction in the number of cases five years down the line because we improved the system response. If we ever take away the decision making for the social workers, then what we’ve done is wrong.

“If a child is behind in school,” said Dr. Piescher, it’s not because a social worker came to the door, but rather events that have occurred for a number of years. We can’t find that in the data. We need the right indicators that we think are meaningful. The same risk factors are present in every system and we need to get underneath that and see what’s driving that beyond just poverty. Are there more nuanced pieces of that and do we need to direct resources in a different way?

Dr. LaLiberte said that she has often spoken with reporters about a complicated issue for 45 minutes, but in the end it is apparent that they just want a nugget of information. Reporters are looking for sound bites, drilled down to the least complex denominator so people can understand it. All nuance, context, complexities in decision-making are not simple, and talking about them in simple ways can derail us.

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