Family Group Decision Making for children at risk of abuse and neglect

Aron Shlonsky; Kate Schumaker; Charlene Cook; David Crampton; Michael Saini; Elisabeth Backe‐Hansen; Krystyna Kowalski

doi:10.1002/14651858.CD007984

Family Group Decision Making for children at risk of abuse and neglect

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Versión publicada: 08 julio 2009 Historial de versiones

https://doi.org/10.1002/14651858.CD007984

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Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effectiveness of the formal use of FGDM in terms of child safety, permanence (of childs living situation), child and family well‐being, and client satisfaction with the decision‐making process.

Background

Description of the condition

Freedom from abuse, neglect and violence is a basic right of all children (UNICEF 1989). However, child maltreatment remains a significant social problem that continues to affect many children worldwide, regardless of age, gender or culture (Pinherio 2006). Estimates of the incidence and prevalence of child abuse and neglect on an international scale are difficult to generate due to differences in how these phenomena are defined across cultures (Kempe 1978), the lack of epidemiological data from most regions other than North America, and the varying methodologies used for existing studies. Nonetheless, the World Health Organization (WHO) estimates that each year, millions of children around the world are victims and witnesses of physical, sexual and emotional violence (WHO 2006). Estimates of the incidence of child maltreatment in North America range from 18.67 child victims of maltreatment per thousand children in Canada (Trocmé 2005) to 41.9 out of 1,000 children in the US (Sedlack 1996). Children who experience abuse or neglect are at risk for a host of troubling short‐ and long‐term psychosocial problems including anxiety, depression, social and behavioural problems, poor educational progress, and parenting difficulties (Clausen 2004; English 2005; Springer 2007).

In most high‐income countries, primary responsibility for child protection rests with legislated child protection agencies, either operated or overseen by the state. While the specific mandate of these agencies differs across jurisdictions, statutory responsibilities usually include: receiving and investigating reports of suspected abuse and neglect; providing ongoing protection services to families in which children have been deemed at risk of future maltreatment; and the provision of out‐of‐home care when children cannot be safely cared for at home. While some families or children self‐refer to a child protection agency, the majority of families referred are “involuntary” insofar as they have not asked for nor consented to the referral.

Traditionally, decision‐making by child protection agencies has been professionally‐driven, with workers conducting assessments of families’ problems and risk profiles, and determining a treatment plan with which families are asked to comply (Merkel‐Holguin 2005; Rockhill 1999). This “top‐down” approach to child protection services stems from the inherent power imbalance between child welfare professionals and their clients: poor families, single female‐headed households, and visible minorities are disproportionately represented on child protection caseloads, while the workforce of child protection agencies is predominantly made up of middle class, educated, workers from the dominant culture (Pelton 1989; Dumbrill 2003). Additionally, the exclusion of parents from decision making is rooted in the presupposition that abusive or neglectful caregivers cannot make appropriate decisions concerning the care and protection of their children.

Within the last two decades there has been a growing acknowledgement of the need to work more collaboratively with families in the provision of child protection services (Littell 2000; Yatchmenoff 2005), to provide services that are sensitive to and protect children’s cultural identities (Connolly 2006), and to work with clients’ own definitions of problems and solutions rather than that of child protection professionals (Dumbrill 2003a; Lee 2004; Altman 2003). One response to these issues has been the introduction of Family Group Decision Making (FGDM) models as an alternative process in child protection.

Description of the intervention

Family Group Decision Making is an umbrella term [1] for practice models that shift planning for children away from “professionally driven” towards a more “family‐centered” approach, with the premise that families are experts on their own situations, and as such, should be considered well qualified to contribute to plans designed to promote the safety and well‐being of their children (Cunning 2006; Merkel‐Holguin 2005). FGDM models typically involve one or more meetings between the extended family and other professionals, during which time a plan is developed for the care and safety of the child(ren) (Crampton 2004). Meetings may be held at several different points in the life of a case; for example, following the initial investigation, when it is determined that a child is at risk of coming into care, prior to re‐unification, or at case closure.

There are numerous models of FGDM used internationally, including Family Group Conferencing (FGC), the Family Unity Meeting (FUM) model, Team Decision Making, Family Team Meetings, and Family Team Conferencing (CSSP 2002; Burford 2000). A central objective of all FGDM models is to provide the family with a stronger voice in decision‐making than has typically been the case in traditional (often adversarial) child protection services. In this way, FGDM models hold the potential to address historical inequities in child protection, and to promote services that are in keeping with children and families’ cultural beliefs and identities (Merkel‐Holguin 2005). Consensus does not exist in the field as to which of these and the numerous variants of these models best fit under the rubric of FGDM. The proliferation of different models primarily occurs in the United States, while most other countries draw upon the Family Group Conferencing model that originated in New Zealand. Therefore, that model deserves special attention here.

Family Group Conferencing (FGC) was created in New Zealand through a collaborative effort between Maori[1], governmental and community leaders, based on traditional Maori decision‐making processes (AHA 2008; AHA 2008a; Connolly 1994). The impetus for the development of FGC stemmed from the overrepresentation of Maori children within both the child protection and juvenile justice systems, a growing acknowledgement that existing systems did not allow for participation of Maori families in decision‐making about their children and did not fully recognize the inclusive view of “family” held by the Maori people[2] (Connolly 1994; Sundell 2001). The Family Group Conferencing model was introduced through the enactment of New Zealand’s Children, Young Persons and Their Families Act (1989), which replaced the former Children and Young Persons Act (1974); the addition of the word “family” to the title of the Act reflected a fundamental shift towards acknowledging the importance of the wider family system in the health and well‐being of children, and in decision‐making and planning for the future (Connolly 1994).

For the purposes of the current review, family group decision making interventions include all models that involve the convening of family and extended family members, identified friends and/or community members; child protection professionals; and, if needed or requested, other professionals, in an effort to collaboratively develop a plan to maintain child safety, facilitate stable and permanent living arrangements, and promote child and family well‐being.

[1] The Maori are the indigenous people of Aotearoa New Zealand, They comprise approximately 14% of New Zealand’s population, living mostly on New Zealand’s North Island (Walker 2006).

[2] The Maori concept of family differs from the traditional Western construct. The Maori words whanau, hapu and iwi, while not readily translatable, have a range of meanings from extended family to tribal affiliation, and comprise the familial structure upon which Maori society is based (Connolly 2004).

How the intervention might work

While the theory of how FGDM processes lead to specific client outcomes remains both understudied and underdeveloped (Crampton 2007), the basic underlying assumption of FGDM models is that, for a variety of reasons, solutions found within the family are likely to be more accepted and effective than those imposed by professionals (Sundell 2004). Most importantly, it is assumed that when families have a central role in planning, family members will be more likely to follow‐through and maintain their involvement with the plan over the long term, leading to enhanced safety, permanence and well‐being for children. Additionally, a primary aim of FGDM is to identify, seek out, and actively encourage the participation of the broad family and community system in caring for the children. In this way, FGDM models aim to strengthen the family and community network. Creating a strong network of support around the child and caregiver(s) may improve outcomes for children. In light of this objective, one of the aims of FGDM may also be to encourage the placement (voluntary, court‐involved, temporary, longer term) of children who cannot be maintained with their birth parents.

Plans resulting from FGDM are also believed to be more consistent with the child and family’s cultural beliefs and identities (Merkel‐Holguin 2005). One potentially promising outcome of FGC noted in the literature is the increased rate of placement with relatives when children do require out‐of‐home placement, and the greater likelihood that, when placed, children will remain with their siblings (Crampton 2007; Pennell 2006; Connolly 1999; Lupton 1999; Marsh 1998; Robertson 1996). Both anecdotal evidence and a growing body of research suggest that participants express consistently high satisfaction rates with the FGDM process (Sieppert 2000; Marsh 1998; Sundell 2004).

Finally, FGDM models frame families as competent and often explicitly focus on their strengths, with the aim of empowering families and shifting their experience of child protection service from one characterized by powerlessness to one of self‐determination and collaboration (Lupton 1999). Literature across disciplines indicates that therapeutic settings that support clients’ sense of autonomy, relatedness and competence are more likely to bring about compliance with treatment, and greater transfer and maintenance of treatment gains (Deci 1985; Ryan 1995).

Why it is important to do this review

To date, FGDM models have been widely implemented in several countries, including New Zealand, the U.K., Canada, the United States, Australia, France, South Africa, Sweden, Norway, Denmark, Israel and the Netherlands (Cunning 2006; Faureholm 2005; Goldstein 2006; Cashmore 2000). While research exploring the effectiveness of these models in achieving key child and family outcomes is scant, some existing studies suggest that FGDM models may contribute to reducing future maltreatment for children (Pennell 2000; Marsh 1998), and increase the likelihood that children will remain within their extended family network when placed in out‐of‐home care (Crampton 2003; Crampton 2007a; Gunderson 2003). Other writers have reached more cautious conclusions, suggesting that FGDM models have limited impact on safety outcomes for children when compared to regular child protection services (Sundell 2001; CSSR 2004). Several researchers have noted the limitations of existing research, and call for studies that involve larger sample sizes and more rigorous control group designs (Lupton 1999; Crampton 2007), and research that focuses on testing which specific elements of FGDM might lead to its effectiveness (Crampton 2004). There have been few longitudinal studies into the effectiveness of FGDM models, and no systematic review has been conducted to synthesize existing research.

Family Group Decision Making models are conceptually compelling and consistent with social work values and principles of empowerment and culturally appropriate practice. These models have been widely implemented internationally in child welfare contexts. In addition to the precedent‐setting New Zealand legislation, several countries and jurisdictions have legislation or policies encouraging the use of FGC or FGDM in cases of child abuse and neglect, and provide government funding for FGDM programs.

Despite the widespread support and investment in FGDM, key outcomes for children and families who receive FGDM interventions (safety, permanence and well‐being) are not well documented, particularly over the longer term (Connolly 1994; Lupton 1999; Maluccio 2000; Sundell 2004; Connolly 2004), and no review has systematically synthesized existing research. The combination of the widespread popularity of FGDM along with the limited (and mixed) evidence of its effectiveness makes this review particularly important. A review will begin to clarify our understanding of the extent to which FGDM models successfully prevent future maltreatment and facilitate permanent, stable living situations for children. This information needs to be readily available to communities where FGDM models have already been implemented or are under consideration.

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Studies will be eligible for this review if they: 1) used random assignment to create treatment and comparison or control groups; or 2) used parallel cohort designs in which groups were assessed at the same points in time (i.e., quasi‐experimental designs that include groups assessed at the same time as opposed to a historical cohort). Single‐group designs and single‐subject designs will be excluded (see 'risk of bias' section for further details on included designs).

Types of participants

Children and young people aged 0‐18 years who have been the subject of a child maltreatment investigation,.

Types of interventions

Any form of Family Group Decision‐Making (FGDM) used in the course of a child maltreatment investigation or during the course of services arising from such an investigation.

This involves convening family, extended family, identified friends and/or community members along with child protection professionals and other professional, community‐based collaterals in an effort to collaboratively develop a plan to maintain child safety, facilitate stable and permanent living arrangements, and promote child well‐being. Therefore, studies will be included in the review if they involve: 1) a concerted effort to convene family, including extended family, friends and community members; and 2) child protection professionals (as well as other professional service providers) participating in; 3) a planned meeting with the intention of working collaboratively to develop a plan for the safety, permanence and well‐being of child(ren); and 4) with a focus on family‐centred decision‐making.

Types of outcome measures

Primary outcomes

Prevention of child maltreatment and increasing family permanence and Placement Stability. Prevention of child maltreatment is measured by the following constructs, and these are arrayed in order of 'best' (i.e., most likely to be accurate) to 'worst' (less likely to be accurate):

Substantiated/verified/indicated referrals to a child protection authority (gold standard)
Referrals (not verified) to a child protection authority
Parent self‐report
Child self‐report
Collateral party report

Analyses may include all of these types of measurements, but these will first be grouped by indicator, 'best' source will be preferred, and studies will be analyzed separately prior to synthesis.

Family Permanence and Placement Stability will be measured by the following indicators:

For children residing in the homes of their birth parents, entry into foster care or other out‐of‐home placement will be interpreted in a two different ways. First, any and all placements will be analyzed as a negative outcome (i.e., FGDM, in this instance, is being used to prevent any placement, including kinship placements, into out‐of‐home care). However, kinship care (placement in out‐of‐home care with relatives) is a unique type of care that FGDM may actually faciliate as an alternative to placement to other forms of out of home care. Therefore, Kinship care will also be interpreted as a positive outcome and analyzed separately (i.e., does the rate of placement into kinship care differ between children receiving FGDM versus children who do not), and the interpretation of this set of analyses will be made within the context of FGDM's stated purpose (i.e., involving family members in child placement decisions).
For children residing in out‐of‐home care (i.e., foster care, kinship care,group care), legal permanence will be interpreted as a positive outcome (i.e., reunification with birth parents, adoption by related or non‐related caregivers, placement with relative caregivers, legal guardianship / legal custody by related or non‐related caregivers (i.e., FGDM, in this instance, is being used to facilitate family permanence).
For children residing in out‐of‐home care, long‐term foster or kinship care arrangements with the same caregiver (i.e., placement stability) will also be considered positive outcomes, though such outcomes are generally held in low regard when compared to legally permanent homes.

Since the primary outcomes listed here are generally events rather than perceptions or subjective impressions, the gold standard or 'best' indicator for the measurement of primary outcomes will be official reports found in administrative data and case files. For prevention of child maltreatment, there may be some studies that utilize self‐report or a report from a secondary party. In such cases, only studies using standardized tools measuring the occurrence of child maltreatment and/or family violence, for example the Conflict Tactics Scale (Straus 1996), will be included.

Studies will only be included in the analysis of primary outcomes if subjects are followed for at least six months after the intervention to allow for sufficient time to observe outcomes. For included studies, longest common follow‐up will be used but separate analysis of short‐term (e.g., 6 months) and long‐term (e.g., 3+ years) outcomes will be conducted for each primary outcome measure.

Secondary outcomes

Secondary outcomes include child well‐being, and client satisfaction with the FGDM process and plan.

Well‐being will be measured through the inclusion of studies that employ commonly used instruments for measuring child well‐being such as the Child Behaviour Checklist (Achenbach 1991). Instruments will be coded for information on reliability and validity, and these will be analyzed to ascertain whether they covary with respect to study outcomes.

Client satisfaction will be measured by any tool developed for the FGDM context, such as the “Amount and Adequacy of Say Scale” and the “Decision Process Ranking Scale” (Pennell 1995) Instruments will be coded for information on reliability and validity, and these will be analyzed to ascertain whether they covary with respect to study outcomes.

Search methods for identification of studies

Both published and unpublished work will be considered eligible for the review. A Trial Search Coordinator (Carmen Logie) will be responsible for coordinating this activity. To the greatest extent possible, the search will not be restricted to any single language or nationality.

A Systematic Information Retrieval Coding Sheet (SIRC) has been developed (see Appendix 2) to record each search for the review. The SIRC will be used to log results for each database and grey literature searched and will include:

1) The date(s) of the search;

2) The name of the researcher;

3) The database used for the search;

4) The specific search terms used in combination (including limiters and expanders); and

5) The number of results for each search strategy.

Such recording facilitates replication of the search strategy. Furthermore, the search strategy will be saved and “copied and pasted” into the review to avoid editing errors.

Electronic searches

Electronic searches for the identification of appropriate studies will include the following bibliographic Databases:

1. Cochrane Central Register of Controlled Trials (CENTRAL)

2. MEDLINE

3. The Campbell Collaboration Register of Controlled Trials (C2‐SPECTR)

4. PsycINFO

5. EMBASE

6. Database of Abstracts of Reviews of Effects (DARE)

7. ASSIA (applied social sciences)

8. ERIC

9. CINAHL

10. International Bibliography of the Social Sciences

11. Caredata (social work)

12. Social Work Abstracts

13. Social Sciences Abstracts

14. Child Abuse and Neglect (CANDIS)

15. Australian Family and Society Abstracts Database

16. Dissertation Abstracts International (DAI)

To ensure maximum sensitivity and specificity, subject headings and word text will be searched in a systematic process.

The search that will be used for Medline is as follows and will be modified accordingly for the other databases listed:

1 family group.tw.

2 family decision.tw.

3 family decisionmaking.tw.

4 family conferenc$.tw.

5 family unity.tw.

6 family team.tw.

7 group conferenc$.tw.

8 group decision.tw.

9 group decisionmaking.tw.

10 team conferenc$.tw..

11 team decision.tw.

12 team decisionmaking.tw.

13 or/1‐12

14 exp child/

15 adolescent/

16 exp infant/

17 (child$ or adolescen$ or boy$ or girl$ or infant$ or toddler$ or baby or babies or preschool$ or pre‐school or teen$).tw.

18 or/14‐17

19 13 and 18

Searching other resources

Reference lists

Reviewers will check the reference lists of all relevant articles that are obtained, including those from previously published reviews. Potentially relevant articles that are identified will be retrieved and assessed for possible inclusion in the review.

Personal communication

Face‐to‐face discussions at meetings, emails, requests on list‐servs, and formal letters of request for information from authors, presenters and experts will be solicited to assist the review team to locate relevant studies. A list of the inclusion criteria for the review, along with a sample of relevant articles, will be sent to these key informants along with the request for studies. The list of experts to be contacted will include principle investigators of eligible studies, program developers, and authors of previous reviews of relevant literature.

Handsearching journals

Journals relevant to child maltreatment will be handsearched by trained researchers to uncover relevant studies not found by electronic database searches. In addition, trained reviewers will search reference lists of relevant articles. These include:

1) Child Welfare

2) Children and Youth Services Review

3) Social Service Review

4) Child Maltreatment

5) Child Abuse and Neglect

6) Journal of Social Services Research

7) Social Work

8) Research on Social Work Practice

9) Social Work Research

10) Child Abuse Review

Grey Literature

Special attention will be made to search and collect relevant studies captured in the grey literature. Specifically, the review will include the following strategies to locate articles:

1) Conference Proceedings (e.g. PapersFirst and ProceedingsFirst, both accessed through the University of Toronto library system); 2) Research Reports (e.g. http://www.evaluationcanada.ca/site.cgi?s=6&ss=8); 3) Government Reports and Policy Documents (e.g. http://www.gc.ca/publications/publication‐eng.html, http://www.usa.gov/, http://publications.gov.au/, http://www.natlib.govt.nz/collections/types‐of‐items/government‐publications, and http://europa.eu/index_en.htm; 4) Book Chapters; 5) Dissertations (e.g. ProQuest Dissertations and Theses, Theses Canada Portal http://www.collectionscanada.gc.ca/thesescanada/index‐e.html; 6) Personal Networks; and 7) Research Organizations’ Web Sites. Grey Literature web‐based sites will be searched to uncover this unpublished literature, such as Grey.Net (http://www.greynet.org/index.html)

Data collection and analysis

Selection of studies

Titles and abstracts of studies yielded by the searches will be independently screened by two reviewers to determine their eligibility for inclusion in the review. The screening of the studies will be carried out by a three‐stage procedure (see Appendix 1) where each screening point will be established in ‘level’ format and each level will consist of increasing scrutiny of the studies based on the inclusion and exclusion criteria of the review.

Data extraction and management

Two review authors, using a data extraction form, will independently extract data on participants, methods, interventions, outcomes, and results (Appendix 3). We will obtain missing data from study authors if possible.

Details to be extracted will include:

1) Study: information regarding the author(s); year of publication; source; country; and language

2) Characteristics of Setting and Participants: eligibility criteria for participants; explanation of recruitment procedures, setting (country, location, clinical/non clinical); demographic features of the sample

3) Sampling: sample sizes for treatment and control; whether power analysis was used to determine sample size; allocation to the treatment and control; explanation of method used to generate the allocation

4) Research Design: Type of design including major features such as random selection, random assignment, and non‐equivalent control group. Features will be assessed according to ‘Assessment of risk of bias’ categories as described below

5) Intervention Data: nature of interventions (for treatment and comparison/control groups); FGC, FUM, or some other form of Family Group Decision‐Making; aim of intervention; length of intervention, whether manuals were used, whether fidelity checks were included, information on possible contamination reported

6) Outcome Data: primary and secondary outcomes, measures used, information on reliability/validity of measures

7) Results: attrition at post intervention and follow‐up; number excluded from the analysis; length of follow‐up; statistical methods; type of data effect size is based on; data needed for effect size calculations.

Assessment of risk of bias in included studies

Risk of bias will be assessed independently by two review authors according to the Cochrane Collaboration Handbook (Higgins 2008). Review authors will independently assess the risk of bias within each included study based on the following six domains with ratings of 'Yes' (low risk of bias); 'No' (high risk of bias) and 'Unclear' (uncertain risk of bias).

Reporting bias within each of the included studies ( e.g. selection, measurement, attrition bias) will be reported in the results and discussion.

Sequence generation

The method used to generate the allocation sequence is described in detail so as to assess whether it should have produced comparable groups

Review authors' judgment: was the allocation concealment sequence adequately generated?