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Copyrighted and posted by permission of Jenna Bernier at Massachusetts Citizens for Children. Originally posted at https://masskids.org/cta/cta_iii_ch08.html
As we have seen, the problems associated with child abuse and neglect can be complex. Not only can abused or neglected children exhibit serious emotional and developmental impairments, their parents may also struggle with alcohol and drug dependencies, emotional disorders, lack of attachment with their children, and deficiencies in parenting skills and knowledge. Also, the physical signs of child abuse – bruises, broken bones, and other more subtle signs of non-accidental injuries – often require experienced medical experts to detect and confirm as abuse-related. These situations are often so complex that no single professional or discipline should have the burden of assessing a family’s full needs and developing a service plan to address them.
All cases of abuse and neglect can benefit from a multidisciplinary team approach to medical diagnosis, assessment, investigation, and treatment. Studies show that in the most serious cases, sound clinical and prosecutorial outcomes are optimized when they are the result of comprehensive, up-front assessments of child victims, joint investigations, quality forensic interviewing techniques, and limitations in the number of child witness interviews.
Multidisciplinary teams are convened to assess a variety of issues including: medical evaluation, the extent of trauma inflicted on the child, the child’s overall diagnostic and treatment needs, the indications for prosecution, the non-offending parent’s position, and whether the offender is acknowledging or minimizing the abusive behavior. There is a growing consensus that the implications of placement decisions are so critical to the child that no one individual should have absolute discretion in this area. Teams can pool the collective wisdom and experience of their members and make sound judgments about contacts between offending parents and their children.
In court-involved cases, the use of teams provides greater likelihood that the abused child will have input into decisions concerning their needs. For example, one jurisdiction uses a written questionnaire to assist in determining parent offender/child victim contact after sexual abuse has been disclosed. It asks simply, “Are the child’s needs being put forth first? ” This child-centered approach ensures that children’s needs are considered over potentially competing agency agendas or individual ideologies.[152]
Generically, Multidisciplinary Child Protection Teams (CPTs) are comprised of professionals from the medical, mental health, child welfare, and legal disciplines. The Teams are convened to evaluate the child’s condition and safety and to implement a service plan to address the needs of the child and family.
A typical Team assessment includes a physical, psychosocial, and developmental evaluation of the child, as well as an assessment of the family’s ability to function and provide a safe environment. The Team’s first priority is to ensure the safety of the child. This could mean a recommendation to remove the child from the family or to provide a range of family services so that the child may remain safely at home. Trained legal professionals on the team determine if a crime has been committed and identify appropriate legal remedies available to protect the child from further harm.
The potential benefits of Multidisciplinary Child Protection Teams are numerous. They not only improve the quality of assessments, treatment plans, and services for abused and neglected children; parents, families, communities, and the child welfare system benefit as well. Research shows that multidisciplinary CPTs:
In addition, a study conducted by the California Attorney General’s Office concluded that the quality assessments provided through the multidisciplinary approach expedite the legal process by decreasing the number of child interviews while increasing the findings of evidence of abuse.[153] Quality assessments, therefore, improve the probability of a successful prosecution in cases of sexual and serious physical abuse.
Teams have a number of potential benefits for communities, as well. These include: promoting community awareness and action with respect to abuse and neglect; increasing an understanding of community strengths and weaknesses; and, developing additional services and resources at the local and state levels.
Assessments can be best provided by permanent, community-based multidisciplinary teams that function under a statewide system that is itself based on consistent principles of practice and accountability. The following section describes such a system.
Child Protection Teams of Florida
The longest-standing and most successful system of child protection teams is in Florida. The enactment of Florida’s child protection law in the early 1970’s, and the substantial increases in reports of suspected child maltreatment that followed, prompted the state to create a system of diagnostic and treatment services for children and families who came to the state’s attention through these reports.[154]
Under Florida statutes, child protective investigators were required to determine the cause of harm or threatened harm for each child, as well as the nature and extent of all injuries from abuse and neglect.[155] Child abuse investigators, however, were unable to access the resources necessary for such determinations. As a result, the Florida Department of Human Resources (DHRS), within which Child Protective Services is located, developed a method to provide specialized medical services to aid investigators in this responsibility. In 1978 the first Child Protection Team (CPT) was established in Jacksonville, Florida.[156]
This pilot program involved a team of child and family experts and an appointed pediatrician with a specialty in abuse and neglect. Together they provided comprehensive assessments, more accurate diagnoses, and appropriate treatment plans for affected children and families. The success of this team, funded through legislative appropriation, led to the development of CPTs in each of Florida’s 15 districts that operate under the Department of Health.
Child sexual abuse reports dramatically increased in the early years of the CPTs operation. Soon CPTs, originally established to evaluate physical abuse and neglect, became specialized in the medical examinations of sexually abused children and the evaluation of sexual abuse accusations. This led to the awareness that many other sexually abused children did not have access to appropriate treatment and services. Thus, in 1984, the legislature funded child protective services to develop Florida’s Sexual Abuse Treatment Program (SATP), a model intervention and treatment plan for child sexual abuse victims and their families that now also operates through funding by the Department of Health.
Although collaboration exists between the CPTs and SATPs, each program has a unique purpose and offers distinctive treatment options.[157] CPTs are prime examples of high functioning public/private partnerships. They are community-based and function independently as non-profit organizations, providing consultative services to Florida’s state child protection agency. Teams are funded by state allocations which support core services, including interviews, case coordination, medical evaluations, psychosocial assessments, psychological assessments, expert testimony, and training.[158]
Children who have been reported to Florida’s abuse hotline and have been accepted by Child Protective Services for assessment meet the criteria for CPT services. These usually include physically abused, sexually abused, or medically neglected children.
Currently, there are 23 teams that provide services 24 hours a day, seven days a week, in all areas of the state, as well as satellite locations for those teams serving large geographic regions.
CPTs function under the direction of a pediatrician with expertise in child abuse and neglect who serves as the medical director. Other consultant pediatricians work for the team either on a fee-for-service or contract basis. Some teams have Advanced Registered Nurse Practitioners (ARNP) that practice with a consultant pediatrician.
A Team Coordinator, usually a social worker or nurse, is responsible for the coordination of daily activities and supervision of social work. The Team also has Case Coordinators, who conduct individual casework and assessment activities. CPTs are actively involved in training other professionals to identify abuse.
CPTs have a licensed psychologist and a consulting attorney, either on staff or on contract. Depending on the particular case, other staff members may include school personnel, representatives from community agencies working with the child and family, or an attorney representing the state. Across Florida, current CPT staff include 133 physicians and ARNPs, 212 social workers as case coordinators, 14 nurses as case coordinators, 46 psychologists, and 18 consulting attorneys.[159]
Many CPTs are now located within the more recently established Children’s Advocacy Centers and function in accordance with the National Standards of Children’s Advocacy Centers. (A general description of CACs follows.) Though child welfare and child health professionals in Florida launched this system over twenty years ago, it has continued to evolve to meet newly identified needs. For example, when Florida recognized the need to reach rural areas with a shortage of trained professionals, they initiated a “telemedicine program.” This program has significantly reduced the number of children needing transportation for evaluation, and has increased successful court actions by improving the medical expertise of local health professionals.[160]
Another example of how CPTs have evolved relates to the state’s aggressive recruitment and training strategies for physicians. All medical personnel participating on these CPTs must complete a required training curriculum. The training encompasses classroom training and a requirement that the physician in training work with an experienced professional mentor prior to being deemed sufficiently experienced to evaluate and treat child abuse cases.
This basic training is supplemented with widely attended regional trainings held twice a year where medical staff consult with their colleagues on complex or unusually cases and learn about the latest advances in the field. These trainings are offered at no cost to the physician.
Consumer and Professional Responses to Florida’s Program
Annual surveys conducted by the Children’s Medical Service division of the Florida Department of Health have consistently found that the majority of children and families involved with Child Protection Teams are very satisfied with the quality of team services. Eighty-seven percent (87%) of participants rated the quality of team services “excellent or good.”[161] Satisfaction among mandated reporters who interface with the teams was even higher.[162]
The role of Florida’s CPTs in reducing subsequent child deaths from abuse and neglect is noteworthy. Data show that only three of the many thousands of children assessed by the Teams later died from abuse or neglect. (In one case, Child Protective Services did not follow the Team’s recommendation that the child not be returned home.) In contrast, 68 child deaths occurred among children served by Child Protective Services who were not referred to the Teams.[163]
Florida’s Child Protection Team Program provides assessments and evaluations by permanent community-based multidisciplinary child protection teams that function under a statewide system based on consistent principles of practice and accountability. The longevity and success of this child protection program makes it an exemplary model for evaluation and study by other states committed to implementing approaches that work.
By working creatively to identify multiple funding streams, CPTs in Florida have demonstrated that fiscal cost need not be barriers to quality assessments for abused, neglected and traumatized children. Florida CPT’s provided 19,142 children and their families with assessments in Fiscal Year 1997-98, at an average cost of $436 per assessment. [164]
Massachusetts Teams
Currently, in the state there are different multidisciplinary team approaches operating in response to cases of child abuse and neglect – Sexual Abuse Investigative Network Teams (SAIN Teams), Children’s Advocacy Centers (CACs), hospital-based Child Protection Teams (CPTs), and Multidisciplinary Assessment Teams (MDATs). The quality and availability of the teams vary widely across the state. They also differ greatly with respect to their specific goals, functions, structures and membership.
Overall, these teams do not make up a statewide, coordinated system with uniform standards and accountability to identify, assess, and treat child abuse victims as they enter the child protection agency. The existence of this basic infrastructure, however, makes it possible to envision the development of an effective, truly coordinated, statewide system.
Some counties are working to develop better coordination among their local teams, and legislation is pending to address the need for statewide Children’s Advocacy Centers and to expand hospital-based Child Protection Teams. These important efforts and the recommendations described below could significantly upgrade Massachusetts’ child protection response and result in more effective investigation, evaluation and treatment planning for children and families.
In describing the various teams operating in Massachusetts, there are a number of issues that are fundamental to the future functioning of all of them.
Confidentiality
Since multidisciplinary teams are specifically designed to cross professional barriers, issues of confidentiality among professionals who participate on these various teams must be formally addressed.
Training
Multidisciplinary teams must be supported through ongoing training programs aimed at enhancing professional skills, clarifying team roles, and supporting good team dynamics.
Decisions by the Courts
The assessments and recommendations made by multidisciplinary teams must be routinely shared with the courts as they formulate decisions on a range of service and placement issues involving abused and neglected children. This will better ensure decision making that is in children’s best interests.
Services
Adequate funding of current effective services and the development of specific family supports and treatment options identified by the various teams are essential to the Teams’ ability to develop and implement service plans that effectively meet the needs of children and their families.
Sexual Abuse Investigative Network Teams [SAIN TEAMS]
The Sexual Abuse Investigation Network (SAIN) program was developed in the early 1980’s by DSS, District Attorney’s Offices, and law enforcement, in an attempt to create a multidisciplinary approach to the investigation and assessment of child sexual abuse cases.
The complex nature of sexual abuse cases requires that various professionals be involved with the child and the family during investigations. In past years, the increased number of involved professionals often resulted in multiple interviews of children. To avoid the potential negative impact of multiple interviews, professionals developed the investigative process used by SAIN teams. It minimizes trauma for children and provides a more structured, systematic response.
The first SAIN teams in Massachusetts began in Springfield in the early 1980s.[165] By 1998, SAIN teams had been implemented in each of the 11 judicial districts of the state.[166] Most SAIN teams do provide support to investigators and to families. However, the main focus of these teams is interviewing child victims of sexual, and, in some counties, physical abuse. Even though there is no standardized model for this process, the interview procedure has been found to be similar across sites.[167]
Each SAIN team has a team coordinator responsible for scheduling team meetings, managing the SAIN process, assisting in the sharing of information, and functioning as a resource for other team members. Most teams have a separate forensic interviewer.
Teams consist of professionals from the District Attorney’s Office, police, and child protective services. While professional disciplines within the team vary across counties, each team is typically comprised of a DSS investigator/supervisor, Assistant District Attorney, a Victim Witness Advocate, a professional from law enforcement, and a child interviewer. When needed, a physician is consulted regarding medical evidence, and some counties have mental health professionals that may consult with the team.
In cases of alleged abuse, pre-interview meetings are held to orient the team, plan the interview, and, if appropriate, gather information from parents. The child interview usually lasts from thirty to sixty minutes. The interview is typically carried out in a small, comfortable room with a one-way mirror. It may also be videotaped depending on the needs of the team. The one-way mirror and videotaped interview are essential, for they decrease the likelihood of the child having to be interviewed more than once.
Specialized interviewers with training and experience in child interviewing, forensics, and child safety conduct the majority of interviews. Other members of the team may occasionally conduct an interview if, for example, they have a better relationship with a child or are better “match” with a child, in terms of gender, culture, or style of interviewing.[168]
Cases that are eligible for SAIN services differ from team to team. Many teams have tried to create a written set of criteria to clarify what constitutes an appropriate referral. However, these criteria are not always written clearly and many are subject to interpretation. One frequent criterion is a required disclosure by the child or clear medical evidence that sexual abuse occurred. But it is very difficult to determine objectively what constitutes a disclosure, and even more taxing to understand the definition of “clear medical evidence.”
DSS is the primary referral source for SAIN cases and participation is voluntary, based on parental consent. At present, DSS is attempting to standardize the criteria and is conducting a statewide survey and developing a reporting protocol.
Massachusetts SAIN teams clearly demonstrate many benefits.[169] SAIN teams:
These specialized teams could logically evolve into full-scale multidisciplinary assessment teams whose role would extend beyond the forensic interview. Today, several former SAIN teams have, in fact, evolved into full-scale Children’s Advocacy Centers (described more fully below). Within this model, children who have been referred because of allegations of serious physical abuse or neglect have the advantage of a forensic, clinical, and medical assessment, as well as follow-up clinical support and case management. The trend to evolve SAIN teams into a statewide system of Children’s Advocacy Centers must be supported and encouraged.
Children’s Advocacy Centers [CACs]
The National Children’s Advocacy Center (CAC) Model was first developed in Huntsville, Alabama in 1985. This model was designed as a multidisciplinary program independent of the major state agencies involved in child abuse investigations.[170] It is similar in purposes to other multidisciplinary approaches, such as the Florida Child Protection Teams and the Massachusetts SAIN teams described above that have expanded their role.
The purpose of the Children’s Advocacy Center model is:
The response to child abuse allegations includes forensic interviews, medical evaluation and referral for therapeutic intervention, victim support and advocacy, case review and case tracking. These components may be provided by the CAC staff or by other members of the multidisciplinary team.
Ideally, CACs are governed by a non-profit board of directors and are located in independent physical facilities where interviews are conducted in specially designed child-friendly environments.[172] Unlike SAIN teams that limit their interventions to child victims of alleged abuse, CACs have been designed to extend their services to non-offending family members of the alleged victim. While SAIN teams were created to deal specifically with sexual abuse, CACs are involved in serious physical abuse and neglect, as well.
The core staff of a CAC typically consists of a coordinator, mental health consultant and trained volunteers who assist in the day-to-day operations of the center.[173] CAC staff is also involved in the coordination of the teams, and in providing follow-up and coordination of training for the team members.
The Nation Children’s Alliance, a non-profit organization committed to the establishment and improvement of Children’s Advocacy Centers, has identified the following components necessary for full membership in the Alliance.
CACs are designed to accommodate the special needs of the community and in this way, each CAC is unique, with varying components. CACs that seek full-membership in the Alliance work towards implementing all of the required components listed above. Within this range of diversity, however, all programs share a common philosophy:[174]
Child abuse is recognized as a community problem. No single agency, individual, or discipline possesses the required knowledge, skills, or resources to provide comprehensive assistance to abused children and their families.
Interventions in child abuse cases must be sensitive to the needs of abused children and their families and these needs must be addressed in a respectful environment.
Collaboration among the various disciplines that comprise the child protection system will result in a more thorough understanding of cases, and in the most appropriate responses available.
Children involved in allegations of sexual abuse, serious physical abuse, or siblings of children who have died from abuse, are eligible for CAC services. Though DSS is the primary referral source for CAC cases in Massachusetts, referrals are also made by other agencies, including police, hospitals, mental health agencies, and school departments.[175]
There are several advantages to the CAC design according to the Final Report of the Multidisciplinary Task Force convened in 1995 by DSS to review models of multidisciplinary team practice.[176] By creating a child-friendly environment located in a site not associated with any one agency, CACs create a less traumatic atmosphere for the child. This setting also minimizes family members’ negative impressions of the child protection system and provides them with a single point of entry to services provided by various systems involved with the CAC.
The CAC’s ability to provide a coordinated and collaborative response is founded on interagency agreements and so its success depends on each agency’s continued ability and willingness to participate and meet commitments. Another factor that affects the CAC’s success is its ability to acquire adequate funding for its site and for the provision of services.[177]
In 1994, the Suffolk County Task Force began designing the first Children’s Advocacy Center in Massachusetts to replace its existing SAIN team.[178] In addition to Suffolk County, there are established centers in Middlesex, Hampden, and Berkshire Counties. Centers are under way in Norfolk, Plymouth, Franklin-Hampshire and Barnstable Counties. Some existing SAIN Teams, such as the one in Essex County, have now expanded their teams to include physical abuse.
Referrals to these multidisciplinary teams have increased dramatically over the past decade, a clear indication of the need for expanded capabilities within these centers.
Hospital-based Child Protection Teams (CPTs)
Hospitals and emergency rooms are frequently the first to identify children who have been the victims of physical abuse, sexual abuse and serious neglect. Since the 1970s, hospitals have understood the need to establish internal systems to address the various needs of these children and their families. Hospital-based Child Protection Teams were initially established to bring together medical specialists and hospital social workers to develop appropriate responses to these cases. State child protective workers became regular members of some of these teams and all worked together to contribute to an appropriate service and treatment plan. In Massachusetts, the earliest CPTs in hospitals were developed at Boston City Hospital and at Children’s Hospital in the late 1960s.
A recent survey conducted by Massachusetts Citizens for Children of recognized experts in child abuse found that statewide there are fewer than ten physicians who identify themselves or are recognized by their peers as experts in child abuse and neglect. [179] It is alarming that in a state recognized as a leading center for expert pediatric medical care, the number of trained child abuse specialists is so low. In contrast, through its statewide, comprehensive system of Child Protection Teams, Florida and its courts recognize 133 such experts while its population base is only one-third larger than Massachusetts.
Hospital emergency room staff, family practitioners, pediatricians, and other specialists treating children are literally lifelines for children who present with injuries and symptoms resulting from abuse and neglect. Failure to recognize non-accidental injuries and to report suspected child abuse cases has cut the lifelines of too many Massachusetts children who are sent home only to return to hospitals dead, dying, or seriously injured.
The major reason for the failure to attract physicians to this important work is economic. Currently hospital-based CPTs operate on woefully inadequate budgets. These multidisciplinary teams generate very little income for the hospital, and in today’s fiscal environment, hospitals are not inclined to underwrite budgets for the teams to the degree needed.
In contrast to Florida, the state legislature has appropriated no funds for this activity, and DSS has no funds within its budget to support this. Consequently, the medical component of most reported cases of child maltreatment is omitted. There are no Fellowships at any Massachusetts hospitals to train the next generation of child abuse specialists. Currently, of the six pediatric specialists in Massachusetts, one is over 65 years of age, one is in his late 50s, and the rest can only do this work on a part-time basis. Also, no support for organized research about child maltreatment exists, despite the fact that over 100,000 cases are reported each year.
The shortage of child abuse experts within medical settings is further compounded by a lack of formal supports for new physicians coming into this field. Without it, physicians interested in child abuse quickly become overwhelmed and discouraged. For example, at Baystate Medical Center in Springfield a resident physician who developed expertise in this area soon became inundated with referrals. During this physician’s tenure of less than a year, referrals from various departments in the hospital increased dramatically. Without an adequate number of other child abuse specialists to help evaluate cases, the physician eventually left the specialty, physically overwhelmed and emotionally drained.[180]
Clearly, physicians need a structured support network they can turn to for consultation around complex cases and where they can gain the emotional support they require. Massachusetts must move quickly to establish and fund a statewide system of hospital-based Child Protection Teams and support the development of a statewide training and fellowship program that would aggressively sponsor, recruit and support physicians to work in this vital area.
Teaching hospitals for children have been shortchanged under federal policies for underwriting the training of physicians. Graduate programs for medical doctors are subsidized primarily through the Medicare health care program for the elderly. Since pediatric centers treat young children, they receive few benefits.[181] For example, the average independent children’s hospital receives about $400 federal dollars per resident physician while the average adult hospital receives $87,000 per resident.[182]
All pediatric hospitals in Massachusetts are attempting to cut costs and improve fund-raising in response to huge fiscal losses.[183] This situation could be turned around through a $285 million dollar proposal in Congress to fund children’s hospitals. This critical federal aid would allow hospitals such as the Floating Hospital for Children, Massachusetts General Hospital for Children, the Pediatric Department of Boston Medical Center, Children’s Hospital, and others across the state to move beyond their current level of service, and expand critical help for abused and neglected children.
Multidisciplinary Assessment Teams [MDATS]
The MDATs are Massachusetts’ most recently implemented type of multidisciplinary teams, and are convened by the Department of Social Services. Initially piloted in January 1997, MDATs are currently operational in the 28 DSS Area Offices.[184] Their stated purpose in 1997 was to:
Long-term goals of MDATs as described by DSS are to improve DSS decision-making early in the case, reduce the time a case remains open, decrease the number of children in out-of-home and multiple placements, reduce the rate of families re-entering the protective service system, and encourage community-based providers to participate more actively with DSS in serving children and at-risk families.
MDATs in Theory
In theory, each MDAT is assigned a DSS team convener, who is responsible for scheduling and organizing meetings, facilitating Team discussions, distributing case materials, and preparing final assessment reports.[185]
Teams are ideally composed of standing members who meet on a regular basis and represent a variety of disciplines. Core DSS members may include a Team Convener, Social Worker, Assessment Unit Supervisor, and Domestic Violence Specialist. External members might include, a Substance Abuse Specialist, Mental Health/Trauma Specialist, and a Pediatrician or health care practitioner.[186]
In addition to its core members, MDATs can seek assistance from other community specialists in specific cases, e.g. a dentist might participate in a case involving serious dental neglect. Team members are meant to play an active rather than consultative role in assessing families and facilitating services.
During the Initial Investigation/Assessment phase of the case, the MDAT could be called upon to serve:
The “highs” and “unknowns” described above are derived from the Risk Factor Matrix used by DSS social workers to determine if a child is at risk.[187] Questions on the matrix are divided into categories: Child Characteristics, Child/Caretaker Relationship, and Caretaker Characteristics. For each question, the social worker making the assessment evaluates the child’s status as no risk, low risk, moderate risk, high risk, or unknown risk. Once the level of risk has been assigned for each question, the social worker determines the overall level of risk, and, if necessary, refers the child to services.
Cases involving MDATs at the Ongoing Case Management phase might include:
MDATs in Practice
While the theoretical premise of MDATs is appealing, an evaluation of currently operating MDATs demonstrates that many are still striving to fulfill their envisioned goals. When MDATs were originally implemented, a five-stage evaluation was planned to monitor the development, progress, outcomes, and impact of these Teams. The most recent analysis of this evaluation, entitled “Phase Two” was written in November 1998 and provides insight into how the MDATs were functioning after one year of operation.[188] Responses to anonymous surveys developed and distributed by DSS and completed by Team members, highlighted benefits, as well as areas that needed development.
Sixty five percent of respondents had been on their team for at least 10 months.[189] Although this percentage indicates length of membership, it does not demonstrate the quality or level of active participation of each member. In other words, it does not distinguish between those members who regularly and consistently attend meetings and those who do not.
Consistent with our discussion above about the lack of pediatric child abuse specialists, the evaluation revealed that few physicians or other health experts were members of MDATs.[190] Lack of funding has been cited as the reason. Although in a few instances, local MDATS have chosen to use flexible funds to support the participation of key medical representatives, there is currently no statewide mechanism in place to fund medical professionals for these teams. Given that most cases reviewed by the MDATs involve moderately to severe abuse or neglect with medical implications, the lack of input from specialized health experts with experience in diagnosing and treating child maltreatment is alarming.
Benefits cited by team members during the evaluation include increased collaboration among a variety of experts, increased collaboration between DSS and service agencies, and increased availability of flexible funds needed to provide creative services to families. Criticisms of the MDATs were that the amount of time required to participate was significant and more than had been anticipated. Many professionals cannot remain on teams where compensation does not adequately match the time and resources necessary for their attendance. Also, 51 percent felt they received too little follow-up information on the cases reviewed.
Half of the “Phase Two” survey respondents indicated that they rarely or never saw the child and family being discussed.[191] Since the quality of any review is highly influenced by direct contact with the family and child in question, some argue that the MDATs are mostly consultative to the DSS social worker and do not conduct true “assessments.”
A recent DSS survey of the kinds of cases being reviewed by ten MDATs makes it clear that a majority of cases being referred have been in the system for some time. These include: families with complex, interacting problems, e.g. domestic violence, substance abuse, serious mental illness; children with multiple 51A reports; children with multiple placements within a short period of time; children re-entering care within 6 months of returning home; and, chronically “stuck” cases. Though there is certainly value to providing input on difficult cases, it appears that the original purpose of the teams to review cases “up-front” and early is not its prime focus.
The need to conduct quality multidisciplinary assessments at the earliest stages of a case is a theme that has been consistently promoted by MCC since its Settlement Agreement with DSS in the mid-80s. As part of their separate investigations into the functioning of DSS, both the Senate and the House Committees on Post Audit and Oversight have embraced the notion of multidisciplinary teams and assessments.[192]
A central recommendation of the 1993 Governor’s Commission Report on Foster Care [193] called for “front-loading” the system, that is, to focus the bulk of resources at the front end of the system when cases are just entering and a quality assessment of the child’s and family’s needs are essential. The rationale is that if cases are properly assessed and addressed early on, they will likely move through and away from the system faster, benefiting the child, family, and the state agency. Such early and comprehensive assessments, it is argued, would minimize poor decision-making that may contribute to cases being “stuck” and those cases that revolve in and out of the system. The need for quality multidisciplinary assessment conducted early on in a case was a prominent recommendation reiterated throughout the Summit’s recent proceedings.
MDATs and Family Based Services Treatment Teams (FBSTs)
In 1999, DSS began to implement a Family Based Services model combining multidisciplinary practice and family strengthening principles within a managed care system. In this model, established child welfare agencies compete to serve as the Family Based Service Lead Agency in their particular area of the state. Through local FBS Treatment Teams, Lead Agencies provide services to DSS clients from an array of local services. Increased family input in choosing appropriate services, and increased use of community supports for families are key to this program. Local, culturally competent experts in child development, substance abuse and other clinical issues can be made available to the network.
Currently, every DSS Area Office utilizes Family Based Services. Open DSS cases are served, as well as cases involving Children In Need of Services (CHINS) referred by the courts.
According to DSS, the roles of these two evolving team models is differentiated in the following way:
These models represent the beginnings of an infrastructure within DSS based on family support principles and multidisciplinary practice. Their development should be supported. However, as these team models evolve, a clearer distinction should be made between the development of a service plan and its subsequent implementation. MDATs are better positioned to assess the child and family, and based on their assessments, to develop a detailed treatment plan. FBS Teams can best implement the treatment plan by creatively utilizing community contacts and flexible funding.
Dividing the roles of these two teams in such a way has important benefits for children and families. The clinical composition of a fully developed MDAT ensures that the treatment plan is tailored to the specific needs identified in the clinical assessment. The MDATs are also not constrained by managed care considerations as they develop treatment plans. In contrast, FBSTs are more limited in their clinical expertise and by their very design are meant to function as agents of the managed care system. This has direct implications for families and the types of services they receive.
For example, an MDAT recommendation could include providing parent aide services to a neglectful mother. Parent aide services by design are based on the development of a relationship between the parent aide and the parent and may take from three to six months to establish. Important gains are often made in the period after the relationship is formed and trust has been built. If an FBS Treatment Team accepts the MDAT’s recommendation for this specific service but limits the duration to three months, it will negate the basic philosophy of this lay therapy approach, thus rendering the entire intervention ineffective.
Recommended treatment plans that are not implemented in full, or services that are provided for a shorter duration than recommended can have dire consequences: service plans fail, parents working in good faith to improve their care taking skills are further stressed, state dollars are wasted, and children remain at risk.
Currently, many workers are reluctant to bring a case to the MDATs because they will need to present it a second time to an FBS Treatment Team in order to obtain services for their clients. Their clients may also have to meet with both teams. This is an inefficient use of limited caseworker resources and discourages families from participating in what they see as a redundant process.
While the functions of these two teams should be distinct and clear, information sharing and coordination between them is essential. Identifying a representative of the FBS Treatment Team to serve as a core member of each MDAT and to act as a liaison would be an ideal way to achieve this.
Family Support Teams
As discussed earlier, DSS cases identified as low risk, cases screened out without any investigation, or those found not to be substantiated after investigation could benefit from Family Support Teams that could coordinate family conferencing and “assessments” at the local level. Family Support Teams that include community-based social workers and other child and family service providers assist the family in identifying local supports that could reduce stresses and improve family life. In this model, parents play a key role in identifying their needs and the supports that would be most helpful in addressing them. Some local DSS offices are introducing the concept of Family Support Teams through “Community Connections,” their community-based partnership program. A further description of this program is included in Chapter 16.
Multidisciplinary Assessments and the Courts
The impact of quality assessments on the handling of child abuse cases by the courts can be significant because these assessments are seen as highly reliable and accurate. For example, Florida CPT cases referred to the courts have an 89 percent rate of conviction or pleas, while the rate of non-teamed cases is only 69 percent. This higher rate reflects the CPTs’ ability to properly send only the most appropriate cases to the court for its review, thus reducing court costs. In addition, data show that Florida courts order 94 percent of recommendations made by CPTs, whereas only 53 percent of services are ordered when recommended by child protective service workers without the benefit of a team assessment. [195]
It is clear that the quality of judges’ decisions in complex matters involving children and families is inextricably tied to the quality of the information they receive. Massachusetts courts and the children they serve could benefit greatly from assessments and recommendations made by multidisciplinary teams. A discussion of this proposal is found in Chapter 13, “Abused/Neglected Children and the Courts.”
RECOMMENDATIONS
Children’s Advocacy Centers
Hospital-Based Child Protection Teams
Multidisciplinary Assessment Teams (MDATs)