February 2019Vol. 20, No. 1Print issueSpotlight on Well-being as a Crucial Part of the Child Welfare Continuum

Issue Spotlight

• Prevention Is Well-Being Work

  Prevention Is Well-Being Work

  Written by Melissa T. Merrick, Ph.D., senior epidemiologist, detailee, Office of the Commissioner, Administration for Children and Families, Children's Bureau

  As I reflect on my 20 years working with and for children and families, I'll never forget the day I was confronted with the reality that I was not in the business of preventing child abuse and neglect.

  In walked a young couple with a 9 month old child, the same age as my daughter at the time. The baby presented with patterned bruising on her torso, and the parents described just needing her to stop crying. As tears streamed down all of our faces, they continued, "We just didn't know what to do!" The father had been spending most of his days looking for work, but there were few jobs for someone with his level of education and nonexistent job training that would actually pay the family's bills. The mother was also unemployed and was struggling to comfort her difficult-to-soothe infant. She did not have access to the mental health services she knew she required to help her cope with her own unresolved trauma. They had no family or social support in their neighborhood, having just moved. They spoke only Spanish and asked whether all Americans regarded Spanish speakers as "less than."

  "Ok," I thought for a split second, "maybe I am just crying because I am postpartum and emotional." No. I was crying because the situation was very sad. It was sad that we, as a field, were not in the business of prevention.  We, as a field and as a society, were actually in the business of blaming parents, particularly young parents, single parents, and parents of color for their challenges and circumstances. We were in the business of saving children from their big, bad, terrible parents, rather than responsibly assuming the roles we must all play to prevent child abuse and neglect and to build, bolster, and strengthen families and communities.

  This same day, I realized that I yearned to be in the business of prevention for children and families—and, frankly, for my own mental health—I joined the Centers for Disease Control and Prevention shortly thereafter.

  A public health approach requires that we assure the conditions for lifelong health and well-being before parental stress becomes unbearable and crisis mode is fully engaged. It requires that we implement policies and practices that stop early adversity like child abuse and neglect before it begins, thereby stemming the flow of children and families who encounter the child protection agency in the first place. It requires that we identify and address the structural, contextual, and historical barriers to thriving communities, families, and children. Given the multigenerational impacts of trauma and adversity and the systemic inequities that accompany such, a multigenerational prevention solution that improves the conditions within which parents are caring for their children is imperative.

  We know that children and families will reap more of the benefits of treatment and clinical services if the conditions within which they are living and developing improve. Not to mention, they will be able to make it into treatment and services in the first place if their basic necessities are met and they have access and means to access services and preventive interventions.

  Prevention is possible if we are willing to work in a different, collaborative, and, dare I say, empathetic way. We must work across systems, across silos, and across disciplines to call for a new narrative for all children and families. My now 10-year-old daughter, and all of our sons and daughters, are more likely to thrive if all children are thriving. Please join me in the actual business of prevention. 
  
   

• Family Time Is a Critical Well-Being Intervention

  Family Time Is a Critical Well-Being Intervention

  Written by Dr. Susan Cohen Esquilin, Ph.D., ABPP-Clinical, and Jey Rajaraman, chief counsel, Family Representation Project-Legal Services of New Jersey

  In many child welfare cases, the removal of a child from parental custody marks the first time the child has ever been out of the care of one or both parents. Whatever the reason for the removal, it is a traumatic event for the child, siblings, and parents. A child who is removed from his or her family and placed in foster care fears the unknown and feels scared and hopeless. The parents are also traumatized. They may worry about where their child is, who is taking care of him or her, and whether his or her special needs are being met. Separation between a parent and child is a known trauma. People involved in the child welfare system are faced with the question of how to prevent trauma and minimize the impact of separation. Recognizing the importance of protecting these connections and ensuring parents and children have continuous contact is paramount. The time spent together between the parent and child should be in an environment that reflects the child's home and community.

  The development of a collaborative relationship between the parent and foster parent can help increase the amount of family time or visitation, if foster parents are willing to supervise visits that require oversight. In addition, this relationship can reduce stress for a parent whose anxiety decreases when they can speak with the child's caretakers about the child's needs and adjustment. Collaborative relationships between parents and foster parents also increase the quality of parent-child visits, when children and parents feel secure in knowing that reunification is supported by foster parents and that the relationships between the adults is a positive one.

  Visitation or parenting and family time is essential for a child's well-being while he or she is placed in out-of-home care and away from his or her family. The objective purpose of parenting time is to maintain the parent-child attachment, reduce a child's sense of abandonment, and preserve their sense of belonging as part of a family and community. A child needs to see and have regular contact with his or her parent(s), as this relationship is the foundation of child development. In the majority of these cases, reunification between the child and his or her family is the primary goal. Visitation maintains and supports the parent-child relationship necessary for successful reunification.

  The importance of family visits for children in out-of-home placements cannot be overstated.

  Research shows that frequent and lengthy parent-child visitation achieves the following:

  • Supports parent-child attachment and reduces children's sense of abandonment while in care.
  • Increases the well-being of children in out-of-home care. For example, children with frequent family contact show higher verbal and nonverbal IQ scores.
  • Positively affects the parents' feelings about the child placement, including reduction in parental worries about their children.
  • Is strongly associated with placement outcomes and with fewer months in care—that is, both family reunification and other permanency outcomes, such as adoption and kinship guardianships.

  Frequent and lengthy family visits for children in out-of-home placement is critical to family reunification, shortening the time spent in out-of-home care, enhancing the social and mental well-being of children, and encouraging parents. The standards for parenting and sibling time mandated by statutes, regulations, and case law are clear. However, the practical compliance with these standards continues to lag behind the intent of the standards.

  New Jersey has long recognized parent-child contact through parenting time. In an effort to ensure that parenting-time schedules are specific to the circumstances of the individual family, New Jersey has created a form order and visitation judicial bench card for child welfare matters. Starting in 2018, courts must include a visitation schedule for the child and his or her parents, siblings, and other family members. In cases where ordered parenting time does not occur, courts must engage in a thorough review of the reasons and develop a plan to mitigate barriers (e.g., transportation, work and school schedules).

  Ensuring families receive meaningful family time requires active engagement of all involved to ensure that barriers to visitation are not only identified but eliminated. Child welfare case workers must be creative in case planning, and state and local child welfare agencies must support front-line case workers to achieve these outcomes. Development and continued support of positive parent and foster parent relationships is crucial. Judicial involvement and oversight through the use of bench cards and form orders can further support assurance that meaningful visitation will be effectuated.
  
  
    

• Parent Well-Being and Parent-Child Relationships Are Key to Promoting Child Well-Being

  Parent Well-Being and Parent-Child Relationships Are Key to Promoting Child Well-Being

  Written by Jerry Milner

  For far too long, the concept of well-being has been something of an afterthought in child welfare, falling a distant third to ensuring physical safety and pursuing permanency. While it is clear that a person cannot experience well-being in the absence of feeling and being safe, in child welfare we can and often do achieve physical safety without addressing overall well-being. The result is that we protect many children and youth from harm without arming them with the strength and skills needed to become healthy, resilient adults who can thrive in the world they live in. 

  When we do consider and talk about well-being, we most often do so in terms of the child's well-being, often in isolation from the family's or parent's or community's well-being. Perhaps arising from the fact that many "well-being" services fall under the purview of organizations and entities other than the child protection agency, it becomes easy for the agency to focus on those aspects of well-being that are within its control. For example, we focus on making sure medical appointments are made and kept to comply with case plan and policy requirements, that educational records are available and individualized education plans are in place, or that mental health screenings are conducted. These are important for sure but not as often do we engage in assessments, develop case plans, and provide supports that address psychological and emotional well-being and what children and families need to feel connected, supported, secure, and, ultimately, to thrive. While we have begun to place more value on social and emotional health since the passage of Fostering Connections, this, too, has fallen short and most commonly manifests in policy and practice to promote school stability and to "normalize" foster care rather than approaching well-being in a holistic manner.

  While we have a responsibility to address child well-being when we are called upon to intervene in their lives, I believe that we must also be concerned with the well-being of the parents and families that we want to be able to attend to their children's needs. Given the intergenerational cycles of trauma, family disruption, and unresolved difficulties experienced by so many of our families, failure to address their needs for well-being can only perpetuate such cycles. Our goal should be nothing less than helping them to thrive. I recently met with a group of parents in a community-based family support program and asked them what it meant to them to thrive. The responses were telling—a house without mold, educational opportunities, access to effective mental health services. No one mentioned wealth or extravagant material possessions.

  Attending to the well-being of parents and families goes to the heart of the most obvious influence on the well-being of children: the strength of parent-child relationships. Removing children from struggling parents, even when necessary, can inflict and/or increase existing trauma for children, parents, and families. By attending to well-being through primary prevention efforts, we have an opportunity to avoid so much of that trauma. We also have tremendous opportunities to rethink how the foster care experience itself, when necessary, can support, rather than harm, the parent-child relationship and strengthen this essential component of well-being.

  A commitment to addressing well-being signals an equal commitment to child protection agencies to work in an integrated manner with other entities that can and do affect well-being every day—the courts, the legal community, service providers, foster caretakers, and community groups and organizations. It cannot—and should not—be attempted in isolation of these key partners and others. I urge everyone to think of parent well-being and healthy, safe intact families as key strategies for achieving child well-being. Let's not forget that the most important thing a child needs is a safe and loving adult and that for the vast majority of children, that safe and loving adult, or adults, are his or her parents. 
   

• Let's Enhance the Well-Being of All Children by Building Vibrant and Healthy Communities Together

  Let's Enhance the Well-Being of All Children by Building Vibrant and Healthy Communities Together

  Written by Frank L. Alexander, director, Boulder County Department of Housing and Human Services, Boulder, Colorado

  It is time for us to lift our eyes from the consuming confines of our individual agency work and aim higher—much higher. We have been working for decades to reach the moment that we have before us, an opportunity to truly transform our historically isolated child protection agencies (CPAs) into component parts within integrated systems of care that build vibrant communities and enhance the well-being of all children. We all know this must be done, we know it is not impossible, and, yet, we can't quite see the path forward. That should only further encourage us to sit together with determination and urgency and get to work. When answers are not easily seen, and when fear of failure arises, we need to be thoughtful in how we approach the work we must do. Carl Jung stated, "in sterquiliniis invenitur", meaning that which we most need to find will be found where we least want to look. 

  Last year, CPAs received 4.1 million referrals involving 7.4 million children. Every day across the United States, we receive referrals on more than 20,000 children. Our child protection systems are overloaded responding to the needs of families with children aged 0 to 5 years that should be met much earlier in our communities. Nationally, between 1,750 and 5,250 children die as a result of maltreatment; 84 percent of child maltreatment fatalities occur in children between the ages of 0 and 5 years, and 50 percent of those occur before the age of 1; 62 percent of all child fatalities occur before the age of 1; the rate of child maltreatment is highest among children under the age of 1, at 24.8 per 1,000, and 50 percent of all child maltreatment occurs before the age of 5; and of the 700,000 children that spent time in care last year, a full 40 percent (280,000) were under the age of 5. The highest rate of fatalities, near fatalities, egregious incidents, out-of-home placements, and child victimization are experienced by children under the age of 1, followed closely by children under age 5. We know that 75 percent of founded instances of child maltreatment are neglect. We know that rates of child abuse and neglect are five times higher for children in families with low socioeconomic status. With all of that being said, we still illogically define child safety as the absence of repeat maltreatment, not the freedom from maltreatment. It is time that we establish a collective national goal to prevent child maltreatment and eliminate child fatalities among our youngest children ages 0 to 5 by positively and proactively supporting strong and healthy families. 

  We do not have a problem that should be or can be owned by the child protection system, we have a public health problem that requires a much more comprehensive solution. The social and economic costs of child maltreatment rival every major public health issue, including diabetes, cancer, stroke, obesity, and chronic heart disease. For children, there are physical, psychological, and behavioral outcomes that negatively impact lifelong health and social vitality. For society, the annual cost associated with child maltreatment is $80 billion, and the estimated lifetime economic burden resulting from new cases of child maltreatment each year is $124 billion. Significant public health issues require coordinated policy and practice solutions across sectors.

  To prevent maltreatment and eliminate fatalities, we need a new foundation. The cornerstone of this foundation is built on strengthening our national alignment among critical federal health and human agencies; private foundations; state and local child protection, human services, and public health agencies; and community agencies serving children and families. By combining direct services for children and families with population-level strategies, we can support the building of vibrant and healthy communities and advance the necessary work of deconstructing the siloes that still largely operate among the health-care, public health, housing, education, and human services systems. The child well-being system needs strengthening and better coordination. Only by activating broad cross-sector coalitions far beyond the child protection agency will we improve child well-being and address the community drivers of health. 

  Together, we know much of what needs to be done. A broad swath of well-documented studies outline the need to advance child abuse and neglect prevention strategies within broad community efforts around strengthening economic supports for families, supporting parents, providing quality care and education early in life, promoting healthy child development, and developing interventions that lessen harm and prevent future risk. Child well-being is cultivated within vibrant and healthy communities. It is time for us to aim higher—much higher. Let's name child maltreatment the public health problem that it is, roll up our sleeves, and build the public will and national alignment necessary to end it.