PROTOCOL: Family group decision making for children at risk of abuse and neglect

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. 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). 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). 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. 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. 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). Children and young people aged 0-18 years who have been the subject of a child maltreatment investigation. 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. Analyses may include all of these types of measurements, but these will first be grouped by indicator, ‘best’ source will be and studies will be prior to the primary outcomes are rather than or the or ‘best’ for the of primary outcomes will be reports found in data and case of child there may be some studies that or a from a In such studies the of child maltreatment and/or family for the will be Studies will be included in the of primary outcomes if are for at the to allow for time to included will be used but of and long-term outcomes will be conducted for each primary outcome outcomes include child well-being, and client satisfaction with the FGDM process and will be through the of studies that used for child well-being such as the will be for information on and and these will be to they with to satisfaction will be by developed for the FGDM such as the and of and the (Pennell will be for information on and and these will be to they with to Both and work will be considered eligible for the A will be for this To the extent the will not be to single or of the the will be and and into the review to To and subject and word will be in a systematic process. will the of all that are including those from that are identified will be and assessed for in the at on and formal of for information from and experts will be to the review to studies. A of the for the along with a sample of will be to these key along with the for studies. 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The will with outcome by for the reports upon which many of the included studies will have been based and the types of outcomes included with the outcomes in the studies. The will also and other of literature for or studies and the range of In cases where outcome is the will be The of risk of due to of outcome will be made for each as a will be conducted and The of will be the following studies may have included more than one of the to of each of the outcome will be will do for by for studies that use or and for studies that two different will be compared with no treatment, will be compared to other regular child welfare service provision or outcomes for or (i.e., compared one control will be will one for in the based upon (i.e., FGDM used sample and of studies that include these will be into within more than and will do for each there is and with to outcomes or there may a at which a the or outcomes that studies make will a of the studies. 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