4 Analysis, Judgement and Decision Making
Treatment itself is intimately bound up with assessment, relying on it as a house relies on its foundation. Consequently, assessment continues throughout the treatment process, despite a change in focus during its course (Jones, 1997). 4.1 The Guidance has emphasised that assessment is not an end in itself but a process which will lead to an improvement in the wellbeing or outcomes for a child or young person. The conclusion of an assessment should result in:
4.2 Generally, all these phases of the assessment process should be undertaken in partnership with the child and key family members, and with their agreement. This includes finalising the plan of action. There may be exceptions when there are concerns that a child is suffering or may be suffering significant harm. 4.3 In many approaches or referrals to social services departments, families are clear about their problems but may not be sure where to turn or how to obtain services. With advice and information, they are able to take appropriate action. This action may be all that is required by a social services department. Where there is a question about whether a child is in need and therefore services are necessary an assessment is required. For some families, the process of assessment is in itself a therapeutic intervention. Being able to look at problems in a constructive manner with a professional who is willing to listen and who helps family members to refiect on what is happening, is enough to help them find solutions. During the assessment process, it may emerge that families will best be helped by agencies other than social services. Armed with this information, families may wish to seek solutions themselves; others may wish to have help in gaining access to other agencies or practical services. 4.4 A significant proportion of families who seek help from social services are unable to resolve stresses or problems solely from within their own emotional or practical resources or from their own support network. It is for these families that assessment may be important in order to identify the nature of their children's needs and, simultaneously, may be the first stage in a longer process of positive intervention. Ultimately, careful judgements must be made about balancing the needs of children and parents. 4.5 In most situations, meeting children's needs will almost always involve responding also to the needs of family members. The two are closely connected and it is rarely possible to promote the welfare of children without promoting the welfare of significant adults in their lives. In some cases, meeting the children's needs may mean giving others either parenting responsibility or legal parental responsibility for the child, either for short periods or on a longer term basis. Where consideration is being given to meeting parents' needs, as part of the plan of intervention, this must be because it is in the best interests of the child and will assist in securing better outcomes for the child. Parents may also require help in their own right as adults who have specific needs. 4.6 In Chapter 3 it was emphasised that gathering information is a crucial phase in the assessment process, which requires careful planning about how best to undertake it. Information may be gathered from a variety of sources, using methods which will be determined by the purpose of the assessment and the particular circumstances of each child and family (see paragraph 3.38). Some of the information may have been gathered through the use of questionnaires and scales, such as those published in the accompanying materials (Department of Health, Cox and Bentovim, 2000). The Home Inventory (Caldwell and Bradley, 1984) and the Assessment of Family Competence, Strengths and Difficulties (Bentovim and Bingley Miller, forth-coming), due for publication later in 2000 will also provide important information about the child's world and family functioning respectively. 4.7 The information should be organised according to the dimensions of the Assessment Framework as a necessary beginning to the next phase of analysis. Information should be summarised under each of the three domains ie. children's developmental needs, parents' or caregivers' capacities to respond, and wider family and environmental factors. The Department of Health has developed assessment recording forms to assist practitioners and their managers in this phase of work (Department of Health and Cleaver, 2000). 4.8 In organising the information, there may be different perspectives to be explored, recorded and taken into account, for example, the child may have a different understanding and interpretation of what is happening from that of either parent or of a professional. These differences are important when developing an understanding of the child's needs within the family context. Different family members may attach different meanings to the same information, for example, the significance of past family history or events. The same information may vary in its salience for different family members, for example, the impact of a bereavement in a family. Sometimes these differences in perception can lead to confiicts in the family or between family members and professionals. In reaching a shared understanding of what is happening in a family, it is important to keep the focus on the needs of the child. This enables family members and professionals to agree a plan of action, even in the context of some differences or tensions, that will address the identified needs of the child with the aim of improving outcomes for the child. 4.9 By this point, there should be clear summaries which identify from the information gathered the child's developmental needs, parenting capacity and family and environmental factors. In each of these domains, both strengths and difficulties should be identified. Children's needs do not exist in a vacuum (Jones, 2000) and, therefore, the inter-relationships between the child, family and environment must be understood. Some factors will work positively to support children's growing up while others will militate against or undermine their healthy development. In weighing up the impact that various factors have on a child, it has to be borne in mind that not all factors will have equal significance and the cumulative effect of some relatively minor factors may be considerable. Thus the analysis of a child's needs is a complex activity drawing on knowledge from research and practice combined with an understanding of the child's needs within his or her family. 4.10 The elements of parenting capacity can be described, and minimum parenting standards or requirements assessed by the practitioner and related to their child. However, it is not possible to ascribe numerical values to each element because parenting capabilities and behaviours are complex and subject to infiuences from within and outside the family (Jones, 2000). Parenting capacity can only be understood within the overall context in which children are being brought up. The analysis should identify the family and environmental factors which have an impact on the different aspects of the child's development and on the parent(s) capacity in order to explore the relationship between the three domains (Department of Health and Cleaver, 2000). At some points in time judgements may be made (based on the analysis of their parental functioning) that the parent is unable to respond to their child's needs. 4.11 To summarise the analysis stage:
4.12 Professionals will be drawing on their respective knowledge bases to inform the judgements they come to about a child's circumstances, whether the child is in need and whether their health and development is likely to be impaired without the provision of services. For some children, decisions will also have been made about whether they are suffering or are likely to suffer significant harm. The knowledge base will include information about the factors which are intrinsic to all children such as temperament, genetic make-up and race, and other factors which may be intrinsic to some children, such as physical or sensory impairments. 4.13 Critical to an understanding of what is happening to a child is the knowledge of the way in which children need to achieve certain tasks at particular ages and stages of development. Bentovim (1998) summarises current views on child development which 'emphasise that what matters for development is that the various systems - biological and psychological - should be well integrated. Development is about progression, change and re-organisation throughout life' (p.66). This normal pattern of development may not be achieved for some children either because of unavoidable factors such as impairments or because they are suffering significant harm (Bentovim, 1998). 4.14 There is a considerable literature to assist professionals when making a judgement about a parent's capacity and assessing what is a reasonable standard of care (Jones, 2000; Cleaver et al, 1999) 'even though research cannot provide the kind of numerical accuracy which is often sought' (Jones, 2000). 4.15 Critical at this phase will be judgements about a number of key issues (Jones, 1998):
4.16 It is important to identify strengths in the child's family system and to use these areas as the basis on which the child's development can be promoted. The more complex the family's problems, the more these will involve sophisticated inter-disciplinary and inter-agency co-operation in order to reach judgements about these issues. Stevenson (1998) provides a cautionary note in such circumstances. 'The families themselves may seem overwhelmed to the point of powerlessness, so the workers may experience similar feelings' (p.18). The refiective process for professionals working with children and families may be stressful, particularly in difficult circumstances. Some children's lives are such that profound, sensitive judgements may be required. This could include judgements about medical treatment in life threatening situations; judgements about whether to separate a child from his or her parents or caregivers; judgements about whether to place children with permanent substitute families. However, careful and systematic gathering of information, and its summary and analysis according to the framework can assist professionals in making sound evidence based judgements. The practice guidance has been developed to assist this process (Department of Health, 2000a). 4.17 Sometimes, where there are multi-faceted problems, assessments can become stuck and little progress made. Reder and Duncan (1999) talk about the danger of assessment paralysis which they describe as 'an impasse in the professional network where the issue of whether the parent has a psychiatric diagnosis becomes the context for deciding about all interventions'. Assessment paralysis can apply in other situations, where the focus of attention becomes stuck on a particular diagnostic issue and decision making is driven by this consideration rather than the child's needs. It requires vigilance and careful management by those staff who hold responsibility for the child's welfare to ensure that progress continues to be made to help the child. 4.18 Social services departments have lead responsibility for undertaking assessments of children in need. In order to arrive at well balanced judgements about the needs of children, practitioners and their managers may benefit from the expertise and experience of professionals in other disciplines. These professionals can act as consultants or advisers to assist and contribute to the assessment processes, which includes analysis of information gathered. This type of input may be as useful to the assessment as the commissioning of specialist assessments. 4.19 In some situations, where the available evidence requires careful analysis by those with particular expertise, sufficient information about a child and the family may already be available. Therefore, the specialist task is to assist in the analysis of available material, drawing on knowledge in particular areas about likely outcomes of certain courses of action. This expert knowledge can assist the practitioner and his or her manager when constructing a plan and deciding how to implement it. 4.20 In drawing up a plan of intervention, careful distinction should to be made between judgements about the child's developmental needs and parenting capacity and decisions about how best to address these at different points in time. These decisions will have to take account of a number of factors including:
4.21 Underlying these critical considerations is the importance of keeping the child at the centre of the planning processes. Three key aspects of a child's health and development must inform the content and timing of the plan:
4.22 The development of secure parent-child attachments is critical to a child's healthy development. The quality and nature of the attachment will be a key issue to be considered in decision making, especially if decisions are being made about moving a child from one setting to another, or re-uniting a child with his or her birth family. (For further discussion of attachment see Crittenden and Ainsworth, 1989; Schofield, 1998; Howe, 2000). 4.23 In complex situations, it may be helpful for those involved in the assessment process to meet to discuss the findings and formulate the plan. This should involve the parents and, as appropriate, the child. Family Group Conferences or multi-disciplinary meetings may provide for the construction of plans for children in need. Working Together to Safeguard Children (1999) sets out the processes to be followed for children about whom there are concerns that they are suffering or likely to suffer significant harm. The role of the key worker appointed when a child's name has been placed on a child protection register, the role of the group of professionals responsible for developing and implementing the child protection plan and the aims, content and processes for constructing such a plan are set out in paragraphs 5.75 to 5.84 of Working Together to Safeguard Children (1999). 4.24 For some families, the findings from the core assessment will indicate that the parents are responding appropriately to their child's needs, but in order to maximise the child's health and developmental outcomes, specific services are required to assist the parents and/or the child. In the absence of particular stress factors, such as those resulting from having a chronically ill child, the parents would be able to bring up their children without external help. However, the presence of these stressors require parents and families to develop new ways of functioning, as well as to accept support from outside their family and friendship networks. In these families, siblings may be affected significantly and services should address their needs. 4.25 It has to be recognised that in families where a child has been maltreated there are some parents who will not be able to change sufficiently within the child's timescales in order to ensure their children do not continue to suffer significant harm (Jones, 1998). In these situations, decisions may need to be made to separate permanently the child and parent or parents. In these circumstances decisions about the nature and form of any contact will also need to be made, in the light of all that is known about the child and the family, and reviewed throughout childhood. Key in these considerations is what is in the child's best interests, informed by the child's views (Cleaver, 2000). 4.26 The following criteria have been identified as suggesting a poor outcome for reuniting children who have been maltreated with their parents (Bentovim et al, 1987; Silvester et al, 1995):
4.27 However, most parents are capable of change, and following appropriate interventions, able to provide a safe family context for their child. At times, children may need to be separated temporarily from their parent or parents. This enables change to take place while the child is living away from home in a safe environment. During this time, it will be important to address the changes required in the parent(s) as well as meeting any therapeutic needs of the child and other family members by active programmes of intervention, appropriate deployment of resources and careful review of progress. If a child is separated from their parent(s), it is essential that parents are able to sustain any improvements made whilst the child is living away from home, when the child returns to live with them. Careful thought should be given to the nature of services required by the parents and child during this transition phase, to ensure that earlier achievements are able to be maintained and continue to be improved upon. For some families continued intervention may be necessary for a considerable length of time until the child is no longer vulnerable. 4.28 Jones (1998, p.108) summarising relevant child maltreatment research findings reports the following features as having been identified in those cases where there are better prospects of achieving good outcomes for children:
4.29 When an analysis of a child's needs and parenting capacity within their family context is completed, there is then a baseline from which further assessment and re-assessment, using the Assessment Framework, can be undertaken to review progress as services are provided. 4.30 In a number of family situations where there is concern about a child's safety and future wellbeing whilst living in his or her family, the findings from a core assessment may provide an uncertain picture of the family's capacity to change. These families are characterised by one or more of the following (Bentovim et al, 1987; Silvester et al, 1995):
4.31 These families often cause professionals considerable concern. It is important that services are provided to give the family the best chance of achieving the required changes. It is equally important that in circumstances where the family situation is not improving or changing fast enough to respond to the child's needs, decisions are made about the longterm future of the child. Delay or drift can result in the child not receiving the help she or he requires and having their health and development impaired. 4.32 The details of the plan are bench marks against which the progress of the family and the commitment of workers are measured, and therefore it is important that they should be realistic and not vague statements of good intent (Department of Health, 1995). 4.33 The analysis, judgement and decisions made will form the basis of a plan of work with a child in need and his or her family. The complexity or severity of the child's needs will determine the scope and detail of the plan. The different circumstances under which the assessment has been carried out will also determine the form in which it is recorded and the status of the plan:
4.34 There are some general principles about plans for working with children and families, whatever the circumstances in which they have been drawn up. First that, wherever possible, they should be drawn up in agreement with the child/young person and key family members and their commitment to the plan should have been secured. There are two caveats which the professionals responsible for the plan need to bear in mind:
Failure to address these issues can be damaging to families and jeopardise the overall aim of securing the child's wellbeing. Second, the plan must maintain a focus on the child, even though help may be provided to a number of family members as part of the plan. As Jones et al (1987) write 'It is never acceptable to sacrifice the interests of the child for the therapeutic benefit of the parents'. 4.35 Department of Health practice guidance (1995a) recommended that professional workers and relevant family members should be clear about the following aspects of the plan which have general application (an abridged list is in Figure 7). With clarity about these matters, it is possible for both professionals and the family to take issue with the other when their expectations are not met or when perceptions and objectives begin to differ. 4.36 Fundamental to the plan, from the beginning, is the commitment of all the parties involved and the signatures to the plan of those who have lead responsibility for ensuring it is carried forward (in social services, this should include the team manager/supervisor as well as the practitioners). There should also be a clear recorded statement on the plan about when and how it will be reviewed. Reviewing the child's progress and the effectiveness of services and other interventions is a continuous part of the process of work with children and families. The timescales and procedures for reviewing plans for children in need which are also part of other guidance, regulations and legislation (child protection plans, care plans for children looked after and pathway plans) are already prescribed. For children in need plans, where work is being undertaken to support children and families in the community, it is good practice to review the plan with family members at least every six months, and to formally record it. Key professionals should also be involved in the review process and in constructing the revised plan.
4.37 The purpose of an assessment is to identify the child's needs within their family context and to use this understanding to decide how best to address these needs. It is essential that the plan is constructed on the basis of the findings from the assessment and that this plan is reviewed and refined over time to ensure the agreed case objectives are achieved. Specific outcomes for the child, expressed in terms of their health and development can be measured. These provide objective evidence against which to evaluate whether the child and family have been provided with appropriate services and ultimately whether the child's wellbeing is optimal.
Prepared 29 March 2000 |
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