Stabilisation of the statutory child protection response: managing to a specified level of risk assurance.

• Author: Mansell, James

Abstract

This paper is a thought piece that considers some of the implications of the model of child protection risk-screening developed in "The underlying instability in statutory child protection" (Mansell 2006). In particular, how might the volatility of the threshold for intervention be stabilised given the underlying system dynamics? It is argued that there should be increased transparency about the range of decision outcomes and feedback about risk-screening performance. Standard hazard-detection estimates should be introduced to facilitate improved understanding and communication and so provide the possibility for balanced decision-making regarding the level of risk assurance and error trade-off to adopt. Doing so will provide some mitigation against the more reactive and destabilising responses to high-profile events such as child deaths and demand pressures. Child protection risk screening will always face pressure to meet incommensurable goals in response to high-profile events. However, being more informed and transparent about the trade-offs between doing too much and doing too little will be a stabilising influence.

INTRODUCTION

When a problem arises, ... one brought about by either internal or external reasons, one that has become so great that it begins to make everyone afraid, the safest policy is to delay dealing with it rather than trying to do away with it, because those who to try to do away with it most often always increase its strength and accelerate the harm which they feared might come from it. (Machiavelli 1531/1979). When you are confronted by any complex social system, such as an urban centre or a hamster, with things about it that you are dissatisfied with and anxious to fix, you cannot just step in and set about fixing with much hope of helping. This realization is one of the sore discouragements of our century. You cannot meddle with one part of a complex system from the outside without the almost certain risk of setting off disastrous events that you hadn't counted on in other, remote parts. If you want to fix something you are first obliged to understand the whole system. Intervening is a way of causing trouble. (Thomas 1974).

Research into New Zealand's surge in rates of notification to the child protection agency and into the underlying dynamics driving this surge revealed the unstable characteristics of the child protection system (Mansell 2006).

The system is unstable because of the conflicting demands of the task that is being undertaken: high-stakes risk-screening decisions are made under conditions of uncertainty. This is exacerbated when the pressures to improve performance ("avoid critical incidents", "manage demand", "avoid hurting innocent families") place conflicting demands on all stakeholders within the child protection system.

Although the risk-screening task is difficult and prone by its very nature to be criticised--balancing as it does the fine line between doing too much and too little--child protection agencies and other stakeholders in the child protection system do themselves no favours by responding to issues reactively and with poor understanding. While many of the attempts to mitigate perceived problems may be well intentioned, they are often misguided and reactive changes made in response to the symptoms of the real issue (e.g. surging demand or critical incidents involving children). The real issue is that risk screening is difficult, costly, prone to error and thus prone to ill-informed criticism.

The challenge to the child protection system (including all stakeholders, such as statutory child protection agencies, commentators, non-government organisations, other government agencies and notifiers) is not to avoid all criticism, but rather to stabilise the situation and avoid unnecessarily disruptive, superficial or unintentional change as a result of such criticism. The ability to defend the level of risk assurance can be bolstered and conflicting demands can be balanced, and so provide a realistic and sustainable service to children at risk. This may in turn reduce the level of criticism directed at child protection agencies.

There are key leverage points that, if addressed sufficiently, will help to stabilise child protection. Structures can be put in place that allow a considered and specified level of risk assurance to be applied and defended--one that provides an optimum outcome for all children and society.

In this paper, the system dynamics underlying and driving the instability in the child protection intake risk screening are outlined (See "Understanding System Instability" below). The screening required for other escalation decisions and the interventions themselves are not considered. The model of intake risk-screening system dynamics presented here forms the basis for identifying leverage points that, if targeted, are argued to improve the system dynamics in ways that provide for a more stable level of risk assurance (see "A Leverage Point for Change" below). In the final sections, the benefits of trying to stabilise the level of risk assurance, limitations in trying to do this and further questions are considered.

UNDERSTANDING SYSTEM INSTABILITY: KEY FEATURES DRIVING INSTABILITY AND CRITICISM

This paper focuses on the instability driven by the incompatibility of two key features of child protection agency intake risk screening.

* Risk screening in statutory child protection is done under conditions of uncertainty (errors are common).

* The outcomes of decision errors have symmetrically high-stakes consequences for all stakeholders, including children, families, decision makers, and the public (Mansell 2006).

The (symmetrical) high stakes of inevitable errors forces child protection agencies to make trade-offs between doing too much and doing too little. This leaves the level of risk assurance open to question and to be altered in response to the issue of the day: either that demand has surged or that children were not saved who might have been.

If the level of risk assurance is low (so the threshold for escalation towards a statutory response is high) then there is a greater chance that there are cases where further abuse that has a chance to be avoided (is screened) is missed ("failed alarm"). These cases lead to concern that statutory and non-statutory agencies and notifiers are not providing enough risk assurance. If the reaction to this is to lower the threshold to provide increased risk assurance, then the chance of identifying and intervening in cases of abuse or neglect increases. However, there is also the unintended consequence of having to process a greater number of cases and some of these will be lower-risk or no-risk cases ("false alarms") (Mansell 2006). The observable level of demand and the increased level of risk screening will consume resources that perhaps would have been better spent on resolving the issues for those children who are in greater need. There is also concern that statutory investigations of low-risk cases may cause more harm than good to the families and children involved (Scott 2006).

This trade-off is encapsulated in a causal loop diagram (Figure 1) representing the current system underlying child protection.

[FIGURE 1 OMITTED]

Conflicting Demands Drive Pressure to Change the Level of Risk Assurance

As described above, at the heart of risk assurance is a trade-off between doing too much and doing too little. Trade-offs between competing demands provide the potential for risk assurance levels to become unstable through constant change to meet conflicting demands to save all children, avoid harming others and do so within constrained resources. This dilemma drives criticism due to the fact that nobody (e.g. child advocates, central agencies in charge of resource allocation, notifiers) is entirely happy because their competing desires can never be entirely met--perhaps failing to recognise that all risk-screening decisions are uncertain by their very nature and so cannot provide absolute assurance for some risks without a corresponding increase in the risks to others.

Delays in Feedback Cause Over-Reactions to Sentinel Events

Due to delays in feedback of demand surges and low levels of information regarding some sorts of outcomes (i.e. false alarms), the system gets driven by sentinel events--events that are influential due to the level of exposure and interest they generate (such as child deaths or surging demand)--that play out over long time periods. Delay in reacting to these events allows the level of risk assurance to oscillate away from the optimum risk assurance trade-off and so tends to drive over-reactive responses in either direction.

Thus, for example, while increasing risk assurance can abruptly increase recorded demand levels, it takes time (months or years) to realise what is happening and to respond effectively to the increased demand. The delay in responding builds increased pressure to respond more dramatically as demand is seen to continue rising. Thus there is increasingly reactive pressure to decrease risk assurance quickly in order to restrict demand "NOW!".

Because these reactions are driven by sentinel events that are not good indicators for the underlying level of risk assurance, the solutions proposed to solve these issues ("manage demand better" and "save more children") are poorly informed and can even be in conflict--i.e. requests to lower and raise risk-assurance levels concurrently to manage both issues.

Lopsided and Incomplete Understanding of Outcomes Also Contributes to Instability

Evidence concerning the drivers of the risk-screening threshold for...