A Study of Outcomes of InterventionOutcome Research in Preventative and Support Services: A Study of Outcomes of Intervention Through Children's Family Centres
Dr Elizabeth Fernandez
School of Social Work
Intervention on behalf of children who are abused and neglected is an important dimension of Australian child welfare. The last two decades have seen an increase in child abuse notifications and the removal of children into protective care. Across Australia there were 91,734 notifications of abuse and neglect in 1995-96 while in 1998-99 there were 103,980 notifications, an increase of 13% (Johnstone, 2000). It has increasingly been recognised that investigation and child removal is not always the appropriate response to these reports and that a large number of the reports that come to the attention of State Community Services Department are about wider child and family problems.
Around the Western world initiatives are emerging which emphasise the prevention of abuse and enhancement of the parenting potential of families and the community. In the UK the principle of partnership with parents, and in the USA the infrastructure of family preservation services have resulted in greater emphasis on family support and shared care in place of the exclusive focus on child rescue. Parallel developments are evident in Australian child welfare reflected in a range of models of family based services (Scott, 1994; Campbell, 1994).
Child abuse prevention is now viewed from a holistic perspective (Garbarino and Eckenrode, 1997; Thompson, 1995). Programmes cover a range of methods which can be categorised as:
- primary prevention, mainly educational campaigns targeted at the community as a whole
- secondary prevention covering “at risk” sections of the population
- tertiary which aims to prevent the recurrence of abuse.
It is mainly the secondary and tertiary programmes with which this research is concerned, particularly the family support programmes which make up 45.7% of all programmes operating (Tomison, 1997).
Family-based services have received considerable public and professional support because they aim to keep families connected and because they are seen as a cost-effective alternative to placement of children. Over the last two decades there have been a range of outcome studies in the USA examining the impact of family preservation services on preventing children’s entry to protective care (Feldman, 1991; Pecora et al; 1992, 1995; Berry, 1993; Bath and Haapala, 1994). Notable studies on family support services carried out in the UK include those of Aldgate et al; (1999); Smith, (1996); Pithouse et al; (1998); Thoburn et al; (2000). There is very limited research in Australia.
Most of these studies have focused exclusively on the prevention of placement as a positive outcome of intervention and relatively few studies have examined how such services affect family functioning (Scannapieco, 1993; Walton and Denby, 1997).
Little is known about the factors that influence outcomes as only a few studies have examined client and treatment characteristics as possible factors mediating successful (Maluccio and Whittaker, 1997; Wells and Whittington, 1993). Additionally, Maluccio and Whittaker (1997) argue that as program methodologies become increasingly sophisticated, it is necessary for research methodologies to in turn respond, implying that empirical research is constantly needed to ensure that the knowledge drawn from past research remains current.
Ainsworth (1993) suggests that research into family-based services is inadequate and therefore valid conclusions about the effectiveness of family-based services are difficult to draw. Due to the patterning of family-based services on the overseas models, critiques of family-based services in Australia introduce a note of caution about differences between countries and cultures (Ainsworth, 1993; Scott, 1994; Voigt and Tregeagle, 1996). There is limited Australian research into the outcomes of these approaches (Scott and O'Neill, 1996). This paper reports an exploratory study of family support services delivered through two Family Centres in New South Wales, Australia.
The Research Project
The aim of the study was to evaluate the impact of family support interventions by comparing the views of families and their caseworkers with respect to the perceived benefits and outcomes of the services offered in the context of changes in family functioning and parent child relationships, and the extent to which changes led to reduced involvement in protective services.
The family support intervention was evaluated over a six-month period by following the experiences of 29 families routinely referred to service. Both observational rating scales and participant questionnaires were used as described below. Data was collected in confidential and separate interviews with the parent/care-giver, the child and the key worker at the initial stages of intervention and six months later.
Selected components of the Family Assessment Form (FAF) (Children’s Bureau of Southern California, 1997) were administered to workers eliciting their ratings of aspects of parenting and family functioning such as emotional attachment to children, consistency and appropriateness of discipline problem solving and coping, care-giver, ability to trust, learning ability and cooperation with the programme for comparison in the first and second phases of interviewing. The parenting stress index (PSI/SF) (Abidin, 1995) was administered in both phases to parents to assess their levels of stress related to parenting of the most difficult child in the family. The PSI/SF has 36 items yielding three 12 item subscales (Parental Distress, Parent-Child Dysfunctional Interaction and the Difficult Child) which can be summed to provide a total stress score. The child interview schedule incorporated a measure of emotional and behavioural development from the Looking After Children Framework (Ward, 1995). The Barnardos workers also assessed a number of client needs and aspects of the therapeutic relationship, using a numerical rating scale. The items included subjective ratings of the care-giver’s perceived trust, understanding of child’s needs, self-esteem and personal functioning and were rated on a scale ranged from 1 (not at all) to 10 (completely).
Semi structured interview schedules were developed for caseworkers and parents which probed issues surrounding family functioning, family and individual (parent/s) history, bonding with children, care and training of children, understanding of children’s needs at their respective developmental stages, social networks and use of community resources. The interviews also elicited accounts of case planning, expectations of interventions and issues surrounding worker/client relationships. In two parent families both parents were interviewed separately. Participating children were restricted to those 8 years of age and older. If there was more than one child over 8 the child who was the subject of the referral and of most concern to the parent was interviewed.
Site of research and subjects
The research was carried out at Barnardos Children’s Family Centres, which offer an integrated set of family support programmes developed by Barnardos Australia to meet the needs of families identified as being at risk of child abuse and neglect. Families in the programme are provided with a range of intensive support services aimed at helping them overcome problems threatening family stability and placing their children at risk. The emphasis is on strengthening families and enhancing their sense of empowerment. The programme adopts a dual focus, that of reducing factors that might contribute to neglect and maltreatment and building protective factors to enhance the family’s resiliency and ability to cope. Interventions are multi-dimensional and include home-visiting, semi-supported accommodation, childcare (daycare), respite care, counselling services, group work, and crisis services. The service also includes Temporary Family Care programmes which provide twenty four hour crisis or respite care. Rapid return to the family is a primary goal, except where safety of the child is an issue. The family was the unit of analysis in the study. Families referred to the Children’s Family Centres at Auburn and Penrith over a 12-month period were included in the study.
The participating families
The families participating in the study and receiving family support services presented with a range of difficulties and concerns. They included families experiencing or who had experienced domestic violence, bereavement, marital breakdown and related trauma while coping with the demands of young children. Physical illness, psychological disturbance and drug and alcohol dependence were concerns impacting on family functioning and parenting in some cases. The sample also included parents with learning disabilities needing support and parenting skills training. Families with children assessed by statutory workers to have been abused or at risk of abuse and of entering care, or of being restored from care, constituted another group served by the programme.
The 29 families included 24 (83%) with a single parent or caregiver and five (17%) with two parents. The number of children in the families ranged from 1 to 8, with a median of three, and most frequently, two children. The average age of the main child is the referral was 6.2 years (4.1 years sd) and a range from 6 months to 14 years. Fourteen (48%) were boys.
The data collected in care-giver and worker interviews were examined initially with descriptive analyses to assess the key areas of need faced by each referred family. Statistical significance of change scores between the pre intervention and six month assessments were examined with paired t-tests, and relationships between variables were explored using Pearson correlations.
Summary of Results
The initial phase of the research confirmed the high level of need for both the child and caregiver, and the challenges faced by the Barnardos caseworkers. The intervention provided by Barnardos was seen as an acceptable therapeutic process by the referred families. According to the FAF, both the caregiver and child’s cooperation with the program improve with time. This was supported by the perceived trust of the Barnardos caseworker, which remained high for the caregiver and improved for the child.
When Barnardos workers were interviewed about each family, soon after their referral to the service, using the FAF they identified the families as having, on average, more than four and as many as ten significant problem areas. At the second assessment, six months after the start of the program the referred families continued to have just over two FAF areas needing ongoing intervention. This represented approximately a 50% reduction in problem burden for the caregivers and children receiving care from Barnardos. Importantly only five of the families continued to have domains rated as “major problems”.
The intervention resulted in significant changes in the caregiver’s ability to interact and discipline the child. For example, on the FAF ratings changes were observed in the caregiver’s ability to discipline the child appropriately and consistently and with less physical discipline. The caregiver had also learned how to show a more appropriate authoritative role of the child.
The research interviews also enabled the trialing of a number of other worker ratings of the caregiver and child’s needs. These numerical rating scales indicated that improved caregiver skills in managing the child were also accompanied by improvements in the worker’s perception of the caregiver’s self-esteem. While self esteem is notoriously difficult to change in the absence of skilled and intensive psychological therapies, a more likely explanation is that self-esteem can be symptomatically low as a result of distress or depression, and as was evident from the PSI/SF scores, this improved significantly in the evaluation period.
The intervention had benefits for the mental health of the caregiver. In their responses to the PSI/SF the caregiver’s level of parental distress was significantly reduced, along with total stress and reduced dysfunctional interactions. The research indicated that the levels of Parental Distress played a key role in the caregivers’ approach to the program and their problem solving ability, so improvement in this indicator were critical to the intervention process.
Clearly, given the level of need of many of these families, the 6-month assessment was very much an indication of “work in progress” rather than time for termination of the service. More complex domains that did not change included bonding style and caregiver learning ability, both of which would be less likely to change in a brief intervention.
Overall the caregiver’s PSI/SF and Barnardos’ worker ratings and FAF responses provided a positive evaluation of the intervention for the families participating in the service. The findings also confirmed that many families required ongoing support at six months, especially with longer standing factors such as bonding style.
Cumulative daily hassles, major life events and an absence of adequate support have all been identified as major sources of stress that can affect a family’s functioning (Falloon, Faporta, Fadden et al 1993). By the time a family comes to the attention of a service like Barnardos, the levels of stress, whether specifically related to parenting, or more generalised is likely to be considerable an in the absence of support, and in the face of challenging child behaviours problem solving break downs, problems accumulate and dysfunctional patterns emerge. Without intervention such problems can become chronic (Falloon et al 1993).
The current evaluation confirmed the level of need of each family and the development of potentially chronic factors such as poor problem solving and an absence of positive family behaviours. The data indicate that in the least Barnardos’ intervention ensures that the levels of distress are recognised and that structured support becomes available to relieve the caregivers and children’s isolation.
Barnardos’ caseworkers work on many different fronts: practical assistance, eg. housing provision, financial assistance (with electricity bills), respite care, as well as more difficult and challenging problems eg. drug dependence and alcohol abuse, domestic violence and inadequate parenting. The level and type of intervention varied according to each family’s circumstances This may take the form of practical help with one area of difficulty (eg. Accommodation needs). Clearly having somewhere to live as opposed to being homeless represents an automatic improvement in the circumstances of the family and can be instrumental in relieving an overall stressful situation and thereby assist family functioning. It was evident from early observations that Barnardos’ multifaceted approach, which included helping with bills, placing children day care, arranging weekends of respite care were perceived by the participating families as alleviating stress and assisting family functioning. Barnardos caseworkers were at the same time addressing more deep-seated problems such as parenting styles, relationship difficulties and specific behavioural problems related to family functioning where change is usually a longer-term process. The true test of success of family support services comes at the level of learned new ways of relating to partners and children, of coping, and of dealing with children’s behaviour so that improved family functioning is sustained.
This paper has outlined an approach to researching outcomes of family based services designed to enhance family functioning and prevent abusive parenting and family breakdown. However there are limitations to the study. The sample analysed consisted of 29 families, these being families who participated in both phases of the study and who were new entrants to the programme recruited over a 12 month period.
Findings from the eleven pre and post-test child interviews, not reported in this paper/chapter add a further dimension to the outcomes of intervention and capture the perceptions and needs of children as service users.
The service interventions researched were focused on the primary need of the family, individually tailored to the families circumstances and involved a range of configurations of services. The importance of isolating differences in service configuration and service delivery based on family needs and problem profiles and establishing association with specific outcomes warrants further explanation to highlight treatment integrity. Research which explores connections between practitioners ’theoretical and value orientations, their choice of interventions, the sociopolitical context and final service outcomes is a further area to be addressed in future inquiry.