The False Dichotomy of “Child Safety vs. Family Preservation”

In a recent op-ed published in The Chronicle of Social Change, Marie Cohen argued that “when a child is left in a dangerous home with multiple strong indications of maltreatment, there is reason to question the balance that is currently being struck between child safety and family preservation.”

This statement is problematic. The goal of family preservation in no way obviates the need for sound safety assessment practices. In the way Cohen has framed her statement she presents these as competing values.

Safety and maltreatment are related but not entirely coterminous. It is true that the federal government uses maltreatment as its proxy indicator for child safety. But when child protective service agencies (CPS) initiate a response to a child maltreatment report, the threshold broadly applied for a safety intervention (removal or in-home safety plan) is immediate or imminent danger of serious harm, not just presence of maltreatment. In actual practice, the vast majority of confirmed maltreatment cases do not involve circumstances that justify the immediate removal of children.

The issues in the Perkins case evolved after the initial safety decision was made and the case was opened for services. Cohen’s argument builds upon the visiting worker’s numerous observations of what appear to be repeat maltreatment and failure to take further action after the child was initially deemed safe enough to remain at home.

One might conclude that the caseworker assessed the child to be unsafe after the initial safety decision, but chose to maintain the family placement anyway. The available information Cohen cites does not seem to support this. Rather, it appears that the caseworker did not deem the observed circumstances to constitute an immediate or imminent threat of serious harm.

As Cohen rightly notes, if these subsequent injuries appeared as new maltreatment then a new report should have occurred along with a new safety assessment by New York City’s Administration on Children’s Services (ACS). Apparently this never happened. But that does not explain why the caseworker and case management agency did not deem these observations to require a change of plan.

So how should this case be examined from a standpoint of learning and system improvement? Unfortunately, the field of child protection has yet to apply a significant and expanding knowledge base coming from the broad and emergent field of safety science when analyzing such tragedies.

Sydney Dekker discusses factors relevant to one aspect of this case in his book, The Field Guide to Understanding Human Error. Why don’t plans change in spite of new information? One reason is cognitive fixation. The situation may lack a well-formulated diagnosis of the problem. People have to make provisional assessments based on partial or uncertain data. The immediate problem-solving context biases people in some direction, and it may lead further diagnosis down the wrong path.

This can lead to what Judith Orasanu calls plan continuation. In plan continuation, early and strong cures suggest that sticking with the original plan is a good, and safe, idea. Later clues that the plan should be abandoned are often typically fewer, more ambiguous and maybe not as strong.

The caseworker appears not to have seen the “strong clues of maltreatment” Cohen notes as indicators of impending serious harm necessitating a change of plan. Obviously the caseworker did not know the outcome, so it is critical to understand the systemic factors that influenced how these cues were interpreted relative to the child’s safety.

Rather than simply saying this is the result of competing philosophies, inquiry needs to focus on understanding the systemic context surrounding each of the decisions the caseworker made to continue the plan and how the emerging evidence was interpreted. Having reviewed numerous child maltreatment deaths on open cases, one such systemic factor comes to mind. “How was safety assessed after the initial determination that the child was safe?”

Safety assessment criteria used by most, if not all, child protection agencies are static (here and now) rather than dynamic across time. They are designed to be sensitive to present or impending danger in an immediate context. They are not designed to be sensitive to emerging danger.

Emerging danger exists when risk factors having the potential to result in serious harm are escalating, relevant protective factors weakening and/or child vulnerability increasing, but the situation has not yet reached the safety threshold. Often, emerging danger looks more like what Dekker described as “drift into failure” than an immediately imminent explosion.

Things may appear safe right up until the child’s death if one only applies point-in-time threat of serious harm safety criteria because the degrading adaptive safety capacities within the family are not being tracked in a way that prompts action before the tragedy actually occurs.

Safety decisions are made in real time and often with incomplete or ambiguous information. I believe they are rarely made purely out of dogmatic adherence to a value orientation.

It is “safe versus unsafe” rather than “safety versus family preservation.” Framing this conundrum as competing policy orientations masks the underlying insufficiencies of tools, criteria, training and workforce when it comes to making safety decisions.

Tom Morton most recently served as the child protection practice specialist for the Commission to Eliminate Child Abuse and Neglect Fatalities. Prior to that he served as director of the Clark County, Nevada Department of Family Services for five years and as founder, president and CEO of the Child Welfare Institute for 22 years.