Bima GRAPHIC OATA 1 Kern Ne ch 78-73 PB 278 449 el [ Eval. of chi\d Abuse] HN ep PusL 4. Title and Subtitle 5. Report Date EVALUATION OF CHILD ABUSE AND NEGLECT DEMONSTRATION PROJECTS | —oecember 1977 1974-1977: VOLUME XII, ELEVEN HISTORICAL CASE STUDIES: FINAL | 7. Author(s) 8. Performing Organization Rept. Berkeley Planning Associates de 9. Performing Organization Name and Address 10. Project/Task/Work Unit No. Berkeley Planning Associates mn 2320 Channing Way 11. Contract/Grant No. Berkeley, CA 94704 HRA 106-74~120 and (Tel.: 415/549-3492) HRA 230-76-0075 12. Sponsoring Organization Name and Address 13. Type of Report & Period DHEW, PHS, OASH, National Center for Health Services Research Covered FR. Vol. XII 3700 East-West Highway, Room 7-44 (STI) 6/26/74 - 12/15/71 Hyattsville, MD 20782 14, (Tel.: 301/436-8970) 15. Supplementary Notes S€€ NI1S Interim Report Nos. NCHSR 78-64 through NCHSR 78-75 for 12 | vols.; 11 vols, give different aspects of these projects of the F.R. and Vol. XII con- tains the 11 historical case studies. Vols. are obtainable by Set or separately. 16. Abstracts A detailed description of each of eleven demonstration child abuse and neglect service projects is provided in this report. Contents include discussion of: the community context; the project's history; organization and staffing patterns; project components Implementation and operation problems; project goals and how well they were accomplish ed during three years of federal funding; project management and worker satisfaction and burnout; clients served and the impact of services on those clients; impact of the project on the local community; resource allocation and service volume and costs; and plans for continuation after federal funding. REPRODUCED BY Fev Words amb Tore Doary NATIONAL TECHNICAL om re INFORMATION SERVICE 15. Supplementary Notes (continued) U.S. DEPARTMENT OF COMMERCE NCHSR publication of research findings does not necessarily represent approval or official endorsement by the National Center for Health Services Research or the Department of Health, Education, and Welfare. Arne H, Anderson, NCHSR P.0., 301/436-8910. 17b. ldentifiers/Open-Ended Terms Health services research Evaluation of child abuse and neglect demonstration projects 1974-1977. (Vols. I-XII): Subtitles: Executive summary; Final report; Adult client impact; A comparative de= scription of the eleven projects; Community systems impact; Quality of the case management process; Cost; Methodology; Project management and worker burnout; A guide for planning and implementing; Child client impact; and Eleven historical case 7c. Stqie9e.1a ‘Group a 18. Availability Statement 19. Security Class (This 21. No. of Pages Releasable to the public. Available from National Report) - Technical Information Service, Springfield, VA 120. Soeur Chass (ThE ah (Tel.: 703/557-4650) 22161 “8 INCLASSIFIED A250! FORM NTIS-38 (REV. 10-73) ENDORSED BY ANSI AND UNESCO. THIS FORM MAY BE REPRODUCED USCOMM-DC 8268-P74 PUBLIC HEALTH CS18-9786V The Berkeley Planning Associates evaluation team includes: Anne H. Cohn, Project Director Frederick C. Collignon, Principal Investigator Katherine Armstrong Linda Barrett Beverly DeGraaf Todd Everett Donna Gara Mary Kay Miller Susan Shea Ronald Starr The work described here was performed under contract numbers HRA #106-74-120 and HRA #230-76-0075. The ideas presented here are those of the authors and not necessarily those of the federal government. A HV 741 J3 4 + 1977 Vv, PREFACE In May of 1974, the Office of Child Development and PURL Social and Rehabilitation Services of the Department of Health, Education and Welfare jointly funded eleven three-year child abuse and neglect service projects to develop and test alternative strategies for treating abusive and neglectful parents and their children and alternative models for coordination of community-wide child abuse and neglect systems. In order to document the content of the different service interventions tested and to determine their relative effectiveness and cost-effectiveness, the Division of Health Services Evaluation of the National Center for Health Services Research, Health Resources Administration of the Department of Health, Education and Welfare awarded a contract to Berkeley Planning Associates to conduct a three-year evaluation of the projects. This report is one of a series presenting the findings from that evaluation effort. Given the number of different federal agencies and local projects involved in the evaluation, coordination and cooperation was critical. We wish to thank the many people who helped us: the federal personnel re- sponsible for the demonstration projects, the project directors, the staff members of the projects, repre- sentatives from various agencies in the projects’ communities. In particular we wish to thank our own project officers from the National Center for Health Services Research--Arne Anderson, Feather Hair Davis and Gerald Sparer--for their support and input, and we wish to acknowledge that they very much helped to insure that this was a cooperative venture. 106 fare viv LIST OF CONTENTS INTRODUCTION . THE FAMILY CENTER: ADAMS COUNTY, COLORADO. . . . . . . . . . . I. PRO-CHILD: ARLINGTON, VIRGINIA . . . . . . . . . . . . . . . . II. CHILD PROTECTION CENTER: BATON ROUGE, LOUISIANA. . . . . . . . III. CHILD ABUSE/NEGLECT DEMONSTRATION UNIT: BAYAMON, PUERTO RICO . IV. ARKANSAS CHILD ABUSE AND NEGLECT PROJECT: LITTLE ROCK, ARKANSAS. . « + + o = os # x 3 = ®« # » # * » vs + = » 2 © v« «Va THE FAMILY CARE CENTER: LOS ANGELES, CALIFORNIA. . . . . . . . VI. THE CHILD DEVELOPMENT CENTER: NEAH BAY, WASHINGTON . . . . . . VII. FAMILY RESOURCE CENTER: ST. LOUIS, MISSOURI. . . . . . . . . VIII. PARENT AND CHILD EFFECTIVENESS RELATIONS PROJECT (PACER): ST. PETERSBURG, FLORIDA . . . . . . . . +. . «+ +. + + .. IX. PANEL FOR FAMILY LIVING: TACOMA, WASHINGTON. . . . . . . . . X. PROTECTIVE SERVICES DEMONSTRATION PROJECT: UNION COUNTY, NEW JERSEY. « « « v © « « o » ow o 5 5 % 2 5 % 2 » » # + XI. APPENDIX: LISTING OF MAJOR EVALUATION REPORTS AND PAPERS . . A. INTRODUCTION History of the Demonstration Effort During the fall of 1974, prior to the passage of the Child Abuse Prevention and Treatment Act, Public Law 93-247, the secretary's office of the federal Department of Health, Education and Welfare (DHEW) decided to allocate four million dollars to child abuse and neglect research and demonstration projects. A substantial portion of that allotment, approxi- mately three million dollars, was to be spent jointly by the Office of Child Development's (OCD) Children's Bureau, and Social and Rehabilitation Services (SRS) on a set of demonstration treatment programs. On May 1, 1974, after review of over 100 applications, OCD and SRS jointly selected and funded eleven three-year projects. | The projects, spread throughout the country, differ by size, the types of agencies in which they are housed, the kinds of staff they employ, and the variety of services they offer their clients and their local communities. However, as a group the projects embrace the federal goals for this demonstration effort, which include: (1) to develop and test alternative strategies for treating abusive and neglectful parents and their children; (2) to develop and test alternative models for coordination of community-wide systems providing preventive, detection and treatment services to deal with child abuse and neglect; (3) to document the content of the different service interven- tions tested and to determine their relative effectiveness and cost-effectiveness. Lhe projects include: The Family Center: Adams County, Colorado; Pro-Child: Arlington, Virginia; The Child Protection Center: Baton Rouge, Louisiana; The Child Abuse and Neglect Demonstration Unit: Bayamon, Puerto Rico; The Arkansas Child Abuse and Neglect Program (SCAN): Little Rock, Arkansas; The Family Care Center: Los Angeles, California; The Child De- velopment Center: Neah Bay, Washington; The Family Resource Center: St. Louis, Missouri; The Parent and Child Effective Relations Project (PACER); St. Petersburg, Florida; The Panel for Family Living: Tacoma, Washington; and The Union County Protective Services Demonstration Project, Union County, New Jersey. Overview of the Demonstration Evaluation In order to accomplish the third goal, as part of DHEW's strategy to make this demonstration program an interagency effort, the Division of Health Services Evaluation, National Center for Health Services Research of the Health Resources Administration (HRA) awarded an evaluation con- tract to Berkeley Planning Associates (BPA) in June 1974, to monitor the demonstration projects over their three years of federal funding, document- ing what they did and how effective it was. The overall purpose of this evaluation was to provide guidance to the federal government and local communities on how to develop community-wide programs to deal with problems of child abuse and neglect in a systematic and coordinated fashion. The study, which combined both formative (or descriptive) and summative (or outcome/impact-related) evaluation concerns, documented the content of the different service interventions tested by the projects and determined the relative effectiveness and cost-effectiveness of these strategies. Specific questions, addressed with quantitative and qualitative data gathered through a variety of collecting techniques, notably quarterly five-day site visits, special topic site visits and information systems maintained by the projects for the evaluators, include: e What are the problems inherent in and the possibilities for establishing and operating child abuse and neglect programs? e What were the goals of each of the projects and how successful were they in accomplishing them? e What are the costs of different child abuse and neglect ser- vices and the costs of different mixes of services, particu- larly in relation to effectiveness? e What are the elements and standards for quality case management and what are their relationships with client outcome? e How do project management processes and organizational struc- tures influence project performance and, most importantly, worker burnout? e What are the essential elements of a well-functioning child abuse and neglect system and what kinds of project activities are most effective in influencing the development of these essential elements? ii e What kinds of problems do abused and neglected children possess and how amenable are such problems to resolution through treatment? e And finally, what are the effectiveness and cost-effectiveness of alternative service strategies for different types of abusers and neglectors? During the summer of 1974, the projects began the lengthy process of hiring staff, finding space and generally implementing their planned pro- grams. Concomitantly, BPA collected baseline data on each of the projects’ community child abuse and neglect systems and completed design plans for the study. By January 1975, all but one of the projects was fully opera- tional and all major data collection systems for the evaluation were in place. Through quarterly site visits to the projects and other data col- lection techniques, BPA monitored all of the projects' activities through April 1977, at which time the projects were in the process of shifting from demonstrations to ongoing service programs. Throughout this period, numer- ous documents describing project activities and preliminary findings were prepared by the evaluators. This report presents part of the final know- ledge gained from the projects' joint experience. Project Profiles As a group, the projects demonstrated a variety of strategies for community-wide responses to the problems of abuse and neglect. The pro- jects each provided a wide variety of treatment services for abusive and neglectful parents; they each used mixes of professionals and para- professionals in the provision of these services; they each utilized dif- ferent coordinative and educational strategies for working with their com- munities; and they were housed in different kinds of agencies and communi- ties. While not an exhaustive set of alternatives, the rich variety among the projects has provided the field with an opportunity to system- atically study the relative merits of different methods for attacking the child abuse and neglect problem. Each project was also demonstrating one or two specific and unique strategies for working with abuse and neglect, as described below: por a listing of other major study reports and papers, see Appendix A. iii The Family Center: Adams County, Colorado The Family Center, a protective services-based project housed in a separate dwelling, is noted for its demonstration of how to con- duct intensive, thorough multidisciplinary intake and preliminary treatment of cases, which were then referred on to the central Child Protective Services staff for ongoing treatment. In addi- tion, the Center created a treatment program for children, includ- ing a crisis nursery and play therapy. Pro-Child: Arlington, Virginia Pro-Child demonstrated methods for enhancing the capacity and effectiveness of a county protective services agency by expanding the number of social workers on the staff and adding certain ancil- lary workers such as a homemaker. A team of consultants, notably including a psychiatrist and a lawyer, were hired by the project to serve on a Multidisciplinary Diagnostic Review Team, as well as to provide consultation to individual workers. The Child Protection Center: Baton Rouge, Louisiana The Child Protection Center, a protective services-based agency, tested out a strategy for redefining protective services as a multidisciplinary concern by housing the project on hospital grounds and establishing closer formal linkages with the hospital including the half-time services of a pediatrician and immediate access of all CPC cases to the medical facilities. The Child Abuse and Neglect Demonstration Unit: Bayamon, Puerto Rico In a region where graduate level workers are rarely employed by pro- tective services, this project demonstrated the benefits of establish- ing an ongoing treatment, under the auspices of protective services, staffed by highly trained social workers with the back-up of profes- sional consultants to provide intensive services to the most difficult abuse and neglect cases. The Arkansas Child Abuse and Neglect Program: Little Rock, Arkansas In Arkansas, the state social services agency contracted to SCAN, Inc., a private organization, to provide services to all identified abuse cases in select counties. SCAN, in turn, demonstrated methods by which a resource-poor state, like Arkansas, could expand its pro- tective service capability by using lay therapists, supervised by SCAN staff, to provide services to those abuse cases. “iv The Family Care Center: Los Angeles, California The concept behind the Family Care Center, a.hospital-based program, was a demonstration of a residential therapeutic program for abused and neglected children with intensive day-time services for their parents. The Child Development Center: Neah Bay, Washington This Center, housed within the Tribal Council on the Makah Indian Reservation, demonstrated a strategy for developing a community-wide culturally-based preventive program, working with all those on the reservation having parenting or family-related problems. The Family Resource Center: St. Louis, Missouri A free-standing agency with hospital affiliations, the Family Re- source Center implemented a family-oriented treatment model which included therapeutic and support services to parents and children under the same roof. The services to children, in particular, were carefully tailored to match the specific needs of different aged children. Parent and Child Effective Relations Project (PACER): St. Petersburg, Florida Housed within the Pinellas County Juvenile Welfare Board, PACER sought to develop community services for abuse and neglect using a community organization model. PACER acted as a catalyst in the de- velopment of needed community services, such as Parent Education classes, which others could then adopt. Panel for Family Living: Tacoma, Washington The Panel, a volunteer-based private organization, demonstrated the ability of a broadly-based multidisciplinary, and largely volunteer program, to become the central provider of those training, education and coordinative activities needed in Pierce County. The Union County Protective Services Demonstration Project: Union County, New Jersey This project demonstrated methods to expand the resources available to protective services clients by contracting for a wide variety of purchased services from other public and, notably, private service agencies in the county. This report presents Historical Case Studies of each of the eleven demonstration projects during the time of federal funding. Included in these case studies are descriptions of the community contexts in which the projects were operating, the projects' organizational and staffing patterns, their functional activities and implementation and operation problems. The projects' individual goals and how well they were accomplished during the demonstration period, their success with clients and their impact on their local child abuse and neglect service systems are presented along with information on caseload characteristics, service output and service costs. vi 1.1 THE FAMILY CENTER: ADAMS COUNTY, COLORADO 1. COMMUNITY CONTEXT Adams County lies north of and adjacent to Denver. The county, with a population of 206,000, has seven unincorporated small towns, but also encompasses a large rural area. Several distinct socio-economic groups, from migrant farm laborers and farmers to blue collar workers and middle income commuters, reside in the area. The majority of the county's families have incomes in the $7000 to $15,000 range (according to the 1970 Census). There are very few Blacks (less than 1%), but Chicanos account for 16% of Adams County's population. II. HISTORY The Juvenile Court was the first agency in Adams County to call atten- tion to the need for constructive intervention in abuse cases. This was due primarily to a local judge who gained national recognition for his approach in dealing with families who came before his bench, and to the Probation Department which supported the judge's philosophy of counseling, rather than incarcerating, parents who were charged with abuse. The Adams County Department of Social Services (ACDSS), concerned about the rising incidence of child abuse (which was reported to have doubled each year since 1965), also began calling attention to the need for improved methods for handling these cases. However, the Department's plans for adding staff to more adequately serve abuse cases were dashed when a state-directed budget freeze in 1973 precluded new hiring. a VE Tan 5, “~ 1.2 In the meantime, other professionals in the community recognized the importance of developing a more coordinated, comprehensive approach for dealing with the special problem of abuse. When news came of possible fed- eral demonstration money, some social workers from ACDSS as well as repre- sentatives from other agencies, including Adams County Mental Health Center's Child Advocacy Team, Adams County Juvenile Court and the Tri- County Health Department, convened in response to the '"Request for Pro- posal" from the Office of Child Development. The various community agencies banded together to suggest a multi-agency approach to child abuse, and developed the model for a program housed separately, but administered by ACDSS. The project would provide intake for all abuse reports in the county, as well as deliver a variety of treatment services to both parents and child- ren. IIT. SUMMARY OF ACTIVITIES First Year Summary The Center's director was hired in mid-July 1974, but did not begin working full-time until August. A coordinator, a researcher, four MSW- level social workers and a nurse began working between mid-August and early October. The School Referral Program, whereby the nurse and social workers were each assigned as liaison to particular school districts, began in September. At the same time, while the staff were also becoming oriented to their new program and the problems of child abuse clients, public speak- ing activities began. I.3 With the first of November, the initial referrals were accepted and the social workers and nurse began providing intake evaluation to all abuse reports in the county. Also during this month, the multidisciplinary re- view team, which had been meeting since February, began reviewing project intakes for the first time. In December, the project moved out cf ACDSS to its own facility, a renovated home with space for the proposed crisis nursery on the first floor and staff offices on the second floor. Extensive time and energy were expended in January 1975 to prepare for the opening of the crisis nursery in February. February was also the month during which the Center social workers reached their maximum expected caseload of five ongoing cases per worker. In March the lay therapy program was fully implemented when the six therapists were each assigned to a family. Also in March, an agreement was worked out with ACDSS in which the Department agreed to share intake responsibilities with the Center, thereby allowing project staff more time for providing direct treatment to their own and protective services' clients. The Center then began taking only the first six new reports per week, with the remainder referred to ACDSS. Second Year Summary Preparation for the extensive evaluation of the project's treatment services began in May after award of the second year of federal funding. A case aide was also hired in May to assist the social workers, help out in the crisis nursery and provide lay therapy to some families. In June, the first session of the project-sponsored child growth and development class was held, with eight parents in attendance. In July the Center brought on a case supervisor to relieve the director of this responsibility I.4 in light of the heavy administrative demands of her job. During the remainder of the second project year, additional services were offered first to abused or potentially abused children. The Univer- sity of Denver began providing speech and hearing testing and therapy to project referrals, and teenagers, under the auspices of a church in the area, gave of their time to provide theraplay (a modified version of play therapy offered by lay volunteers). Structured, therapeutic activities were introduced in the crisis nursery in order to prepare children for return to their own homes. And, a local day care home began housing the project-directed therapeutic day care program for abused children. To better coordinate activities with local law enforcement agencies, the project called a meeting in late 1975 to discuss procedures for refer- ral; ACDSS (protective services), the district attorney's office, the Sheriff's Department, and various police departments all participated. The Community Relations Board, made up of 10 interested citizens, also held their first meeting in late 1975. The Board, which was to serve in an advisory capacity to the project, was charged with providing feedback to the Center on its community image, generating more local funding, and educating the state legislature on abuse and the work of the Center. In March 1976, the project worked out a new arrangement with ACDSS, which further limited the number of intakes the Center would handle, from six per week to a maximum of four per week. In exchange, the Center agreed to expand its ongoing caseload size to 8-10 cases per social worker. Third Year Summary The major activity during the first two months of the third funding year was a drive to have Social and Rehabilitation Services (SRS) rescind L.5 its decision to eliminate its contribution to the demonstration projects, thereby forcing reduction in the third year budgets for all eleven projects. The Center's multidisciplinary review team members and consultants, inter- ested professionals in the community, and local mayors, counselmen and com- missioners were all approached and asked to contact Congressmen and Senators. The end result was reconsideration by SRS and additional funds were allocated. Whereas some staff turnover had begun in the second year, more serious turnover took place in the third year. One set of houseparents, the pro- ject's coordinator, one of the social workers, and two lay therapists left within four months of each other. There was a problem with replacement for some of the positions because of the uncertainty of future funding. With the introduction of a new protective services unit in ACDSS in November 1976, the project's social workers began regular rotation with protective service workers for handling abuse intakes. This relieved workers from responsibility for the first four intakes per week, thereby reducing the total number of intakes carried out by the Center. Some new treatment services began in the third year. Two therapeutic groups for children were initiated, both led by project social workers. Therapeutic foster care, which involves a project staff member working with selected foster parents who have been trained in handling abused children, was also started. Extensive consulting and training were offered by Center staff during the third year. Workshops and presentations were made in a variety of settings, from national conferences to state and local agencies and volun- tary councils. I.6 IV. ORGANIZATION/STAFFING Although the project was separately housed from ACDSS, it was adminis- tratively and financially responsible to the Department. The project's fiscal matters were handled by ACDSS accountants, and the Department con- tributed financially to the Center through in-kind services, by directly allocating some operating funds, and by making child welfare payments for children eligible for placement in the Center's crisis nursery. The pro- ject, however, did its own program planning, and due to its special funding status, had its own personnel policies and procedures. Because of the model established under the grant, most abuse referrals coming to the Center were transferred after intake evaluation to the protective services unit of ACDSS for ongoing treatment. This arrangement necessitated routine communi- cation between the two agencies; regular meetings were held between the Center director and the ACDSS staff liaison (the Supervisor of Social Ser- vices) and protective services supervisors. Figure 1: Organizational Chart ACDSS Consultants: Social Workers, Pediatrician, Family Center Director Psychologist, 2 Psychometricians 1 ta 2 —r——— Coordinator R.N. Researcher Clerk/ Supervisor Typist Y. 1 ——— Case Volunteers Six Lay Four Four Social Aide Therapists Houseparents Workers 1.7 V. PROJECT COMPONENTS Community Education The main conduit for community education was the Speakers Bureau, which was set up as a multi-agency effort to conduct programs on child abuse throughout the community. The Bureau consisted of project staff and a few representatives from ACDSS (the protective services unit), Tri-County Health Department and the multidisciplinary review team. Presentations of the Bureau were supplemented by evaluations which determined how many people attended, their perspectives, and their response to the informa- tion provided about the dynamics and treatment of abuse. The Bureau was very active throughout the three year history of the demonstration; com- munity response indicated an increase in awareness of the Center, the ‘reporting law and community services for abuse. Professional Education Primarily concentrating on the public school districts, the Center assigned staff members as liaisons to each of the districts. Each staff member provided training programs for personnel in his/her district and also arranged referral procedures between the district and the project. Since the program began in September 1974, the number of referrals from school personnel increased significantly from the time prior to the pro- ject's implementation. Throughout the history of the project, training in child abuse was also provided to many agencies and groups, including Denver public schools, local community colleges, Head Start staffs, day care and foster parent organizations, the Adams County Mental Health Center, physicians' office staffs, hospital staffs, and a variety of other professionals. Another I.8 form of training was the consultation carried out by project staff. Speci- fically, county Departments of Social Services throughout Colorado and pro- grams in other states have received consultation on implementing the Center's complement of services. Several agreements were made pertaining to coordination between the Center and other institutions or agencies (see Table 4 for a detailed list of these agreements). Legislative Activity The project director took an active role in working with state legis- lators during their 1975 debate on revision of the Colorado Child Abuse Reporting Act. The director and coordinator also presented testimony at two legislative hearings on the need for giving children's services in general and child abuse programs in particular a higher funding priority, and they both participated in a broad-based committee formed to promote revision of the state's termination of parental rights act. In the last months of the demonstration period, two other political efforts were under- taken by project staff. One involved attempting to defeat a proposed bill to open multidisciplinary review team meetings to the press and the second was supporting legislation to close day care homes for which there were substantiated incidents of abuse. Project Research Project research included extensive monthly tabulation and analysis of data on Center cases, monitoring the effects of the Speakers Bureau and School Referral Program, and evaluation of abusive parents' and abused children's functioning before, during and after treatment. This evaluation 1.9 was carried out in conjunction with three consultants from the University of Colorado at Boulder (two doctoral candidates and a university faculty member). The first step was to review the literature and others' exper- iences concerning a variety of developmental and behavioral tests. This led to choosing several tests that were appropriate as diagnostic tools for children's treatment planning, for tracking behavior changes, and for assessing the effectiveness of various treatments. The general format was to test all families in the project's caseload and children in the crisis nursery, with follow-up testing during subsequent months in treatment. Intake and Initial Diagnosis During the project's first year, non-management staff members spent most of their time on intake and, therefore, developed an optimum process for handling this work. An "on call" system was set up, an approach to be used for meeting the reported families and gaining their trust was agreed upon, procedures for substantiating cases were established, and formal, written follow-up reports to the sources that reported the cases were initiated. When reports involved child battering, a social worker and the staff nurse made the initial home visit together. The nurse gave the child a preliminary physical examination and developmental assessment and was responsible for any necessary medical follow-up. Most new cases were transferred to ACDSS protective services unit after the Center social worker had completed the case evaluation and after the multidisciplinary review team had reviewed the case. 1.10 Multidisciplinary Review The multidisciplinary review team, which served as a mechanism for diagnostic review of cases, met weekly to assess staff reports on all Cen- ter and ACDSS child abuse intakes. The team, chaired by the project director, consisted of the assistant District Attorney and representatives of the protective services unit (ACDSS), a local police department, Juvenile Court, the Mental Health Center, Tri-County Health, and a rotating repre- sentative from the schools. Because of the large number of cases reviewed each week, a procedure was worked out whereby a subcommittee of the team and staff met first to review most cases; the team as a whole then reviewed and made recommendations on the most serious or complicated cases. The multidisciplinary review team also served indirectly to monitor the abuse- related agencies in the community, to ensure that they were carrying out recommendations of the team. Case Management The Center's caseload size was limited during the first two years to no more than five cases per worker. This restriction on the number of cases carried on a regular basis was to allow social workers time to deal with the large numbers of intakes and to set up and implement various treat- ment services, as well as carry out coordination and education activities. In the third year the project social workers expanded their ongoing case- loads to between eight and ten. Treatment In addition to individual counseling, adult clients in the Center staff's own caseloads may receive individual therapy, family and/or marital I.11 counseling. They may also be referred to a Parents Anonymous group, one of which is sponsored by a Family Center social worker. Individual coun- seling and play therapy might be provided to children in the project caseload. The following treatment services that were provided by the Center were also available to abuse clients of ACDSS: Medical Care: As mentioned previously, the project nurse provided medical examinations of children during the first contact with a family suspected of being involved in an abuse incident. She also daily examined the children in the crisis nursery. The project, in addition, worked out an arrangement with a local medical group to be on-call for emergencies involving abused children. Speech and Hearing: Students at the University of Denver tested the speech and hearing of all abused children identified by the Center or ACDXS; these test results assisted the social worker in treatment plan- ning. If any of the children needed further speech or hearing therapy, the project provided transportation to weekly treatment sessions offered by the University. In January 1977 a special therapy group for abused children with speech delays was started under the direction of a University speech pathologist and a project social worker. Lay Therapy: The families assigned to each of the six therapists, most of whom were paid a small hourly wage for up to 15 hours per week, all had the abused child(ren) in the home and, in each case, the parents, while isolated from others, asked for the help of a lay therapist. Between March 1975 when the first lay therapy cases were brought on, and April 1977 a total of 27 families had lay therapists working with them. K.12 Child Growth and Development: From eight to ten parents were enrolled in the ten-session child management classes co-conducted by the project nurse and a social worker. Child development from birth to six years was conducted in the course of the classes. These classes, which began in the spring of 1975, continued throughout the demonstration history to be a re- source to abusive parents who lacked knowledge and parenting skills. Group Therapy: The Center offered a therapeutic group for parents beginning in early 1975. Also, two different time-limited therapy groups for high school-aged mothers or mothers-to-be were held at a local school and a group for abused children was begun in the third demonstration year. Crisis Nursery: The crisis nursery, which could accomodate six child- ren at any one time, provided food, shelter and emotional support for child- ren from dysfunctional families. Children were accepted if they were actually abused or if they came from potential abuse situations. A parent could request voluntary temporary placement of his/her child, but the actual placement had to be arranged by Center or ACDSS staff. Between February 1975 and April 1977, the nursery houseparents (two couples who put in four days per couple) provided a 24-hour homelike environment for a total of 121 children. Therapeutic Day Care and Therapeutic Foster Care: A day care and a foster home were selected to take placements from the Center's and ACDSS' caseloads. These homes were to provide a therapeutic milieu for abused or potentially abused children who displayed behavioral, emotional and developmental problems. In each case, special training in dealing with abused children was provided to the day care mother and the foster parents, and social workers from the Center acted as liaisons, making regular 1.13 consultation visits to the respective homes. One child was placed in the therapeutic foster home for a period of 10 months, and a total of six child- ren were placed in the day care home between January 1976 and April 1977. VI. IMPLEMENTATION/OPERATION PROBLEMS Implementation Problems: Different Expectations for the New Project Despite the fact that many different agencies were involved in design- ing the proposed program, it became apparent soon after award of the grant that there was a conflict in the expectations of the role the Family Cen- ter was going to have. The proposal itselx had presented an extensive package of services, all of which could not possibly be delivered within the limitations of the program budget. Therefore, choices had to be made. The administrative staff at ACDSS (the project's grantee) interpreted the intent of the grant to be project provision of intake evaluations for all abuse referrals in the county. However, other community agencies believed the project would become a new extensive treatment resource. To rectify the situation, the Center director had to devote a great deal of time at the beginning to explain the rationale for emphasizing intake and clarify- ing the intended services of the project. Over time, however, the original position taken by ACDSS was altered and today the project has only limited intake responsibility. Role of the Multidisciplinary Review Team Soon after the initial interagency meetings called to respond to the federal government's '"Request for Proposal,’ the people in attendance 1.14 decided that a multidisciplinary review of county-wide abuse cases was essential for effective intervention. The first meeting of the multidis- ciplinary review team was on February 4, 1974, three months before the county received the demonstration money. The team, meeting regularly before the Center began, did not feel integrally linked to the new project and was not eager to come under new leadership. Furthermore, there was some confusion over the role the team should play in the project's policy for- mulation, some members feeling that this was also part of their responsi- bility. The project director had to work slowly with the team encouraging commitment to the Family Center and assuring members that, although the project was accountable first to ACDSS, their opinions would also be sought. Later, in order to further integrate the team, the project director assumed responsibility for chairing team meetings, a role identified as her respon- sibility in the grant proposal. Working Relationships With Other Agencies Establishing a satisfactory working relationship with ACDSS was a con- tinuous endeavor. First of all, the caseworkers in the protective services unit had expected the new project to lighten their workload; instead, the concentrated community and professional education effort of the Center re- sulted in a much larger number of referrals, and protective services case- loads increased. Resentment on the part of the caseworkers over this reversal, and feelings of envy and distrust of this new organization and its staff, proved difficult to overcome. Ongoing, open communication and continual reinforcement of the joint effort between the protective services unit and the Family Center gradually reduced the anxieties between the two staffs. Secondly, at the administrative level there was, initially, a 1.15 difference of opinion over the extent of the program's accountability. ACDSS saw the Center as an extension of the Department, as additional staff for its protective services function while the Family Center staff believed that, while some key department procedures should be adhered to, the pro- ject should have a distinct image so that it could begin without running into preconceived notions about the "welfare department.' It soon became apparent that written procedures and protocols were important tools for working out the relationship between the administrations and staffs of the respective programs, and that once roles were clarified, more satis- factory interaction could result. From the outset, the Center also had a somewhat tenuous relationship with local law enforcement. Because of the Center's less-than-enthusiastic reception by the various :law enforcement agencies, and because a degree of mutual suspicion existed between the Center staff and the officers in certain departments, special attention had to be given to developing closer working ties. Providing All Intake for the County The first three months' experience, with the Center serving as the sole intake unit for the county, proved that this type of approach could result in rapid response to all reports. In fact, positive working rela- tionships were cemented with reporting agencies because of the quick reac- tion on the part of the Center staff. However, the staff soon became overwhelmed with the large volume of intakes and it was determined that so much time had to be spend on the intake process that staff could not devote time to other activities, particularly beginning the treatment pro- gram for parents and children that was also called for in the project's 1.16 grant. Therefore, by March 1975 the Center had to work out an agreement with the protective services unit, whereby the Center would take only the first six abuse reports per week. This was reduced to four intakes per week in early 1976, and eventually, by the third year, project staff managed to negotiate an arrangement of stricy rotation with protective service workers for handling intake. Use of the Crisis Nursery Difficulty arose in restricting both the kind of placements and length of stay for the crisis nursery. Before the nursery opened, criteria were established regarding the appropriate type of placement (potential or actual abused children who were expected to return home) and the expected stay (10 days to two weeks); however, it was clear after the first few months that the nursery was turning into a longer-term care home, and that many of the children went from the nursery into foster care. Whereas the goal to return most children home was kept, it was decided that more time was necessary to resolve family and child problems and the nursery should be used for longer-term care. The actual length of stay averaged 21 to 25 days over the course of the project. Operation Problems: Staffing The project's proposal did not include a casework supervisor and, after a few months of operation, the director realized that she could not be both an administrator and supervisor ror a program of this size. Her irregular schedule made it difficult to provide continuity in supervision of the 1.17 social workers, nurse and houseparents. The second year refunding propo- sal requested funds for hiring a supervisor. Finding houseparents for the crisis nursery was particularly difficult. A full-time couple was hired within a relatively short time -- about one month -- but locating suitable relief houseparents was a long, time-con- suming process. The Center advertised throughout the community but was discouraged by the few respondents. After months of searching, the Center hired two qualified couples who rotated duty on weekends. Finally, when this weekend rotation became too cumbersome and when it was apparent that the nursery responsibilities were too exhausting for even five straight days, it was decided to hire another full-time couple, thereby having two couples equally divide the round-the-clock houseparent duties. Use of Project Treatment Services Despite a dearth of treatment services available to children in Adams County, the project had mixed success in getting referrals from ACDSS case- workers. It seemed that some of these caseworkers were not used to sharing —_ hn for clients, and were hesitant because of the expected extra time commitment necessary for coordination on these cases. Over time, with extra energy on the part of project staff to entice referrals and with positive outcomes from project-provided treatment, more ACDSS caseworkers began sending clients, and by the end of the federal demonstration period there were waiting lists for some Center services. Community Relations Board The first meeting of the people who had been asked to serve on the Board was held in November 1975, more than a year after the project began 1.18 operating. After initial enthusiasm, particularly around the project's funding crisis in early 1976, the Board faltered and never really became a viable advisory body. Some reasons come to mind: the multidisciplinary review team in some sense served as a quasi-board, dealing with system- wide issues, thereby weakening the apparent need for another such group; no ongoing role was articulated for the Board members so that they could develop a commitment to their purpose; and, the project staff did not de- vote the large amount of time necessary for maintaining such a board. VII. FUTURE PLANS With carryover funds, the project continued at full staff through June 1977, although the ongoing cases of the social workers were terminated by the first of June and referred to either protective services, the Men- tal Health Center, or private counseling. The staff spent the remainder of the time writing up the results of the project. The Center as a discrete program will not continue. It is expected that ACDSS will pick up certain of the services, including the lay therapy program, the school referral program, and some children's treatment. Four of the Center staff positions also are to be made permanent civil service slots at ACDSS. Negotiations were underway with Human Services (the local United Way Agency) to manage the crisis nursery, with ACDSS purchasing the service; however, while these talks were taking place the nursery had to close. As of this writing the project staff had submitted two proposals for future funding, but no word was yet fcrthcoming. %.19 VIII. PROJECT GOALS Overall, the Adams County project was quite successful in meeting its stated goals. Goal 1: To foster a multidisciplinary approach in Adams County for the prevention, detection and treatment of child abuse. After three years of project activities aimed at effecting a multi- disciplinary and coordinated child abuse service system, evidence of inter- agency cooperation, especially in the areas of detection and treatment of abuse cases, was abundant. It must be pointed out, however, that in comparison to a lot of communities across the country the Adams County child abuse service delivery system was already highly coordinated across agencies before the project began. Several steps were outlined as soon as this goal was decided upon as necessary precursors to a truly multidisciplinary approach to child abuse. First of all, the project's multidisciplinary review team was expanded to include even broader input into case diagnosis and treatment planning than already existed. The team added a paralegal from the District Attorney's office, all the protective service supervisors from ACDSS, a police offi- cer, and school representatives. Another step to coordination among the various agencies and individuals working on abuse cases was a regularized mechanism for case feedback. To this end, it became a policy that all treatment recommendations from the multidisciplinary review team would be written up and sent to the source of the original abuse report. The multi- disciplinary review team further promoted communication with other agencies by inviting outside staff to attend team meetings to discuss progress on cases. Attendance by project staff at meetings specifically related to 1.20 coordinating the local abuse services system was also seen as critical for achieving this goal. Many of these meetings were meant to encourage area agencies and institutions to develop new abuse treatment resources. Positive changes occurred in the county over the three years of the demonstration which indicated a more coordinated, multidisciplinary agency approach to the abuse problem; some changes could be traced directly to the Family Center's effort. Specifically, new service resources were developed in the community. For more than a year a local church organized its young adult group to volunteer on a weekly basis to work with children in the Center's caseload. A day care and a foster care home agreed to take abuse referrals and provide specialized attention to these children. The University of Denver, Department of Speech Therapy, provided free evalua- tion and treatment to abused children in Adams County. And, a local pri- vate medical group agreed to be on-call to the project to provide medical care as needed. Almost without exception, there was agreement that most of the key agencies in the child abuse system worked well together, shared information and responsibilities for case handling, and were comfortable in referring new reports of suspected abuse and neglect for services. The schools, the Mental Health Center, the Health Department and ACDSS all in- creased their identification of suspected cases. Goal 2: To improve client functioning by providing responsive intake and treatment. In order to move toward achievement of this goal, that is, improve- ment in the clients treated by the project, steps were taken to organize intake and treatment services. Within the first months of the project, staff successfully implemented a thorough intake process. In general, 1.21 Center workers were able to complete the entire intake in a total of 15 hours over two weeks, although on occasion they would keep the case in in- take longer if they determined this to be beneficial to the client. Imple- mentation of treatment services for both parents and children was a particularly successful step in working toward meeting this goal. In addition to the crisis nursery, many hours of other therapeutic treatment services were provided to children by the project. The project also set up several treatment services to work with abusive clients, Subjective impressions from project staff are that many of the treat- ment services were helpful to parents and children, but it is not possible at this juncture to assess the degree to which the implementation of thorough and responsive intake and treatment for children and parents has actually improved family functioning. Thorough analysis will have to wait until both the project's and BPA's service effectiveness studies are com- pleted. Goal 3: To demonstrate the role of a nurse as an important part of a child abuse team. In order to achieve this goal it was decided to define three functions which would be particular to the qualifications of a nurse. First of all, she was to accompany the social workers when they went out to investigate reports that indicated actual abuse. The nurse provided medical examina- tions and developmental assessments to all involved children and followed through with assistance to medical treatment, if necessary. Another aspect of the nurse's job that took her special training was providing medical care to the children living in the crisis nursery. In addition to pro- viding a physical examination for each child placed there, she also made 1.22 daily visits to the nursery to detect any sign of illness which might spread quickly if not treated in time. Between November 1974 and January 1977, the nurse provided intake and ongoing medical assessments to 268 children. The third role in keeping with a medically trained person was that of liaison between the project and the medical community. Between October 1974 and January 1977 the nurse personally contacted and provided informa- tion on child abuse and the Family Center to over 50 private physicians in the county. Additionally, she gave 14 in-services to other local medi- cal personnel. The impacts of this effort to demonstrate the effectiveness of a nurse in a child abuse agency can be illustrated. The Juvenile Court began accepting her testimony as a medical expert; that is, the nurse's medical assessments done during the intake investigation could be entered into court proceedings, if needed. Her testimony then relieved private physi- cians from testifying, something that makes doctors reluctant to identify and report suspected cases. Further evidence of the importance of the nurse's role was the change in attitudes on the part of private medical personnel and physicians. While there was no increase in the number of reports from private physicians, the ongoing contact between the nurse and the private medical community served to shift some perceptions of the abuse problem. A local medical group agreed to provide on-call services to the Center and other area physicians began calling the project's nurse for con- sultation on treating cases. The final effect of the Center's nurse was the cementing of a smooth working relationship with the Health Department. The project nurse's provision of ongoing in-service and case supervision for Health Department staff led to their increased understanding, with 1.23 more identified cases and more child abuse-focused treatment provision by Health Department nurses the results. Goal 4: To determine the most effective treatment, within the context of a social services department, for abused children and their families. The project decided at the beginning to implement a research component, but to restrict it to testing the effectiveness of those types of services which could be implemented in a public social service agency context. With the assistance of consulting psychologists from the University of Colorado, the project developed a research design which included administration of developmental and behavioral tests at the beginning of treatment and then periodically thereafter in order to measure changes in functioning. Parents were given self-esteem, marital adjustment and parent/child interaction questionnaires at intake, during treatment, and then at termination. Parents who participate in child management classes were also given an additional questionnaire at intake and termination to assess child rearing practices. All children who entered project treatment services were administered a standardized psychological test, plus a semantic differential and behavior survey. Children six years and above are also administered the self-esteem and child adjective checklist. The data was collected until May 1977. With the assistance of the consultants, positive change in test scores will be analyzed and from this a determination will be made as to the more effective services for assist- ing both abused children and their parents. Goal 5: To heighten community awareness about the dynamics and treat- merit of child abuse, and about the need tc report. 1.24 Most of the project's education effort was handled under two program components, the Speakers Bureau and the School Referral Program. Since Goal 6 covers the School Referral Program, discussion here does not include educational efforts in the county schools. The Speakers Bureau was made up of all project staff, as well as a few from the multidisciplinary re- view team and other agencies. The Bureau not only responded to requests from various groups, but also sought out audiences to address concerning abuse, the reporting law and the Center's program. These presentations were made to the staffs of a variety of service delivery agencies, as well as to the medical community, to many in education and to law enforcement agencies. In addition, presentations were made to community groups, pro- fessional organizations and churches. The project also educated the com- munity by distributing literature and pamphlets on abuse and the project to anyone requesting information. There was a general consensus among the relevant professionals in the community that information on child abuse has increased tremendously over the three years of the demonstration effort. Radio, television and the press had covered the issue, and the Denver area had been blanketed by in-service training programs for staffs of service agencies. Because of this general increase in public education on the abuse program, it was not possible to measure precisely the direct impact of the project's education program. However, as illustrated, there was a general increase in reports to ACDSS and the Center (after November 1974) from sources which might be expected to have been affected by the project's education effort. The dramatic increase in self-referrals suggests that people were increas- ingly aware of the abuse syndrome in themselves and were less anxious about asking for help. 1.25 Selected Sources of Abuse Reports to Number of Reports ACDSS (and the Family Center after b November 1974) 1973 | 19747 | 1975 | 1976 Public agencies (not directly part 36 98 96 of the child abuse system) oT Private referrals (acquaintance/rela- 55 128 | 160 tive/neighbor/private physician) oC Self-referrals 5 -- 16 37 pata unavailable Further evidence of the successful impact of the community education effort was new legislation and funding allocations for handling the child abusé problem. In mid-1975 Colorado passed a new reporting law. The fact that one of Adams County's own state representatives sponsored this legislation and the other local representative supported it was seen as partially due to the project's effective education effort. In addition, the state legislature for the first time agreed to earmark funds speci- fically for protective services, something about which the project director was called upon to testify. Even more importantly, from the point of view of seeing the direct impact of the Center's public education program, was the support of the Adams County Commissioners, who allocated the equiva- lent of about $36,000 in in-kind services over the life of the project, including computer time and a full-time CETA case aide position. Goal 6: To increase the knowledge of school personnel and their involvement in the child abuse service system. Under the auspices of the Center's Schcol Referral Program, all of the county's school districts were provided intense in-service education 1.26 over three years. The Center's social workers, coordinator and nurse were each assigned a district and they met regularly with the teachers and principals in the schools. In all of these school districts, pro- cedures were established for immediate referral to ACDSS or the Center on cases of suspected child abuse. All county parochial schools and day care centers also were reached and provided information. The results of this intensive school education campaign were dramatic. In 1973, reports from schools (including Head Start) to ACDSS numbered only 13; by calendar year 1975, after the project conducted its first round of school in-services, the number of reports from schools to ACDSS and the Center together rose to 60, representing a 360% increase; and in calendar year 1976 the total reports from schools were 113, an 88% increase over 1975. Another outcome of the School Referral Program was increased parti- cipation on the part of some schools in disseminating information and edu- cation about abuse. Both teachers and high school students began making presentations in classrooms, and some schools incorporated material on child abuse into their ongoing curricula. Goal 7: To provide continuing child abuse coordination, referral and treatment services in Adams County after the demonstration funds have been reduced. During the three federal funding years, the project staff and parti- cularly the Center director met with the state legislators both formally and informally rdgarding the need for more abuse services. To this end, a formal presentation was made by the Center director to the legislature's budget committee to explain the scope of the demonstration project's pro- gram, especially the crisis nursery, lay therapy, and the role of the nurse. 1.27 Meetings were also held with the state-level Department of Social Services office, to lobby for support of protective services and the project's ser- vices. Many other contacts were made with local officials regarding the need for abuse services in Adams County. Various city council members and mayors, the County Commissioners and state and federal representatives all either were contacted in person or by mail and phone. Project staff realized that, in order to have the services which they consider vital to treating abusive parents and their children continue, ongoing effort had to be given. There was success in obtaining some state and local financial support to supplement federal dollars while the project was demonstrating its new services. However, the political and fund-raising efforts were not entirely successful. While many of the project's procedures are being emulated by protective services, the interagency coordination and referral process set in motion appears to be continuing and some of the new treatment sercices are being picked up by ACDSS, the Center as a distinct visible unit has been ended. Goal 8: To develop a child abuse program model which will be appli- cable to other Departments of Social Services in the state and around the country. Whether the model of a free-standing treatment program under Social Services supervision will be duplicated is as yet not known. Thorough descriptions of the project's lay therapy and school education programs have been drawn up and distributed to hundreds of people and presentations on the project's treatment services have been made out of the county, serv- ing to promote replication in other areas. Despite the fact that there is a need to disseminate the final evaluation of the project's effectiveness I.28 and cost, already some of the apparently successful program elements are being adopted. For example, the crisis nursery standards of the Center were used as a model in developing state standards, and the lay therapy approach of the project has been adopted by other counties. IX. PROJECT MANAGEMENT AND WORKER SATISFACTION The Family Center, relative to the other eleven demonstration projects, was a medium size project, with moderate complexity and a diversity of pro- gram activities. At the time of the project management assessment site visit, there were about 40 persons contributing time to the Center, 15 of whom were full-time staff (the remainder were part-time staff, consultants and volunteers). The project's average monthly caseload was 26 clients; its average monthly budget was $17,029. The Family Center staff perceived their project to be highly formal- ized and centralized. The project, an extension of the Department of Social Services, had to comply with the Department's rules and regulations and the project staff felt that they were not included in 920 dechelons which directly affected their jobs. Further, within the project, job descriptions and operating procedures defining the staff's relationships to each other and to the Department had been specified and were enforced. However, staff did have a measure of autonomy in the daily operation of their jobs. Worker Satisfaction To many observers, the Adams County project was considered to be an effective, productive program. In contrast to the project's popularity with others both locally and nationally, many of the staff reported that they were disappointed in the project's accomplishments, particularly 1.29 believing that the project missed its golden opportunity to develop a truly preventive approach to child abuse. The staff's dissatisfaction with the project was reflected in the results of the evaluator's management survey: with the exception of peer cohesion and staff support, the other organiza- tional dimensions -- job autonomy, task orientation, clarity, innovation, leadership and communication -- were rated moderate to low. Except for clarity and communication, the project's mean scores for the survey's dimensions were below the overall means for the eleven demonstration pro- jects, Approximately 50% of the workers report low job satisfaction. A pri- mary factor accounting for high worker dissatisfaction with project manage- ment was incompatibility between worker's expectations and the program goals. The project proposal had been written by ACDSS and the host agency intended the project to provide an intake unit that would reduce the exces- sive workload of ACDSS social workers. When the project was funded, no one from ACDSS chose to leave their positions to work in the project and, consequently, all of the project staff were recruited from outside the = agency, many from outside the Denver area. The new staff, predominantly recent MSW graduates, had high hopes of working in a preventive-oriented program that did community education and developed and implemented inno- vative treatment programs; no one was as interested in doing intake or being a part of county protective services. The project director was in the unpopular position of negotiating a compromise between the project staff and ACDSS. ACDSS had ultimate authority over the project, and the project director recognized her responsibility to work with the Department and to modify intake responsibilities gradually. Therefore, the workers had to 1.30 assume the intake responsibility in addition to their other interests of treatment and community education. The project's relationship with the host agency was also highly prob- lematic. Soon after the project was implemented, ACDSS social workers and supervisors expressed hostility toward the project. Personality conflicts which existed between certain individuals in both agencies were aggravated by initially sharing cramped quarters and by the project staff's criticism of the quality of work performed by the average ACDSS worker. Another critical reason for this strained relationship was that project workers were trying to divest themselves of intake at the same time that increased reporting had increased rather than decreased ACDSS's workload. Partially because of the resentment between the project and ACDSS, ACDSS workers tended not to refer their clients to the project's new treatment programs, and the project staff had difficulty in referring their families from in- take to ACDSS for ongoing management. Another aspect of the workers' dissatisfaction came from a sense of imposed control and accountability; some believed that they were being checked on and, consequently, their confidence and motivation were under- mined. At the beginning of the final year of the project, the communica- tion concerns reached crisis proportions. In a series of special staff meetings, the staff confronted each of these issues and began to deal with their expectations about working together. As a result, many of the prob- lems within the project were worked through and, as the staff began to deal with their internal problems, they also tried to improve their rela- tionship with the host agency. 1.31 Burnout Nearly 70% of the project staff, including terminated and non-terminated workers, felt very burned out (defined as those falling in the bottom one- third of an administered "burnout scale'). While many of the communication problems within the project and between the project and ACDSS had a negative effect on workers, the project's high rate of burnout seemed to be most highly influenced by intake responsibilities. All reported that it was a draining and thankless job because parents are angry and resentful and did not want a worker in their homes, and most clients were not motivated at this stage to work on their problems. This client attitude was contrasted with the workers' strong desire to do treatment and to work with motivated clients. Consequently, workers burned out because they sensed most of Heir work had little meaning or reward. As was stated earlier, intake duties gradually decreased over the life of the project, and workers reported that they were then more able to balance out the unpleasantness of intake with other, more personally meaningful treatment and educational activities. X. ANALYSIS OF CLIENT DATA Client Flow The prospective client first came to the Center's attention through referral from one of several sources; over time, schools made up the high- est percentage of referrals. Neighbors and acquaintances were also impor- tant sources of referrals. The calls came directly to the Family Center staff member on duty, who then took initial information over the phone. If the call was clearly not related to actual or potential abuse, the social worker referred the caller to an appropriate community resource. 1.32 To every referral of suspected abuse, some type of response was made within 24 hours of the referral. In situations that seemed to be emergen- cies, a home visit was made immediately. The social workers, under super- vision, decided whether or not to ask a law enforcement officer to accompany them on an initial home visit; such a request, however, was rarely made. The worker's assessment consisted of talking to the parents, and to the child if possible, and viewing the physical and emotional environment of the home. The project nurse gave the suspected abused child a physical examination. If the child was in imminent danger, a policeman or sheriff's deputy was called, since law enforcement officers were the only ones who could remove the child from the home for up to 72 hours without a court order. When it was necessary to keep the child from returning home, the social worker prepared the court report required for a hearing. Part of determining whether the case would be appropriate for either the Center or the protective services unit included a check with the state's Central Registry and the protective services and public assistance -indexes at ACDSS for evidence of any history of abuse. People associated with the family were asked to comment and provide background information during the assessment process. If the family needed any immediate advocacy services, arrangements were made by a Center social worker while the intake process, which usually took two weeks, was still underway. Near the end of the intake process, the social worker and other staff members involved discussed the merits of the case with the supervisor; then, based on the discussions and the primary intake person's judgment, a report was written for the weekly multidisciplinary review team meeting. The team made comments and recommendations concerning the case report, usually 1.33 concurring with the proposed treatment plan. Over 90% of the Center's intakes were transferred to the protective services unit of ACDSS for continuing treatment. The project did provide ongoing case management, counseling and other treatment for the approxi- mately 26 cases it kept after the intake process. Project staff also pro- vided treatment services for some families who were carried by the protective sdrvices unit. All ongoing project cases that were current were reviewed and reassessed regularly with the supervisor. Termination occurred when it was felt that the client could function adequately without the support of Center services. However, due to their perceived needs, these clients appeared to require long-term services, and therefore remained in the Center's caseload for up to two years. Client Characteristics The characteristics of the cases described in this section are from data on all the substantiated reports that came through the project's in-. take process and were opened as ongoing cases either at the project or at protective services. The highest percentage (21%) of the reports were from various schools. Hospitals, agencies other than social service agen- cies, and social service agencies were also conspicuous public or insti- tutional referral sources (15%, 14%, and 12%, respectively). Acquaintances or neighbors referred 11% of all cases, and self-referrals made up another 11% of the incoming reports. The project's mandate was to respond to and treat child abuse cases rather than child neglect. Therefore, only 4% of the project's intakes involved actual physical neglect. Whereas 37% of the intakes were physi- cal abuse cases, a full 46% were potential abuse. Less than one-fifth of 1.34 the cases opened (18%) involved assault (that is, either severe or moder- ate abuse and neglect or sexual abuse). For 47% of the project's intakes the mother was responsible for the maltreatment, in contrast to the father being responsible 31% of the time, or both mother and father being responsible in 16% of the cases. No legal action was taken in 40% of the cases opened, but in 11% of the cases a court hearing was held. Reporting the case to another mandated agency was decided upon 56% of the time, and to the central registry 21% of the time. Over three-quarters of the eases (77%) had no record of previous abuse or neglect before being reported. The following household characteristics were represented. In 24% of the cases only one adult was present. Additionally, the project's intakes had an average of 2.3 children in the family, with 12% of the families having four or more children. Families with no minorities present made up 75% of the cases. Neither parent had a high school degree in 58% of the families, and in 23% of the families, no one in the household was em- ployed. Whereas 42% of the families made $5500 or less per year, only 15% were receiving public assistance. The average age of the mother of the household was 27 years and the father was on average 31 years. In 36% of the families at least one parent was a teenager. Among the project's intakes, marital problems were the most often occurring factor leading to child maltreatment, with this an issue in 44% of the cases. Financial problems and a parent having been abused as a child were also critical presenting problems, each showing up in 41% of the cases. Social isolation and heavy, continuous child care responsibilities 1.35 were seen to be critical problems in about one-third of the cases (35% and 32%, respectively), and mental health problems were a contributing factor in 29% of the cases. It is of interest to note that over the course of the project's history some 110 reports were received which did not complete the intake process and were not opened as cases. Sixty-one percent of these complaints were found to be unconfirmed reports and 22% were discovered to have been already open in another relevant agency. For 9% of these reports not subsequently opened as cases, it was not possible to locate the family in question, and 7% of the complaints were outside the project's guidelines. .36 Table 1 Client Characteristics Source of Referral Private physician . . . . Hospital. . . . . . . » Social service agency . SChool.: « » + + &« v°5 +» Law enforcement . . . Comrt + «+ « + « = +» Parent. Sibling . Relative. . Acquaintance/neighbor . Self. « « « + + 5 2 2 » Anonymous . . . . . . . Other agency. Type of Maltreatment Potential abuse or neglect only . Emotional maltreatment only . Sexual abuse. v Is Physical abuse. . . . . Physical neglect. . Physical abuse and neglect. Severity of Assault Not serious . Serious . Responsibility for Maltreatment L325 11% 11% .14% Mother. Father. Both. sw ww @ Other . «ss + + » =» + # Legal Actions Taken None. . Court hearing . Reported to endated agency : Reported to central registry. (N=349) . 3% .15% «12% .21% . 9% 1% 0 ° 0 o 47% .31% .16% . 6% .40% 11% . .56% .21% Previous Record/Evidence of Maltreatment None. Previous record/evidence. Demographic Information Average number children in family . . Families with preschoolers. Families with one adult . Families with no high degree , school Families with no minorities . Families with no one employed . Families with less than $5501 per year income. Average family income . Average age of mother . Average age of father Families with teenage parents . Problems in Household Leading to Maltreatment Marital . Job related . Alcoholism. Drugs . : ’ Physical health . Mental health . New baby. . . Argument/ fight. Financial problems. Mentally retarded parent. Pregnancy . Heavy continuous “child care . Physical spouse abuse . Recent relocation . Overcrowded housing . Abused as child . Normal method of discipline . Social isolation. . 4% .14% .29% 11% .21% 41% .32% 12% .18% .10% 41% .26% .35% .44% .21% 0 0 % 9 ° 1.37 The Quality of Case Management The case management process of the project was assessed during two rounds of site visits conducted in 1976 and 1977. Such aspects of case management as timeliness, the amount of contact between case manager and client, case diagnosis and regular review, referral mechanisms, coordina- tion of information, service continuity, and client participation were reviewed. Sixty-three percent of the randomly sampled cases for the assessment showed that the potential client was contacted the same day as the incoming report was made. Another 30% were contacted no later than the third day after the initial report. One-third of the cases had at least one more client contact prior to the decision on a treatment plan, and a full 61% had two or more such contacts, reflecting the project's comparatively thorough intake process. Almost two-thirds of the cases reviewed (65%), indicated that the clients in question received treatment services within two weeks of their first contact with the project, whereas 26% waited no more than a month to start treatment services. The project made extensive use of multidisciplinary team reviews, with 100% of its cases having at least one such review. As indicated in Table 2, these reviews most often occurred during intake. Case conferences or staffings were not used as often -- less than one-half of the cases (47%) had any case conferences during their history. Consultants, on the other hand, were used often. In 58% of the cases at least one consultant was called in, and in 36% of the cases three or more consultants were used. Client participation, as measured by the client's presence at a multidis- ciplinary team review or at a case conference, was not the norm at the 1.38 project, with the clients present only 10% of the time. For over three-quarters of the cases (78%) the current case manager also carried out the intake, and in 72% of the cases there was only one primary case manager over time. It was the usual practice to have at least one other project staff member providing treatment to Center clients -- 61% had one or more other providers from within the project. Just over one-half (56%) of the clients also were receiving services from outside agencies. While an open case, 48% of the cases were contacted in some manner once a week or more, with another 38% contacted once or twice a month. After termination from the project's caseload (which occurred 59% of the time in 4-12 months and 41% of the time in 12-24 months) almost two-thirds of the cases (65%) showed evidence of a follow-up contact to determine the client's status. Table 2 Case Management Characteristics* Time Between Referral and First Client Contact Same day. ec um mow es ws wu »63% 1-3 days. . . . . . . . .... .30% 8-7 QAYSy + + 4 + » © 0 0% ww ow I Within two weeks. . . . . . . . . 3% Within one month. . . . . . . . . 3% Over one month. . . . . . . . . . 0 Number of Client Contacts (after initial contact) Before Treatment Plan NODE. ¢ o « o » « 5 5 & = » = = » 3% ONE . v v ov » v » & % 5 % % #5 vw «33% TWO « & « % + = @ © » « & # 5 203% Three-five. . . . . . . . . . . .35% Over five . . . . . . . . «. . . 3% Time Between First Client Contact and First Treatment Service Within two weeks. .65% Two weeks to one month. 27% Over one month. . . . . . . . . 7% No treatment given. 0 Use of Multidisciplinary Review Team At least one review . . . . . . 100% Review during intake. . . . . . .98% Review during treatment . . . . .13% Review at termination** . . . . .23% (Table 2 continued on following page) 1.39 Table 2 (continued) Use of Case Conferences (staffings) At least one conference . . . . .47% Conference during intake. . . . . 5% Conference during treatment . . .45% Conference at termination** . . .19% Use of Consultants NOC: + + « # 4 = & 3 33 =» +» +» 232% ONE ©» 5 + + « = ow = 5% » = « 210% THO = % « 2 w = = #% » = » » « +235 Three-five. . . . . . . . . . . .18% Over five . . . . . . . . . . . .18% Client Participation Client presence at MDT's and/or case conferences . . . . . . . .10% Contact With Referral Source For background information. . . .93% For progress reports. . . . . 72% Responsibility for Intake Current case manager. . . . . . .78% Other staff member. . . . . . . .23% Number of Case Managers DUC . 5 + =» 5 a » 3 3 & # » + «12% TWO + + » vw wa mm aw +259 More than £W0 i 5 ame x oa ws «5% Reason for Two or More Case Managers Joint management. . . . . . . .N=4 Staff turnover. . . . . .. .N=5 Staff snavailability. . . .. .N=O Lack of success with client . .N= 2 ‘Other . . + + + + + + + + «+ +» «N= 1 Number of Treatment Providers in Project (other than case manager) NONC. + = +» « « @ « « +» » = « » +59% ORE & wv & + 3% 3 3 0 + » v » »30% TWO + v 5 o 2 + 5 2° 8 5 » # » ood% Three-five. . . . . . . . . . . .10% Over £ive « « 5 o + + = « «+ +» «0 Services From Outside Agencies. .56% Evidence of Communication With Outside Agencies. . . . . . .. .86% N=22 Frequency of Contact by Case Managers Once per week or more . . . . . .48% Once or twice per month . . . . .38% Less than once per month. . . . . 2% Once or twice only. . . . . . . . 7% Varied over time. . . . . . . . . 5% None. + + « + © 5 » « =» =» » » «wD Follow-Up Contacts** At least one contact (client/ other agency . . . ve » 3» » +059 Two or less with client ceo. . J78% Three-five. . . . . . . . . . . .13% Over five . . . . . . . . . . . . 9% Length of Time in Treatment** . Through three months. . . . . . . 0 4-12 Months « « « « + » « » = » «59% 1<2 YRAYS + » = = » « + = » « » +41% Over two years. « « « « « +» +» « ».0 Total cases reviewed = 40; total terminated cases = 22. * Owing to rounding, percentages may not sum to 100%. xk Terminated cases only. 1.40 XI. COMMUNITY IMPACT Summary Some of the significant changes that took place in the Adams County abuse system since the finding of the demonstration project were: (1) a large increase in the number of services available to abuse clients, both children and parents; (2) bringing the schools into the abuse service sys- tem, primarily in identifying cases, but more and more as collaborators in providing services to abused children in the school setting; (3) develop- ing new procedural agreements between agencies; (4) a more thorough intake process; and (5) greater knowledge and awareness on the part of the health community. Despite the many positive steps forward in the three demonstration years, some problems identified by key actors in the community must still be resolved. The project and ACDSS' protective services unit still did not effect a smooth, efficient transfer of those clients that have been through the intake process at the Center and were then transferred to a worker at protective services for ongoing services. Further, it has been difficult on occasion to persuade protective service workers to refer their clients to the full array of services offered by the project. Also, some professionals in the community see a need to improve the working relationship between law enforcement agencies and ACDSS and the Center; philosophical differences on the need for out-of-home placement seemed to be a source of tension. And finally, the proccess of handling neglect cases requires modification in light of the 1975 iaw. There have been complaints that the definition of reportable neglect is too vague and that service follow-through to date on the part of ACDSS has been irregular. 1.41 System Operations Before Project Funding Prior to federal funding of the Family Center, the child abuse and neglect service system in the county was already quite centralized, with ACDSS serving as the focal agency through which most cases were channeled. Although prior to 1975, the Colorado reporting law required that all re- ports of abuse be made to a law enforcement agency, in Adams County ACDSS traditionally received more initial reports than the Sheriff's Department and all police departments combined. ACDSS was, in addition, the primary service provider to abuse and neglect families. Other community agencies, such as the Health Department (Tri-County Health Department), and the Mental Health Center, also had demonstrated concern about the problem and were identifying and providing services to these families. The Juvenile Court in Adams County was and still is integrally part of the primary service system. Until the mid-1960s, when ACDSS expanded its protective services unit, the Court was the primary agency to investi- gate abuse and neglect cases. After ACDSS demonstrated its ability to adequately intervene, the Court stopped investigation of such cases and’ now refers all incoming reports to ACDSS. The Court's current role is to act on petitions for removal of the child(ren) from dangerous environments and for supervision of Center families. The county's primary public hospital resource is Colorado General Hospital, a state-supported hospital located in Denver. The Hospital, which houses the nationally reknowned National Center for the Prevention and Treatment of Child Abuse and Neglect, was also part of the county's ser- vice system even before the demonstration project was a reality. Most cases needing medical attention were brought to Colorado General, and the 1.42 child abuse identification and treatment program at the hospital involved ACDSS on all cases originating in Adams County. Other agencies and institutions which potentially could have been part of the service system for families of abuse and neglect were isolated from the mainstream. The school districts had a self-contained method for deal- ing with suspected abuse and neglect. Most school personnel would not or could not identify child abuse in the classroom and, if they did, were reluctant to report it because of fear of parent retaliation and/or past negative experience with ACDSS' response to their reports. Except for the most extreme cases, schools attempted to intervene on their own. Private hospitals and private medical personnel in the county were also segregated from the abuse/neglect service system. Again, the reason seemed to be a lack of familiarity with the symptoms and dynamics of abuse and neglect, as well as a hesitance to report. Although most agencies reported to ACDSS, law enforcement agencies re- ceived a significant number of child abuse reports from the community at large. However, the various police departments and the Sheriff's Depart- ment in the county were separate from the rest of the service system, pri- marily because of a difference of opinion about appropriate intervention strategies. Law enforcement agencies believed that removal of the child and strong legal penalties were required in these cases, and ACDSS believed that therapeutic services to the families would be more fruitful. The law enforcement agencies in general conducted their own investigation on all reports received and, if warranted, pursued criminal investigations. Colorado has had a Central Registry for all child abuse cases since 1967. The purpose of the Registry is to maintain statistical records for 1.43 program planning and to provide a central listing of families with past histories of child abuse so that Departments of Social Services around the state can better plan their services. Also, the registry is used to check on those applying for day care and foster care licenses. Any person who identified a suspected abuse (or neglect case after 1975) case is requested to complete the reporting form and copies are sent to the local Department of Social Services, the appropriate law enforcement agency and to the Cen- tral Registry. The service system as a whole had several gaps in mid-1974 when the demonstration project was funded. e In addition to the lack of identification of cases by several reporting sources, there was little outreach into the community to identify abusive or neglectful families. e Prevention services in the way of education or identification of high-risk families were not provided in the county (although ACDSS had set a precedent of readily accepting potential abuse cases, which can be defined as a preventative measure). e Services for children were the most notable deficiency in the treatment service delivery system, and there were only limited treatment services available for parents as well. e Only Colorado General Hospital provided follow-up on terminated cases. eo Because child neglect was not a reportable offense, procedures for the community's handling of neglect cases were not clear; those who might report were not sure of what should be repcrted and response to these reports was definitely more fragmented than for abuse cases. 1.44 The most obvious duplication of services prior to 1974 was in the area of investigation of suspected cases, particularly those in which both ACDSS and law enforcement were involved. Because the two agencies were approach- ing the case from divergent perspectives, it was felt necessary by both parties to carry out separate assessments of the case, thereby making the family undergo similar (and uncomfortable) questionings. The Health Depart- ment and other agencies or institutions that identified abuse or neglect cases would also conduct investigations on their own before deciding to refer a case to ACDSS, which in turn would conduct its own evaluation of the case. System Operations After Project Funding The direct impacts of organizing the Center and its subsequent opera- tion were quite dramatic. First of all, the multidisciplinary spirit that fostered the project carried over to an ongoing multidisciplinary review team which began meeting before any word on project funding was heard. The team managed to keep the participating agencies working together in a joint effort, and effectively enhanced consideration of the alternatives avail- able in handling and treating child abuse cases. The social workers of both the project and ACDSS developed a more thorough intake process, pri- marily a result of multidisciplinary review team requirements for assess- ment of intakes. Few changes in functioning occurred in those agencies which already had been cooperating together before project funding. The primary changes were in law enforcement agencies and in the school districts. In 1975 the Sheriff's Department hired & new investigator who was assigned to handle abuse cases and, also in late 1975, the various law enforcement agencies 1.45 began working with the Family Center and ACDSS to coordinate investigation of abuse cases. Partly due to the new reporting law, but also in part due to efforts on the part of the project staff, it was agreed that the law enforcement agencies would be called in for a joint investigation of severe physical abuse (burns and broken bones) as well as sexual abuse; all other referrals would usually be handled solely by Center or ACDSS workers. A procedure for identification and referral of abuse cases was worked out in all school districts in the county. Because of early positive re- lations between schools and the Family Center, principals and other school personnel no longer felt the need to carry out their own preliminary inves- tigation of suspected cases, but were willing to refer suspected cases to ACDSS or the project immediately. Tri-County Health Department and the Mental Health Center continued to be the predominate agencies accepting referrals for ongoing services. While neither had treatment services only for abuse cases, their respec- tive staffs became more sensitive to the special needs of these clients through the in-service training provided by the project and other train- ing resources. System Dimensions Table 3 illustrates the changes in county-wide reports received between 1973 and 1976. The reports to ACDSS, including the project, have increased by 170% since 1973. Colorado General's reports, on the other hand, have decreased somewhat since the project began, a finding in keeping with the Center's effort at encouraging Adams County hospitals and medical personnel to treat local abuse cases. Abuse Reports: 1.46 Table 3 Adams County, 1973-1976 1973 1974 1975 1976 All Valid | A11 Valid| All Valid | All Valid Agency Rpts. Rpts. | Rpts. Rpts. | Rpts. Rpts. | Rpts. Rpts. ACDSS (including the b c Family Center begin- 206 170 UA 267 404 319 554 456 ning 11/1/74)2 Colorado General Hospital (Adams UA 15 UA 39 34 31 57 24 County cases only) Sheriff's Department UA UA UA UA UA 83 UA 74 4 Involving children 12 years old and younger only. b UA = data unavailable. “Figure from actual Family Center data plus extrapolation of ACDSS data collected between February 15 and December 30, 1974. Table 4 shows the changes in referral sources from 1973 to 1976. Over the four year period reports have increased significantly from almost all sources. With the outstanding exception of private physicians, the pro- fessional and community education of the project appears to have paid off in terms of identification of pcssible new cases. 1.47 Table 4 Source of Abuse Reports to ACDSS (including the Family Center after 11/1/74): Children Birth-12 Years, 1973-1976 Source of Reports 1973 | 19742 | 1975° | 1976° ACDSS S -- 48 21 Physician 5 -- aa 2 Hospital 44 -- 30 69 Law enforcement 28 -- 24 S1 School 13 -- 60 113 Court 5 -- 0 0 Other agency 36 -- 98 96 Relative 18 -- = 50 Acquaintance/neighbor J 285 -- 128¢ 108 Anonymous 1 -- st 0 Self-referral 5 -- 16 37 Other 17 -- 0 7 Total 206 -- 404 554 3pata unavailable Ppased on actual collected data from the Family Center and estimation based on ACDSS data tabulated for November 1974-October 1975. “Estimated from percentage distribution of referral sources for children birth-18 years. Referrals from physicians, relatives, anonymous per- sons and acquaintance/neighbors were collapsed under one category in 1975. At an early stage of the intake process a decision was made on whether the report was valid (i.e., whether the case was either actual or potential abuse). ACDSS together with the project took in a large percentage of 1.48 potential abuse cases. In 1973, 40% of all valid cases were identified as potential abuse; in 1976, 54% of all new cases were potential abuse. Also, usually during intake, a decision was made on whether to in- volve the Court and/or recommend foster care placement. These two actions are not necessarily synonymous since children can be placed voluntarily and the Court need not be party to this decision. The Court saw a steady increase in the number of petitions filed on abuse and neglect cases, from 131 in 1973, 186 in 1974, 219 in 1975 to 252 in 1976 (petitions involving abuse rose from 77 in 1975 to 100 in 1976). Also, foster care placements increased, as seen in Table 5. Further, the average length of stay of these children placed during each of the years increased from about eight weeks to 13 weeks. Both of these increases are substantial, indicating perhaps one of four possibilities: an increase in available foster homes in the county; an increase in the number of foster care workers to handle the demand; a change in policy towards encouragement of more placement; or, an increase in more serious cases (it is suspected that this last possibility is not the case, however). Table 5 Foster Care Placements for Abused and Neglected Children: Adams County, 1975 and 1976 1975 1976 Number of abused and neglected children 2642 352 placed in foster care Average length of stay of children laced in foster care 7.7 weeks}13.3 weeks %Extrapolated from data tabulated for February-December 1975. 1.49 Legislation In mid-1975 Colorado passed new legislation to expand the existing reporting law. The major changes in the new law were: Child neglect was added to child abuse as a reportable offense. The list of professionals required to report was expanded from five to 15 (others may report). County Departments of Social Services were indicated (in addition to law enforcement agencies) as agencies mandated to receive reports. A misdemeanor-level charge and a fine up to $200 were levied as a penalty for non-reporting; previously there was no penalty. Patient/physician and husband/wife communication is no longer considered privileged with regard to abuse and neglect. Departments of Social Services are now required to be available to receive reports 24 hours a day and to coordinate all investi- gation on reports, in addition to providing social services. The Central Registry must now expunge all unsubstantiated reports from records. Multidisciplinary child protection teams must be organized in all counties with 50 or more reports per year, in order to review new cases. The project played a role in guiding the developmwnt of the current law. The project director provided review and comment on all drafts of the bill and testified at legislative hearings, encouraging the expansion of reportable offenses to include child neglect and the centralization of reporting and investigation within the Department of Social Services. The 1.50 positive experience with the multidisciplinary review team in Adams County served as a model for the mandated inclusion of such teams throughout the State. The new statute had little effect in Adams County as of the end of the federal demonstration period because the county already had many of the new requirements in operation. However, the multidisciplinary review team was expanded to include new members as required in the law, and the Family Center, ACDSS and law enforcement staffs held meetings in order to effect an efficient division of responsibilities for investigating abuse and neglect reports. The impact of the requirement to report neglect cases was not felt at ACDSS, at least through mid-1977. In 1975 an estimated 348! substantiated cases of neglect were opened, and in 1976 there was actually a decrease to about 2882 new cases opened. Community Resources In the past three years, since the project's inception, significant staff additions were made in two key agencies which are part of the abuse system. The Sheriff's Department added a special officer to serve as the child abuse expert and liaison on these cases, and ACDSS added a new pro- tective services unit (four workers plus supervisor) in the fall of 1976, mostly in response to the tremendous increase in cases since 1974, The number of abuse and neglect services available in the community also increased substantialiy. Most of the new services were either pro- vided directly by the project or through its coordinative efforts. In le xcrapolated from data tabulated for May-December 1975. 2g xtrapolated from data tabulated for February-December 1976. 1.51 mid-1974 the only services available from ACDSS staff specifically for children were foster care, day care and very limited residential treatment. Colorado General Hospital, through its special abuse program, delivered medical evaluation and care for some children from Adams County. The Men- tal Health Center's Child Advocacy Team provided counseling to a few school-aged children with special needs, some of whom were abused. Tri- County Health Department delivered medical follow-up by public health nurses to abused and neglected children in their caseload. The project, however, set up several new treatment services for abused children. The Family Center staff directly provided medical evaluation of suspected abused children, as well as play therapy, individual and group therapy, family therapy, crisis nursery care, therapeutic day care and therapeutic foster care. The project, through the University of Denver, arranged for speech and hearing evaluation and therapy for all children from abuse situations. In addition, some school personnel, through the efforts of the project staff, were brought into the service picture by providing monitoring and specialized attention to children identified as abused. Besides new children's services, services for parents were added. Before project funding ACDSS, for the most part, offered case management, individual counseling and advocacy services to abusive and neglectful parents. The Mental Health Center also had made available individual and group therapy. In addition to expanding these services just mentioned, an infusion of new services included group therapy, parent education classes, and lay therapy under the auspices of the Family Center; three Parents Anonymous chapters organized around the county; and provision of parent- ing and child development instruction to potential and actual abuse and 1.52 neglect cases in their caseload by Tri-County Health Department public health nurses. Community System Coordination As mentioned earlier, part of the abuse system was already well coor- dinated before the demonstration project began; ACDSS, the Court, the Men- tal Health Center and Tri-County Health had informal and formal arrangements for referral procedures, and one of the multidisciplinary review team's purposes was to ensure that the appropriate agencies were cooperating in the handling of abuse cases. To some extent, coordination also was sup- ported by the Central Registry which requests that all people actually witnessing a suspected case complete the reporting form; the form, in turn, is forwarded to both law enforcement and ACDSS. Since its inception the Family Center spent a great deal of time in further coordinating the entire abuse service system. Most coordination- related meetings attended by project staff were with ACDSS, but a large number of these meetings were with various schools and other county ser- vice agencies, including the Mental Health Center and Tri-County Health Department. Less time for coordination efforts went into working with law enforcement and hospitals. By far, most coordination meetings (about 80%) were aimed at further coordinating existing services (this was seen in the very high number of meetings between ACDSS and the project, a large major- ity of which were to continuously monitor working relations between the two staffs). A somewhat smalier amount of the coordination activity of the project was directed at developing new resources, and the remainder of the time for community coordination was spent on coordinating research and influencing legislation. One of the primary focuses of coordination 1.53 on the part of the Center was contributions of time to the Metropolitan Child Protection Council, a group of Denver-area lay persons and profes- sionals who are attempting to promote area-wide cooperation and expansion of services. As a result of its coordination effort, the Center was able to effect collaborative agreements with several of the agencies in the service sys~ tem. In addition, while not directly attributable to the work of the Center, other agencies in the county also worked out both formal and in- formal working arrangements. Table 6 outlines the formal collaborative agreements worked out between the project and other key agencies. Education and Public Awareness Through the School Referral Program, school personnel by far were the largest targe: of the Center's educational presentations, having been the audience more than 30% of the time over the three demonstration years. The Speakers lureau also reached many others, including notably, all rele- vant community agencies, students, and charitable, civic and religious groups. Table 4 showed that these targets of the project's education efforts indeed increased their reporting substantially since the project's inception. The various abuse agencies in the Adams County project's service area all perceived a general increase in the level of educational activity around child abuse, both from child abuse professionals and in the news- paper and on television. Personnel in these other agencies themselves contributed a great deal to heightened public awareness by participating in efforts on the subject of child abuse. ACDSS workers made several com- munity presentations; the local judge who handles juvenile cases was often 1.54 called upon to give talks (however, these were mostly out of county); Colorado General Hospital child abuse staff were continually participating in presentations as part of the Denver National Center Training Work; the local Health Department's nurses made presentations in classrooms on parent- ing; and the various school districts began to incorporate more parenting and child development information into some classes for junior high, high school and adult education students. Table 6 Family Center Formal Collaborative Agreements Agency Content of Agreement ACDSS --Representation on multidisciplinary review team (MRT) --Agreement on definition of intake responsibilities and case referral procedures Juvenile Court --Representation on MRT School districts --Procedures for referrals on suspected abuse cases --Representation on MRT Law enforcement agencies --Division of investigative responsibilities for abuse reports --Representation on MRT (one police department only) Colorado General Hospital --Procedures for referral to Hospital Mental Health Center --Representation on MRT --Case referral arrangements Tri-County --Representation on MRT Health so : — . £ Department Referral procedures, joint staffing of cases --Supervision by Center nurse on Health Department's abuse cases District --Representation on MRT ' Atorasy $ --Guidelines for District Attorney involvement in abuse cases 1.55 XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS This section of the case study is based on data collected over three sampled months during the course of a year (October 1975, April 1976 and October 1976). Staff time per service (including donated time) and budget allocations per service were compiled. It is estimated that the Adams County project staff and consultants put in 37,680 hours over a year's time (this equaled an 18 person-year effort), using an estimated average annual budget of $186,696. Of the client-related services of the project 7% of the staff (and consultant where applicable} time went into intake and initial diagnosis, 4% went towards case management, 5% was devoted to multidisciplinary team review, and 5% was put into lay therapy. In contrast to these relatively small percentages spread over several ‘services, 29% of total staff time was devoted to the project's crisis nursery. Of the non-client services, coordination and community education (including professional education) consumed 7% of the staff time, and general management took up 8% of the total time. Staff development and training used up 9% of the time, and the project's research effort took up 6% of the time. Budget expenses generally reflected the allocation of staff time with two noticeable exceptions. Whereas general management used up only 8% of the staff time, it used up 24% of the budget. On the other hand, the crisis nursery took 29% of staff time on average, compared to only 10% of the bud- get. General management costs are high because of the use of very expen- sive time (that of the project director with no volunteers to speak of). The crisis nursery, which was staffed seven days a week, used comparatively less expensive time (that of houseparents and some volunteers). 1.56 On average, the project staff together worked on 22 intakes per month and maintained an active caseload of 26 per month. The monthly volume of services shows that the project intensively delivered a wide range of ser- vices per month including, among others, about 40 individual counseling contacts, 79 lay therapy counseling contacts, 44 group therapy sessions, 41 individual therapy contacts, and 33 medical care visits. The project's multidisciplinary team reviewed about 38 cases per month, and the crisis nursery covered on average 127 child-days per month. Table 7 displays two unit cost figures, one based on actual budget dollars per unit of service delivered, the other based on ''social dollars" which are actual budget dollars plus a dollar value attributed for donated time and resources (e.g., volunteers, including students, and consultants who were either contributing their time or were reimbursed at less than their market rate). In general, there were minimal differences between the two types of unit costs, with the dramatic exceptions of the costs of multidisciplinary team reviews and psychological or other testing. Where- as the actual cost to the project budget for one multidisciplinary team review was $13.76, the real costs of the team's time amounted to $87.78 per review -- demonstrating the significant amount of valuable time con- tributed by various people to this work. The type of testing included in the category of psychological and other testing for this project is that of speech and hearing testing, which was provided free of charge by the University of Denver. This explains the large difference between the small administrative cost per test picked up by the project (§.44) and the real cost of such tests ($33.47). 1.57 In actual dollars, an intake cost the project $50.95 per month, and carrying one case cost about $27.00 per month. Some of the more expensive services were court case activities which cost $42.85 per case, family counseling which cost $20.42 per contact (because often more than one worker was involved in each contact with the family), and play therapy ($13.16 per child-session). Parents Anonymous, which some project staff members sponsored, and group therapy were two of the most inexpensive services (at $2.32 and $3.05 per person-session, respectively). 1.58 Table 7: Project Resource Allocation and Service Costs Resourses a10aution to Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost | to Community Community Education 2% 2% Professional Education 2 3 Coordination 3 4 Staff Development/Training 9 9 Program Planning/Development 1 2 General Management 8 24 Project Research 6 9 BPA Evaluation 1 2 Outreach -— = 10 cases $ 6.78 $ 8.11 Intake/Initial Diagnosis 7 8 22 intakes 50.95 57.90 Case Management/Review 4 4 26 ave. caseload 27.01 27.26 Court Case Activities 1 1 6 cases 42.85 46.08 Crisis Intervention During Intake -- -- 7 contacts 2.1 7.11 Multidisciplinary Team Review 5 3 38 reviews 13.76 87.78 Individual Counseling 1 2 40 contacts 7.63 2.77 Parent Aide/Lay Therapy 5 4 79 contacts 8.78 8.82 Couples Counseling 1 1 19 contacts 10.34 10.68 Family Counseling 1 1 7 contacts 20.42 21.04 Individual Therapy 2 2 41 contacts 10.22 10.22 Group Therapy 1 3 44 person-sessions 3.08 4.05 Parents Anonymous 1 1 54 person-sessions 2.32 2,54 Parent Education Classes 1 1 33 person-sessions 4.83 5.49 Crisis Intervention After Intake -- -- 10 contacts 4.29 4.29 Child Development Program 2 2 22 child-sessions 6.71 6.71 Play Therapy i 1 10 child-sessions 13.16 13.96 Crisis Nursery 29 10 127 child-days 12.63 12.66 Medical Care 2 2 33 visits 5.70 5.79 Transportation/Waiting z 1 20 rides 11.97 14.60 Psychological/Other Testing -- -- 8 person-tests .44 33.47 Follow-Up -- -- S person follow-ups 6.42 6.56 Total Annual Person Years/Budget 18.1 $186,696 Average Monthly Caseload = 26 11.1 PRO-CHILD: ARLINGTON, VIRGINIA I. COMMUNITY CONTEXT Arlington County is a small (26 square miles), affluent suburb of Washington, D.C. It is composed primarily of large residential neighborhoods, sprawling shopping areas, very light industry, and many white-collar office complexes. Only 3.7% of the population in 1970 had incomes below the poverty level, well below the national average of 10.37%. In the same year, slightly more than half the population (52.2%) had moderate-level incomes, and fully 44.1% had household incomes over $15,000. Nearly one-fourth (23.8% of Arlington's population of 174,284 persons) is under 18 years of age, with 6.8% less than five years old. II. HISTORY OF PROJECT In 1973, an amendment to the existing Virginia Child Abuse Laws made it mandatory that child protective services be provided. The responsibility for providing such services for abused/neglected children and their families was vested in the State Department of Public Welfare, which then delegated it to local departments of protective services. In Arlington County, this agency is the Department of Human Resources, which was established in 1968 and merged the former health, mental health and welfare agencies. However, five years before, in 1968, services for abused/neglected children and their families were being provided in Arlington County by the Bureau of Child and Family Services, Division of Social Services, of the Department of Human Resources. 11.2 In June 1973, the Bureau of Child and Family Services sponsored a work- shop on "Protective Services to Children" for professionals in Arlington. The workshop was devoted to discussions of abuse/neglect and the protective- preventive services necessary in Arlington to deal with the problem. Uniform referral and reporting requirements, the role of the Protective-Preventive Services Unit in providing services (in contrast to investigations) to abused and neglected children and their families, and community education were all stressed at the workshop. Out of the concern expressed at the workshop, a Protective Services Task Force was established in September 1973 to attempt to resolve some of the prob- lems related to abuse and neglect. The Task Force included a public health nurse, a visiting teacher, a police officer, a probation counselor, a repre- sentative from the county attorney's office, a pediatrician, and representa- tives from the Northern Virginia Hotline, Northern Virginia Family Services, and the Division of Social Services. The impetus for the new federal grant was the need felt by the staff of the Protective-Preventive Service Unit, the Task Force participants, and others in the community for a more comprehensive and innovative program to deal with abuse and neglect, utilizing a multidisciplinary approach. The proposal, written by staff of the Protective-Preventive Service Unit, was primarily concerned with establishing new program components whose success had been at least partially demonstrated in other programs across the country. The propo- sal also dealt with the weaknesses and gaps in the current Protective-Preven- tive Services program, particularly the lack of coordination among agencies and the fragmentation and duplication of services. 11.3 '""Pro-Child," the new project, was funded in May 1974, and encompassed the old Protective-Preventive Services Unit of Social Services, including previous staff and budget. III. SUMMARY OF ACTIVITIES First Year Summary Because the new federal grant was incorporated into the already-existing Protective-Preventive Services Unit, the project became operational quickly. All new staff were hired in June, with the exception of the homemaker, who was not hired until October. By July, the Advisory Board and the Multidis- ciplinary Team were functioning, and the Educational Task Force had been estab- lished. Staff also distributed the first project newsletter and developed all reporting forms during the summer. During the early months, project staff continued to provide services to many people who had been clients before receipt of the new grant (approximately 180), and to accept new cases as they were referred. In the fall, the project concentrated on developing agreements with the schools, the Juvenile Court and the police to clarify the roles and responsi- bilities of each agency and promote early referrals of abuse/neglect cases to Pro-Child. The day care program (WAY) was developed in September, and by November the project had contracted for three emergency family homes to care for children during a crisis. Educational efforts in the community, including the development and distribution of a document entitled "Community Standards’ for Children," and the distribution of posters and pamphlets designed by the project continued. I1.4 A new state law for child abuse and neglect was passed in March. The project had provided input into the writing of the law, which designates the local Division of Social Services (Pro-Child in Arlington) as the agency to receive all reports, conduct investigation and provide services to abuse and neglect cases, and spent time during the winter and spring helping to develop the procedures for implementing the law. During this time, the project's case- load grew to over 230 cases, each of which received direct services from the staff, including individual, couples and family counseling, group therapy (two adult groups operating), and advocacy and supportive services (including homemaking and transportation). An art therapy class for children (a form of play therapy) was begun in May to help in the diagnosis of children and provide an outlet for them to express themselves. Second Year Summary Numerous staff changes occurred during the second year; the project director, intake worker, homemaker and two secretaries were replaced, and a second intake worker was hired. Two new social workers from the Family Services Unit of DHR became part of the Pro-Child project, but the majority of their cases are ADC-related. Implementation of the new Virginia child abuse law required the develop- ment of a 24-hour reporting capability, which the project fuifilled by developing a contract with an already-existing community hotline. One Pro-Child staff member is "on-call" every day for one-week time periods. A state central registry was also mandated in the new law, necessitating a change in reporting procedures; all cases of child abuse and negiect must now have forms filed with the state at each of four specified time intervals. 11.5 Pro-Child assumed its own intake function during the summer, and all calls were referred directly to one of the two intake workers rather than being initially screened by a central DHR intake unit. Staff continued to carry caseloads of 25-30 clients. A play therapy group for children six to nine years old, and a group therapy session for adolescents were added to the project's service complement. The WAY program was revamped and housed in donated church space. It became an all-day day care program two days a week for 15-20 children aged two to five, under the management of a new program director paid through Pro-Child funds. Project staff continued to respond to all community and professional education requests, and the Advisory Board to the project became a semi- autonomous group in order to more effectively lobby for necessary changes in the community child abuse system. Third Year Summary Major staff turnover, eluting the project director, five social workers and the nurse occurred during the third year. This occurred without serious disruption in the project's activities, although new personnel are only tem- porary due to the uncertainty of funding beyond the federal grant period. Few changes in services occurred during the third year, although the art therapy class for children was discontinued when federal funds were cut back. A major activity during the third year was developing a funding base to continue the project beyond May 1977. To this end, the Family Shelter Home and the psychiatrist to the Multidisciplinary Team were approved as Title XX vendors and the project received funds from the County Board of Supervisors and the state to maintain the current program through June 1977, 11.6 at which time the project hopes to be included in the county's fiscal year 1978 budget for the following year. IV. ORGANIZATION AND STAFFING The project is housed within the Bureau of Family and Child Services of the Division of Social Services in the Arlington Department of Human Resources, as was the previous Protective-Preventive Services Unit. In addition to the federal monies received through the new grant, the State of Virginia and Arlington County have continued to provide monies to support the protective-preventive service workers (six social workers, a super- visor, and regularly designated time of a pediatrician, attorney, and Pupil Personnel Supervisor) and other administrative costs. Although the project is somewhat autonomous in its day-to-day affairs because of its federal grant status, it is nonetheless subject to all depart- mental regulations and procedures, and the overall management and accounta- bility rests with the Division of Social Services of the Department. All policy decisions and many administrative and program decisions are made jointly by the project director and the Chief of the Bureau of Family and Child Ser- vices within the Division of Social Services. The Pro-Child project consists of a project director with overall respon- sibility for the project, a project coordinator, two intake/assessment social workers providing initial investigations and assessments of referrals, six ongoing social workers, a public health nurse who provides medical input, a case aide, a homemaker, and twe project secretaries. Volunteers and students are used in both direct services and administrative capacities. The organi- zational relationships of these staff members and their accountability both IL.7 within the project and within the Department of Human Resources is depicted on the following chart. Figure 1: Organizational Chart Department of Human Resources; Division of Social Service Bureau of Child and Family Services Director: Project Pro-Child Coordinator l Advisory Consultants: Board Psychiatrist, Psychologist, Lawyer, Pediatrician Two Four Two Project Intake Ongoing Homemaker Volunteers Ongoing Students Secretary Workers Workers Workers Case Aide 11.8 ¥. PROJECT COMPONENTS Community Education In addition to providing direct services to clients, all Pro-Child staff have been involved in providing educational presentations for the community. These presentations are directed at helping citizens become more aware of the dynamics of child abuse and neglect, their reporting responsibilities, and the resources that are available in the community to combat this problem. Pro-Child staff have been interviewed for newspaper and magazine articles, appeared on local television and radio shows, distributed posters and pamphlets throughout the county and given presentations to many groups, including ser- vice clubs, students and auxiliaries. Professional Education In order to acquaint local professionals with the problems of child abuse and neglect, the Virginia Code requirements related to abuse and neglect and the services available from Pro-Child and other agencies, the project staff have held meetings, training sessions, and interviews with a wide variety of community agencies. Most of these efforts have been aimed at professionals who are apt to come in direct contact with abuse or neglect situations, including personnel in the schools, the Juvenile and Domestic Relations Court, and hospitals, as well as police and private physicians. In addition, professionals in other direct service agencies, including staff of the Division of Social Services, have received some educational material froin Pro-Child. 11.9 Coordination Efforts to develop a more coordinated community system, one of the goals of the project, hinge both on the educational efforts described above and on extensive coordination activities with community agencies. Prior to passage of the new state law in early March 1975, the project's attempts at coordination were primarily in the area of centralizing reporting so that one agency, instead of three, would have responsibility for receiving and investigating all reports of abuse and neglect. Agreements were reached with both the police and the court that all abuse and neglect reports would be forwarded immediately to Pro-Child for investigation. The Virginia Code now makes this reporting procedure mandatory. Written referral procedures and forms were distributed to other community agencies to promote easy referral to Pro-Child. The forms are being used by many agencies and there has been a noticeable increase in reporting from these sources. Attempts to coordinate service delivery include developing procedures for referrals and follow-up between service delivery agencies, and joint con- sultation on individual cases whenever necessary. Legislation and Policy During its first year, staff of Pro-Child worked with state legislators and other agency personnel to draft a new child abuse and neglect law in Vir- ginia. The new law, Title 63.1, passed in March 1975, designates the local department of welfare (Pro-Child) as the sole agency to receive reports. It broadens the definition of abuse and neglect, provides penalties for failure to report, and mandates 24-hour reporting and investigation coverage, the use 11.10 multidisciplinary teams, and the establishment of a state Central Registry. Each of these provisions was supported by Pro-Child, and the multidisciplinary team approach was patterned, in part, after Pro-Child's program. The project director and coordinator were involved in the statewide task forces respon- sible for devising regulations to implement the law. Research The evaluation efforts of the project have included the development of monthly statistical summaries of all cases, logs of client contacts, and other record keeping procedures required by the Department or the state agency, as well as cooperation with all BPA evaluation procedures. Additional research efforts include: (a) an analysis of referral sources to determine the effectiveness of Pro-Child's educational efforts; (b) analysis of client success and recidivism rates; (c) a survey of clients to determine their impressions about the project and the services they received; (d) parti- cipation in a research study by a professor of social work and students to test maternal attitudes of Pro-Child clients; and (e) participation in a research study by a graduate student to assess the impulse control or Pro- Child clients. Case Management and Regular Review Each of the social workers on the staff provides general casework ser- vices for all clients in his or her caselcad (approximately 25 per staff mem- ber) either individually or as a team with other staff members. Home visits, telephone calls, and office visits are all used to maintain close contact with clients. J1.11 The workers provide a supportive, non-judgmental framework for discus- sing the families' probléms and attempting to resolve them. In the course of this casework, they assess the needs of the family and provide, either directly or through referral to other agencies, the services required. Agen- cies in Arlington that provide supplementary financial assistance, clothing, food, transportation, legal aid, egc., are used as referral sources by Pro- Child workers. In addition, many services are available through other units of the Division of Social Services, e.g., ADC assistance and public health clinics, including a well-baby, dental, mental health, child diagnostic and evaluation, growth and development, alcoholic and drug abuse clinics. Follow- up on referrals is usually provided. Each worker reviews his or her ongoing cases at least once every three months. At this time the client's progress is assessed, any new problems are explored, and if warranted, new goals and treatment plans for the client are established. Less formal, ongoing review of cases takes place with each worker's supervisor on an as-needed basis. Court Case Activities Staff social workers who are faced with the need to present a case in court are given legal counsel by the lawyer who is a member of the multidis- ciplinary team. The County Attorney's office has donated 20% of this lawyer's time to the project. | The social workers prepare the necessary petitions with assistance from the lawyer, explain all of the proceedings to the parents and child, and appear in court to testify and make recommendations about the c¢isposition of the case. They then provide the necessary assistance in implementing whatever 11.12 decision has been reached by the court. If a case requires foster care ser- vices, Pro-Child usually continues to work with the family while the child is in care, in order to effect early family reunification. Psychological Testing Psychological testing of both adults and children is provided by the psychologist who serves as a consultant to the project and is a member of the multidisciplinary team. His interpretation of the tests administered is aided by his thorough knowledge of the types of cases which Pro-Child handles. His continuing availability to workers for consultation helps provide more appro- priate treatment planning. Multidisciplinary Team Review Multidisciplinary team reviews of complex or problem cases are held on a bi-weekly basis. Two cases a session are usually reviewed with all staff and consultants, including a pediatrician, psychiatrist, psychologist, lawyer and a school representative. In addition, other professionals who have direct knowledge of a case, for example, a public health nurse or school social workers, are often asked to attend these meetings. The meetings are held both to enable an individual worker to better deal with a specific case and to provide con- tinuing education and exposure to a variety of problems for the remainder of the staff. Individual Therapy and Counseling The treatment mode most frequently used by Pro-Child staff, either alone or in conjunction with other services, is individual therapy or counseling. Through this technique, the staff attempt to engage clients in a dialogue 11.13 that permits the client to explore his or her feelings about problems he or she is encountering, to analyze various solutions to the problems, and to choose a course of action suited to achieving his or her desired goals. This counseling usually takes place in the client's home or the Pro-Child offices, as often as necessary, and is not limited to strict "appointment' times. The counseling tends to be intensive when a client first enters the project and around crisis periods, and gradually tapers off as clients become more able to cope with their problems. Group Therapy Three staff members co-lead group therapy sessions for many Pro-Child clients. There are currently afternoon and evening mothers' groups and an adolescent group; each has approximately 10 participants. Two of the social workers are also jointly offering family therapy sessions for a few of their clients. Day Care During its first year, Pro-Child provided day care for up to 15 children one day a week through a contract with the local YMCA. The primary purpose of the WAY program (Wednesday at the Y) was to give the parents some relief from their daily child care responsibilities and to provide an opportunity to assess the developmental difficulties of the children. The children were provided with a variety of learning experiences, went on field trips and had structured play time. During the second year, the program was expanded to 20 children participating two mornings a week and is now housed in donated church space. 11.14 Special Family Care Homes Pro-Child has four family care homes for the temporary day and over-night care of children. Three of these homes take children of all ages for short periods and one home works only with adolescents. One of the homes for younger children is subsidized by Pro-Child, so that there is always at least one slot held open for real emergencies. The other homes are reimbursed, based on the number of days and nights a child is in care. These homes are particularly appropriate for situations where brief child care is needed, e.g., a family crisis requiring a "cooling down' period or a temporary hospitalization. Play Therapy An art therapy class for up to six children was provided once a week by a trained art therapist. These classes provide a mechanism for the improved diagnosis of children's psychological problems and provide the children with an acceptable way of expressing themselves. Homemaking Services Homemaking services, including assistance in household management, budget preparation, and nutrition counseling, are provided for many clients by the project's homemaker. Medical Care The public health nurse, who is a member of the staff, provides medical screening and provides nursing services and routine medical care for parents and children when required. In addition, many other forms of medical care are available to Pro-Child clients through clinics and special programs opera- ted by the Department of Human Resources. 11.15 Transportation County cars are available to the case aide and other staff to provide clients with transportation to shopping areas, medical and other appointments, Pro-Child activities, and the day care program. In addition, the three staff members providing group therapy supply participants with transportation to and from these sessions. Financial Support A modest amount of money is available, partly through the grant and partly from private donations, to make small loans to clients in a financial crisis. Food, clothing and other supplies are also provided to clients who are in need. VI. IMPLEMENTATION/OPERATION PROBLEMS Because the project was added onto an already operational child Protec- tive services unit, it was spared some of the early implementation issues faced by totally new programs. Some of its later implementation issues, how- ever, stem directly from being housed in an agency that has both local and state regulations and procedures with which to — The most significant issues which the project has faced include the following. Staffing Because the project was formed from an already existing program, most of the staff were already a part of the project at the time of the grant award. Highly qualified staff were quickly found for most of the new positions. Only the homemaker and pediatrician positions took a iong time to fill. Afillia- tion with a public agency requires that ail hiring proceed according to I1.16 Civil Service regulations. These regulations often hold up actual hiring for weeks, or months, which is what happened when the project was recruiting for a homemaker. This same problem was faced early in the second year when four staff positions were open owing to loss of three staff members and the addition of a new position (a second intake worker) funded in the second year grant. Even though the people to fill these positions had been selected, there was little the project could do in these circumstances, beyond making a concerted effort to complete all paperwork quickly, attempting some compromises with the personnel department and other DHR units from which staff were transfer- ring into Pro-Child, and in developing contingency plans that shifted some of the workload from the unfilled positions onto existing staff. Role of Pro-Child within the Community Although Pro-Child had a certain legitimacy from its position within a public agency, there were some initial problems implementing the roles that project staff envisioned for themselves within the existing community system. The laws in effect at the time the project began did not prcvide for reports to be made to the project, although Pro-Child was designated as the agency to provide "protective services." Staff considered a single agency that would receive reports, conduct investigations and provide necessary services the only way to coordinate the system and remedy the existing gaps and dupli- cations in services that the fragmented system had fostered. Through pain- staking negotiations and compromises with key agencies (pclice, juvenile court, schools, other DHR units) on all sides, the project had developed the necessary procedures and mechanisms for this kind of system even before the 11.17 new Virginia law mandated a single Department of Welfare (Pro-Child) reporting agency in early 1975. In retrospect, the method they found most useful was early and continuing participation of representatives of key community agencies in all discussions about the project, its aims, and the relationships that needed to be developed in the community in order for an effective system to operate. The project now has a core of committed community agency professionals who participate both formally, through the Advisory Board, and informally in developing the plans and procedures of the project that affect other agencies. Multidisciplinary Approach From its inception, the project was committed to developing a multidis- ciplinary approach to the problem of child abuse and neglect through the hiring of a variety of people from different disciplines and the implementation of the multidisciplinary team. The team was, from the beginning, favorably received by all participants and has proved an invaluable source of guidance for staff members attempting to deal with complex cases. It was more difficult for some social work staff, who were accustomed to handling their own cases alone, to adjust to the concept of working as a team with other project staff who were not social workers. There was con- siderable confusion about the roles and responsibilivies of new staff mem- bers (public health nurse, homemaker, case aide, parent aides), and there were problems in determining the proper role for Pro-Child staff in cases where other professionals were simultaneously involved with a family, e.g., other public health nurses, psychiatrists, probation officers, staffs of other agencies. Frank discussions with all staff members, and some role 11.18 clarification by the project director resulted in a greater exchange among staff and, gradually, productive working relationships were developed. Initially the project had difficulties integrating the parent aides into the overall program. Although several volunteers were trained early in the project's history, their work with parents on an ongoing basis was sporadic because staff was uncomfortable with the concept of non-project personnel dealing directly with clients. In the final year, however, six parent aides were working consistently with families. A more gradual in- troduction of the parent aides, allowing sufficient time for staff to participate in their orientation and training and to become confident in their abilities might have alleviated this problem from the outset. Criteria for Acceptance and Termination of Cases Prior to the project's implementation, the Protective-Preventive Services Unit accepted both substantiated cases of abuse and those cases in which there appeared a potential for abuse. Although new staff positions were added with the additional project funds, the number of referrals had been steadily in- creasing to the point where all workers perceived their effectiveness was diminished by the sheer number of cases they were handling. In addition, some of the preventive cases they accepted merely because there was no other available resource to handle the client's problems, particularly adolescents, were inappropriate, in view of the services Pro-Child offers. After thoroughly discussing the problem, the staff developed specific criteria for the accep- tance of cases including a priority ''weighting" for different types of cases. The highest priority was given to cases where an incident of abuse or severe neglect has recently occurred. For the mest part, these criteria were ad- hered to during all screening of cases, and cases that were determined to 11.19 be inappropriate for Pro-Child services were referred, whenever possible, to another agency or program for service. Much the same problem has arisen in regard to termination criteria and procedures, since many cases have been open to the agency for years on a "maintenance status, involving little more than periodic contact to assure the worker that the situation remained semi-stable. Although the project never developed formal termination criteria, this was an area which staff believe more attention should have been paid. Development of a 24-Hour Hotline From the inception of the project, staff were committed to the develop- ment of 24-hour coverage via a hotline number that could be used by profes- sionals and community residents to report abuse/neglect cases during the . hours Pro-Child is not officially open. The most feasible method for this coverage was to tie into the Northern Virginia Hotline, a county organization staffed by volunteers that provided 24-hour counseling and referral services to people who call with a variety of problems, e.g., drugs, alcoholism, mental health disorders, housing problems. All the arrangements for this system had been worked out by the project coordinator and the director of the hotline early in the first program year and Pro-Child staff were willing to assume this project; however the project staff believed they were entitled to compensation, in the form of overtime pay or compensatory time off, for the evening and weekend hours they were on-call. The Division of Social Services' Chief was willing to authorize compensation for time actually working (e.g., doing a home investigation), but not merely on-call time. This impasse continued for the remainder of the first year and the 24-hour coverage system was not implemented. 11.20 However, the new state legislation which required 24-hour coverage finally led to resolution of the issue. For projects housed in public agencies, it is clear that developing programs that require changes in personnel or staff payment procedures can be very complicated, since it is difficult to implement changes for one unit of an agency that are not applicable to other units. While compromises were made on both sides, little could be done to resolve the issue without the impetus of the state requirement. Coordination with Other DHR Units Project staff expressed concern that the Pro-Child project was never well-integrated into the existing Department of Human Resources overall pro- gram and that coordination with other units had been difficult. In part, some of the strained relations are probably due to feelings that the Pro- Child project staff members were, by virtue of their federal project status, favored by the Department and had less difficulty providing services because of their increased resources. On the other hand, in the early days of imple- menting the project, more attention was focused on other community agencies, because it was assumed that coordination with DHR, in which the project was housed, was less problematic and could be resolved at a later date. The project finally realized that good working relationships with other DHR units were particularly important since many of their clients require services provided by these units (foster care, adult services, ADC assis- tance, etc.). Many meetings were held with these units and educational pre- sentations made to try to bolster the image of the project within the Department. 11.21 Project Continuation Securing the necessary funds to continue the entire Pro-Child program after the federal funds expire has been a primary problem and source of frustration during the third grant year. Indications early in the project's history were that a combination of local money and additional state support (including use of Title XX funds) could be expected to finance the program components currently funded federally (approximately 1/2 of the total program). In December of 1976 the County Board of Supervisors unanimously agreed to support the project from March through June 30 1977, when a new fiscal year would begin and the project's application for full-year funding would again be considered. Since that time, however, indications are that the Depart- ment of Human Resources is not actively supporting the project's bid for additional local or state funds, a move that seriously threatens any chances of funding. While the project is continuing to actively pursue state and local public support and may look for private funding, the lack of support and guidance from the Department has caused serious morale problems among staff and has led to early termination of some aspects of the program. VII. FUTURE PLANS After a protracged period of uncertainty (from March through June), the County Board of Supervisors and the State have provided funding for two additional social worker slots for Pro-Child and upgraded an additional slot to a supervisory level. Thus, all indications are that the project will be able to continue its program almost intact, except for the provi- sion of homemaking services and nursing support (neither the homemaker's nor the nurse's position were funded). Homemaking services, however, are 11.22 still somewhat available through other units within the Department of Human Resources, and the project director is currently attempting to develop an agreement with the Department of Public Health to provide some portion of a public health nurse's time for project-related clients. Project staff are also working to finalize an arrangement with the Diagnostic and Evalua- tion Clinic of DHR, and a community civic group to provide the space, materials and staff to operate an expanded day care program which would be primarily funded through Title XX. Indications are that this program will become operational in the fall. The Multidisciplinary Team has been re-activated. It now includes the previous members (except for the psy- chiatrist, who was replaced by a psychologist) who meet once a month to review and provide input on the case management of particularly problematic families. Community and professional education activities, which had virtually stopped pending the approval of additional funds, will resume in the fall. The project will still have the use of one Family Support Home and an Emergency Foster Home for crisis placement of children/parents without going through the Courts. The general case management and service provision activities of all staff will remain as previously, but the project will now provide services to an unspecified (but hopefully small) number of former state offenders. New legislation in Virginia has transferred service provision to these children and their families out of the Courts as much as possible, and into community agencies such as mental health and social services. Tremendous professional and community support for the project, and the staff's dogged determination to provide DHR, the county and the state with adequate evidence of the project's success can be credited for the 11.23 final victory in maintaining the project's services beyond the demonstra- tion period. Although originally there was little support from DHR, in view of other Departmental priorities, eventually it became clear that the project's proven track record made it the logical program to absorb any new staff positions allocated to the Department, and the Department began lobbying for the two Pro-Child positions. VIII. PROJECT GOALS The Pro-Child project has made significant progress towards accomplish- ment of each of the goals articulated by staff as high priority during the demonstration period. New and innovative services for abusive and neglect- ful parents and their children have been provided to approximately 400 cases per year by project staff. Educational programs have been presented to nearly every identified agency in the county involved or potentially nvolved in the child abuse and neglect problem. As a result of these educational presentations and additional coordinative efforts, and strengthened by new Virginia legislation, a more comprehensive and integrated system for dealing with all phases of the problem, from identification through reporting, case management, treatment and follow-up, has emerged in Arlington. Because the project is housed within the local protective services agency, it appears likely that many of the positive gains achieved by Pro-Child will be of a lasting nature, since this agency is a permanent component of the state Department of Human Resources. The specific accomplishments made by the project toward achieving its high priority goals are as follows: 11.24 Goal 1: To develop public awareness of the problem of child abuse and neglect by providing education in the detection, prevention, protection and care of the abused child, and to develop a know- ledge of services available in the community and an understand- ing of the alternatives to placement of the child. The project has made very significant efforts to educate both the lay and professional citizens as to the etiology of child abuse and neglect and the current Virginia law related to suspected cases, and to instill non- punitive, therapeutic attitudes toward people experiencing this problem. Project staff have surpassed their targeted figures for these educational efforts. In fiscal year 1976 alone, the staff gave over 133 written and oral presentations, reaching an estimated 2100 professionals and non-professionals in Arlington. The people receiving education represent the Arlington com- munity, other divisions of the Department of Human Resources, schools, courts, hospitals, military and other public and private agencies. Professionals reached via educational efforts included social workers, physicians, teachers, probation officers, nurses, police, counselors, school principals and lawyers. The non-professionals included day care providers, students, volunteers, members of civic and service clubs, and general citi- zens. Although the project has not conducted an overall evaluation of the extent to which the education has increased the knowledge and awarness re- garding child abuse and neglect of those reached, some assessments have been made. Questionnaires to determine knowledge and attitude changes were dis- tributed to members of the Adviscry Board and 57 people in their respective agencies. All of these people responded that they were more knowledgeable 11.25 about the problem of child abuse/neglect and were more aware of the appro- priate procedures to follow if the problem was suspected than they had been prior to the education received from Pro-Child staff. Similarly, a group of 45 people at a meeting of the Virginia Council of Social Workers responded unanimously that the presentations by project staff had increased their know- ledge and awareness. In addition to these assessments, positive responses to queries regarding increased knowledge and awareness were received from the personnel in each of the five key agencies (police, schools, courts, hospitals and juvenile courts) and community personnel when interviewed by a member of the Berkeley Planning Associates staff. These respondents addi- tionally volunteered that Pro-Child was the single agency in the county respon- sible for the educational efforts related to child abuse and neglect currently ongoing. Another measure of the positive outcome of this education is the in- crease in referrals to the project from sources who have received some con- tact and previously referred infrequently. As of fiscal year 1976, these increases were 300 percent from hospitals, 235 percent from schools, and 300 percent from physicians, all substantial increases. As a proportion of total referrals, however, hospitals have only increased from two percent in fiscal year 1974 to five percent in fiscal year 1976, and private physicians, who reported one percent of the total cases in fiscal year 1974 reported just two percent in fiscal year 1976. The schools, in contrast, have shown a marked increase, having reported only nine percent of all cases in fiscal year 1974, and reporting 19% of all cases in both fiscal years 1975 and 1976. Each of these sources of referrals also appear quite knowledgeable regarding the types of situations appropriate for referrals to the project. II.26 One hundred percent of the referrals from hospitals and physicians, and 70% of the referrals from school personnel are valid upon investigation. Goal 2: To identify, diagnose and treat abusive and neglectful fami- lies and those in high risk situations with more innovative, effective and efficient methods. One of the major aims of the Pro-Child projecy was to be able to pro- vide a wide variety of services that were more appropriate for abuse and neglect clients than was previously possible under the protective services agency program. The services which have been developed to date include 24- hour hotline services for reporting cases, an intake process for abuse and neglect cases which is separate from the more bureaucratic DHR intake pro- cedure, multidisciplinary team review of particularly severe or problematic cases, group counseling for mothers, couples, families, adolescent girls and alcoholics, homemaking services, medical care provided by a nurse who is part of the staff, a two-day a week day care program for children, two play therapy groups, an art therapy group, and a socialization group for children, and five temporary shelter homes to be used by clients during time of crisis. Obviously, not all clients are able to effectively use all of these innova- tive services, but it appears that most clients have made use of one or more of these new services in addition to receiving the more traditional individual counseling and supportive services. At the current time, it is difficult to assess the actual effectiveness of these services, as data from the BPA evaluation has not yet been com- pletely analyzed. It appears, however, that in fiscal year 1976, in about 70% of the cases terminated so far, the reason for termination was that the primary caseworker judged the case to be ready for closure. The remainder 11.27 of the cases which could be considered "unsuccessfully" closed were termi- nated for the following reasons: complaint not valid (9%), client unable to be contacted (3.5%), client refused services (3.5%), and family moved while receiving services (12%). The recidivism rate (based on the percent- age of new reports which were for families previously open to the project) has dropped from 12.6% in fiscal year 1975 to 6.5% in fiscal year 1976. Goal 3: To facilitate a more effective coordination and expansion of community resources for the delivery of services to abuse and neglect clients, including better defining respective agency roles. The Pro-Child project has made many positive gains toward coordinating the community system for dealing with child abuse and neglect, and everyone surveyed by BPA staff agrees that the changes implemented by the project, and then strengthened by state law, have resulted in a more efficient and effective system. Coordinative contacts have been made with and referral guidelines and reports sent to personnel in the courts, schools, District Attorney's office, police, all DHR units, hospitals, Head Start programs, Arlington Hotline, mental health clinic, Junior League, Northern Virginia Services League, YMCA, state delegates, Recreation Department, and the Northern Virginia Family Services agency. These agencies and institutions include all those in Arlington who could reasonably be defined as potentially involved in child abuse and neglect problems. Pro-Child has used its 13 member Advisory Board as the primary educa- tion and coordination agent between its program and the agencies represented on the Board. Other mechanisms for ongoing communication and coordination 11.28 between agencies include providing feedback to complainants on the status of cases they have referred, inviting personnel from other agencies who are familiar with a Pro-Child case to participate in the case conference or multi- disciplinary team review of that case, and maintaining informal contact with the agencies referring cases about progress of the case throughout the treat- ment process. Both the coordinative efforts of Pro-Child and the new Virginia law which centralizes the reporting system for abuse and neglect have reduced most of the duplication in the community system. It appears that all agencies save one are now reporting cases directly to Pro-Child for investigation and treatment planning. In the case of the juvenile court, both a review of cases reviewed by the court, and interviews with personnel there have indi- cated that some percentage of abuse and neglect cases (albeit small) are still being handled directly by the court staff rather than being reported to Pro-Child. The outcomes of the coordination efforts undertaken by Pro-Child have been positive, markedly improving the efficiency and effectiveness of the system to deal with reported cases; the reporting, investigative and treat- ment duplication which plagued the system prior to fiscal year 1974 have been eliminated. However, with respect to expanding community resources avail- able for these clients, only the project services developed under the new grant have in any way expanded Arlington's resource base, and there are some easily identifiable gaps in the community system which, so far, the project has not been able to remedy. As in many communities, there is a lack of adequate foster homes, especially homes appropriate for use by Pro-Child. Psychiatric services for children and programs for adolescents are almost 11.29 totally unavailable for these clients. There is little, if any, oureach into the community by Pro-Child or any other agency. Homemaking services are very scarce, although Pro-Child has a homemaker on its staff for diss and neglect clients, and there are few community agencies or groups with funds to provide emergency financial assistance. Finally, there is a lack of appropriate services for cases of sexual abuse. Goal 4: To strengthen family functioning wherever possible and there- by reduce inappropriate placements. Ten new services have been developed specifically to strengthen family functioning, including: group counseling, family therapy, day care for child- ren, family support homes, 24-hour hotline services, medical care, homemaking services, case aide transportation, volunteer aides to families, and con- sultation services to other agencies dealing with abusive and neglectful parents and their children. About 80% of the current caseload are receiving these services. Pro-Child has also developed an agreement with the Foster Care Unit of DHR which is a major step toward ensuring that reunification of families wherever feasible is the primary emphasis of treating both children and parents. Under this agreement, when a child requires placement in foster care, but Pro-Child perceives this placement will be necessary for only six months or less, the Pro-Child worker on the case remains the primary case- worker for that case, rather than a foster care worker. In this way, the child can be protected, but parents continue to receive the treatment they need to enable them to care for their children in the future. Decisions as to return of children in foster care are made jointly by the Pro-Child staff member working with the parents and the foster case worker assigned 11.30 to the child. It is estimated that this agreement is being met in over 85% of the cases requiring foster care. Although there are no criteria at present to measure "inappropriate" placements in foster care, there has been a significant overall reduction in foster care placements. In fiscal year 1974, 5.7% of the total case- load of 995 children were placed in foster care, compared to 2.9% of the total caseload of 1329 children in fiscal year 1976 and a projected 3.0% of the total caseload in fiscal year 1977. Only 12% of the children placed in foster care in fiscal year 1974 were returned home during that same year, while 49% in fiscal year 1975 and 55% in fiscal year 1976 were returned within one year of placement. Goal 5: To increase the medical community's awareness of suspected abuse/neglect situations, the services available, and there- by increase referrals. Steps taken to achieve this goal included presentations to physicians, nurses and auxiliary medical personnel in public and private agencies and hospitals, and distribution of informational packets to medical personnel in the community. In addition, medical personnel are involved in both the Advisory Board and the multidisciplinary team, and other project components. A pediatri- cian who is the director of school health programs, and a child psychiatrist participate on the multidisciplinary team. The Director of Social Services at Arlington Hospital was the Chairperson of the Advisory Board for some time. There is one nurse who is a staff member of the project, providing medical supervision for clients requiring it, and other public health nurses make joint visits with Pro-Child staff on over 20% of the home visits and participate in case conferences as appropriate. 11.3] Despite these attempts to involve the medical community, an examina- tion of the referrals do not reflect any significant increase in referrals from these sources. Referrals from hospitals have increased from 2% in the year before the project began to 5% during fiscal year 1976, and referrals from private physicians have risen from 1% to 2% of total referrals in the same two years, neither change being as large as desired. While it is clear that the medical input into project operation has been significant, it appears that the educational efforts designed to encourage more reporting from medical sources have not been successful to date. Goal 6: To conduct evaluation and follow-up studies and participate in research to determine the effectiveness of Pro-Child, and to assess the implications of abuse and neglect on parents and children. The Pro-Child project has been active in developing its own evaluation studies, participating in other research studies, and cooperating with the National Evaluation of the Joint Demonstration Projects. Two studies have been undertaken by project staff to evaluate the effectiveness of their program. The first was an assessment of the develop- mental progress of children in the day care program, and the second was an evaluation of other agencies' perceptions of Pro-Child's success as measured by questionnaires distributed to personnel of the agencies represented on the Advisory Board. Pro-Child staff and many clients have participated in six other research studies carried out by other evaluators in the nearby vicinity. These stu- dies were assessing such variables as the social isolation of Pro-Child clients, the protection and nurturing abilities of people with abuse and 11.32 neglect problems, age and impulse control, interaction patterns of family members, empathy and role modeling techniques, and a pre-test of an inno- vative interviewing method. In addition to these research activities, the project has cooperated fully in the National Evaluation. Close to 100% of the BPA forms have been completed and the staff have been extremely conscientious in completing all other tasks for this evaluation. IX. PROJECT MANAGEMENT AND WORKER SATISFACTION The Arlington project is one of the largest projects among the eleven demonstration projects. It has a total staff of 22 workers, 15 of whom are full-time. The average monthly budget is $22,161, and the project served approximately 179 clients each month. The project's organizational structure is highly complex, in part because there are seven different disciplines actively involved in the pro- gram, and also because the project engages in a variety of activities in- cluding community and professional education, coordinating with other agencies, and extensive treatment options. Although the project staff repcrt a high degree of informality in their work environment, the project is nonetheless still subject to the regula- tions, procedures and specified job descriptions of the Division of Social Services. The project is somewhat less formalized than most in rule obser- vation, and reports a high degree of job autonomy. Although highly centralized, with the overall management and accounta- bility resting ultimately with the Division and project director, project staff perceive they are afforded adequate participation in the decision 11.33 making which affects the project and their daily work. Workers in this project, unlike most protective service workers, select their own clients based generally on their interests and skills from a weekly intake staf- fing of all new clients. Management The Arlington project provides an unusual opportunity to examine a model of project management that was specifically designed to minimize worker burnout. The project proposal was written by a staff member in the Division of Social Services who had worked several years for the Department of Social Services, and who was beginning to experience the burnout pheno- menon. Having been requested by the Department Director to write the demon- stration project grant proposal, she took this opportunity to design a project specifically aimed at reducing the burnout both she and other co- workers had experienced. In this ideal project, workers would have access to a variety of services to provide for clients' needs (e.g., money, day care, homemakers). They would also be able to participate in decision making that affected them and their jobs (e.g., rather than finding a new case in the mailbox, a worker would choose his/her own clients). An environ- ment of trust and support, where staff could share both their problems and creative ideas, would be fostered, and workers would be allowed sufficien latitude to test innovative client treatment options. Flexibility of work styles and opportunities for personal growth on the job would be stressed. When the project monies were awarded to the Division these, as well as other creative management ideas, were implemented. As a result, the project ranks very high among the eleven demonstrations in leadership, 11.34 communication, staff support, job autonomy, innovation, peer cohesion, and job involvement. Overall job satisfaction is 71%. Most workers report that the project is well-managed, combining a formal organizational struc- ture with flexibility and staff opportunity to participate in decision making. Most staff are satisfied with the support and trust that exists among workers and the positive feedback they receive, particularly the notice that is always forthcoming about a worker's accomplishments. It is apparent from all reports that the project's leadership and staff co- hesiveness created an atmosphere conducive to high staff morale and a sense of the project's effectiveness and accomplishments. Despite these positive aspects of the project, there are also manage- ment problems for which no satisfactory solutions have been found. The limitation of working within a bureaucratic organization and the difficul- ties encountered in obtaining needed services for clients from cther divi- sion units and community agencies remain problems. The staff's greatest complaint was the amount of time wasted obtaining services for their clients due to agency regulations and red tape. Some of these problems resulted from a conflict that existed between other units in the Depart- ment and the project. There was a history of conflicts among division supervisors, and these were exacerbated when the addition of demonstration monies allowed an exvansion of staff, increased resource availability, and singling out that unit (primarily the protective services unit) as an elite group. The subsequent resentment interfered with inter-unit working arrange- ments, even though project staff established relationships with individual workers in the other units and were able to improve somewhat the coordina- tion between units. In the second year some of the inter-unit strife was 11.35 reduced through planned educational and cooperative meetings between units, but the problem of limited service resources elsewhere in the community continued as a problem for the project. Another problem that had a demoralizing effect on staff was the exten- sive paper work requirements of the Division, Title XX regulations, the newly-developed central registry and the national evaluation. Workers reported that the amount of paperwork involved in service purchases pre- cluded all but the most needy clients from obtaining day care and other services. Other workers noted the problems involved in securing state cars for visiting clients. These bureaucratic tangles served as disincentives toward providing clients the necessary services that were not available directly through the project. Approximately 36% of the workers in the Pro-Child project reported some aspects of burnout. The problems mentioned above accounted for some of the workers' discouragement, but, in addition, there was a certain pessimism among staff who had worked with the project over two years about the meaningfulness of their client work. Many of the project's clients have difficult problems that do not respond quickly or easily to social work intervention. For some workers, it was especially disheartening to work with a client for months and begin to see progress, only to have it sabotaged by external forces. Some staff felt that their MSW training did not prepare them with the advocacy skills needed to manipulate environmen- tal forces on behalf of their clients. Others were discouraged by the clients' hostility and lack of appreciation. But all staff agreed that they were better able to cope with these despondent periods because of the peer support, positive feedback and encouragement that a trusting, sharing work environment provided. I1.36 Turnover Pro-Child experienced a fairly high turnover rate; 58% of the staff left the project during the three years. Many left for personal reasons, including a move, retirement or to have a family. A very small percentage reported that they left their jobs because of a disillusionment about the positive accomplishments that could be achieved by the profession or the agency, or because of the difficulties working with this client population. An even smaller percentage reported that they left the agency because of project management or supervision. The primary reason given for job ter- mination was self-actualization of needs. A significant percentage reported that they left the project because of limited opportunities for growth and promotion in the project and because of better opportunities in a new job. X. ANALYSIS OF CLIENT DATA Client Flow Referrals to Pro-Child are received primarily from schools, other agen- cies, parents and acquaintances. Every new referral is assigned to one of two intake workers for investigation. This worker makes a series of home visits to assess the home situation, the primary problems contributing to the abuse or neglect or potential abuse situation, and the client's motiva- tion for accepting services. Collateral contacts are made with other people or agencies who know the family in order to gather as much information as possible. If a report is invalid or the persons involved cannot be found, the case is closed. If a report is inappropriate for Pro-Child, but the family has other problems, a referral is made to another agency or to a unit within DHR. For those cases that require only minimal service to help the 11.37 family maintain stability, the intake worker herself will often provide the necessary services for a few weeks and close the case. If, in the intake worker's judgment, the family will need ongoing services and support, she completes the family assessment, develops an initial problem diagnosis and presents the case to the full staff for assignment to an ongoing worker. Cases are assigned to ongoing workers based both on a staff person's desire to work with the case and on an attempt to maintain an overall equal distri- bution of cases. The process of diagnosis and treatment planning, which begins at in- take, continues through the first few meetings that the ongoing worker has with the client. The worker will ascertain more fully what the problems are and what services the client feels would be most helpful. The worker helps motivate the client to discuss his or her feelings and problems more fully and to agree to continued intervention by the project. Through con- sultation with his or her supervisor, outside agency personnel (if appro- priate), and the project's consultants will formulate a treatment plan and present it to the client. If necessary, psychological or other tests will be administered to parents and/or children. Particularly complex or prob- lematic cases may be presented to the multidisciplinary team for a shared diagnosis and treatment plan formulation. Those services that are most appropriate to the client's needs, and which he or she is able to accept, are provided either directly by the pro- ject or through referral to other agencies. Continuing contact is maintained with other agencies, usually teachers or other service personnel who know the client, in order to assess progress or the development of new problems. Cases are reviewed every three months and new goals and treatment plans may II.38 be established. A case may be reviewed by the multidisciplinary team any time a worker feels the need for additional input or is worried about the unsatisfactory progress of a case. Each of the consultants is also avail- able for individual conferences about particular cases during the weeks the team does not meet. Services for both parents and children are provided as long as is necessary to promote adequate family functioning. Normally a client remains in treatment until the family situation has stabilized, and the worker feels confident that there is minimal or no dan- ger to the child and that the parent can no longer benefit from services. Many times clients will move from the area or will refuse further services, which, unless there is enough evidence to bring the case to court, also results in termination. Client Characteristics Table 1 depicts the characteristics of the clients and the cases re- ferred to the Pro-Child project. The largest single source of referrals (22%) is school personnel including teachers, principals and guidance coun- selors. Acquaintances/neighbors and the Department of Human Resources (of which Pro-Child is a part) referred 17% and 13% of all clients, respectively. Parents, Court personnel and self-referrals each accounted for 7% of all other reports. The remainder of the cases were primarily reported from relatives, law enforcement agencies, hospitals, physicians and other agen- cies. Seventy-one percent of those cases reported had no previous record or evidence of about or neglect. Physical neglect accounted for 31% of all cases, while physical or sexual abuse accounted for 16% of the cases. In contrast, 21% of the cases were ones of emotional maltreatment, while 30% were potential or high risk 11.39 cases only. The remaining 4% of the reports were cases of combined physi- cal abuse and neglect. Almost one-quarter (24%) of all categories of cases were severe or moderate cases of abuse or neglect, or were cases of sexual abuse. Seven percent of the cases required a court hearing for a legal disposition to be made. This breakdown both between the types of cases accepted (e.g., abuse or neglect, emotional or physical, actual or poten- tial) and the severity of those cases, is indicative of the project's over- all approach to case acceptance. In general, all cases of child abuse/ neglect, whether actual or potential, and irrespective of severity, are accepted for at least minimal service provision by the staff. Because resources for these families are scarce in Arlington, there is definitely a philosophy among the staff that if the project does not extend services to referred clients, they will receive no help from other sources. This philosophy is also reflected in the reasons for not accepting certain cases. Of the 238 cases referred to Pro-Child but not provided services, 114 (48%) were unsubstantiated cases, 77 (32%) were cases which could not be located or the clients refused services, and 44 (19%) were cases that were already open in another agency or were referred to another, more appropriate, agency. Only 11 (5%) of the cases were not opened because staff believed the case inappropriate for Pro-Child. In 54% of the cases mothers were responsible for the maltreatment of the child; in 20% of the cases fathers were so responsible; and in 23% of the cases both parents were involved. Family composition and socio-economic characteristics of the Pro-Child cases reflect the general Arlington population. These families, 32% of which were single-parent households, had an average of two children, but 11.40 almost half (45%) were single-child families. Pre-school children were present in 57% of the households. Half of the families were comprised of adults without a high school degree, although in only 17% of the households were none of the adults employed; all of these families were on public assistance. The average family income was $10,000, reflective of the middle nature of Arlington, but 46% of the families had incomes below $5501 per year. Even though the average age of the mothers was 32 years and that of fathers was 36 years, fully 55% of the families had adolescent parents. The primary problems of the families, which may have led to, and certainly were at least a factor in the maltreatment of the child, included marital difficulties, financial worries, mental health problems, and social isolation. 11.41 Table 1 Client Characteristics Source of Referral Previous Record/Evidence of Private physician : + «v « +» +» + » 2% Maltreatment Hospital, «. « + » vv » ». vv 2 3 ww» 5% None. . . . vue 71% Social service agency . . . . . .13% Previous record/evidence. so» 229% SCHOOL. oo wo nw # & » « 5 v » » wodd Law enforcement . . . . . . . . . 6% Demographic Information COUTL « = « + » « 0 v » » » wm & 2% Average number of children in PaveMt, « « vv. + v& viv. w.n » ¢ 75 £ Sibling . . + + vv 4 uo... 1% amily . . . «oe. 2.3 Relative. . . 6% Families with preschoolers. + 21.57% Acquaintance/neighbor i oe 5 » e179 Families with one adult ET 245 Self, . o » osha le No high school degree in family .50% ANONYMOUS + » + « + + ov ou. 39 No minorities in family . . . . .66% Other agency 11% Families with no one employed . .19% Tl ETE Br Tile Average family income . . . . . .$10,000 Average age of mothers. . . . . .32 yrs. pe of Morerestnert, i Re of fathers, . « » « »36.yrs. Potential abuse or neglect only .30% Families with teenage parents . .55% Emotional maltreatment only . . .21% Sexual abuse. . . . . . . . . . . 2% Problems in Household Leading to Physical abuse. . . . . . . . . .14% Maltreatment Physical neglect. . + « + +» + + «31% : Physical abuse § neglect. . . . . 4% Marken i i i ) : ) : : hi Severity of Assault Peden sion sive ne gl) Not Sezious + « « + + » 5 3 wm &» +70% Physical health , . |, . « 4. + «20% Serious . vv 5 vw & + + ww. sw 224% Mental health... . . . . . . . . .34% New baby. « « » 5 i + » 5 » »-% 228% Responsibility for Maltreatment Argument/fight. . . « +-« + + 221% Financial problems. . . . . . . .42% ¥okner Por Ee ee Ee a” +342 Mentally retarded parent. « vie 223% Both... LL... ll. las Pregnancy. . .. 2 Other re Ce Heavy continuous child care . . .21% Eth or of pat t Physical spouse abuse . . . . . .10% ; Recent relocation . . . . . . . .16% Legal Actions Toker Overcrowded housing . . . . . . .10% None. . . . > Hh mw oe wl ame 280% Abused as child . . . . . vie BY Court hearing we low wud Normal method of discipline von w)2% Reported to mandated agency . . .56% Social isolation. .. . . . « «iu 28% Reported to central registry. . .21% (N=367) 11.42 Quality of Case Management In general, the case management practices at the project, evidenced in the reviews undertaken, were adequate. On most quality of case manage- ment measures, the project scores were within the average range of all projects' averages. Most cases (58%) were seen within seven days of refer- ral, slightly lower than the average across all projects, and 71% of the clients received services within two weeks of the initial contact. Very few cases (15%) are reviewed by the multidisciplinary team compared to a 34% average for the group as a whole, and only 28% of the cases ever re- ceive a case conference (staffing) at all, compared to 60% in the total demonstration group. Clients rarely participate in the service planning process, but this tended to be true for all projects. Most cases (95%) had only one case manager (compared to 78% of the demonstration group as a whole), and extensive contacts were made with referral sources for both background and progress information. In over half of the cases (54%), the clients received services from only the primary case manager, and in another 33% of the cases, only one other treatment provider was involved in the case, indicating perhaps a lack of service options of inadequate use of existing resources. Slightly better than half (59%) of all clients received some services from outside agencies, again indicating a lack of options or inadequate use of existing resources. Most cases (89%) remained in treatment from one to 12 months, with 13% of the cases terminated with- in three months. Other observations of the review teams were that enough attention is given to meeting parents' treatment needs; the multidisciplinary team is not used to optimum capacity, and termination is probably occurring too I1.43 quickly (in order to handle the flow of new cases) to be considered good practice. Table 2 Case Management Characteristics* Time Between Referral and First Client Contact Same day. . + +» + ss » » = » » 515% 1-3days. : « +» « + vv » =» » » 217% 4-7 dAYS: & + + + w+» +» vw +» « 220% Within two weeks. . . . . . . . .13% Within one month. . . . . . . . .22% Over one month. . « + « « « « » » 7% Number of Client Contacts (after initial contact) Before Treatment Plan NONE. . 5 + « » on « 5 » & « » x +36% One .. v2 » vv 2 « » » & a & .m +3503 TWO vv & sn © © o ¢ » & « » « 5 «26% Three-five. . . . . . . + « «. . . 9% Over five . . . . . . . . . .. . 4% Time Between First Client Contact and First Treatment Service Within two weeks. . . . . . . . .71% Two weeks to one month. . . . . . 9% Over one month, . . . . . . . . .18% No services given . . . . . . . . 2% Use of Multidisciplinary Review Team At least one review . . . . . . .15% Review during intake. . . . . . . 3% Review during treatment . . . . .12% Review at termination** . . . . . 1% Use of Case Conferences (staffings) At least one conference . . . . .28% Conference during intake. . . . .18% Conference during treatment . . .17% Conference at termination** . , . 4% Use of Consultants NONE. . « « o 4 + o + o » » # +» 37% One . . uw + 3°% +. 0 « « vio ww. u9% TWO « « 5 « # # = 3 +» o « oie » 15% Three-five. . . . . . . . . . . .12% Over five z= = a + + = + + » sn ur 5% Client Participation Client presence at MDT's and/or Case - Conferences . » . « + oa wv 9 N° Contact with Referral Source For background information. . . .89% For progress reports. . . . . . .81% Responsibility for Intake Current case manager. . . . . . .47% Other! staff member. . . . . . . .53% Number of Case Managers ONE « & + x a 4 i's + & & » w+» $905 THO « o % © % 4 & & « & » % = '» 5% More Than two = + + « + + = & =» = 0 Reason for Two or More Case Managers Joint management. . . . . . . N= 0 Staff turnover. « = +» « + +» +» N='l Staff unavailability. . . . . N= 2 Lack of success with client . N= 0 Other . . « « + 4 » » « « » «» N=0 Number of Treatment Providers in Project (other than case manager) NOTE. « &« « 5.4 5 » o » % » =» +» «34% ONE . 5.8 v = » 5 » = 4 » & le, n30% TWO o 4 vo # =» £5 5 5 5 + » 2» dy Threa-Five. . +. + + +» = « oo v's vw 9% Over Five . « « v = « + + ww wis 2% (Table 2 continued on following page) 11.44 Table 2 (continued) Services from Outside Agencies. .59% Evid ¢. Commas . it] Outside Agencies . FO - 1 N=27 Frequency of Contact by Case Managers Once per week or more . .26% Once or twice per month . .57% Less than once per month. .11% Once or twice only. . . . . . . . 4% Varied over time. . . . . . . . . 2% NORE. + # ov % # 9 + » w » » ® = « 0 Follow-Up Contacts** At least one contact (client/. other agency). . . . . . Two or less (with client) Three-five (with client). . . Over five . . . . . . . . . Length of Time in Treatment Up to three months. . . . . 3-12 MOALRS . + + + + x ww + ow 1-2 years . Over 2 years. * Throughout , percentages may not sum to 100% owing to rounding. *k } Terminated cases only. Total cases reviewed = 46; total terminated cases reviewed = 46. .61% .94% . 4% 2% 13% .76% 11% 11.45 XI. COMMUNITY IMPACT Summary The system for dealing with child abuse and neglect has undergone many positive changes since implementation of the demonstration project in May 1974. Centralization of the system, with Pro-Child (protective services) as the sole agency mandated to receive reports, forward case data to the central registry, undertake treatment planning, and coordinate service pro- vision with other community agencies has been enhanced both by Pro-Child's educational and informal coordination efforts and by implementation of a new state law. Most agencies report that cases identified by their staff are now being referred to protective services, although it is probably the case that some cases are in fact being handled by the court and schools without referral to Pro-Child. In general, however, the system is func - tioning at a much more efficient and effective level. All new cases reported to Pro-Child are also reported to the Central Registry. An increase in the total number of cases reported to protective ser- vices has occurred between fiscal year 1974 and fiscal year 1977. This increase can be correlated with the increased staff capacity at the pro- ject (from 7 to 12 people) that has allowed more education and coordina- tion to be undertaken. No other community agencies have increased the resources they commit to the child abuse and neglect problem, either in terms of staff, or in terms of the kinds or amounts of services they pro- vide to their clients. There have been only a few changes in the sources of reports to pro- tective services, with the percentage of reports from the local welfare 11.46 department (DHR) increasing slightly, while reports from schools, relatives and neighbors have increased dramatically. The project's educational focus on these groups has certainly contributed to this increase, although national publicity has no doubt played some part. In general, implementation of the demonstration project and the new state law have contributed most substantially to changes in the community system in Arlington, and there is some evidence to suggest that the project has played the major role in the community changes. The two areas in which the project has been most successful in the community are in the develop- ment of numerous new service components (e.g., group counseling, day care, children's therapy), and in the formal and informal education and coordina- tion provided to professionals and community residents. The latter efforts have contributed to developing a core group of people committed to increasing the effectiveness of the overall system, and have laid the groundwork for a system that deals more carefully and consistently with people who have prob- lems in the area of child abuse and neglect. Community System Operations The primary service delivery system for clients with child abuse and neglect problems prior to implementation of the demonstration project in May of 1974 consisted of several agencies working relatively independently of each other. The Protective Services Unit of the Department of Human Resources had the responsibility of providing services to substantiated and potential child abuse/neglect cases, but was not legally mandated to receive reports, although they did receive them from some agencies and individuals. The police and Juvenile Domestic Relations Court, the legally mandated agencies to receive reports, worked inconsistently with each other and with 11.47 the protective services agency. Thus, cases were reported to any of three agencies and in some cases, a single case was reported to more than one agency. Duplicate investigations were occasionally carried out by these agencies. The criteria for '"substantiating' reports varied; the police and the courts maintained a strict legal definition, while protective services used broader criteria, including "potential" as well as actual abuse/neglect cases. None of the community agencies reported cases to the state Central Registry, although required by law to do so. The disposition of cases and the services received by clients depended, in part, on the agency which received the report, with each agency prescrib- ing primarily those services available or known to it. Several gaps in the community system existed. There was virtually no outreach into the community. Preventive services were provided only tc clients referred to protective services as ''potential' abuse and neglect cases, although some other community agencies, e.g., mental health services, Northern Virginia Family Services, etc., were no doubt providing some pre- ventive counseling services without labeling clients as potential abuse cases as such. Because there was no provision for 24-hour services in the community, reports of abuse and neglect received after hours (often the most serious cases) went to the police and were handled in much the same way as any criminal complaint. Few other community agencies perceived a role for themselves with re- spect to abuse and neglect cases. Except for severe cases, the schools, hospitals, and public and private social service agencies handled abuse and neglect cases in the same ways in which they would handle all ''social ser- vice" problems. 11.48 In 1974 the demonstration project, Pro-Child, became part of the exist- ing protective services agency, almost doubling the resources available to that agency. Because this was already the agency most capable of providing treatment services, one goal of the project from the outset was to have protective services become the central Arlington agency for both the receipt of reports, service planning and treatment, making referrals to other agen- cies as appropriate. Through intensive education and coordination endeavors, this had practically been accomplished by project staff when a change in the state law mandated that protective service agencies across the state become the only agencies legally designated to receive reports. Thus, Pro- Child has become the central focus for the child abuse and neglect system, ensuring that reported cases are handled consistently, and providing the link with other community agencies (the courts, police, schools, hospitals and community treatment agencies) to promote coordination of the system. Criteria for accepting clients based on the type and severity of abuse and neglect, and definitions of what should be considered abuse and neglect have been developed and distributed to all community agencies by the pro- ject. Procedures for referring cases for treatment have been established, but the primary treatment source remains the project. A 24-hour reporting system has been developed by the project to provide off-hours coverage. The Advisory Committee to the project includes representatives of most key agen- cies in the community and serves as another focus of coordination for deal- ing with both policy and programmatic issues of the chiid abuse and neglect system. 11.49 Caseload Size and Case Outcomes During the baseline period (FY74) 279 cases were reported to protective services. In fiscal year 1975 this had risen to 341 cases, an increase of. 20%. In fiscal year 1976, 367 reports were received, and in fiscal year 1977, the projected number of reports is 432. This figure represents a 65% increase in reporting over the baseline period. This increase, however, may be due to the recent centralization of the reporting system, with many re- ports which used to be received by the courts and police now being forwarded to protective services. However, data from the Juvenile Court also shows an increase in the reports received, from 30 reports during calendar year 1974 to 70 reports during calendar year 1975. Staff from the police depart- ment maintain that all cases identified by them are immediately reported to protective services, so an increase in reports cannot be validated from that source. From the data of the court and protective services, it appears that the reported incidence is in fact increasing at a fairly substantial rate. Of the 270 reports received by protective services in fiscal year 1974 (baseline period), 70% were substantiated, but during fiscal year 1975, 84% of the 341 reports received were substantiated. Although not a dramatic increase, this change is perhaps indicative of a heightened awareness on the part of both agency personnel and the community of the kinds of cases which ‘are appropriate for referral to Pro-Child. There have been several changes in the source of reports to protective services during the demonstration project period. One significant change is the reduction in the proportion of cases reported by the Department of Human Resources from 29% in fiscal year 1974 to 19% in fiscal year 1976. This perhaps indicates that a broader range of cases across the community 11.50 are being identified, rather than primarily those cases previously known to the social services or 'welfare' system. Two other changes are readily evi- dent. The proportion of reports from schools has snareased from 2% to 19% and the proportion of reports from relatives and neighbors has increased from 19% during the baseline year to 32% in fiscal year 1976. It is likely that the project's educational efforts, which were focused on both the general community and school system during the first year, contributed to these changes by clearly defining to school personnel and community residents the kinds of cases which should be reported and to whom they should be reported. Although data on the final disposition of all cases in the Arlington system, particularly cases that were referred to the court, are not currently available, the following table illustrates changes in the foster care place- ments of abused and neglected children during the project period. Foster Care Placement and Returns, FY74, 75, 76, 77 FY74 FY75 FY76 FY77 No. % No. % No. % Ne. % Total children in project 995 | 100 | 1205] 100 | 1329] 100 | 14627 100 caseload Children placed in foster 5715.7 86 | 5.0 aol 2.9 443 3.07 care Children returned home in 7 12 52 60 22 55 NA same fiscal year Average length of stay NA 3.2 months| 3.1 months NA pata from previous Pro-Child director's statistics. Data from Pro-Child's re-funding application, February 1976. 3projected on basis of first five months data. 11.51 Although the project has served an increasing number of children every year, the percentage of children placed in foster care has decreased by almost 50% since federal funding. Additionally, the proportion of children placed who are returned home in the same year has increased dramatically. Many factors are probably contributing to this, including Pro-Child's empha- sis on providing alternatives to foster care, and the staff's desire to have children returned as soon as the home situation can be considered safe, while providing continuing supportive services to parents. Legislation New state legislation was passed in March of 1975 which considerably broadened the definition of child abuse/neglect, and also provided a more centralized organizational structure for handling reports and providing, ser- vices to these clients. The most important changes in the legislation include: designation of the local social services agency (protective services) as the sole agency to receive reports; provision for development of a state-wide 24-hour report- ing system; establishment of a central registry; and inclusion of penalties for non-reporting. By means of its educational program, Pro-Child is continuing to alert both community agencies and residents to the provisions of the law and pro- viding them with information relative to reporting suspected cases. Staff of all community agencies interviewed felt that the new law would increase the effectiveness of the system for dealing with abuse/neglect cases and understood their responsibilities under the new law. 11.52 Community Resources With the exception of the demonstration project (protective services), no agencies in Arlington have staff specifically committed to dealing with child abuse and neglect problems. Rather, staff of these other agencies, including probation officers of the court, the juvenile division staff at the police department, school social workers, foster care workers, hospital social service staff, public health department staff, hotline referral staff and staff in several counseling agencies, provide services to abuse/neglect clients in much the same way as they would to other clients. Because of the problems defining abuse/neglect cases, most of these agencies do not have data on the actual number of cases to which they provide services, and therefore, cannot estimate the percentage of staff time committed to abuse and neglect. With the receipt of the demonstration grant, protective services was able to increase its staff from seven to 12 workers, and additionally to acquire the consultation services of a psychiatrist, psychologist and a lawyer. The services available through protective services include: case management; multidisciplinary team review; individual therapy and counseling; group counseling; psychological testing; couples and family counseling; day care; art therapy for children; homemaking services; babysitting and child care; and ancillary services including transportation and emergency funds. All but case management, individual therapy and counseling, and ancillary services are new services developed subsequent to federal funding. Services available through other community agencies are limited pri- marily to counseling and therapy and to some advocacy and support services. 11.53 There is little in the way of outreach or preventive services available anywhere in the community, and follow-up of cases terminated trom protec- tive services or other agencies is seldom carried out. Volunteers have not been used to any great extent in the Arlington system. The project has made some gains in their attempts to expand and coor- dinate the services available in Arlington, but the primary service expan- sion to date has been from the federal demonstration grant, which leaves it unclear whether many of the services currently provided by protective services will be continued after termination of the grant if additional money is not forthcoming. Community System Coordination The coordination of the community system dealing with child abuse and neglect in Arlington has changed in several areas since the implementation of the Pro-Child project. The Advisory Committee to the project includes representatives from the schools, police, court, hospital, Public Health Department, and several private and public social service and referral agen- cies. These representatives are the coordinative link between protective services and all other agencies, and the monthly meetings of the Committee serve as the vehicle for jointly establishing many of the procedures under which the system operates. The primary coordination efforts to date among all these participants have been in the areas of reporting, investigation and feedback to complainants, and the procedures developed are closely ad- hered to by most agencies. Forms for reporting cases have been developed by Pro-Child and distributed to all relevant agencies, and the use of the 11.54 Pro-Child phone number and after-hours hotline number have been carefully explained. Procedures for conducting investigations, particularly during off-hours (when police assistance may be necessary) have been developed. Forms for providing feedback to complainants (both agency staff and com- munity residents) have been developed, although these are not always used. Coordination on individual cases is achieved primarily when a protec- tive services staff member initiates contact with other agencies about specific cases. Approximately 10 coordinating contacts have been made by project staff each month. Changes in the state law have also contributed to better coordination of the Arlington system. Centralization of reporting within protective services and a clearer definition of reportable incidents has led to more focused identification, investigation and treatment provision, all of which are done primarily by protective services, but which are also coordinated with other agencies as necessary. The state record keeping system which went into effect in June 1975 covers all child abuse and neglect reports in Virginia. This aids in coordination between contiguous counties (e.g., Arlington and Fairfax counties) which is important since so many in this population are very mobile. The information in the central registry will also provide basic data on reported cases which, if made available to all community agencies, should increase their awareness of the problems in the system and help spur further coordination between agencies. Education and Public Awareness The level of education and training on child abuse and neglect has in- creased substantially since the baseline period (FY74). Prior to implemen- tation of the project, few community agency personnel except protective RAT THT GET — 11.55 services staff had received any education or training about the etiology of abuse and neglect, criteria for identifying cases, or the resources avail- able in Arlington to deal with the problem. Since that time, staff of Pro- Child have provided education and training sessions to staff of most key community agencies including schools, court, police, and hospitals. Many other agency staff, such as public health nurses, foster care workers, day care staff, and staff of other counseling agencies have also received educa- tion since implementation of the project. Efforts to educate residents of the Arlington community have included speaking engagements with community groups, television and radio appearances, and contributing to newspaper and magazine articles. In terms of sdumaihenal effort, less priority has been placed on general community education than on professional education. Pro-Child staff have provided approximately eight educational sessions per month to professionals and community resi- dents. The primary results of this education have been increased requests for additional education, and to some extent, an increase in referrals to the project. Representatives of all key agencies interviewed agreed that the amount of education/information provided to professionals and community residents has increased markedly since fiscal year 1974. They also agreed that, in addition to the proliferation of newspaper and magazine articles which is generally occuring around the county, protective services has been the pri- mary agency in Arlington providing education about abuse and neglect. None of the agencies interviewed have increased their own education efforts, nor do they perceive this as an appropriate role for their staff, which raises some questions about the continuity of educational efforts if the project cannot carry them out due to lack of money after federal funds run out. 11.56 XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS The allocation of both staff time and dollars during the project's operation reflects the project's emphasis on direct services to clients, both parents and children. During 1976, 14.23 person years of effort were expended on the project, at a total budget of $225,984. Table 3 depicts the average allocation and service unit costs. With the exception of general management and day care, both the pro- portion of time spend on various project activities and the proportion of the budget those activities consumed are quite similar (within two per- centage points). General management cost proportionally more due to the high salaries of senior level staff performing that function, and the actual cost of day care was lower than the proportion of staff time allo- cated because of the use of unpaid volunteers working in the day care program. About 5% of the resources (staff time and dollars) were expended in educational activities, 1% of coordinating activities within the community, and 14% on general management, staff training and program development com- bined. Research and evaluation activities consumed 4% of the resources. The project served an average of 179 clients per month, offering most clients a combination of counseling or therapy (individual, group, couples, family or lay therapy), crisis intervention, diagnostic services, and sup- portive services such as homemaking, medical care, babysitting, transpor- tation and emergency funds. A small number of cases were reviewed by a multidisciplinary team, and about 19 cases per month were court-involved cases. The management and review of all cases consumed about 27% of the staff's time and the project resources, by far the largest proportion of 11.57 both expenditures on any single activity. Day care expenditures (6% of the dollars and 12% of the staff time) were also proportionally higher than other categories. Conducting intakes, providing individual counseling (the primary adult service offered), and transporting clients were the next largest resource-expensive activities. As is depicted in Table 3, the unit costs of activities remained rela- tively stable during the demonstration period, with a few notable exceptions. Case management, multidisciplinary review and play therapy unit costs were significantly higher as caseload size or the number of cases reviewed or the number of children in play therapy were lower than average, reflecting both more intensive services to fewer clients and the fixed costs of con- vening the team and having the play therapist conduct a session, irrespec- tive of the number of cases reviewed or the children served per session. The wide fluctuation in unit costs of several other services, including homemaking, court case activities, crisis intervention and medical care appear to reflect primarily a difference in the intensity (staff time) with which the service was provided. The unit costs of most services were well within the average for the demonstration projects as a whole. It is interesting to note that in Arlington, as in the other projects, the costs of multidisciplinary team reviews are high, $50 actual cost per review and almost $100 if the value of donated time is included in the calculation. Outreach services, in- take and initial diagnosis, and court-case activities are also costly — vices, due to the amount of staff time required to carry out these activities (much of which is spent locating clients or waiting with them). Table 3: 11.58 Project Resource Allocation and Service Costs RESolECe Alioisuion to Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost | to Community | ° Community Education 1 2 Professional Education 3 3 Coordination 1 1 Staff Development/Training 2 7 Program Planning/Development X 1 General Management 6 13 Project Research 1 1 BPA Evaluation 3 3 Outreach 1 3 12 cases $23.53 $23.87 Intake/Initial Diagnosis 8 8 32 intakes 46.42 46.42 Case Management/Review 26 28 179 average caseload 29.67 25.85 Court Case Activities 4 4 19 cases 38.75 44.12 Crisis Intervention During Intake 1 1 26 contacts 8.71 8.76 Multidisciplinary Team Review 1 1 6 reviews 51.96 99.57 Individual Counseling 7 8 273 contacts 5.92 5.97 Parent Aide/Lay Therapy 2 -- 20 contacts 7.16 7.29 Couples Counseling -- -- 9 contacts 9.55 9.55 Family Counseling 1 1 23 contacts 9.95 9.95 24-Hour Hotline -- -- 12 calls 4.91 4.91 Individual Therapy -- 1 11 contacts 12.01 12.01 1 Group Therapy 1 2 72 person-sessions 4.18 4.29 Crisis Intervention After Intake 1 1 29 contacts 10.10 10.10 Day Care 2 6 153 child-sessions 6.9% 8.42 Play Therapy 2 1 30 child-sessions 5.75 6.37 Homemaking 1 -- 8 contacts 5.90 £.90 Medical Care 2 2 12 visits 12.46 12.60 Babysitting/Child Care -- 3 222 child-hours .50 «52 Transportation/Waiting 8 6 293 rides 4.00 4.21 Emergency Funds -- - 6 payments ww = Psychological/Other Testing -- 1 9 person-tests 26.37 26.37 Follow-Up w= -- 11 person foilow-ups 4.05 4.05 Total Annual Person-Years/Budget 14.23 $225,984 | Average Monthly Caseload = 179 111.1 CHILD PROTECTION CENTER: BATON ROUGE, LOUISIANA I. COMMUNITY CONTEXT East Baton Rouge Parish is the local government unit encompassing the city of Baton Rouge as well as some surrounding bedroom and rural communi- ties. The parish has a population of approximately 297,000, about 29% of which is Black. Approximately 40% of the population is 17 years old or younger, the age range of children protected by the state's abuse and neglect reporting law. The 1970 census showed 13.6% of the parish fami- lies below the national poverty level (as defined by the U.S. Department of Commerce), 20.9% of the families earning over $15,000 a year, and ha remainder in the middle-income range. Baton Rouge, the largest city in East Baton Rouge Parish, is the capital of the state and, therefore, headquarters for the various state agencies. Louisiana State University, the largest university in the state, has its main campus in Baton Rouge, and its Graduate School of Social Work has provided both consultation and job placement referrals to the Center. II. HISTORY Until 1972, Louisiana was without a comprehensive law for the protec- tion of abused and neglected children. This did not mean the abuse and neglect problem went undetected, as some parishes had developed procedures for handling reported abuse and neglect in the family courts and a few law enforcement agencies had established special units tc respond to such 111.2 cases. Baton Rouge, led by a local pediatrician, played a strong state- wide leadership role in promoting greater awareness of the abuse and ne- glect problem and in advocating a multidisciplinary, multi-agency approach to case handling. However, concerned individuals and agencies across the state became increasingly alarmed at the lack of a clear mechanism for reporting suspec- ted cases, at the public's misunderstanding about the seriousness of the problem, and at the uncoordinated approach to service delivery. A broad- based advisory committee was organized, and it became the motivating fac- tor behind drafting updated legislation regarding the reporting of child abuse and neglect. The bill, passed in July 1972, required everyone who is a witness to report cases of abuse and/or neglect, and authorized the Division of Family Services (the state's public social service agency) to investigate all reported cases. Concurrent legislation proposed a central abuse/neglect registry and Child Protection Centers in the state's five metropolitan areas. Unfortunately, no funds were allocated to start these Centers, which were meant to provide special referral, investigation and treatment services to abusive and neglectful families. The problem persisted. In 1973, 16 confirmed cases of abuse and 83 confirmed neglect cases were reported to the State Central Registry for East Baton Rouge Parish and the Parish Sheriff's Department handled 174 "cruelty to children" cases in that 12 month period. Earl K. Long Hospi- tal, Baton Rouge's charity hospital, recorded treating 20 abused and 14 neglected children between January and August 1973. When news of possible federal demonstration funding came, interested professionals were convened by the State Department of Education, Bureau 111.3 of Early Childhood Education, to apply for the grant. This group included representatives from the Baton Rouge Mayor's Office, Earl K. Long Hospital, the Sheriff's Department, the State and Parish Division of Mental Health, the Division of Family Services, the School Board, 4-C's (Community Coor- dinated Child Care), the Family Court, and Louisiana State University's School of Social Welfare. Support was obtained from the governor on down. The proposal asked for funds to set up a Child Protection Center in Baton Rouge based on the model proposed by 1972 Louisiana legislation. The pro- ject would be part of the Division of Family Services, but would be placed in and share staff with Earl K. Long Hospital. To further sciidify an interagency approach, the fiscal agent of the proposed project would be the Bureau of Early Childhood Education, also known as the State Office of 4-C's. III. SUMMARY OF ACTIVITIES First Year Summary Following award of the demonstration money in May 1974, the Baton Rouge Child Protection Center was organized. The director, chosen from within the Division of Family Services, was hired in July. She immediately brought in four MSW-level social workers, all of whom were experienced caseworkers, but had just completed their graduate studies. A half-time pediatrician, on the project payroll since July, made up the sixth member of the original staff complement. A public education specialist and a homemaker were added to the staff in September and, after a lengthy search, a supervisor was hired in late October. RTT ERE LS 111.4 The first reports were taken by the project staff in mid-August; most of these were from a backlog in the Division of Family Services' parish office. Word of the new project spread quickly, however, due to a con- certed community education effort, and abuse and neglect reports were soon coming from a wide range of sources. With December came implementation of 24-hour coverage for reporting of suspected cases. The social workers began rotating responsibility for being on-call, using a beeper for receiv- ing after-hours reports. A fifth social worker was added in January 1975, but still the project could not adequately serve all new referrals. There- fore, in mid-March an agreement was made with the Protective Services Unit of the Division of Family Services to share intake and treatment, with the project being in charge of abuse cases only and Protective Services hand- ling neglect. Other significant events during the first year of the project included the initial meeting of the Center's Advisory Board in November 1974. Over 40 representatives of community agencies were present, an indication of wide support for the new project. The Board, which took an active roie from the outset, continues to serve as the Center's community liaison. Also, a three-day workshop on the dynamics of abuse was sponsored by the Center in early April 1975. Targeted for professionals in the community, the sessions attracted an average of 90 participants per day. Second Year Summary In mid-May, the Center hired a sixth social wcrker in order to handle the volume of referrals coming in. By the end of May the Center moved into its permanent facility on the grounds of Earl K. Long Hospital. The 111.5 mobile unit was expansive in comparison to the temporary quarters which the staff had occupied for more than ten months. By summer of 1975 the staff were providing some ongoing therapeutic treatment services in addition to the intake and crisis intervention ser- vices they had always delivered. Group therapy sessions for mothers and adolescents and couples counseling were the primary modes of treatment offered. Time for provision of treatment was in part made available after reorganization of the staff, which placed two of the social workers into an intake unit with the remaining four in a treatment unit. However, sig- nificant staff turnover (without replacement), which began in November and did not end until the beginning of the third project year, necessitated the eventual disbanding of the intake unit and the cessation of most therapeutic treatment services. Third Year Summary By June of 1976 the staff, which had shrunk to two workers, had all been replaced and the project operated for most of its third year with a full staff. Therapeutic treatment services were provided to some project clients through referral agreements worked out with the local Mental Health Centers and through a contractual, purchase-of-service arrangement with a private counseling service. Near the end of the third year of federal funding, the project again began providing its own regularized therapeutic counseling to some parent-clients. The Center's Advisory Board was very successful in 1976 and 1977. Passage of a new state law on termination of parental rights, the develop- ment of an emergency sheiter care facility for children two years and older, and incorporation as the Baton Rouge Council for Child Protection were III.6 three significant accomplishments. The public education effort of the Center was expanded in the third year. A team made up of a social worker, a consulting lawyer and the pedia- trician, as well as the director and public education specialist, would together make presentations to community groups. IV. ORGANIZATION/STAFFING The project grant was awarded to the State Department of Education, Bureau of Early Childhood Development, which acted as fiscal agent and re- served the right to review all project contracts. Bureau of Early Child- hood Development staff also provided technical assistance to the Center, particularly in matters of public education, and served in an advisory capacity as the need arose. In addition, the project shared one staff position with the Bureau's local office, the Baton Rouge 4-C's. The Department of Education contracted with the state office of the Division of Family Services to operate the project. The Center used the state's reporting procedure for its record keeping and hired through the state civil service system. Also, the project received some funds from the state office; state money paid the salaries of the supervisor and two of the six social workers. Because of the model mandated by state law, the project was also directly linked to Earl K. Long Hospital. One of the Center staff members, the pediatrician, was housed at the Hospital and the Center's facility was on the Hospital grounds, giving project staff immediate access to Hospital services. II1.7 Although the project staff was not technically responsible to the Advisory Board, this group, made up of representatives of various community agencies and interested professionals, provided guidance and direction. The Board, approximately 30 in number, was divided into six committees. Each committee met regularly; the Board as a whole met every other month. The six committees were the Policy Advisory Committee, the Emergency Shelter Care Committee, the Legislative Committee, the Public Awareness Committee, the Resource Committee, and the Comprehensive Emergency Ser- vices Committee. As illustrated in Figure 1, the Center, when fully operating, had three full-time and one part-time staff, and two regular consultants. Figure 1: Organizational Chart e Legal consultant State, Division of Family Services e Psychological consultant Public Education Specialist Child Protection Half-time Center Director Pediatrician Supervisor | Six Social Homemaker Administrative Workers Assistant Two Secretaries 8 III 111.9 VY. PROGRAM COMPONENTS Community Education The Center's director and pediatrician both were responsible to some degree for representing the project when invited to speak on radio and television or to the various charitable, voluntary, church and profes- sional groups in the community; however, the full-time public education specialist was primarily in charge of the extensive community mim, effort. In addition to public presentations, a working relationship was developed with the local media which paid off in the form of feature stories, free public service announcements and billboard space. A . chure and information packet about child abuse and the Center's work was widely distributed. Beginning in early 1977, a team of Center staff and consultants began making community presentations, rather than one staff member at a time, as previously. Professional Education In the first year, the project's primary professional education effort was provided by the staff pediatrician for Earl K. Long Hospital's house staff. Also, as mentioned previously, a three-day area workshop on the dynamics of abuse was held for people in the fields of social work, medi- cine, law and law enforcement. In the project's second year, many presen- tations were made by staff to a range of professionals who requested in-service education and training on child abuse. This ad hoc approach continued throughout the third year, with the exception of a more concerted effort to specifically reach school personnel. 111.10 Coordination After an initial round of visits to a core of agencies that it was hoped would work with the new project, the first Center director then kept in contact with these agencies, either informally, with regard to specific case referral requests, or more formally, in attendance at community-wide policy and planning meetings. During the course of the three demonstra- tion years of the project, several agreements were made to formalize interaction between the Center and other agencies; the School Board, Sheriff's Department, the parish office of the Division of Family Services, the City-Parish Family Court, Earl K. Long Hospital, the two local Mental Health Centers, and the Health Department all made agreements with the Center. Also, during the last demonstration year, a purchase of services contract was worked out with a private family counseling agency whereby the agency would accept a specified number of Center referrals. Another focus of the Center's coordination activity was its Advisory Board, which provided the Center with a broad base of community support and lobbied for community awareness regarding the needs of abused and neglected children and their parents. In addition, the Board can be credited with assisting in the successful negotiations for emergency shelter placement facilities, which were non-existent in Baton Rouge prior to the project. Legislation and Policy People associated with the Center, either as staff or as Board mem- bers, were prime movers in promoting the changes in Louisiana's abuse and neglect reporting law that brought the state into compliance with the fed- eral Child Protection Act. In addition, the Advisory Board's Legislative 111.11 Committee successfully managed passage of a new state Termination of Parental Rights Act, making it less difficult to initiate and complete the termination process. Intake and Initial Diagnosis The project supervisor handled all incoming calls during regular hours, and assigned a social worker to assess the situation further. If the call was urgent, it was automatically given to the worker on call that day. The worker made an immediate home visit and determined any necessary action. If the report appeared to be less severe, the case was assigned to a worker on the basis of workload and expertise in handling certain types of cases. The Center provided 24-hour coverage for the reporting of suspected cases; the social workers rotated this responsi- bility. Because of the Center's tie to Earl K. Long Hospital, all children in need of medical attention were brought in by the parents and/or the. project social workers and given priority. If it was determined that re- turning a child to the home might be dangercus, and no emergency placement was found, the child was admitted to the hospital on a short-term basis whether or not such action was medically necessary. Complicated cases, those taken through the court or those involving several people and agencies, were addressed at multidisciplinary disposi- tional conferences held once a week. These meetings brought together Center staff as well as consultants who suggested a diagnosis and recom- mended a plan of action. 111.12 Case Management The six social workers were responsible for providing or arranging for the services that clients needed to facilitate stabilization of their lives, such as day care, food stamps and other public assistance. If cases were determined to need court intervention, then reports and testi- mony were prepared. All cases in the ongoing caseload were reviewed periodically with the Center supervisor; if the case was particularly difficult, a staffing was held. Treatment Individual Counseling: most regular ongoing counseling for Center clients was provided by referral, either at a Mental Health Center or at Family Counseling Services, under contract to the project. Center social workers also provided counseling for some clients who required only short- term treatment. Crisis Intervention: most contact with clients, once the intake pro- cess had been completed, the family situation stabilized, and necessary support services or counseling arranged, came at times when new family crises arose. The social workers, available to their clients at all times, responded immediately to critical situations and provided the necessary advice, support and referral until the crisis had passed, thereby attempt- ing to prevent potential reabuse. Medical Care: the project's proximity to and special relationship with Earl K. Long Hospital meant that medical care for children of clients could be easily arranged. The project's pediatrician provided any neces- sary medical attention. 111.13 Homemaking: the homemaker was a vital part of the Center's services from the outset. She filled two roles: for some families she provided one-time-only assistance in the form of babysitting or transportation to appointments; however, her most important function was that of a friend and advocate to those families with whom she worked for several weeks or even months. For ongoing cases, she visited the home once or twice a week, helping with household activities and acting as a teacher and role model for mothers who were not able to cope with their situations. VI. IMPLEMENTATION/OPERATION PROBLEMS Implementation Issues (First Year) Defining the caseload: at first, it was planned that the Center would provide services to all abuse and neglect cases in the parish. The project was to carry out intake and keep clients in treatment for a short term (about three months). It was expected that in that time, the clients’ lives would have become stabilized and the cases could be transferred to the Protective Services Unit for limited services and monitoring. However, after the Center bégan taking clients, it became clear that the initial four social workers could not handle all the referrals and also provide ongoing direct treatment. Moreover, it was not feasible, in most cases, to keep clients for only three months, since the worker needed this amount of time just to begin establishing a trusting relationship with the client. Several alternatives were considered: (1) the Center could reorient its work toward intake and crisis intervention only and cases could be moved to the Protective Services Unit as soon as possible, thereby allow- ing a faster turnover of cases; (2) the Center could ask the parish office oT 111.14 of the Division of Family Services to verify all instances of suspected abuse and neglect identified in its caseload before the cases were referred to the project for intake; (3) a volunteer program could be started to pro- vide more assistance in working with clients; (4) the staff could be in- creased; or (5) the parish Protective Services Unit could alleviate the caseload burden by handling neglect cases while the Center handled only abuse. Over time, the project managed the demand with a combination of some of the alternatives under consideration. A social worker was added when the caseload became overtaxing. When that action proved inadequate, an agreement was worked out with the Protective Services Unit whereby it began taking neglect cases again -- after the state office of the Division of Family Services promised the Unit additional workers. And finally, project-provided therapeutic services were curtailed and referral arrange- ments to outside agencies for such services set up. Hiring a supervisor: the original proposal's budget did not call for a casework supervisor; consequently the project director initially assumed this role in addition to her other responsibilities. Since the number of cases rose appreciably in the first two months, the director was inundated by the workload and saw the impossibility of maintaining a dual role. She immediately requested funding for a supervisor position, and because it had not been budgeted originally, Division of Family Ser- vices funds had to be used. In retrospect, it was thought that if the project had not begun accepting referrals until after the supervisor had been hired, the inefficient handling of cases during the first few months of the project's operation could have been prevented. 111.15 Heavy workload: the Center's public education and information effort was extremely successful, due, in part, to having a full-time public edu- cation specialist on the staff. The intense level of educational activi- ties led to a large number of cases per worker almost from the beginning and, even with the addition of new workers, the caseload reached 28 cases per worker in March of 1975. This caseload size was contradictory to the project proposal which called for no more than 20 cases per worker, in order to allow time for ongoing treatment and 24-hour coverage. Heavy use of the after-hours service added to the workload. The workers ex- pressed concern that they were not adequately compensated for the restric- tions and disruptions 24-hour duty caused in their lives. Frustration caused staff morale to drop to a point that changes had to be made. The project began taking abuse cases only and added a sixth worker, to share the cases and the 24-hour coverage. And, the state was finally convinced to provide more liberal compensation for night and weekend on-call work. Temporary facilities: from its inception the project had intended to be housed at Earl K. Long Hospital. When it was learned that the planned facility would not be available, a temporary place was found at area office of the Division of Family Services. The temporary offices proved to be a continuous source of strain because was inadequate, with all social workers crowded into one large room and, by the third or fourth month, the staff had a sense of overstaying its welcome. Lack of space | also meant lack of privacy for client interviewing, which impeded open communication between caseworker and client. Red tape at the state level ‘and complicated state building codes delayed the move until May 1975. III.16 Lack of child placement facilities: from the outset the project faced a lack of placement facilities for children. There was no emergency shelter care and the supply of foster homes and day care facilities was inadequate. Although the Foster Care Unit of the Division of Family Ser- vices is responsible for maintaining an adequate number of foster homes, the Center had difficulty in getting more than a few placements. Earl K. Long Hospital served to ease the situation somewhat through its agreement to keep children in the hospital until placements were found, even though their stay was not medically required. The project, through its staff and Advisory Board, finally alleviated this problem to some extent by bringing it to the attention of the community and searching for appropriate sponsors and facilities. Coordination with key community agencies: The parish office of the Division of Family Services during the first year of project operation had a strained relationship with the Center. Speculation about the causes of this tension included the following: traditional methods of bureau- cracy being disturbed by the new project, with its special attention and experimental status; a sense of competition arising from the Center being under the direct jurisdiction of the state office of the Division of Family Services instead of the parish office; and/or the project not agreeing to handle cases of abuse and neglect when the workload exceeded the 20 cases per worker stipulated by the grant, a luxury which the parish office staff had never had. The Foster Care Unit of the parish office was parti- cularly resistant because the Center placed increased demands on their limited number of foster care homes. Over time, the relationship improved due to continuous communication between the Center and the parish office. 11.17 Working with the Baton Rouge schools was also difficult during the first year. After a round of presentations by Center staff to school ad- ministrators, it was discovered that information was not disseminated to the classroom teachers, who are vital reporting sources. Teachers ex- pressed reluctance to report suspected cases; some believed reporting would jeopardize their relationship with the parents, and others believed the project was ineffectual when it did not always have the reported child removed from the home. Besides the problem of failure to report cases, the lack of trust on the part of the schools was an issue that the Center had to address. Direct education of classroom teachers became a priority. By the end of the initial year of the project, an agreement with the School Board called for classroom teachers to report to visiting teachers (school counselors) on suspected cases and the visiting teachers would report to the Center. Operation Issues (Second and Third Years) Use of volunteers: during the first year the Center accumulated names of people who had volunteered their services. After the project's program was well underway, it was decided to organize the volunteers. Several weekly orientation meetings were held, individual screening took place isolating the specific interests of each volunteer, and then inten- sive training was carried out. However, using volunteers effectively proved to be difficult. Every social worker was given a list of names and phone numbers, but they soon found that most of the volunteers worked during the day and were not available when it was most critical or on short notice. Further, the type of work that the volunteers seemed to prefer, i.e., playing with children, was not as critical as some of the I1I.18 other tasks which the social workers had identified as appropriate to their needs. It became apparent that a large amount of paid staff time was necessary to successfully coordinate and define roles for volunteers, and without this support, volunteer assistance ceased by the middle of the second year. The Center hoped that there could be a useful role for volun- teers, but a new, concerted effort would be required to use them effectively. Staff turnover: loss of staff in the second year left a major void in the project's operation. Two of the social workers left in November 1975, the director left in December of that year, the supervisor who was also acting director left in March of 1976, and two other social workers left in the spring. All of these staff losses were without replacement for an extended period. Lack of staff led to several restrictions, includ- ing a moratorium on community public relations and education because there was not enough staff to handle referrals generated by these activities. Also, the social workers, drained from handling crises and intakes, could no longer provide ongoing therapeutic treatment, and these activities stopped. The shortage led to the closing or transferring of many cases (possibly prematurely), with the remaining two social workers and super- visor carrying very large caseloads. The state office of the Division of Family Services and the State Civil Services Board were reluctant to make exceptions in hiring requirements (credentials, experience or salary level) and, therefore, it was not until spring of 1976 when the Louisiana State University School of Social Work graduated a new class that there were people who met the job qualifications as well as were willing, because of a tight labor market, to accept the positions. 111.19 Provision of treatment services: during the last project year, par- ticularly with the filling of all staff positions, there was pressure on the staff to resume provision of regular treatment services. The major problem was a lack of on-site space for treatment sessions, although this would change with the planned move to new, larger offices. In the mean- time, referral arrangements for counseling were made with a private agency, as well as with a private psychiatrist. Some staff believed that crisis intervention and limited individual counseling, in addition to thorough intake, was all that the Center could and should provide, while others were pushing for freeing up time from intake and other responsibilities in order to begin to see clients for regular, therapeutic treatment. VII. FUTURE PLANS The state Division of Family Services committed funds for the con- tinuation of the Child Protection Center beyond the expiration of federal funding. Since the Center in Baton Rouge is one of several such programs throughout the state, it is no surprise that it is being maintained in | close to its present form. Only one staffing change oécurred due to more restrictive budgeting -- the public education specialist position was not picked up. The major unresolved issue, however, is administrative responsibility for the Center, presently directly under the state office of the Division of Family Services. While there had been some moves in the past to place the Center under the Division of Hospitals, the umbrella agency that operates Earl K. Long Hospital, the real pressure has been to move juris- diction to the parish office of the Division of Family Services. Strong I11.20 opposition has developed to this proposed change in affiliation, but a final decision has not yet been made. VIII. PROJECT GOALS Goal 1: To provide expeditious intervention for and disposition of child abuse referrals. Overall, in the first year of the project considerable gains were made toward reaching this goal. First of all, criteria for the type of intakes accepted were worked out. Developing a smooth working relation- ship with its host institution, Earl K. Long Hospital, was another step that the project took to facilitate response to abuse reports. Provision of 24-hour coverage for incoming reports also contributed to efficient and effective intake. The final action that the project undertook towards specifically meeting this goal was to set up a mechanism for multidisci- plinary dispositional conferences. By the fall of 1975, 90% of the refer- rals were responded to within 24 hours and the entire intake process, including psychological evaluations and dispositionals, were completed in three to four weeks for more than 80% of the cases. By the end of the second year, due to the severe staff shortage, it was clear that the project was almost no further ahead in terms of provid- ing expeditious intake than at a point just four or five months after the beginning of operation. Response time to referrals and the length of time to complete intake fell off markedly. However, at the beginning of the third year all positions were filled and new staff oriented and trained. This meant that the project again was checking on referrals promptly and completing most intakes in less than a month. 111.21 Goal 2: To improve client functioning by developing a variety of treatment approaches for child abuse. Soon after the project successfully set in motion its investigation and intake procedures it began to establish several treatment services aimed at abuse clients. It was to be the implementation of innovative direct treatments, along with the multidimensional intake process and the community and coordination activities, that would serve to distinguish this as a demonstration project. Over a several-month period during the first project year, some treatment services were introduced, but for the most part these services were used for only a limited number of clients and, at the end of the demonstration period, the project staff was providing no therapy except individual counseling. The project provided, however, since its begin- ning a useful and successful support service to many of .its clients, that of homemaking. The homemaker served as a key resource to families in need of household management assistance and/or respite from child care. Goal 3: To foster coordinated community-wide child abuse services. The efforts on the part of the project's director, during the initial months of operation, to incorporate the Center into the existing abuse services network and to expand the service resource network paid off in terms of improving communication among the various agencies. Establish- ing procedural protocols with some key agencies, and regular attendance by project staff at meetings to encourage the development of new community resources contributed toward a more coordinated system. The lack of administrative leadership during the second project year meant little of the necessary follow-through for maintaining the coordi- native arrangements set in motion, so that some working relationships 111.22 never really took effect in practice or, if they did, they began to break down. However, some of the results of the early coordinative work did last, particularly as evidenced by the effective functioning of the Cen- ter's Advisory Board. And, with the addition of new staff in the third year, renewed efforts developed new resources for abuse clients, including emergency shelter care facilities for children two years and older, an expanded referral agreement with the Mental Health Centers, and a purchase- of-service arrangement with a private counseling service. Goal 4: To integrate physicians and certain other professionals into the child abuse services system by directing education efforts toward these targeted groups. Following a three-day workshop in April 1975 for the Baton Rouge pro- fessional community, the project took steps toward organizing a concerted effort to reach certain groups, i.e., physicians, school personnel (pri- marily teachers) and law enforcement officers. The project's second year refunding proposal set out a detailed plan to reach the physician community by approaching them through their professional organizations and through the private hospitals, particularly through emergency rooms. A systematic approach for reaching schools was also spelled out. Again, due to staff shortages during the second year, actual organ- ized implementation of the professional education component was held up. While the targeted professional groups were not contacted as planned, there was always a willingness on the part of project staff to respond to all requests to make presentations at symposiums, professional meet- ings, other agencies' in-service training and to students in professional training. I11.23 In terms of impact, private physicians were still, for the most part, operating apart from the rest of the child abuse service system. With the other targeted professions -- school personnel and law enforcement officers -- more progress was noticed in terms of their understanding of child abuse and the project's role in handling reports. Goal 5: To develop training programs for greater community awareness and understanding of the dynamics of child abuse and of child rearing in general. A full-time public education specialist, plus other project staff, spent a significant amount of time in working toward achievement of this goal. It is always difficult to determine the real outcome of these edu- cation efforts in terms of greater awareness and knowledge on the part of the community. Certainly, personnel in the various abuse-related agencies throughout the parish perceived that the general public was more aware in 1977 of the child abuse situation and how to respond to a case of suspected abuse. Another method for looking at achievement of this goal (i.e., actual new awareness and understanding of abuse) is increase in reporting from the general community. Between 1974, when the project began its educa- tion, and 1976, reports from relatives, acquaintances and anonymous per- sons to the project and to the Protective Services Unit increased from 52 reports in 1974 to 153 in 1975, and then fell slightly to 134 in 1976. From these data it appeared that the general public in Baton Rouge became more aware of child abuse and where to report. The project did not carry out any planned activity toward changing or improving child rearing practices in general, a stated focus of part of this goal. aE EEN EAL SS 111.24 Goal 6: To improve the project's internal management and support the community need for additional services by gathering and maintaining program statistics. During most of the demonstration period, the project supervisors, already inundated with other responsibilities, were the only persons main- taining program data. While only minimal information was collected to support achievement of this goal, at least one change was effected based on collection and assessment of service statistics: data on need for shelter care was used by project management and the Advisory Board to pressure the state into contracting for emergency placement beds. Toward the end of the demonstration period, maintenance of client data was dele- gated to one of the social workers, who made plans to use the information for program planning purposes. IX. PROJECT MANAGEMENT AND WORKER SATISFACTION Description The Child Protection Center was a relatively small project with a full-time staff of 13 workers. It served an average caseload of 83 clients with an average monthly budget of $13,906. The organizational structure of the project was not complex. There were only four different professional disciplines involved in the program activities: social workers, an attorney, a doctor and a psychologist. A moderate level of diversity characterized the project's activities, which included professional and community education, coordination, and case management responsibilities. 111.25 The project was highly formalized in that the staff were held account- able by the state civil service system for procedures and policies related to recruitment, employment and promotion. The project itself operated fairly informally, e.g., there was no rule manual that defined how the staff members were to relate to each other. Rule observation was rela- tively lax. The project was highly centralized, under the direct supervision of the Division of Family Services, which was ultimately responsible for pro- gram and policy decisions. However, the project operated fairly autono- mously because it was supervised by the state office of the Division of Family Services as opposed to the local parish office. The state office had less time and motivation to monitor the project staff than would have been true of the local parish office. Satisfaction There appeared to be a high degree of ambivalence among project staff regarding the project management and their own job satisfaction. In the management survey, staff reported moderate to high rankings for most of the management dimensions, that is, leadership, innovation, peer cohesion, staff support, autonomy, task orientation, clarity and communication. Although 83% of the staff reported high overall job satisfaction on the written questionnaires, in individual interviews workers stated they were highly dissatisfied with many aspects of their jobs, i.e., the state bureaucracy, the project leadership, and the pressure and stress of work- ing with abusive parents. The project's 62% turnover rate and the staff's reported burnout rate (40% high burnout, defined as those falling in the bottom one-third of an administered "burnout scale') seem to verify that many workers were unhappy with the project and their jobs. Some of the workers' ambivalence about the project could be explained by the particular characteristics of this project staff. For many of the workers, employment in the project was simply a substitute job until oppor- tunities were available in other specialities (e.g., medical social work, planning, juveniles). The project met their immediate needs and WES TR but never really satisfied their interests and expectations. For other social workers, the project offered an opportunity to gain work exper- ience and be eligible for promotional opportunities in more desirable state jobs. Most of the social workers reported that they did not believe anyone could work with abusive parents beyond a year and a half. They accepted the job knowing that they would leave or burn out in a year. Management Issues In addition to the staff characteristics there were a number of management problems that contributed to and speeded up burnout and turn- over among project staff. The majority of the workers were recent MSW graduates with new professional values and expectations. The project was their first job out of school and they were struggling against the state bureaucracy and limitations in the system. The battle produced substan- tial disillusionment with the state, project and clients. The project's biggest problem with the bureaucracy occurred during the first year. In order to implement 24-hour coverage, develop coordi- nation and referral agreements, and provide community education, many of the workers reported working over ten hours a day. They felt that the state should reimburse them for this excessive overtime. The staff's initial requests were ignored. Finally, the workers filed a formal 111.27 grievance, and after some delay were given an official agreement on over- time compensation. Another problem the staff experienced with the civil service system occurred in the second year. Because the state never communicated clear- ly its civil service and hiring procedures and because of system errors, workers employed during the second year on emergency appointments were not placed on the official job registry and therefore were unable to collect overtime compensation, were bypassed for raises and workers' bene- fits, and were required to take several state tests. The most frustrating aspect for the workers was that they never had the correct information to negotiate for their own rights effectively. Some of these newly hired workers remained with the project only about four months, leaving as soon as they had located jobs in other community agencies. Internal staff dynamics also served to limit the project's effective- ness during part of the second and third years. After being with the pro- ject a little over one year, the project director accepted a promotion to the state office. Most staff by that time were beginning to feel strain from their work. Most had been in graduate school together and had developed a comaraderie that both enhanced and was detrimental to their work experience. The workers who also socialized together found them- ‘selves talking about project and clients all the time and they began to identify more with each others' work crises than with the clients who were in crisis. The staff had made a comni tment to each other and to the director to work with the project at least two years, but when the direc- tor announced that she was leaving, others interpreted this as permission to leave also. II1.28 The supervisor was appointed acting director and was required to do both administration and supervision until the director's position could be filled. Unfortunately, the state office was unable to find anyone who wanted the director's job and would not appoint the acting director because of a civil service technicality. No one in the state system wanted the job because of the expected workload and because the staff were reputed to be demanding. The acting director left within months, discouraged with the dual job stresses and the unresponsiveness of the bureaucracy. Most of the remaining workers followed suit and only two social workers were left by May 1976. For nearly six months all regular treatment services were dis- continued and the project was severely crippled. Finally, in response to pressure from the funder, the state began to assume a more active role in recruiting staff. By this time the new class of MSWs had graduated from the local university and were willing to work in the project. In the mean- time a supervisor from the State Juvenile Shelter applied for the project director's position. The project was completely restaffed by August 1976. The new director, with limited child abuse experience, was not given any orientation to the project or staff, and did not receive any training for the position. When he took the job, he and the remaining staff mem- bers who had stayed with the project from the beginning and who had helped manage the program since the acting director left in March, did not have a clear idea of what his role and responsibilities in the project were. Consequently, the staff and the project director were soon in conflict. There were formal weekly staff meetings, but no one was willing to broach the topic of staff discomforts. Instead, workers often spent many hours 111.29 venting complaints; energy needed for serving clients was displaced on the internal project conflict. There was no one in the project or in the state office who was willing to facilitate the resolution of the staff difficulties. Consequently, staff turmoil interfered with project pro- ductivity. Even after the project was fully staffed, most of the inno- vative treatment programs were not reinstated, client crises became more debilitating to workers, and they felt continuously overworked. X. ANALYSIS OF CLIENT DATA Client Flow The prospective client first came to the attention of the Center through reports from one of several sources, primarily law enforcement agencies, the parish office of the Division of Family Services, and schools. Neighbors and relatives also reported many suspected occurrences of abuse. All incoming phone calls went to the Center's supervisor and he or she recorded essential information about the nature of the complaint and the source of referral, and then attempted to sort out the validity and ser- iousness of the complaint. Calls from agencies were routinely investigated, but calls from individuals were screened over the phone, weeding out those that involved family or neighborhood altercations or were otherwise in- appropriate for the project caseload. Situations that appeared to be strictly neglect cases were referred to the Division of Family Services, since the Center handled only abuse cases. If there was any doubt about the validity of a referral, the super- visor sent the social worker on-call that day to investigate the matter. II1.30 When the report appeared to be urgent, a worker responded within 24 hours; otherwise, up to two weeks or more might pass in some instances before an initial contact was made. The intake investigation involved a home visit in order to talk to the alleged abuser and, to the extent possible, to the rest of the family. Others, including the reporting source, also might be interviewed for pertinent information. If the social worker believed the abused child was in immediate danger, the child was taken out of the home, most often to Earl K. Long Hospital for examination and a temporary "hold." If the family needed financial, legal or health and welfare assis- tance, the appropriate advocacy services were arranged while intake was in progress. For many clients, psychological examinations were also scheduled. Depending on the complexity of the case and the number of other agen- cies involved, the diagnosis and treatment planning process could take two or three weeks. As mentioned earlier, consultants were called upon when a case necessitated either legal or psychological advice and a multidis- ciplinary review might have been held if so warranted. The court became involved if change of custody was recommended for the abused child(ren). If the court ordered foster care, the entire case was transferred to the Foster Care Unit of the Division of Family Services. In addition to case management and individual counseling, the Center itself offered homemaking for clients. Referral for treatment could also be arranged. Cases were reassessed periodically at a meeting between the social worker and supervisor. Length of treatment depended on the posi- tive changes in the family situation. Termination from the project took two forms. If the social worker and supervisor agreed that no more services were necessary or if a client 111.31 moved from the parish, the case was closed; if some monitoring of the family was considered important, the case was transferred to the Protective Services Unit of the Division of Family Services. No formal follow-up procedure had been adopted, but terminated clients were reminded about the project's 24- hour coverage and were encouraged to contact the Center whenever they needed assistance. Client Characteristics The description that follows of the project's caseload is based on data from cases that were both substantiated and accepted for ongoing ser- vices. This means that the picture presented here does not include those cases that, after investigation, were found to be unsubstantiated, those for which intake was not completed, and those that were open a month or less. The largest source of reports to the project by far were from schools (27%). Law enforcement agencies, hospitals and relatives were the next most common reporting sources; 18%, 17% and 16%, respectively. Only 2% of the cases were self referrals. Almost half (49%) of the Child Protection Center cases involved phy- sical abuse alone, with another 14% involving sexual abuse. Comparatively, the relatively small percentage of physical neglect, emotional maltreat- ment and potential abuse or neglect cases reflects the project's evolving acceptance criteria, from taking all abuse and neglect cases initially to limiting their intakes to physical or sexual abuse only. In looking at the project cases in another way, 27% included assault (that is, severe or moderate abuse and/or neglect, including sexual abuse). 111.32 The mother or mother substitute was responsible for the maltreatment 50% of the time, with the father responsible 35% of the time, and both father and mother liable in 13% of the cases. No legal action was taken in 25% of the cases; however, formal court hearings were held 10% of the time. Reports to another mandated agency occurred 21% of the time and to the Central Registry 30% of the time. Seventy-nine percent of the cases had no record of previous abuse or neglect before being reported to the project. | For 28% of the project's cases only one adult was in the household. The average client family had 2.6 children and 66% of the families had preschool children (six years or younger). The project families had a low level of education; 73% did not have even high school degrees repre- sented. In 59% of the cases there were no ethnic minorities in the families, while in 31% of the cases there were no employed adults in the household. Whereas 57% of the families had incomes under $5500 per year, only 28% of the families were on public assistance. The average age of the mothers in caseload families was 30 years and the fathers 33 years. In 45% of the cases there was at least one teenage parent. The most prevalent problems in the household leading to maltreatment of the children were financial, marital, and continuous child care respon- sibilities. Job related and mental health problems also appeared rela- tively important as contributors to child maltreatment. 111.33 Table 1 Client Characteristics Source of Referral Private physician . « + « +» » + » 2% Hospital: « + « » v uw 17% Social service agency . 11% School. . . v .27% Law enforcement . . .18% Court « « » « = a % 5s # 3:9 » » » 13 Parent. . « « » +» s # + » = » +» 2 5% Sibling . + vv + vv vv vv. . 0 Relative. . . cs B® .16% Acquaintance /neighbor + 0 ow x x un 3% Self, « « + « 4 » 5s % 5 nu # wx » 2% Anonymous . . . . . +. + « « « . . 5% Other.agency. . . . . . . . + +. . 3% Type of Maltreatment Potential abuse or neglect only . 9% Emotional maltreatment only . . 6% Sexual abuse. . « + « « + + .14% Physical abuse. . . . . . . . . .49% Physical neglect. . ' .18% Physical abuse and neglect. . 4% Severity of Assault Not serious . .73% Serious . .27% Responsibility for Maltreatment Mother. « « + + « © 4 2 5 » « = +50% Father. « « « a « wo » » 5 » v #359 Both: i « « « 4 = 3 5» » = ® » 13% Other » + 5 + ss 5 2 os w =» » » 3% Legal Actions Taken None. . . . “WB ow wm +25% Court hearing “ LW 10% Reported to mandated agency co. 021% Reported to central registry. . .30% Previous Record/Evidence of Maltreatment None. . . . : ® Previous record/evidence. Demographic Information Average number of children in Family « + © ¢ « + « « ow © » » Families with preschoolers. Families with one adult . . . Families with no high school degree . « + 5 wv + ov vow 6 wu Families with no minorities . Families with no one employed . Families with less than $5500 per year . . . tn Bump i Average family income . . . . . Average age of mothers. . . . Average age of fathers. . . . . Families with teenage parent. Problems in Household Leading to Maltreatment Marital . wl Ee ew ee Job related . « «+ + 2" ¢ « 5.5 i» Alcoholism. o « « .« « + + =» = » Drugs . ERE Physical health TEE EEE Mental health . + « « « + + New baby. i o « » 5 oo 2 » = = » Arguinent/Eight. + « « © v = » » Financial problems. . « +. ... Mentally retarded parent. . . Pregnancy . . v & = wow Heavy continuous "child care . Physical spouse abuse . Recent relocation . . . . . . Overcrowded housing . . . . Abused as child . . . . . Normal method of discipline : Social isolation. . . . . . . (N=131) .79% .21% « 2.6 .66% .28% .73% .59% +31% .57% .$7,400 .30 yrs. +33 yrs. .45% 41% .24% . 8% . 2% .16% 24% 11% .18% 46% . 5% . 2% +39% .10% .16% 11% .16% .14% .15% IIT.34 Quality of Case Management The information collected for the case management assessment indicated that the project provided, in most instances, better than average intake compared to the norm of all the demonstrations combined. Thirty-three per- cent of the cases sampled for the assessment were contacted within the same day as the report; an additional 24% were contacted within three days. How- ever, 19% of the cases reviewed were not contacted until over one month from the date of the incoming report. Many of the cases not responded to until over a month later turned out to be suspected mild neglect reports that had been trasferred all together to the project early in its operation, after being backlogged at the Protective Services Unit -- they continued to be backlogged at the Center. Thirty-eight percent of the sampled cases showed at least one additional contact with the client before a treatment plan was completed, and a full 50% had two or more such client contacts. This com- pares favorably with the norm across the demonstration projects of 42% of the cases seen two or more times after the initial contact before a treatment plan was determined. In 61% of the cases reviewed, treatment services began within two weeks of the first contact between project and client. On the other hand, a full 25% of the clients received no therapeutic treatment services at all. A portion of the project's cases were formally assessed and reassessed, either by a multidisciplinary review team and/or staffings; 27% had at least one multidiscipliinary team review and 42% were reviewed in case con- ferences or staffings at least once. For one-third cf the reviewed cases, an outside consultant (e.g., lawyer, psychologist, etc.) was used. There was only minimal direct client participation (7%) in the case management 111.35 process, as measured by client presence at a multidisciplinary review or a case conference. For 84% of the cases, the primary case manager interviewed for the assessment also carried out the intake. This reflects the fact that the project's intake unit was short-lived. Whereas 32% of the clients had no other project staff member working with them besides the case mana- ger, the remaining 68% did. In most cases this meant that the project's homemaker was one of the other project staff members assigned during the course of treatment and often the project supervisor provided temporary counseling and crisis intervention to clients as well as the case mana- ger. Some short-term therapeutic groups also included some of the clients. Of the clients in the sampled cases, 64% were also receiving services from outside agencies. Of these, there was evidence of communication with these agencies regarding the client and his/her progress 93% of the time. Twenty percent of the project's cases were active for three months or less. About two-thirds were open 4-12 months, and 13% were open between 1-2 years. Following termination, in 56% of the cases at least one follow- up contact was made either with the client or with another agency from which the client was receiving services. 111.36 Table 2 Case Management Characteristics* Time Between Referral and First Client Participation Client Contact Client presence at MDT's and/or Same day. . . . . . . .. . . . .33% case conferences . . . . . . . . 7% 1-3 days. « « o 4 2 5 » + v5 » 228% Ao7 daYS. « « + % + 0% 3 5s % » 5. 99 Contact with Referral Source . . 0, i ha weeks. tern nn x For background information. . . .84% Over one month trons "19% For progress reports. . . . . . .49% Responsibility for Intake Number of Client Contacts (after initial contact) Before Treatment Current case manager. . . . . . .84% Plan Other staff member. . . . . . . .16% one. Ll l lls Number of Case Managers THO &« « + « + 2 wo w » » # & ».w13% ONE 5 « « » + » #3 5 » # » & » 497% Three-five. . . . . . . . . . . .30% TWO 2 « = 2 v » » + » v» v # & = »13% Over Five . « + « « 5 « » » a # 7% Morethan two . . . . . . . . . . 0 Time Between First Client Contact Reason for Two or More Case Managers and First Treatment Service ; Joint management. . . . . . . =1 Within two weeks. . . . . . . . .61% Staff TUTNIOVEY. « « « + +» « = 2 Two weeks to one month. . . . . . 3% Staff unavailability. . . . . =3 Over one month. . . . . . . . . .11% . Lack of success with client . =0 No treatment given. . . . . . . .25% Other + + + ow « » » #5 5 5 » =3 Use of Multidisciplinary Review Number of Treatment Providers in Team Project (other than case manager) At least one review . . . . . . .27% Nome. « « « 4 4 + « + + 5 » vw =» 432% Review during intake. . . . . . . 4% One « « + +» + » 2 vs » » » » & & 24% Review during treatment . . . . .22% TWO + « » # % vw 5 » » » ® # 5 & +21% Review at termination** . . . . . 0 Three-five. . . . . . . . . . . .20% Over five « « « 4 + 4 » « uw 5 » «= D Use of Case Conferences (staffings) Services from Outside Agencies. .64% At least one conference . . . . .42% Conference during intake. . . . .20% : : ; : Conference during treatment . . .24% Evidence of Communication with 935% Conference at termination** . . .16% Se once vs wr un "N=28 Use of Consultants Frequency of Contact by Case ——————— Managers g Hons. Corn nnn ol Once per week or more . . . . . .36% Teo . » oor rrr 2s Once or twice per month . . . . .22% Three-five. . . . . . . . . RIL Less than once a month. . . . . . 2% over five A Once or twice only. . . . . . . . 4% : ’ Varied over time. . . . . . . . .33% NORE: « % © = & = 8 = # #% 6 » « 2% 111.37 Table 2 (continued) Follow-Up Contacts** Length of Time in Treatment** At least one contact (client/ Through three months, . , . . . .20% other agency). . . . . . . . . .56% 4-12 months . . . . . . . . . . .67% Two or less (with client) . . . .93% 1-2 Yar8 . 4 4 4» » » wee + vw 135% Three-Five, + + ov « v +» wv +» =» =» 4% Over two years. «. » + » + + « + = 0 Over five ©. « ¢ v. ooo %. 04 50 28 * Throughout, percentages may not sum to 100% owing to rounding. * %k Terminated cases only. Total cases reviewed = 45; total terminated cases reviewed = 45, XI. COMMUNITY IMPACT Summary Many positive changes have taken place in the Baton Rouge child abuse and neglect service system since the project began. Three of these changes, however, are most noteworthy. First, a new level of awareness about the magnitude of the abuse and neglect problem led to increased coordination among personnel of the various agencies and to a doubling of the staff in the local Protective Services Unit. Second, the provision of 24-hour crisis intervention by the demonstration project staff provided the general pub- lic and certain reporting agencies (hospitals and law enforcement, pri- marily) immediate access to assistance from trained social workers. The extensive use of the 24-hour call system (25 to 35 calls per month) proved that the service was meeting a tremendous need. And finally, the project's affiliation with Earl K. Long Hospital helped ensure that medical care was provided to many children who otherwise would not have received it. 111.38 Some community-wide problems still need to be resolved before the service system can become fully effective. The most important are the following: the private medical community has not yet met its responsi- bilities in reporting suspected cases; the project needs ongoing support from the state office of the Division of Family Services for maintaining adequate staff capacity; and the Mental Health Centers and the private counseling agency which accept project referrals have not yet worked out an adequate treatment approach for working with abuse and neglect clients. Community System Operations A spirit of informal cooperation among the key agencies characterized the community abuse/neglect services in Baton Rouge prior to the federal funding of the Child Protection Center. The system was not centralized around a single agency, but instead some of the key agencies and institu- tions had evolved a division of responsibilities. Prior to the passage of the 1972 reporting law, the Probation Department of the City-Parish Family Court had the responsibility for handling abuse and neglect cases. In the late 1950s already the Court had worked out an agreement to have the Sheriff's Department conduct the initial investigation on severe cases. With the implementation of the 1972 state reporting law, the Court divided responsibility for abuse and neglect cases with the Division of Family Services; the Court handled those families that did not qualify for pub- lic assistance and the Division of Family Services, Protective Services Unit, handled those who were public assistance recipients. The Family Court was also responsible for filing petitions regarding removal of child- ren from the home. Most petition requests originating from outside the Probation Department came from the Division of Family Services. 111.39 In addition to homemaker services, the Protective Services Unit of the parish office Division of Family Services provided traditional pro- tective services: investigation, counseling and advocacy services. This unit was very short-staffed for the volume of cases reported and, there- fore, following the delivery of services during a family's crisis period, the case was transferred for maintenance to the regular welfare services staff. Foster care was and still is under the jurisdiction of the Division of Family Services. All cases that require placement of the child(ren) when a willing relative or friend cannot be found, are automatically transferred to the Foster Care Unit for ongoing case management and ser- vices. Law enforcement agencies are one of the mandated agencies to which the public can report suspected abuse and neglect, and before the incep- tion of the project, the East Baton Rouge Sheriff's Department was the agency receiving most initial reports in the community. Publicity efforts had encouraged the public as well as other police departments to make re- ferrals to the Sheriff's Department and its Child Abuse Team, which had developed a reputation for effective handling of suspected cases. Their policy was to conduct immediate investigations, but then to call in either the Division of Family Services or the Family Court workers. The city's private hospitals and physicians were very uninvolved in the abuse/neglect services system. However, Earl K. Long Hospital, the local public (charity) hospital, became a leader in the community in pro- viding services. The Chief of the Pediatrics Department at the Hospital was primarily responsible for bringing the problem of abuse and neglect to the attention of the state leadership. He aided in the upgrading of ITI.40- the local service system by developing and urging implementation of the shared responsibility services model which was in effect prior to the Child Protection Center. Total house staff participation in in-service training on recognition of child abuse and neglect, a bi-weekly Pediatric Family Clinic which provides regular follow-up to all hospital-identified abuse and neglect cases, and a policy of providing temporary shelter for children until alternative placement can be found are evidences of the Hospital's commitment to abuse and neglect services. Before the demonstration project began, school personnel were iso- lated from the abuse/neglect services network. Visiting teachers, a special unit handling truancy, were responsible for dealing with abuse and neglect cases discovered in the Baton Rouge schools, although most were not aware of the scope of the problem. These teachers worked with school nurses and social workers in deciding how to proceed in alleviating any situation that arose. If it was decided that a child was seriously en- dangered, a referral was made to either law enforcement, Protective Ser- vices or the Court. Other community service agencies were also removed from the main de- livery system. The two Mental Health Centers and the East Baton Rouge Health Unit (the parish public health department), with resources to acco- modate individual case referrals from the Court or Protective Services, were not knowledgeable about the dimensionz of the abuse and neglect situation. These agencies had no special programs for abuse and neglect, and with minor exceptions, were not a source of reports of suspected cases. 111.41 The state has a Central Registry which began keeping abuse and neglect reports in March of 1973. The Registry uses the American Humane Associa- tion's reporting form and was originally set up to enable protective ser- vices workers to track repeat abusers who were moving around the state. However, little use has been made of it for disposition of individual cases; instead, the Registry data serve primarily as a program planning tool for the Division of Family Services. Over its three years of operation the project became the focal com- munity agency for the handling of abuse cases. Originally, it was planned that the Center would provide parish-wide intake and short-term services (three to six months) for both abuse and neglect cases, but this proved impossible given the ever increasing volume of reports and the limited staff. Therefore, in exchange for increased state funding to fill three more Protective Service slots, the parish office of the Division of Family Services agreed to take all reports and deliver ongoing services to child neglecting clients while the Center would provide those services for child abusing clients. There were, thus, separate entry points into the system, depending on whether the case was one of abuse or neglect. The other abuse/ neglect service agencies had been alerted to this shared role, and for the most part referred appropriately; the general public was given the Center's phone number for reporting purposes, but the Center staff then referred all neglect reports on to Protective Services. Both the Protective Ser- vices Unit and the project used day care, the Mental Health Centers, special school-based learning programs and charitable organizations, such as the Salvation Army and churches for referral of clients for additional III.42 services. The project also had special contractual arrangements with a private counseling agency. The major change in Earl K. Long Hospital's service since the Center began was a reduction in the length of stay (from three to four weeks to less than one week) for abused and neglected children admitted without a medical diagnosis for lack of outside placement possibilities. This was due to the development of two emergency shelter care homes, a few more foster care homes, the concerted efforts on the part of the project staff to find relative placements as soon as possible, and the reduction of the number of available beds at the Hospital. With the project's inception, the Family Court's Probation Department no longer received reports or provided services for abuse and neglect cases. Instead, the Court began acting only in the capacity of holding hearings on cases which require Court involvement, that is, change of custody cases or cases which the social workers believe should have court supervision. Other legal changes in the abuse/neglect system have been: (1) an increase in the number of private or legal aid attorneys in court cases (the project itself contracted for an attorney to regularly consult with its social workers on all court-involved cases); (2) a requirement that only the District Attorney's office (and not the Probation Department) could file petitions on abuse cases; and (3) the development of a procedure whereby judges set specific follow-up dates for review of progress on cases. After the project began, the Sheriff's Department Child Abuse Team continued to be the key child abuse/neglect investigator among the parish law enforcement agencies. The Center and Protective Services almost always called in the Child Abuse Team to accompany them in dangerous situations 111.43 or when a child had to be removed. It was felt that the local police departments, which sometimes must respond to abuse calls, were still not as sensitized to the handling of abuse cases as the Shdériff's Department. The Sheriff's Department also came to rely on the project to a great ex- tent for joint intervention of abuse reports. The Child Abuse Team was dissolved in late 1975, but one of the deputies continued to function as the liaison on abuse calls. The provision of in-service education to several schools by the pro- ject brought school personnel in more contact with the abuse/neglect sys- tem. The School Board adopted a policy to facilitate the handling of abuse and neglect by ensuring that the appropriate visiting teacher was called in on all suspected cases; he or she then reported to either the Center or Protective Services. Caseload Size and Case Outcomes Table 3 illustrates reporting changes in four agencies which are part f of the abuse/neglect system. By extrapolating the Center's five month | experience in 1974 to a full year (66 to 158) it is clear that the volume | of reports to the project jumped considerably from 1974 to 1975. The effects of the project's extensive public education were felt. The drop in reports to the Center in 1976 might be partially explained by the in- crease in reporting to Protective Services Unit during that year when the Unit began handling all neglect cases (for part of 1975, the project accep- ted neglect cases). Another possible explanation is that with the severe staff shortage in early 1976, the project was not able to maintain its high intensity public education effort and community awareness of child abuse and reporting responsibilities diminished. 111.44 The increase in reports from 1974 to 1975 to Earl K. Long Hospital was most likely due to its affiliation and working relationship with the project; the project social workers brought all cases of abuse or neglect needing medical examination to the Hospital, whereas before reports were received from Hospital personnel identifying cases in the emergency room or in clinics. The slight decline in reports from the Hospital between 1975 and 1976 probably reflects the project's corresponding decrease in incoming referrals. Volume of Reports: Table 3 East Baton Rouge Parish Number of Reports Abuse Neglect Total | Agency 1974 1975 1976 | 1974 1975 1976 | 1974 1975 1976 Child Protection Center 252 187 171 | 41% 61 9 66 248 180 Protective Services 26° 4 0 60° 100 168 86 104 168 Earl K. Long Hospital 44 100 127 | 19 65 15 63 165 142 Sheriff's Department gsb 42 22 110° 37 26 163 79 48 #pata since Center opened, August-December 1974. Dpigure extrapolated based on actual data for January- October 1974. There are two probable reasons for the sharp drop in Sheriff's Depart- ment reports. First, the project, through its publicity efforts over the course of three years, spread the word that people should report to it rather than the customary sources, either the Family Court or law enforce- ment. Secondly, the Child Abuse Team in the Sheriff's Department, which III.45 was alert to abuse and neglect situations, was disbanded in late 1975, leading to a decrease in awareness of the problem among the juvenile offi- cers. This meant that fewer cases were identified as either abuse or neglect. Table 4 illustrates referral sources of all abuse and neglect reports (substantiated and unsubstantiated) to the project, Protective Services and the Sheriff's Department. Whereas there were 126 more abuse and ne- glect reports community-wide in 1975 and a drop of 35 in 1976, the sources of reports remained quite consistent. Some minor changes included an in- crease in reports from law enforcement agencies, more cases identified from within the Division of Family Services, and a moderate decline in reporting from relatives. Cases reported to either Protective Services or to the project could be handled with or without Court involvement. Data on cases that were brought to the Family Court showed that 43 abuse or neglect hearings were held during 1975 and 42 such hearings were held in 1976. While there were no data for 1974 or before against which to make comparisons, personnel at the Court believed that since the project's inception there were more formal hearings called, rather than the previous method of informal hear- ings in the judges' chambers. Source of Child Abuse/Neglect Reports: Table 4 East Baton Rouge Parish Agency Reported to: Total to the Three Agencies: Child Protection Protective Sheriff's Center Services Department 1974 1975 1976 Source of Reports 1974" 1975 1976 | 1974" 1975 1976 | 1974 1975 1976 | Number 3% | Number 3 |Number 3% Division of Family Services 13 15 8 14 14 29 0 1 14 27 9 30 7 51 13 Physicians 1 4 3 3 0 0 7 0 0 11 32 4 1 3 1 Hospitals 8 35 25 8 5 13 7 4 0 23 7 45 10 38 9 Law enforcement 7 26 17 3 5 16 2 2 2 12 4 33 8 35 9 Schools 12 32 35 6 5 10 11 7 1 29 9 44 10 46 12 Court 3 6 1 1 5 0 0 3 7 2 2 .5 Other agency 0 0 0 2 4 3 3 0 2 7 1 0 Spouse 3 19 21 3 5 19 31 11 5 37 12 35 8 45 11 Sibling 0 1 0 0 3 0 0 3 0 0 0 7 0 0 Relative 13 44 27 20 29 34 44 11 5 77 24 84 20 66 17 Acquaintance/neighbor 3 38 23 9 13 20 38 14 17 50 16 65 15 60 15 Anonymous 2 13 9 5 16 19 15 19 3 22 7 38 31 8 Self-referral 0 9 10 0 10 2 .5 Other 1 0 1 1 16 Unknown 0 0 0 1 0 14 0 1 n 14 3 0 Total 66 248 180 86 104 168 [163 79 48 315 100 | 431 100 | 396 100 Center opened, August 1974, PRe ferral source figures extrapolated from actual data collected for January-October 1974. 9% III III1.47 For out-of-home placements, cases which the Court must act upon (handled without a formal hearing, however, if all parties agree), the figures as seen in Table 5 show little difference in the number of child- ren placed between 1974 and 1975, but a dramatic increase in placements in 1976. Given that the total number of abuse and neglect reports to the project and Protective Services (the agencies which recommend placement) stayed almost the same between 1975 and 1976 (352 and 348, respectively), it appears that an explanation of this phenomenon is two-fold. foster care and emergency shelter slots were available in the community More and, therefore, children who needed out-of-home placement could be acco- modated, whereas before they could not. Further, there seemed to be an emphasis on the part of the project and Protective Services staffs to advocate out-of-home placements as a solution of choice rather than other modes of intervention and, with the increase in available placement slots, the staff were able to place more children outside the home than previously. Table 5 Foster Care Placement: East Baton Rouge Parish 1974 1975 1976 Number of abused/neglected children placed in foster care 63 69 138 Number of abused/neglected children placed since beginning of year who are returned home 40 25 77 Percentage of abused/neglected children placed since beginning of year who are returned home 63% 36% 56% 111.48 Legislation The project's primary legislative effort was in the area of revising the state's termination of parental rights law. A subcommittee of the Cen- ter Advisory Board, headed by a consulting attorney who was under contract to the project, worked diligently in attempting to loosen up the very re- strictive law, which made it almost impossible to terminate parental rights. In mid-1975 the state legislature passed the new law, which outlined spe- cific steps and time limits for moving toward terminating rights of those natural parents who show no interest in their children's well-being. Community Resources Overall, since the project's inception, there was a general decrease in the number of staff in other key abuse and neglect agencies. Prior to federal funding of the Center, Earl K. Long Hospital had a Child Trauma Team which handled the assessment and disposition of hospital-based abuse and neglect cases. In addition, the Hospital social workers provided social work counseling to identified abuse/neglect cases in inpatient and outpatient treatment. With the advent of the project, a new staff pedia- trician was hired jointly with the Center, to spend half-time directly on abuse and neglect cases. With the development of a successful working relationship between the project and the Hospital, the Trauma Team was dis- banded since it duplicated the Center's work. The Family Court had 17 probation officers spending approximately 10% of their time managing and providing services to abuse and neglect cases prior to the implementation of the project. When the Center began and the Probation Department ended its involvement in handling these types of cases, the number of staff actually working with abuse and neglect cases III.49 in addition to the judges and their staff was reduced to three intake workers who prepared neglect petitions. In 1976 it was decided that these intake workers could no longer legally prepare ncglect petitions and today no probation officers work directly on abuse and neglect cases. Prior to the project's development, the Sheriff Department's Juvenile Division had implemented a Child Abuse Team to coordinate all abuse and neglect investigations. For both internal political reasons and because the members of the team were either transferred or on leave, the Team stopped functioning in the fall of 1975. There are two major exceptions in the general reduction of community agencies' staff for abuse/neglect cases. First, the Protective Services staff almost doubled -- from three workers plus a supervisor in 1974 to six workers plus a supervisor in the spring of 1975. This staff increase was due directly to pressure from the project to divide intake and case management responsibilities with Protective Services after it was dis- ti $l : { ‘covered that there was too great a workload for the Center staff alone. Second, the District Attorney's Office set up a special abuse/neglect sec- tion. One attorney was designated to handle these cases, including the preparation of all petitions. The new abuse and neglect services available in the Baton Rouge com- munity since the beginning of the demonstration have been either directly implemented or supported by the project. A full-time homemaker was on the i Center staff and 24-hour crisis intervention was provided by project social workers to suspected abuse and neglect cases or to clients receiving ongoing i services. Medical care began to be delivered to all reported abused and a neglected children and two emergency shelter care facilities to accomodate TTR i] 111.50 children over two years of age who have to be removed immediately from their dangerous home environments were opened. Community System Coordination Of all the meetings attended by project staff in the course of the project's three years for the purpose of promoting community coordination of agencies and services, over 65% were with a variety of agencies in the community which also identify or provide services to abuse and neglect families, such as schools, law enforcement agencies, hospitals, the Family Court, the District Attorney's Office, and 4-C's. Almost 20% of all coor- dination-related meetings were held with the Division of Family Services, either with the state office or with the local Protective Services Unit. The remaining staff time on coordination activities was spent with legis- lators or with community-wide resource planning groups. Another focus of the Center's coordination activity was its Advisory Board. The Board members put in innumerable hours attending meetings and lobbying for community awareness regarding the needs of abused and neglected children and their parents. Prior to the project's beginning in mid-1974, the East Baton Rouge Parish agencies which were part of the abuse/neglect system had made some formal collaborative agreements among themselves for greater efficiency in handling cases. The Division of Family Services had made referral arrangements with both Earl K. Long Hospital and the Mental Health Centers, and had developed a division of abuse and neglect intake and service re- sponsibilities with the Family Court. The Court had also developed pro- cedural agreements with the School Board, the Sheriff's Department and Earl K. Long Hospital, while local Mental Health Centers had worked out 111.5] a referral mechanism with the School Board. However, the project succeeded in further coordinating the service delivery system in Baton Rouge by means of new collaborative arrangements with a variety of agencies. Table 6 illustrates the formal ties estab- lished. Table 6 Child Protection Center Formal Collaborative Agreements With Division of Family Services, --Division of abuse and neglect Protective Services Unit casework responsibilities With Earl K. Long Hospital --Sharing a staff position (project's pediatrician half-time at the Hos- pital --Procedures for referral to Hospital emergency room --Arrangements for project staff to handle all social work on hospital- ized abuse cases With Family Court --Procedures regarding hold orders With Sheriff's Department --Joint investigation procedures With School Board --Referral and case feedback proce- cures With Mental Health Centers --Referral and case feedback proce- dures With Family Counseling Services --Purchase of services Education and Public Awareness Personnel in the parish abuse/neglect service agencies all believed that both the professional and lay communities were more aware of the child abuse and neglect and what was being done about it than when the Center began its work. Other agencies' staff members contributed to some degree 111.52 to this overall increase in knowledge about child abuse and neglect, how- ever, most of the increase in community awareness could be attributed to the concerted effort of the project staff itself. The project had a full- time public education specialist whose task it was to coordinate the dis- semination of information to the general public. This was accomplished through the use of all aspects of the mass media, and by talks and audio- visual presentations. Other Center staff, primarily the director, also made PreSERERE Ons on abuse and neglect and the project's role in the sys- tem. During the last demonstration year (1976-1977) a team made up of the project pediatrician, the project director, a staff social worker, the public education specialist and a legal consultant visited several schools and other community groups to make presentations. Over the course of the three year demonstration period, approximately 25% of all educational presentations were made to students; another 25% were to community groups, such as civic and religious organizations. School personnel and law enforcement staffs also made up a significant percentage of the total audience of Center education. The major public education to the ongoing educational activities was a three-day workshop in the spring of 1975 for Baton Rouge professionals. XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS This section of the case study is based on data from three sample months during one year (October 1975, April 1976 and October 1976). Staff time per service, including donated time, and budget allocations per ser- vice were collected. It is estimated that the Baton Rouge project staff and consultants put in 20,600 hours over a year's time; this equaled a 9.9 person-year effort, with an average annual budget of $175,500. 111.53 For the client-related services, 27% of the time went into ongoing case management and review activities, 8% went into intake and 6% was put into homemaking. Coordination activities and professional and community education consumed 12% of staff time. Staff development and training acti- vities took up 8% of the time, and general management used, on average, 18% of the time. Budget expenses generally reflect the allocation of staff time, with some noticeable exceptions. Whereas case management took 27% of staff time, it used only 19% of the budget. On the other hand, general management used up 27% of the budget compared to 18% of the time, and medical care consumed 8% of the budget for only 2% of the total staff time. Both general manage- ment and medical care used proportionately large amounts of very expensive time (a physician and a large percentage of the project director) while case management used up comparatively less expensive time (social workers and a high percentage of typists' time to keep up the case records). On average the project staff together did 27 intakes per month and maintained an active caseload of 83 per month. Fifty-two individual coun- seling contacts were made in a given month, which works out to less than one (0.6) per month per case. Many crisis intervention contacts were also made in an average month -- 16 such contacts for clients in intake and 21 ¥ for clients in the active caseload. Other notable monthly outputs included six multidisciplinary reviews (one to two at each of the weekly meetings of the team), 20 homemaking contacts (about one per working day per month), and 21 medical visits (again, about one per day). The average of 19 rides provided per month cannot be considered typical, because it is the result of 40 rides provided in October 1975 when the project had an active volun- teer component to a low of three in October 1976. III.54 Table 7 displays two unit cost figures; one based on actual budget dollars per unit of service delivered, the other based on "social dollars," or actual budget dollars plus a dollar value for donated time and resources (e.g., volunteers, including students, and consultants who were reimbursed at less than their going rate). In general, there were only minimal dif- ferences between the two figures for the Center, due to a relatively limited volunteer component. Most of the differences between the two unit costs for direct client services are accounted for by a social work student who worked at the project for her placement. In actual dollars, an intake cost the project $36.54 per month and carrying one case cost $35.22 per month. Some of the more expensive ser- vices were court case activities, which cost $175.40 per case (this included the use of a consulting lawyer), multidisciplinary team reviews at $67.63 per review (many staff and consultants met to review only a limited number of cases), and medical care at $90.48 per visit (this suggests under-utilizing the staff physician who was paid a flat rate regardless of the number of children brought in). The homemaking unit cost might seem high ($21.46), but it must be pointed out that a typical homemaking contact for the pro- ject most often included the better part of one day. Table 7: 111.55 Project Resource Allocation and Service Costs wat 4 ade Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation [Allocation | Average Monthly Volume | Unit Cost | to Community Community Education 3% 3% Professional Education 6 5 Coordination 3 3 Staff Development/Training 8 7 Program Planning/Development 1 1 General Management 18 27 Project Research 1 1 BPA Evaluation 2 2 Qutreach -- - 3 cases $12.85 $16.98 Intake/Initial Diagnosis 8 6 27 intakes 36.54 40.54 Case Management Review 27 19 83 average caseload 35.22 36.99 Court Case Activities 2 3 3 cases 175.40 175.40 Crisis Intervention During Intake 2 2 16 contacts 7.83 7.83 Multidisciplinary Team Review 2 3 6 reviews 67.63 71.30 Individual Counseling 3 2 52 contacts 4.98 5.69 Couples Counseling? -- -- 14 contacts 3.75 3.75 Family Counseling -- -- 10 contacts 11.11 11.11 Individual Therapy? -- -- 16 contacts 9.84 9.84 Crisis Intervention After Intake 1 2 21 contacts 5.16 5.16 Homemaking 6 3 20 contacts 21.46 21.46 Medical Care . 8 21 visits 90.48 90.48 Babysitting/Child Care? 3 2 110 child-hours 1.06 1.06 Transportation/Waiting 2 1 19 rides 17.45 19.04 Psychological/Other Testing -- -- 6 person-tests 32.50 32.50 Follow-Up -- -- 4 person follow-ups 11.92 11.92 Total Annual Person Years/Budget 9.9 $175,524 Average Monthly Caseload = 83 8Averages based on data from October October 1976. 1975 and April 1976 only; these services were not provided in fi i i I» Iv.1 CHILD ABUSE/NEGLECT DEMONSTRATION UNIT: BAYAMON, PUERTO RICO I. COMMUNITY CONTEXT The Child Abuse/Neglect Demonstration Unit obtains its cases from the Bayamon region where the Commonwealth's Department of Social Services (DSS) has nine local offices. Bayamon, the third largest city in Puerto Rico (population of 170,500) is one of six urban areas that compose the San Juan metropolitan area. Lying to the west of San Juan, the Bayamon region has 377,511 (1970 Census) inhabitants who live in the cities of Catano, Corozal, Dorado, Naranjita, Toa Alta, Toa Baja, Vega Alta and Vega Baja, in addition to Bayamon. Urganization of this formerly agricultural area over the past two decades has produced large concentrations of unemployed and impoverished people, and an unusually young population (35% under 15 years; 1970 Census). The institutional structure needed to provide services to this population has lagged far behind the need. Definitions and estimates of the prevalence of abuse and neglect vary according to the respondent's position and socio-economic class. However, consensus appears to exist that the cases of physical abuse and cruel treat- ment (''trato cruel') are a small percentage of the total number of cases of abuse and neglect. Physical abuse appears to arise most frequently from the misapplication of older standards of corporal punishment such as belt whipping. (Physical discipline is an accepted practice in most Puerto Rican families.) "Trato cruel" refers to any unduly hard and violent acts that make a child suffer pain. IvV.2 Neglect of children is more prevalent and takes several forms. Moral neglect involves exposing children to "immoral" lifestyles or encouraging them to live "immorally' (open exhibition of prostitution, obscene language, engaging children in sexual acts, sending children to beg). Abandonment involves leaving children unattended (frequently without food). Other Cases of neglect are those in which the child's health or education is imperiled. Frequently, cases of neglect arise from sudden stresses combined with a long- term problem such as alcoholism, prostitution or mental retardation. IT. HISTORY After joining the Commonwealth's Department of Social Services in 1972, the Specialist for Protective Services became increasingly concerned about the large number of abused children, throughout Puerto Rico, who were re- moved from their homes while little attempt was made to work with their parents. By the time cases of abuse or neglect were brought to the atten- tion of DSS, the situations were so grave that the staff felt there was little they could do to keep the family together. DSS's heavy caseloads (averaging 50 cases a month) precluded anything but minimal service to the family. In mid-October of 1973 the Specialist learned of the availability of federal funds for child abuse demonstration projects. The director of the Special Resources Section of the Planning and Evaluation Division of DSS, another evaluator from that division and the Protective Service Specialist drafted a proposal. Their intent was to determine whether a more inten- sive casework approach, using master's level social workers, would make a difference in the final outcome of child abuse and neglect cases and in the Iv.3 incidence of abuse and neglect. If the demonstration were successful, they hoped to apply the model to the eight other regions of DSS in Puerto Rico. They sclected Bayamon because both the need for social services and the incidence of child abuse appeared to be high in that area. In addition, the regional office was supportive of the idea of having a special child abuse and neglect unit in the region. ITI. SUMMARY OF ACTIVITIES First Year Summary DSS received notice of the award of the contract in May of 1974. A director, social worker and secretary were hired in early September, and two social workers, two health educators, and a secretary joined the staff in October. The staff began working with a few clients in November. The small number of referrals from the DSS local offices necessitated that in January i the director and the social workers meet with the staff of the local offices to review individual case records. The number of referrals increased slow- ly during the subsequent months. In February, the staff began to use the services of the project's consultants for the purposes of diagnosis and general case discussion. By the end of June the project had a caseload of 32 cases. Under development were plans for a diagnostic review team, group therapy sessions, and several summer camps for parents and children. Beginning in November, the health educators developed a full program for publicizing the reporting law and the demonstration project to profes- sionals in community agencies and to the public anf for educating parents and community members on a variety of subjects affecting family life and children. Iv.4 As part of the changes connected with refunding for the second year, the director hired, in July of 1975, a fourth social worker to work with prevention cases and a research assistant to collect evaluation data. Second Year Summary The Unit solved its office space problem by moving to its own offices in July 1975, only a half a block away from the regional DSS office. In August 1975 the project was serving its targeted number of 45 cases. In December 1975 the fourth social worker, who had started in July, had a full caseload of 15 potentially abusive and neglectful parents. In February, a new social worker replaced a social worker who resigned to accept another job. Starting in February 1976, the project started terminating cases and by June had closed out 14 cases. In addition to the individual, couples and family therapy offered by the project's consulting psychiatrist and psychologist, the Unit initiated during the fall of 1975 a series of 19 group therapy sessions attended by mothers in the project's caseload. The project's consulting pediatrician thoroughly examined every child under 12 years old. During the year the project conducted several positive behavior rein- forcement activities for families. In July 1975, 40 clients and their fami- lies attended two three-day outings at the DSS camp. In December 1975, 250 people attended the Unit's Christmas party. In March and April 1976, the project took more than 60 clients to the zoo and to old San Juan. In June 1976, 85 clients and their families attended a four-day camp. The health educators conducted extensive lecture discussion groups reaching over 2000 people in the Bayamon region. v.5 In July 1975, the Unit organized an Interagency Committee on Child Abuse and Neglect which met monthly. The Committee developed and imple- mented a system for reporting cases of child abuse and neglect and prepared a training program for staff of the member agencies. Rutgers University provided special training to the project's staff and consultants as well as to some of the members of the Interagency Com- mittee. Third Year Summary In August 1976, the project relocated to a new office which was five minutes by automobile from the previous one. In January 1977, the director resigned to accept a teaching position at Sacred Heart University. One of | the social workers assumed the directorship. As the project was reducing its caseload in anticipation of its completion in April, a number of the new director's cases were terminated or assigned to the remaining three social workers. Also in January, the senior health educator left the project. During the year the project reached a peak caseload of 58 cases in November 1976, with a maximum of 18 cases for one social worker. None of the services provided by the Unit changed significantly. From September to December 1976, the project conducted a series of group meetings for mothers which used crafts as a means of improving communication and increas- ing participation. In September 1976, the staff conducted four day-long training sessions for Bayamon region's 40 DSS social service technicians. Others trained later in the year were the staff from the alcoholism program, Bayamon schools, Bayamon CRUV, and the Bayamon Sub-regional Hospital. With the completion of most of the training sessions, the Interagency Committee disbanded. The health educators focused most of their attention on parents and professionals in areas outside of the city of Bayamon using the Maternal Infant Care program, public health centers, Head Start centers, and CRUV housing projects as settings for these educational activities. Rutgers University continued to train project staff. The project evaluator completed several reports on the type of client served, the effec- tiveness of treatment, the characteristics of abusive parents in Puerto Rico, and the relative effectiveness of services provided to a comparison group selected from the caseload of the San Juan local offices. IV. ORGANIZATION/STAFFING The supervisor of the project is the Protective Service Specialist of DSS (see Figure 1). The director is responsible for supervision of staff, selection of and consultation on clients, program planning and development, and the project's formal contacts with other DSS departments and agencies. The health educator and assistant oversee the community education component of the program and occasionally instruct clients in financial and home manage- ment matters. The four social workers interview families, make diagnoses (with the assistance of the project consultants -- a psychiatrist, psycholo- gist, and pediatrician), provide casework and group work services, and assist in obtaining additional services for their cases. Three of the social workers handle cases of child abuse and neglect, and the fourth works with families where there is a high probability of future child abuse or neglect, although an isolated incident may have occurred. The social workers can use the project monies for meeting emergency needs. Figure 1: Organizational Structure Planning and Evaluation Division Evaluator Research Assistant Department of Social Services Secretary of Assistant Secretary for Services to Families Program Director of Services to Families Protective Services Specialist Director — Health Educator Assistant Health Educator Four Social Workers consultants psychiatrist administrative authority psychologist pediatrician LTAI IV.8 A psychologist from the University of Puerto Rico, hired and supervised by the Planning and Evaluation Division, carries out the research and evalua- tion component of the project. The Department of Social Services is paying for the Protective Service Specialist's time, office space, janitor and utilities, and emergency use of the department's car. V. PROJECT COMPONENTS The Child Abuse/Neglect Demonstration Unit has the following components: case identification, coordination, community education, professional educa- tion, case management, research and evaluation, positive behavior reinforce- ment activities, and staff training. Case Identification With passage of Law 191 in July 1974, public consciousness was raised about the need to report incidents of abuse or neglect to DSS. Although the project does not directly receive reports, one of its functions is to ensure that all potential cases are referred to DSS. DSS refers all substantiated cases to the project. The director and staff have been in contact with all key referral sources in the Bayamon district to make their existence and pur- poses known. Each agency has copies of a referral form which notifies both the local office of DSS and the project when a parent is suspected of child abuse. The following agencies make most of the referrals: school districts, Head Start, Health Department, hospitals, Corporation for Urban Renewal and Housing (CRUV), Youth Action, police, District Adult and Juvenile Courts, Mental Health Center, Services Against Addiction, and the mayors’ offices in Bayamon, Dorado and Toa Alta. The director and staff members speak on IvV.9 radio and television about the program and the need to report suspected cases to DSS. The project has developed educational material on abuse for teachers, doctors and public community agencies. Coordination The project attempts to improve the linkages among community agencies so that cases are identified and are promptly referred, treatment services are shared, and the management of cases is easily coordinated. The project has established an interarency task force of professionals representing agencies that deal with child abuse or neglect to facilitate this coordina- tion. The health educators meet with the staffs of key local agencies to describe the project and discuss the project's objective of working closely with local agencies to provide services and improve the community system. In working with the families, regular contact is maintained with the local DSS offices, the police, the juvenile and adult courts, the regional office of the CRUV, the mental health center, hospitals, and Services Against Addiction. Community Education The health educator and her assistant are responsible for teaching people to be better parents. They work primarily on three levels. At the first level they meet with parents of children who are in organized pro- grams like Head Start or in the public schools, to discuss such topics of concern as child development, nutrition, child management, alcoholism and drug abuse. These sessions tend to be small and discursive. At the second level, they hold meetings in the community, frequently under the sponsor- ship of a recognized community group, to make more formal presentations on v.10 many of the same topics covered in the smaller sessions. The staff selects those communities they feel have the greatest potential for abuse and neglect. The Health Educator enlists the assistance of Youth Action volunteers to distribute the materials and to publicize meetings. An experimental approach to community education at this level has been to get members of a local community to organize around child care issues and to use the health edu- cators as resource people. The final level involves talking on radio and television and using the printed media to publicize approaches that can be taken to improve the welfare of children. The health educators continually seek out and develop their own audio-visual materials and handouts. Professional Development Another responsibility of the health educators is to teach professionals how to recognize child abuse and neglect and how to make referrals. The health educators hold workshops and distribute information to staff with- in DSS, teachers and social workers in the schools, and professionals in the schools, and professionals in other agencies in the region. The staff holds day-long training sessions for key personnel in community agencies. Case Management The Case Management Unit carries an active caseload of 60 families -- 45 where an incident of abuse or neglect has taken place, and 15 where abuse or neglect will probably occur. In order for a case to be accepted by the project, there must be a reasonable possibility of the children's living with at least one of their parents. As long as the parents are not insti- tutionalized and the child is not permanently removed, the Unit works with the case. Iv.ll The consultants (a psychiatrist, psychologist and pediatrician) perform any necessary examinations and make recommendations to the social workers handling the case. In some instances they may provide short-term treatment. Because it is difficult to get parents to attend meetings, the primary treat- ment is usually individual casework; however, group therapy is used where deemed feasible and beneficial. Individuals are referred to other agencies such as the mental health center and the hospitals for long-term psychiatric care, pediatrics and emergency medical services. The social workers assist in obtaining supportive services such as day care, temporary foster care, homemaker services, public assistance, food stamps, transportation, food, clothing, and medicine. The health educators are available at the request of the social workers, to instruct clients in home management, nutrition, and personal hygiene. The social workers periodi- cally meet with the director to review their cases and a multidisciplinary team meets once a month to discuss particularly difficult cases. Positive Behavior Reinforcement Activities The entire staff offers clients special recreation-type opportunities in order to help families to communicate with each other more effectively and to participate more openly in group settings. These activities usually take place for several days at a DSS camp where staff share quarters with clients and their families and educate parents on a variety of subjects relating to child care and coping with personal problems. Research and Evaluation One of the project's objectives is to test the hypothesis that more intensive casework will (1) reduce the incidence of child abuse and neglect, Iv.12 (2) maintain healthy family units. To evaluate the validity of this hypothe- sis as demonstrated by the Bayamon program, the project draws on the services of a University of Puerto Rico psychologist hired and supervised by the plan- ning office of the DSS Research and Evaluation Division. Staff Training Staff training is an ongoing element of the overall program. The staff makes use of the experience and knowledge of the staff at the Department of Social Work at the University of Puerto Rico, the DSS specialist in protective services, and an HEW funded training program at Rutgers University. The staff receives training in such subjects as special social work techniques for dealing with abusive and neglectful parents, approaches to diagnosis, use of psychiatrists, legalities of protective services, and Puerto Rican laws pertaining to minors. The staff periodically attends national workshops. VI. IMPLEMENTATION/OPERATION PROBLEMS There have been two types of implementation issues: those that were real and those that might have been potentially problematic. The following are some of the major issues of both varieties. Referrals At the end of December 1974, the local DSS offices had referred 12 cases to the project; of these, eight were accepted. The lack of clients necessi- tated the project staff's visiting the local DSS offices to seek potential cases rather than wait for the local offices, whose staffs were strained by implementing Puerto Rico's first food stamp program, to perform the necessary paperwork for making referrals. As a result of the project's efforts, the v.13 caseload increased slowly but steadily. The clients' great need for advocacy services were another reason for the slow start; the project social workers had all they could handle, even with the light caseload, in securing assis- tance for their clients. (Slowness in receiving referrals may have forestalled, at times, full use of the project resources.) Suitable Office Space Although the project started working with only a few cases, the limita- tions of their offices became readily apparent. First, located on the second floor of the regional DSS building, the offices were small and only a few were partitioned. Along one side of the office ran an opening to the first floor, from which considerable noise emanated. In addition, the other side of the office was used by regional DSS staff who had to pass through the project's space in order to get to the elevators. Besides the noise and cramped quarters, there was a lack of privacy that precluded holding inter- views in the office. In July 1975, the project moved to spacious quarters a half-block away from their former offices. Administrative Delays The project has encountered a number of delays in obtaining approval of contracts, obtaining requisitioned supplies, and receiving authorization to print educational materiels. While these delays may be endemic to govern- mental activities, particularly in Puerto Rico, the project was able to carry out some of its planned activities as fully as it desired. The director managed to circumvent most of the bottlenecks, but the delay in obtaining approval from the DSS central office for publishing educational materials hindered full execution of that project component. v.14 Lack of Community Resources The project has a number of resources that are not ordinarily avail- able to staff in the local DSS offices. Nonetheless, like the local offices, the project relies on DSS for foster care placement and homemakers, CRUV for public housing, the health centers for medical care, and the mental health center for long-term treatment. Although DSS has a shortage of places in foster care homes, the project had managed, through the power of persuasion, to arrange for such services for clients. The staff had expected this deficiency to cause delays and pose obstacles to successful treatment of clients. Since the caseload has increased, the project obtained special funds in its second-year budget to keep places available for its clients. Another shortage is that of homemakers. DSS employs homemakers to assist the workers in the Division of Families with Children and other DSS programs. Because new minimum wage legislation will raise the salaries of these home- makers dramatically and because of budgetary constraints, DSS is reducing this service. The project director obtained money in the second-year budget to hire two full-time homemakers, but she was unable to find anyone who was qualified. In April 1975, the project, in trying to secure a home for a low-income family on an emergency basis, was confronted by the refusal of CRUV to provide a place. Only by going to higher authorities was it possible to obtain housing for the family. The project still relies on CRUV for low-income housing, but their prior experience expedited the securing of apartments. Since May 1975, when the project hired a psychiatrist who also works for the mental health center, it has been able to receive the long-term care services it desired from the mental health program. mm tn — + ee ev ee — a —— v.15 Case Histories Because of the social workers' priority of first providing services to clients and because of the time-consuming nature of the cases, the social workers were unable to keep the case histories current or complete during the first half of 1975. The BPA client forms were used to substitute for many of the written case notes. The director and social workers recognized the need to develop a system of note-taking to supplement the BPA forms, in order to have a record of all the relevant information for future case manage- ment and review. In July 1975, staff members revised the outline of essential information that was formulated at the beginning of the year and write brief monthly summaries of their clients' progress. Rapid Response Protective services programs, which frequently deal with emergency situa- tions, often depend on administrative flexibility to facilitate taking quick action when necessary. Efficient response of the project to client needs had been limited in two important areas -- foster care placements and emer- gency funds. Reliance on DSS for foster care placements was not working satisfactorily because DSS could not find sufficient openings in foster homes. Departmental restrictions on the use of emergency funds hampered the project's ability to meet client needs for food or clothing. In crisis situations, to rectify the situation, the project had to develop its own sources of foster care placement and had to contest regulations governing emergency funds. I1V.16 Different Objectives of BPA and Local Evaluations During the first few months there was some confusion about appropriate roles for the two evaluations. It appeared that, in some arcas, Berkeley Planning Associates was going to duplicate work that the local evaluator had intended to undertake. Moreover, the local evaluator had some concerns about the methodology that was being used to assess client impact. After several opportunities to discuss roles and evaluation designs, the confusion was resolved by reaching an understanding of the slightly different focus of each evaluation. The local evaluation used a classic research design and focused on changes in specific indicators of "positive family function- ing." Also, the local evaluator took a more psychological approach to evaluation and did not examine the costs or cost-effectiveness of providing services. Evolution of Approaches to Implementing Goals The project's overall goal has remained constant from the start: to test a regional model of providing protective services in order to determine whether it should be implemented throughout Puerto Rico. Some aspects of the model that were not part of the initial conception were developed and tested. The project experimented with increased caseloads; worked on preven- tion cases; used camps both to impart new parenting skills and to change children's behavior patterns; and tested the effectiveness of using special resources such as consultants and emergency funds. Although there was some initial discussion of adhering to a fixed model, the project took an experi- mental approach. 1v.17 VII. FUTURE PLANS DSS administrators have decided that the project was successful in demon- strating the value of having a specialized regional unit to deal with cases of child abuse and neglect. However, DSS administrators think replication of the model is too expensive given the available resources. Hence, they are going to continue to fund a modified unit in Bayamon and two other regions. Each unit will have a master's degree social worker as director, two or three social service technicians, a health educator, and a secretary. The maximum caseload will be 20 cases. Staff will be continuously trained. The project staff will terminate all of the cases by the end of April. Leftover funds will probably be used to support the staff for several months to train new staff and other professionals in the Bayamon region. DSS is implementing an island-wide hotline which will make immediate referrals to local offices and the specialized child abuse units in those regions where they exist. The former health educator is responsible for pub- licizing this service. VIII. PROJECT GOALS The project's overriding goal has been to determine the relative effec- tiveness and appropriateness for Puerto Rico of a specialized child protection unit operating at the regional level. The unit uses master's level social workers, who have had some field experience, to work exclusively with abusive and neglectful parents. A special feature of this prototype is its community education component, which seeks to promote public awareness of the problem, so that cases are reported and more community resources are spent on preven- tion and treatment of child abuse and neglect. Since the project's goals are IV.18 so closely tied to its demonstration nature, the goals have been oriented toward determining what changes occur both in clients and in the community. The following are the project's goals as set forth in the second year refunding proposal: (1) General Objective. To determine the relative effectiveness of two models for treating child abuse/neglect cases: the "traditional model" cur- rently being used by the Department of Social Services and the model adopted by the Bayamon Child Abuse and Neglect Demonstration Unit. If the latter model proves to be more effective than the traditional model, recommendations will be made to the Department of Social Services for its implementation island- wide. (2) Objective Related to Client Impact. To improve the functioning of those families in which children have been abused or neglected or are likely to be abused or neglected, which have at least one parent in the region and which have a reasonable potential of staying together if social services are provided. (3) Objectives Related to Community Impact. (a) To promote awareness and understanding in the Bayamon region of the problem of child abuse/neglect; and (b) to change the overall community system by fostering better coordina- tion among involved agencies and by improving the identification and referral procedures currently being used. (4) Objective Related to Research. To determine characteristics of abusive and neglectful parents and to develop indicators of potential abuse and neglect specific to Puerto Rican families. Iv.19 General Objective DSS administrators, the staff, and the local evaluator have concluded that the Bayamon model is more effective for treating child abuse/neglect cases than the traditional one. The Department is funding three regional units for fiscal year 1977 based on the successful experience of the Bayamon project. Objective Related to Client Impact As of January 1977, the project had terminated 40 cases. The local evaluator found in a study of the first 30 clients that for 17 the incidence of abuse/neglect had been significantly reduced. The social workers feel that there has been general improvement in all the clients served by the project. Objectives Related to Community Impact The project appears to have increased the level of consciousness of the problems of child abuse/neglect in the city of Bayamon, the region, and in Puerto Rico. The health educators reached thousands of parents with their public presentations and distributed thousands of pieces of educational material. There were numerous radio and television broadcasts and several newspaper articles. The project trained all of the staff of the major service providers in the region (with the exception of the police), and disseminated resource materials for use by those professionals in their educational work. The system for dealing with child abuse and neglect appears to have im- proved during the project's three years of operation. The project has improved communication among the various key agencies. Frequent contact by staff and the Interagency Committee appear responsible for the improved relationships among agencies. Another contributing factor was that the Interagency Committee IV.20 developed a form for making referrals and for providing the project with a way of following up on suspected cases referred to the local offices. As of January 1977, about 20 referrals had been made using these forms. Objective Related to Research The local evaluator successfully fulfilled this objective with an informa- tive report which profiled typical abusive and neglectful parents in Puerto Rico and estimated the probable incidence of abuse on the island. IX. PROJECT MANAGEMENT AND WORKER SATISFACTION Walking into the Bayamon project is like a breath of fresh air. One is immediately struck by the warmth and nurturing atmosphere which pervades the work environment. Upon closer scrutiny one's initial feelings are borne out as you hear and see people talking and sharing with one another. The con- sensus in the project is that 'co-workers'" make the difference in coping with an emotionally and physically exhausting job. Organizational Structure Bayamon is a relatively small project. There is a total number of 12 staff, nine being full-time. The project's average monthly budget is $15,622. The program is moderately complex, engaging in a number of diverse activi- ties including community education, community coordination, professional training, and direct service. The organizational structure has a low level of complexity, with four different disciplines actively involved in the pro- ject's activities. The organizational structure if fairly formalized; job descriptions, a rule manual and codification or procedures are written out and followed. There seems to be more informality at the daily work level, since most workers exercise a high degree of autonomy in their own jobs. v.21 Decision making regarding agency procedures, policies and program planning is highly centralized. Within the project, staff report that they partici- pate in decisions that directly affect their jobs. For example, workers can decide what will happen at a parents' day camp, but they do not decide whether or not to have the camp. Many of the workers feel that they would prefer to have more input into the organizational level decisions. Management All staff seem to agree that their project is very well managed. They report that the leadership is very good. The project director gives good direction, but is not authoritarian. She is very supportive and always has an open door to listen to workers' concerns. Communication is also considered to be good. Everyone knows what they need to know to do their job. There are both formal and informal structures for communication about program and client information. There appears to be no destructive gossip. Everyone feels that they have license to work in their own style with clients and have the necessary autonomy to do their job. One of the outstanding strengths in the project reported by each and every staff mem- ber was the good, health co-worker relationship. Everyone feels that they have established a strong support network that sustains them when frustra- tions with other agencies and difficult clients exhaust them, and this is the reason they have been able to stay with the project for three years. While the project management appears to be exemplary, the tremendous bureaucracy that the project is submerged in causes great frustration for all workers. Foremost, the bureaucratic red tape interferes with workers' ability to get clients the services they need. There are long delays on every request for service. When the project moved into their new quarters v.22 the staff did not have telephones for six weeks until the central office could make the arrangements for installation. Consequently, clients did not have direct access to workers, and workers were compelled to use the telephones at the central office some distance away from their own offices. Further, the project does not have direct access to funds necessary to pur- chase supplies needed for their program components. There are always delays in obtaining approval of contracts, obtaining requisitioned supplies, and receiving authorization for extra activities (e.g., printing educational materials). While the project director managed to bypass many of these bottlenecks, many delays did hinder the full execution of project activi- ties and presented an extra source of frustration for workers. Secondly, workers feel very insecure as provisional workers, their job classification due to the project's demonstration status. The central office does not give the project staff any extra benefits or retirement benefits. Most workers feel very insecure and resent the lack of commit- ment demonstrated by the central office. Because of these bureaucratic hassles, workers feel they are less effective in their jobs. The high group cohesiveness among project staff has made it possible for everyone to espress frustrations and anger openly, however, and receive support to continue coping with the central office. Thereby, less of this frustration is directed at clients. Turnover/Satisfaction/Burnout Only two staff members have left the project: a service worker and the project director. The project director, who had been with the project about 2-1/2 years, resigned to accept a position teaching in the local uni- versity School of Social Work. A staff member was promoted to the director- v.23 ship position for the remainder of the project. The project staff has been stable throughout the project, but some instability in project operation occurred because the project itself moved twice during the three years. There is a very high feeling of job satisfaction among all workers. Interestingly, while there is 100% high job satisfaction, almost 30% of the staff report high burnout and 43% report moderately high burnout. In conversations with workers it became clear that this staff, although ex- hibiting high esprit de corps, was suffering emotional and physical exhaus- tion. There are a number of reasons why burnout occurred among such a competent staff and in a well-managed project. The workers themselves express extremely high expectations regarding what they must accomplish. Several social workers expressed it this way: 'this project is like our child. We will do anything to make it work. We work nights, we don't take our vacations, we work weekends. We have success but we are exhausted. "This pride we all feel is good professionally, but sometimes we are so tired it is hard to continue working." Linked with this high expectation and desire by the staff to help their clients is the difficulty of getting services from other public bureaucratic agencies. In order to get housing, welfare and medical care for their clients, workers must spend a lot of time and energy cutting through red tape. And, for many clients, there are no services available in the community to help them. In addition to these factors is the serious problem presented by the Bayamon client load. Many clients have very difficult problems; they are either mentally ill, very poor, or very isolated multi-problem families. All are those who do not make much progress, or if progress is made, it is up and down. IV.24 Coupled with the workers' high expectations and the exhausting nature of the work is the fact that workers do not take their vacations and tend to work long hours. While most workers nurture themselves with family acti- vities, reading and various social activity, most workers feel that they need a large block of time set aside for recuperation. But, if the staff take their vacations, then other workers must assume an increased load. Because people feel so close to one another, they are hesitant to create additional work for their peers. One worker summed up the solution: 'There just seems to be too many demands for the amount of time available for clients; either we must reduce non-client demands or reduce the number of clients." X. ANALYSIS OF CLIENT DATA Client Flow Neighbors and relatives are the most probable sources of referral. The agencies most likely to report a case of abuse or neglect are the pub- lic school (social workers or teachers), the health center (nurses), the police, the Corporation for Housing and Urban Renewal (CRVV), and the hos- pitals. The report is usually made to the local office of the Department of Social Services, the agency legally mandated to receive reports. Some of the agencies making referrals fill out a referral form which they send to the local office as well as to the project. The service technician in the local office records the nature of the complaint and the resource of referral. The supervisor of the local office assigns the case to a worker, who usually makes a home visit within 24 hours. If the case appears to meet the projects criteria, it is referred to the project director, who v.25 passes the case on to the project. If the case meets the criteria and a social worker does not have a full caseload, the project director will ask the social worker to talk to the DSS worker, interview knowledgeable individuals, and make a home visit. In cases where a doubt exists, the project will provisionally astont the case until the social worker can investigate the case. If the case is accepted, the local DSS office will terminate its responsibility for the case. If the case is not accepted, the project will explain its reasons and suggest other actions. The social worker makes an initial assessment, looking at the family and child's histories, the quality of care of the children, the circum- stances surrounding the incident (s) of abuse or neglect, and an assessment of the family's living conditions. If the child is under 13 years old, the project's consulting pediatrician examines the child. To obtain an assessment of a parent's or child's mental status, the social workers con- sult the project's consulting psychologist or psychiatrist. On the basis of this information, the social worker arranges for advocacy services while the intake is in process. The project director reviews the case and treatment plan with the social worker. The period of diagnosis may take several months, particularly where diagnostic tests are needed, but diagnosis is usually completed within a month. In addition to case management and individual counseling, the project offers individual and group therapy. Initially, the social workers work to improve the client's overall living conditions by arranging for advo- cacy services like housing, public assistance, or medical care. When neces- sary, the social workers obtain help for clients through other community IV.26 services such as day care, the drug abuse and alcohol center, or temporary foster care. They assist in any legal proceedings that might be pending or they may take legal action to safeguard the child's welfare. The main focus of the social worker's services is to help clients change their atti- tudes and modify their conduct in order to improve their functioning as adults and parents. At the request of the social workers the consulting psychiatrist and psychologist will provide individual and group therapy for clients. The project ends its involvement with a case whenever the parents have moved out of the region or a child has been permanently removed from a home, after making sure that a local DSS office in another region is in charge. When the social worker thinks that the potential for future abuse or neglect is tolerable and that major gains in attaining goals have been achieved, the project terminates the case. Client Characteristics As can be seen on Table 1, the projects caseload is fairly evenly divided into potential cases (25%), emotional abuse or neglect cases (22%), physical abuse cases (20%), and physical neglect cases (28%). Of these cases, almost all of whom were referred by the social service host agency, somewhat under half (42%) were those in which serious maltreatment occurred, and close to two-thirds of the cases (63%) had a previous record or evi- dence of maltreatment. Despite the seeming severity of the cases, only 1% had a court hearing; in only 3% were the children removed from the home. The families were relatively large, with an average of 3.3 children; most families had preschool children (83%) and two adults in the household (77%). The families, which were a mixture of native Puerto Ricans and a few other v.27 ethnic groups, were not highly educated (63% had no high school degree), and they were poor (73% had $5500 or less as an annual income). However, these were older parents (fathers' average age was 39 and mothers' was 31) and typically employed (in only 35% of the families was no one employed). The most frequently cited problems in the households in addition to finan- cial ones include: marital problems manifested in arguments and fighting, alcoholism, poor health, and heavy, continuous child care responsibilities. In general, these were difficult cases, multi-problem cases, even though 25% were identified as high risk or potential rather than actual. These cases, close to handpicked by the staff, are the very kinds of cases the project chose to serve. 1V.28 Table 1 Client Characteristics Source of Referral Private physician. . . . . .-- Hospital . . . . . ce... 8% Social service agency. « % 273% School « « + + « s « vs » « 3% Law enforcement. . . . . . . 2% Court. + « « + « = » vw a » 3== Parent . + « « » vw & v3 « + oF Sibling. . . + «5 5 5 = » s== Relative . . . csv 2% Acquaintance/neighbor «ix» 3% 1 RE LL. . Anonymous. . . . . . . . . .-- Otheriagenty . . = » + » » » 3% Type of Maltreatment Potential abuse or neglect only. = = . . 25% Emotional maltreatment ONLY. « « oo o = 5 = « » « +22% Sexual abuse . . . . . . . . 2% Physical abuse . . . . . . .20% Physical neglect . . . . .28% Physical abuse §& neglect co. 3% Severity of Assault Not serious. . . . . . . . .58% Serious. s « + « +» + « = « 425% Responsibility for Maltreatment Mother . . . . . . . . . . .48% Father . o « « « = + 4 # =» «25% Both « = 2 « 5 « « « 5 + « 214% Rher: = « « » = +» +» +» &» =» 15% Legal Actions Taken None . . . ee ee. W44% Court hearing. s a5 » 0% 1% Removal of child temporarily . . . . . . . . 3% Removal of child permanently . . . . . . . .-- Previous record/evidence of mal- treatment None . . . ’ oo «37% Previous recordfevidence . « 03% Demographic Information Average number children in family. . . v + & » 5.3 Family with preschoolers v. + +53% Family with one adult. . . . .23% Family with no high school degree. . . . vy v 103% Family with no minorities. . .38% Family with no one employed. .35% Average family income. Families with less than $5500 per year. . . . .73% Families with teenage parent .28% Average age of mothers . . . . 31 Average age of fathers . Problems in Household Leading to Maltreatment Marital, + « « = « © o = » « +53% Job related. . « +. + « « » «+» 8% Alcoholism . « « + « « « « +» »36% Drugs. . . v © AFT w wo Physical health. TEETER Mental health. « « « + = « +» +38% New Daby ..5 « 5 = 5 « 4 » » =» 7% Argument/fight . . . . . . . .50% Financial. . . « x ou ow D3 Mental retardation of parent . 3% Pregnancy. . . . sw ow ow wo Heavy, continuous child care .38% Physical spouse abuse. . . . .23% Overcrowded housing. . . . . .11% Abused as child. . . . . . . .16% Normal method of discipline. .14% Social isolation . . . . . . .15% Recent relocation. . . . . . .16% (N=95) .$5000 . 359 yr, 1v.29 The Quality of Case Management In general, with few exceptions, the Bayamon project used excellent case management practices. Intakes were thorough; records were well kept; contact with clients was intense and continuous; and reviews occurred fre- quently. Cases were referred to the project from the social services department. Although the time between actual referral and first in-person contact with the client was often one month, during this month project staff conducted extensive review of the cases, collected background information, and talked with the referral source. The number of contacts with the client prior to the development of a full treatment plan varied from one to over five, depending upon the complexity of the case, although some treatment ser- vices were offered within two weeks of the first contact. More than two- thirds of the cases were reviewed by a multidisciplinary team and all cases were reviewed in case conferences. While consultants were rarely used for case management issues, and clients never participated in their own case reviews, referral agents were used extensively in providing information about the case. Typically, the person performing the case management fanc- tion also performed the intake (deviations from this were due to turnover in one staff position), and was the primary treatment provider as well. The project tended to provide clients with all needed services rather than refer them elsewhere. IV.30 Table 2 Case Management Characteristics* Time Between Referral and First Use of Consultants Client Contact None. . . . . . . +. «vv +... .37% Same day. . . . .. .. .... . 6% ONE « « » » » vw 4 uv + uw 5 % » 5 WAY 1-3 days. . . . . . .......6% TWO « o « 2 a 2 5 5 + 5 + + 2 « » 9% 4-7 days. . . . Cee eee. W21% Three-five. « « « + « 4 » + « « 24% Within two weeks. Cee eee. J 13% Over five . . . + « + + « « + & J19% Within one month. . . . . . . . .40% Over one month. . . . . . . . . .15% Client Participation Number of Client Contacts (after Client presence at MOTs and/or case conferences . . . . . . . . 0 initial contact) Before Treatment ion Contact with Referral Source Mads rp ashen bi For background information. . . .93% OEE AE EE EEE 2 Two . . . . TT or For progress reports. . . . . . .62% Three-five. . « : «+ « + « +» « « 21% EIT Over five . + « : « « + sv « » v + 3% Responsibilicy for Intake Current case manager. . . . . . .62% Time Between First Client Contact Other staff member. . . . . . . .38% and First Treatment Service Number of Case Managers Within two weeks. . . . . . . . .68% Two weeks to one month. . . . . .18% One « = « » « vv o «+» » » + 5 +28% Over one month. . . . . .. . . .15% TWO + = « » EE EE. Noservices given . . . «. . . +. , O More than two ro aes ere uD Use of Multidisciplinary Review Reason for Two or More Case Team Managers At least one review . . . . . . .71% Joint management. . . . . . . N=0 Review during intake. . . . . . .13% Staff turnover. . . .... N=9 Review during treatment . . . . .64% Staff unavailability. . +... N=O Review at termination** . . . . .27% Lack of success with client . N= 0 Other . . « 2 + 4 + » « » » » N=0 Use of Case Conferences (staffings) - At least one conference PRE” 100% Bumber of Treounont Prdviders.An Conference during intake. .. . .63% Project (other han case manoger) Conference during treatment . . .97% None. « « o os » 5 « 5 «5 + « +».:02% Conference at termination** . . 100% ONG « +» + « 5 2 6 » vw + 3» + + ».+22% TWO 4 » «» oo » w & = » 5 » 3 + + #13% Three-five. + « 4 + « ow + » + » «0 Over five = « ¢ ow 5 « 5 + ¢ » w 2.3% (Table 2 continued on following page) Iv. 31 Table 2 (continued) Services From Outside Agencies. .406% Evidence of Communication With Outside Agencies . . . . . . . 100% N=16 Frequency of Contact by Case Managers Once per week or more . Once or twice per month Less than once per month. Once or twice only. Varied over time. None. uN SOO NO OW of of of of Follow-Up Contacts** At least one contact (client/ other agency). . . . . Two or less with client Three to five Over five Length of Time in Treatment** Up to three months. 3-12 months 1-2 years Over two years. Total number cases = 35; total terminated cases = 12. * Owing to rounding, percentages may not sum to 100%. *% Terminated cases only. .54% .46% XI. COMMUNITY IMPACT Summary The major change in the Bayamon community was an increased awareness by professionals and the general public of the special problems of child abuse and neglect, and an increased commitment to finding ways of combat- ting the problem. This change appeard to have resulted Wn a small increase in the services applied by the various agencies to preventing or treating individuals who abuse or neglect their children. This was most true in the city of Bayamon office. Also, other agency staff appeared to have focused more on the special problems of abusive and neglectful parents and their children. In particular, the schools appeared to be more sensitive to the problem and relied more heavily on DSS and the project staff. The Interagency Committee made it possible for the first time for administra- tors and key workers in the various agencies to discuss the problems of child abuse and neglect in Bayamon, and to jointly develop solutions. The health educators reached a large audience of professionals. Their specially-developed materials and stimulating presentations appeared to have inspired other health educators to undertake similar education efforts. There are more referrals being made by professionals to DSS than before the project started. Professionals in the community are more aware of the availability of resources in Bayamon for helping their clients. Nonetheless, the system for dealing with child abuse and neglect in Bayamon has gaps and deficiencies. Outreach and prevention were virtually non-existent. Identification of abuse continued to be poor, but some improvement had been made. The community system still lacked a hotline for v.33 24-hour reporting and for parents on the verge of hurting their children to obtain help. The shortage of adequate housing and jobs compounded the prob- lems that DSS workers and project staff were helping their clients overcome. Community System Operations Prior to the implementation of the demonstration project in May of 1974, the organization receiving most of the reports of abuse or neglect in Baya- mon was the local office of the Department of Social Services (DSS). Other agencies such as the schools referred cases only when they were unable to provide the necessary services themselves. If a child had been physically or sexually abused, other agencies like the Municipal Health Center would immediately refer the case to the police. The police would usually investi- gate the charge and, if substantiated, would refer it to the District Court as a felony case. Since DSS did not have sufficient coverage for reporting, the only agency that could be contacted after the hours of work was the police. Another type of case that would not necessarily be reported to DSS be- fore May of 1974 was the failure of parents to provide adequate shelter, clothing or food for their children, a situation termed abandonment in Puerto Rico. Frequently, one of the parents or a relative would request the District Court to take legal action against the parent. Since public resources are scarce and other social problems appear more serious, many agencies did not bother to report cases of mild or moderate neglect. Those neglect cases reported to the local DSS office were usually complaints from neighbors and relatives, or requests by other agencies for assistance. The courts some- times called on DSS when the custody of a child was an issue, since DSS had IV.34 the legal responsibility to supervise and provide foster care homes and insti- tutions for special children. In September of 1974, the staff in key agencies other than DSS appeared to have little consciousness of the etiology of child abuse or of the under- lying pathologies associated with neglect. During the period preceeding the project's initiation, the other agen- cies in the community worked together sporadically. Investigations were con- ducted separately. Referrals were made haphazardly. A number of gaps existed in the community system. There was no outreach into the community to iden- tify parents who were abusing, much less neglecting, their children. Pre- vention efforts were minimal, consisting primarily of classes on child development for parents and teachers of first graders in the the Northern Bayamon public school district, and pre-natal, well-baby and family plan- ning clinics operated by the Municipal Health Center. The home economics and health classes taught in the public schools occasionally touched on such subjects as child development or management. Follow-up was virtually non-existent with the possible exception of the school system whose social workers occasionally re-investigated cases if a child continued to exhibit problems. None of the agencies had received any special training on child abuse or neglect, or on the responsibilities of the various community agencies. The police appeared to have no awareness of the phenomena of child abuse and looked upon the matter simply as taking legal action against the parent(s) if a child were hurt. Frequently, the anti-social actions of older child- ren were interpreted by the police as matters of juvenile delinquency even though the child's behavior was a direct result of parental negligence or 1v.35 their willful encouragement. The courts generally treated child abuse as a felonious matter. The courts usually handled abuse and neglect in one of three ways: (1) the administrator referred the case to the Juvenile Cham- ber of the Superior Court because it involved the custody of a child or juvenile delinquent; (2) the administrator or the District Court judge man- dated the case to the Adult Chamber of the Superior Court because it involved assault and battery or incest; or (3) the case was handled in the District Court because it involved misdemeanor charges against the parent(s) for failing to provide child support. There was no system in the courts for recording the number and disposition of cases of child abuse and neglect that were heard. In July of 1974, the long-standing practice of referring dependency cases to DSS was codified by Law 191. Beginning in September of that year all those who had knowledge of a child being abused, particularly those holding professional jobs such as teachers, doctors, pharmacists, etc. were required to notify DSS within 48 hours. Very few agencies were aware of the passage of the law when the demon - stration project started to function in September of 1974. Although DSS had established a central registry in January of 1974, DSS was virtually the only agency filling out the forms and even their response rate was low. Caseload Size and Case Outcomes The reported incidence of child abuse and neglect has increased since the project's implementation. During the baseline period of 1974, there were approximately 71 protection cases from the city of Bayamon that were referred to DSS. However, although many of these cases involved incidents 1v.36 of child abuse and neglect, DSS did not differentiate among the types of pro- tection cases. Hence, there is no way to know exactly the number of cases received by DSS during the baseline period. As part of the evaluation, the local DSS staff recorded on special forms the reports of child abuse, neglect, and abandonment for 1975. There were 83 reports of child abuse, neglect and abandonment, of which five were repeat reports on the same situations (see Table 3). Of these 83 reports, 44% were substantiated. In 1976 there were 105 reports, of which eight were repeat reports. Of these 105 reports, 56% were substantiated. Table 3 DSS Caseload and Reporting Statistics: 1974, 1975 and 1976 Caseloads 19741 19752 19767 Reports by Type: Abuse NA 31 57 Abandonment NA 32 19 Neglect NA 20 29 Total 71 83 105 pepartomento de Servicios Sociales, Oficina Local de Bayamon, Programa de Servicios a Familias con Ninos-Movimiento de Solicitudes (1974). Note: This statistic refers to all pro- tection cases. Figure adjusted due to unavailable data for May 1974. 250urce: BPA form filled out by DSS local office. IV.37 As far as the source of reports were concerned, in 1975 and 1976 reports were divided approximately equally between agency and non-agency sources (see Table 4). The schools were responsible for almost one-fifth of the reports. The hospital increased its percentage of reports from 2% in 1975 to 10% in 1976. The courts were responsible for a few percent. The police made only one report during 1976. According to the local Bayamon DSS office, both the schools and hospitals were making more referrals, but also many of these referrals were unsubstantiated. This situation was particularly true for the hospitals. In mid-1976, to keep better record on the child abuse and neglect situa- tion in Puerto Rico, the central DSS office improved the monthly reporting form for all local offices by adding the following categories: abuse, ne- glect, abuse as a result of alcoholism or drugs, mental regardation, and abandonment. IV.38 Table 4 Referral Sources to pss! 1975 1976 Source of Reports Number Percent Number Percent DSS 8 10 13 12 Hospitals 2 2 10 9 Police 2 2 1 1 Schools 15 18 18 17 Court 6 7 4 4 Other agencies 7 9 10 10 Spouse 17 21 10 10 Family member 9 11 2 21 Neighbors Al 13 15 14 Self referrals 4 5 2 2 Anonymous 1 1 0 0 Unknown 1 1 0 0 Total 83 100 105 100 source: BPA form filled out by the local DSS office. Legislation Working with the Interagency Committee, formed in July of 1975, the pro- ject began in the latter part of that year to consider revisions in Law 191, the Puerto Rican reporting law. Work began on formulating specific recom- mendations to the Legislature for revision of the law. DSS established a IV.39 special task force to make recommendations to the Legislature. Law 191 broadly specified who was required to report to DSS including such professionals as teachers, doctors and nurses. Reportable situations were those causing a physical or mental deterioration in a child as a result of abuse. No definition of abuse or '"maltrato' was given. Neglect was not explicitly made one of the reportable situations. The law provided a fine of $100 to $500 and a charge of misdemeanor for failure to report, although this provision of the law was not enforced. All informants were granted both civil and criminal immunity and all information was to be kept confi- dential. The law did not mandate that any services be provided for abuse cases. The law was amended by Law #104, June 2, 1976. Community Resources During the period from May 1974 to April 1977, the project and the local DSS office were the only two agencies in Bayamon whose primary purpose was to deal specifically with child abuse and neglect problems. The other agen- cies frequently served their clients without considering whether they had abused or neglected their children. Since these other agencies did not keep any statistics on abuse or neglect, they could not estimate the percentage of their staff time committed to providing service to abuse or neglect cases. The staff resources provided by the project include four masters degree level social workers and the part-time services of a psychiatrist, psycho- logist, and pediatrician. The project has offered the following services to its 60 clients: case management, multidisciplinary review, psychological and psychiatric testing, pediatric examinations and health care, individual therapy and counseling, group therapy, and ancillary services such as Iv.40 transportation and emergency funds. The social workers engaged in obtain- ing supportive services such as housing, day care, temporary foster care, medical assistance, and drug and alcoholism treatment. The project also offered positive behavior reinforcement activities such as summer camps, outings, and parties for client families. In January of 1977 the local DSS office for Families with Children had a staff of two masters level social workers, one of whom was the director, and eight bachelor's degree social workers (called technicians). One tech- nician carried out the intake function for all cases referred to the Families with Children office and the remainder of the staff functioned as social workers. The director estimated that the one master's level social worker and the two technicians who carried the most abuse cases spent about 100% of their time dealing with those clients, while the other six technicians spent less than 10% of their time on abuse cases. As a group, the director estimated that the workers spent approximately one-third of their time deal- ing with abuse. In 1974 the office had eight workers, two of which had master's degrees in social work. The services available from DSS included: case management, social work counseling, psychiatric evaluations, homemaking services, day care, adoption services, foster care, and placement in insti- tutions for the developmentally disabled. The local DSS office was providing more immediate service in January 1977 than in the fall of 1974. Whereas in 1974 it was common for protective service cases to go unattended for several weeks or more, in 1977 if a case appeared to be an emergency, a social worker would visit the home immediately. In situations which appeared undangerous, the staff were seeing the cases within three or four days. The staff were using a goal-oriented case record v.41 keeping system which was reviewed every six months. They appeared to be more thoroughly diagnosing child abuse cases and had a clearer concept of when it was appropriate to terminate cases. The services available through other community agencies were more limited, primarily consisting of counseling and some advocacy and support services. The school social workers provided counseling and assistance to parents in obtaining the needed services. The school districts offered some group ses- sions as well. In the northern school district of the city of Bayamon, there were nine social workers assigned to the elementery through senior high schools. According to their supervisor, they spent approximately 50% of their time on child abuse and neglect situations. In school year 1974-1975 the social workers had 940 cases.* In the first semester of school year 1976-1977 these workers had 1200 cases. In January 1977, the Municipal Health Center had an entirely new admin- istration. The one social worker who had been providing assistance to fami- lies and patients and making referrals to DSS had left the hospital when CETA funds which paid her salary were no longer available. Considering support services, there continued to be a critical shortage of low-cost housing. Since a change of housing was frequently necessary in order to stabilize a family situation, the lack of housing meant that some approaches to treatment were not as effective as they might have been. * : Note: since the district did not classify cases, these figures repre- sent all kinds of situations, not only child abuse and neglect. 1V.42 Essential services for children were provided through the Head Start programs, day care and the schools. Play therapy and therapeutic day care, however, were not available. Medical care for children was available through the Municipal Health Center for those who could not afford private care. However, the long waiting lines and the deteriorating physical conditions of the facilities make medical care difficult to obtain. The new director of the Center plans to establish community clinics, remodel the Center, and improve its services. The addition of a new subregional hospital, however, improved the quality of secondary care. Nonetheless, preventive health pro- grams in the Bayamon area continued to be very limited. In summary, during the period from May 1974 to January 1977, there had been a small increase in the quantity and quality of community resources available for treatment of child abuse and neglect outside what the project was offering to its clients. Community System Coordination The project was the principal means of facilitating coordination among the agencies in Bayamon. None of the other agencies appeared to have made any formal agreements for coordinating their services to abuse or neglect cases except for an informal working relationship between the schools and the local DSS office. The Interagency Committee, convened under the auspices of the project, represented the first time that most of the key community agencies had assembled to discuss the special community problems relating to child abuse and neglect. Agencies that were involved included the Head Start programs run by the city of Bayamon and the Evangelic Council, the Department of v.43 Services Against Drug Addiction, Police Department, Alcoholism Program, Department of Instruction, Local Health Center, Department of Housing and Urban Renewal, and several of the larger hospitals that serve the region and the island. During the fall of 1975, the committee developed a form to be used by all agencies to refer cases to DSS and the Unit. In 1976, these forms were circulated to all key community agencies. A Health Board composed of representatives of the various community health agencies met during 1975 to develop programs to meet Bayamon's most serious health prob- lems, particularly those pertaining to children. During the period from May 1974 to January 1977, according to records maintained for the national evaluation, the project spent approximately 8% of its total budget on coordinating with other agencies, primarily on edu- cational and administrative matters. The bulk of these coordinative efforts were to arrange meetings or to accumulate educational material for meetings. Some of these efforts were spent coordinating for administrative purposes or treatment to clients. Time spent on attempting to develop a more effective community system for identifying, referring or treating parents who abuse their children represented several percent of the pro- ject's budget. These figures do not include many of the project's activi- ties which had the indirect effect of improving the community system but which were accounted for under other headings in the project's record keeping system. Education and Public Awareness The staff of the various community agencies became more aware of the problems of child abuse, and to some extent neglect, in Bayamon, and more knowledgeable about where to refer cases. Almost all of the training that IV.44 the agency staff received was a result of the project's health educators’ efforts. According to statistics collected by the project, approximately 270 professionals were educated by the project in Bayamon during the period from May 1975 to January 1976. Almost three-quarters of those trained were teachers. Others included staff of Head Start, Municipal Health Center, Department of Health, and Department of Housing and Urban Renewal. The project made presentations before several professional conventions. In the period from January 1976 to December 1976, over 400 profes- sionals were educated. Principal among these were the local offices of DSS. Other agencies included the schools, alcoholism program, and Bayamon CRUV. The local Bayamon DSS office staff appeared to have made significant gains in improving their skills and awareness as a result of the project's educational activities. Similarly, the schools were enthusiastic about the project's training and appeared more capable of identifying and refer- ring cases of child abuse and neglect. The health educators made presentations before the parents of Head Start and public school students, community groups at the community centers in the housing projects, and mothers attending the well-baby clinic at the Municipal Health Center. In total, the project educated over 2100 people from May 1975 to January 1976. From January 1976 to December 1976, the project educated over 4100 people. In addition, the project participated in a dozen radio and television programs acquainting the public with child management, child development, social workers, child abuse and neglect, the project, and the reporting law. Several of the major daily newspapers ran articles on child abuse and neglect and the project. IV.45 In addition to the project, the public school health educators appeared to have focused more attention in their high school classes on child develop- ment and care. The school public health educators trained the health teachers on child development and the special problems of neglect and abuse. XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS Table 4 shows how project staff and consultant time and project budget were allocated, on average, to different project activities, as well as dis- playing typical monthly service volumes and unit costs for different activi- ties, A full 40% of staff time was spent on the provision of treatment ser- vices to clients; while over one-quarter of this was utilized in the review and management of cases, the project staff still managed to spend signifi- cant proportions of their time on different kinds of counseling and therapy services. With an average monthly caseload size of 70, and with up to eight new cases coming into the project in a typical month, the project offered: 92 individual counseling or therapy contacts a month; 34 sessions of family or couples counseling; 37 alcohol, drug or weight counseling sessions; and four group therapy person-sessions. One hundred fourteen person-sessions of parenting education were offered to clients and some members of the gen- eral community. The unit costs of services were quite stable over time with the exception of multidisciplinary team reviews which increased sub- stantially when the project started to pay professionals to come and sit in on the team. The cost to the project to provide a unit of any of the services was not substantially different from the cost to the community, given that the project used very few donated or volunteered resources in 1V.46 service provision. The unit costs, in general, are higher than one might find in the typical protective services department, undoubtedly due in part to the level of expertise on the staff. Of the 60% of project resources not used for direct treatment services, % of staff time (and 4% of the budget) was spent on preventive activities; 16% of time (and 8% of the budget) was spent on community and professional education; and 23% of staff time (32% of the budget) was spent on overhead activities including staff development and training, program planning, and general management. The project additionally spent 11% of its budget on its own internal research. 1v.47 Table 5: Project Resource Allocation and Service Costs Resource Allocation to Activities Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Annual Unit Cost tivity Allocation| Allocation | Average Monthly Volume | Unit Cost| to Community evention 7% 4% mmunity Education 11 4 ofessional Education 4 ordination 4 aff Development/Training 8 ogram Planning/Development 1 neral Management 13 27 oject Research 10 11 ‘A Evaluation 2 2 itreach -— -— 11 cases $ 7.75 $ 8.75 itake/Initial Diagnosis 2 2 8 intakes 16.00 19.00 ise Management/Review 10 9 70 average caseload 16.25 17.00 urt Case Activities 2 1 4 cases 33.50 33.75 iltidisciplinary Team Review 2 1 2 reviews 118.00 118.25 idividual Counseling 7 6 67 contacts 12.50 , 12,75 uples Counseling -- 1 9 contacts 10.75 10.75 mily Counseling 3 2 25 contacts 12,35) . 12/50 \cohol, Drug, Weight Counseling 1 1 37 person-sessions 10.50 10.75 dividual Therapy : 2 25 contacts 10.50 - 10.50 roup Therapy 1 -- 4 person-sessions 24.00 24.25 irent Education Classes 1 1 114 person-sessions 4.75 4.75 risis Intervention After Intake 2 2 7 contacts 29,25 ! 29.50 1ild Development Program S 4 -- -- -- :dical Care -- 1 6 visits 38.50 38.50 »1low-Up 1 1 8 person follow-ups -- -- ytal Annual Person Years/Budget 38.5 $150,912 Average monthly caseload = 70 ARKANSAS CHILD ABUSE AND NEGLECT PROJECT: LITTLE ROCK, ARKANSAS I. COMMUNITY CONTEXT Demographically, the three demonstration sites of the Arkansas Child Abuse and Neglect Project are similar. Each county has a single major town of under 100,000 population, and in each of the counties most of the people live in the major town. In other respects, however, the sites are unique and present different challenges for the local projects. The most important town in Garland County is Hot Springs National Park, a spa, resort and race- track town. The racetrack attracts a transient population in the spring, and in the summer tourists come to enjoy the scenery and water sports in the nearly Ouachita Mountains and to use the mineral water baths downtown. Many downtown establishments cater to the older visitors who come to the baths and in fact, about one-third of the permanent population is over the age of 65. In the winter, activities downtown and in the old-line hotels fall off dramatically. In Jefferson County, the major town is Pine Bluff, located south of Little Rock on the Arkansas River. Most employment in Pine Bluff is in agriculture or industry, and there are several industrial parks on the out - skirts of town. It is a settled town of mostly permanent, long-term resi- dents with strong class distinctions. The population of Pine Bluff has declined since the last census. Washington County is the second most populous county in Arkansas after Pulaski County (Little Rock). It is also the fastest growing county in the state. Most of the people live in Fayetteville and Springdale, two low- density towns lying contiguously along the principal north-south highway in the county. Fayetteville is the home of the University of Arkansas and attracts light industry and service industry, as well as mobile upper middle- class and professional families from many parts of the U.S. It is set in the scenic Ozark Mountains, in the northwest corner of the state, and offers the variety of cultural and professional opportunities usually found in a major university town. II. HISTORY Following the passage of the child protection legislation by the Arkansas legislature in 1967, the rate of reporting of child abuse and neglect cases to Arkansas Social Services began to increase. As the Social Services staff strained to provide adequate service to the growing caseload, it became apparent not only that additional resources would have to be committed to child protection, but that some new kind of community system would be needed to counter the apparent increase in incidence of abuse. Key to following the serendipitous fashion in which the Arkansas system for child protection evolved is the recognition of two independent and parallel efforts which were brought together by an abusive mother. One side of the history begins with the Pulaski County Task Force for Child Abuse, an organization which expanded, under the sponsorship of the 4-C Committee of the State Office of Early Childhood Development, to include the professionals who had served on an earlier Child Protection Committee at the University of Arkansas Medical Center and a corps of community people. While the Task Force moved forward, with the help of Dr. Ray Helfer, to ———— eens explore the available models for child protection, an informal effort was independently taking place which would ultimately lead to the creation of a workable system of volunteer service delivery to families in which child abuse had occurred. In the summer of 1971, Sharon Pallone, the founder and present-day director of SCAN, began working with an abusive mother as a volunteer lay therapist. In the course of events, Dr. Young, the Chairman of the Task Force, also worked with the woman, thereby becoming aware of Ms. Pallone's approach. Since the volunteer group concept resembled the model that had been proposed to the Task Force, Ms. Pallone was encouraged to recruit addi- tional volunteers who were then trained by Dr. Young, Ms. Pallone, and Social Services. By the summer of 1972, the group of volunteers had established a non-profit corporation, SCAN (Suspected Child Abuse and Neglect) Volunteer Services, Inc., and had been contracted by Social Services to offer treat- ment services. In time, as the caseload and lay therapy staff grew, and SCAN gained credibility within Arkansas Social Services, local task forces were formed in other counties of the state where public interest in the formation of SCAN units was fostered. By the fall of 1973, SCAN had hired a State Coor- dinator, held a second training session for new volunteers, and was operating local SCAN units in three additional counties. At this time, members of the staff at the University of Arkansas Graduate School of Social Work became aware of the availability of demonstration funds in the field of child abuse and approached SCAN and Arkansas Social Services to develop a proposal. The program, which was federally funded in the spring of 1974 for three years, involves three local SCAN units working in consort with Social Services vV.4 Coordinators in each county, who have responsibility for case knowledge and tracking and of facilitating the delivery of services provided by the county to SCAN clients. The two agencies share the project purpose of demonstrating the feasibility of the volunteer model, in which lay therapists provide pro- tective services for children and families such that the quality of the family relationship can be improved to insure the child's safety in his or her own home. Management of the multi-county project takes place in the state offices of Arkansas Social Services and in the central SCAN office, both in Little Rock. III. SUMMARY OF ACTIVITIES Summary of First Year e Hired and trained two-person staffs for three demonstration counties (Garland, Jefferson, Washington); | eo Recruited and trained volunteer lay therapists; e Organized Parents Anonymous groups in demonstration counties; e Formed hospital diagnostic teams in each project county; e Formed additional consultation teams in two counties; e Solidified agenda and presented two SCAN trainings in Little Rock; eo Provided technical assistance in the passage of state child abuse legislation which expanded reporting requirements and permitted Arkansas to meet federal guidelines; e Relocated state offices of Arkansas Social Services (and the demon- stration project management) to new quarters; e Experienced smooth transition of directorship in one demonstration county (Garland); V.5 Developed and distributed public information packet; Extensive community and professional education program mounted in all project counties; Achieved operational model of a community-based volunteer service coordinated with Social Services. Summary of Second Year Garland County project closed after months of effort to make the model workable had failed to result in a caseload size that justi- fied the expenditure. Referrals were limited due to non-acceptance of the project by the community's bureaucratic structure; Resignation of project director and subsequent assumption of adminis- trative responsibilities by first director's supervisor in the Social Services hierarchy; Second county experienced turnover of SCAN director (Washington); Two SCAN trainings held in Little Rock; SCAN/Social Services model replicated in three additional counties under Title XX matching funds (Drew, Pope, Yell); Community and professional education program continued; Monthly director's meetings initiated in Little Rock for coordina- tion, training and program planning purposes; Reactivation of Task Forces in counties to raise donor money to meet the Title XX 25% match for program continuation. Summary of Third Year SCAN/Social Services model replicated in three additional counties (Benton, Craighead, Mississippi); V.6 e Three SCAN trainings held in Little Rock; e Commmity and professional education program continued; eo Complete staff turnover in third project county (Jefferson); eo Central Registry brought up to date; e Efforts underway in the state legislature to include half of each county's donor money as a line item in the state budget. IV. ORGANIZATIONAL STRUCTURE AND STAFFING PATTERNS The most notable feature of the Arkansas project's organizational struc- ture is its unity and cohesion, despite the fact that it is dispersed among four different cities and in two separate offices in each city. In each of the three demonstration counties there is a separate local SCAN office, housing the SCAN staff, and a Social Services Coordinator, located in the county offices of the Division of Social Services. In Little Rock, the pro- ject headquarters are in the State Department of Social Services, and SCAN headquarters are on the grounds of the Arkansas State Hospital. The DHEW demonstration grant is housed within the Division of Social Services with subcontracts to the Graduate School of Social Work and SCAN. At project headquarters a management information system is maintained, containing monthly client data. Day-to-day decisions, needed for the refinement of the inter- action between SCAN and Social Services, are made here. Management consul- tation is provided by the Graduate School of Social Work, which furnishes this service to numerous social projects in Arkansas. Figure 1 is a diagram of the Arkansas project organization. The organi- zation contains only one formal chain of command, that within the SCAN organi- zation connecting SCAN headquarters with the local SCAN units and the lay therapists; the rest of the project organization operates by cooperative V.7 ~e a ess em ep re ce st me es ses von) Figure 1: Organizational Chart ED pv —— — — — — — — — — — ——— — — — — 7 Fem" Lo [ Project Management | | | State SCAN I Director Consultant | Director SCAN I Headquarters [1 ] project | headquarters Assistant | State SCAN | in the Management I Coordinator | central Consultant | | office L__1 | of Arkansas | TTTTTTT TT TTT TTT Social Services am Eo Rt ise eed) ro-mm-fETEAnI IE Ty | Social I Social | | Local local | bm | Services | Services he- SCAN SCAN | | I Agency Coordinator | | | Director unit Lg 4 | Office | od. | | | ! mms bd | I | If § nr ol E | £1512] Assistant =| = | = | ! Local SCAN S| al a Director | =] S| §». | pod || | | local project | | Loy | 1:3 Bg 1 I 1 I Lay Therapists Clients Po (approx. 15) I ] I. i ro | I agreements. The Social Services coordinators work within the organizational framework of the local Division of Social Services. Written procedures have been developed by the project for coordination between the Social Services coordinators and the local SCAN directors. The Project Director works within the organizational framework of the State Office of Social Services and, in fact, spends three-fourths time with that organization, with her salary paid by them. The Project Management Consultant and her assistant take care of the day-to-day monitoring of the project, short-term problem solving and technical assistance for local projects in the demonstration counties. The State Director of SCAN, Inc., deals with the overall policy development for that organization and with the overall coordination of SCAN with Arkansas Social Services. She supervises the operation of SCAN state-wide and is avail- able for consultation on all abuse and neglect cases. Her half-time involvement in the project is divided between SCAN and expansion efforts throughout the state. SCAN Volunteer Services, Inc., has a Board of Directors that develops policy for the organization. The State SCAN Coordinator provides the day-to- day supervision of the local SCAN directors and attends the ''staffing sessions" that each project holds every two weeks. The key to successful case management at the local level is the effec- tive coordination between the SCAN Director and the Social Services Coordi- nator. The Local SCAN Directors are primarily concerned with the evaluation and initial disposition of new referrals to the project and with case manage- ment of the SCAN cases in their communities. They supervise the work of the lay therapists, provide some individual counseling to clients, provide support and back-up for the local chapter of Parents Anonymous, and devote time to community education and the coordination of community services. They work V.9 in tandem with the Assistant SCAN Directors. The Social Service Coordinators are responsible for expediting and facilitating the delivery of services from the Division of Social Services to the SCAN clients who are to receive them. The Coordinator works in close cooperation with the SCAN director on the development of case plans and participates in case reviews both at the SCAN staffing sessions and at meetings of the hospital review team. In addi- tion, the Coordinator keeps the Social Services records for SCAN cases, assists in the development of foster homes and arrangements for day care, and sometimes speaks at community functions. The Lay Therapists make themselves available for accepting cases assigned to them by the SCAN Director. They sometimes participate in the initial investigation of a case during intake and then begin their lay therapy on an intensive basis when they are assigned to the case. Their hours are flexible, but they are on call to the families they are working with 24 hours a day, seven days a week. The lay therapists are reimbursed for up to $50 of their expenses per month and are considered volunteer staff members. This reim- bursement is a critical consideration in the lay therapy model, in that, depending upon the personal financial situation of the volunteer, the $50 monthly budget may offset any disadvantages they may experience in volun- teering. Turnover among the lay therapists usually occurs only when a lay therapist moves from the community or when there is a change in the lay therapist's own family situation. Many of the lay thera- pists have college degrees, and some have been trained in or have worked in various professions which help them in their work and add to the effec- tiveness of the semi-monthly case reviews. V.10 Vv. PROJECT COMPONENTS The project components have evolved somewhat from the model that had been proposed to the original task force. Education The project provides public education, professional education and train- ing for the lay therapists. The public education provided by the local pro- jects takes place mostly in the form of various kinds of speaking engagements with schools, community groups, and other organizations in the county. The presentations are made mostly by the SCAN directors and their assistants, Sometimes the Social Service Coordinators, lay therapists and SCAN clients participate. The original proposal specifically expressed the intention to promote prevention of abuse in the community, and the project does attempt to find opportunities where their public education efforts will reach a clientele that is at risk. The project also responds to professional groups that request information and also seeks out professional groups, such as the police, who should be informed of the project's position in the community and the nature of the child abuse problem. At the headquarters level, staff members furnish public education pro- grams with a wider scope, including speaking engagements throughout Arkansas and out of state, dissemination of a packet of informational material that can be sent in answer to written requests for information, and broad circu- lation of the monthly project newsletter, FOCUS, which is intended primarily for the project offices, but which is sent to a variety of other groups and agencies. An integral part of the operation of SCAN is the recruitment and train- ing of lay therapists. The lay therapy training session in Little Rock runs v.11 for three days and is very intensive. The training sessions take place two to three times a year and are generally scheduled to accomodate the volun- teers who are waiting to begin. The SCAN training sessions are open to and attended by other members of the community besides lay therapists. A typical training session includes lectures, panels and presentations on the following topics: Orientation to SCAN; How to Identify Child Abuse; Dynamics of Child Abuse; Early Childhood Development; How Parents Deviate; Lay Therapist Case- work Presentations; Parents Anonymous Panel; Transactional Analysis; Principles and Techniques of Interviewing; Legal Aspects of Child Abuse; and Social Services and SCAN. After the initial training session, the lay therapists continue to receive training in the form of the guidance given them during the semi-monthly staffing sessions, and also attendance at special seminars on selected topics several times a year. Diagnosis Cases usually come to the project as a result of the project's coordi- nation and education efforts. The efforts to develop referral procedures and agreements with other agencies have led to referrals from those agencies, and promotion of SCAN in the community has led to neighbors and relatives, as well as the abusers themselves, reporting directly to SCAN rather than to other agencies. Some diagnosis is inherent in the evaluation of a refer- ral, and further diagnostic consultation occurs during intake and during the ongoing case review. Several kinds of diagnostic consultation have been designed for the project. First, the local SCAN Director and Social Services Coordinator can consult with SCAN headquarters after the evaluation to make the initial v.12 disposition. After the case has been accepted it is reviewed every two weeks at the SCAN staffing session until it is stabilized. Then there is occa- sional review as part of the periodic follow-up that continues as long as the family stays in the community. For cases that originate at the hospital, there is periodic review by the hospital teams that were formed in each of the demonstration counties as a result of project efforts. For non-hospital cases a separate consultation team has been established in two of the counties for periodic review. These consultation teams are made up of mental health and social work professionals who review cases periodically on a community- wide basis. Referral to other agencies is an integral part of the project since SCAN accepts only cases of abuse and severe neglect, and then usually only cases in which the child is 12 years old or younger. Inappropriate cases that are reported directly to SCAN are referred by the Social Services Coordina- tor to Arkansas Social Services where that group's crisis intervention, counseling, and other services are made available. Treatment The SCAN units principally offer crisis intervention and lay therapy as treatment services. The local staffs have also organized Parents Anony- mous chapters, multidisciplinary teams, and hospital committees in the demon- stration counties and provide continuous support for them. Within Parents Anonymous, they arrange for volunteers to be on hand to care for children while their parents are in the session; they provide transportation to the session when it is needed; and, above all, they provide the patient and sen- sitive coaxing, sometimes extending over several weeks, that is needed to v.13 get some parents to come to Parents Anonymous. Through Arkansas Social Ser- vices, the local projects also make day care and foster care services avail- able. Lay therapy counseling is the name given to a complex set of responsi- bilities. The prime task of the lay therapist is to establish a trust relationship with the client. From this basic therapeutic friendship, various hats are assumed by the lay therapist, such as that of parenting model; marriage, sex education and/or child development counselor; as well as that of a resource and advocate for needed auxiliary services, including home- making, babysitting, day care and transportation. In assuming any and all of these responsibilities, the lay therapist strives to maintain a non- judgmental, non-punitive relationship with his/her clients with the end goal of enabling the parent to reach discipline alternatives to abuse and to achieve independence. Crisis intervention is a distinct service of the project and an inte- gral part of the lay therapy. Sometimes a case is initiated through SCAN's intervention in a crisis situation that is reported to the project. Once a case has been accepted by SCAN and a lay therapist is assigned, the lay therapist is ''on call" to the family 24 hours a day, and although it is not always scparable from the rest of the lay therapy, a portion of the lay therapy is actually crisis intervention. Originally, crisis intervention was considered not only a distinct service but also a form of protection for the child; it has evolved into a service that is considered to help the family as a unit. Following the mutual decision to close a case as stabilized, the lay therapist continues to keep in touch with the family from time to time to assess its ability to function independently. et bm —— V.14 VI. IMPLEMENTATION/OPERATION PROBLEMS The Arkansas project had few serious implementation problems; however, some issues appear to be inherent in this kind of model in which a volunteer service is provided in cooperation with a county Social Services Division. Legitimacy Since the Division of Social Services carries the legal responsibility for providing protective services, some individuals and agencies in the com- munity questioned whether SCAN, as a private non-profit corporation, could be accepted as a legitimate agency for satisfying the legal mandate. The project staff feels that its model could have had a better start in the com- munity if they had prepared a circular that clarified the legal position of the private group and reassured those concerned about it by including signa- tures of appropriate officials. Credibility There was, as well, the matter of legitimacy in the broader sense of gaining acceptance by other agencies as a dependable and effective group. SCAN's efforts to establish credibility with other agencies and thereby gain their confidence and support were dependent upon their consistent demonstra- tion of capability. Confidentiality During most of the first year the local projects were at a slight dis- advantage in diagnosing and reviewing cases of clients who were receiving treatment elsewhere in the community. The confidentiality agreements between clients and the community mental health centers or private counseling v.15 services precluded the sharing of information about clients there with SCAN. In one of the communities, arrangements have been made for sharing this information if the client gives his or her written consent. Cooperative Procedures between SCAN and Social Services Since the Social Services Coordinator works within the organizational structure of Arkansas Social Services and occupies office space there while working closely with the SCAN Director for the project, it is essential that priorities and procedures be established to ensure efficient joint decision making. During the first year, written procedures were developed as they were requested, and the project headquarters has re-emphasized them periodi- cally, especially at the time of turnover in the position of Director or Coordinator. Beyond this, however, it has been necessary to gradually define the Coordinator's position more and more clearly with the local Department of Social Services, in order to develop a clear chain of command and distri- bution of responsibilities. Lay Therapist's Administrative Work The principal service of the project is lay therapy, provided by volun- teers who receive only a maximum compensation of $50 a month for expenses. The concept of lay therapy as an effective service involves an element of informality, i.e., a therapeutic friendship between the client and someone else in the community who does not represent authority or the threat of puni- tive action. For both of these reasons it is important that the lay thera- pists be as unencumbered as possible with administrative duties and paper work, and the project felt that the lay therapists could not be asked to do a great deal of extra administrative work. This matter was settled by getting V.16 additional staff positions -- first, an Assistant Management Consultant at project headquarters who travels to the demonstration counties to get the needed information and, second, an Assistant Director for each SCAN office. The assistant directors were already needed to absorb some of the growing workload of the directors, and the addition of the evaluation work necessi- tated a full-time position. Physical Dispersion of the Project The project operates in four different cities and in two different offices in each. The State SCAN Coordinator travels to each demonstration county every two weeks, which helps to keep the local projects in touch with each other, and the State SCAN Director and project headquarters staff make occa- sional visits to the local projects. This does mean, however, that meetings always imply extensive travel time, which must be taken from time that staff members could use for some other purpose. The Centrex telephone system makes it possible for the various parts of the project to have frequent telephone contact, and the project initiated, in the spring of 1975, a monthly news- letter, FOCUS, which summarizes the month's developments for all members of the project. It was felt by the project staff that provisions in the form of centralized and coordinated communication, as well as through funds for field contact, must be made to accomodate physical dispersion. VII. FUTURE PLANS The continuation of both SCAN demonstration counties and the seven non- project counties is quite secure in that the contract with the Division of Social Services was renewed and written into the State Plan. The funding v.17 mechanism will be Title XX matching funds for the demonstration counties after the expiration of the grant in April 1977, as it is for the other SCAN counties. Under Title XX, each SCAN unit is responsible, through its own efforts or those of a representative Task Force, to raise 25% of its annual budget through donor money. On the average this amounts to approximately $10,000 per county. Both project counties have already met their donor money quota for the post-grant period. While all the Title XX counties have annually responded to the necessity to generate their matching funds, the arrangement is problematic for a long-term funding program. The time and energy required to run such a campaign interferes with the ongoing adminis- tration, and ultimately the service delivery, of the project. Now that the Division of Social Services has made a commitment to SCAN's value as an essen- tial service provider, they are currently working to include one-half of the counties' Title XX share as a line item in the state budget, with the hope that Task Forces in the counties will assume responsibility for raising the remainder. VIII. PROJECT GOALS An assessment of goal attainment for the Arkansas Child Abuse and Ne- glect Project must address two distinct sets of objectives: the original six goals proposed in the initial grant application, as well as the revised set of four goals submitted in the second year progress report. Of the original goals, four were fully accomplished during the first year of the demonstration project. The second year goals clarified those objectives which were partially or wholly unmet during the first year and supplemented them with additional goals. While the overall project has made impressive V.18 progress toward accomplishing both sets of goals, one counterproductive event should be recognized at the outset, namely, the closing of the Garland County SCAN office in February 1976. Although this event has been offset with the opening of six new units, none was added to the demonstration project. The closing was not regarded by the central staff as a failure of the model, but rather as a valuable lesson in the necessity of gaining community agencies’ support and commitment to the new service effort prior to opening a unit. Original Goals Goal 1: To organize and train a voluntary lay therapist team to work with the abused child and his family in three counties in Arkansas. The three counties chosen to participate in the demonstration project included Garland, Jefferson and Washington, each of which differed geogra- phically and demographically from the other two. At the time the grant was awarded (spring 1974) the SCAN/Social Services model had been in operation in Jefferson and Washington counties for nearly a year, albeit not at the level envisioned in the grant. The four objectives designed to accomplish this first goal were met during the first year; they included hiring staff for each county, developing task forces, and recruiting and training lay therapists. During the first year the project staff for each county was comprised of a director and secretary at the local SCAN office and a social services coordinator who, although paid by the project, was housed in the local divi- sion of Social Services. Each of the projects was completely staffed by September 1974. The following year one staff position was added in the form of an assistant director. v.19 Since efforts to mobilize the communities had been initiated by SCAN early in 1973, active task forces on child protection were functioning in all three of the project counties before the demonstration grant was awarded. In Garland County, 18 of the 75 attendees at the first meeting became regular members whose major efforts included community education, encouragement of reporting, and recruitment of volunteers. Jefferson County developed an active task force of 22 members out of a conference on child abuse and ne- glect which drew 200 attendees in Pine Bluff. The task force divided into three sub-groups (diagnosis, education, and treatment) and in the course of its functioning helped to develop the hospital diagnostic team in Pine Bluff, conducted professional education seminars, and aided in recruiting lay thera- pists. The kick-off seminar on child abuse in Washington County drew 140 attendees early in 1973, with little immediate follow-on interest in the development of a task force. However, an individualized appeal, accompanied by media publicity, resulted in an eventual task force of 48 members which supplemented SCAN activities, such as professional education and recruitment of lay therapists. The third and four objectives to accomplishing the goal of developing lay therapist teams involved the recruitment and training of volunteers. Prior to the grant, Jefferson had seven and Washington County had eight trained lay therapists. Since April 1974, there have been seven formal training sessions held in Little Rock and two special sessions held for counties in particular need of additional lay therapists. In the course of the train- ing sessions, Garland County trained 16 lay therapists, Jefferson County trained an additional 20, and Washington County trained an additional 25. These figures represent the volunteers who later assumed a caseload; v.20 significantly larger numbers attended the training sessions than became active lay therapists. The turnover among those who were active has resulted in current lay therapy teams of 19 in Jefferson County and 14 in Washington County. This compares very favorably with the anticipated need of 10 lay therapists for each county. The Garland County project was closed in Feb- ruary 1976, as mentioned earlier, and consequently has no lay therapists at present. The following table illustrates the accomplishments of this objective: Garland Jefferson Washington Active lay therapists prior to grant 0 7 8 Total trained lay therapists 16 27 32 Current active lay therapists 0 19 14 Goal 2: To develop diagnostic teams in community hospitals in three demonstration counties to staff and diagnose cases of child abuse and neglect that are found among the patient population. In meeting this goal, the task forces and projects in each county iden- tified the appropriate persons to serve on such a diagnostic team by notify- ing hospital administrators, doctors and nurses of the projects' existence and purposes. Later, presentations were made to explain these in greater detail and to explore the purposes and functions of the proposed diagnostic team to those willing to participate. Cooperation was immediate in all three counties and hospital diagnostic teams were established early in the first year of the demonstration. The Garland County team numbered 13 when it was operating; the Jefferson County team is fully functional with 17 members; and Washington County teams, developed at both the Fayetteville and Spring- dale hospitals, have ten and seven members, respectively. v.21 Goal 3: To develop consultation teams comprised of protective service specialists, mental health specialists, pediatricians, etc., to provide consultation and assistance in those cases of sus- pected abuse and/or neglect that are not reported through a hospital setting. Listings were developed of all doctors, nurses, lawyers, public officials, teachers, counselors, and other professional perspectives. Subsequent mail- ings of information helped to identify interested individuals, who in turn joined the Task Forces and/or signed letters of agreement to provide consul- tation services on request. By the end of the first year Garland County had two such agreements; Jefferson County had 10; and Washington County had eight. Although the goal was considered accomplished, both of the two current projects have continued to solicit agreements from additional consulting perspectives in their communities until Jefferson County presently has 23 professionals, and Washington County has 38, who are available for consultation on treatment planning and review of cases which are not hospital-based. While initially the team was conceived as a formal multidisciplinary review team, it was found that a great many more professionals were willing to consult on cases on an informal, ad hoc basis. Hence, the current large pool of consultants, representing social work counseling, mental health coun- seling, legal advocacy, medical advice, and academic and religious perspec- tives, is available from which the project can request attendance at the regular bi-monthly staffings. Goal 4: To coordinate the SCAN volunteer effort with all services and supportive agencies in the counties served. While this goal was partially met in the first year, it was clarified v.22 and expanded in the second year grant application and will be discussed under Revised Goals. Goal 5: To organize a Parents Anonymous group in the counties where one does not yet exist. In each of the demonstration counties, the project staff sponsored, in cooperation with the national organization, a chapter of Parents Anonymous. By the summer of 1974, groups of varying sizes were active in all three coun- ties: Garland County averaged seven attendees; Jefferson County averaged 12; and Washington County averaged four. While the goal was met initially, the chapter in Garland County ceased with the closing of the SCAN office, since no sponsor could be found to continue the group. In Washington County, the PA group was discontinued for nine months. During this time, some of the regular members began attending the Parent Education classes. The series of classes, which drew an average of 30 attendees, continued through the summer and fall of 1976. Parents Anonymous was reactivated in October, 1976, with an average attendance of 8 to 10 persons. Jefferson County's Parents Anonymous group, averaging 15 parents now, continues to meet weekly. In addition, there have been PA groups started in each of the expansion counties, as well as the continued meeting in Little Rock of Arkansas' first PA group, which was started more than four years ago by the SCAN staff. Goal 6: To assist in providing a coordinated comprehensive community- based volunteer service to abused children and their parents in the three demonstration counties -- a model that can be expanded to statewide coverage. In many respects, this goal is a composite of the previous five, although it goes beyond the others in its implications for a specific goal of expansion. v.23 Insofar as the other original goals were met during the first year, so was the sixth. However, the last clause which referred to expanding the model to statewide coverage was not formally clarified in the revised goals for the second year. The project nonethless formed the nucleus of six additional county SCAN/Social Service units. Revised Goals In December 1974, when BPA conducted the Nominal Group Process for the purpose of clarifying goals, only two of the original six were not already fully accomplished. Consequently, the overall goal for the remainder of the project proposed to continue to demonstrate the feasibility of the volun- teer model which utilizes lay therapists in providing protective services to children and families involved in the problem of child abuse and neglect. Goal 1: Identify, develop, expand, contract for, and coordinate county- wide resources necessary for more effective SCAN/Social Services. The SCAN units achieved early coordination with the major county re- sources including social services, community hospitals, schools, Head Start, juvenile courts, public health and community mental health clinics. During the first program year, cooperative procedures between SCAN and Social Services were developed, and orientation meetings were held for the involved county and central staff. The individual county SCAN directors and Social Services coordinators had the task of promoting working relationships with the other mandated agencies, initially with the object of obtaining verbal agreements. By the second year, the goal was expanded to gain written agreements from these and other community service providers, resulting in the development of county resource directories. The directories listed cooperating agencies, services provided, contact persons and similar useful information. V.24 By the end of the second year, the county directors estimated that they had tapped approximately 90% of the available service providers. Written agreements, totalling 11 for Garland County, 11 for Jefferson County, and 30 for Washington County, were compiled in the resource directories. In addition, plans for assistance from community groups (including sororities, church groups, and civic organizations) were developed during this time. As a consequence of this coordination of service provision and referral procedures, the number of referrals from agencies with which aggreements were made has increased manyfold (e.g., in Pine Bluff, referrals increased from six in June 1974 to 34 in March 1976). While acceptance of referrals from the agencies has not changed markedly, the service providing agencies understand the dynamics of the problems better. It is important to remember throughout this discussion that the critical service being provided to SCAN clients is lay therapy and most other services are viewed as supplemental to it. Goal 2: To support the cooperative efforts of public agencies/private agencies/volunteer groups to provide specific services on behalf of clients. The primary service provided by community public and private agencies is that of consulting on project cases under the auspices of the hospital diagnos- tic team or in a staff development or general consulting capacity. Some direct services, such as food stamps and the well-baby clinic, are provided as well. By the end of the third year the three projects had developed the following agreements with individuals to serve as consultants: Garland Jefferson Washington Hospital diagnostic team 13 17 10 Staff development and general project consultants 2 23 30 v.25 The disciplines represented on these teams include hospital adminis- trators, social service workers, mental health counselors, physicians, attor- neys, public health nurses, police, rectors and school counselors. Volunteer groups, which have agreed to supply specific support services, supplement the above mentioned disciplines with emergency food, clothing and shelter, babysitting, transportation, and donor funds. In Garland County, two such volunteer groups were in agreement at the end of the second year, with four and six respectively in Jefferson and Washington counties. Since the beginning of the project, the hospital case diagnos- tic team reviews have increased to approximately twelve hours per month in each county; general consultation at project staffings has increased to about three hours per month; and staff development by outside consultants has increased to four hours per month. The project directors estimate that 70-80% of all cases are discussed with consultants at one time or another. About 50% of SCAN cases receive some services from volunteer agencies or groups, albeit not always through direct referral by SCAN to the service provider. Goal 3: Ensure immediate delivery of services to project clients and encourage other agencies to accept and provide services to project clients on a more immediate basis. In fact, it was very difficult to improve upon the responsiveness of SCAN in either evaluating intakes or delivering lay therapy services, since crisis referrals are responded to immediately with staff evaluation and sub- sequent assignment, and all other referrals are responded to within a day or two. In part, increasing the number of lay therapists (as discussed under the original goals) has enabled the project to maintain its service V.26 delivery speed, since new cases do not have to be held awaiting a service provider. However, recently the need has been felt for additional staff to keep up with the increasing evaluations. While the caseload has increased six times in the three year period under consideration, the paid staff has only doubled, placing considerable administrative and case management pres- sures on the staff. The project has relinquished early expectations to secure priority treatment from other agencies in the community for SCAN clients. While the goal is considered unrealistic in the light of other obligations these ser- vice providers have, it is often accomplished through the persistence of the lay therapists in facilitating their clients' satisfaction of needs. Goal 4: Educate the project community, including professionals, regard- ing dynamics of abuse and the necessity of reporting as provided by state law. There is a total of nearly 20 speakers available in Jefferson and Washing- ton counties for responding to appropriate speaking requests. The projects receive four to five inquiries each week, which ultimately materialize into about 90 personal appearances each year. In Washington County alone, approximately 1200 individuals attended presentations in 1975. Most of the key agencies (schools, hospitals, police, court, mental health, public health and day care) received at least two pre- sentations, with a total cumulative attendance of 275 professionals. Four- teen speeches to various classes at the University (Social Welfare, Home Economics, Child Development, Secondary Education and the Legal Clinic) exposed more than 400 students to the SCAN program. Twelve presentations to community groups (PTA, Kiwanis, Hospital Women's Auxiliary and the like) v.27 reached another 400 lay people. And an inestimable proportion of the com- munity was reached through the various media coverage (radio spots, seven newspaper articles, and a local television feature interview) and the dis- tribution of 5000 pamphlets. Preventive education efforts for populations at risk numbered 11, counting the Parent Education course offered by the project. Attendance averaged 30 parents or prospective parents at these sessions. The proportion of self referrals to the project and the proportion of prospective clients who are aware of SCAN has increased moderately. Where- as none of the six referrals to Pine Bluff in the first month of the project were self referrals, currently two or three of the 29 to 34 referrals each month are self referrals. Approximately 60% of the prospective clients in Pine Bluff and 50% of those in Fayetteville express awareness of SCAN and its purpose when initially visited. While originally most reports came from interested citizens, the results of professional education efforts can be seen in the nearly equal split between professional and lay reporting. The school authorities and medical professionals are responsible for most of this increase in professional reporting. v.28 IX. PROJECT MANAGEMENT AND WORKER SATISFACTION Organizational Structure The Arkansas project is one of the largest projects among the eleven demonstrations. In addition to the seven full-time staff, there are appro- ximately 130 workers involved in the SCAN program. Lay therapists, social service coordinators, and a pool of professional consultants make up this added manpower resource. The two county offices serve an average of 73 clients a month, operating on a combined monthly budget of a modest $11,129. The project's organizational structure is highly complex because of the wide dispersion among the project offices, the number of agencies joint- ly participating, and because of the seven or more professional disciplines that actively contribute to the project's activities. The project has formalized guidelines and working arrangements for the three major agency participants (Social Services, the University and SCAN), delineating procedures for coordination both at the central and local levels. While job descriptions were written for the first year grant, there remains high flexibility and somewhat ambiguous operating rules within SCAN. Prior to September 1976, there did not exist any for- malized personnel record keeping syste. Records of workers' absenteeism and turnover did not exist. There were no written operating manuals de- fining promotion opportunities, recruitment and hiring practices, or a formalized system for sharing information. It is in the central office in Little Rock that policy decisions and program plans are made. Further, the central office exercises some control and input into decisions made by local offices via control over the budget, and through the regional coordinators who are largely responsible for supervising county offices and coordinating v.29 the local directors with the central office. Despite the important role Little Rock has in project policies, the county directors tend to be highly autonomous, exercising personal latitude in planning and implementing pro- ject activities. Management Problems As mentioned previously, the SCAN project has a widely dispersed or- ganizational structure and involved inter-agency effort at both a central and local level. It is not surprising that the key management problems between the central and local offices and among the SCAN county directors and social service workers are concerned with coordination and communica- tion problems and decision making roles. Often coordination and communi- cation between SCAN central office and the state office of social services has been facilitated by the University's management consultant available to the project to assist with inter-agency disagreements. But at the county levels, much of the coordination has been successful or unsuccessful depend- ing upon the personalities, commitment and other priorities in the local offices. Because most SCAN workers perform a capable job with their clients, the local social services have grown to trust and value SCAN's assistance. With increased trust, many initial coordination problems have been resolved. Within SCAN itself, the primary source of coordination is the centrex phone system which allows much informal contact among the SCAN workers. Another source of coordination has been the state office coordinator who travels to the local districts every two weeks and directs the staffing with the lay therapist and local administrators. In addition, a management assistant from the University publishes a newsletter once a month and tends to assist in sharing information on personal and program developments. As v.30 SCAN has grown there has been some effort, albeit belated, to create a sup- port group among the local directors to coordinate activities, share ideas and give assistance to each other. Many SCAN lay therapists report that they do not know anything about how decisions are made or how the central office is run. Many feel disassociated from the central office. Informa- tion sharing also tends to be one way (down rather than up); hence, many local staff members resent the central office's seeming reluctance to elicit or use input from the counties, and they have begun to resist this one way flow of information. Management Some of the growing dissatisfaction with the management and organi- zation from SCAN workers is because SCAN's tremendous growth in the last few years is taxing the agency's existing structure and tradition. While additional state-level coordinators have been added to cope with the new county programs, until recently there has been little consideration of revising the decision making process or promoting cross-county coordina- tion. Historically communication and decision making are controlled pri- marily by the SCAN Director. This was more feasible when SCAN consisted of one office and an informal group of volunteers. Now, as the program has become much more complex, decisions made by a single individual appear to be insensitive or inappropriate to each county's needs. SCAN training is a particularly apt example of the agency's isolated decision making and heavy emphasis on tradition. Training has always been held in Little Rock, despite the fact that lay therapist recruits increasingly come from outlying counties and must drive long distances and stay at considerable personal expense in Little Rock. The number of potential recruits has v.31 outgrown the facilities in the last few sessions, requiring many to sit long hours on the floor. Previously, recruits could be screened through- out training because of the close and intimate contact with the SCAN leaders. Now screening is less systematic and primarily relies on indi- viduals to drop out. Initially all attendees of the training were new recruits and required basic orientation and background information. Now many lay therapists have come to 4-6 sessions and find the material irre- levant to their more sophisticated needs and expectations. County direc- tors have tried to modify this training with only minor success, i.e., recent training sessions have included several seminars for advanced lay therapists. A charismatic leader was primarily responsible for establishing SCAN. Although she has had the able assistance of others, she has played an un- questionable role in SCAN's success and direction. She has always main- tained ultimate control. However, as the agency grew, there was a need for management and decision making systems to become more routinized. This has happened very slowly and in an unplanned fashion. Recently, the local counties have become more vocal in demanding some input into decisions that affect them, and are beginning to assert their power and introduce ideas that will make the organization and management more relevant to its increased size and more varied program activities. Turnover While there has been only moderate turnover among the full-time staff, three out of an average staff size of seven, there has been high turnover among the lay therapists. Over half of the lay therapists in both Washington and Jefferson counties left after an average stay of 8.8 months. A small ¥.32 percentage stated they left because they were burned out; about 25% left because they were moving; about 25% left because they were thought to be ill-suited for the job; and approximately 50% left for personal or medical reasons. Some of the complaints mentioned by volunteers, in explanation of the turnover, included: "I never did know what I was supposed to be doing with my families"; '""Most of our families do not know why we are coming nor do they want us to visit them. Few families are grateful for our efforts'; 'There is no real supervision or help in the handling of our cases. The group staffing is often depressing because no one's clients seem to be getting better'; "I don't feel able to help many of these fami- lies because they have so many problems.' Many lay therapists feel unappre- ciated and unrewarded by SCAN staff and the Little Rock office, evidenced by the disregard they feel at the training sessions. Many feel strong value conflicts with clients and feel unable to work with some clients. Most of the reported burnout (33%) occurred among those lay thera- pists and the few staff members who lost their jobs when job descriptions were changed without their input. Interestingly, despite the nagging management struggles, most workers in the SCAN projects report high satis- faction (73%) and very little burnout. This consistent enthusiasm for the project seems to be due to the reported great opportunities for self growth and development that staff have experienced through their work with SCAN and with community professionals and clients. In addition to personal growth opportunities, there is a strong commitment by all SCAN workers to each other and to the SCAN program that transcends the organization. And, finally, most of the workers who are highly satisfied and motivated also experience strong supportive family relationships and extensive social v.33 activities that nurture them off the job and provide a healthy distraction from their work. X. ANALYSIS OF CLIENT DATA Client Flow Almost all referrals to the project come by telephone, from other agen- cies in the community, particularly Social Services and the Juvenile Court, and from neighbors, relatives, anonymous callers and self-referrals. A referral to the project is taken by the local SCAN director or, if she is out on a case, by the Assistant Director or the Secretary. For all reports, the SCAN director calls the Social Services coordinator to find out anything that Social Services may have in their records about the case and then pre- pares for the home evaluation. At this time a report is sent to the Central Registry. An attempt is made by the local SCAN staff to evaluate all cases within 48 hours, but crisis cases are evaluated immediately, regardless of the time of day or night. During the evaluation, the SCAN evaluator takes a non-threatening position with the family, offering help and trying to get the family to accept SCAN services. If there is any reason to suspect that abuse might have occurred or be potential, a lay therapist will be assigned and begin visiting the client at once. If the initial evaluation indicates that the case is a neglect case, it is referred to Social Services, the appropriate agency. Once the evaluation has shown that there has been abuse or severe ne- glect, or that there is potential for it, the case is entered in the SCAN V.34 caseload and begins to be reviewed at the semi-monthly SCAN staffing ses- sions. A preliminary case plan is made by the local SCAN director and the lay therapist, with assistance from the State SCAN Coordinator and the Social Services Coordinator in some (i.e., severe) cases, to provide any immediate services beyond the lay therapy, such as day care or counseling, which need to be arranged through Social Services. Besides the reviews at SCAN staffings, the case will be reviewed by the Multidisciplinary Team at the hospital if it is a hospital case or a particularly serious case, and possibly by the community consultation team in the counties that have one. The progress of treatment is subsequently reviewed as needed. The main service offered by the Arkansas project is lay therapy, which takes place during visits to the client's home. Depending on the severity of the case or the degree to which it is stabilizing, the intensity of the lay therapy counseling provided may vary widely. Typically, a relatively new, difficult case receives considerably more than the average six hours of lay therapy counseling per month. In general, the lay therapists strive for some form of weekly contact with their clients. In addition, clients may receive individual counseling or participate in Parents Anonymous. As a case stabilizes, which may be six months or more after the initial referral, the intensity of the lay therapy will normally taper off from several visits a week to a much lower frequency. The project continues to maintain contact with the client indefinitely, however, through a systema- tized six month follow-up procedure. The case will be mentioned from time to time during staffing sessions and during the diagnostic review team meet- ings. In this way, SCAN is in a position to resume more intensive treatment as soon as there are signs of need for it. If an unstabilized client moves from the county or state, the case 1: rcferrea to the appropriate agencies. V.35 Client Characteristics For the client analysis, the cases from Jefferson County and Washington County were pooled, for a total sample of 180 clients from the Arkansas pro- ject. As can be seen on the following table, cases were referred to these projects from a variety of sources, most notably the medical community (25%). Cumulatively, other agencies in the community, with the exception of the courts and law enforcement, supplied the bulk of the referrals; however, acquaintances and neighbors as a single referral source provided a signifi- cant proportion (17%) of the cases. In 70% of the cases the SCAN unit re- ported the case to the mandated agency, i.e., the Division of Social Services. Nearly two-thirds of the cases had recorded evidence of previous maltreat- ment. In half of the cases, physical abuse was identified as the presenting problem, with an additional 8% being cases of combined physical abuse and neglect. About 11% of the cases were physical neglect and a similar propor- tion were emotional maltreatment cases. Fifteen percent of the cases revealed potential only, for abuse or neglect, and a very small proportion were cases of sexual abuse. In over 40% of the cases, the assault was judged to be serious. And in nearly three-quarters of the cases the mother was involved in the maltreatment; she was solely responsible in over half. The majority of the cases were white, two-adult, uneducated, unemployed, low-income ($5400) households with two children, mostly pre-schoolers. While half of the families had teenage parents, the average age of mothers was 25 years; of fathers, 29 years. The largest problem cited in the household as leading to maltreatment was financial (57%), followed by marital (40%), heavy continuous child care (39%), and social isolation (38%). V.36 The problems which typify the project's clients closely reflect those identified as the target population in their goals. It is interesting to look at the disposition, however, of those cases referred to the project but not accepted for treatment. Of the estimated 130 reports received during 1975 and 1976 in Washington County alone and not accepted, over 80% of them were neglect reports and, consequently, outside the project's guidelines in most instances (88 of the 130 referrals). Only one case was referred to a more appropriate agency, other than the Division of Social Services to which the neglect cases were referred. A significant number (24) of the referrals were unconfirmed and occasionally the family could not be located (12 cases) or the case was already open in another agency (11 cases). Only two clients refused services. v.37 Table 1 Client Characteristics Source of Referral Private physician . Hospital. . . . . Social service agency , School. ’ Law enforcement . Court . Parent. Sibling . 2 ® i Relative. . . . Acquaintance/neighbor : Self. Anonymous . Other agency. Type of Maltreatment Potential abuse or neglect only Emotional maltreatment only . Sexual abuse. Physical abuse. Physical neglect. Physical abuse and neglect. Severity of Assault Not serious . Serious . Responsibility for Maltreatment Mother. Father. Both. Other . Legal Actions Taken None. . . . « . ‘Court hearing . Reported to mandated agency ’ Reported to central registry. (N=180) 11% .14% 12% 11% . 3% . 3% . 2% 1% 11% 17% . 6% . 9% .14% .15% .11% . 4% .51% 11% . 8% .57% .43% .52% .25% .20% . 2% .19% .15% . 70% .48% Previous Record/Evidence of Maltreatment None. Previous re sord/evidence . Demographic Information Average number of children in family . . . ’ Families with preschoolers. Families with one adult . Families with no high school degree . . Families with no ‘minorities mE Families with no one employed . Average family income . . . : Families with less than $5501 per year . . . oe Average age of mothers. Average age of fathers. : Families with teenage parents . .38% .62% Problems in Household Leading to Maltreatment Marital . Job-related . ’ Alcoholism. « « + =: & Drugs . . . : Physical health : Mental health . v New baby. . . ss 6 00 Argument/ fight. Financial problems. : Mentally retarded Rater: Pregnancy . . : Heavy continuous "child care . Physical spouse abuse . Recent relocation . ‘ Overcrowded housing . . . . Abused as child . + wv 2 & » Normal method of discipline . Social isolation. .18% .23% 17% .15% .57% . 5% .39% 11% . 24% .26% 21% .31% . 38% .40% .18% 0 kG) ° o 0 ° V.38 The Quality of Case Management The case management process of the project was assessed during two rounds of site visits conducted in 1976 and 1977. Such aspects of case management as timeliness, the amount of contact between case manager and client, case diagnosis and regular review, referral mechanisms, coordination of informa- tion, service continuity, and client participation were reviewed. Sixteen percent of the randomly sampled cases for the assessment showed that the potential client was contacted the same day as the incoming report was made. Another 25% were contacted no later than the third day after the initial report, and another 14% were contacted within four to seven days. This means that nearly half of the clients in the sample were first contacted after a week or more had elapsed since the referral. In over a third of the cases, the decision on the treatment plan was made without any additional contact with the client. However, 38% of the cases had at least one more client contact and 20% had two or more such con- tacts prior to the treatment plan decision. In 80% of the cases reviewed, treatment services were initiated within two weeks of the first contact with the project, reflecting the immediacy of the lay therapist's assumption of responsibility upon assignment of a case. The project made extensive use of multidisciplinary team reviews, with 71% of its cases having at least one such review. As indicated in Table 2, these reviews most often occurred during treatment. Case conferences or staffings were used even more frequently -- 93% of the cases had case con- ferences during their history. Consultants, on the other hand, were not used often. Only 20% of the cases called in one or more consultants. Client participation, as measured by the client's participation at a multidisciplinary v.39 team review or at a case conference, was below the norm with clients present only 5% of the time. Reflecting the project's specialization of intake and initial evalua- tion being conducted by a staff member (the director or assistant director) and subsequently assigned to a lay therapist for service delivery, 89% of the cases had a different current case manager from the one who carried out the intake. In 73% of the cases there was only one primary case manager over time. Due to the supervisory role provided in most cases by the director and/or assistant director, 43% of the cases had one or more other service provider from within the project. Nearly Swo-thinds (63%) of the clients were receiving services from outside agencies. While an open case, 51% of the cases were contacted by the case manager once a week or more, with another 24% contacted once or twice a month. Ter- mination from the project's caseload occurred within three months in 15% of the cases, within 4-12 months in 77% of the cases, and within 12-24 months in 9% of the cases. Over half (57%) of the terminated cases showed evidence of a follow-up contact to determine the client's status. Table 2 Case Management Characteristics” Time Between Referral and First Number of Client Contacts (after Client Contact initial contact) Before Treatment Same day. + +. + + + + 5 5 + + = 10% Flan 1-3 days. + + + + + + + + +. . . .25% NONE: « 5 « » = 5 = 5 » a. % 5s «36% 4-7 days. + + + + + + 4 » v 5 » «14% BRE « « «a 5 = 3 = » wie ad engl ie W305 Within two weeks. . . . . . . . .23% TWO 5 5 2 & » & w 2° % wd ov olen ios Within one month. . . . . . . . .10% Three-five. . . . . . . . . . . .18% Over one month. . . . . . . . . .13% Over £ive + . « +» « « + +» +.» + 5% (Table 2 continued on following page) V.40 Table 2 (continued) Time Between First Client Contact Reason for Two or More Case and First Treatment Service Managers Within two weeks. . . . . . . . .80% Joint management. . . . . . . .N= 3 Two weeks to one month. . . . . .17% Staff turnover. . . + + 4 » sNm 2 Over one month. . . . . . . . . . 3% Staff unavailability. doa ow om NE 3 No treatment given. . . . . . . . 1% Lack of success with client . .N= 2 Use of Multidisciplinary Review Other , + +» + vv vv vv + B=2 Team Number of Treatment Providers in At least one review . . . . . . .71% Project (other then case manager) Review during intake. . . . . . .13% None. + = « » & % % 4 » & 5 = +» «57% Review during treatment . . . . .64% ONE , + + « v % 0 5 4 wo » » + «10% Review at termination** . . . . .27% TRO 2 +» 4 8 » 5 # # » 4 8 « » w209 Use of Case Conferences (staffings) Tages. five. GE 40% At least one conference . . . . .93% ; : : a Conference during intake. 64% Services From Outside Agencies. .63% Conference during treatment . . .91% Evidence of Communication With Conference at termination** . . .63% Outside Agencies. . . . . . . . .65% Use of Consultants N=26 None. . . . .. . ... .... .80% roquency of ontace by Cage One . . . . . . +. ev... 3% pagers Two . . . . +. «vv vv vo vv. . 5% Once per week or more . . . . . .51% Three-five. . . . . . . . . . . .12% Once or twice per month . . . . .24% Over five : 4 5 + sv vw 2 » + » = 0 Less than once per month. . . . . 5% : 9 Client Participation 060 9 Sules only. ents 159 . . . . . . . . . (J Client presence at MDT's and/or Nope. . . . . ..........0 case conferences . . . . . . . . 5% Follow-Up Contacts** Jol ow-Up Lontacts Contact with Referral Source At least one contact (client/ For background information. . . .73% other agency). . . vy v © ¢37P For progress reports. . . . . . .45% Two or less with client FR * [1 0, Responsibility for Intake Thasective With Client. or > . . . . . . 0 Current case manager. . . . . . .1l1% : : Other staff member. . . . . . . .89% Length of Tine in Troatvens Through three months. . . . . . .15% Bunber of Case Managers 4-12 months . . . . . . . . . . 77% One . . « vv vv vv vo ov. 73% 1-2 ¥8878 + + + » « 2 » » + » & +» I TWO . « » Ce ee ee ee. W21% Over two years. . . . . . . . . . 0 More than £0 Ce ee ee ee... 6% Total cases reviewed = 41; total terminated cases = 34. * Owing to rounding, percentages way not sum to 100%. * % Terminated cases only. v.41 XI. COMMUNITY IMPACT Summary The coordination and integration of the existing community system, as well as the development of new components within it, have improved consider- ably over the funding period of the demonstration project. In addition to centralizing reporting to the Division of Social Services (either directly or indirectly through SCAN), the case management function was centralized in SCAN, a private agency under contract to Social Services to deliver treat- ment services in child abuse cases involving children under the age of 12. To supplement the services commonly provided by Social Services, the project has developed additional resources, including hospital diagnostic teams, multidisciplinary consultation teams, lay therapy, and Parents Anonymous. The diagnostic and consultation teams provide a professional arena for the integration of the key referring and service-providing agencies in the com- munity, while lay therapy and Parents Anonymous integrate the extensive in- formal network of self-help and support services. Responsibility for coordinating these two systems rests in the ability of the county project directors to function effectively in both professional and non-professional environments. To complement the expansion of the resource base, an aggressive educa- tion and public awareness effort has been pursued by the project. While initially the staff sought out forums for community and professional edu- cation, they are now sought by these groups in an active schedule of approxi- mately 90 presentations annually for each project county. The resulting impact of these efforts on reporting statistics is apparent, with a total _ aD a v.42 increase of reports for abuse/neglect of 163% during the three years of the demonstration. Since substantiations have only increased 29% over this same period, however, the appropriateness of the increased reporting is somewhat in question. With a few exceptions (notably increased reports from physicians and hospitals and decreased reports from law enforcement agencies, the courts, and acquaintances and neighbors), the proportion each source represents of the total reports has remained fairly constant. Within these proportions, however, the actual number of referrals has, in some cases, doubled, tripled, even quadrupled in the three-year period under consideration. The declines in referrals from the reprisal agencies in the system would seem to corro- borate the finding that cases are being identified by other agencies in the system before they require legal intervention. Recognizing the three fundamental gaps identified in the service delivery system (i.e., insufficient day care facilities, insufficient treatment facilities for abused children, and insufficient treatment programs for parents of/and abused children over 12), the coordination and functioning of the community system for abuse/neglect in ACAN counties has made signi- ficant progress during the demonstration period. All of the gains made should be interpreted as permanent or at least the new baseline to which future improvement will accrue, since the SCAN/Social Service model has been adopted into the State Plan and additional counties throughout the state plan to develop similar systems. V.43 Community System Operations The ACAN (Arkansas Child Abuse and Neglect) demonstration project was funded in three counties in Arkansas. In two of those counties the SCAN/ Social Services model was already in place when the grants were awarded. Since that time, the model has been replicated in six additional counties for a total of nine SCAN counties including the original project in Little Rock. The community system for dealing with cases of child abuse and neglect is similar in all the SCAN counties, with a few minor exceptions. Before SCAN, some cases that were discovered by citizens in the community were reported to several different agencies, and cases discovered by members of the agen- cies were reported at least to Social Services and sometimes to another agency. Many cases were simply not reported. The main community agencies that provided services for families in which child abuse or neglect had taken place were Social Services and the Juvenile Probation Department of the court. For cases that were not referred to juvenile court, the services mostly ‘amounted to crisis intervention, temporary shelter for the child, if indicated, and some casework and advocacy by caseworkers in Social Services. While each of the demonstration counties experienced some unique situa- tions in the development of their system, for the purposes of this report, the experience of the Washington County project will be used to illustrate the community system, its functioning and related dimensions. Washington County is the second most populous county in Arkansas after Pulaski County (Little Rock), with a population of 77,370 in 1970. It is’ also the fastest growing county in the state. Most of the people live in "Fayetteville and Springdale, two low-density towns. The median family income in 1970, at $6825, is one of the highest in the state; nearly 10% had incomes V.44 of $15,000 or more annually. The low median age (25.3) for the county re- flects the student population from the University of Arkansas. Prior to the demonstration project, the primary service delivery system for identifying, diagnosing and providing treatment for abuse and neglect clients consisted of two main agencies (Washington County Social Services and Ozark Guidance Center), with several other agencies referring cases to them (juvenile court, the police department, the school districts, the public health department, and the hospitals). At that time, the state reporting law mandated the welfare department and the police department to receive reports. There was no cross reporting requirement, although the agencies involved did not hesitate to refer cases to each other. In addition to the absence of centralized reporting, the basic gap in the system was the insuf- ficient treatment program which responded directly to the needs of dbusive parents. The two service providers in the community delivered the standard com- plement of services to abuse/neglect cases as well as to other appropriate cases. The Division of Social Services conducted immediate investigations of reports, provided immediate protection and court action as required by the case, provided foster care and permanent placement arrangements when necessary, and offered social work counseling and support services to the families. The Ozark Guidance Center offered individual and family therapy, marriage counseling, play therapy, a mothers' group in home and child manage- ment, and an in-patient unit. With the institution of SCAN, which operates via contract through the Division of Social Services, a centralized case management function was developed, which in turn tapped the already operating resources in the com- munity as well as developing additional resources. A hospital-based Child V.45 Protection Team, a multidisciplinary consultation team, Parents Anonymous, and lay therapy through SCAN volunteers constitute the major new resources for which the demonstration project is responsible. Other efforts to muster service providers have coordinated such resources as emergency funds, trans- portation, medical care, and babysitting into a centralized resource direc- tory to which the project can refer. A very recent service developed in a coordinated effort by SCAN and Head Start is the Parent Education Program which draws from the expertise of many community agencies in delivering child development and management classes. During the course of the first year of project operations, changes in the state law centralized reporting in the Division of Social Services and expanded the list of agencies and individuals mandated to report. While Social Services has extended the mandate to SCAN, the Division remains the single agency ultimately responsible in the county for receiving reports and forwarding them to the Central Registry in Little Rock. While there is evidence that some agencies, and particularly private citizens, feel more comfortable reporting to SCAN, all agencies interviewed realize that Social Services is the final, authorized recipient of those reports. While little has been attempted formally in the outreach and prevention functions of a model system, the main service providers who come in contact with a wide range of clients are sensitive to the dynamics and their impli- cations for potential abuse. The schools, Head Start, and the public health department, in particular, try to alert SCAN of potential cases. The identification function in the system has expanded tremendously since the inception of the project. This has been the result of extensive V.46 community and professional education. There is some indication from the com- parison of the substantiated reports to total report volume that the criteria for abuse and neglect have not been adequately communicated, since the gap in the ratio widens each year, rather than closing. Investigation of reports was always a highly responsive function in the system although it was susceptible to duplication by various agencies. While joint investigations between the project and agencies like the court and the police have not increased, there is an operating awareness of the need for immediate investigation and referral of cases appropriate for SCAN and Social Services. The project, in turn, attempts to evaluate each report within a day or two of receipt and makes the initial disposition based on their findings: opened as a SCAN case if abuse or severe neglect of children under 12; opened by Social Services if neglect or involving children over 12; or unopened if unsubstantiated during evaluation. Prior to the project's development of the Child Protection Teams in the hospitals, and the multidisciplinary consultation team, the decisions involv- ing treatment planning, referral, placement and termination were done pretty much in isolation by the Division of Social Services taking responsibility for the case. Now, these decisions enjoy the multiple perspectives of the members of the teams, who review case needs and progress at all critical junctures in service delivery. The most profound change has undoubtedly been in the focused treatment program of lay therapy offered by the project. The philosophy of 'reparent- ing the parent', which underpins the complex treatment modality delivered by trained volunteers to abusive parents, was not offered by any other ser- vice provider in the community. Much of its credibility as a valuable and v.47 valued service in treating abusive parents comes from the other agencies in the service delivery system, most impressively from the mental health ser- vices. The major service delivery gap, observed in interviews with nearly every community agency, is the absence of sufficient day care facilities, which most service providers view as a critical support service to the parent during treatment and as a therapeutic service to the child. Increasingly, as the project and other agencies have worked with these cases, the desirability of treatment services for the children involved has gained priority in their assessment of additional service needs. There is also a concern that abused children over 12 become the target solely of legal intervention without the necessary complement of treatment services which both parent and child re- quire. Caseload Size and Case Outcomes In each of the counties in which a SCAN unit has been formed, the volume of reports and referrals has increased. To illustrate the dimensions of this increase, the following discussion is based on information collected in Washington County. Comparing data collected by the Division of Social Ser- vices from 1973 through 1976 on Table 3 reveals a pattern of continued increase in reports. Total reports for abuse/neglect increased 163 in three years from 112 in 1973 to 295 in 1976, with the bulk of the increase occurring in the first year. The pattern is highly differentiated, however, for abuse and neglect. Reports of abuse increased nearly 500% over the data collection period, with the major proportion of this increase experienced between 1973- 1974. Neglect reports, on the other hand, did not show such a dramatic increase overall (i.e., 64% for 1973 through 1976), and despite relatively steady V.48 increases annually between 1973 and 1975, neglect reports decreased during the last reporting period by 25%. Table 3 Division of Social Services Volume of Reports: 1973-1976 Washington County, Arkansas Reports 19731 1974 1975 1976 Abuse Number of reports 26 87 94 154 Number valid 18 57 44 55 Percent reports substantiated 69% 66% 47% 36% Neglect Number of reports 86. 128 185 141 Number valid 48 71 45 30 Percent reports substantiated 56% 56% 24% 21% Total Number of reports 112 21s 279 295 Number valid 66 128 89 85 Percent reports substantiated 59% 60% 32% 29% pata for 1973 extrapolated on basis of information collected for July 1973 through December 1973. While the reporting has increased, substantiations of those reports have undergone very different patterns. Overall, the number of valid reports of abuse/negiect increased from 66 in 1973 to 85 in 1576, for an increase of only 29%. However, within that time period substantiations peaked in 1974 v.49 at 128 valid reports, or nearly double the baseline figure; subsequently, the 1975 and 1976 figures represent continued declines from the preceding year. The proportion of reports being substantiated has also declined from 60% in 1973 and 1974 to about 30% in 1975 and 1976. These trends, in varying degrees, occurred in each of the two categories. The widening gap between the volume of reports and the proportion of those reports which are substantiated suggests two hypothetical explanations. It is possible that education efforts have over-sensitized the community to the problem, or perhaps failed to convey the definitions of abuse and neglect that are operating in the agencies. It is also possible that, in the absence of a full complement of social services, reports of families in need of other services are being channeled into the very responsive abuse/neglect system. Displayed in Table 4 are data on origination of reports to the Division of Social Services in Washington County. Since the baseline period (1973), reports have increased substantially from every source except law enforcement and the court. This may be explicable by the perceptions of those agencies, as well as of the project, that cases are being reported prior to the point of necessitating legal intervention. Reports from other agencies (e.g., social service, physicians, hospitals, schools) have doubled, tripled and even quadrupled their volume, although their proportions of the total have not shifted significantly. The exception to this observation is reports from Social Services (which includes SCAN), which in 1973 accounted for 0% of the total and in 1976 represented 11%. Public education efforts appear to have paid off as well with each of the individual source categories increasing reporting many-fold. V.50 Table 4 Division of Social Services Source of Reports/Referrals: 1973-1976 19731 1974 1975 1976 Source of Reports # % # % # % # % Social Services 0 0 1 -- 8 3 37 11 Physician 8 7 9 4 33 12 23 7 Hospital 2 2 9 4 15 5 19 6 Law enforcement 8 7 12 6 9 3 13 4 Court 10 9 9 4 6 2 10 3 School 12 11 21 10 29 10 28 8 Other agency 14 13 32 15 36 13 22 7 Spouse 0 0 0 0 1 -- 7 2 Relative 18 16 40 18 43 15 35 10 Sibling 0 0 0 0 2 1 0 0 Acquaintance/neighbor 38 34 77 36 68 24 104 31 Anonymous 2 2 0 0 13 5 16 5 Self-referral 0 0 7 3 8 3 16 5 Unknown 0 0 0 0 8 3 € 2 Total 112 100% | 215 100% | 215 100% |336 100 pata for 1973 extrapolated on the basis of information collected for July 1973 through December 1973. 2Colums may not sum to 100% due to rounding. Data collected from the Central Registry in Little Rock on reports from Washington County indicate an enormous increase in reporting during the last year of the project. Interpretation of Table 5, which identifies the sources of these reports, must recognize that the numbers represent incoming reports prior to substantiation and do not represent individual cases, but rather all reports whether duplicative or not. Additionally, these 'sources" indi- cate the origin of the report to the Washington County Division of Social Services since all reports to the Central Registry emanate from there. Statistical data retrieval is only possible on the total reporting since substantiated cases are kept in individual case files and are not readily accessible for data analysis. It can be seen, however, that reports from Washington County increased well over 300% during the study period. Significant increases occurred in reports from hospital personnel, social workers, law enforcement officers, relatives, neighbors and other sources such as babysitters and anonymous citizens. The increase in self-reporting is impressive. . 52 Table 5 Sources of Abuse/Neglect Reports to the Arkansas Central Registry from Washington County, 1974-1976 1974 1975 1976 Sources # % # % # % re Physician 11 15.1 12 14.5 18 21.7 Coroner Dentist 1 0.3 Osteopath Intern Registered nurse 2 2.7 6 2.2 6 1.9 Hospital personnel 4 4.8 14 4.5 Teacher z 3.6 2 0.6 School official 10 13.7 6 7:2 12 3.3 Social worker 4 5.5 5 6.0 23 7.4 Day care worker 2 2.7 2 2.4 4 1.3 Other child care 3 3.6 9 2.9 Mental health professional 1 1.2 3 1.0 Law enforcement officer 5 6.8 5 6.0 19 6.1 Parent 2 2:7 2 2.4 6 1.9 Relative 5 6.8 7 8.4 34 ¥0.9 Neighbor 11 15.1 15 18.1 60 19.2 Other 3 3.6 13 4.2 Self 1 1.4 21 6.7 SCAN 4 1.3 Other (includes citizen, friend, babysitter, anonymous) 20 27.4 9 10.8 63 20.2 Total 73 100.0 83 100.0 312 100.0 y.53 The incidence of new and repeated possible abuse which required hospital attention in Washington County declined 40% from 17 cases in 1975 to 10 in 1976, while new possible neglect cases increased 80% from 11 to 20 during the same period. One plausible interpretation for this reversal is that the provision of a new service (SCAN) to abuse cases has had the effect of reduc- ing cases requiring hospital intervention. Yet, while the neglect cases are benefitting from the same public education campaign and are consequently more visible, the service delivery system has not expanded to accomodate and treat these cases. Additional support to this interpretation is the increase of referrals to SCAN in the face of declining abuse cases as contrasted with decreased referrals to Social Services despite a significant increase in neglect cases. The following table illustrates these observations with selected data from the major hospital facility in Washington County. V.54 Table 6 Washington Regional Medical Center, 1975-1976 1975 1976 Number new cases identified as possible abuse 15 9 Number repeat cases identified as possible abuse 2 Number cases evaluated by Child Protection Team* 28 14 Number new cases identified as possible neglect 1 20 Number repeat cases identified as possible neglect 2 0 Number cases evaluated by Child Protection Team* 22 27 Number children retained in hospital overnight 17 21 Number cases referred to Protective Services 22 17 Number cases referred to SCAN 6 10 Number cases referred to court 1 4 * New and review Table 7 illustrates the disposition of those cases in Washington County requiring legal intervention. During the study period (1973-1976), an 82% increase occurred in the number of court hearings involving abuse/neglect cases. Although double counting due to multiple disposition of a case occurs in 1974 and 1975, trends can be observed. While removal of the child has increased absolutely during the project period, it has decreased in propor- tion to the total dispositions of the court. More of the removals are court ordered temporary placements than voluntary temporary or court ordered per- manent placements. Both of these latter categories experienced an upsurge ¥V.55 during the first two years of the project with a subsequent return to the previous rate in 1976. By the end of the project period, a substantial pro- portion of the cases were dismissed for insufficient evidence, which indi- cates either that a large number of inappropriate cases are being brought to the attention of the courts or that the court and reporting agencies (normally, social services) do not share common criteria in defining child abuse and neglect. Table 7 Selected Juvenile Court Case Dispositions: 1973-1976 Washington County, Arkansas 1973 1974 1975 1976 No. court petitions involving abuse/neglect cases! ri —— — om No. court hearings involving abuse/neglect cases 38 54 54 69 Disposition of Cases: Case dismissed: insufficient evidence 4 7 13 17 Child at home under supervision 14 17 16 15 Court ordered temporary removal of child 12 8 17 23 Voluntary temporary placement of child 1 8 10 3 Court ordered permanent removal of child 5 10 8 4 Consent to adoption 2 9 1 3 Action deferred; case pending -- -- 4 4 Total 38 59° 69° 69 lyashington County Juvenile Court does not accept initial reports of abuse and neglect. 2nTotal disposition' larger than "total hearings" due to multiple or overlapping disposition for some cases. V.56 Legislation New state legislation was passed in July of 1975 which significantly re- fined the definitions of cases to be considered child abuse or neglect and provided for a more centralized organizational structure for handling reports. The most important changes contained in the legislation include: expansion of individuals mandated to report suspected abuse and neglect; clearer articu- lation of the definitions of abuse and neglect; designation of the Division of Social Services of the Department of Social and Rehabilitative Services as the sole agency mandated to receive reports, rather than the police and welfare departments; reduction of legal penalties for non-reporting; procedural require- ments to be undertaken upon receipt of a report; the establishment of a single statewide telephone number for reporting cases of suspected abuse and neglect; and the appointment by the court, in every case filed under the Act, of a Guardian ad Litem for the child. The Guardian ad Litem is charged in general with the representation of the child's best interests, and in many cases SCAN is appointed in this role. There is, however, some question that this may con- stitute a conflict of interest, since SCAN is co-jointly involved in bringing these cases to court. Both SCAN and the Division of Social Services contributed considerable momentum to the efforts to amend the previous law. By means of letters, lobby- ing and testimony, staff members lent their support to the new bill. The staff of the project and community agencies interviewed in Fayetteville uniformly expressed confidence in the new law, its comprehensiveness and expected effec- tiveness in dealing with abuse and neglect cases. Although not all community agencies interviewed were fully aware of their responsibilities under the new law, the project's educational program continues to provide clarifying infor- ’ mation on the provisions and implications of the law. v.57 Community Resources With the exception of the demonstration project (SCAN and the Division of Social Services), there are no agencies in Washington County with staff assigned exclusively to child abuse and neglect problems. The providers in other agencies (e.g., probation officers in the court, criminal investi- gative officers in the police department, school social workers, foster care workers, hospital social service staff and emergency room personnel, public health department staff, and staff in two counseling agencies) deliver ser- vices to abuse/neglect clients in much the same way as they would to other clients. In the absence of differentiation among clients, none of these agencies can estimate accurately either the actual number of abuse/neglect cases to which they provide services, or the percentage of staff time com- mitted to the problem. While the demonstration grant in Washington County resulted in the iden- tification of a Coordinator role within Social Services for coordinating ’ between SCAN and the division, it did not increase the number of staff posi- tions assigned to casework on abuse/neglect cases. Neither did it affect the investigation, counseling, and advocacy services already provided by that agency. Expansion of the resource base did occur, however, in the form of the SCAN unit (four staff members and ten lay therapists) and with the development of the consultation services of the hospital-based Child Protection Team and the Multidisciplinary Consultation Team. The services available through SCAN include: case management; multidisciplinary team re- view; hospital diagnostic team review; lay therapy; individual counseling; sponsorship of a Parents Anonymous group; sponsorship of parent education classes; ancillary support services, such as transportation, emergency funds, and occasional babysitting; and advocacy services. V.58 In each of the demonstration grant counties in Arkansas, the SCAN units have developed Resource Directories containing written agreements with pub- lic and private agencies who have agreed to supplement the services provided by SCAN. In addition to individual and group counseling and therapy, legal aid, and placement services, the agencies provide a wide range of support services, including emergency medical care, shelter, babysitting, financial assistance, food, clothing, and transportation. While there has not been consistent need to resort to these available services, they have responded to requests. In Washington County, signed agreements have been secured from approximately 65 public and private agencies and individuals. The single critical gap in the resource base is perceived by all to be the absence of continuous day care facilities. With reductions in the level of state fund- ing, which resulted in a cessation of state day care in December 1975, the projects have made efforts to raise funds locally to match federal funding for day care. The project has made substantial gains in coordinating the services available in Washington County, with the major resource expansion effort being the development of lay therapy as an additional service in the com- munity. Since future funding of the SCAN units is anticipated through the combined public and private sources, it would appear that the existing ser- vice provision and coordination is likely to continue after termination of the grant. Community System Coordination Several system changes in Arkansas have resulted in better coordina- tion of the key agencies handling abuse and neglect cases. At the statewide level, a legislative change centralized reporting to the Division of Social v.59 and Rehabilitation Services of the Department of Social Services. In turn, Social Services, through a formalized state agreement, has granted SCAN the status of the receiving agency in counties with SCAN units. Those reports made directly to SCAN are forwarded immediately to the local division of Social Services, and subsequently forwarded to the Central Registry in Little Rock. At the county level, the most critical coordinating function is repre- sented by the relationship between Social Services and SCAN, in which con- stant communication is maintained in order to deliver services to each agency's specific case focus. SCAN cases include those abuse and gross ne- glect cases involving children under the age of 12; Social Services, on the other hand, serves all other neglect cases, and cases involving children over 12. These criteria for service provision are not, of course, screened by the referral source, and entail close coordination between the two agen- cies in order to respond quickly and appropriately to reports. Other changes which have improved the interagency coordination at the county level include the formation of the two consultation teams; the Child Protection Team, and the Multidisciplinary Consultation Team. The former is based at the community hospital (in Washington County, Child Protection Teams have been staffed for each of the two major hospitals), and meets on an as-needed basis. Team members include representatives from pediatrics, psychiatry, social work, hospital administration, SCAN, Social Services, Public Health, pediatric nursing, and the director of nursing. For non- hospital based cases, the Multidisciplinary Consultation Team members attend SCAN staffings to review cases when requested. This team consists of repre- sentatives from Social Services, SCAN, the community mental health center, V.60 university departments of Social Welfare and Counselor Education, school counsel- ors and psychological examiners, and church-related social service agencies. With the exception of law enforcement representation, the major agencies in the community system are intimately involved in the management of abuse/neglect cases. In addition to the consultation teams wich have set up regular proce- dures for interacting and coordinating their functions, the SCAN units main- tain a Resource Directory of additional public and private agencies who have submitted written agreements to provide supplementary services to SCAN clients. Responsibility for initiating activities on individual cases with these groups is incumbent upon SCAN. Within the juvenile court, a staff position, Com- munity Resources Specialist, was recently formed to coordinate existing and develop new resources within the community for cases requiring court inter- vention. Additionally, this person is assigned the role of active liaison with SCAN for the juvenile court. While procedures for referral, investigation and feedback have been developed, they operate at an informal and cooperative level rather than through formalized and statutorily mandated channels. Key to understanding these informal collaborative arrangements is consideration of the size of the catchment area which each SCAN unit is serving and recognition of the close operating relationships among the few agencies in the communities. Education and Public Awareness Since the baseline period, substantial increases in the level of educa- tion and training specifically related to child abuse and neglect have occurred in each of the project counties. Prior to implementation of the project, only the staff of the Division of Social Services had been familiarized v.61 with the etiology of abuse and neglect, reporting laws, means of identify- ing the dynamics, and the resources available in the communities for deal- ing with the problem. Since that time, however, the staff of the local SCAN units have provided an active educational program to train staff of most of the key community agencies and to alert the community at large to the prob- lem and its solutions. In addition to three or four lay therapy training workshops held annually in Little Rock, which average 100 attendees includ- ing current staff, new volunteers, and interested professionals and lay people, each county unit presents about 50 sessions each year at various levels of information complexity within their communities. In Washington County alone, approximately 1200 individuals attended presentations in 1975. Most of the key agencies (schools, hospitals, police, court, mental health, day care, and public health) received at least two presentations, with a total cumulative attendance of 275 professionals. Fourteen speeches to various classes at the university (Social Welfare, Home Economics, Child Development, Secondary Education and the Legal Clinic) exposed more than 400 students to the SCAN program. Twelve presentations to community groups (PTA, Kiwanis, Hospital Women's Auxiliary, and the like) reached another 400 lay people. And an inestimable proportion uf the com- munity was reached through the distribution of 5000 pamphlets and the var- ious media coverage (radio spots, seven newspaper articles, and a local television feature interview). Representatives of the key agencies perceived the increase in education ‘and information dissemination efforts proliferating from the SCAN unit at both the professional and community levels. Several of the agencies (not- ably the hospital and juvenile court) include references to SCAN in all their V.62 public appearances and routinely call on the project to train new staff mem- bers. Among the results attributed to these efforts have been requests for additional information and presentations, interagency coordination improve- ments, donor money, volunteers, and in general, a better understanding of the problem of abuse and neglect and the procedures within the community for confronting it. XII. PROJECT RESOURCE ALLOCATION AND SERVICE COSTS The Washington County Child Abuse and Neglect project maintained an average caseload of 30 clients on an annual budget of slightly more than $67,000. As- suming a case would require a year of service provision, the average annual cost per case was $2,242. As illustrated on the following table, approximately half of the project's time and 35% of its budget were expended on direct services, which reflects the intense usage of reimbursed volunteers in the delivery of the project's major treatment modality, i.e. lay therapy counseling. About 15% of the staff time and budget were directed toward community activities; with an- other 8% of the time and 10% of the monies allocated to research activities. Project operations utilized the remaining 30% of staff time and 40% of the budget. These allocations were quite stable during the year of intensive cost accounting months; marked fluctuations occurred in only three service compon- ents. Resources allocated to staff development and training appeared to decrease over time; however, in actuality two of the months overstated the normal investment since they coincided with intensive lay therapy training workshops held in Little Rock. Normally these workshops occur only three times a year. Although the proportion of time allocated to general manage- ment decreased over time, the proportion cf the budget increased, reflecting V.63 salary increases and the concentrated efforts of the paid staff on these functions. While case management and regular review consumed an increasing proportion of staff time, it did not utilize a corresponding increase of the budget. This implies an enlargeing case management role for the lay therapists in addition to maintaining the level of direct counseling as initiated. The service package offered by the Washington County project included intake and initial diagnosis, case management and regular review, and lay therapy counseling. Small proportions (3% or less) were devoted to multi- disciplinary team case reviews, court case activities, individual counseling, Parents Anonymous, and parent education classes. This service mix was stable during the demonstration effort and represents the lay therapy model as prac- ticed throughout Arkansas. Both the volume of service units delivered and the per unit costs of some fluctuated over the three accounting months. Case management, provided at approximately $24.50 per case per month, however, was relatively stable. - On average 143 lay therapy counseling contacts were provided monthly at an average cost of about $3.30 per contact; the monthly volume increased drama- tically from 108 in October 1975 to 170 in October 1976, with a corresponding decrease in the cost per contact (from $5.50 to $2.10). Individual counseling was provided in small amounts (on average only 7 contacts per month) at sub- stantially higher cost per unit (nearly $14 per contact). At an average of 18 intakes per month, the cost per intake was approximately $14, although it ranged from $10 to $20 per unit. Several services were provided quite inexpensively: parent education classes at $.75 per person session; crisis intervention after intake at $1.30 per contact; transportation at $1.80 per ride; and Parents Anonymcus at $4.85 V.64 per person session. Court case activities was the most costly service pro- vided by the project at $95 per case per month. When the value of donated resources is considered, MDT reviews experienced a dramatic increase from $12.65 per review to nearly $230 per review. Only one or two court cases and MDT cases were handled by the project each month. The cost of lay ther- apy counseling contacts and crisis intervention after intake increased in substantial amounts when the value of donated resources was introduced. Table 8: Project Resource Allocation and Service Costs Resource Allocation to Volume and Unit Costs of Services Activities Average Average Annual Annual Average Average Time Budget Actual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost | to Community Community Education 6% 7% Professional Education 2 2 Coordination 6 6 | Legislation/Policy 1 1 Staff Development /Training 18 17 Program Planning/Development 4 5 General Management 9 18 Project Research 3 4 BPA Evaluation 5 6 Intake/Initial Diagnosis 5 5 18 intakes $14.07 $13.91 Case Management/Review 16 14 30 average caseload 24.55 26.07 Court Case Activities 2 2 1 case 95.20 95.20 Crisis Intervention During Intake -- -- 2 contacts 17.10 16.22 Multidisciplinary Team Review 3 1 3 reviews 12.67 229.15 Individual Counseling 2 1 7 contacts 13.84 11.14 Parent Aide/Lay Therapy 15 9 143 contacts 3.29 5.33 Parents Anonymous 2 2 14 person-sessions 4.86 6.34 Parent Education Classes 1 1 69 person-sessions 0.74 0.74 Crisis Intervention After Intake -- -- 8 contacts 1.30 2,53 Transportation/Waiting =. - -- 20 rides 1.81 1.81 Follow-Up -- -- 2 person follow-ups 11.59 11.59 Total Annual Person Years/Budget 77.54 $67,272 Average monthly caseload = 30 S9°A THE FAMILY CARE CENTER: LOS ANGELES, CALIFORNIA I. COMMUNITY CONTEXT Although technically within the city of Los Angeles, the project actually serves people only from within the old King Hospital Service Area (in refer- ence to the Drew/King Medical Complex), a catchment area of 88 census tracts encompassing 320,000 people living in the areas of Comptom, Watts, and Willow- brook. The population is 40% Black, 40% Chicano and 20% Other. The Region is a socially and economically depressed area with an average per capita income of only $1500, a 20% unemployment rate and an average educational attainment of 7.2 years. Additionally, 42% of the families are headed by women alone. IT. HISTORY Since the inception of the Martin Luther King, Jr. Hospital, staff were cognizant of the high number of abused and neglected children being seen (approximately 10% of all pediatric admissions involve some form of abuse/ neglect or failure to thrive), and in 1971 an in-house symposium was organized to further explore the dynamics of the problem. It was then brought to the attention of those present that, for the most part, the handling of cases by all agencies involved (including the Department of Public Social Service, Courts, and Police) emphasized child protection, which usually meant foster home placement, and punishment for parents, which many times led to incarcera- tion. While the policy of the Hospital at that time dictated a procedure for treating abuse/neglect cases which invcived both the Departments of Pediatrics and Psychiatry, it was also revealed that many physicians who came into contact VI.2 with potential cases were reluctant to make a diagnosis of abuse or neglect. This hesitation arose out of having to '"'prove' a suspicion, of having to spend time in court proceedings, of feeling frustrated in taking over decision-making from parents and of not being able to really help in any meaningful way. The Pediatric Department responded to the issue by assigning one person to attempt to coordinate all abuse/neglect cases. Eventually this department joined with Psychiatry to seek to organize a program which would meet a full range of needs for the entire family and not just their medical ones. The direction of the proposed activity was to be toward a reorientation of the traditional approach to abuse/neglect cases toward a coordination of the available but fragmented services for these dysfunctional families. A task force then made contacts with community agencies, including Public Health and DPSS; a research design and treatment program were drawn up, and demonstration OCD/SRS funds were sought. The overall goal of the new project, named the Family Care Center, was to provide families with the services re- quired to eliminate abusive behavior, improve parenting skills and foster the healthy development, both physically and emotionally, of young children through a program of short (4-6 month) residential treatment for children and intensive therapy with their parents. ITI. SUMMARY OF ACTIVITIES First Year Summary Although the core outline of the Family Care Center's program and organ- izational structure had been specified in the grant proposal, the two most critical elements, staff and a facility, had not been identified. Both of these became, in the ensuing months, serious obstacles to the implementation VI.3 of the project, so much so that it was a full 18 months after the grant award before the Center was fully operational. An ad hoc Planning Committee, composed of members of the Department of Psychiatry and Pediatrics of the Charlie R. Drew Postgraduate Medical School (including the two Principal Investigators of the project), and representa- tives of community agencies and groups such as the Department of Public Health, Department of Public Social Services, the police and Parents Anonymous met regularly during the first year to finalize organizational and operational plans, begin recruiting for a Project Director, and finding appropriate space for the Center. After recruiting for over nine months for a Black child psychiatrist to direct the Center (in keeping both with the racial mix of anticipated clients and the intense therapeutic approach envisioned by the Principal Investigators), it was determined that attracting such a person was unrealistic and the Plan- ning Committee then sought a director with both clinical experience in family therapy and an administrative/management background. The Project Director was selected in December, 1975, but it was another six months before the remainder of the staff were hired. Between May, 1974 and June, 1975 the Planning Committee was also attempt- ing to secure appropriate space for the facility. A site was originally chosen on grounds which now house Drew's Special Education and Child Care Center; however, zoning for that property would not allow a residential facility and obtaining a variance to the law would have taken a full year or more, so the idea was abandoned. The second choice was to use a public school located across the street from the hospital, but after several months of negotiation this, too, had to be abandoned as an alternative. It finally became clear that locating space immediately adjacent to the Drew/King Medical Complex was VI.4 infeasible and the Committee began to look for space in nearby neighborhoods. Finally, in June a facility consisting of two buildings and adequate outdoor play space was found about two miles from the hospital complex. The final planning area concerned reimbursement from DPSS for children residing at the Center. The project had desired a "contract rate" be established, which would be higher than the usual "residential rates, but it was determined that at least a full year under the lower rates is required before an application of contract rates would be considered. The project is receiving about $500 per month per child in addition to federal funds. Second Year Activities Between May, 1975 and October, 1975, the remainder of the staff were hired, the facility was renovated to meet the needs of the program, and the operating procedures were developed. In October, the Center officially opened and the first children were accepted. The Center accepts children between 0-6 who have been physically abused or are considered failure to thrive cases. By December, 10 children, the maximum census, were in resi- dence. During the remainder of the second year, the Center staff were providing services to the 10 children and their families, developing new agreements with both the hospital, DPSS and the court concerning appropriate placement criteria, and attempting to iron out operating problems and change or add program com- ponents as needs were identified. The services provided in addition to residential care included individual and joint therapy for parents, referral to other service providers, a Parents Anonymous group (not affiliated with the national organization), a Parent Involvement Group, and occupational therapy sessions provided by a therapist from the hospital. Transportation for parents was provided by the case aide. v1.5 Few of the parents, however, were as actively involved at the Center as was originally anticipated. Children received nurturing, support, and some stimulation from the Child Development Specialist and the foster grandparents who were at the Center on a rotating basis 8 hours a day all week. Play therapy for several children was provided by Psychiatric residents, and several students also provided child care. Medical care was provided at the King Hospital. There was frequent staff turnover of the houseparents during the second year because of the major demands on their time and the relatively low pay, which posed severe problems on other staff in attempting to insure adequate 24-hour coverage for the children. Third Year Summary Although the project had continued to provide services to the children and their parents from October, 1975 through May, 1976, the program had never really stabilized as the Director, Principal Investigators at the Medical School or staff had desired and anticipated. Lack of agreement among staff as to the appropriate ways to proceed, confusion about roles and responsibili- ties of project personnel and Principal Investigators, and lack of open com- munication among all participants have been cited as the primary contributing factors which led to a major change during the summer of 1976. Two key staff left the project and the Department of Psychiatry assumed the leadership role for the project since the new Chairman of Pediatrics (the previous chairman was the designated Co-Principal Investigator) had other priorities. The entire project was reviewed by the Project Director and the Principal Investigator with some assistance from outside consultants. New program components, and particularly the relationship between services, were defined. new job descriptions prepared and a new emphasis on child treatment (rather than child care) was formulated. When the new Milieu Coordinator (a new position subsuming the previous Treatment Coordinator and Early Childhood Specialist slots) was hired in October, she began to build the children's program. Each child was tested by an outside early childhood specialist and specific treatment plans were drawn up. The child care specialist along with the foster grandparents was responsible for implementing these plans. Play therapy for several children was reinstituted, this time provided by the Milieu Coordinator. The children's play area was redecorated with more appropriate developmental and "learning" toys, and adequate ''crawl space' for infant and toddlers. Plans for involving the parents in the Center's activities were also implemented. During the latter half of the third year, also, much activity surrounded securing additional funds for the Center to continue after the federal monies were discontinued. Project proposals were submitted to the State and to private foundations, but to date no new funding has been found. No new children were accepted after December, 1976, and by February only six children were in residence at the Center. IV. ORGANIZATION/STAFFING The Family Care Center is run as a joint project between the Department of Psychiatry and the Department of Pediatrics of the Drew Postgraduate Medi- cal School. Two faculty members there are the Co-Principal Investigators. Its budget includes the federal grant allocation, a set reimbursement rate for each child in residence through the Department of Public Social Services, and in-kind contributions of staff time from the Medical School and King Hospital. The project is housed in a two-building facility a few miles from V1.7 the hospital. Major policy and program decisions are made jointly by the Project Director and the Co-Principal Investigators, although the Project has over- all day-to-day management responsibility for the project. Following the reorganization early during the third year, staff to the project, in addition to the Project Director, included: a Treatment Milieu Coordinator responsible for the children's program and the integration of parents' and childrens' services; a psychiatric social worker with primary responsibility for providing treatment to parents; an Early Childhood Teacher who carries out the individual children's treatment activities; a Project Aide who transports parents and children and performs administrative functions; a chief houseparent, three houseparents and a cook who maintain the facility; seven foster grandparents and three volunteers, all providing child care, and two clerks. Figure 1: Organization Chart Co-Principal Investigators Project Director Treatment Milieu Psychiatric Coordinator Social Worker I rT 1 Foster Early Volun- Clerks House- Project Grand- Child- teers parents, Aide parents hood Cook Teacher VI.8 V. PROJECT COMPONENTS Community and Professional Lducation Until the third year, little in the way of community or professional education was carried out due to the numerous problems encountered in simply maintaining the treatment program. However, during the third year, the Project Director did begin to make presentations to community and civic groups and to become involved in local panels and workshops. The few children able to be accepted by the Center mitigate against extensive publicity about the project except for fund raising or volunteer-generation purposes. Coordination Again, because the Center is so small and does not occupy a pivotal position in the community system for dealing with child abuse and neglect, most coordination efforts undertaken were centered around solving problems with other agencies which directly impinge on the Center's operation. Thus, agreements were reached with DPSS, the hospital and the courts about the proper timing of children's placement at the Center, sharing of records for families in treatment and procedures for terminating clients and future place- ment if necessary. The one community coordination endeavor in which the Center has piayed a role is the very recent development of a South Central Child Abuse Council with representatives from DPSS, the schools, King Hospitzl, the Mental Health Center and the federal child abuse Resource Center. Although the actual goals of the Council have not been specified, it is anticipated that coordination among all agencies in the South Central area of Los Angeles dealing with child abuse will be a primary focus. v1.9 Research Although generating knowledge related to the etiology of child abuse among this population was one aim of the project, little was able to be accomplished beyond maintaining case status statistics and some analysis of factors contri- buting to the abusive situation among these clients. The project has generally cooperated with the BPA evaluation. Treatment Services for Parents Individual Counseling and Therapy: Parents whose children are residing at the Center receive ongoing counseling on a weekly basis usually at the Center but sometimes in the home. The Psychiatric Social Worker works with the parents around problems of self-esteem, relating to children, marital or relationship inadequacies, and other problems which the parent might have. This counseling/therapy is the primary treatment mode for parents. Self-Help Group: A self-help group (patterned after Parents Anonymous) was developed for parents. It meets on a weekly basis and has a lay leader and a professional social worker as a consultant. The group accepts both project parents and parents who are not part of the Center's program. Parent Involvement Group: This group, which meets on a weekly basis, was designed to help young isolated mothers to develop adequate socialization patterns and to form new friendships. The group decides on the activities to be pursued which might be things like a shopping trip or going out for lunch. Conjoint Therapy: Conjoint therapy, for parents and children, is being provided by the Treatment Milieu Coordinator. Parents become part of the play therapy process with their children and the leader observes the parents’ communication with the child, the way of handling behavior problems and VI.10 general relating patterns. Feedback about more positive ways of dealing with the child are then provided. Parent Activities at the Center: Parents are expected to spend consid- erable time with their children while they are residing at the Center. During this time, parents play with the children, learn more appropriate parenting skills by observing the child, teacher and foster grandparents and begin to better understand child development. Follow-Up: Extensive follow-up is provided to all families when children leave the Center, often for several months. This follow-up consists of weekly phone contact, visits to the home, and, often, return visits to the Center in order to handle any problems of reunification and establish a stability in the situation before the family is officially terminated. Treatment Services for Children Child Development Sessions: Following testing by the Childhood Special- ist, a series of treatment plans for children are formulated. These are imple- mented on a daily basis by the Early Childhood Teacher and Foster Grandparents under the supervision of the Treatment Milieu Coordinator. The sessions usually involve the development of cognitive, language, motor skills or socialization skills. Play Therapy: Play therapy sessions are provided to older children, when required, on a weekly basis. Originally provided by a psychiatric resi- dent from the hospital, they are now run by the Treatment Mileiu Coordinatox. Infant Stimulation: The infants and young toddlers at the Center parti- cipate in an infant stimulation program developed by the Coordinator and implemented by tne Early Chiidhood Teacher, foster grandparents and volunteers. VI.11 Nurturing and Guidance: In addition to the above concrete services, an important aspect of the Center's program is the nurturing and guidance pro- vided by staff, especially the houseparents and foster grandparents. These staff spend extensive time periods with the children, playing with them, listening to them and providing the warmth and caring necessary to healthy development. The children are provided with appropriate role models, both male and female, with whom to identify and look to for support and guidance. Medical Care: Medical care for the children, both episodic and pre- ventive is provided by the King Hospital. Each child also has a Medi-Cal i card if treatment by a private physician is required. Transportation: Transportation of both parents and children is provided whenever necessary. Usually parents are transported to the Center and other appointments as required. Children are taken to the hospital, on outings, and to school if they are enrolled. VI. IMPLEMENTATION/OPERATION PROBLEMS The Family Care Center has faced numerous problems implementing and oper- ating the project, many of which began as soon as the grant was awarded, and some of which were only really resolved during the project's third year. The project did not begin operation until 18 months after it was funded, much longer than any other project. While all the problems cannot be directly attributed to any one source, certainly the development of a residential pro- gram is more complicated and time consuming than a day program, and the organizational structure both within the Drew Medical School and between the Co-Principal Investigators and the project staff were always problemmatic. The most significant issues are described below. VI.12 Securing a Facility The project faced problems from the outset in finding and renovating a suitable facility. Space on or adjacent to the hospital was always desired and much time was lost negotiating for hospital buildings and then working to have a variance to zoning laws accepted for a building across from the hospital. When none of these were successful, the search broadened to the general Compton area, but it was still difficult to find space which met the criteria for a residential facility (enough space per child, adequate bed- rooms, doors and exits, room for staff and offices, and adequate outdoor play area) and the project's budget. Even when space was secured, a full year after the project was funded, major renovation was required before it could be used. Project Leadership and Decision-Making The leadership of the project was designed to be a joint one between the two Co-Principal Investigators at Drew Medical School and the Project Director. Because of the distance from the hospital and the lack of clear communication about roles and responsibilities, decision-making often took longer than is necessary, again causing delays in implementation and some loss of close cooper- ation between the individuals involved. There was confusion also, when the Chairman of the Pediatrics Department left, about who was to function as the second Co-Principal Investigator. At one point the Pediatrics Department dropped out of the whole project, but later became involved again. To some extent, some of these problems may be inevitable when two somewhat competing Medical School/Hospital Departments, each with its own priorities, seek to jointly make decisions about a single endeavor. And to some extent some of them might have been alleviated had more clear decision-making responsibilities between all parties (e.g., major policy Vi.13 decisions versus management decisions) been articulated. Children's Program Development Although from the outset the children residing at the Center received superlative care from the staff, there was always a desire to expand the thera- peutic programs available for them and to structure the time they spent in growth-producing ways. The therapeutic program never really took shape until the middle of the third year when a new staff person was hired to replace the previous Early Childhood Specialist. This previous staff person's experience had not been with infants and toddlers and it was difficult for | her to develop a program that met their needs. A Play Therapy program ran during the second year but was eventually dropped and, other than this, the program was primarily operated on a day care center philosophy rather than a treatment philosophy. Eventually, these problems were resolved, but too little time was then available before the end of the grant to assess the effectiveness of the new approach. Coordination Between Parents' and Children's Programs Originally, it was hoped that parents would be fully involved in the activities of the Center, spending extensive amounts of time interacting with their children, learning new skills, and helping to implement structured acti- vities for the children. This happened very infrequently during the second year, in part because the parents could not really be forced to spend time there, but also because there were few incentives, in the way of encouragement or structured soslvicies for them, provided to do so. During the third year, more attention was paid to integrating the parents into the overall program, providing conjoint therapy for parents and children and devising activities that were enjoyable for both parents and children to share. Cad VI.14 Timing of Intake For the first year of operation, the project received most referrals from the hospital, often only the day the child was to be released, and usually before any court action had taken place. The Center was then ill-prepared to accept the child (no records had been transferred, staff had not talked to parents) and often, after the child was accepted, a subsequent court hearing would allow the child to return home, in effect causing the Center to be used as a "temporary shelter." Eventually, agreements were reached with DPSS, the hospital and the court about the timing of Intake; children are now only accepted after a judicial decision has been reached regarding placement, and staff of the Center have time to plan for the arrival of the child, including receiving records and interviewing parents before the child is transferred. Houseparent Turnover Twelve houseparents have left the project Since it began operation. Since the project is a residential facility, the loss of one or two house- parents at any time places a tremendous burden on staff and the other house- parents to cover the facility 24 hours a day until replacements are found. There is a need to be very confident about the commitment a houseparent makes when she is hired and to stress the need for adequate notice of termination. Project staff re-analyzed some of the original criteria developed for houseparent selection, particularly the criteria that houseparents be older women with extensive child rearing experience. They now are willing to accept younger people with perhaps more energy to commit to the children, and a higher tolerance for the confusion created by ten children under six years old inter- acting with each other on a daily basis. Also, the project has developed more realistic work schedules (a primary problem) so that houseparents are not as VI1.15 overburdened. Contract Versus Schedule Reimbursement Rates The project is currently reimbursed a set monthly scheduled rate by DPSS for each child under care. They believe their actual costs for maintaining the children is much higher and would like to negotiate a ''contract' rate with DPSS which is in closer agreement with their costs. Because a certain amount of time must elapse before this contract rate can be negotiated, it could not be accomplished during the life of the project. If the project con- tinues, hopefully the new, higher rate will be available. Pediatric Consultant The Chairman of the Pediatric Department at Drew Medical School was act- ing as a key consultant to the project before his leaving that post in December, 1974. Since no new chairman was found for a long while, the project had little pediatric input, and did not have access to a single person for con- sultation, but had to work with whomever was available at the hospital when problems arose. When the new chairman was selected, other priorities of the department precluded his active involvement with the project. Staff definitely would have desired and benefitted from more consistent pediatric consultation than was available. VII. FUTURE PLANS The Project Director has been pursuing various funding possibilities for the period after the grant runs out, including both state and private i foundation funds; however, none of these have been successful to date. VI.16 Although the project could become operational very quickly if money were forthcoming, it was decided that the best interests of the children required some early action toward a stable placement for them rather than waiting until the fund actually ran out. Consequently, in mid-March, all the child- ren were removed from the Center. Several were placed with their parents or other family members and the remainder were placed in foster care. Project staff will continue to provide follow-up to these families until the entire project closes, or until additional funds are secured, at which time the Center would again become fully operational. VIII. PROJECT GOALS The Family Care Center has made some progress toward the accomplishment of all of its goals, but the severe implementation problems faced by the pro- ject have hampered full success. Project staff have had the most success meeting their goals related to developing the services outlined in the grant proposal and in developing some coordinative agreements with other agencies related to the Center's operation. They have had no success in reaching the goals related to expansion of the program via a new and larger facility and the addition of new service components, which are really longer range goals. Goal 1: To physically and emotionally re-Integrate client families at the earliest possible date. The project has always maintained that its services were designed to provide short-term (6-16 weeks) therapeutic services to parents and children in the hopes of re-integrating the families. Part of their approach has been to require that parents not only receive individual counseling service, but v1.17 that they spend concentrated amounts of time with their child, and other children, while the child is in residence at the Center. While some parents have spent no time at the Center, and others visit only sporadically, some parents have shown great interest in this phase of the treatment and do spend considerable time with their children. Several things occur simultaneously when parents visit the children. The Treatment Mileiu Coordinator works with parents and children in Conjoint Therapy to help parents understand the child's development and facilitate further development. Houseparents are available to help parents learn to deal effectively with the children, and to develop appropriate expectations of the child's capabilities. And, finally, parents are exposed to a variety of children of different age groups which helps them better understand their own child. In addition to visiting with their children, parents are encouraged to deal with unresolved parenting problems both in the individual counseling sessions they attend and in the Self-Help Group if they participate in this service. Finally, re-integration of families is encouraged by allowing the child- ren to make periodic home visits (e.g., one day or a weekend) several times before they are actually discharged. ' Problems which occur during these visits can then be dealt with by the staff before the child is permanently returned. When a child is returned home, the staff continue to make follow-up visits periodically to assess the parent-child interaction and to offer help to parents until they are satisfied the family can cope effectively. i As of December 1976, 24 children had been or were in residence. Of the 16 children terminated as of that time, eight had been returned home, five were VI.18 placed with relatives other than parents, and three children were placed in foster care. ‘The average length of stay at the Center has boen approximately five months, slightly longer than anticipated. Goal 2: To develop cooperative working relationships with DPSS and the judicial system. Because of the problems surrounding the Intake process, and to a lesser extent those of termination, the Center spent extensive time coordinating with both the courts and DPSS. Agreements were reached by all parties that children would be accepted for residence only after the court had completed a judicial review of the case and found placement to be suitable. This has reduced the number of children placed for very short periods of time. The closer ties with the court developed through coordination efforts have also resulted in the Center's recommendations at the time of termination being solicited by the court, and the court's more ready acceptance of those recommendations than in the past. Coordination with DPSS has been extensive, since DPSS workers maintain legal responsibility for cases at the Center. DPSS workers act as primary referral sources to the Center, are involved in all acceptance, treatment planning and termination decisions, and are kept informed of the status of the care throughout the treatment process. A Supervisor of Children's Ser- vices at DPSS is at the project one day a week to deal with any problems be- tween DPSS and the Center. She began a series of coffee klatches designed to eventually acquaint all Protective Services workers and supervisors with the Center and facilitate more cooperation. The Center has not developed an Advisory Board as anticipated, which might alleviate some of the above coordination problems. v1.19 The outcome measures identified for this goal include an increase in referrals to the project from the court and DPSS and the acceptance of recom- mendations about families from the Center by DPSS and the courts. There has been a slight increase in referrals from DPSS, although most referrals still come from the hospital. Part of the problem surrounding re- ferrals and intakes is that no clearly defined criteria for acceptance into the Center's program, nor specific intake procedures have been agreed upon by the Center and DPSS. Consequently, it has been easier to work with the hos- pital, with whom the project has more contacts, than to deal with all the prob- lems which would arise if more DPSS referrals were accepted, given the current ambiguous and often dysfunctional intake procedures. Referrals are not really received from the court, but if the case of a child who is residing at the Center comes up for a hearing, the referee will sometimes recommend that the child remain at the Center. In about 30 percent of the cases which are heard involving children at the Center, however, the recommendations of Center staff are either not requested or, if presented by the staff, are not accepted by the court. It is clear that much more coordination, perhaps in the form of written agreements, needs to be undertaken, especially with court personnel, but also with DPSS, if an adequate process of referral, intake and treatment planning is to be carried out by the Center. The staff are aware of these problems and are currently working to resolve some of them. VI.20 Goal 3: To expand the project's facility and services so as to include more families than can presently be accommodated at one time. The project staff have wanted to expand both the nner and kind of ser- vices, and the amount of space available to house children for some time, although little progress toward doing this has been made. Many of the same problems encountered during the first grant year when the search was made for the current facility have been continual problems around expansion. Staff of the hospital would like to have the facility close to the hospital, but have not been willing to provide the money for a facility right on the hospital grounds. Strict zoning laws and the difficulty of meeting licensing and certification requirements for sleeping and playing space for children using conventional buildings or houses have also been problematic. The problem appears to be reluctance on the part of all concerned to commit themselves to the expanded space until all of the financial implications are known. Because the project has a lease on the current facility, it is unlikely that anything will be decided in the near future, although the project director has negotiated repeatedly with the hospital for expanded space. The possi- bility of receiving grant monies from public and private sources to offset some of the costs of the larger facility are also being explored. The only new service for families developed since these goals were articulated is the Parent-Involvement Group and Conjoint Therapy for parents and children. The Self-Help Group has been quite successful and the project would like to support two or three more groups such as this, using volunteers as group leaders. These new groups would be available for non-Center clients, thus expanding the number of families served. To date, however, these new ¥1.21 groups have not been formed, and the Center still provides active services to only 10 children and their families at any one time, although some other families are receiving follow-up services. Goal 4: To sustain the project beyond the federal grant period. The Project Director had been seeking additional funds for continuation of the Center beyond the grant period, but to date nothing has been accepted. Proposals were submitted to the state and to private foundations and a certain amount of negotiating with the hospital has occurred. Because of money received from DPSS (if contract rates were established, the Center could receive as much as $750/month per child) the project does not require its full operating budget to be picked up, but even this reduction in the amount requested has not brought results. Goal 5: To add new children's services, including a day care center, pre- school program, and a day/night crisis nursery. The staff have identified an overwhelming need in the Compton/Watts area for additional services for children who have been abused, especially services not requiring full-time residence in a specific facility. They would like to be able to provide some of these services themselves, but feel that without more staff and a larger facility, these services are not feas- ible. Very little progress, therefore, toward accomplishment of this goal has been made, since a larger facility was never acquired. v1.22 IX. PROJECT MANAGEMENT AND WORKER SATISFACTION The Los Angeles project had written an innovative program proposal, but the lack of coordination between the co-principal investigators from Drew Medical School and the poor organizational structure, serious manage- ment problems and co-worker disruptions mitigated against the program realizing its potential, Organizational Structure The Los Angeles project was a small program with 23 total staff mem- bers, 12 of whom were full-time. Because the project was a residential treatment program, the average monthly budget of $15,796 is somewhat larger than one would expect for a program that served only nine families at a time. The original program was designed to be moderately complex with a variety of treatment options, and four different disciplines involved, but much of the planned diversity in program activity was never implemented. The program was, however, extremely complex in the structural relationships it had with the departments of Pediatrics and Psychiatry at the Medical School. Officially, there was a high degree of formality in the prescribed rules, regulations and job descriptions; however, the project itself main- tained highly informal, non-specified arrangements with the host agency. Major policy decisions and program planning required approval by the co- principal investigators in the Pediatrics and Psychiatry departments; thus the project was centralized in authority. Some confusion existed among the staff regarding who had decision making responsibility about program activities and individual job performance, and there was little consensus v1.23 among the workers regarding the amount of autonomy they could exercise in their jobs. Management Many of the management problems experienced by the Center have been alluded to, affirming the impact that management concerns have had on the implementation and daily operation of this program, and offering one expla- nation for the project's apparent lack of success. One of the dominant management problems was the relationship between the project and the host agency (Drew Medical School) and specifically the problems arising from the relationship of the two co-principal inves- tigators from competing departments, Pediatrics and Psychiatry. The two departments were forced to collaborate after the original proposal from the Pediatrics Department was rejected by OCD pending the addition of a mental health component, i.e., Psychiatry. From the very beginning the two departments disagreed on expectations for the project, the designation of a project director, and the procedures for coordination. The project director, hired nearly 18 months after the project was funded, was placed in the difficult position of having to work with these two departments, which were by then undergoing a number of internal changes in leadership and program goals, further complicating an already strained partnership. Because of this situation, staff roles were never delineated, department responsibilities and commitments were never specified and lines of authority were not drawn. Consequently, there was always confusion and ambiguous guidelines about the management of the program. Under different leader- ship these conflicts might have been handled more effectively, but this project director never believed that he had the mandate or flexibility to VI.24 manage the program and make decisions because of political repercussions, and thus believed the whole situation unworkable. To further complicate the coordination and communication problems that existed among the project administrators, and perhaps as a result of these difficulties, there were also communication problems among the pro- ject staff. Project management consisted of both a project director and a treatment coordinator. Unfortunately, both persons were responsible for supervising the same staff; exclusive lines of authority did not exist. This structural problem was further complicated because both people were unable to work together or deal directly with mutual communication prob- lems. Tension, conflict and verbal battles were the result, affecting the whole staff. Staff were given contradictory job descriptions and discre- pant evaluations of work performance. Because the project director was at the same Line somewhat inaccessible to the staff, as he tried to cope with his problems with the medical school, he was unaware of other communi- cation and co-worker problems that began to interfere with program opera- tion and service delivery. Formal communication structures did exist in the form of regularly scheduled staff meetings, but these sensitive com- munication problems and interpersonal issues were never raised or dealt with openly. As the problems became more disruptive, the director tried to remove one staff member, but because he failed to label the problems correctly and share the issues with the entire staff, they misinterpreted his actions and motives, and effectively blocked this staff change. During the second year, after several key staff members had left the project, workers reported an improvement in their work environment and enhanced job satisfaction. While there continued to be management problems, many ¥1.25 of the internal stresses had been reduced. Upon examining these earlier job pressures, staff report that clients had never caused personal emotional stress, but that internal problems of the project were pervasive and were the cause of anxiety and psychosomatic complaints. When the program stabilized after a staff crisis that had existed nearly a year, workers finally were able to provide the necessary services to clients. Turnover/Burnout/Satisfaction There was high turnover in this project, primarily among the house parent and children's staff. This turnover was due to the long hours house- parents were required to work and the low pay they received. There was some effort to shorten the hours, and to carefully screen and inform re- cruits about the job's demands, in hopes of reducing the turnover that jeopardized the children's program and placed greater demands on other staff. With changes in the parent treatment staff, there was improved communication between children's staff and project director. Improved communications helped to anticipate and correct minor grievances before they escalated. There was turnover in two key positions among the treatment staff. This turnover can be directly attributed to the management problems already discussed -- communication problems, co-worker conflicts, and the confusion that existed in role definition and lines of authority. These problems also had an impact on the workers who chose not to leave the project, some of whom report low job satisfaction (about 40%) and many of whom were burned out by the experience (50%). Project morale improved somewhat in the last few months of the project after staff changes and a revitalization of the children's and parents' program occurred. VI.26 X. ANALYSIS OF CLIENT DATA Client Flow All referrals to the project are recommended by DPSS and the court, after placement has been judicially mandated. The actual placement must be made by DPSS since the project is reimbursed for the care of children through that agency. Children who are between 0-6 years of age and who have been previously abused, but generally recovered from their injuries, are accepted, so long as parents agree to become involved with the Center's activities and are not severely emotionally ill or have a substance abuse problem, and it appears that the Center's services will be appropriate to the family's problems. Children receive behavioral and developmental testing at entry and an extensive diagnostic evaluation of the parents and the parent-child relation- ship is undertaken. The case is then presented to the Diagnostic Treatment Team and a general plan for service for both parents and children is formu- lated. The Intake process generally lasts two to three weeks. The Treatment Team includes the Psychiatric Caseworker, Treatment Milieu Coordinator, Early Childhood Teacher and the Chief Houseparent of the Center, psychiatric con- sultant from the King/Drew Medical Center, and limited participants from DPSS, court and other agencies involved with the family. The treatment process lasts from four to five months. During this time, both parents and children are involved in numerous activities: individual counseling, conjoint therapy, self-help group, Parent Involvement Group, play therapy, developmental sessions, etc. New goals for parents and children are developed at appropriate times and particularly troublesome cases can be brought back to the Treatment Team fcr further consultation. VI.27 A Discharge Disposition Conference is scheduled approximately one month before the '"projected" end of treatment. The purpose of the conference is to decide on future action, including: return of the child to his/her family, alternative placement of the child, or additional services through the Center. If it is decided that the child and family can no longer benefit from the Center's program, a recommendation for placement, either with the family or otherwise, is made to DPSS. If the child is returned a post-discharge follow- up plan for the child and family is formulated. After the child is discharged from the Center, active follow-up of the family occurs, often for several months, until staff are satisfied that the reunification is satisfactory and the family is stabilized. Client Characteristics The Family Care Center had a capacity to service 10 families per month, providing primarily residential and attendant care for children and minimal therapeutic services for parents. Data on client characteristics is available for only 12 families over the entire demonstration period. Almost all of the cases received by the Center were referred from the Martin Luther King Hospital through Protective Services to the Center. Each of the cases involved some form of physical abuse, and the inaltreatment was either established or there was a very strong indication that abuse had occurred in every case. Over half the cases were severe or moderate cases of abuse, and one case also indicated emotional neglect. Mothers were responsible for the maltreatment in 5 cases, and fathers in 4. Because of the crisis orientation of the Center, and the need to place the child then for protection, 10 of the 12 cases were involved with the County either prior to or while receiving services. Four cases had previous records of abuse, while eight did not. VI.28 The socioeconomic characteristics of the families reflect the low income area of Compton-Watts in which they reside. All families were minority, primarily Black, and one-third of the families were single parent families. In over half the families, no one was employed and 50% of the families were on public assistance. The average income of these families was $3,800, by far the lowest income average for the demonstration group as a whole, and in only 4 of the 12 families did any adult have a high school degree. The average age of the mother was 21 years and, in general, this population of parents was much younger than those in the other demonstration projects. Over half the families cited financial difficulties and heavy, continuous child care responsibility as the severe problems, while another quarter experienced difficulties with drugs, marital problems, and the stress associated with a new baby in the household. One-third of the families were having problems coping with social isolation. In general, it can be said that the Family Care Center served a very different population, and a much more problem-ridden one, than the other demonstration projects. The parents were younger, poorer, less well educated, and were plagued with the multiplicity of problems associated with one of the worst ghetto areas in the county. Although the families were small (usually one child) the children were all pre-schoolers, generally a disruptive age. Physical aggression, many times quite serious, was the way these parents mistreated the children, necessitating removal of the children tc the Center and usually court intervention. VI.29 Quality of Case Management Thirteen cases were reviewed at the Family Care Center to determine the quality of the case management practices. In 12 of these cases, less than one week elapsed between referral and the first contact with the client, and all but one client began receiving teatment services within two weeks after the first contact. Ten of the thirteen cases had the benefit of a Multidisciplinary Team Review and all but one case had both Intake and Treatment Conferences (general staffing) to provide input into. decision making about the case. Extensive use of consultants (more than 4) were used in 10 cases, and in all 13 cases, contact was made with the referral source to elicit background information. There was little turnover in case managers and only in rare cases (2) did the case manager change during the treatment process. One-third of the cases had only one treatment provider, one-third had three, and one-third had 4-6 different treatment providers. Contact with other agencies, including provision of outside services, was made in most cases (11 of 13). At least two follow-up contacts were made with every client, following an average of 4-12 months in treatment. Despite these relatively effective case management practices, some serious problems were uncovered by the quality reviewer. The project's emphasis clearly is on the child who is in residence and few services are actually provided to the parents. It was felt that theMultidisciplinary Team was not functioning effectively and treatment goals were set too quickly and without client input. All evidence pointed to a primitive approach to treatment with severe demands placed on parents to comply with numerous rules and regulations. Little supervision was provided to the A VI.30 professional staff, house parents, or the numerous volunteers. Concern was also expressed about the clients' records which, overall were incomplete and disorganized. There were few social histories, information on the abusive incident, or evaluation of the child in the records, and little assessment of the families' functioning or the information about treatment plans in relation to observed familial problems. XI. COMMUNITY IMPACT The Family Care Center had little impact on, nor was it greatly influenced by, the remainder of the community child abuse and neglect system in Los Angeles. Due primarily to its small size (it provided services to fewer than 10 families, on average, during the course of the demonstration period) and the project's policy of restricting clients to only those from the general Watts-Compton area (a very small area in the city of Los Angeles) but also because simply attending to internal project operations required the major share of the staff's attention during the first 2-1/2 years of operation, few contacts with other community agencies were made beyond those required to facilitate referrals to and from the Center by the local Protective Service Agency. Also, until the final six months of the project's operation, project staff were able to carry out very minimal education of either professionals or community citizens. Thus, because the operations of a project this small size could not be expected to markedly influence the operations of a child abuse and neglect system in a city of the size and complexity VI.31 of Los Angeles, and because only a fraction of the staff's time was spent in areas of community coordination or education, no analysis of changes in community system function was carried out in the study of the Family Care Center. XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS The following table indicates the ways in which the Family Care Center allocated both staff time and project resources to various activities during the course of the project. These figures depict the major emphasis of the project, namely the provision of residential care for children, including a child development component, combined with minimal therapeutic service pro- vision to parents. Fully 62% of the project staff time was spent in either the provision of residential care or child development sessions; although, due to the very large number of volunteers, this time only consumed 29% of the project's actual resources. The next largest expenditure was for over- head, including general management, staff training, and program planning. These activities accounted for 23% of the staff time spent on the project, but, due to the high salaries of the staff involved in program management/ direction, fully 47% of the project's resources were expended carrying them out. Staff also spent about 7% of their time (and 9% of the project's resources) on educational activities and coordination endeavors in the com- munity. Only 3% of the project's rescurces were spent on research or eval- uation activities. In addition to the provision of residential care, including child development sessions, none of the other direct services provided to clients, including outreach and intake activities, general case VI. 32 Project Resource Allocation and Service Costs Rasoives Mloca ion to Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Actual Unit Cost Activity Allocation [Allocation | Average Monthly Volume | Unit Cost| to Community Community Education 2% 1% Professional Education 2 3 Coordination 3 5 Staff Development/Training 9 11 Program Planning/Development 2 3 General Management 12 33 Project Research 1 1 BPA Evaluation -- 2 Outreach -- 2 S cases $18.67 $18.67 Intake/Initial Diagnosis -- 2 6 intakes 3.93 3.93 Case Management/Review 2 3 9 average caseload 33.38 34.28 Court Case Activities -- -- 4 cases 33.98 33.98 Crisis Intervention During Intake* -- -- 4 contacts 9.10 9.10 Multidisciplinary Team Review -- 1 4 reviews 27.16 27.16 Individual Counseling 1 1 20 contacts 18.07 18.60 Parent Aide/Lay Therapy -- -- 5 contacts 18.45 28.45 Couples Counseling a -- 4 contacts 16.87 16.87 Family Counseling* -- -- 2 contacts 17.19 17.19 Alcohol, Drug, Weight Counseling* -- -- 3 person-sessions 18.18 18.18 Individual Therapy 2 3 35 contacts 15.15 15.22 Parents Anonymous* -- ro 19 person-sessions 0.59 4.80 Crisis Intervention After Intake -- -- 6 contacts 12.58 12.58 Residential Care 43 18 207 child-days 35.94 36.22 Child Development Program 17 9 155 child-sessions 16.16 16.27 Play Therapy -- -- 10 child-sessions 3.18 5.84 Special Child Therapy* -- -- 46 contacts 2.12 2.12 Medical Care -- -- 19 visits 10.05 10.35 Babysitting/Child Care 2 2 -- =" == Transportation/Waiting 2 3 42 rides 13.49 13.50 Psychological/Other Testing -- -- 4 person-tests $5.96 55.96 Follow-Up —e - 6 person follow-ups 20.88 20.88 Total Annual Person Years/Budget 18.82 $236,280 Average Monthly Caseload = 9 * Service provided for one month only. VI.33 management, individual parent counseling or therapy, babysitting and trans- portation, consumed more than 3% of the staff's time or the project's resources. The Family Care Center staff spent about 19 person years providing services to nine families per month. Approximately 207 child days of residential care were provided each month at an average cost of $36 per day, and 155 child development sessions were provided to these same children each month at a cost of about $16 per day. About 55 individual counseling or therapy sessions were provided each month to parents; the counseling on cost about $19 per session, while the therapy sessions averaged $15 per contact. The overall management of the families at the Center, including regular review of cases cost $33 per family per month. Working with cases requiring court intervention (four cases per month) cost $34 per case. Psychological testing of children, which about four children received each month, was extremely expensive ($55 per child), due primarily to the contracted service of an outside consultant to perform the tests. It is interesting to note that while many project staff (primarily Foster Grandparents and CETA employees) were not paid out of grant monies, the costs of overall program management was so high that virtually no cost saving was experienced by using these 'free" resources, as a comparison of the actual costs and hidden costs, or actual cost to the community (which includes the ascribed cost of volunteers) shows. oo TEC E——— SN RE I — ET TOE —- d = “ : . : - - ) = gy . TT Twas oo . 1 41 = Lal ) a yr Re ey ¥11.l THE CHILD DEVELOPMENT CENTER: NEAH BAY, WASHINGTON I. COMMUNITY SETTING The Makah Indian Reservation occupies 28,000 acres on Cape Flattery at the mouth of the Straits of Juan de Fuca. It is 75 miles to the west of Port Angeles, a city of 16,000 inhabitants. Of the approximately 1,400 people living on the Cape in 1970, 300 resided on the Air Force Base or at the Coast Guard Station and 900 lived in the only town, Neah Bay. There are about 700 Makahs living in Neah Bay or elsewhere on the reservation. A tribal survey of households in 1974 revealed that 44% of the families earned less than $4,000 per year and almost 60% of the Makahs were under 20 years of age. Unlike other tribes on the Olympic peninsula, the Makah tribe has re- tained ownership over almost all of its resources, and derives revenues from salmon fishing, the sale of timber rights, several motels and restaurants, and for businesses on the reservation. Major sources of personal income are fishing, lumbering or hauling timber, tourism, and small businesses. Even though it is only within the past decade that the Makahs have enjoyed any material prosperity and even though incomes are still low by urban stan- dards, the quality of life apparently has been high. From an outside observer's perspective, Makah society has, until recently, been dominated by men; the women have been responsible for child rearing. Although both parents openly give affection and material comfort to their children, discipline and daily care generally fall tc the mother. In some cases, neither parent may discipline the children. This lack of control VII.2 may explain some of the teenage delinquency, the inability of some adults to cope with the demands of the work-a-day world, and the high potential for alcoholism that many Makahs have. To some extent, the white culture's attitudes toward child-rearing have influenced and are influencing Makah values. This is particularly true of young parents leaving their children with relatives when the responsibilities of parenting becomes burdensome. Although this has been a pattern common to the Makahs for many generations (and traditionally accepted), today the grandparents and community professionals consider this an irresponsible act. Parents, particularly mothers and grandmothers, assimilating the values of white culture, have developed stricter ideas than their ancestors had about how children should look and how they should behave. Another source of behavioral change seems to be the white culture's transition in attitudes about women's roles in society. Makah women are slowly taking on more respon- sibilities outside the home and expecting more from men at home. One area that has not received much of the community's attention until recently, prob- ably because it was not of interest to men, is social services. It is pre- cisely in this area where women have taken a leadership role. Although its importance has diminished in recent years, 'familism'" is one of the strongest influences on local politics and on what (and how) community services are provided. Even though there are marriages among members of different family clans, each Makah identifies with one of a dozen or so major family groupings. Families tend to dominate in particular sectors of the community's life, like fishing or education. Charges of nepotism and favoritism are exchanged frequently where staff are hired to fill new posi- tions or tribal funds are apportioned to various projects. The fact that V11.3 social services have not come under the influence of one particular family is both a blessing and a bane. Although there may be an occasional problem surrounding hiring, social services have not been restricted as they might have been through association with a family. On the other hand, they have not had the advantage of the advocacy of a particular family. II. HISTORY In the fall of 1973, at a meeting of Head Start directors, the head of the Makah Reservation Head Start program heard about the proposed demonstra- tion effort in child abuse and neglect. She saw this program as a means of working more closely with parents, educating them on their children's needs, and training a few to become professional community workers able to reach parents having difficulties raising their children. Having received the proposal packet (days before the deadline), the Director of Head Start called together a number of people she thought might be interested in such a project. The Head Start Director, several of the reservation's Community Health representatives, the school principal's wife, the day care nurse, the reservation's planner and the reservation's federal grants writer held a meeting to brainstorm on ideas for the proposal. These professionals had talked about child neglect issues in the past and felt that there was no system for handling neglect cases on the reservation. Much of the mild to moderate neglect occurring on the reservation was attributed to ignorance of child needs, poor parenting skills, and such underlying social and economic problems as unemployment and alcoholism. Previously, the community lacked a way of organizing itself for effec- tive planning and program development that responded to social needs in Neah VII.4 Bay. The collected professionals hoped that through the award of the fed- eral grant such a system for child welfare needs could be developed. The grants writer took the ideas generated at the brainstorming sessions and produced a proposal. Notice of award of the contract was received at the beginning of May 1974, and the Project Director for the Child Development Cen- ter (CDC) was selected by the reservation Head Start Committee in early July. ITI. SUMMARY OF ACTIVITIES Summary of First Year ® The Child Development Council provided, for the first time, a place where social service professionals at Neah Bay can (and do) regularly meet to discuss mutual problems, identify community needs, and develop programs and services to meet those needs. In addition, the project * Expanded two-member CDC staff to include two CETA social worker trainees. ° Assisted in location of a satellite DSHS office (Department of Social and Health Services) at Neah Bay which reduced travel time and incon- venience and increased the level of homemaking services available at Neah Bay. ° Established coordinative agreements with other agencies to refer child welfare cases to the CDC. ° Coordinated the operation of a food and clothing bank. ® Developed and distributed pamphlet on the activities of Head Start, Day Care and the Child Development Center. ° Supervised movies and dances for the community's teenagers. Vi1.5 Summary of Second Year ® Presented two seminars on child development, effective parenting and an overview of legislation pertaining to child welfare. ° Started the first parent education classes ever to be held at Neah Bay. ° Underwent major staff changes, including resignation of original director, promotion of community worker to acting and ultimately permanent director, promotion of CETA trainee to permanent community worker position. ° Contracted with consulting psychiatrist to train staff, review cases, provide therapy to parents and children, and lead the parent educa- tion group. ° Involved parent volunteers in education and outreach efforts. ° Assumed primary case management responsibility for abuse and neglect cases. ° Published monthly newsletter on social services programs and recent plans and developments. © Initiated multidisciplinary clinic meetings to confer on case Hl management and treatment planning. ° Recognized by all community professionals as the principal agency to report or discuss a case of child abuse or neglect. ° Gained significant learning experience for the staff in their effort to fill the current gap for fully-trained Makah social workers. ® Promoted the development of legislation at the state level that would increase the self-determination of Native Americans in dependency matters. VII.6 Summary of Third Year ° Expanded staff to include a full-time home management aide to aug- ment counseling and outreach services. ® Reorganized staff to reflect the division of program responsibili- ties into administration, community education and treatment. ° Regularlized meetings with the tribal judges. ° Participated in landmark child custody case as the investigative agent of the tribal court. ° Recognized as placement center by community, tribal court, and Port Angeles DSHS office. ® Assisted in gaining foster home licensing authority on the reser- vation. ® Identified by Port Angeles juvenile authorities as representatives on the reservation to work with first offenders and their families. ° Granted training responsibility for the houseparents at the Youth Resources Center, a juvenile detention facility. ° Assumed responsibility for planning and delivering the parent edu- cation classes. ° Moved from the Tribal Center to the Teen Center. ° Coordinated the distribution of surplus furniture to needy families. IV. ORGANIZATIONAL STRUCTURE/STAFFING The Makah Indian tribe is governed by the five-person Tribal Council (serving three-year terms, with two members elected each year), headed by the Tribal Chairperson. Responsible to the Tribal Council and the tribe are eight committees that oversee most activities on the reservation. These —— VII.7 include the Economic Development Committee; the Fleet Skippers Committee (the reservation owns and operates its own fleet of fishing boats); the Timber Committee (the tribe owns most of the reservation land and, as a major source of income, sells timber to commercial lumber concerns); the Health Board (through the Indian Health Services the reservation operates a health center); the Housing Committee; the Education Committee; the Law and Order Committee (the tribe has its own law enforcement agents on the reservation); and the Constitution Committee. The committees and the Tribal Council have respon- sibility for hiring and firing tribal employees and for setting policy. The day-to-day management of the tribe is the responsibility of the Executive Director and his staff. Federally-funded projects come under the auspices of this Executive Director (given that the Tribal Council itself has approved the project). The HEW Coordinator oversees Neah Bay's health, social service and edu- cational programs, including the Child Development Center. The Coordinator's assistant manages some of the programs, including the Center. Therefore, the Child Development Center staff are organizationally employees of the tribe, responsible to the HEW Coordinator and her assistant, who in turn are responsible to the Executive Director (see Figure 1). The Child Develop- ment Center staff has all the rights, privileges, and restrictions of all other tribal staff. FIGURE 1: Organizational Structure Tribal Council Executive Director Tribal Committees Law and Order \ [ Baucation q - Indian Health Clinic Meetings ~ -— — |e we = Consultant HEW Coordinator Assistant HEW Coordinator Child Development Center Director Community Workers 1 Child Development Council | Administrative linkage Advisory, informal linkage Home Management Aide Representative Community Health 8 IIA yi1.9 Although during most of the demonstration period the Child Development Center was housed in the Tribal Center, the five-member staff, all of whom are Makah Indians, rclocated to the Teen Center in the fall of 1976. The director, while managing some cases, is primarily responsible for program direction through administrative and coordinative efforts within the social service network. One of the community workers is responsible for planning and providing a community education program, while the other has the func- tional role of administrative secretary to the director. Both maintain some casework responsibility as well. The home management aide is the principal service deliverer, providing counseling and homemaking services to the Cen- ter's caseload. In addition, an HEW Community Health Representative shares office space and community identification with the Center staff. She soliges those cases referred through the Indian Health Clinic and functions as the community outreach worker for the WIC program. For two years of the grant, the CDC has contracted with a psychiatrist from the University of Washington's community psychiatry faculty to train staff and other professionals, review case progress, provide therapy to parents and children, and direct a parent education group. As part of their work, the Child Development Center staff participate in the Law and Order Committee, the Education Committee, and the Indian Health Clinic meetings, since it is these committees that govern the acti- vities of those professionals who have contact with child abuse and neglect cases. In addition, the CDC employees are staff members to the Center's advisory board, the Child Development Council, which is ccmposed of repre- sentatives from all the reservation-based and reservation-related agencies that could be handling child abuse and neglect cases. The Council provides VII.10 direction for the project by serving as a forum for the discussion and plan- ning of the Center's activities. During the three year demonstration period, personnel changes included the promotion of the original community worker to replace the project direc- tor; the promotion of the CETA trainee to a community worker position; and the addition of a home management aide. V. PROGRAM COMPONENTS The Child Development Center program includes the following components: coordination, legislation and jurisdiction, case management, community edu- cation, professional education, youth and family activities, and staff training. Coordination A major element of the project is the development of a coordinated sys- tem of case identification and service delivery. Prior to establishment of the project there was no system for handling neglect cases nor was there any formal coordination between the many different agencies that might be involved in a case. The 29-member Child Development Council, composed of represen- tatives from all social service-related agencies on the reservation, met frequently during the formative stages of the project for sharing informa- tion about what services are available to reservation residents, how to improve those services, and how to better coordinate them. Through the activities of the Council and efforts of the staff, an interim abuse and neglect policy was formulated for Neah Bay. In addition to the activities of the Council, the staff members meet regularly with several Tribal Committees VII.11 and the Indian Health Clinic. At these meetings they are able to learn about and discuss other groups' plans and to share information on their own plans and activities, as well as coordinate the case management and service delivery to common clients. As a result of these coordination acti- vities, the Center serves as the central agency to which abuse and neglect cases are reported and through which cases are monitored. For a time the Center published a monthly newsletter on social service programs and development to encourage participation and facilitate coordi- nation. The Center's staff developed a social service directory covering available services in Port Angeles and Neah Bay. The staff is also active in improving the quantity and quality of services that affect social well- being at Neah Bay, since these indirectly affect the well-being of children. For example, staff members heiped obtain a DSHS local office at Neah Bay to provide more responsive financial assistance and homemaker services. In another area, they have coordinated and supervised the distribution of free food, clothing and surplus furniture to needy families. Legislation and Jurisdiction The residents of the reservation are governed in certain matters, includ- ing the area of child abuse reporting and dependency, by Washington State law; however, a formal tribal policy relating to child abuse and neglect and other dependency cases was passed by the Tribal Council in September 1976. Formally, all reports of abuse and neglect are to be made to the Division of Protective Services in the Department of Social and Health Services (DSHS) in Port Angeles. Informally, however, professionals working on the reser- vation currently refer all suspected cases to the Child Development Center, which maintains contact with DSHS when necessary. For the last year of the V11.12 project, total responsibility for these cases was tacitly relinquished to CDC, since the new DSHS worker concentrated his efforts on other communi- ties' problems. While remaining available to the Center on an as-needed basis, the social worker's weekly visits to the reservation were discon- tinued. The Center welcomed the development of a reservation-wide policy on abuse and neglect, which specified not only reporting requirements, but also definitions of abuse and neglect appropriate to the reservation population, and delineated mechanisms for handling abuse cases. A key element in the tribal policy is to make sure the tribe will have the authority to decide on the disposition of foster care and adoption cases. Temporary authority to license foster homes on the reservation was granted to the DSHS homemaker, with the tribal judges making the placement determinations and CDC providing investigative services and counseling when appropriate. The first perma- nent adoptive placement by an Indian tribe's court system was recently com- pleted in Neah Bay, throughout which the Child Development Center functioned as the investigative agency. Case Management and Service Delivery As initially conceived, the Child Development Center was not going to take primary responsibility for the management of child abuse and neglect cases, although it was intended to monitor the progress of families identi- fied as needing help. Referral and coordination with other service providers, as well as providing an Indian liaison with the families, were the main case- work roles the CDC fulfilled during the initial stages of the project. How- ever, as the staff's expertise and confidence in their counseling skills v11.13 increased, and other agencies recognized this growth in competency, the Child Development Center has assumed traditional caseload management functions. In addition to providing counseling services (including individual, marital and family), they conduct preliminary investigations for the school, health clinic, and court system, make referrals to appropriate providers in the community, and help arrange for supportive services for families such as day care and transportation. The staff performs a variety of advocacy tasks for troubled parents as well as non-troubled parents. Frequently, the staff members are asked to intervene with another agency to make sure that food stamps or welfare checks are received, or to deal with an interfamily con- flict. Individual and family therapy is provided through the Center by the consulting psychiatrist. Community Education The Center seeks to educate the general community about issues relating to child abuse and neglect, particularly effective parenting. This effort has included two large seminars for parents and professionals on child develop- ment and management, child welfare legislation, and foster care and adoption. During the last year of the project, parent education classes were offered which presented information on topics of concern identified by the parents. Professional Education The Center attempts, through a variety of activities, to educate the community's professionals about child abuse and neglect. Staff members make presentations to teachers and other professionals, as well as hclding othe shops for them on the nature of a coordinated, comprehensive child neglect program, child development, and child abuse and neglect legislation. VII.14 Youth and Family Services There have been few organized activities on the reservation for young people and parents. In addition, there are no family activities. The Center works with other members of the community on developing a set of youth and family activities (primarily recreational) that will help alleviate some of the boredom felt by young adults and parents, while enhancing family linkages. The staff works closely with high school students in developing recreational activities, such as movies, dances and cultural events. Staff Training The project provides its staff members with a variety of training exper- iences. Staff attends workshops -- on child abuse and on social services -- held at various locations on the west coast. In addition, the staff members are enrolled in correspondence courses at a community college in order to earn their college degrees and supplement their present skills and knowledge. During his monthly visits, the project consultant meets with staff to discuss cases and to help further their abilities as social workers. The Center has financially supported the academic training of three social worker trainees who have worked for other agencies like Day Care and Head Start. VI. IMPLEMENTATION/OPERATION PROBLEMS Open Communication and Attitude of Helpfulness When the project was first started, the staff perceived that one of the primary concerns of Neah Bay parents was that the project would take their children away if they were not ''good" parents. Also, project staff members recognized that in a community as small as Neah Bay, one person's disgruntle- VII.15 sont would thwart their effectiveness, and they made a concerted effort to create a climate of openness and helpfulness. Staff members attempted to keep everyone who was interested informed of their activities by circulating minutes of the meetings, progress reports, and project documents, and by attending meetings of other organizations. Staff members made a point of keeping their office doors open and encouraging people to drop in whenever they were in the vicinity. This style of openness and helpfulness may have been responsible for keeping resentment and animosities to a minimum. Mutual Trust with DSHS The confidence that the DSHS Protective Services supervisor and social worker had at the outset in the Center's staff made it possible for both state and Makah interests to be better served. If the state had attempted to intervene in Makah family problems without the Center's participation, it is likely it would have encountered suspicion and resistance. Conse- quently, DSHS would not have been as able to respond to crises. The Center's staff members have been able to quickly assess the situation, in a non- threatening manner, and to determine the nature of the family's need. In time, as a new DSHS caseworker was assigned, reliance on the Center's judg- ment freed the Port Angeles worker to concentrate on other communities problems. Parental Involvement While frequent participation by individuals with minimal, if any, prob- lems of neglecting their children's welfare gave the Center a norn-stigmatizing image, the Center originally had difficulty in gaining the involvement of those parents most in need of assistance. The Center tried to gain the VII.16 participation of some parents by getting their friends involved and by asking them to take some responsibility for a project activity, like managing the clothing bank or developing a workshop presentation. The staff has speculated that the barriers to participation may be the lack of babysitting services, the lack of interest in programs that are offered, the lack of awareness of their availability, and some psychologi- cal constraints. A brief experiment making babysitting available in the evening at the Head Start Center when recreational events for mothers were going on did not increase participation. Attempts were launched to increase the variety of therapeutic programs offered by the Center and in the community, and to increase awareness of the availability of services. The staff members expanded the network of people involved with the Center in order to make it possible to involve those parents who were currently uninterested in the Center's programs, but who were most in need of gaining parenting skills and working on their personal problems. Community Involvement The Center's staff, with the assistance of the Council, actively involved as many community members as possible in the planning and running of workshops, conferences, and recreational events. Although, as mentioned previously, the Center's staff has tried to work in an open and helpful manner, the Cen- ter's acceptance in the community has been partially a result of the staff's ability to get others interested in the Center's projects. At one time or another the Center has had the following groups working on projects: Tribal Council, teenagers, parents, clergy, teachers, as well as all the organiza- tions represented by Child Development Council members. VIIL.17 More Effective Use of Social Service Resources Although a number of people, many of whom are Makahs or Native Americans, are paid to provide different kinds of social work services, there has been a need for further developing capabilities of those providing service in order to provide a more intensive and wider range of services to parents who are having serious problems raising their children, and to individuals with personal problems. The following individuals currently provide some degree of counseling and social work services to different groups on the reserva- tion: BIA social worker, community health representatives, public school counselor, DSHS case worker, Child Development Center director and community workers, alcoholism and drug abuse counselors, the community worker for the Law and Order Committee, the reservation probation and parole officer, the Indian Health Clinic's mental health worker and consulting psychologist, and the Center's consulting psychiatrist. Perhaps because the Child Development Council contains many of these individuals, or representatives from their organizations, and because the Makah style does not readily lend itself to critical or goal-oriented analysis, the Council was unable to address the issues of how to best use the array of potential counselors and social workers. It took some time for the Center to systematically look at what changes needed to be brought about to improve the social service system at Neah Bay, although early on there emerged a consensus on a few major needs, like improved recreational opportunities, increased number of foster care homes, and the desirability of a DSHS office at Neah Bay. VII.18 Staffing Transition With the resignation of the original project director after the first year of operation, the subsequent promotion of the community worker to the directorship, and the promotions of the CETA trainees to community worker positions, a period of transferring confidence and negotiating responsibili- ties both within and outside of the agency followed. Confidentiality While client rights to privacy and confidentiality are always an issue in a service providing agency, the Child Development Center was multiply handicapped with the conditions in Neah Bay. The extremely small size and interrelatedness of the community, the hostility and suspicion toward record keeping on the part of the populace and the professionals, the "fishbowl" effect of having offices in the Tribal Center -- all contributed to the decision not to keep client records, other than worker's case notes. This decision has had obvious implications for the evaluation of the impact of CDC services on clients. VII. FUTURE PLANS The future of the Child Development Center remained insecure right up to the expiration date of the demonstration grant; at which time a three- month extension of the federal funds was awarded. During the first half of 1977 several funding alternatives were being considered, although most observers and participants expressed pessimism that any stable funding would materialize in time to provide program continuity or, in fact, to allow the program design to remain intact. Alternatives being pursued included: merging the Center and the Substance Abuse Center into an vi1.19 umbrella family services agency; expanding the DSHS satellite office to include counseling positions; increasing the Community Health Representa- tive (CHR) positions sponsored by the Indian Health Service; and seeking federal and/or state grant funding as an autonomous program or in conjunc- tion with the Head Start program. The last of these alternatives was, in fact, realized, such that in October, state funding will cover a multifaceted Children and Family Ser- vices Program which houses the Child Development Center (staffed by the current director and two caseworkers) and a child care center with a sep- arate director overseeing day care, infant care and Head Start. Interim funding was provided by the Tribal Council and Head Start to bridge the gap between the termination of the demonstration grant and the commencement of the state funding. This interim period was devoted to planning and coor- dination in order that the division of authority and service responsibility be clarified within the new program structure and for the community. In addition, the Child Development Center staff maintained a caseload of 25 clients throughout the transition, providing direct services (e.g., individual, couples and family counseling) and coordinative services with other providers in the community. The anticipated role the CDC will be performing corresponds closely to that which evolved through the demonstra- tion period. By utilizing several of the staff, trained under the grant, to deliver direct services and provide service coordination in the community, the identity and momentum of the agency will be unimpaired. During the community system's interviews conducted in January 1977, it was evident that the Child Development Center was a valued resource and that the prospect of its termination was of serious concern to every agency in VII.20 the community. The situation at that time was perceived as one in which the CDC had developed into a central and vital service provider such that none of the community agencies (the Indian Health and Mental Health Clinics, the Community Health Representatives, Head Start, the schools the court system) could imagine how they would restructure their programs to accomo- date the increased demand for case management and preventive education which CDC had been providing. On all fronts, this increase was perceived, not as new or developing problems, but rather as testimony to the accep- tance of and confidence in the services being made available. The need had always been there; after a long struggle to gain recognition by the existing agencies and the community at large, the CDC was seen as a viable resource for counseling services, child development classes, court inves- tigations, and central coordinative services that were truly responsive to the community's needs. The project staff, the HEW director and the Tribal Council are justifiably ebullient with the appearance of what pro- mises to be stable, long-term funding of a needed and successful service program. The continuation funding marks an important gain in the tribe's efforts to create a program ''by and for Makahs'" and corroborates their expectation that such a program would succeed where outside interventions had not. VIII. PROGRAM GOALS The two overriding goals of the Makah Child Development Center project were ambitious ones, since they pointed to permanent change in a social ser- vice delivery system which had grown incrementally over the years without having at its core a central integrating agency. In three years, however, vii.21 the Child Development Center has made remarkable progress in accomplishing the goals of (1) changing the existing delivery of services for child abuse and neglionk from a haphazard to an orderly, coordinated and effective system, and (2) implementing and testing a comprehensive and positive child develop- ment program that is designed and developed by and for Makah parents and administered by the Tribal community. Key to appreciating the complexity of these goals is the clause 'by and for Makahs." Although importation of individuals who already had the planning, administering and counseling skills may have enabled the implementation of a more aggressive demonstration pro- ject, such a program would ultimately suffer the impermanence of previous externally designed programs which have contributed to an oft-heard divase in Neah Bay: ''they come and they go." The fact that on a shoestring budget the five-member staff of the Child . Development Center have developed skills within themselves, which will remain a permanent resource for the Tribal community, is an impressive accomplish- ment, as is their progress toward each of the nine specific objectives which they identified as measurable steps toward the realization of their goals. These objectives fall under three generic headings (coordination, education and service delivery), and for the purposes of this discussion, the nine presented in the third year grant application will be grouped thusly. This articulation of the project's objectives will be used since, in addition to refining the language of the previous applications, several supplemental aims were presented. vil.22 Coordination Goals Goal 1: Develop more comnication among community leaders, between parents, school staff, and among community workers in order to achieve a concensus on the priorities for meeting the social service needs. During the first two years of the project, the major tool for increas- ing communication among the sectors of the community listed was the monthly meeting of the Makah Child Development Council. While formal Council meet- ings were discontinued in November 1976, the Council members initiate smaller, spontaneous meetings when appropriate. In addition to two outside agencies, the Department of Social and Health Services (DSHS) and the Bureau of Indian Affairs (BIA), the following agencies are represented on the Council: the Health, Education and Welfare office, Head Start, Day Care, the Makah Indian Center for Alternatives to Substance Abuse, the Public School, Law and Order, the Community Health Representatives, the Parent-Teacher Association, and the Indian Health Clinic. While the Council now numbers 29 members, average attendance is about 15, including occasional parents who attend. More re- cently, the project staff has initiated weekly meetings with various disci- plines from the school, the Law and Order Committee and the Indian Health Clinic which serve to coordinate referrals and expand perspectives on treat- ment planning. The CDC staff has regularly attended meetings of various tri- bal committees, including Law and Order, Education and the Tribal Council. While the general intent of these meetings is to improve the quality and quantity of social services provided on the reservation, the specific plans formuiated for new services indicate the council's priorities: the child development seminars, development of a group home at Neah Bay, teen activi- ties, and parent education classes. Vii.23 Goal 2: Emphasize the need for long-range social service plans by encouraging discussion with community workers and residents in the area on the subject of community development. Throughout the Child Development Center's involvement with other agen- cies and individuals in the community, the concern for long-range planning has surfaced whenever the immediate pressures of delivering services have eased. Many of the inter-tribal workshops and seminars held by the Indian Nation have directed their attention to these concerns, which are subse- quently shared with those in the community who did not attend. Several of the long-range needs perceived at the inception of the grant justified indi- vidual goals and are now coming into being through the efforts of the pro- ject. For others, such as the development of the teen center and the senior citizen center, the CDC has been supportive and instrumental in their achieve- ment. The Makah Child Development Council remains the prime forum for long range collective planning, albeit such planning occurs independently within each of the represented agencies. Goal 3: The Child Development Center will obtain recognition by com- munity leaders, workers, and the public as one of the vehicles for discussing, planning and educating in the areas of nutri- tion, child development and family planning, as well as a center for information and referral to appropriate community agencies. As time has passed, the requests for CDC staff presentations have in- creased until at this point every agency in the community has been exposed to the Child Development Center, including the Air Base. The staff continues to present two or three formal talks a month, primarily at the school. The VII.24 resultant increase in referrals from all sources in the community is indica- tive of the perception by community leaders and the public at large of the Child Development Center's credibility as a varied and responsive resource. From practically zero referrals during the early months of the project's existence, the Center responds to five or six referrals a week, some of which they appropriately redirect, but increasingly more of which enter their own caseload. Additionally, these referrals come from every agency in the com- munity system, including the Indian Mental Health Clinic, which refers child rearing and welfare concerns to the project. The Center enjoys as well the strong support of the Tribal Council which is manifested in its sponsorship of lunches, meetings and occasional travel for staff development workshops. Education Goal Goal 4: To encourage and foster the training of Makahs as social workers and counselors, in such areas as counseling in child develop- ment, marital relations, adolescents, parenting and substance abuse. Approximately 25% of the project's annual budget was devoted to training the staff as social workers and counselors. This proportion includes the consultant's time for child development training, parent discussion groups, counselor therapy training, and case management training, as well as the pro- ject's travel budget to related conferences and workshops and specific train- ing classes for social worker trainees, day care, Head Start and Lome management aide. There are currently 20 Makah Indians who are functioning as social workers on the staffs of various social service agencies in Neah Bay. At present, the four project staff members and the Community Health Representa- tive (CHR), who shares the CDC office with the project, are training under Vi11.25 the consultant. The four staff members have in addition taken training in counseling techniques from the worker in the Indian Mental Health Clinic. A work-study program through a community college in Washington was designed for the CDC staff by the Training Coordinator for the Tribal Council. Service Delivery Goals Goal 5: Provide counseling for individuals in the Neah Bay community, in order to assist them in coping with problems relating to child behavior and fragmentation of families. As of January 1977, the Child Development Center had a total active caseload of 20 clients, with an additional 25 clients considered stabilized and requiring only infrequent follow-up contacts. This marks a significant change in the project's focus, since for well over a year and a half the project did not so much consider itself a service provider as a service coordinator. With the continued training and staff development, however, the workers gained self-confidence and an awareness of the unmet need for counseling services. Concurrent with the counseling skills, the workers have developed case management techniques in order to accommodate the expand- ing need for documentation and case histories. While the length of the counseling sessions vary, the workers contact their active clients at least once a week by telephone or in person. The services are delivered in the office, the client's home, in the car or the restaurant; wherever the client and the worker feel most comfortable. The types of counseling available include marital, individual, child development, adolescent, and advocacy counseling. Goal 6: Educate and encourage the education of parents and prospective parents on child development and parent effectiveness in order to improve their parenting ability. VII.26 Since June 1975, the project has sponsored one or two Parent Education classes each month. Attendance varies between five and 12 parents and pro- fessionals, with usually one or two students from the high school attending. Depending on the topic, which is advertised in advance on the local radio stations, the parent types vary from prospective to single parents, couples to grandparents. While it is difficult to assess the proportion of '"in need" parents, the attendees are often the result of home visits to clients to pique their interest. A sample of the topics covered, which were selected by the parents themselves from a range of possible subject areas, include: stages of growth; father-son relationships; 11-14 year olds -- what happens during this age?; how or when do you spoil a child; the effects of stress, moving and family changes; how and when to discipline; alternatives to discipline; the single child and the changing social, cultural, life styles and values; how and when children develop perceptual thinking and learning abilities; stages of development of emotions and morality. In addition, preventive classes are presented by the project staff in the high school in various class subjects, with typical attendance of 15. The staff also designed and published an information booklet for new mothers, which includes child development information, as well as identifying poten- tial stressful situations in child rearing with alternative responses and their likely consequences. Goal 7: Encourage the development of programs to provide recreational activities such as ceramic studios, exercise classes, parti- cipation in school programs, professional education for indi- viduals of the Neah Bay community. vI11.,27 While this goal fundamentally addresses the needs of all Neah Bay resi- dents for recreational activities, in actuality the focus to date has been on the development of a youth program. In addition to identifying available funding for recreational programs, the project has sponsored dances and movies for the Makah youths with predictably good attendance. It is the hope of the staff that the combined effect of these activities, the class presenta- tions, and the sympathetic counseling available through the project, will develop a positive relationship with the high school students, so that the educational efforts planned in the future will be well received and have the preventive effect anticipated. The new teen center, into which the CDC relocated, is expected to provide a conducive atmosphere for future activi- ties for the tribe's adolescents. The one real gap which was never effec- tively addressed is the complete absence of recreational activities directed toward the adults in Neah Bay, for many of whom the only respite from work is community meetings or social drinking. Goal 8: Assure that children who cannot remain in their natural home are placed in the most suitable environment. While initially this goal was more forcefully stated in terms of pre- venting foster care placement off the reservation and returning Makah child- ren to the reservation, the project staff has determined that in many instances placement in Port Angeles may be preferable for the child while the crisis is happening. In fact, the total number of placements off the reservation each year has diminished over time. This is a function of the children, who were placed two years ago, growing old enough to return to Neah Bay and establish their own households, since very few placements have occurred during the last year. The staff views this phenomenon as a positive indi- VII.28 cation that families are assuming more responsibility for their children, thereby reducing the need for intervention. Since the project has been operating, three foster homes in Neah Bay have been added for a total of five available homes. Depending upon the situation, however, children may be temporarily placed with relatives or placed in Port Angeles through the Department of Social and Health Services. The CDC staff performed a significant role in a landmark case in the Indian Nation's efforts to gain legal jurisdiction over its peoples. The Makah Tribe's Law and Order Committee handled the first child custody case to be decided by an Indian tribe's court system. Due to the increased coor- dination between the court and CDC, the entire responsibility for investi- gating the four petitions was carried out by the Child Development Center. Throughout the process, observers lauded the professional efforts of the staff, their thoroughness and objectivity in collecting and presenting the information. It is important to keep in mind the relational connections which make the sensitivity of adoptive investigations multiply so in a com- munity the size of Neah Bay. Goal 9: In coordination with the homemaker in the Makah Department of Social and Health Services Statewide Office, the Makah Child Development Program will provide and identify services in the area of home management and family care. This goal was added in the third year grant application in response to the perceived need for additional homemaker services to those supplied single-handedly by the DSHS homemaker. The new position was initially con- ceived as a half-time role, however, it was increased to a full-time position for the last six months of the grant in order to accommodate the rapidly growing yi1.29 caseload and the functional reorganization of the CDC. In coordination with the DSHS homemaker, the project staff found this service to be uniquely appropriate as an outreach effort, since many other problems could be iden- tified and referred to the CDC for treatment planning. The homemaking assis- tance was seen as an acceptable entre to many families whose needs would not be readily visible to the worker. However, since the DSHS homemaker was restricted to delivering services only to individuals who quality for public assistance, the new staff position expanded the service (and conse- quently the project's outreach efforts) to a broader spectrum of the community. IX. PROJECT MANAGEMENT AND WORKER SATISFACTION Things are happening on the Makah Indian Reservation. Indirectly, much of it is due to the efforts of the Child Development Center. One of the exciting outcomes of this project has been the development of a cadre of trained Makah workers who now have management and organizational skills and who are prepared to assume leadership roles in their community. Organizational Structure Neah Bay is a very small project: five full-time staff and an aver- age monthly budget of $4643, reflecting the very small reservation the project serves. Over the life of the project an average monthly caseload of approximately eight clients has been maintained. In the last year, however, the caseload size — grown to an average monthly load of 45 clients, 20 active and 25 stabilized cases. With the growth in caseload size, an additional full-time worker has been employed to assist in ser- vice delivery. The project is highly complex in the sense that the pro- gram activities include parent education, community social service VII.30 coordination, legislative activity and direct services; yet, the organi- zational structure is not complex since only two different disciplines are involved in the operation of the project. The project operates in a fairly formalized setting, with job descriptions and rule manuals d- tailing poli- cies and procedures. However, among the project staff, there is a high degree of informality, demonstrated through the sharing of various job and administrative duties and a fairly egalitarian attitude, despite the dif- ferences in status and role assignments. The project is highly centralized in that all decisions are made by the Tribal Council and the project is held accountable by them and is dependent upon them for all policies and procedures. But, again within the project, there is equal participation by all staff members in making decisions on program changes, service inno- vations and assignment of tasks. Management The project appears to be highly formalized and centralized with for- mal job descriptions, titles and job specialization, but, because at the operational level there exists a participatory style of management, per- iodically there is confusion regarding roles, status, duties and program direction. The chameleon-like organizational structure, the project's own evolving nature, and the relatively inexperienced staff combined to create some of the management difficulties reported by the project in the areas of leadership, communication and planfulness. As might be expected in this situation, there were initially conflicts among the staff about who would do what, where, when and how. Some staff felt imposed upon, others felt that their positions were being threatened. As the project staff became more confident and more clear about program objectives and personal VI11.3l preferences, communication channels opened up between workers and many of the suppressed resentments and confusions were aired and resolved. Now a staff member with a personal problem or work-related stress interfering with her performance can share this difficulty with co-workers and is assured that she will receive support and permission as she resolves the conflict. Other workers will assist her with her job until the problem is alleviated. This atmosphere of caring and sharing has provided an environment in which daily tensions and disagreements are being resolved and many of the management concerns are confronted. A strong sharing bond has developed among the co-workers and has been a critical factor in the project's successful accomplishment of their program goals. Turnover The project staff membership has been stabilized since the beginning. There has been only one turnover when the first project director was pro- moted to a substantially higher position. The stabilized staff has pro- vided the continuity to build the linkages and networks necessary for the successful community social service system that is now working with fami- lies and children. Burnout and Satisfaction One of the exciting paradoxes about the management of this project is that this fairly successful project is staffed by inexperienced workers who have not had the educational training that the workers in many of the other eleven projects have had. None of the workers had experience with abuse and neglect prior to the project. With the exception of the first project director, none of the workers has had formal administrative re- sponsibilities. But, this team accomplished much in the short span of VI1.32 three years. Outsiders and evaluators might be tempted to label the seeming non-compliance with £111ing out forms and other sensible requests as in- efficiencies and ineffective project management. But, since the intent of management is to integrate the human characteristics of the workers and clients with the organizational structure into an effective and efficient working agency that accomplishes its goals in keeping with its cultural ways, this project management has been successful. The staff followed a plan of management that made the most sense in their environment and that was responsive to their needs. While maximizing training opportunities and skill development workshops offered by the evaluation, consultants and numerous other resources, they adapted what was learned to the special demands presented by their clients living in a reservation setting. Now the Makah Indian Tribe has five well-trained workers who are using their skills to cope with many of the long-standing problems that exist on the reservation. How then, in view of the project's success and unanimous high job satisfaction score by project members, do we explain that there was some feeling of burnout in this project? An obvious clue is the staff's very pessimistic appraisal of the available opportunities for promotion and advancement. Evidence of this is the staff's constant surveillance of all job vacancies and the sense of competition that exists among them for any job opening that promises more opportunity. Not only is there little oppor- tunity for promotion with the project or Tribal Council, but the chances for advancement with any social service agency in the community also appear dismal. The disheartening fact is that regardless of project staff skills and achievements of the last three years, they do not qualify for jobs in v11.33 their field because they do not have formal degrees. 'What happens next when the project ends?" This seemingly bleak personal future must explain some of the burned out feelings that are reported by the workers. X. ANALYSIS OF CLIENT DATA Client Flow While the original project design did not envision the Child Develop- ment Center as a major caseload carrying agency, it has evolved into a treat- ment center serving 45 cases at the time of the final site visit. By law, the formal case management responsibility rests with the Port Angeles DSHS, Division of Protective Services. However, the DSHS office informally dele- gated its responsibility for the Makah cases to the Child Development Center as the staff's competency became apparent. Most recently dependency issues, which had previously been the exclusive domain of DSHS, have been handled through the joint efforts of the CDC and the tribe's Law and Order Committee. It is important, when discussing the client flow, to recognize that the project's cases span all aspects of child welfare concerns. While instances of abuse and neglect occur on the reservation, the project's image in the community reflects a less stigmatizing focus on child development problems. Case identification in such a small community is a relatively simple process, since most professionals, and indeed the community at large, are aware of individuals in need of services. The most frequent sources of referral are the Indian Health Clinic, the elementary and high schools, Head Start and Day Care Centers, and Law and Order. A steadily increasing number of residents contact the Center seeking assistance. While few cases zre VII.34 initially reported to DSHS anymore, those few are verified with the Child Development Center, which makes a preliminary investigation of the situation. Initial investigations and diagnoses are handled by all staff members, Should the case be one of abuse or require DSHS notification or involvement, such as foster care placement, the director reports the situation to DSHS. Frequently the Center's consultant or the team attending the Indian Health Clinic meetings assist in the assessment and treatment planning. Treatment services available from CDC include individual counseling and therapy, couples counseling, parent education, family counseling, and homemaking services. Services which the project can arrange or refer clients to include medical care, day care or Head Start, individual therapy, well-baby clinic, and the alcoholism treatment program. The project staff maintain case manage- ment responsibility for those clients determined as predominantly child welfare problems. Most cases move from being considered '"active'" by the workers to being "monitored" before termination. Monitoring is essentially going on continually with past, present and future clients, since the interaction among the social services network is such that few individuals with problems escape the notice and ultimately the intervention of the service providers. V11.35 XI. COMMUNITY IMPACT Summary The Child Development Center has changed the framework and manner in which social services are provided to Neah Bay families. In contrast to the pre-grant period when social welfare services were provided by the state from a distant office and the few service providers on the reservation were uncoordinated and under-staffed, the community has developed its own informal social service system with the Child Development Center as the catalyst for many of the activities that improve families' ability to care for their children. In the development of new resources and the centralization of authority in child welfare concerns, the project has closely cooperated with existing education and service providers so that organizational affiliation has not hindered the delivery of services or the monitoring of family situa- tions. Until the last year of the project, there was no formal case manage- ment in Neah Bay, although the project staff served a similar function by closely monitoring families. However, during the final year of the grant, this situation changed dramatically. While not creating formalized social service intake forms and case progress documentation, the caseload of the Child Development Center climbed to 45, with 20 considered active by the staff and 25 in a "stabilized but monitoring" status. Treatment planning is carried out in the context of staffings, held jointly with the project's consulting psychiatrist, and in the multidisciplinary team reviews held at the Indian Health Clinic. During these meetings, the needs of particular families and the appropriate services and providers are discussed. The v11.36 major unfilled service needs continue to be the absence of recreational acti- vities for the adults in the community and the lack of trained therapists located at Neah Bay on a full-time basis. The community's awareness of the needs of parents and children appears to have increased during the time the project has been operating. Before May 1974 the Head Start program was probably the only activity alerting people to the needs of children. The project has increased this awareness by making the community conscious of the special needs of its parents and children and the need to educate prospective parents. Change comes slowly to a community as steeped in tradition and as small as Neah Bay. Many of the changes are difficult for outsiders to observe. In addition to the lack of adequate jobs, the conflicts in values between the outside culture and the Makahs and the isolation of Neah Bay make it difficult to improve conditions quickly for those parents having difficul- ties fulfilling their own and their children's needs. Nonetheless, it would appear that Neah Bay has developed a system for helping those parents in need and protecting the welfare of its children. The Child Development Center has played a critical role in this change. The project was the largest single agency, in terms of staff size, ad- dressing the problems in the social service delivery system, and it quite naturally became the core of the system. - A significant additional factor, which helped to focus the system, was the fact that the entire staff was Makah, and consequently had access to families in the community that non- Makah service providers could not reach. Many of the forward strides in developing a cohesive community system for dealing with child welfare vi1.37 problems can be expected to continue, following the end of the grant period, since the Child Development Center will be subsumed under an umbrella agency, the Child and Family Center. Community System Operations Prior to the implementation of the project in May of 1974, the respon- sibility for dealing with child neglect or the rare case of child abuse in the small community of Neah Bay was not assumed by any agency. Those who came into contact with a family where a child's welfare was in jeopardy pro- vided whatever minimal services were within their resources. School teachers might refer the situation to the principal or the atten- dance counselor. If parents were refusing to send their children to school, the principal might refer the matter to the Tribal Judges. If the family was on welfare, the principal might call the Child Protective Services unit in the Washington State Department of Social and Health Services (DSHS) in Port Angeles. The Head Start program, which served approximately 60 children, had been in operation for several years. Through the program, the teachers had a chance to observe most of Neah Bay's three and four year olds. Almost all the children were examined by a physician during their first month in the program. Where there was an emotional problem, the case was referred to the Mental Health Representative at the Indian Health Clinic or to the program's consulting psychiatrist who visited for one day each month. The Head Start staff felt they had no place to refer cases requiring more thorough investigation and ongoing help. On a few occasions when a family was on VII.38 welfare, the Head Start Director might call DSHS to provide assistance to the family or to protect a child. The most common type of call to the Tribal Police was for abandonment of a child at home when there was no one to care for him/her. If the Tribal Police were called, they usually would remove the child temporarily until the parents returned home and would notify the Tribal Judges. The Indian Health Clinic occasionally encountered cases of neglect, but the nurses and doctors, as non-Makahs, were reluctant to report the situa- tion. In some instances they might advise the Mental Health Representative at the Clinic of the situation, or in the case of gross negligence they might notify the Tribal Police. Another resource, used on occasion, was the Community Health Representatives (CHR) who worked out of offices at the clinic and were responsible for various community activities. The nurse or doctor might ask the CHR to check on the family when she was making home visits in the community. The tribe did not have any legal jurisdiction over dependency matters. Nonetheless, the two Tribal Judges, who are Makahs and employed by the Bureau of Indian Affairs (BIA), might ask the police to investigate or they might hold a hearing to see if the matter could be settled without involv- ing the Juvenile Division of the Clallam County Superior Court (which legally has jurisdiction over dependency cases). Strong sentiment has developed against the practice of having ncn-Indians living off the reser- vation adopting Makah children. The Tribal Judges, feeling they had no resource to deal with the problems of persistent neglect, might ask the parents to voluntarily accept a decision on placement of their children or to receive counseling from the probation and parole officers. V11.39 DSHS, the agency charged under the state reporting law of 1971 to investigate cases of neglect or abuse, is located in Port Angeles.* In earlier years, DSHS sent a case worker to Neah Bay once a month. In 1974 a case worker was visiting Neah Bay for half a day each week. Once a report was made to Port Angeles it took up to five days before the case worker might be able to investigate. In emergencies DSHS could ask the Tribal Police to investigate and take some action such as removing the child. Because of the remoteness of Neah Bay, the treatment services that DSHS could offer to Neah Bay residents were few, consisting primarily of coun- seling by the Child Protective Services case worker. Foster care was often the only solution for a family situation that did not improve quickly. In Neah Bay, prior to May 1974, there was no outreach to identify fami- lies that were having difficulty adequately caring for their children. Pre- ventive activities were limited to the physical examinations of the Head Start children, the WIC (Women and Infant Children food program), and the monthly well-baby clinic run by the Indian Health Clinic. The high school offered no classes on child rearing or child development. None of the agencies followed up on cases once the original problem that had led to their involvement was resolved. During the period from May 1974 to January 1977, the Child Development Center became the center of the community system for conducting investiga- tions, assisting in the initial dispositions, and coordinating the delivery "Note: Under the State Law, the law enforcement agency is designated as another responsible agency for receiving reports, but, since for Neah Bay it was not appropriate to involve the Port Angeles Police, which are the nearest law enforcement group, this part of the law was not operation- alized. VII.40 of services including provision of counseling by the staff and individual therapy by the project's consulting psychiatrist. Because of the trust that the Child Protective Services supervisor and case worker had in the project staff, DSHS relied on the project to identify and investigate cases. The Port Angeles unit only took action on requests from the project, and closely coordinated with the project its contacts with Neah Bay welfare recipients who were having difficulty caring for their children. At the same time, the project gained the confidence of other service and education providers at Neah Bay (school, police, judges, Indian Health Clinic, Community Health Representatives, Head Start/day care) who felt able to report their concerns to the project and work out a way of jointly helping parents and children in need. The project's advisory board, the Child Development Council, com- posed of representatives of all the service and education agencies on the reservation and DSHS and BIA, facilitated the coordination of services. Much of the treatment planning and case monitoring took place in the Indian Health Clinic meetings which were attended by representatives of the school, the court, the health and mental health clinics, and all of the Child Develop- ment Center staff. Most of the community agencies referred cases of neglect directly to the project. Except for the referrals between the project and Child Protec- tive Services, the number of reports from community agencies to DSHS has decreased to practically zero. The Port Angeles Juvenile Court has developed open communication with the Tribal Court during the time since the project was initiated. With increased availability of foster homes on the reservation, the tribal court, supported by the investigative services of the Child Develop- ment Center, has assumed responsibility for temporary placements. They VII.41 jointly conducted the first child custody investigation and decision to be made by an Indian tribe's court system. | The project did not develop any criteria for determining which fami- lies would receive service since it viewed itself as serving all Neah Bay . families, whatever the need. Initially, the project did not consider its role to be that of case manager; rather, it functioned for two years more as a monitor of families that were known to be having problems. During the last year of the grant, however, as the staff skills increased and the mag- nitude of the child welfare problems became known, the project workers have assumed the full range of case management responsibilities from investiga- tion, diagnosis and referral to treatment planning, service delivery, and coordination. In addition to counseling by the staff, the project provided some parents with individual therapy sessions and couples counseling by its consulting psychiatrist once a month. Although the parents receiving these services were not always the ones most in need of service, the skills developed by these couples probably were transferred to other parents in the community and helped to create an atmosphere that made therapy more acceptable. A new resource in the community was the satellite DSHS office at the Tribal Government Center which opened in the fall of 1975. Although no Child Protective Services staff were involved, the full-time homemaker has provided many of those receiving public assistance, including some 30 families with dependent children, with a much-needed service as well as providing outreach services for the Child Development Center. The project coordinated closely with the homemaker when families were in crisis and required someone to remain in the home and care for the children. The financial aid worker at VII.42 the satellite office also made it possible for more Makahs to receive prompt service. In the fall of 1974 the Makah Indian Center for Alternatives to Sub- stance Abuse (hereafter called the Alcoholism Treatment Center) started to provide drop-in service, counseling, and Alcoholics Anonymous groups to Neah Bay residents. Since alcoholism affects a large number of Makahs, the initia- tion of this program filled one of the biggest social service needs at Neah Bay. The project has provided Neah Bay with its first outreach services. Working closely with the CHR for WIC, the staff have sought out families w— help was required and provided the necessary services. In the last year outreach efforts were significantly augmented by the addition of a full- time homemaker aide to the project staff. The project has made a contribution to the community in the area of ‘prevention by helping organize dances and movies, fostering the development of recreational activities for parents, especially those who are socially isolated, sponsoring monthly parent education classes, putting on workshops on child growth and development, running an emergency clothing and food bank, and distributing surplus furniture to needy families. Caseload Size and Case Outcomes The available data does not portray the dimensions of child neglect in Neah Bay or the manner in which cases are handled or disposed. The reasons for this ambiguous situation are several-fold. Neglect at Neah Bay is gen- erally of the mild variety. Frequently, it means leaving children unattended over night, failing to provide adequate meals, or not providing proper clothing for the children. Since this kind of neglect is usuaily a chronic VII.43 phenomenon, many reports are repeats. Because Neah Bay is such a small com- munity, the Child Development Center may have knowledge of a situation long before any report is made. In many cases there will be nothing that could be called a formal report, but rather, someone may casually mention to one of the staff that a family is having trouble. The project responds to 5 or 6 informal referrals a week, some of which they appropriately redirect but others of which enter their own caseload, after initial investigation, for treatment planning and services. Referrals have come from most agencies, in similar proportions to the informal reports demonstrated in the following table. Table 1 Reports to Child Development Center, 1975-1976 1975 1976 Number reports: abuse 4 2 Number reports: neglect 11 3 Source of reports: Protective services 1 1 Indian Health Clinic 1 1 School, Head Start/day care 5 0 Juvenile judges 0 0 Sibling 1 0 Relative 6 3 Neighbor 1 0 MY VII.44 The increased referrals and subsequent need for case management is seen by most as testimony to the acceptance of and confidence in the services being made available, rather than a reflection of new or developing prob- lems in child welfare on the reservation. The number of reports to the Port Angeles Child Protective Services unit from non-project sources declined from five in 1974 to zero in 1976, as demonstrated in the following table. Table 2 Reports of Abuse/Neglect to Children Protective Services, Department of Social and Health Statistics 1973 1974 1975 1976 Child Development Center S 2 Relative 2 2 1 Acquaintance/neighbor 1 Anonymous 1 Unknown 1 1 Total Reports 2 5 7 2 With regard to the disposition of cases, only one case was referred to the Juvenile Court in 1975 and one in 1976, and the project staff were closely involved in the decision to remove the children. In the first case the child was subsequently returned home; in the second the placement was permanent. During 1975, four children were placed in foster homes, three of which were on the reservation. In 1976, six children were placed in foster homes, all VII.45 of which were on the reservation. The project assisted in helping children that were in foster homes during the grant years to return to their fami- lies. In addition, the project arranged for four children to be placed temporarily in a foster home until the parents were ready to resume care of their children. Legislation Since Indians have special legal status in the United States, it is not always clear which of the various laws -- federal, state or tribal -- are applicable in different situations. For reporting child abuse or neglect, the Makahs are subject to the Washington State law which makes the reporting of non-accidentally inflicted death, physical injury, physical neglect or sexual abuse mandatory for certain professional persons, i.e., teachers, physicians, social workers, clergymen, DSHS employees, etc. However, the law is virtually meaningless for Neah Bay, since there are rarely any cases of child abuse or severe physical neglect. Because the community is not anxious to publicize its problems to outsiders, or to alienate members of the community by making reports, the law is ignored. So long as the repcrt- ing law does not affect them, the project and the community have not been concerned about changing it. The project and other community professionals have wanted to change "Washington State law so that the Makahs would have jurisdiction in depen- dency matters. Under Public Law 280 passed by Congress in 1952, the states have legal authority in certain areas if they reserve that right. Washington State passed legislation which gives the State jurisdiction over adoptions, foster care placements, and juvenile delinquency. VII.46 The project staff and other Makahs have worked with the Affiliated Tribes of the Northwest, and other Indian nations, to revise federal and state laws regarding dependency. The community also revised the Tribe's Law and Order Code, which governs legal matters on the reservation, to in- clude dependency issues. It will be several years at least before the necessary legal changes can be made; in the meantime, since many of the professionals in the community, as well as the project's staff, would like to assert tribal authority as much as possible, the staff have been acting informally on a number of dependency cases with the tacit approval of Child Protective Services and the Juvenile Court. The landmark child custody case, occurring during the last year of the project, was a powerful declaration of the Indian nation's right to self-determination. Community Resources The Child Development Center increased the resources available in Neah Bay for identifying, investigating, and treating cases of child neglect, and for arranging supportive service providers. The project's staff, com- prised of the director, two community workers and one homemaker aide, was the catalyst for many of the activities that took place in the community relating to families and children. In addition to counseling and homemaking services by the staff, the project offered, through its consultant, three hours of individual therapy per month, and one hour of parent education per month. Elsewhere at Neah Bay, the following people are available to provide counseling and therapy: one community health representative, one public school counselor, one public school attendance counselor, three alcoholism and drug abuse counselors, two probation and parole officers, one Mental Health VII.47 worker at the Indian Health Clinic, and the consultants to Head Start, the schools, and the Indian Health Clinic. There has been one other homemaker available to people at Neah Bay; however, her caseload is restricted to public assistance recipients. Trans- portation for medical purposes has been available through the Indian Health Clinic. Day care for families in which both parents were working or study- ing has been available through the Day Care Center. The project ran an emergency clothing and food bank, as well as assuming responsibility for surplus furniture distribution. Authority to license foster homes was granted to the DSHS homemaker, which eased the demand for Indian homes for foster placements. Although the Child Development Council has discussed the develop- ment of a group foster home facility, the idea is unpopular for a variety of reasons, including the concern that Makah children be brought up with Makah families. The staff's personal growth as counselors has meant that one of the gaps in the community's service system has gradually closed. Neah Bay could benefit from the presence of a full-time therapist. However, for a thera- pist to be effective, he or she would have to be an Indian and most likely a Makah. Since there are currently no people with those qualifications, the second most feasible solution is to train people such as the project staff or the Mental Health Representative to become therapists. In addition, the cost of having a full-time therapist is probably beyond the financial means of a community as small as Neah Bay. The resources, in terms of developed skills, expertise.and community and professional acceptance, will remain in the community following the termi- ‘nation of the grant ;with the security of state funding assured, the Child VII.48 Development Center can be expected to continue as a cohesive force in the community. Community System Coordination Prior to implementation of the project, there was little discussion of matters pertaining to child and family welfare among agencies. Many agen- cies did not know where to turn for assistance. The goal of coordinating services has taken some time to develop. The Child Development Council has been one forum for service and education agencies to exchange information on their programs. The staff have regularly attended meetings of other agencies such as the Law and Order Committee and the Indian Health Clinic. They also published a monthly newsletter on social service programs and developments for all Neah Bay residents. In the project's early days, the most common way of coordinating services was through the informal and almost daily contact between the project staff and the workers in the various agen- cies. However, during the last year weekly multidisciplinary team meetings held at the Indian Health Clinic helped to regularize the system. Although no formal contracts have been written, the staff have established informal understandings related to contacting each other about family situations that might be of concern to the project. The confidence that the Port Angeles DSHS has had in the Center's staff has made it possible for both the State and Makah interests to be served. DSHS has relied heavily on the judgment of the project's staff and tried to provide whatever services were at its disposal as requested by the project. The increased authority granted the satellite DSHS office in Neah Bay reflects this close working relationship. em tin ce etal wheres dad Ga = VII.49 There is no central record keeping system, nor is there a likelihood that any such system will be established. The smallness of the community and the political problems that might be created by such a system appear to out- weigh the few benefits that might be realized. Education and Public Awareness The amount of education of professionals and the general community in Neah Bay on subjects relevant to child abuse and neglect has increased as a direct result of the project's activities. The primary focus of the pro- ject's educational activities has been on increasing the knowledge of pro- fessionals and community residents about child development patterns and the resources available from the project to deal with parent-child problems. Annually, the project averages 15 presentations to professionals, including "day care/Head Start, the schools, the Alcoholism Treatment Center, and the Indian Health Clinic. In addition to the monthly parent education classes, educational activities for the general community average five per year. One of the most successful attempts to educate the general community was the child development seminar, originally envisioned as an annual event. Attended by approximately 140 people, two-thirds of whom were Neah Bay resi- dents, the seminar covered such topics as child development and management , child welfare legislation, and foster care and adoption. Another vehicle was the monthly newsletter published by the project for all Neah Bay resi- dents. Increasingly successful in reaching Makah parents has been the pro- ject's monthly parent education classes. VII.50 There has been a slight increase in the amount of education provided by other programs. The school sponsored a program during the summer of 1975 in which the early childhood specialist at the elementary school visited Neah Bay homes and talked to parents about the creative use of toys. The project made a presentation to high school students in the fall on child development, but the school has not developed any special education programs on child development. As the Community Health Representative gained more knowledge of child development, she was able, through her informal contact with WIC participants, to share information with parents on child care. XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COST Functioning on the smallest annual budget of the eleven demonstration projects at about $56,000 per year, the Child Development Center maintained an average monthly caseload of eight clients, with a range from one to 14. Following the period of time used to generalize cost data (October 1975 through October 1976), the project's client load increased to 20 active cases with an additional 25 considered to be stabilized, but under obser- vation. Certainly by the end of the project considerably larger propor- tions of the project's resources were being allocated to the direct service components of case management and review, MDT reviews and individual counseling; however, the allocation of time and money displayed on Table 3 reflects the earlier orientation toward far more concentrated efforts in community activities and project operations. On average these data show that approximately half of the staff time and three-quarters of the budget were expended on staff development and training, program planning V11.51 and development, and general management activities. The remaining half of the staff time and quarter of the budget were divided approximately equally between community activities and direct services, with a small proportion of each devoted to the BPA evaluation. These allocations were very unstable over the year of intensive cost accounting, caused in part by the coincidence of the cost accounting per- iods occurring during months of intensive staff training or community workshops, and in part by shifts in the program orientation from a case monitoring and coordinating function within the community's social service structure to an active case managing and service providing role. Addi- tionally, with an average staff of five persons, shifts in a single indi- vidual's role definition could and did dramatically affect the overall allocation of resources. Service efforts were initially restricted to a small subset of those possible, and included intake and initial diagnosis, case management and regular review, MDT reviews, individual counseling, and parent education classes. As the service provision aspect of the project was stepped up, during the last cost accounting month (October 1976), additional services were added which more closely reflect the project's service package for the last year of operation. Supplementing those previously mentioned, ‘these services included: outreach, court case activities, crisis intervention (both during and after intake), homemaking services and trans- portation. The volume of service units delivered did not vary significantly for those services offered more than one month; however, the cost per unit, in some instances, did. For those services provided during at least two V11.52 of the cost accounting months, the following average unit costs prevailed: intake and initial diagnosis cost approximately $20 per intake when aver- aged, although the cost decreased considerably over time; case management averaged approximately $30 per case per month, but fluctuated somewhat erratically; individual counseling averaged about $6 per contact, and parent education classes averaged about $21 per person-session -- both were quite stable over time. Multidisciplinary team case reviews, which gained a significant role during the last year, were provided at a cost per review of approximately $30. As the only service for which donated resources were expended, the cost per review increased nearly five-fold to about $140 per review when values were ascribed to these contributions of professional time. Table 3: Project Resource Allocation and Service Costs Resouints St lotecion to Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost | to Community Community Education 5% 2% Professional Education 4 5 Coordination 7 4 | Legislation/Policy 7 6 Staff Development/Training 19 17 Program Planning/Development 16 13 General Management 14 36 BPA Evaluation .6 2 Qutreach -—- -- [9 cases $ 8.45 $ 8.45] " Intake/Initial Diagnosis -- -- 2 intakes 19.40 19.40 Case Management/Review 6 6 8 average caseload 29.88 29.88 Court Case Activities -- -- [ 2 cases 8.60 8.60] Crisis Intervention During Intake 3 1 [ 4 contacts 13.87 13.87] Multidisciplinary Team Review 1 [5 reviews 28.20 137.80] Individual Counseling 5 2 19 contacts 5.90 5.90 | Alcohol, Drug, Weight Counseling -- —— [ 5 person-sessions 3.94 3.94] Individual Therapy -- 2 [ 2 contacts 41.25 41.25] Parent Education Classes 1 2 5 person-sessions 20.90 20.90 Crisis Intervention After Intake Lm -- [ 9 contacts 3.65 3.65] Homemaking r= cm nice oB smo [LO contacts 5.91 5.91] Transportation/Waiting ae Hay] [5 rides 12.80 12.80] Total Annual Person-Years/Budget 3.4 - -| $55,884 Average Monthly Caseload = 8 * Figures in brackets Were offered during the last accounting month only. ¢€S IIA wn a bm mgs - ir = I re a S ES Vii1.1 FAMILY RESOURCE CENTER: ST. LOUIS, MISSOURI I. COMMUNITY CONTEXT The City of St. Louis is one of the major urban centers in the country, and as such suffers from most of the problems associated with urban areas. With a population of over 600,000 in 1970, St. Louis had 26.5% of its house- holds below the poverty income level and another 37.4% with incomes between $5,000 and $10,000 per year. II. HISTORY OF PROJECT During late 1973 two students and a professor from the George Warren Brown School of Social Work at Washington University in St. Louis became con- cerned about the available resources for treating cases of child abuse in the St. Louis community. Other than activities of the governmental agencies legally mandated to deal with the problems of child abuse and neglect, there did not appear to be any other group or program in the community dealing with the problem or providing treatment resources for families involved in abuse situations. The group saw a need, then, for a program to provide some community resources to help families with abuse problems. Its idea was to develop an outreach program, a "storefront" type operation, with a hot line and crisis intervention services. While its intent had been to seek foundation funding for such an under- taking, the group soon heard of the DHEW monies that were to be made avail- able for demonstration projects dealing with the problems of child abuse VIII.2 and neglect. It was clear, however, that HEW was looking for more comprehen- sive programs than what the group had originally conceived. Consequently, the group shifted its focus to the development of a full-fledged treatment center, with services for the entire family. An organizational sponsor was needed for the program in St. Louis, and the group considered three possibilities: the George Warren Brown School of Social Work, the Jewish Community Center, and St. Louis Children's Hospi- tal (SLCH). Based on the strong interest of the Director of the hospital's Department of Social Services, the decision was made to develop a hospital- based program, with St. Louis Children's as the sponsor. The group worked through the Department of Social Services to establish ties with the hospital. The group, now including the hospital director of social services, wrote its grant proposal for the Family Resource Center (FRC), and began making community contacts to develop support for the potential program. It continued, also, to develop and strengthen its hospital base, working with the chief of child psychiatry for the hospital as well as the director of house staff training. Meanwhile, committed to the development of resources for child abuse and neglect treatment in the St. Louis community, whether or not federal monies could be obtained, the group continued to seek other funding sources. It was notified of the grant award from DHEW late in April 1974, at a time when it was working on a funding proposal to the United Way. VIll.3 III. SUMMARY OF ACTIVITIES First Year Summary With the receipt of the grant in May 1974, the core staff began looking for a facility, seeking a large residence which would provide a ''warm'" setting near the hospital which was its parent agency. By June 1, a suitable building was leased and renovations began. The project now existed, as a separate entity from the hospital, but under its sponsorship and with a hospital ser- vice component. During that month a Hospital Coordinator and Parent's Program Coordina- tor were hired, joining the Project Director and Children's Program Director. The month of July was a time for ''gearing up.' The project developed a pre- liminary intake instrument which they hoped would serve research needs as well; staff development and training began; and the design of the project team's operation started. The project had planned to be ready for intake by August, and as a result of its education and media activities, referrals gegan to come in that month. In the process of responding to referrals, staff recognized need for further definition of intake procedures clarifica- tion of various staff members' roles, and extensive outreach services. By August, more staff had been added and the project began formally accepting cases in September. And, during November, a written agreement for coordinating with the Division of Family Services was finalized. During the winter, parent counselors were recruited and trained; an Intake Coordi- nator was hired to refine the intake process; and the treatment programs began to stabilize, with individual and group counseling and therpay, as well as parent edication and parent counselors for the adults, child develop- ment classroom and play therapy for the children, and supportive services VIII.4 including child care, transportation and diagnostic testing. In April, the project began working closely with Jolly K to establish a Parents Anonymous chapter in St. Louis. The spring months saw a steady increase in the project's active caseload, which by May had grown from eight to 19 cases. Throughout the first year, the project staff provided community and professional education, and worked on coordination with other agencies. Some staff turnover occurred during the first year, with a change in the Hospital Coordinator, the Child Development Classroom Teacher, and at the end of the year, turnover in the practicum student staff. Second Year Summary During its second year of operation, the project steadily increased its caseload, increasing during that time from 25 to 42 families. Services were expanded and new ones added, including a father's group, recreational therapy, behavior management training for parents, family and marital therapy, and a second children's classroom program. The project began to provide evening services, one night a week, and offered 24-hour availability of staff to its parents through a beeper system. A major activity of the second year was joint sponsorship of a community workshop by the project and Division of Family Services, with attendance by staff from a variety of community agen- cies with responsibility for working with cases of child abuse. Finally, the project formed a Board of Directors and became a not-for-profit corporation on its own, thus separating the official tie with St. Louis Children's Hos- pital. By the end of the second year, the project had over 75 people work- ing as staff or volunteers. ViIil.5 Third Year Summary In its third year, the project continued stabilized with basically the same program as the second year. The number of families in treatment grew to 60, and adaptations were made in the services offered as the staff felt appropriate. Service expansion included the addition of several children's services such as group therapy, summer programs (field trips), and school intervention. A particular effort during the third year was directed toward securing stable non-federal funding sources for continued project operation. The project had started on this early in its existence, but efforts intensi- fied in the last year of federal funding. IV. ORGANIZATION AND STAFFING Until incorporating on its own, the Center was housed as a special pro- ject of SLCH's Department of Social Services. Its budget is covered almost totally by the federal demonstration monies, which were channelled through the hospital. During its first year of operation, the project also obtained limited local funding, securing a $4000 grant for its children's program and a $400 donation for special needs. Even while housed organizationally in SLCH, the Center operated the bulk of its program out of its own facility, a large residence in close proximity to the hospital grounds. It functioned semi-autonomously, with operational program and policy decisions resting primarily with the Center's Director. The tie to the hospital has been an important one for the Center in the Staff's view, particularly in establishing credibility within the community, The staff organization of FRC includes three Program Coordinators, ‘With responsibility for each of the distinct program areas of the Center, who VIII.6 work with the teaching, social work and other volunteer staff in carrying out the Center's programs. The Project Director administers the program. An important characteristic of FRC is the use of students as an integral part of the staff. Students, participating in the Center for practicum experience toward an MSW or other degree, commit a full year to the project and devote 15 to 20 hours weekly to the project on a regular schedule, handling their own cases or teaching responsibilities. Volunteers also play in integral role as parent counselors, teaching aides, child care aides, and in community education activities. V. PROGRAM COMPONENTS Community Education Community education is designed to make the community aware of the Center and the services it offers, to change attitudes and promote understanding about the problem of child abuse, and to make people knowledgeable about resources in the community system for dealing with the problem of abuse. In addition to several presentations by or about FRC in the media, Center staff make presentations to community groups, including community clubs, students, and prospective volunteers, on the dynamics of abuse, resources for reporting and treating abuse, and legal aspects of abuse. Over one million people were reached via media presentations and several hundred through direct group presentations during just the first year. FIGURE 1: Organization Chart Board of Directors Secretary FRC Projec t Director 1 Parents' Program Research Coordinator Coordinator { 1 Social Social Parent Worker Worker Counselors Volunteers 1 Children's Coordinator [ 1 Diagnostic Classroom Classroom Teacher Teacher Teacher Volunteers Teaching Assistants L'IIIA VIII.8 Professional Education The Center works with professionals from other agencies in the community to increase knowledge about child abuse and neglect, its identification (detection) and effective treatments. FRC has a slide presentation and video tapes that are used by community agencies and hospitals. One hundred sixty agency representatives attended sessions on FRC at its community open house. Presentations emphasizing forms of intervention and needs of abusive parents have been made to professional groups, including nurses, social workers, physicians, teachers, staff of the Division of Family Services (DFS) and mixed groups. A special emphasis in the professional education component during the first two years was the training program provided by the Hospital Coordinator to physicians, nurses and other staff of SLCH. Coordination A primary concern of the Center staff has been the establishment of working relationships with community agencies that have responsibilities for handling child abuse cases. The long-range goal of coordination is the development of an effective community network for providing services in abuse situations. FRC engaged in extensive coordination activities that resulted in the establishment of referral procedures with 11 agencies, procurement of a written agreement with the Division of Family Services (St. Louis City), participa- tion in meetings to discuss FRC program design, and establishing a Parents Anonymous Chapter in St. Louis. In addition, the Center increased its con- tact and coordination efforts with the county Division of Family Services as more and more of its referrals came from the country. Finally, during Viii.o its third year, the project joined with other community agencies in forming a Child Abuse Council. Legislation and Policy FRC staff worked with others in Missouri on drafting a proposed major revision of the child abuse law, passed in June 1976, and mental health legislation affecting children. The proposed law was researched and drafted by the Governor's Committee for Children and Youth, on which FRC had staff representation. Research The research efforts of the project have included the development and implementation of record-keeping in the project, including logs for client contacts, monthly reports on client status, children's records, and family summaries. In addition, research activities include: e Performance of a series of tests (Denver Developmental, PPVT, Vine- land and others) on all "target" children (i.e., abused children) whether or not they become active in the Center's children's pro- grams, to characterize the developmental characteristics of abused children; e Performance of a more in-depth series of tests (including McCarthy, Vallet, etc.) on all children enrolled in the Center's programs, to further refine the characterization of cognitive characteristics of abused children; eo Conceptualization of the treatment components of the program; e Participation in the national evaluation. esata pe 5 SRY VIII.1O0 Treatment Services Individual Counseling and Therapy: The Center offers these services on a weekly basis to selected parents. While these treatment approaches are considered important for some cases, the Center does not use them as the primary treatment, depending on group work and the parent counselors for primary treatment and using individual work as needed. Couples and Marital Therapy: For clients with problems in the marriage or couple relationship, the Center offers this counseling service, usually using male and female co-therapists. Parent Counselors: Each volunteer parent counselor is assigned to one parent, and has made a commitment to the Center for at least one year. The parent counselor's responsibilities include remaining available to the family on a 24-hour on-call basis, making frequent home visits, and establishing a trusting relationship which will allow the parent to turn to the counselor both in crisis situations and for a basically supportive relationship. For some parents the parent counselor is the only service they receive through the Center, while other parents with counselors are actively involved in other project activities. Group Therapy: Group therapy for parents is an important treatment service of the Center, which is offered to every parent. Both mothers' and fathers' groups are offered, on a weekly basis, and are directed by co- therapists. Parents Anonymous: During its first year, the Center staff initiated the development of a PA chapter in St. Louis, In conjunction with a visit to the St. Louis area by Jolly K, founder of PA, the Center developed a VIII.11 publicity effort to attract parents who might benefit from PA, recruited sponsors and offered Center space for meetings. A special PA telephone line has been established at the Center to receive calls and provide information to parents who are interested in joining the group. A group met regularly for some months, and then terminated, but a new group is now in the planning stage. Parent Education and Behavior Management Training: During the first year; a six-session parent education program was provided for the Young Mothers' Group. In addition, education in child management or behavior management techniques is provided for some parents on a one-to-one basis or in a group, either in the parent's own home or at the Center. Recreation Therapy: These sessions, offered periodically over the Cen- ter's three years, provide an opportunity for parents to work on arts and crafts projects while building social skills through interaction with other participants. In addition, the project plans family picnics and outings, and other recreational activities designed to increase social skills and opportunities of its parents, and to create a warm atmosphere among Center families. Crisis Intervention, Diagnosis and Referral: In addition to the avail- ability of staff and parent counselors to respond to crises occurring in the families participating in the Center programs, the project offered a special crisis intervention, diagnosis and referral service through the Hospital ‘Coordinator in SLCH during its first two years. She responded to all cases of abuse identified at the hospital, meeting with the parents, assisting them in crisis situations, providing counseling as necessary and arranging VIII.12 an appropriate referral for the family, either for FRC services or to another community agency. Child Development Classes: Two child development programs are offered. One is designed for abused children who need remedial work in language, cog- nitive and motor development skills. It is designed for children between the ages of 2% and 5. The program, which includes half-day sessions five mornings a week, has as its primary focus individual "prescriptive" activity sessions tailored to each child's needs. The sessions are complemented by group activity and free play. Breakfast and a snack are included each day, and these meals are an integral part of the therapeutic program. Eight to ten children participate at any given time. The program is under the direc- tion of the Classroom Teacher who works with the Diagnostic Teacher, student teachers, and several volunteer child development aides. A second group of children, with behavioral rather than developmental problems, are served in an afternoon program. These children are slightly older than the morning group. Play Therapy: Play therapy is used both for children beyond the age range of the Child Development Program, and as a complement to that program for some children who can benefit from both. The Children's Coordinator and some student social work staff provide this treatment. Child Care: Students and other volunteers provide child care at the Center for children of parents attending group therapy sessions, family or marital counseling, and for parent counselors during their meetings. This service also allows Center staff to have an opportunity to observe siblings of children in the Center's programs as well as abused children who are not involved in the Center's programs. VIII.13 Transportation: The Center provides daily transportation to and from Child Development Classes for all children, as well as taxi vouchers for parents who need transportation to and from the Center. In addition, some of the Center's services are provided in the parent's own home. In addition to the services discussed above, the Center offers medical care, testing services and special therapy through purchased service arrange- ments, and 24-hour crisis availability to parents in the program through use of a "beeper" telephone system. VI. IMPLEMENTATION AND OPERATINGAL PROBLEMS The project has faced many issues in implementing its program. Certain issues have been specific to the Center's particular situation, but many are relevant for any new agency attempting to provide services in the child abuse field. Some of the most significant issues are discussed below. Staffing Although the project has developed a strong staff, this was not accom- plished without difficulty. The salaries that could be offered were rela- tively low, and the fact that the project is federally funded for a specified period (and thus cannot necessarily offer indefinite job security) served to make finding staff more difficult (yet may have assured strong motivation on the part of the staff who have become part of the Center). Because the Center administrators could not find people with extensive experience in child abuse, they found it necessary to revise their experience criteria to include persons with backgrounds in working with families or children, and with some experience in, or dealing with, community agencies in St. Louis. VIII.14 A particular problem in staffing has been identifying experienced minority persons for treatment work. One noteworthy positive experience of the project has been the use of student staff in the Center's programs. The practicum students working at FRC are an integral part of the staff, committing themselves to the project for a full year, and spending 15-20 hours per week at the project. Each student handles his or her own cases, providing individual counseling, doing case management, providing play therapy, serving as a child development teacher, or co-leading one of the therapy groups, under the direction of one of the staff coordinators or the Project Director. While there are, of course, some problems associated with the use of students (students are with the program only one year and thus annual turnover must be planned for), the Center has found these practicum students to be an essential re- source, handling major and continuing responsibilities, and participating fully in the Center with the other staff. Acceptance by Community Agencies Instituting a new agency, outside the established legal network for receiving reports and referrals of child abuse and neglect cases, required major efforts in terms of developing cooperative arrangements with other community agencies. The Center experienced some normal resistance from other agencies, partly due to apprehensions that the Center would change established procedures for reporting and handling of child abuse, and partly to a sense on the part of agencies that the project was conceived and funded without their input. VI1i.15 Project Leadership and Decision Making: The original design for the FRC administration included a rather complex administrative structure: a collegial directorship (pediatrician 10%, child psychiatrist 10%, and social worker 30%), and Associate Director for Administration. This design was con- structed as an interdisciplinary management approach to child abuse and as a mechanism for incorporating SLCH personnel into the structure. Practical aspects of management and decision making soon emerged, necessitating some revision in the rather cumbersome structure. After much consideration, a full-time position for a project director with basic day-to-day responsi- bility was established in the first six months of project operation. It was important for the Center, in addressing the dual objectives of good administration and efEivioni linkages with the parent agency, to develop a structure which was practical for both ends. Limited Staff and Resources The most pressing problem identified by all staff during the first year was the lack of adequate staff to respond to the treatment needs of parents. Staff limitations in a small Center preclude the provision of individualized therapy and counseling in all but a few cases, and thus group therapy and the use of volunteer parent counselors are seen as the primary treatment modes for parents. The lack of resources to treat more parents impinged on the children's program as well, for without resources to serve more parents, the Center could not bring more children into its programs. The inability to provide more services to parents also meant that some referrals from other agencies were refused, and while this is probably an inevitable problem that a small specialized agency must face, it could strain relationships with other agencies at early stages in the project's development. FRC has found |__ VIII.16 that as its program develops, it has been able to serve more families within the constraints of its limited resources, but this has been a slow develop- mental process. Criteria for Acceptance A problem related to the limitation in project resources is the need to identify a population for whom the Center's services can be beneficial, considering what the project can offer, and to develop criteria for accepting cases. Admission criteria were not initially designed by the project, which decided to '"test out" several types of families to ascertain the particular families that could use the FRC services. General admission criteria now exist for identifying families to be accepted into the FRC program, or alternatively, referred elsewhere. Perhaps the major criterion for accep- tance is parent motivation and willingness to seek treatment, since FRC clearly defines itself as a voluntary agency. Proportion of Time Spent in Direct Treatment Staff members saw a significant portion of their time being spent in meetings, and in planning and implementing the Center's programs during the first year, leaving a smaller portion of their time for provision of direct treatment than they felt was desirable. Although this could be a frustrating situation, staff recognized the necessity of certain meetings and planning sessions. While treatment planning meetings, case conference meetings, and policy meetings are time consuming, they are essential in providing well planned effective services to families. The realization that they are part of a field in a very developmental stage, without a set ''technology". or all the "answers' to serving abusive families, helped the staff to understand vIi1.17 the need for spending so much time planning and implementing rather than doing, but it did not relieve the frustration. Eventually, several types of meetings were eliminated. Transportation Transportation for parents and children has been a significant problem for the Center. For many months, a regular driver for the children was un- able to be obtained and no Center vehicle was available, so that the driver had to use his personal car or a staff member's car. Parent transportation is another problem. Most of the parents in the Center do not drive, and staff members spend significant amounts of time going out to the homes, and sometimes driving parents to the Center. The hospital provided taxi vouchers, as a donated resource during the first year, but these did not continue. Efforts to obtain local funding specifically for a Center van were eventually successful. Staff feel that their experience indicates a need for planning for transportation of the clients at the proposal stages to enhance the likelihood of achieving a reliable solution. Channels of Communication with the Federal Funding Agency Establishing clear communication concerning expenditures and other grant management matters has at times been a problem. The project feels that better communication channels at this level might have facilitated reaching solu- tions to other implementation problems. Continuing Funding Despite the fact that the Center director, staff and Board began to plan in the first year for funding needs following the demonstration period, the VIII.18 funding future remained uncertain going into the second half ot the demon- stration's last year. Small amounts of local foundation monies were obtained even during the first year. However, a stable funding base is difficult to secure, even with pre-planning and the avoidance of waiting until the last minute to seek support. VII. FUTURE PLANS The project has been successful in pursuing several funding possibili- ties for May 1977 and on, including: e Securing a Purchase of Service contract with the state Division of Family Services; e Obtaining United Way funding. The project had pursued this during its second year, but was unable to obtain funding due to a United Way policy against assisting federally funded programs; ® Obtaining foundation, charitable corporation and trust funding of $50,000. ® Other fund-raising activities, including assistance from community fund-raising groups (e.g., Lions), parent and volunteer fund-raising efforts, establishing a Friends of FRC organization built on sponsor donations, and a funding appear letter, yielded about $10,000. The project's operating budget has been $12,500 to $13,000 per month. Given its new funding sources, its budget will be expanded and the project is working toward opening one or two branch locations. The project staff have also found that its fund-raising activities have generated increased publicity and community support for its program. VI11.19 VIII. PROJECT GOALS The Family Resource Center has made progress toward each of the five goals it established for itself. Particularly noteworthy achievements have occurred in the areas of community education to develop greater awareness of abuse and improve reporting and attitudes; professional and lay worker training; and developing a family treatment approach providing an educational and therapeutic environment for parents and children. Some progress has also been made in improving the service network in the metropolitan St. Louis community, but the project has not played as significant a role here. Finally, the project has also begun working toward its fifth goal of expanding the relevant knowledge base pertaining to child abuse, although its efforts have not been as heavily concentrated in this erea. Goal 1: To develop a family treatment approach which will reduce the incidence of abuse in FRC families by providing an educational and therapeutic environment for both parents and children. Toward this goal, the project has succeeded in developing a comprehen- sive set of therapeutic and educational services for parents and children, and has succeeded in involving several members of most families in direct treatment at the Center. In addition, while client outcome data is sparse at this time, interim indicators of treatment outcome indicate positive move- ment toward the goal of reducing incidence of abuse and improving family functioning. Goal 2: To improve the child abuse service network in the metropolitan St. Louis community through establishing referral procedures with agencies for FRC families, identifying the nature and VIII.20 scope of FRC services for the agency network, involving agency staff in FRC meetings and initiating with agencies to expand services for abusive families. FRC has taken several steps toward increasing the coordination among child abuse service agencies in St. Louis, with some positive results. In addition, passage of a new state child abuse law has had salutary effects on the coordination of the service network in St. Louis. Substantial improve- ment is still possible, however. Staff of the project participated actively on the Governor's Committee for Children and Youth, charged with drafting an improved state child abuse law for Missouri. The outcome of this pro- cess was a new law which has substantially improved the design of the com- munity system in St. Louis. Treatment resources in the community for abuse have expanded in terms of the new services now offered by FRC itself. No other new services have yet been established, and thus only a small portion of the population in need can benefit from the wide range of services which might be valuable to them. Improved cooperation between the Juvenile Court and other agencies involved with abuse has been a desired outcome in the St. Louis community for some time. While no particular responsibility for the change can be ascribed to the demonstration project, community agencies have recently reported some improvement in working with the Court. Areas where improvement could still be made in St. Louis include reporting of cases by such sources as physicians and others who have traditionally not reported; more coopera- tion on cases (rather than just training and informational conferences) by such agencies as DFS, the schools, the police, the Court, and the major hospitals and FRC; and increased treatment resources for the majority of cases seen in St. Louis. V111.21 Goal 3: To provide a community education program which will develop greater awareness of this problem, improve attitudes toward abusive parents and their children, and encourage community support for programs servicing this population. In taking steps to reach this goal, FRC has made numerous presentations to community organizations and school groups. In addition, media coverage has included appearances on numerous programs as well as spot announcements, reaching audiences of several hundred thousand people. The outcome of the community education efforts is a definite perception that the community is more knowledgeable about abuse, based on the increase in reports of abuse made to St. Louis agencies, increased referrals to the Center, and requests to the Center for community education presentations. The number of reports to DFS approximately doubled in the last half of 1975, following passage of the new state law and institution of the new reporting line. Increased self-referrals to the project, from 13 during the first seven months of FRC's accepting cases to 39 during its second year, also indicate an attitude has been fostered which enables families with abuse problems to seek help for themselves. A final manifestation of the effects of the project's community education TT the increased community support for the project's treatment program. The project now has 35-40 regularly participating volun- teers in its program. An active Board of Directors, made up of representa- tives from various segments of the community, has also been formed. And, four different community groups and local foundations have made substantial donations to the Center. Goal 4: To organize training programs for professional, student and lay workers involved with abused children and their parents. VIII.22 The project has carried out numerous training sessions for professionals, including social service professionals, school and day care personnel, nurses, physicians and lay workers. It has held training sessions for students in the field, and has provided practicum training for students in social work and childhood education. In every case, these activities have exceeded the targets which the project had set for itself, in terms of the amount of exposure planned for training of community personnel. Project staff have noted an increase in professional knowledge about abuse dynamics and treat- ment, evidenced in requests for in-service training by professionals in day care centers, mental health agencies, and hospitals. Particularly among education personnel, who have traditionally had relationships with children, the project has noted increased understanding of the abusing parents. No substantial change has yet been seen, however, in the amount of reporting of abuse cases by those professionals previously reluctant to report. Goal 5: To expand the relevant knowledge base pertaining to child _ by (a) participating in the national evaluation, (b) developing a process for conceptualizing program components for dissemination of the FRC model to the field, (c) deter- mining methods for measuring behavior change in parents and children, (d) testing and diagnostic assessment of target children, (e) identification of characteristics of clients, and (f) formulation of admission criteria. While the project has definitely made some beginnings toward achieving this goal, this is the one goal from which efforts were diverted in favor of other priorities. Participation by the project in the National Evalua- tion has been excellent, both in terms of the completeness and timeliness vill.23 of data collected for the evaluation and in terms of contributing to the development of an effective and useful evaluation design, particularly with regard to evaluating the impact of services on children. Conceptualization and dissemination of material on the program model has been initiated, as discussed under Goal 1, but more work in this area is planned, particularly in developing a more complete write-up of the parents' treatment program. Work on developing a method for measuring behavior change in adult clients remains to be done; plans are for use of the '"Goal Attainment Scaling" tech- nique. Diagnostic assessment of children has been done for abour 40 child- ren, but retesting has only been done on a small number of children termina- ted from the project's child development classrooms. IX. PROJECT MANAGEMENT AND WORKER SATISFACTION St. Louis is a small project with six full-time staff members and a moderate size monthly budget of $15,654. The project maintains an average caseload size of 40 clients. The project appears much larger when one con- siders the nearly 70 students and volunteers who participate in the variety of program treatment activities. The Family Resource Center is a highly complex organization. The project utilizes students and volunteers in addi- tion to the seven different disciplines actively involved in the project. The program activities include a diversity of treatment programs, community and professional training and education, cooreination, research, and legis- lative activities. The organization is fairly formalized; there are specific job descrip- tions and an operating manual that defines the project's procedures and VIII.24 policies. There seems to be more informality among the staff in actual rule observation. The project is moderately centralized in that policies and program decisions are ultimately made by the project director, with in- put from staff. The Board's role in decision making is fairly undefined at this time. Decision making that pertains to individual jobs seems to be moderately centralized in that coordinators appear to be responsible for final decisions. This is probably due to the use of volunteers and students in the actual service delivery programs, requiring coordinators to assume more responsibility in supervising and overseeing individual work. X. ANALYSIS OF CLIENT DATA Client Flow FRC receives referrals from Division of Family Services, the local child- ren's hospitals, and a variety of local agencies, as well as self-referrals (about 25%) and referrals from other individuals. The project accepts only abuse cases. For those cases not screened out at point of initial referral, a staff social worker makes in-person contact with the family, usually a home visit. Those cases that are not appropriate to the project, either because there is not a potential or actual abuse situation or because there are psychological problems of a type or severity inappropriate to the pro- ject, are referred elsewhere for help. The aim of the initial contact is to communicate FRC's desire to help, to explain what FRC offers, to clear up any confusion in the parent's mind about the legal aspects of the situa- tion, and to begin to develop a relationship on which to base ongoing treat- ment. Participation in FRC's programs is completely voluntary. Sp ea VI11.,25 An initial plan is established and the case is assigned to a staff member for primary responsibility. The diagnosis phase will usually involve a series of developmental tests on the abused children in the family to deter- mine their needs and whether Child Development or other children's programs would be appropriate. Following this diagnosis and treatment planning phase, parents are placed in the appropriate treatment service(s). One or both parents may be involved; children can be placed in the Center's programs only if the parent is participating in Center services. Staffings are held periodically on cases and each case is reviewed at three-month intervals at a case conference. Workers from DFS or other agen- cies active in the case are invited to participate in the review. At this time, progress is reviewed and new goals may be established, with the treat- ment plan being revised as appropriate. Length of time in treatment depends on the individual situation of the client. Termination sometimes occurs because a family leaves the area or other- wise becomes unavailable for further treatment. The basic criteria for ter- mination as a ''successful' case is based on a judgment that family functioning has improved to the point where abuse has come under control for a given period of time and the family feels relatively secure. A child will be terminated from the Child Developmental Program when the developmental or behavioral problems have been remediated. At that time, the child will be referred to a regular day care or school program. Client Characteristics Referrals to the Family Resource Center were primarily from social service agencies (largely DFS, the mandated protective services agency in Missouri) and self-referrals, each accounting for about one-third of referrals. YVIII.26 Another 20% came from hospitals, a reflection of the project's close ties with St. Louis Children's Hospital. Physical abuse was the main problem in 60% of the cases; under 4% of the cases had physical neglect as the main problem, reflecting the project's emphasis on abuse cases only. Abuse of moderate or severe nature occurred in 37% of the cases, and 22% of the cases could be considered severe in terms of an index of the overall family situation, weighting the severity, number of household problems, previous evidence of abuse, and substantiation of the abuse. Compared to most other projects, FRC had relatively high proportions of cases where children had been removed from the home or placed in foster care. About half of the cases had been reported to the mandated protective service agency, and only a small proportion had involved criminal action. Most cases (69%) had no previous record or evidence of abuse or neglect. In over 70% of FRC's cases, responsibility for the maltreatment was ascribed to the mother, a substantially higher proportion than in any of the other projects. One adult families accounted for 35% of the project's cases, with about half having both father and mother present. One-quarter of the families had one child, with the average number of children being 2.3. Sixty percent of the families had at least one parent with a high school degree, a higher proportion than any other project. The father was employed in almost 80% of the cases; the mother in 22%. A fairly low proportion (45%) compared to other projects, had minorities in the family. One-third of the families were on public assistance, and almost three-quarters had incomes of $5500/year or less. The average age of mothers was 26 and fathers 30, with 55% of the families having teenage parents. Multiple problems vi11.27 existed in many of these families, with financial difficulties in 49% of the families, marital difficulties in almost half, and mental health prob- lems as well as parents having been abused as a child each in about one- third of the cases. Cases referred to the project but not accepted for services occurred most often because the client refused services (reflecting the voluntary philosophy of FRC), or because the report of abuse could not be confirmed, or because the case was already being seen by or was referred by FRC to a more appropriate agency. VIII.28 Table 1 Client Characteristics Source of Referral Private physician . Hospital. . . Social service agency 3 . . SChOOl: + + « '¢ » « » % & # wo = Law enforcement . Court . Parent. Sibling . Relative. . : Acquaintance/neighbor : : Belf, 4 + 4 v 2 v + » » © © Anonymous . Other agency. Type of Maltreatment Potential abuse or neglect only Emotional maltreatment only . Sexual abuse. Physical abuse. Physical neglect. » Physical abuse and neglect. Severity of Assault Not serious . Serious . . « + « + + + + Responsibility for Maltreatment Mother. . . . . . . . . . . .. Father. . on Both. « « + v oo # & » Other . . « « « «= = «= Legal Actions Taken None. . Court hearing. . . Reported to mandated agency . Reported to central registry. (N=78) . 4% .19% . 35% 1% C3 1% 0 0° . 3% . 33% . 8% .13% 17% . 1% .60% 0 ° 5% .73% .12% . 14% 1% .19% .12% 47% .18% Previous Record/Evidence of Maltreatment None. Previous record/evidence. . Demographic Information Average number children in family. Pr g ® Families with preschoolers. Families with one adult . . Families with no high school degree. « « vv + «4 > Families with no minorities . Families with no one employed . Families with less than $5501 per year income . . . . . . Average family income . Average age of mother . . . Average age of father . Families with teenage parents . Problems in Household Leading to Maltreatment Marital . Job-related . Alcoholism. Drugs . . EEE Physical health “uu Mental health . . . . . . . New baby. . . : Argument/ fight. Financial problems. . . . . Mentally retarded parent. Heavy, continuous child care. Physical spouse abuse . Recent relocation . Overcrowded housing . . . Abused as child . Normal method of discipline . Social isolation. .68% .32% 2 2.5 .26% .35% 41% .55% .44% .73% .$5500 .26 yrs. +30 yrs; .55% .44% .18% . 6% . 5% .14% .31% . 9% .22% 495% . 0 56% .10% .10% .13% .36% 21% .50% ¥111.29 The Quality of Case Management A review of case management practices of the Family Resource Center showed that almost one-third of the cases were contacted the same day as referred, and almost 60% within the first three days, comparing favorably with the total demonstration effort cases. Somewhat longer times elapsed, however, for this project than others between first contact and first treat- ment service -- 42% of the cases received treatment within two weeks, but 26% not until after one month. Multidisciplinary review was not heavily used, with only 16% of the cases having this service. However, over 90% of the cases were provided "staffings'" or case conferences, with the client present 50% of the time. Both of these figures exceeded the averages across projects. The project had separate intake and treatment staff in many cases, and almost 40% of the cases had more than one case manager during the period of treatment, often due to staff turnover. The project usually involved several staff in each client's treatment program, with over 40% being ‘treated by three or more staff. Seventy-two percent of the cases were also receiving services from outside agencies. Table 2 Case Management Characteristics* Time Between Referral and First Number of Client Contacts (after Client Contact initial contact) Before Treatment Same day. . . . . . . . . . . . .31% Plan 1-3 days. + + « + + +» xe © 0 428% NONE. « « # os 4 + 8 8 & 0 vw ov o17% 4-7 daYS. » 0-0» ov v0 x vv =» 1% ONE + « o # 5 5'v #a #0 & 2 % & & +37% Within two weeks. . . . . . . . .12% TWO wv ov 4% 5 wo 8 a & ee @ 8-00 2 Within one month. . . . . . . . .10% Three-five. « « + « 5 % « « « +» 4 223% Over one month. . . . . . . . . .12% Over Five , + « + os a & a #5 3 +» +a20% (Table 2 continued on following page) VIII.30 Table 2 (continued) Time Between First Client Contact and First Treatment Service Within two weeks. . . . . . . . .42% Two weeks to one month. . . . . .24% Over one month. . . . . . . . . .26% No treatment given. . . . . . . . 8% Use of Multidisciplinary Review Team At least one review . . . . . . .17% Review during intake. . . . . . .14% Review during treatment . . . . . 6% Review at termination** . . . . . 0 Use of Case Conferences (staffings) At least one conference . . . . .95% Conference during intake. . . . .79% Conference during treatment . . .84% Conference at termination . . . .38% Use of Consultants None. . . . . « « v « « « « « « 73% ONE . + + +v + vv vw a ov ve... 4% TWO + v vo vv ww» vw vv «= = » = = 3% Three-five. . . . . . . . . . . . 8% Over five . . . . . . . . . . . .10% Client Participation Client presence at MDT's and/or case conferences. . . . . . . .50 0 ° Contact with Referral Source For background information. . . .55% For progress reports. . . . . . .63% Responsibility for Intake Current case manager. . . . . . .37% Other staff member. . . . . . . .63% Number of Case Managers ORE. vv 5 sw wt 4 + uv» 2 61% THO oo don vw» vw 0 + v2 wu v 320% More than two . . . . . . . . . .13% Reason for Two or More Case Managers Joint management. . . . . . . .N= 2 Staff turnover. . . . . . . . .N=7 Staff unavailability. . . . . .N= 0 Lack of success with client . .N=1 Other « +. + « v.o +» oo » = « =» oN®= 7 Number of Treatment Providers in Project (other than case manager) None. . . + « + « «v « « + « + « 15% One . . +. vv + vv ve eee. J11% TWO « « 4 mv ov v Ais & % wv sheds Three-five. . . . . . . . . . . .40% Over five . . + + + « « « + » +» .3% Services From Outside Agencies. 72% Evidence of Communication with Outside Agencies. . . . . . . . .78% N=25 Frequency of Contact by Case Managers Once per week or more . . . . . .62% Once or twice per month . . . . .16% Less than once per month. . . . . 3% Once or twice only. . . . . . . . 3% Varied over time, . . . . . . + .13% NOBE., + » # = © » » « » »v »+ 1. 53% Follow-Up Contacts** At least one contact (client/ other agency) . . . . . . . . .65% Two or less with client . . . . .92% Three-five. . . « « «+ « + » « + «8% Over five . . . . . «+ ¢ + ¢« +4.+0 Length of Time in Treatment** Through three months. . . . . . . 8% 4-12 months . . . . . . . . . . .60% 1-2 years . . . . + + + +o «+. 220% Over two years. . . . . . . . . .12% Total cases reviewed = 38; total terminated cases = 25. * Owing to rounding, percentages may not sum to 100%. *% Terminated cases only. Vill.3] XI. COMMUNITY IMPACT Summar, Reported incidence of abuse and neglect is up substantially in St. Louis. Some move within major agencies to assigning staff specifically to abuse and neglect cases can be seen. Increased education of professionals and the general community has occurred. Finally, a 24-hour statewide reporting hot line has been implemented. The new state child abuse and neglect law appears to have brought about the most significant changes in the community system in St. Louis. The impetus for the new law cannot be attributed to any one cause, but included the need to be responsive to federal requirements, recognition on the part of most persons in the community of the deficiencies of the original law, and efforts of key people, including members of the demonstration project staff, to remedy gaps in the old legislation. The demonstration project also had some significant effects on the com- munity system, chiefly the injection into the system of some new services; widespread education efforts; the beginnings of coordination between agen- cies; and some changes inspired by the project's example and community education efforts (e.g., Cardinal Glennon's assignment of a single hospital worker to handle abuse, which they directly attribute to observing the success of SLCH-FRC's similar approach). The major remaining problems include lack of real coordination among agencies and the lack of intensive treatment services except for those fami- lies in the caseload of the demonstration project. VIII.32 Community System Operations Prior to 1974, and until new legislation was passed in Missouri in June 1975, two agencies had primary responsibility for responding to reports of abuse and neglect: the Division of Family Services (DFS) or the Juvenile Court. The law further stated that reports 'may'" be made to the appropriate law enforcement authority. In practice, major referral sources, such as hospitals, schools, and other agencies and individuals, chose between the two agencies sometimes on a philosophical basis, sometimes on the basis of which could be expected to respond most quickly and thoroughly. The two major children's hospitals reported to DFS, and only when pressed to the Court. The schools sometimes reported to DFS and sometimes to the Court, when they reported. The police reported to the Court, on cases which they reported at all. In fact, the police department believed that it was the primary agency to which reports should be made and was disturbed that it was not receiving more os. Both DFS and the Court received self-referrals, and reports from relatives, neighbors and other individuals. The law did provide for coordination between the Court and DFS, by requiring that each forward copies of every abuse and neglect report to the other. Both agencies carried out this requirement, at least for the most part, but each suspected the other of not forwarding all reports. The law passed in mid-1975 changed the system radically. All reports are now to be made to DFS, through a central toll-free hotline number. The Court is not to receive initial reports, although DFS is required to forward information on all substantiated cases to the Court. Vi11.33 Duplication of effort was an obvious problem under the original sys- tem. Both the Court and DFS investigated each case, whether initially reported to them or reported by the other agency. In addition, hospital social workers and medical staff did their own investigations on cases which they identified; school social workers investigated school-identified cases; and the police investigated cases reported to them. The focus and purpose of the investigations done by these different agencies varied of course; nevertheless, much of the material overlapped and was needlessly repeated by each agency. Duplication of investigative procedures is reduced, although not eliminated, under the new system. Caseload Size and Case Outcomes Reported incidence in the city of St. Louis is up strikingly for DFS and somewhat for other agencies. Table 3 shows the number of reports to DFS through the hotline in the 4% month period after implementation of the new law (mid-August to December 1975) was 598. This compared to just over 620 reports for the entire year in each of the preceding years of 1973 and 1974. For 1976, the first full year following the new law, over 2000 reports came in. Abuse reports to the Court were stable between 1973 and 1975 at about 75 reports in each of the three years, with a slight increase during 1976 to 91 reports. Neglect reports showed a slight increase over the three year period and a major jump in the fourth year. Only abuse statistics are available for the two remaining agencies tabulating data for BPA: St. Louis Children's Hospital showed almost a 25% increase between 1973 and 1974 in the number of cases identified, with a levelling off between 1974 and 1976; the schools reported a doubling of the number of abuse cases identified VIII. 34 there between 1974 and 1975 although the total number is small and no statis- tics are available for 1976. No statistics are available from the police, although interviews with police personnel indicate that the number of cases of abuse reported to them is down since the new law. However, the number of abuse cases seen by the police was small even prior to the new law, accord- ing to those interviewed. Table 3 Reports of Abuse and Neglect 1973 1974 1975 1976 +4 + + + QO 0 [3] Q Q o — 1] 0 — QQ Q — Q Q ~~ 0 — «© — «© 0 — © 0 — « Agency s 2 Bl2 ¥F 2/2 2 2132 28 2 2 2 e112 2 fl =z 2 g& 2 2 £ DFS = -= 623) -- -- 623) -- -- 598*| -- -- 2012 Juvenile Court| 71 180 251| 75 215 290 | 75 218 293 91 300 391 St. Louis Children's 101 -- --| 124 -— -- 1132 -- -- 128 -- -- Hospital Schools -- -- -- 6 -- -- 14 me -— - — =" * August -December, 4); month period only. VIII.35 One question that always arises when major increases in abuse and ne- glect reports occur is whether the increase in reported cases reflects large numbers of inappropriate reports, because members of the community are '"over- reacting" and reporting situations which do not involve abuse or neglect. There is an indication that the proportion of reports to DFS in St. Louis which can be substantiated has remained stable, or even slightly increased, since the new hotline was implemented and the number of reports increased. Substantiation rates ranged from about 58% in 1973 and 1974 to an average of about 65% in the months immediately following implementation of the new law. Partial data available from the Juvenile Court on substantiation of abuse and neglect reports indicates no clear trend in substantiation rates, with the proportion of cases substantiated remaining about 10 to 15 percent. A second issue of interest is whether any change has occurred in the sources of reports -- are agencies or individuals now making reports who did not do so in the past? Interviews with DFS personnel indicate that more ‘reports are being received from schools and hospitals, as well as from physi- cians. The increase in reporting from physicians is attributed to a change in the director of the city hospital and increased education of hospital physicians by social workers. Reports to the Court from hospitals and schools and law enforcement agencies are down, both in numbers and as a proportion of the total, plobidsty because many of these agencies began reporting to DFS instead of the Court after the law change in 1975. All cases identified in the St. Louis system, with the exception of some reported to the police and possibly the Juvenile Court, do get into the social service network. However, not all receive the same type or VIII.36 intensity of services, since some clients receive these services through the hospitals, some through the schools, some through FRC (the demonstration project), and some through DFS. It is difficult to determine whether any real change has occurred in the type and intensity of services provided to families in this community. One is tempted, then, to conclude that there has been no significant change, with the notable exception that those fami- lies who are served by FRC receive intensive services. These families, however, are a select number, since the agency only carries an average case- load of about 50 families. Some additional discussion of the type of services available in the community is presented in the following section. The ultimate disposition of cases is, of course, the most important question: what happens to these families? Comparable data on case dispo- sition has not been available for the four years spanning the demonstration project implementation. A satisfactory answer to the question of what happens to these families would require a thorough study, with records maintained on the outcome of all cases entering the system. Legislation and Community Resources Legislation. As is evident from the earlier discussion, a major legis- lative change occurred in Missouri during 1975. The specification of persons required to report abuse and neglect was expanded. The definition of abuse and neglect was specified in greater detail, and the age of children for whom such occurrences are reportable was increased from under 17 to under 18. The major system change, which has been discussed above, was the focus on Division of Family Services as the single agency to receive all initial reports. Other changes included legislative language encouraging the use VIiI1.37 of multidisciplinary services; permitting temporary custody in certain situa- tions; requiring DFS to provide continuing education on abuse and neglect; and requiring a Guardian ad Litem for all children involved in court hearings. Community Resources. While agencies in St. Louis are not able to pro- vide estimates of the dollar resources devoted to service in the area of child abuse and neglect, changes in staff resources, usually the major resource in any service agency, are determinable. With DFS as the one excep- tion, no real change occurred between 1973-1974 and 1976 in this area. In 1973-1974, 30 full-time equivalent workers within DFS provided service for abuse cases. Not all abuse and neglect cases were served by specialized workers, however. By 1976, DFS had 69 full-time equivalent protective ser- vice workers, including supervisors, doing intake or specializing in treat- ment of abuse and neglect cases. This was a major change from the decentralized system of earlier years, where each office handled protective cases as they | saw fit, often without using specialized workers. The Juvenile Court has 15 a special Neglect Unit to handle all abuse and neglect reports, as well as other cases not involving delinquency. The size of this unit has grown from five to eight full-time workers over recent years. During the past year, the Unit kas moved toward even more specialization, with three of the eight workers now specializing in abuse and neglect, spending 50% of their time on these, rather than other cases. For the two hospitals, Cardinal Glennon has a diagnostic team and six social workers, devoting part-time to abuse and neglect cases, and have had this set-up for several years. In early 1977, they assigned one of these workers to handle all abuse cases. St. Louis Children's Hospital, the sponsor of the demonstration project, origi- ‘nally had 7-8 social workers devoting part-time to abuse and neglect cases VIII.38 and a child abuse team. In 1975, they reorganized to have one full-time abuse worker (funded through demonstration project monies), a diagnostic team, and eight workers handling neglect cases, which required perhaps 10% of their time. The police and schools made no real change in staff resources for abuse and neglect cases, with their existing staff of about 70 juvenile officers and 55-60 school social workers, respectively, devoting a small proportion of their time to abuse and neglect. The demonstration project added an average of about 10 staff and up to 40-50 volunteer personnel to the resources for treating abuse in St. Louis. It is unclear, however, at what level the project will continue after May 1977. Staff of other . agencies dealing with abuse should remain stable. There have been some noteworthy changes in service resources in the St. Louis community. Prior to the time when the demonstration project was initiated, the community had several service gaps; there was no 24-hour reporting, and there were limited treatment resources -- no lay therapy/ parent aides, no group treatment, no Parents Anonymous, child management, therapeutic day care or crisis nursery for abuse and neglect cases. The new law and the provisions for reporting abuse and neglect have implemented a 24-hour reporting and response system. As an adjunct to the demonstration project, a Parents Anonymous group was begun. Several other services were added by the project, although only for its own limited caseload -- parent aides, therapeutic day care, child management and group therapy. V111.39 Community System Coordination The two major agencies with responsibility for abuse and neglect cases have always had coordination mechanisms, as required by the law, for sharing reports with each other. Coordination beyond this has been problematic, Court staff often feeling that DFS does not provide the type of information needed by the Court, and DFS often unsatisifed by the Court's follow-through on cases. The new law has changed the basic coordination process somewhat, with DFS now receiving initial reports on all cases, though it must share reports on all cases of injury or disability from abuse or neglect. No definite change has yet been observed in other coordination problem areas. A written coordination agreement was established in 1974 between DFS and FRC. This was a major accomplishment for both agencies, since it estab- lished clear ground rules for their cooperation on cases, and since written agreements for coordination between agencies were not used in the past by any St. Louis agencies. The agreement outlines procedures by which FRC will have major responsibility for certain cases, while still ensuring that DFS will follow the case sufficiently to carry out its legal mandate. Procedures for worker coordination, such as for joint case staffings and other case coordination practices, are spelled out. The agreement may have premature, however, and many of the procedures outlined failed, at least so far, to become truly operational. Coordination other than that outlined above has always been, and remains, a problem in this community. Neither the schools, the police, nor the foster care agency have any specific coordination arrangements, other than following legal reporting and referral procedures. The two children's hospitals, during 1973-1974, shared card files on abuse and neglect cases to guard VIII.40 against "hospital hopping" and held joint CAM (Child Abuse Management) meetings. As of 1975, however, these joint meetings had been abandoned, and the card file was no longer reciprocally maintained. At the end of its first year of operation, FRC jointly sponsored with DFS a community-wide child abuse workshop. Participation was good by all key agencies, as well as others, and certainly continuation of such joint 7 endeavors can enhance cooperation and coordination. The project has also devoted significant effort to establishing coordination, either formal or informal, with a wide range of agencies in St. Louis and has arranged referral procedures with a number of them. In summary, the coordination system in St. Louis' service delivery sys- tem for abuse and neglect still leaves much to be desired. The major coor- dination arrangement is the legally mandated centralization of reports. This is an advance over the dual, uncoordinated system of the previous legis- lation, but there remain real misunderstandings about reporting requirements, which can probably only be remedied by increased communication and coopera- tion among currently isolated agencies. The Central Registry, further, cen- tralizes all reports in one place, but in the past no routine feedback of this information has been returned to major reporting agencies, other than gross counts on a city and county basis. The demonstration project has devoted significant effort to coordination, and has some notable achieve- ments, but its efforts have been primarily directed toward establishing two-way coordination between itself and individual agencies, and community- wide coordination is still a major problem. The newly established community- wide committee, the Child Abuse Council, may help to improve this situation. + — VIII.41 Education and Public Awareness Special training about abuse and neglect has been Jmited in most of the key agencies, and, except at DFS and the demonstration project, has shown no real change over the past few years. Court and police training in these areas rests Beiaily on the initiative of the individual, who can attend local seminars and workshops, as available. Both agencies do, how- ever, encourage this, and try to provide funds for the training. In-service training is also provided to the neglect unit staff of the Court by its supervisor. Training in the schools focuses on the reporting law. Both hospitals provide in-service training, and utilize the materials developed by the demonstration project for their in-house training. SLCH, with the advent of the project, uses its full-time abuse worker to provide compre- hensive training to nurses, emergency room staff, new medical staff and others on a routine basis. The most significant change in staff training on abuse and neglect has been at DFS. In 1973-1974, training was minimal, and the two staff trainers who provided this resource were not really used. With the new law and some reorganization, there are now one state training specialist and nine local training specialists, a 100% improvement in the estimation of key DFS per- sonnel. All of the five key agencies interviewed, with the exception of the police, indicated an increase in general professional and community educa- tion between 1973-1974 and 1976. Most attributed this increase to the effect of the new law, the publicity and education surrounding the 24-hour hotline, and the education carried out by the demonstration project. Over this time period, DFS progressed from accomplishing little or no outside VIII.42 education, to having its statewide abuse specialist-trainer canvas the state conducting education sessions, and locally, being joined by top DFS staff to educate a range of groups. She works now with a Task Force, including the abuse worker from SLCH, formerly a member of the project staff. Each of the other agencies, with the exception of the schools, conduct community and professional education on request. The primary recipients of this training seem to be hospitals, with a variety of other groups receiving edu- cation on occasion. The schools, additionally, provide high school courses on family life and parenting, including treatment of abuse and neglect. The demonstration project, during each full year of operation, made over 100 community education presentations, including talks with community organizations and student groups as well as media spots and discussion pro- grams. The staff also made large numbers of professional education presen- tations, reaching social service professionals, school and day care personnel, nurses and physicians. XII. RESOURCE ALLOCATION, SERVICE VOLUME AND COSTS As the Project Resource Allocation Table shows, the Family Resource Center allocated almost half of its budget to direct treatment activities (48%). This included 15% of the budget for direct services to children, 12% for direct services to parents, and 21% for case management and services for families. Actual staff time allocation to direct services was greater in each case, however, with 65% of staff time going into direct treatment. Staff time was also more heavily allocated to children's services (28% for children's programs versus 15% for adult services). Community functions represented 8% of staff time (6% of the budget), research about 6-7% of time —— BE ———— tm seat: 2 BE ] VIII.43 and budget, and "overhead" functions 20% of staff time but 40% of the budget. Child development classes and group therapy were the ''staple'" ser- vices of the project, with transportation and babysitting, as supportive services, also being very frequently offered. Unit costs for parents’ services ranged from $2.86 for an individual therapy session (one hour long) to $14.24 for parent education sessions. Unit cost for a child development class (about three hour sessions) was about $6.00. Donated resources (student social workers, volunteer lay therapis-s, ''volunteer' physician) were used in most treatment services, with particularly heavy use in lay therapy, medical care, babysitting, parent education, and coun- seling and therapy. The project carried a relatively small average monthly caseload of 40 cases, and had a total annual budget of about $160,000. VIII.44 Project Resource Allocation and Service Costs Resource Sllogsiton to Volume and Unit Costs of Services Average Average Annual Annual Average Average Time Budget Actual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost| to Community Community Education 4% 3% Professional Education 2 2 Coordination 2 1 Staff Development/Training 10 8 Program Planning/Development 6 5 General Management 4 27 Project Research 4 3 BPA Evaluation 3 3 Outreach 2 1 1 case $49.60 $57.00 Intake/Initial Diagnosis 4 5 13 intakes 48.97 55.96 Case Management/Review 7 40 average caseload 25.94 33.01 Court Case Activities 1 1 4 cases 20.92 20.92 Crisis Intervention During Intake l 1 8 contacts 9.97 9.97 Individual Counseling 2 2 67 contacts 3.19 4.39 Parent Aide/Lay Therapy 4 2 28 contacts 5.60 11.02 Couples Counseling 1 1 18 contacts 5.54 6.50 Family Counseling 1 1 9 contacts 8.93 15.92 24 -Hour Hotline -- -- 12 calls 2.86 2.86 Individual Therapy 2 1 27 contacts 2.86 7.27 Group Therapy 4 4 106 person-sessions 4.24 6.00 Parent Education Classes 2 2 17 person-sessions 14.24 19.75 Crisis Intervention After Intake 1 1 22 contacts 4.60 4.78 Child Development Program 22 13 285 child-sessions 5.96 8.03 Play Therapy 1 1 16 child-sessions 5.24 8.34 Medical Care -- -- 4 visits 5.94 22.76 Babysitting/Child Care S 1 87 child-hours 1.10 4.19 Transportation/Waiting 4 3 433 rides 0.92 0.95 Psychological/Other Testing 1 1 18 person-tests 8.31 8.54 Follow-Up -- -— 5 person follow-ups 5.75 11.35 Total Annual Person Years/Budget 12,27 $160,068 Average Monthly Caseload = 40 I1X.1 PACER: ST. PETERSBURG, FLORIDA I. COMMUNITY SETTING Pinellas County, occupying almost 300 square miles, is largely urban in character. The county has extensive coastline and inland waterways that attract many retirees and tourists. For these reasons, the county is sup- ported almost exclusively by service industry. The total population in Pinellas County in 1970 was 522,329. Of this total, 1.1% were under one year of age; 4.1% were 1-4 years of age; and 17.8% were 5-17 years old. Of particular importance in understanding the county and how its resources are allocated is the fact that 29.5% of the population is over 65 years old, compared with a nation-wide average of 9.8% in that age bracket. The population increased by almost 49% during the 1960-1970 decade, although the under-five population decreased by 2.7%. This increase has placed great demands on the available services and facilities, especially housing. Nine percent of the families in the county had incomes below the poverty level in 1970. Of these 13,903 families, 5,184 had children under 18 years of age. Most of the county's families (76.6%) were in the moderate income bracket and 14.4% had incomes above $15,000. The county presents an atypical population distribution and growth pat- tern; both strain the development of adequate social services for all segments of the population. IX.2 IT. HISTORY OF PROJECT PRIOR TO FEDERAL FUNDING The Juvenile Welfare Board of Pinellas County, Florida was established by state statute in 1945 as an independent agency with taxing powers and a mandate to initiate, coordinate and oversee services to Pinellas County's children. The Juvenile Welfare Board (JWB) offers planning, funding and other support to agencies/projects that serve youth, in an effort to fill the gaps in needed services in the county. The Board works in conjunction with community leaders and agencies that serve children to formulate common goals, to plan and implement ways to achieve those goals, to research the needs of children and evaluate the services available to them, and to pro- mote public awareness and education about such needs and services. Funds for these endeavors come from a portion of the county's taxes appropriated to the JWB. Since its inception in 1945, the Juvenile Welfare Board has provided support for development of programs in such areas as foster care, youth recrea- tion, juvenile court services, child guidance, marriage and family counseling, homemaker services, protective services, day care, services for retarded and handicapped children, residential treatment services, camps for emotion- ally and socially maladjusted children, and group homes for children. In 1961, in response to a need for services to protect abused and neglected children in Pinellas County, the Juvenile Welfare Board helped establish a Protective Services Unit within the Division of Family Services, Department of Health and Rehabilitative Services, through provision of funds to that agency. In 1971, state legislation was passed that provided for the detection and correction of abused, maltreated children through the Department of 1X.3 Health and Rehabilitation Services. This agency receives all reports of abuse and neglect, investigates those reports and notifies the juvenile court in the appropriate county. In addition, the Department maintains a central registry of all cases of child abuse. In the same year, legislation was passed that required the state to provide protective services for all abused and neglected children through state agencies. The state allocated funds to finance most of the present services. In Pinellas County, however, the Juvenile Welfare Board continues to fund three of the 17 staff members in the Protective Services Units of the Division of Family Services in order to maintain a high level of quality services. Community agencies, including the JWB, saw a need to improve the services available to abused/neglected children and their families and to address the question of "prevention' of abuse and neglect. In 1973, a two-day "Institute for the Battered Child" was sponsored by the Juvenile Welfare Board. Repre- sentatives of many child service agencies attended. The sessions stirred the interest of these agencies, which pledged their cooperation in addressing perceived problem areas. When federal plans to fund demonstration projects concerned with child abuse/neglect were announced, it was agreed that the Juvenile Welfare Board, with continuing input from the child service agencies, would write a proposal incorporating specific components related to the pre- vention of child abuse and neglect and proposing the development cof new treatment programs and strategies to enhance the current delivery system. In May of 1974, the project received federal funds to implement the proposal. IX.4 IIT. SUMMARY OF ACTIVITIES Summary of First Year After receipt of the federal grant in May 1974, the Director of the Juvenile Welfare Board began searching for a Project Director and other staff. The Project Director and Secretary were hired in August. During the next two months, the remaining three staff members were hired and the project became fully operational. Most of the fall was spent refining the plans for the project, providing numerous educational speeches and seminars, and attempt- ing to implement several of the project's components. In December, after a visit by Jo L of Parents Anonymous, a new Parents Anonymous Cnapter was begun in Pinellas County. The Assistant Director re- cruited the two group leaders and provided support to them during the early months of the group's operation. The first group of nine Parent Aides was recruited, trained, and assigned to their families in January. Each has been actively providing services to their clients since then, under the supervision of the Parent Aide Coordina- tor. Also during that month, the original Training and Education Coordinator left the project, but was almost immediately replaced with a new staff member. An agreement with the State Attorney's office to purchase the services of two law students was signed in March. These students assist DFS workers in the preparation of the court-related materials necessary in contested dependency cases. Additional Parent Aides were recruited in the early spring and the first Child Management Class was begun in April. During the first year, project staff provided numerous education and training sessions to local community groups and professionals. A large, three-day conference, jointly sponsored by PACER and the local Medical Society, IX.5 was attended by over 200 people. Other activities pursued during the entire first year was the development of the Hospital Trauma Team, the Maternity Ward Monitoring Program, and the Medical Central Registry. None of these Copii were operational in June 1975, but staff were actively pursuing their implementation. Summary of Second Year In the second year all program components had become operational with the exception of the Medical Central Registry. Because of the medical com- munity's opposition to the Registry it was believed that this component could not be implemented until the Family Consultation Team had had a chance to demonstrate its usefulness and earn credibility with local physicians. Physician opposition had also stymied implementation of the Maternity Ward Monitoring component. But in the second year the PACER staff shifted direction and this component was renamed the New Parent Information Service (NPIS). Rather than the hospital base suggested in the Maternity Ward Moni- toring concept, NPIS was a community-based component. Specially trained volunteers delivered packets of information regarding community resources, useful to families and children, to the home of new born infants. ‘During this visit to the home, the volunteer completed an interview with the family members. This interview was designed to detect high risk situations and unusual stress in the home. Follow-up contacts were planned for all fami- lies determined to be high risk. The data from a three-month sample, in which all new mothers listed in the local newspapers were interviewed, had not been analyzed by the end of the second year. As a result of the very active education and training component, a major child abuse conference for the community and over 200 formal education and IX.6 training sessions were completed in the second year. The Family Consultation Team began formal organizational meetings in September of 1975 and began to review cases in January 1976. The team had circumvented the legal difficulties which had blocked progress in the first year by organizing themselves as a hospital-based team that would assist Health and Rehabilitative Services (HRS)* with treatment planning for their clients. Hospital families would be reviewed by the team after they were accepted into the HRS caseload and brought to the team as HRS clients. Summary of Third Year During the third year education and training continued to be a very active component. In addition to the numerous requests for education from community agencies, formal training sessions were held with representatives from the schools, the hospitals, and SES. Over 500 professionals received education and training in the third year. For the grand finale, the PACER staff sponsored their third Child Abuse Conference. This very successful conference, focusing on community coordination problems, was attended by nearly 300 professionals representing a wide variety of social and public agencies. For most of the third year the parent aide program functioned at a re- duced level. There were no new aides recruited or trained to replace the parent aides who had resigned. No new families were accepted for treatment. Staff efforts during this year were directed toward finding a new home for this component when the project ended. While there have been many interested agencies, no one has found the funds to continue the program. Parents Anonymous has had a somewhat shaky history in this project. In the third year one group blossomed into an active chapter, but the second * HRS is the single agency mandated to receive reports of abuse and neglect. X.7 group became inactive. Marriage and Family Counseling at the Juvenile Welfare Board has agreed to assume the sponsorship of the PA group and will assign a counselor to work with the groups early in 1977. This component will con- tinue after federal funding. The Family Consultation Team has been well received by its members, and they were committed to continuing the multidisiplinary team approach. Many of the problems that had tormented the team during the first six months have been resolved. A social worker from the Children's Medical Service was elected to replace the PACER staff member as coordinator for the team after the project is terminated. This component is assured of continuance after PACER is terminated. The Legal Intern Component functioned at a decreased level for nost of the third year because of budget cuts. However, the intent of this component, that of involving the State Attorney's Office in representing HRS in dependency cases, has been accomplished and will continue after the project has been terminated. The Child Management Classes have been operating virtually independent of the project this third year under the direction of the Pinellas County school system, and will continue to do so after the federal funding period for the PACER project. During the third year, the coordinator for the NPIS component has been overseeing the completion of as many interviews as possible and analyzing the findings from the prior year. This component is very popular with a number of community people. The PACER staff has written a number of grants to foundations and government funding sources requesting monies to develop this program idea, but have been unsuccessful. There is an indication that IX.8 the Juvenile Welfare Board will continue this component in some form in their training component. IV. ORGANIZATIONAL STRUCTURE/STAFFING PATTERNS The PACER staff includes the Project Director, the Assistant Project Director, the Parent Aide Program Coordinator, the Training and Education Coordinator, the Planning Specialist and the Project Secretary. The rela- tionships of these staff members to each other and to the Juvenile Wel fare Board and its staff are depicted in Figure 1. Project PACER is one of several service projects operated directly by the Juvenile Welfare Board. Staff members occupy a suite of offices in the same building as other JWB staff and programs and benefit from being able to share various facilities and equipment as well as from having direct access to the JWB staff for consultation. The Juvenile Welfare Board provided 25% of each of the four JWB staff consultants' time to the project as an in-kind contribution. In addition, 10% of each of nine -JWB administrative staff are supported by the PACER grant. Although it is relatively autonomous in day-to-day affairs, the project staff is directly responsible to the Director of the Juvenile Welfare Board for major policy and financial decisions. The Advisory Board to the project consists of representatives of various child service agencies and other community groups. The Board advises and consults with project staff in the planning and implementation of project components. Board members assist in the development of a more coordinated child abuse and neglect system in the county by explaining the PACER program to their respective agencies and by serving as the communication link between the project and other agencies. Figure 1: Organizational Chart Juvenile Welfare Board Act Juvenile Welfare Board ____ Executive Committee, Youth - “| Services’ System Advisory Council JWB Funded Programs [|~— — — — — — Executive Director of JWB — — — = — - Youth Services System Advisory Council I I ] Marriage and PACER: Administrative Community Family Counseling Project Director Staff Services | 1 Advisory Council Assistant Project Director I [ i Parent Aide Training and Planning and Project Family Consultation Team Coordinator Education Research Secretary Coordinator Specialist NPIS Volunteers 16 Parent Aides Legal Interns Parents Anonymous 6° XI IX.10 Within the PACER project the organizational structure is a flat organi- zation with all staff members operating fairly autonomously, developing their own program components, but directly responsible to the project director. Despite this autonomous job design, the staff functions primarily as a team, relying upon one another for assistance and feedback in the operation of their respective components. The project staff has been stable for the three years of the project, with one staff turnover occurring in the first few months of the project. V. PROJECT COMPONENTS The project components, those defined in the proposal and some additional areas proposed since them, were all designed to begin addressing the issue of prevention and to provide some innovative programs that would supplement existing protective services. The implementation of these components has required long negotiation periods and many compromises in order to make them acceptable and useful to the agencies with primary case responsibility. Community Education The project has made numerous presentations, speeches and information sessions to various community groups to develop a better understanding of the dynamics of child abuse and neglect and to reduce the stigma attached to this problem. The presentations made the various services available in Pinellas County more widely known and promoted early referral and interven- tion in suspected cases before a serious incident occurs. The project director and other staff have made appearances on television and radio shows and have contributed to various articles published in the IX.11 local newspapers. Pamphlets, flyers and other written materials dealing with a variety of subjects have been distributed to community groups and organizations. Professional Education The education and training of professionals in Pinellas County has been a focal point of the PACER project. The staff has developed alternative training 'packages' designed primarily for professionals who are most likely to encounter child abuse and neglect in their work (e.g., police, private medical and hospital personnel, teachers and day care workers); many other local agency staffs and other professionals have also been included in edu- cational presentations. The project has purchased audio-visual equipment and various tapes and programs on child abuse/neglect and has taped some materials of its own. These materials are often used in educational presentations and are on loan to other agencies for their consi education and development REN One unique aspect of the PACER efforts is that its educational Diaghens are accredited by various professional groups such as the Board of Education and the medical society; these continuing education credits further motivate professionals to attend the sessions. PACER has also encouraged the inclusion of child abuse/neglect material in existing training and in-service programs of local agencies and has helped develop the necessary materials. Coordination The coordination efforts of the project have emphasized developing work- ing relationships with other community agencies and providing a process for integrating the project's new components and services into the existing ser- vice delivery system. In the third year, the project sponsored a local child IX.12 abuse project that addressed the coordination problems in Pinellas County. Research The Planning Specialist, who began working with the project as a statis- tical assistant, has developed the overall research and evaluation component of the project with assistance from the JWB Evaluation Consultant. Evalua- tion of the training component consists of an assessment of the knowledge and attitudes of training participants after a training session is held, and gathering feedback information About the participants' general reactions to the training. A short questionnaire is used to ascertain this information. Referral rates from professionals who have received training will be moni- tored as another way of measuring the success of training. Written reports from the Parents Anonymous sponsors and, possibly, feed- back from the participants will be analyzed to determine the usefulness of the group and the ways in which it might be improved. Client contact logs and review forms, as well as the BPA client instruments, are being used to assess the progress of families who have been assigned a Parent Aide. In addition, a short questionnaire may be given to clients to assess their per- ception of the usefulness of the Parent Aide program. The Planning Specialist is carrying out an extensive survey of DFS case records for the years 1971-1974 in order to gather data about case character- istics, source of referrals, recidivism rates, foster care placements and case dispositions. This information will be used as baseline data for future analysis of the system's operation since the implementation of PACER. Other evaluation/research efforts include a needs assessment regarding service and coordination gaps in Pinellas County, surveying 75 local community agency directors, and a management information system which is available for 1X.13 planning and program development for children's needs. Data from HRS records is being used to collect the relevant data. Treatment Services Parents Anonymous: A visit by Jo L of the National Parents Anonymous Organization spearheaded the development of a local chapter in St. Petersburg. One PACER staff member took the responsibility for finding the two co-sponsors, securing a facility, finding babysitters, and publicizing the beginning of the group. After a long period, during which many participants dropped out of the group or attended only irregularly, this first group has become very cohesive, with eight members regularly attending the weekly sessions. The Assistant Project Director and another staff member have been leading the groups because group sponsors could not be recruited. Child Management Classes: PACER staff prevailed on the Adult Education Department of the county to include a class, for the parents of infants and toddlers, directed at solving common parenting problems and promoting posi- tive and healthy interaction between parents and children. Several classes are held each quarter in various locations in the county and have been very successful. Over 300 people have enrolled in these classes. Parent Aides: Sixteen Parent Aides have been recruited and trained and are now actively involved in the families to which they have been assigned. The Parent Aides were recruited through advertisements and at public appear- ances by project staff. They were carefully screened by the Parent Aide Coordinator and Project Director and selected on the basis of their maturity, experience with child rearing, commitment to the project, and the amount of time they could be available to their assigned families. I1X.14 After extensive training, a Parent Aide is assigned to a family with which he or she appears to be compatible; changes in assignment may be made if either the Aide or the family is unhappy with the match. The role of the Parent Aide, as defined by PACER, is that of a "loving friend" and advocate who helps support the parent, and not that of a thera- pist or professional counselor. The Aides help families work out problems, discuss alternative ways of parenting, and intercede with other agencies when necessary. They also provide transportation, babysitting and home- making services. The Aides attempt to help the parent find relief before a crisis occurs. Other Program Components Legal Interns: PACER contracted with the State Attorney's office to provide legal assistance to Protective Services workers in preparing and filing the required petitions for contested dependency cases. Two part-time law students assist the workers in carefully describing the home situation and developing the required evidence for a court hearing. A State Attorney appears in court for the hearing to present the case of the DFS worker. New Parent Information Service: NPIS is a preventive oriented compo- nent that provides helpful information regarding social services and other resources available in the community for families and children to parents with new-born infants. During a home visit in which the trained volunteers deliver these materials, they also interview the families to detect high risk situations. For those families who are experiencing unusual stress, the volunteers are trained to assist them in locating appropriate services and support in the community. 1X.15 Family Consultation Team: This service is believed to improve the sophistication of identification, diagnosis and treatment planning by inte- grating different disciplinary approaches into one family plan. There were no such multidisciplinary teams available in the 12 major hospitals in Pinellas County before PACER was instrumental in starting the Family Con- sultation Team in All Children's Hospital. Representatives on the team include a pediatrician, lawyer, psychologist, social workers from hospitals, HRS and the schools, as well as a representative from the State Attorney's office. It was believed that the team could help improve the quality of case management of abuse and neglect cases in Pinellas County and also become a forum for coordinating community services. Within one year, the team has proved to be a viable, active mechanism for assisting individual HRS workers in improving treatment planning with their clients and has been a stimulus to the participants regarding their role in developing a coor- dinated community child abuse and neglect system. VI. IMPLEMENTATION/OPERATION PROBLEMS Project Component Development The primary implementation issue was the inability to implement three components of the project that were included in the original proposal -- the ‘Hospital Trauma Team, the Maternity Ward Monitoring Program and the Medical Central Registry. In each case, the project was unable to garner from the medical personnel of local hospitals the cooperation necessary to implement the programs. The points of contention appeared to be grounded in the issue of ''con- fidentiality', although the common situation of medical non-involvement in IX.16 child abuse projects is also a problem. The key issues were whether a physi- cian can release information about a patient to the non-physician members of a Hospital Team, and whether a new mother can be identified as 'potentially abusive or neglectful" through Maternity Ward Monitoring, even if only for the purpose of offering optional services, without breaching the medical code of ethics. Project staff members attempted to provide answers to these questions and solve the problems by presenting testimony and recommendations of other Teams and hospital programs operating around the country, and by developing a relationship of mutual trust and compromise with hospital physi- cians, but even these efforts had little success. One clearly successful attempt, however, was the three-day workshop sponsored by PACER. In addition to involving the Medical Society as a co- sponsor and having physicians chair many sessions, Dr. Bart Schmidt from the National Center for the Prevention of Child Abuse and Neglect spoke per- sonally to many physicians about the need for, and probable success of, a Hospital Team. This direct contact with physicians who had actually worked in a successful abuse/neglect project may have dispelled many physicians’ fears. At the current time, it appears that one hospital may be willing to help implement a Hospital Trauma Team, although both the Maternity Ward Monitoring Program and the Medical Central Registry will probably remain undeveloped for some time. Project Role Definition Because of the extensive publicity and education efforts in the early 1970's, which clearly explained that the Division of Family Services was the primary reporting, investigation and service agency for child abuse and neglect cases, many community individuals and agencies were confused about 1X.17 the role PACER was going to play in this tightly structured system. Some saw the project as an offshoot of Protective Services and expected the pro- ject to provide direct caswork services; others initially construed it as a "funding" program, since it was housed with the Juvenile Welfare Board. Although project staff were very clear about their role in relation to other agencies, particularly HRS, this was not always understood. The Project Director's personal contacts with most child service agen- cies and the educational presentations to community groups stressed the uniqueness of PACER's supplemental services and helped clarify the roles and responsibilities of different programs in the child abuse and neglect system. As a result, the role definition issue has almost disappeared. Community Agency Coordination The project encountered initial resistance and uncooperative attitudes at some community agencies with which it attempted to develop coordinative relationships. This reaction was due in part to the project's being a small program operating outside the mainstream of the local protective services system. However, there were two other situations that caused the strained relationship. First, although representatives of the Juvenile Welfare Board did con- sult with many child service agencies in the proposal writing stages, repre- sentatives from these agencies did not feel that the developed proposal incorporated their suggestions or concerns. And, of course, those agencies that were not consulted at all never had strong commitments to the project. These residual feelings prompted some agencies to remain aloof from the pro- ject, if not actually hostile to it. IX.18 A second problem that was somewhat related to the first was that many agencies felt that the pressing need in Pinellas County was for more direct investigative/casework services, because the Protective Services unit was so overwhelmed. They felt that the project was not addressing the primary problem since it focused on prevention. Contacts made with community agencies to foster cooperation and reliance on the Advisory Council (which includes representatives of most child service agencies) for consultative and explanatory purposes were the methods most used by PACER staff to combat the lack of coordination and involvement with the project. Although breaking down resistance has been a tedious process, incurring many setbacks, the project's willingness to continue efforts focused on coordination have paid off. Role of the Advisory Council PACER is in the peculiar position of being housed in the agency that funds, in part, most other child service agencies in the community. Repre- sentatives of these groups, along with representatives of other agencies, make up the project's Advisory Council, which debates, and in some cases exercises a strong influence over project activities. This is a unique situation and one in which there are difficulties with decision making. Certain agencies, as mentioned, maintain bad feelings about not having been involved in writing the project proposal; furthermore, conflicts between agencies on PACER's council and the Juvenile Welfare Board, which have little to do with the project, get transferred to PACER. This situation has resulted in two distinct problems for PACER. On the one hand, the Council has, at times, played merely a "rubber stamp' role in relation to project activities, preferring to maintain an attitude of non-involvement when PACER could have IX.19 used its input. On the other hand, in at least two instances, the Council has argued so strongly for a particular viewpoint that the project staff acquiesced to its wishes, although not fully agreeing with the decision. PACER, because it operates outside the community's established child abuse/neglect system, needs to communicate with representatives of the agen- cies in that system and to obtain their support in order to plan and implement with the greatest chance for success. However, it is equally necessary that the project be able to function independently of its Advisory Council when necessary, in order to adequately carry out its program and responsibilities as planned. Smaller, well-defined councils whose roles and responsibilities are more clearly spelled out and agreed upon might be more effective in the long run for a small agency project. Interdisciplinary Communication One of the persistent problems facing project staff is the lack of under- standing and communication among professionals from different disciplines about each other's expertise, areas of interest and differing perceptions. It appears particularly acute between medical, legal, law enforcement and social work professionals since each works from different reference points. Part of the problem being experienced in developing the Hospital Trauma Team, the Medical Registry, and the Maternity Ward Monitoring components, as well as the initial problems in developing the Legal Intern Program, can be traced to misunderstandings and misconceptions among the staffs of the agencies involved. The project is attempting to deal with this issue by meeting fre- quently with all key professionals in the community and by maintaining an open, flexible attitude when negotiating with various professionals -- while maintaining its standards of high quality services for clients and the IX.20 appropriate roles for various professionals in the child abuse and neglect system, VII. FUTURE PLANS The PACER project as it is presently constituted will not be in opera- tion beyond May of 1977. As previously discussed in "Third Year Summary Activities' many of the project's components have been successfully spun off into other community agencies.* The successful training and educational activities will be continued by Juvenile Welfare Board in their training program. The project director will become the training coordinator with JWB Community Services Team. One other PACER staff member will be assist- ing her in that program. In that position, she looks forward to building on the excellent foundation established by the PACER staff. HRS has also established a new training unit and is interested in assuming responsibility for child abuse education and training in the community. The fate of the Parent Aide program remains uncertain. HRS, the schools, Children's Medical Services, as well as other community agencies, have ex- pressed an interest in the program, but monies are scarce and no one has made a firm commitment. The important coordination role performed by PACER will be assumed by a new community committee also named PACER. In the fall of 1976 PACER's advisory board disbanded and reconstituted themselves as an independent committee that would deal with child abuse and neglect problems. This com- mittee made application to become a standing committee of the Youth Services * Parents Anonymous, legal interns, child management classes, family consultation team, and perhaps NPIS. IX.21 System Advisory Council (YSS). YSS is a newly formed comprehensive community council aimed at addressing all problems of youth in the county. PACER was accepted by YSS and has proceeded to elect a chairman and is working on defining the scope of their activities. In addition to these coordinative possibilities, the project director in her new role as training coordinator with JWB will also be in a position to stimulate community coordination through specific education programming. Research activities will halt when the project ends. The Juvenile Wel- fare Board will have some ongoing research relating to child abuse and neglect as a result of the Research and Evaluation Unit's new management information system that will be monitoring all of their funded projects. One of these projects is HRS, the mandated agency serving abuse and neglect families. The greatest uncertainty for most of the PACER staff is ''where will we be working after May 1977?" The job market is very competitive and there are very few jobs available. This bleak future has created a high degree of stress for the staff and has directly influenced the staff's low morale and decreased productivity in these last few months. VIII. PROJECT GOALS The goals of the PACER project have been: Overall Goal Statement Parent and Child Effective Relations Project (PACER) is a preventive effort with the overall goal of significantly reducing the true incidence of child abuse and neglect among Pinellas County families, and to do this by strengthening the ability of families to properly care for and nurture children. We recognize that this goal may be impacted by the current changes 1x.22 in socio-economic conditions and that project efforts may initially influence reporting rates in a spiraling manner. Achievement of this goal is to be accomplished through pursuing the following objectives: Primary Objectives (1) (2) (3) (4) (5) to provide educational programs and community information aimed at the public in general and at high-risk groups in particular; to provide training programs for professionals and para-professionals for the purpose of increasing their knowledge of child abuse/neglect and their professional responsibility; to enhance case finding and treatment planning for both children and their families through the development of child trauma teams, a law intern program, and a child trauma medical registry; to develop new treatment services for identified abusers/neglectors and potential parents at risk, including Parents Anonymous and Parent Aides; to initiate a procedure for early identification of high-risk fami- lies and a method for follow-up and referral to service resources. Secondary Objectives (6) (7) to provide the impetus for a coordinated community system of com- bined preventive and corrective efforts aimed at minimizing child abuse and neglect in Pinellas County; to improve the overall data base regarding the subject of child abuse to facilitate improved prevention, detection and treatment of the condition at the county, state, and possibly national levels; >x.23 (8) to assess the cost of hospital care of abused children and their families both before and after establishment of child trauma teams. These objectives are much the same as those stated in the original grant proposal. Some goals, however, are now perceived by project staff as either more long-range or less critical than others, and these have become the three "secondary objectives.'" They will receive slightly less emphasis than the primary objectives. Goal 1: To provide educational programs and community information aimed at the public in general and at high risk groups in particular. PACER seems to have successfully achieved the first of their five goals, that of increasing the awareness of the community with special emphasis on both high school and college students. This goal was accomplished by first canvassing all local community and civic groups, informing them that PACER was available to provide education regarding child abuse and neglect. Every request was filled. But further, as a result of these educational efforts, PACER became the recognized resource on child abuse and neglect in Pinellas County by most students, civic and church groups. In a 2% year period of time, PACER delivered over 60 lectures and speeches to as many different civic and community groups. The broadest coverage given to their educational efforts was through nearly 70 different media presenta- tions which included TV, radio, and newspaper coverage. As intended, PACER placed greater emphasis in providing education to high school and college students. The staff provided over 140 presentations in most of the major high schools and colleges in the county. This figure does not include the number of individual conferences held with students, giving assistance with class reports on the subject of child abuse and neglect. IX.24 Goal 2: To provide training programs for professionals and para-profes- sionals for the purpose of increasing their knowledge of child abuse/neglect and of their professional responsibility. PACER has provided extensive education and training to major professional groups, the police, schools, hospitals, and social agencies working with families and children. They have been successful in accomplishing their second goal to the extent that through these educational activities and the three major conferences, they exposed a large number of people to the etio- logy of abuse and neglect and the laws pertaining to reporting cases and had begun to make professionals aware of the existing gaps in current family services. The staff has been largely unsuccessful in impacting upon the physician community, private schools, day care facilities, and HRS. Private physicians and private schools are still not reporting abuse and neglect incidences, and have not reached out to PACER requesting education. In the last year PACER has begun to make some inroads into HRS, but for most of the project's life, HRS was undergoing major reorganization and was not motivated, or not able, to use PACER's assistance. Since HRS is the mandated agency working with abuse and neglect and is viewed by most of the community to be dysfunc- tional, there has been a major setback to improving the child abuse community system because PACER was not able to make inroads sooner. PACER had been active in providing education to day care facilities in the first year, but unfortunately did not give as much emphasis to this group in the second and third years. Despite these shortcomings, there is evidence that PACER's education and three major conferences had an impact on the community. More professionals X.25 than ever are requesting more advanced training. Some of the hospitals have begun to use PACER's materials for in-service training. Some hospitals have started new programs focused on nurturing healthy parent-child relationships. All Children's Hospital's Family Consultation was a direct outcome of the first child abuse conference sponsored by PACER. As noted earlier, HRS has begun to request training and assistance from PACER and as a result of PACER's influence has begun organizing their own training unit to address their internal staff training needs. The public school system, under the leadership of the social work super- visor, has relied upon PACER's guidance and as a result of their training to his staff have consequently completed their new standard school procedure for handling abuse and neglect situations. Finally, the impetus for the new community coordinating committee, also named PACER, was motivated by the dissonance created among community pro- fessionals through PACER's education training activities. Goal 3: To enhance case finding and treatment planning for both child- ren and their families through the development of child trauma teams and a law intern program. In accomplishing their third goal, PACER implemented a legal intern pro- gram in March of 1975 and was instrumental in starting one Family Consultation Team in All Children's Hospital in January of 1976. The second multidisci- plinary team planned for the Morton Plan Hospital in Clearwater never material- ized. In addition to the actual operationalization of these two programs, there have been definite impacts on investigations and treatment planning in HRS. It is difficult to assess from our data any improvements in case- finding. IX.26 As a result of the legal intern program, the State Attorney's Office is now defending HRS workers in dependency cases. As a result of this involvement the State's Attorney has won the disposition in 35 of their 36 cases between March of 1975 and May 1976. Further, court officials feel that in the last year there has been a 100% improvement in the HRS worker's presentations of evidence. Seemingly, greater protection of the parents’ legal rights has been another indirect outcome of the legal intern program; because HRS workers have legal representation judges have been more prone to assign legal counsel to parents. One interesting outcome of this program has been a closer scrutiny by the State's Attorney into the caliber of casework, investigation, assess- ment and protection of children done by HRS workers. This "watch dog role," while tending to make some workers defensive, has also provided for increased accountability by HRS workers. Initially, HRS workers were reluctant to bring their cases to the Family Consultation Team, but as individual workers availed themselves of the team's assistance, their positive feedback has helped resolve many of these problems. As a result of the team, HRS workers are beginning to make more referrals to community resources in their treatment planning. Some report that the team provides a good model for coordination in the community and represents the only major effort in Pinellas County to develop a coor- dinated approach to delivering services. The team is working and has been successfully spun off from PACER into a community-based team working closely with HRS. 1X.27 Goal 4: To develop new treatment services for identified abusers/ neglectors and potential parents at risk, including a Parent Aide program, parent education classes and Parents Msytivds groups. PACER's fourth goal emerged after reviewing the community's existing agencies dealing with abuse and neglect, and seeing a need for more innova- tive preventive services. This fourth goal, that of implementing parent aides, parent education and parents anonymous programs was accomplished during the first year of operation. But each of the services had varying levels of success. By using the following outcome criteria (how many people were served, what the community's reactions were to the service, and whether or not the service has been spun off into the community) we can better judge the project's accomplishment of this goal. The parent aide program has served over 25 different families with 16-18 parent aides active in the program. Eighty percent of the clients have shown some progress since initiation into the program. About 80% of the families are self referrals in a period of crisis. These are parents who are not eligible for services from HRS. Only 20% of the clients are referred by HRS workers. This low referral rate from HRS is indicative of some of the philosophical differences which exist between HRS and the parent aide program regarding treatment intervention and protection of the child. These diffi- culties have retarded PACER's efforts throughout the three years to integrate the parent aide program into HRS' ongoing operation. The parent aide program is highly regarded by most of the community pro- fessionals interviewed. Some of the HRS workers who have used the service report that the program has been very valuabie in assisting with their own nse = rmm———— IX.28 clients. Despite these many positive recommendations, neither HRS or other agencies have made a firm commitment to adopting the program. There are several interested parties, but no one appears to have the small investment necessary to pick up the program. The child management classes have been extremely successful, appealing to people of all ages. This effort has been co-sponsored with the Adult Home Economic Education Department in Pinellas County. During the three-year per- iod, the classes have grown from one class a week with one instructor, to four classes a week with three instructors. The classes are offered in var- ious parts of the county and have reached approximately 300 people. The Adult Home Economic Education Department has been very pleased with the success of these classes and the enthusiastic praise received from all enrollees. They will continue to sponsor the classes after the PACER project has ended. Parents Anonymous groups were established early in the project's fund- ing period, but the service has had a turbulent history. The project has had trouble recruiting and sustaining project sponsors and maintaining active par- ticipation by group members. In the last two years, two of the project staff have had to assume the leadership of the groups. Presently attendance in one group has stabilized, but the second group is inactive. Over the three years about 80 people have attended the PA groups. About 40% of the pecple attended one meeting. About 10% have attended between 10-20 meetings. The average length of attendance appears to be four meetings. While HRS workers feel that PA is a valuable service and tend to refer their clients to the groups, PACER reports that they receive very few referrals from HRS. Other community profes- sionals praise the concept of maintaining the groups. Perhaps due to this com- munity support, the Marriage § Family Counseling Program in JWB has agreed IX.29 to assume sponsorship of the group after project termination, so the project has been successful in spinning off the program into the community. Goal 5: To initiate a procedure for early identification of high risk families and a method for follow-up and referral to service resources. PACER did not initiate a procedure for early identification of high risk families or a method for follow-up and referral to service resources. The project's attempts to establish a maternity ward monitoring program was squelched by the local medical community and hospital administrators because of their concerns about legal complications and confidentiality issues. However, the project was able to demonstrate on a limited basis another pre- ventive program called New Parent Information Service (NPIS). This service, community-based, relied on trained volunteers to deliver a packet of informa- tion about community resources to new parents and to administer a question- naire that could identify those families who needed community services. A sample of three months was chosen in which families were to be interviewed. Of the 405 families listed in the local newspapers for those months, 52 fami- lies were interviewed by approximately 18 trained volunteers. The staff had anticipated using 24-25 volunteers, but had difficulty getting inter- viewers to complete their assignments before dropping out of the program. Also, many follow-up interviews were not completed due to this high drop-out rate among the volunteers. While the program was well received by both families and community agencies, PACER has not been able to spin off the program into existing social service programs. The staff has written a number of proposals to foundations and government agencies, but to date these efforts have been unsuccessful. 1X.30 The findings of this demonstration effort are presently being written up by the project staff and were not available for this report. Goal 6: To provide the impetus for a coordinated community system of combined preventive and corrective efforts aimed at minimizing child abuse and neglect in Pinellas County. Not until the third year of project operation was this goal addressed. Because of the massive education and training efforts and the work completed through many of the other components, such as the Family Consultation Team, an environment was established in which coordination issues could be addressed. During this last year, PACER sponsored a major community workshop that brought together professionals from the local agencies to work on coordination prob- lems. This conference was well received and professionals felt their aware- ness of the problem had been heightened. Prior to this conference, PACER had reorganized its advisory board into a community committee with broader agency participation. This committee is also called PACER. This group will continue working on Pinellas County's coordination and program needs in the area of abuse and neglect after the project ends. IX.31 IX. PROJECT MANAGEMENT AND WORKER SATISFACTION A parent aide program and a multidisciplinary team were begun, pro- fessionals and community received quality training and education, and a coordinating committee is underway in St. Petersburg to cope with the child abuse system's deficiencies. Sadly, many of the PACER staff could not appreciate or enjoy those accomplishments and the positive response the community has made to their efforts. Organizational Structure St. Petersburg is a very small project with six full-time staff and an average monthly budget of $9704. Since PACER is primarily a coordi- nation and education/training project, the program only serves a client population of 18 families who are enrolled in the parent aide program. If one includes the number of volunteers who have worked with the project over the last three years, the total number of staff increases to 55. Because over seven different disciplines are actively associated with PACER's variety of programs, the project's organizational structure is highly complex. The project staff comply with the procedures and guide- lines established by the host agency, the Juvenile Welfare Board (JWB), but these appear to be enforced in an informal and somewhat capricious manner. There do not appear to be clear guidelines specifying the rela- tionship between PACER and JWB. Most of the project staff report that the decision making both in reference to their jobs and the organization is highly centralized. There is no consensus regarding the amount of personal autonomy people exercise in their jobs. A —————— IX.32 Management The project's relationship to the host agency seems to have produced a number of problems for most of PACER's staff in the areas of job morale, job motivation and task involvement. This mistrusting and suspicious relationship was especially visible during the last eight months of the project. Much project staff energy seemed to be invested in these dif- ferences. Some of this conflict can be explained by factors surrounding the initiation of PACER. The project proposal had been written by some members of JWB's staff, but the staff hired to do the job were all new- comers to JWB, and many of them were new to the St. Petersburg area. Additionally, during the first year the JWB director had been focusing his energy on other JWB programs and did not give the project an adequate introduction to the agency or share with his staff PACER's role and soe portance to the overall program. To many workers in JWB the 'PACER crowd" symbolized an elite group of professionals who were paid more and given too much latitude. These factors, coupled with PACER staff's more aggres- sive attitude regarding their role in agency decision making and their outspokenness on a number of issues, combined to create tension and fric- tion between the two staffs. In the second year many of these differences were dealt with by the JWB director and PACER team through joint staff meetings in which PACER's role and purpose were clarified. There followed some efforts to develop a sense of mutuality by both PACER and JWB. However, the project staff has continued to operate with a low grade hos- tility and resentment toward JWB and the agency goals and policies. Many of these resentments were intensified with the project's termination. The staff felt especially rejected when JWB would not make a commitment IX.33 to adopt the PACER programs or most of the staff. Termination became a very demoralizing process for most PACER members. While the staff unanimously feels that PACER itself is very effi- cient and well managed, there seems to be no consensus on the written questionnaire responses regarding the quality of leadership, communica- tion, peer cohesion, or job design issues. People agree that they have learned a lot, that they have used a team approach in assisting each other with work responsibilities, but at the same time workers do not rate the individual AATRGeIE process very high. The workers' ambivalence about the project management and the extremely high percentage of burnout in the program (50% of the members were highly burned out, 33% were moder- ately burned out) can be explained at least in wath by the lack of support felt by all staff and the personal characteristics of this staff. The PACER staff never felt validated. All workers report that they have never been told by anyone in JWB that they had done a good job. Within PACER itself, workers felt that they did not receive sufficient positive feed- back, praise, or words of appreciation. Some reported that following a success ful presentation or conference, workers did not offer positive feedback to each other, but rather talked about the overall reaction of the audience. The conversation was ''gossipy' rather than personally rein- forcing. On the surface, while management processes seem excellent, because there was this negative affect that surrounded project activities and com- munication, and because of the lack of personal feedback, staff remained ambivalent about each other and the program. Personnel characteristics also explain the lack of consensus among the workers regarding management and the high burnout rate in the project. IX. 34 Many of the staff have experienced or are experiencing personal disappoint- ments, losses, or problems which tend to overlap with the job. Because of the small size and the extensive job sharing, much time was spent on the job providing support to each other on these personal issues. While this type of sharing can bind staff together, it can also immobilize and interfere with work relationships and job responsibilities. This seems to be the case with this project. The staff never seemed to confront this dilemma directly or determine how to sort out the boundaries between the personal investment in each other's lives and the job responsibilities and work relationships. X. ANALYSIS OF CLIENT DATA Client Characteristics As can be seen on Table 1, cases were referred to the project primarily from three sources: social agencies, self-referral, and the protective services agency. About one-quarter of the cases were potential abuse and neglect, slightly over one-quarter were emotional maltreatment, and slightly more than one-quarter were physical abuse. In a majority of the cases serious abuse or neglect had occurred, but in one-third of these cases, no court hearings were held, and only one-fifth had any court intervention. In a majority of the cases, both the fathers and mothers were abusers of the children; only in one-quarter of the cases was the mother the only known abuser. Most of the cases had had no previous record or evidence of abuse or neglect. There was an average of 3.4 children per household; over one-third of the families had four or more children in the family. In two-thirds X.35 of the cases there were preschoolers, accounting for the nearly 15 fami- lies that reported heavy, continuous child care as a serious family prob- lem. Only a small number of families had only one parent present in the home. The average mother was 32 years of age and the average age of fathers was 33 years. Over one-third of the families were teenage parents. About four-fifths of the parents reported being abused as a child. There were no minority families served in this project's caseload. In nearly one-quarter of the cases there were problems of unemployment. The average yearly salary was $6600, but most of the families lived on $5501 or less. None of the families were on public assistance. The major presenting problems of the St. Petersburg cases were: marital problems (13), job related (6), alcoholism (5), physical health (8), mental health (8), financial problems (13), heavy continuous child care (15), and finally, social isolation (12). Of the 57 families who were referred to PACER, but rejected for ser- vices, 12 did not comply with project guidelines, eight were uncongizmed reports, five could not be located, two were cases already opened with another agency, and in two cases, the families refused services. Twenty- eight of these 57 clients rejected for services were referred to more ‘appropriate agencies. IX.36 Table 1 Client Characteristics Source of Referral . 1/2 . 1/2 1/3 Other social agency . . Protective services . 2 @ g Self-referral . . . . . . . . . Type of Maltreatment Potential abuse/neglect only. Emotional maltreatment only . Sexual abuse. +t EE BE b Physical abuse. . . . . . . . . Physical neglect. : Physical abuse and neglect. . NN UTD UT WW Severity of Assault Not serious . . . . . . . . . . . 11 Serious . . . . Lo... 4 ee. 7 Responsibility for Maltreatment Mother. . . . . . . . . +. +. . 5 Father. . . . « + « ¢ + « + + « « 2 Both: = + « vv v vs» ww u 0 6 ot » Xo OLNEY ov + +o ov o 4 + % 8 » 9 oo & & == Legal Action Taken None. . . . Eee Ew EE Court hearings. ’ : Reported to mandated agency ¢ ALN Previous Record/Evidence of Maltreatment None. . . . « vw x « 12 Previous record/evidence. Fu 6 Demographic Information Average number of children in family. . . . . . 3 Families with preschoolers. . Families with one adult . Families with no high school degree . +: « + © « + 5 0 » ws Families with no minorities . . Families with no one employed . Average family income . . . Average age of mother . . . . Average age of father . Problems in Houshold Leading to Treatment Marital o « + 2 0 2 2 » =» » =» Job related . . « « . « « 4 Alcoholism. +. "« + 4 5 « + + Drugs . . IIE Physical health wma Mental health . . . . . . New baby. . . . . . . . . .. Argument /fight. . . . . . . . Financial problems. : Social isolation. . . . . . . Overcrowded housing . . . . . Heavy, continuous child (N=18) 12 10 18 5 . $6600 32 yrs. 33 yrs. 00 = 00 00M TON WN — — TTT Nn IX.37 XI. COMMUNITY IMPACT Summary Protective Services in Florida is relatively new. It was approximately six years ago that the state legislature authorized its existence. Prior to that, the Juvenile Welfare Board had established a protective service program in Pinellas County which functioned very well. When the state system began, many of the skilled, experienced social workers in Pinellas County were transferred throughout the state to assist in implementing the new sys- tem. Many of the problems evidenced in the current Florida system and Pinellas County in particular are also due to recent system disruptions and innovations. The Central Registry and the mandated reporting requirements of this state system placed a great strain on an agency learning to fulfill its task. To further aggravate the system, in 1975 the state legislaties. in an effort to improve the inadequacies perceived in the state bureaucracy, mandated a state-wide reorganization of all social and health services into one umbrella agency called Health and Rehabilitative Services (HRS). The intent of this reorganization was to minimize existing fragmentation of ser- vice delivery, a problem in most state departments of social service, and to begin treating the family's problems as a unit. As a result, all child services, abuse, neglect and dependency, were channeled through a central intake, and assigned to case managers who would be responsible for serving the whole family's needs. Workers who had been child abuse specialists in protective service were now generalists working with dependency, abuse, and the myriad of multi-problems families presented. Their past experience had not prepared them for this demanding, diverse set of family complaints. Staff were transferred, promoted, and/or fired. These changes have gone on for two years IX.38 and staff morale is very low. Because this reorganization happened to occur at a time when Florida was having its worst year financially, and the country was suffering serious financial limitations, it was implemented with less manpower resources than had been originally planned and without the time for training and orientation necessary to smooth out many rough spots. Need- less to say, service delivery was chaotic. Into this turbulent environment enters the newly funded project, PACER, whose intention is to improve the coordination and functioning of the com- munity system and to start preventive programs for abuse/neglect. The most natural agency to share in this endeavor and who would most benefit from PACER's expertise and promise of training and education was HRS. This was not to be the case. HRS could not or did not invite PACER to provide training and assistance to their workers. In fact, throughout most of PACER's exis- tence, HRS was to be the weak link in developing a community system. Because the Pinellas County system had so many needs, the contributions of the PACER project have been to provide an educational training milieu which would create a climate for the growth and development of a community child abuse system. In addition to setting a climate of awareness and infor- mation, they have directly and often indirectly, spearheaded the establish- ment of preventive programs, realizing that a system unable to handle the total number of reports must give high risk people programs that can prevent crisis abuse/neglect situations. Now the community has two Parents Anonymous groups, parent education classes and parent aides who can give clients the individualized attention they require. Also, because of PACER's legal intern program, the State Attorney's office is now defending HRS workers with court cases. A multidisciplinary team, housed in All Children's Hospital, has 1X.39 provided assistance to HRS workers in treatment planning for their clients. Due to these project activities, PACER has made tentative inroads into HRS, and has been invited to assist them in training their workers. HRS has become much more active and cooperative on the Family Consultation Team. As a result of the legal intern program, they have improved their court case presentations. Further, PACER is now negotiating with HRS to assume ongoing supervision of the parent aide program when the project terminates. Concommitant to these activities, PACER pursued the development of a coordinated approach among social service agencies in the prevention and treatment of abuse and neglect. In the third year, they have successfully implemented PACER, a widely representative community committee, to fulfill these objectives. Hopefully, this committee will continue working for system “changes after the project has ended. All of these new directions are indications of system progress even though the overall effectiveness of the community's response to abuse prob- lems to date is perceived by most community agencies to be deficient. PACER's contribution has been creating an environment for community participation in improving large system problems on a local level by increasing the aware- ness and education of professionals in the schools, hospitals, police and HRS. Community System Operations In 1971, a new Florida statute mandated the Social Economic Services (SES) to become the centralized agency for conducting investigations and carrying out case management functions for all child abuse and neglect cases. All community agencies and citizens are required by this law to report any known incident of abuse or neglect. These reports are to be made to the IX.40 state-wide emergency hotline or the local district office of SES. Most agencies in Pinellas County, including the police, hospitals and schools, have developed procedures for reporting directly to the local district office of SES (only about 5% of the reports to Pinellas County SES are received from the Central Registry), but representatives of these agencies feel that the current reporting system has a number of problems created by the inadequacies of the existing structure to handle the large number of reports and to provide adequate supervision to families investi- gated and substantiated as abuse or neglect clients. Bottlenecks were created in the system when SES was given sole respon- sibility for investigating all cases of abuse and neglect without the con- comitant provision for additional required resources or the development of a structure to work with the increased demand upon the agency. Since 1971 there has been a vastly increased number of referrals to SES from sources who had previously been providing investigation and inter- vention with clients themselves. Prior to the passage of the new law, the police had received reports and completed investigations of cases before referring either to SES or the State Attorney's office. Now, according to the law, they are required to refer all cases directly to SES and investigate only those few cases of sexual abuse or criminal physical abuse. Due to the hospitals’ increased awareness to the law's mandate and educational efforts increasing staffs' knowledge of abuse and neglect indicators, hospitals in the area have developed a more systematic procedure for reporting cases immediately to SES and currently rely solely on SES to complete the investi- gative function. Relying on SES relieves them of fear of suit or the poten- tial disruption of the medical plan of treatment for the child by the family. IX.41 While hospital staff seem to be good about reporting public patients and children seen in the emergency room, statistics indicate that physicians are still not reporting their private patients. The schools usually report cases of abuse/neglect to SES. They have recently instituted new reporting procedures in which teachers report to their principal all suspected cases of abuse and neglect. The principal, in turn, reports to the school's social worker. The school social worker may or may not make a home visit before contacting SES. The social workers’ in the schools prefer to delegate all investigation to SES because these intrusions into the families often disrupt their working relationships with families and interfere with the child's education. Many of the children reported to SES from the schools are children with attendance problems who are considered to be neglected because they are being deprived of an educa- tion. Thus, the centralization of the reporting and investigation functions, encouraging the police, hospitals, and schools to refer clients to SES for investigation, has contributed to bottlenecks in SES. The Central Registry also contributes to the bottlenecks in the system. Because the Registry is not computerized, the staff must hand tabulate all calls and record keeping, and cannot speedily code and relay reports to local districts. Currently, there is a 3-4 month delay between receipt of a report and notification of the local SES office. After a 3-4 month delay, the SES staff cannot adequately investigaté these reports or give meaningful assis- tance, since in many cases the family's situation has changed considerably in the interval. Recently some of these problems with Central Registry have improved. IX.42 In 1975 another legislative bill was passed requiring the complete re- organization of HRS. SES as one major department within HRS was drastically altered. The intake function for all abuse, neglect and dependency cases is now carried out by a centralized intake unit within SES. Workers skilled in working with dependency clients and those skilled in investigating abuse and neglect are now working with both kinds of clients interchangeably. Little or no orientation and training of staff was provided prior to their assumption of these new responsibilities. Furthermore, the reorganization planning committee had estimated that this new system would require nearly three times the manpower that was actually assigned. For these reasons, staff of SES are experiencing overwhelming morale problems which may also be interfering with the agency's functioning. Because of the backlog of cases created during the reorganization, the central intake unit was referring cases to supervision units before a thorough investigation and assessment had been made. Supervision units felt overworked and resented this imposition created by centralized intake. Further, because youth dependency workers were now handling intake they often did not recog- nize abuse or neglect situations. For a long time the supervision units felt they were receiving a disproportionate number of abuse to dependency clients. Now the central intake system seems to be working better. Workers understand their jobs better and the intake structure is finally completed. But some of the improvement may be partly due to the recent agreement between the juvenile division of the police department and HRS. This agreement stipu- lates that juvenile detectives will coinvestigate abuse reports with HRS workers, collecting criminal evidence when appropriate and as preparation for possible court intervention. This new partnership assures the family IX.43 that their legal rights are protected and also that evidence necessary in court is collected. This agreement is a positive step because the youth officers are very well trained and highly informed professionals who have a good understanding of abuse and neglect and their role in protecting children. Not surprisingly, there are also a number of gaps in the treatment planning and services provided to families under HRS supervision. Clients usually only receive counseling, case management, or removal of child, and are in treatment for anywhere from six months to several years. Tentative findings indicate that a low percentage of clients actually get referred to community agencies for treatment service. Most clients are referred for services within HRS, e.g., welfare assistance, food stamps, foster care, Title XX benefits. There is strong indication that abuse/neglect clients are not receiving necessary medical services. The social worker from the Children's Medical Services has begun a campaign to inform both HRS and school social workers about the medical services available through their agency. Consequently, there has been improvement among workers in pro- viding medical services to their clients. The large caseloads, often above 30 cases per worker, have led to a situation where those clients in immediate crisis receive the workers' atten- tion and other clients are left to fend for themselves. Another problem in the community which contributes to HRS's problems in providing services to clients is the territorial lines drawn between com- munity social agencies. Agencies appear to be isolated from each other, each providing its own services to its own clients and very rarely coordinating services for mutual clients. Until recently, there had been few efforts IX.44 to build a network of services that could address the diverse needs of abuse and neglect clients. The SES staff is overwhelmed and has little time or energy to invest in building such a treatment network, and in the past no other agency in the community has wanted to tackle such a challenge. PACER has begun to fill this gap through a variety of education and coordination efforts. It is quite likely, however, that effects of PACER's efforts will not be felt in the system for several years. Caseload Size and Case Outcomes There is little reliable data for the year 1973-1976 available from the schools, hospitals, courts and HRS in Pinellas County to describe changes from year to year. The data available consists of summary figures for the number of abuse/neglect reports to HRS and data from the PACER's review of a sample of HRS case records for the years 1971 to 1974. While these years do not cover the activity of the project, one does gain some insight into the caseload characteristics and begin to understand some of the problems in this community system. HRS records indicate that the number of reports of abuse and neglect tended to increase from 1871 in 1973 to 2246 in 1974, but then decreased in the next two years (1975-1976) from 2017 to 1978 reports. The increase in reporting in 1974 could be due to the extensive education sponsored by the state when introducing the Central Registry. There are several possible explanations for the decreased numbers of reports in 1975 and 1976. One is that bottlenecks occurred in the central registry that delayed or misplaced referrals to the local districts. A second explanation is that the organi- zational changes within HRS occurring in 1275 and 1976 played some role. Workers in HRS's supervision units report that abuse and neglect reports IX.45 decreased when dependency workers were combined with protective service workers in the central intake. Apparently dependency workers were less likely to recognize abuse and neglect complaints as valid. After the intake personnel received more training and feedback from protective service workers, the number of abuse and neglect cases increased. Also, community professionals indicated in interviews that they were reluctant to report abuse/neglect situations to HRS because of the confusion within the organization. They feared that by reporting a child to HRS, and not having any assurance that the family would receive an adequate assessment or services, they were only placing the child in further danger with its parents. It is unlikely that the decrease in the last few years is due to fewer children in Pinellas County, since recent statistics indicate that there are over 90,000 school age child- ren in Pinellas County. This represents an increase in school age children in the last few years. The second source of available data that describes some of the character- istics of the abuse/neglect caseloads in HRS is a sample review of 406 case records, nearly 11% of the closed case records for 1971-1974. This sample consists of cases in which workers made at least one field visit, but does not include cases that were closed through office visits, letters or phone conversations. In this sample, 32% of abuse/neglect children reported were under three years of age, 19% were between the ages of four and seven, 16% were between the ages of eight and 11, and 22% were between 12 and 14. The primary types of abuse were beatings (47%) and bruises (25%). Burns were the third largest type of abuse (11%). The largest situations of neglect reported were dis- organized households (39%) and unattended children (26%). Only seven percent IX.46 of the neglect reports were cases of malnutrition. Twenty-five percent of the abuse/neglect reports were from neighbors, 19% from police, nine percent from relatives, seven percent from schools, four percent from hospitals, three percent were self-referrals, and only two percent from physicians. The reporting patterns in this sample indicate that neighbors and police are the primary sources of reports. Schools and hos- pitals seem to be a minor source of reports, and physicians are the least likely professionals to report child abuse and neglect cases to HRS. Unfor- tunately, data on the sources of reports is not available for the last two years to demonstrate whether PACER's extensive educational program has changed the reporting patterns of the schools, hospitals, and physicians. Of the 406 cases reviewed in this sample, 55% of the reports were con- sidered valid, 39% were invalid, and six percent were of unknown status. In 19% of the cases considered valid, reabuse occurred. Eighty-seven percent of the reabuse cases were reinvestigated. Of the 30 children placed in foster homes, 20% were returned home in less than three months, 43% remained in foster homes for 3-12 months, and seven percent were placed for over a year. Of the 104 cases in which final disposition hearings were held, 33% were returned home, 27% were permanently removed from their homes, 15% were placed under a court order, 11% were placed under temporary custody, and less than one percent were placed for adoption. Legislation and Community Resources Legislation. The Florida State legislation has had a major impact on the current functioning of the child abuse system in the state. In 1972, after establishing the statewide "hotline," and widespread publicity, the I1X.47 number of reports increased to 19,120 and for the combined first three years there were 75,314 reports of abuse and neglect in the state. In comparison with the rest of the country, these rates are extremely high. For example, in looking at the 21 states for which data is available for 1973, Florida, with 26,500 reports, is twice as high as any other state except Michigan and four times as high as all but four other states. Pinellas County has experienced the same high reporting rates as the remainder of the state. In 1973, there were 3249 reports of alleged abuse or neglect received in Pinellas County. In 1975 there was another major legislative change which had direct impact on the functioning of HRS and the child abuse system in Pinellas County. In response to widespread criticism of HRS regarding mismanagement and in- efficiencies, the state legislators ordered a complete reorganization of that department, including the SES. In addition to the high number of reports which had completely overloaded the system, the agency was now further disabled by major organizational changes. Programs were shifted, categories of services were discontinued or integrated into other areas of service. As a result of these changes, a central intake was established to handle dependency clients, juvenile offenders, and abuse or neglect clients. The changes are still being implemented and the full impacts of this restructuring has not yet been felt. Workers are now in new surround- ings, often in other parts of the state, with new client loads, and with fewer resources than promised to do the job. The hospitals, police, schools and social service providers report that they too have been disrupted by these massive changes within SES. They do not know to whom to report, who is responsible for what functions, nor if IX.48 they can assume that clients referred to SES will ever receive services. Problems which already existed in the child abuse system have only been made more clear by this present turmoil. If only one agency is mandated to serve abuse and neglect clients, and that agency is completely disoriented, one might assume that services to clients will also be disrupted. In 1974, the Juvenile Welfare Board held a legislative workshop to which they invited the Pinellas County delegation to the state legislature. The PACER project director presented in the workshop a discussion of the changes needed in the Florida Child Abuse Law to bring it into compliance with the Mondale requirements. After the workshop, PACER's director main- tained correspondence with a legislator. Together they wrote a proposed new law. In April of 1975, the new bill was introduced into the state legis- lature and was passed in June of 1975. There are still some weak areas in the law, but the PACER staff plans to wait another year before suggesting additional revisions. Community Resources. Over the last two years only the demonstration project's resources have changed the allocation of manpower and financial resources to abuse/neglect problems in the county. No significant changes have been made by the major institutions, hospitals, schools and police. In addition to adding substantially to the manpower available in Pinellas County to deal with abuse and neglect problems, the demonstration project has made efforts to add several innovative programs that could in- crease the system's capabilities to provide treatment and prevention ser- vices. One new service introduced and supervised by PACER was a parent aide program. Eighteen parent aides were made available to SES workers to assist them in providing intensive services to their clients, and have been working IX.49 with individual families providing transportation, lay therapy, assistance in receiving day care, treatment. and medical care. The parent aides, unlike the overworked SES workers, are able to provide clients with the intensive, long-term relationship needed to work through personal problems. While this service is appreciated and used by some HRS workers, others have not availed themselves of this opportunity, and still others for a variety of reasons have discontinued the parent aide's involvement with their clients. As part of their "preventive" focus, the parent aides have recently begun to work with self-referrals who call PACER for assistance. These clients tend to be high risk or potential abuse cases who are ineli- gible to receive services from HRS. Another preventive service introduced by PACER is a series of child management classes established in the public school's Adult Education Pro- gram. In a year's time the classes have grown and are now available four nights a week in various parts of the county. Close to 300 people have attended over the year. PACER also hired two legal interns to work with the State Attorney in researching and documenting cases which are presented in court. The HRS ‘workers, never adequately trained to prepare cases for court, had made inefficient use of court time and many cases had been removed from the court because of improper documentation. The legal interns work with the state attorney in providing training to HRS workers in preparing for court pre- sentations. Individuals who work in the court report that HRS workers now seem better prepared, clients' rights are now better protected, and court cases flow more efficiently through the system. IX.50 A New Parents' Information System (NPIS) was implemented by PACER on a demonstration basis this year. New parents were interviewed in their homes and presented with packets of information regarding community services avail- able for new parents, families and children. The interviewer was trained to identify high risk families and to direct those families to appropriate social services. Of the total number of families interviewed (162), 43 (27%) were considered to be in need of services. Out of this total number of families interviewed, those families which were considered to be at extremely high risk was 10.8%. PACER has also sponsored two Parents Anonymous groups in the county. Attendance has been low and progress is discouragingly slow, but the service does provide a meeting place for high risk parents who are reluctant to use professional assistance. In the last year, one group became very active and positive change in the lives of several families occurred. HRS workers tend to refer clients to this service. A medical multidisciplinary team was viewed by PACER as a critical tool for increasing the skills of HRS workers in diagnosis and treatment planning, improving the current level of case management, and as a method for moti- vating the various community professionals to become participants in pro- viding treatment for abused and neglected clients. In January 1976 the Family Consultation Team, housed in All Children's Hospital, began reviewing cases referred to the team by HRS staff. The team became a community-wide effort after a presentation by Dr. Kempe's Denver team at the child abuse conference sponsored by PACER in the spring of 1975. After the conference 4 prominent local physician, with assistance from PACER, assumed responsibility for implementing this team. Many months of effort by this physician and PACER 1X.51 were required before the team became a reality and began meeting regularly. HRS workers report that through the Family Consultation Team they have be- come more aware of community resources available for their clients and have also been helped to improve their treatment planning skills. However, most workers have not brought their cases to the team, and more work is needed to encourage workers to avail themselves of the team's expertise and support. Community System Coordination The only formal coordination agreements between HRS and other community agencies are those mandated by law. All community agencies, including the courts, police, hospitals and schools, are required to refer all suspected abuse/neglect clients and reports directly to HRS. HRS, in turn, is only required to send copies of its reports to the court when it is seeking spe- cific court dispositions. Recently HRS signed an agreement with the juvenile division of the police department to assist them in investigating abuse reports. This agreement gives HRS intake workers added resources and cover- | age for 24-hour immediate response to abuse reports. There are indications that this agreement has improved investigation and assessment functions in HRS. Informal agreements exist between the schools and the PACER project to provide education and training to school social workers and teachers. HRS also has informal agreements with PACER regarding the use of parent aides, parent education classes, Parents Anonymous groups, and education ‘and training resources. PACER in turn occasionally requests specific assis- tance from HRS staff when offering educational training sessions held in ‘the community. All other coordinative efforts between agencies are highly contingent upon individual workers' personal working relationships with | IX.52 staff in other agencies, and usually occurs in response to treatment plan- ning for individualized cases. Since the advent of the Family Consultation Team there has been addi- tional opportunity to bring together many different disciplines to assist HRS staff in diagnosis and treatment planning for their clients. In turn, as the team reviews HRS cases it suggests treatment plans requiring coordi- nation of community resources. One potential consequence of the team's" efforts might be the development of formalized ties between community agen- cies and SES. Education and Public Awareness The PACER project has taken on the major responsibility for providing education and training in Pinellas County. PACER has concentrated on pro- viding education to the medical society, schools, law enforcement agencies, SES, social service providers, and civic groups. The following table lists the number of educational/training sessions PACER has delivered in the last three years to both community and professional groups. The schools, including day care providers, college and high school students and school social workers and teachers, have received the greatest amount of education from PACER. HRS received the lowest number of educa- tional training sessions. Recently, as a result of the reorganization, HRS has felt a strong need for more extensive training and is talking with PACER about developing a series of training sessions for the intake and supervision workers. IX.53 Table 2 PACER's Educational Activities, December 1974 - January 1977! 11/74- 7/75- 1/76- 6/75 1/76 1/77 “Total General Community Student classes (high school §& college) 38 8 95 141 General community groups 15 7 34 56 Media (TV, radio, newspaper) 29 24 14 67 Professionals School staff 7 10 16 33 Police | 6 4 11 HRS staff -- -- 5 5 Hospital 11 12 1 24 Nurses 1 7 1 9 Professional agencies 24 44 17 85° Day care 25 -- 5 . 30 Workshops & conferences (present & sponsor) g 43 6 15 hese numbers are estimates and tend to under-report because of data collection errors. 21h addition, PACER presented 14 training sessions with various community agencies. Each training was two (%-day each) sessions. Stach year PACER sponsored one major conference with attendance ranging between 200-300 at each conference. IX.54 There has been extensive media coverage in Pinellas County, including TV talk shows, radio talk programs, and newspaper articles. The effective- ness of this media coverage is indicated by the results of a recent poll taken in a local shopping center. Nearly 90 percent reported child abuse was a major problem in Pinellas County. Over 90 percent said they would report any suspected case to the Central Registry or SES. These data pro- vide one indication that the general community is aware of the child abuse problem and is very knowledgeable about their reporting responsibilities and the requirements of the state law. In addition to these educational efforts, PACER has organized and implemented three major conferences. The first conference, held in 1975, included Dr. Kempe's team from Denver. The attendance was nearly 250 people. as a result of that conference, a leading pediatrician became committed to implementing the child trauma team. The second conference, in the spring of 1976, focused on developing coordination between agencies in the community. Nearly 550 people attended and 92% of those replying to the conference eval- uation survey reported that they were extremely pleased with the conference's effectiveness. In January of 1977 the final conference was held, focusing on coordination problems in the county. Nearly 300 professionals were in attendance. The hospitals report that they are now beginning to provide information about abuse and neglect in their own service training programs. Other com- munity agencies are also beginning to use PACER’s visual aids and materials in their in-service training programs. The police have begun to participate in many of the educational programs on abuse and neglect presented by PACER and are helping to inform professionals about the police officers' role and contribution in abuse/neglect. IX.55 XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COST The allocation of the project's resources, time and dollars are good descriptors of the PACER program activities. Table 3 depicts the average allocation of both time and dollars for the year 1976. As is evident in the table, a total number of 8.1 person-years or over 16,848 hours were used by the project. The corresponding budget for the year, not including the dollar value of donated resources. was $122,472. Since the project's primary purpose is to provide community and professional education as well as community coordination, most of the project's resources are allocated to non-direct services. Nine percent of the budget was spent on prevention, 15% on community and professional education, and 4% on community coordina- tion. About 28% of the budget was allocated to general overhead functions, staff development and planning, program planning and development, and gen- eral management. Parents Anonymous and lay therapy are the only two treatment services provided by the project. About one-third of the project time and 17% of the budget is allocated to these direct service activities. One project staff member spends most of her time supervising the lay therapy program. This accounts for nearly 23% of the project time allocated to services. About 3% of a staff member's time is devoted to the multidisciplinary re- view team, and another 3% is spent on Parents Anonymous. About 378 lay therapy hours, or $1719, was donated as time and resources to the project's lay therapy program. This donated time explains the project's relatively minor budget allocation for direct service in relationship to the amount of time spent in delivering the services. ———— ee et A———. +. $2 A—————. a IX.56 Costs for the various components tended to decrease in the last cost accounting period, with two exceptions. The allocations for professional education and community coordination increased in the last year. This in- crease reflects the project's intense effort in their last year to provide professional education to everyone in the community. The increase in time and money allocated to community coordination indicates the project's in- creased efforts to establish the community-wide coordinating board that would replace PACER's coordination function in the community. There was little noticeable change in project budget and time alloca- tion for direct services, but in the last year less time was spent in pro- viding direct services as lay therapists dropped out of the program and were not replaced. Also in preparation for project termination, the pro- ject staff spent less of their time supervising direct services and began to devote more time to hunting for new homes for the services they had developed. Table 3: Project Resource Allocation and Service Costs RSSOUTCS Aliocasion to Volume and Unit Costs of Services Activities Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost | to Community Prevention 9% 10% Community Education 5 7 Professional Education 10 12 Coordination 4 5 Legislation/Policy Staff Development/Training | Program Planning/Development General Management . 14 31 Project Research 2 BPA Evaluation 4 4 Case Management/Review -- -- 18 average caseload $ 2.06 $ 2.06 Court Case Activities -- 3 -- -- -- Multidisciplinary Team Review 3 : 4 reviews 100.17 223.90 Parent Aide/Lay Therapy 23 5 135 contacts 3,71 13.86 Parents Anonymous 3. 4 98 person-sessions 10.89 10.89 Parent Education Classes -- i 15 person-sessions 4.84 20.28 Crisis Intervention After Intake l -- — -- Babysitting/Child Care 2 -- -15-child-hours 4.58 Transportation/Waiting -= -- 6 rides 9.29 Total Annual Person Years/Budget 8.1 $122,472 Average Monthly Caseload = 18 L5°X1 X.1 PANEL FOR FAMILY LIVING: TACOMA, WASHINGTON I. COMMUNITY SETTING Pierce County, Washington, an industrial center which has, in recent years, experienced economic decline, is located at the south end of Puget Sound about 40 miles from Seattle. The county, which includes Tacoma, once an important lumber port and the first manufacturing city in the region, now survives through its commercial links with Seattle, ongoing smelting activi- ties, and heavy federal funding. Nearly 427,000 people live in the county. Despite the relatively high unemployment rate, only eight percent of the population is below poverty level. Seventy-two percent of the families have moderate-to-middle incomes; 20 percent make $15,000 or more a year. The county's age distribution is lower than the national average. Over eight percent of the population is under five years of age and 25% of the popula- tion is Sekreen 5 and 17 years of age. These statistics reflect a signi- ficant population growth in recent decades. II. - HISTORY OF PROJECT PRIOR TO FEDERAL FUNDING In the summer of 1970 an attorney from Pierce County Legal Assistance Foundation (PCLAF) and a local Juvenile Court worker recognized a general need for services and a lack of present resources in the county for ongoing treatment in the area of abuse and neglect. At this same time, a survey by OEO outreach workers in the south end of Tacoma found many families lacking a knowledge or understanding of how to cope with the "system" when involved in abuse/neglect problems. Metropolitan Development Council (MDC) incorporated X.2 this service need in program guidelines for their funding year of 1971-72. With that guideline's activation and the two original assayers of need, an ad hoc board of six was formed in March of 1971 which worked to establish what was later to become the Panel for Family Living. Through MDC, the Com- prehensive Mental Health Center (CMHC) received OEO funds to establish weekly group therapy sessions and periodic child development/management classes for abusive or neglectful parents. In October 1971, a VISTA volunteer was assigned to PCLAF to manage coordination and intake responsibilities for the program. Therapists (with MSW backgrounds) and teachers (with MSW and counseling backgrounds) were hired to run groups, and teach parenting skills classes. Parents for group therapy sessions and child management classes were drawn from local agencies of Children's Protective Services, Juvenile Court and PCLAF. During 1971 and 1972, five parent aides were trained to provide additional support ser- vices to parents involved in therapy or class. (Two of these parent aides remained with the program for well over a year.) Throughout 1971 and 1972, monthly meetings of the ad hoc board continued, drawing interested individuals from agencies throughout the county concerned about child abuse and neglect (Children's Protective Services, Juvenile Court, the schools, CMHC, Emergency Room Nurses Association, etc.). In addition, with the support of the ad hoc board members, Jolly K, founder of Parents Anonymous in Los Angeles, was brought in to assist in the establishment of a Tacoma-based chapter, which is still functioning. As the term of the first VISTA volunteer was completed, a second VISTA volunteer was recruited to continue as coordinator. Child development classes and group therapy continue. (Funds from United Way helped to defray child care and X.3 transportation costs.) By January of 1973, this ad hoc board which had grown to more than 20 members, had elected officers and decided to incorporate as a private, non- profit organization. The Panel for Family Living has become a viable agency within Pierce County and was engaged in a number of activities. The project was housed in a building operated by Mary Bridge Children's Hospital. Board membership grew and participation by individuals from many different community agencies in the Panel's monthly meetings increased. A teaching program for foster home and receiving home parents caring for abused children was estab- lished with the financial support of MDC. And a proliferation of committees grew from the Panel, dealing with child abuse education, legislation and fund raising. Realizing that the OEO funds administered through Comprehensive Mental Health were inadequate -- given the Panel's goals -- members of the Panel wrote a grant proposal to seek funds from federal, state or private agencies. This proposal, with some modifications, was submitted to HEW in late fall of 1973, resulting in the selection of the Panel for Family Living as one of eleven projects in the National Demonstration Program in Child Abuse and Neglect. The primary purposes of this project were to develop a more coordinated community-wide child abuse and neglect system, to educate both the community in general and involved professionals about child abuse and neglect while testing some direct service strategies for a small number of client families. Between the time that this proposal was submitted to HEW and word was received about the award of the grant, the OEO funds for the Panel ran out. The County's Comprehensive Mental Health Clinic donated money to cover the costs of group therapy and Bates Vocational School provided child development X.4 classes at a modest fee. With the Continuing Medical Education group at the University of Puget Sound, the Panel helped sponsor a two-day community education seminar on child abuse (featuring sessions with Ray Helfer). The seminar introduced over 400 professionals to the dynamics of child abuse and case identification techniques. By April, at the time federal funding came through, membership on the Panel had risen to 50 persons. ITI. SUMMARY OF ACTIVITIES Summary of First Year The Panel quickly implemented its program. Within a few months after notification of funding, the Director had been hired, space secured and all key staff members hired. The Panel's rapid implementation of the program was facilitated by the organizational base that had been developing for three years prior to the receipt of federal money. Momentum of the volunteer involvement in the program increased markedly at this time, with enthusiasm for the program coming from many different segments of the community. By early autumn, the Panel had worked out the strategy for its new treatment program. And, throughout the fall, implemented parts of that plan. During the fall months the Panel not only accepted new cases, but carried over close to 50 cases from pre-funding days. The Panel had a fully operational program by January of 1975. During the winter months, the Panel's progress became hampered. The original director left the program and three months passed before a new director took over. In the interim, intake was closed, many cases were terminated, and many of the treatment services were tempor- arily stopped. X.5 Summary of Second Year A new director joined the project as it entered its second year, along with several other new treatment, research, coordination and support staff. This new staff spent the summer months deliberating the structure and pro- cess of many of the Panel's activities, primarily treatment and research. By fall, intake was reopened, as were the Panel's treatment services. By January the caseload size had grown from its low in May of 18 to over 50. A research design, focusing on the effects of the Panel's treatment program, was finalized and data collection began. During the second year the Panel took a much more systematic approach to training and education. A series of multi-session workshops, seminars and institutes, targeted at special professional groups as well as the general community, were planned and imple- mented. The most notable was a large-scale, long-awaited workshop series with school personnel. Finally, during the year the Panel systematically began contacting and working with the array of child and family agencies in the county. This included a survey of selected minority groups’ attitudes toward child abuse and neglect and appropriate services. Summary of Third Year During the first eight months of the third year, the Panel continued to pursue its activities as in the second year. Most project resources were allocated to community and professional education and coordination. There was, however, a noticeable decline in volunteer participation in Panel activities. During the final four months of federal funding, most energies have been directed toward phasing out while simultaneously attempting to secure funds for continuation. General intake was closed in January (new cases were accepted for parent education classes only through March). No new treat- X.6 ment services began after February. All cases were terminated before June 1. Only education/training activities continued as usual. IV. ORGANIZATIONAL/STRUCTURE STAFFING The Panel, which is housed on the third floor of an old, brown brick apartment building on the grounds of Mary Bridge Children's Health Center, is a private, non-profit corporation which has no formal affiliations with any other organization. The Panel is governed by its Panel members and its Executive Board. A number of committee chairpersons, the president, vice- president, secretary and treasurer of the Panel and two at-large members con- stitute the Executive Board. The rest of the Panel's activities are carried out by the paid staff and regular volunteers who are responsible, through the Project Director, to the Panel and its Executive Board. In addition to the federal demonstration monies, the Panel's funds consist of in-kind con- tributions from professionals and some agencies, fees for training and con- sultation services, small grants, and small donations. The Panel staff consists both of people paid out of the federal grant and people who are ''volunteers,' either because they are working for no pay or because their salary comes from some other agency, such as a university or Programs for Local Service. The use orf large numbers of volunteers, in many different capacities, has been the hallmark of the Panel program. Be- cause of the large numbers of volunteers working with the Panel, turnover has been considerable. The core of the staff, those receiving federal monies, consists of a Director, a Training and Consultation Specialist, a Direct Ser- vices Coordinator, an Outreach Worker, a Research Consultant, a Research Assistant and an Office Manager. A Community Resource Specialist and a sec- retary are supported out of CETA funds. X.7 Volunteers fill important staff roles such as parent aides, outreach workers and research assistants. In addition, the chairpersons and members of each of the Panel's committees are volunteers, who contribute importantly to the Panel's programs by ensuring that the committees carry out activities related to the accomplishment of program goals. These committees include: Education Committee, Public Policy Committee, Membership Committee, Public Relations Committee, Speakers Bureau, Fund Raising Committee, Consumer Committee, Seminar Committee, and Personnel Committee. Members of the Multi- disciplinary Diagnostic Team, a volunteer group, meets intermittently to review the Panel's difficult or troubling cases and to give consultation to other community workers. Students and other interested persons volunteer to help with clerical and other tasks. Vv. PROGRAM COMPONENTS The main components of the Panel's program include Coordination of Com- munity Services; Community Education; Professional Education; Research; and Services to Parents. Community Education One goal, and therefore, one program component has been "promoting and improving commmity awareness and attitudes regarding child abuse and neglect." In order to accomplish this goal, the Panel organized a Speakers Bureau to respond to requests from a variety of community groups to give talks either on Panel activitiies or child abuse in general. Staff and volunteer mem- bers of the Panel serve as speakers. Staff organized and ran a series of small institutes on abuse and neglect for the general public. In addition, the Panel has given several large conferences in Pierce County and elsewhere X.8 in the state on child abuse and neglect and has distributed information about its program (brochures, posters and the like) as well as pursuing some other public relations and publicity activities (newspaper articles, television programs). Professional Education Another goal and program component of the Panel has been ''to provide training resources for involved professionals in Pierce County in the recog- nition and appropriate handling of real and suspected abuse and neglect cases." Informally, through the existence of the Panel as a forum for con- cerned professionals in Pierce County, this goal has been pursued. The Panel's own activities such as monthly membership meetings brought together individuals from different disciplines and agencies and provided them with opportunities to exchange information on child abuse. As mentioned, the Panel sponsored several large conferences on child abuse which were attended by professionals as well as lay persons. These conferences, as well as numerous speeches and institutes for smaller groups, focused on the nature and dynamics of child abuse and neglect, appropriate treatment modalities, awareness of the professionals' own feelings and the relation of these to case handling, and early detection and prevention of abuse. A special con- ference for school personnel was held, as was a conference on sexual abuse. As requested, members of both the Panel and staff provided teaching and consultation to agencies in Pierce and neighboring counties who are pro- viding services in abuse and neglect abatement. And, finally, the Panel established in its own offices a resource library on abuse and neglect, which is available to any professional or lay person in the ccunty who may wish to use it. X.9 Coordination of Community Services in Child Abuse and Neglect A third goal and program component of the Panel has been "to provide a method for developing coordinated community services in child abuse and neglect." The efforts to achieve this goal come primarily from the volun- teer members of the Panel itself with the support of the whole staff. The Panel has attempted to insure that all agencies and individuals involved with child abuse and neglect in Pierce County are represented on the Panel. The staff and members of the Panel continue to seek participation of new persons and agencies in the Panel's activities. Members gather once a month for general meetings and more frequently, in smaller groups, for committee meetings. The Panel has served as the focal point for sharing information about existing services and for planning new treatment and preventive ser- vices, both through the general activities of the Panel and through its committees. Research The Panel's research plans changed considerably during federal funding both as the research staff has become aware of the limitations placed on it by availability of resources and as there has been turnover in the research staff. During the second and third years, no emphasis was placed on asses- sing the impact of the Panel's program on the community at large, as was planned originally. The focus of the Panel's research has primarily been on the effectiveness of the services offered by the Panel, as determined by careful monitoring of progress in individual cases in the Panel's case- load and comparing data gathered with that obtained from a matched control group. X.10 Services to Parents Outreach/Intake: When cases have been referred to the Panel, either by community agencies or by parents themselves, one of the Panel's direct service workers is assigned to the case. This person typically re- mains with the case throughout treatment, taking primary responsibility for case management, and maintaining contact with the client at least once a month. However, the most important aspect of the outreach process has been establishing the initial ties with the parent and the parent's family in order to capture the parent's interest in participating in the Panel's program. Diagnostic Team: One of the services offered by the Panel has been the Diagnostic Team. Like so many of the Panel's other activities, this team is primarily a volunteer effort, composed of a clinical child social worker, the chief of medicine at the local children's hospital, a children's protective services worker, one of the parent education teachers, the Panel's services workers, a psychologist, the Panel's Director (serving as Team Coordinator), and the Panel's Office Manager (serving as Recording Secretary). The team has done individual assessments of families referred to it either by the Panel itself or by other agencies in the community. Parents themselves have sometimes been present at these assessments which include a review of the history of the case, establishment of goals of treatment, and prescription of one of many possible treatments. Cases have been periodically brought back to the team for review and refinement of treatment goals. The worker referring the case to the team plays a primary role in collecting information prior to the reviews of cases by the team, but professionals from other agencies working with a given case are also X.11 present at team meetings to give a broader perspective. The team, which typically reviews one case at a meeting, has met intermittently. At its peak it was meeting twice a month, but during most of the period of federal funding met once a month or less frequently. Parent Education Classes: The Panel offers its own parent educa- tion classes, which are designed to meet the specific needs of abusers and neglectors. Although these sessions follow a specific curriculum, their structure is very informal and involves a lot of client participation. Con- tent is designed to match the age of parents' children as well as other special needs. Special parent-infant classes have been offered which allow parents to bring their babies to class. Leaders are retained on a consultant basis to offer an 8-10 week series; beginning and advanced series are offered. They are assisted by paid trainees. The number of parents per session is between eight and ten; the number of series offered simultaneously is between one and three. Parents are reimbursed for necessary babysitting and travel or provided with transportation. Parent Aide Counseling: Parent Aide Counseling has been offered to limited numbers of the Panel's clients (between 8-16 at any one time). Each Parent Aide, after receiving extensive training from the Panel staff, is assigned to one or two families and provides many supportive services. The Aides' role includes befriending the parent(s), being available to talk and to help. The actual nature of their work varies from case to case; the emphasis is on assisting the parent when help is necessary, without doing for the parent what he or she can do for him or herself. The Parent Aides, all volunteers, are supervised by the Training Specialist. Group Therapy: Group therapy sessions have been held weekly, run by co-therapists who are hired as consultants to the Panel. The sessions, X.12 which are two hours long, encompass a variety of group therapy techniques, selected on the basis of what seems most appropriate for the members of the group at a given time. Six to eight parents are in a group; the Panel has had one or two different groups running simultaneously, although it has been difficult to get referrals to this particular service as well as to maintain high attendance. A parent may be a member of a group from three months to one year, or longer. Parents are reimbursed, when necessary, for babysitting services for their children and are reimbursed for, or provided with, trans- portation to the meeting place. Parenthood Skills Training Program: Parenthood skills training was provided to select families with specific child management probiems. The training, which combined the use of home visits and videotaping parent/child interactions, was directed at providing parents with alternative parenting skills. Only 2-3 families received this service, which lasted about three months, at any one time. VI. IMPLEMENTATION/OPERATION PROBLEMS During the federal grant period, the Panel experienced both implementa- tion and operating problems. Some of these problems may be unique to small private agencies implementing a child abuse and neglect service program; others are relevant to any child abuse service program. Program Start-Up Because the Panel had been in operation as a small volunteer-based agency for two years prior to federal funding, the volunteer Panel members were very anxious to move ahead quickly in the implementation of the new program X.13 components. This occurred despite some resistance on the part of the newly hired staff. In retrospect, the staff feels that the program was implemented a bit too hastily, without enough forethought about what kind of cases would be taken, how many, and how cases would be managed. The result was a great deal of confusion during the first year about the Panel's service program, subsequent questions about the Panel's research program, and ongoing concern about the program's being in operation long before personnel policies and other important administrative issues had been settled. Problems with being a Volunteer Based Program The Panel had an extremely active group of volunteers prior to federal funding. With the advent of a paid staff and alteration of the Panel's activities, predictable difficulties or resentments arose. The long-time volunteers felt threatened by the new paid staff members who were starting to take over certain responsibilities and, perhaps, part of the credit for the Panel's successes. Although these difficulties were not immobilizing, the staff and the volunteers had to be sensitive both to the changing roles and responsibilities that resulted from the presence of full-time and paid staffing patterns, and to the varied opinions about how the Panel ought to proceed with its activities. As the Panel loses its federal funding, the problem of role definition arises again. During the period of federal fund- ing, volunteers were active in all phases of the Panel's program, but they came to depend heavily on the paid staff. The result has been both a "burning out" of volunteers and the changing of roies for volunteers to play. As the Panel moves into a period of reduced funding, it will be concerned with identifying ways to re-involve volunteers in the day-to-day operations of its program. X.14 The Panel has had, in comparison with the other demonstration projects, a small budget, given the range of activities and the actual amount of re- sources utilized. The Panel has depended on volunteers, students and indi- viduals paid out of special funds in order to carry out its program. However, the dependence on students and others who can commit themselves for only specified lengths of time creates inconsistencies. Turnover has continued to be high as students and other volunteers come and go. While these addi- tional personnel allow for greater quantity of services, maintaining quality or consistency becomes difficult. In this regard, the Panel will continue to have difficulties; solutions lie in sorting out specialized roles for volunteers, for which minimal disruptions will occur when there is turn- over. Client-Related Issues Historically (i.e., during the years prior to federal funding), the Panel has actively publicized its programs as being directed toward helping parents with parenting problems. Specific references to abuse and neglect were not made. When the Panel received federal funding and expanded its program, it did "inherit' many cases from the existing caseload. Some of these cases were not abuse/neglect, or even labeled as potential abuse/ neglect cases. This situation was highlighted as a problem when one client, upon finding out that the Panel was in fact focusing on abuse/neglect, instructed his attorney to questicn the Panel about whether or not the client was being inappropriately labeled owing to the nature of the Panel's focus. At the urging of the Executive Director, the Panel decided to be more open about the fact that the Panel's programs are for parents who abuse X.15 and neglect their children and not just for parents who are having diffi- culties parenting. Early on the staff spent a lot of time discussing how clients should be assigned to different treatment services. One school of thought, coming largely from the research staff, was that clients should be allocated ran- domly across service strategies. The second school of thought was that parents should be very deliberately and carefully assigned to services. This is clearly an issue in and of itself, but it is also reflective of a broader issue that the Panel has confronted. There have been conflicts between what the more research-oriented participants view as an appropriate way to proceed and what others view as appropriate. This problem is not uncommon in any project, particularly demonstration projects. The conflict was seen later, when the full implementation of the Panel's research design meant the expansion of original intake visits from one to two-three hours in order to collect necessary data. The Panel has found that the role of the receptionist/telephone answerer is a most critical one. Parents, as well as professionals from various agencies, call asking for help and/or information. The self-referral is undoubtedly the most difficult call to handle. The Panel met the potential difficulties of this situation by ensuring that its telephone answerer (s) was provided with training, by a community Mental Health Center consultant, on how to handle calls. Thus, the first contact many parents had with the Panel would be a positive, reinforcing one. Two of the Panel's treatment options, group therapy and the nultidis- ciplinary team, were associated with difficulties. Neither service was in large demand, and indeed apparent lack of interest resulted in the most X.16 modest provision of these two services. One to two group therapy sessions were functioning at any time, with an average of 5-6 clients per group. The Panel's capacity was much greater, but neither clients nor referral agencies seemed interested. The multidisciplinary team, which was to meet twice a month, reviewing two cases at each meeting, in fact met most fre- quently once a month, reviewing one case. Lack of demand on the part of Panel and other agency treatment workers for this service, as well as a generalized feeling among staff that "it takes so much time and energy to get prepared to present a case to the team" resulted in the low usage. Both of these services seemed beneficial when used; perhaps more education about the utility of these services to Panel staff and community agency staff alike would have resulted in greater usage. Director's Responsibility As the Panel was implementing its full program, it became clear that there was much more for a "director'" to do than any one person could handle, given the great emphases both on running a treatment program and on effect- ing a more coordinated child abuse/neglect system in the county. The solution was to hire a Direct Services Supervisor to take the burden off the Director. The message, perhaps, is that the demands of a treatment program are such that the director of treatment simply cannot also main- tain an active education and coordination program. Budgetary Constraints The Panel has encountered a number of difficulties related to the bud- get. Certain parts of the budget have been totally unrealistic, in view of the Panel's goals and objectives. For example, too little money was set X.17 aside for printing and data processing costs -- a grave problem for a pro- gram specializing in community and professional education. The resultant constraints placed on an organization that needs to maintain extensive com- munication with many people and that plans to collect large amounts of data are considerable. Furthermore, the Panel has found that, as its volunteer effort increases, costs seem to increase at an equivalent rate. VII. FUTURE PLANS While the Panel for Family Living will in all likelihood survive as an organization the end of the federal funding period, given the extensive community support, it will undergo changes. The Panel secured several small grants from local foundations and agen- cies as well as part of a federal training contract. These small monies, along with a few remaining CETA positions and the time of interested volun- teers, will allow the Panel to continue its coordination and education acti- vities for at elast one more year with threee paid staff. The services of the training specialist will continue to be available to professional groups desiring to learn about or upgrade their skills in dealing with child mal- treatment. The Speakers Bureau will continue, primarily using volunteers. And the library will remain intact and located at the Panel office, with all materials still available to the community on loan. The core staff, supple- mented by CETA workers, will consist of a Program Coordinator, a Training Specialist and a Secretary/Bookkeeper. The treatment portion of the program was closed in the spring of 1977. Panel volunteers and the few staff mem- bers, recognizing the loss to the community in ending these services, will undoubtedly engage in a variety of activities to support and enhance existing X.18 services for abuse and neglect clients, particularly those offered by pro- tective services. In the late spring the Panel elected a new Board. This new Board and the enthusiasm it engenders in the many volunteers, will have a lot to do with the longer term viability of the Panel. X.19 VIII. PROJECT GOALS The goals of the Panel have been: @ To provide a method of developing coordinated community services in child abuse and neglect; e To provide direct services to parents in order to reduce the inci- dence of abuse and neglect in their families; ® To promote and improve community knowledge and attitudes regarding abuse and neglect; e To provide training resources for involved professionals and para- professionals in the recognition and appropriate handling of cases of real and suspected abuse and neglect; e To develop ongoing research and evaluation of the Panel's activities. During the period of federal funding, the Panel has been successful in its community and professional education pursuits, has made an impressive in-road in developing a coordinated community system and has implemented a small pilot test, with a complementary research project, of select treat- ment services for abusers and neglectors. Progress toward accomplishment of the education and coordination goals has been steady, jointly pursued by the paid staff and more than 50 volunteers who have remained active in the Panel; the treatment and research goals have had a more sporadic, and thus less impressive, history. With respect to the coordination goal, while the Panel has not made a systematic (or planful) effort to coordinate the Pierce County child abuse and neglect system, a method for doing so has been developed. The Panel has successfully brought together, in the form of active Panel member- ship, most of those in the County providing services to or concerned with X.20 abuse and neglect. Either as a direct or indirect result, an atmosphere in which communication and working together are valued has been created. Many conflicts or confusions between agencies are settled informally, at Panel meetings. People have faces to connect with the names and positions of those they work with in other agencies; this greatly facilitates working together on individual cases. Even without continued funding, the group of Panel members will undoubtedly continue to meet and lay plans to improve awareness of and delivery of services for abuse and neglect in the county. With respect to the Panel's treatment goal, the Panel has developed a treatment program, including home counseling, parent education classes, group therapy, and parent aide counseling, for abusive and neglectful parents; the reincidence rate during and after treatment appears to be very low. Thus, in one sense this direct services goal of the Panel has been met. The Panel's treatment program has been more of a pilot project than an ongoing treat- ment facility, however. While the Panel has been able to fill some of the treatment gaps in the community system, the number of openings for different treatment services, and thus the number cof cases served, has been small; twice during the three-year period the Panel has closed intake and many of its services. Because of these factors, the community has not come to rely on the Panel for client services, although in general the community has a high regard for these services when they ave offered. With respect to the community education goal, it appears that the atti- tudes of people in Pierce County with regard to abuse and neglect have changed since the Panel received federal funding. The Panel has done a tremendous amount of community education; if one believes that such educa- tion activities affect community attitudes, then the Panel has undoubtedly X.21 had an impact in this area. Whether or not the whole community has been hit by these activities is not clear. The community education activities have not been provided in a systematic way, directed toward target audiences, but rather have been provided on a request basis, which may have resulted in over-exposure for some groups and under-exposure for others. The Panel's educational and training activities directed at profes- sionals and paraprofessionals have been more organized and targeted than the community education activities; the Panel has become well respected in Pierce County for their work in this area. The Panel's professional education goal has probably been as fully realized, if not more success- fully, as any of the Panel's goals. Undoubtedly, many professionals with- in and outside the commmity are better educated as a result of Panel activities; however, certain groups, notably physicians and lawyers, have barely been reached and those reached can undoubtedly learn a good deal more. However, professional education is regarded by the community as the Panel's primary role and it appears that they have done a very good job. And finally, with respect to the Panel's research goal, the Panel's research activities have changed direction and scope considerably since federal funding, due both to turnover in the research staff and reassessment of what was doable. The result is that while the Panel has had an ongoing research component, it is still very young and by the end of federal funding some data analysis will have been undertaken using a control group. Thus, while the research has been carefully designed and eventual results will be useful, the Panel has not completely accomplished this goal. Client services will have been evaluated, but not the impact of the Panel on the community, as originally planned. X.22 IX. PROJECT MANAGEMENT AND WORKER SATISFACTION Tacoma is a highly complex organization both in number of disciplines involved in the program and in the great diversity of program activities. Despite the highly manifold nature, Tacoma is a well-managed and highly efficient project. Organizational Structure Tacoma appears to be a very small project. They had eight full-time staff members and a $10,000 per month budget over the lifetime of the pro- ject. But, in addition to the full-time staff there are over 100 active professional board members, consultants and volunteers affiliated with the project. Also, students from local colleges actively work with the project. When the total numbef of staff are counted, Tacoma is one of the largest projects among the eleven demonstrations. This project, both board and staff, are involved in a wide variety of program activities including edu- cation, training, advocacy and services. Also, over nine different dis- ciplines are actively represented in project activities. This accounts for the high degree of complexity in Tacoma's organizational structure. The project operates fairly informally -- rules and procedures evolved only late the the second year -- but tends to be highly centralized in decision making because board members have ultimate decision making authority. How- ever, the staff actively participate in decisions made about their own jobs and have a high degree of personal autonomy. Relationship with Host Agency Tacoma is one of the few projects in which the board has an active role in the project operation and makes program and administrative decisions. X.23 They wrote the personnel policies and decide budget allocation, and deter- mine accountability and monitoring systems. The Panel's board has always been an active participating body, operating somewhat informally through committees of peers. Management problems occurred when this dynamic inde- pendent group of volunteers was faced with the responsibility of managing a staff of 7-8 people, also professionals with ideas and plans sometimes differing from those of the board members'. This type of an arrangement tends to create special management problems in terms of role clarification, communication and coordination, and Tacoma is no exception. Nearly 1-1/2 years were spent establishing lines of authority and responsibility, clari- fying roles, and instituting procedures for communication and coordination. The task was somewhat more difficult because the first director of the pro- ject had also been the past president of the board and ''one of the gang." As director, the board members found his status somewhat confusing. ''Was he a board member or is he a staff member?" Resolution of many of these management issues became feasible with the election of a new board presi- dent and the hiring of the second director. Both were committed to develop- ing new patterns for board and staff interactions. The resulting solutions placed an overwhelming burden of coordination and communication upon the project director and executive board. The project director, in addition to individual meetings with project staff, attends all executive board meetings and the committee meetings of the board. Approximately 15 hours a week of the director's time are spent in meetings, communicating both formally and informally about both project and board activities. Acting as the interface between the board and staff demands much of the project director's time and energy, and is not always as personally satisfying as X.24 program planning and project implementation activities, but because both of the directors of this project have been willing to work closely with all participants, the Panel has had a smoother implementation of their program than could have been anticipated. Internal Communication As one enters the project's offices, one is impressed with the effi- cient work-oriented atmosphere. People are busy with their own work and there is very little hint of conflict or dissension. But, in fact, staff report quite openly that many conflicts have existed or continue to exist among each other. People have intruded upon each other's space and have strong differences of opinions, conditions that are common when strong, independent individuals work together in a small physical space. But the interesting difference between Tacoma and other conflict ridden programs is that in Tacoma there is a structure or an agreement among the staff that all differences are to be dealt with directly and assertively. An unspoken rule is that all staff members have a right to demand and receive respect and responsiveness. And, it appears that staff do deal with personal con- flicts fairly quickly and decisively. When differences occur that indi- viduals cannot work out, the project director acts as intermediator and facilitates the compromise. It is difficult to deal with angry feelings or conflicts; the strength of this project's ongoing operation has been that these rather sensitive areas are not ignored or repressed but con- fronted directly and openly. So despite the recurring tensions, staff are able to work out agreements and continue working together without disrupt- ing program operation. X.25 Job Design For most people in the projects, their job design allows them high autonomy, flexibility and variety. Most workers feel that they are included in decisions made about their job and program that they are involved with. They report low job pressure and high staff support and good peer cohesive- ness. Most workers seemed to be task-oriented and highly involved with their jobs. But rarely are people involved with each other in their job- related tasks. Because of the many different program activities handled by such a small staff, each individual staff member is largely responsible for a complete program, i.e., training, service, or community education. Consequently, there is a high degree of job-related isolation. Some of the symptoms expressed by different staff members are: '"What is missing is an overall appreciation for the interdependent parts." ''Personally people get along well, but lack a job cohesiveness." 'People could do a better job if they knew what others were doing and could see how each job is important to the total agency.'" These are frequent complaints of highly specialized jobs. People become competent at their own job but miss the grand scheme. For many people, specialization does not create problems, but in the Tacoma project there are individuals who feel that they have missed something and resent the isolation. 'No one knows exactly what I do and therefore cannot give me specific feedback and recommendations." So while the project is highly efficient and effective, a high percentage of the staff report low satisfaction (41.7%) and feelings of being burned out (33.3%). This can be explained partially by job specialization and con- comitant job isolation. X.26 Turnover/Satisfaction/Burnout Tacoma has a fairly high turnover rate. Seven out of an average monthly staff of eight, as well as many volunteers and students, left the project during the first 2-1/2 years of operation. This turnover seems to be less a reflection of the project management than directly an outcome of the pro- ject design. The project utilizes volunteers, students and CETA employees for many of the program activities. Students change regularly following the school calendar. Several CETA positions were eliminated when their funding ended. Other staff left when the project's research plans changed. In fact, the project has only lost three major staff members: the director, a community worker, and a service worker. Of these, the director left because of greater opportunities in the next job. As mentioned earlier, there is a significant amount of dissatisfaction and burned out feelings among workers presently employed in the project. Some of this dissatisfaction and burnout can be explained by personnel expectations. There happen to be a number of individuals who are under- utilized and feel misplaced in their present jobs. While these individuals do not feel that the project is poorly managed or inefficient, they feel that they are not being challenged and are not growing in their present jobs, but due to external ——__n have not terminated employment. Dis- satisfaction does not seem to reduce the overall performance of the project, but at the same time it does contribute to a malaise about activities that might explain some of the recurring tensions znd internal non-job related conflict that 2=xists and is handled in the project. X.27 X. ANALYSIS OF CLIENT DATA Client Flow The process for identifying, diagnosing and managing cases changed considerably during the three-year federal arin period. In general, the client flow process became considerably more simplified over time, with reductions in the number and types of reviews a given case was to undergo. During the last year and one half, the process was generally as follows: all initial referrals were directed to the Direct Services Supervisor. On the basis of initial information received over the phone, and occasion- ally a home visit, she determined if the case were an appropriate one for the Panel, i.e., an abuse or neglect case which could benefit from one of the Panel's select services, and then assigned the case, either to herself or one of the outreach workers. Goals of treatment were then determined by the outreach worker, with possible consultation from the Direct Services Supervisor, and decisions were made regarding what services a client was to receive. The final choice of services was, however, left up to the client. The treatment staff met weekly, to review some of the workers' cases; in addition, workers were provided with individual supervision by the Direct Services Supervisor. Cases were reviewed at regular tervals at meetings between the Outreach workers, the Direct Services Supervisor (and sometimes Project Director), and others involved in serving the fam- ily, e.g., group therapists, parent aides. Client Characteristics As can be seen on Table 1, cases were referred to the project from a variety of sources, most notably the medical community and self referrals. Fewer than one-quarter of the cases had a previous record or evidence of X.28 abuse or neglect. The greatest proportion of cases were physical abuse; it is interesting to note that in 38% of the cases parents were said to be abused as children. Close to one-third of the cases could be categorized as those in which serious maltreatment occurred; appropriately, the same proportion of cases were heard by the courts. These are quite reflective of the project's intake criteria. Mothers were most frequently identified as responsible for the maltreatment, although only 34% of the cases had only one adult (typically the mother) in the household. Two-thirds of the families had pre-school age children, reflected in the most frequently cited problem in the household leading to the maltreatment -- heavy, con- tinuous child care responsibilities -- and the fact that one-third of these families had a new baby. Large proportions of these cases had little education (in 70% of the families no one had a high school degree), and low incomes (69% had an annual income of under $5500), although in over half of the families at least one adult was employed. This may in part be explained by the relatively young ages of the parents (60% of the families had at least one teenage parent). In terms of racial/ethnic characteristics, the families were reflective of the county in general -- in 80% of the families there were no minorities. In addition to the above cited problems, 40% of the families experienced marital difficulties, and 36% a recent location. Although these cases are very much like the ones the project said it intended to serve, it is interesting to look at the cases referred to the project but not accepted for treatment. Of the esti- mated 120 reports received during 1975 and 1976 and not accepted: 38 were inappropriate referrals; 25 were unsubstantiated cases; five could not be located; five were already in treatment elsewhere; four refused service; X.29 59 were referred to another agency; and 47 were turned away because the Panel's caseload was full, Table 1 Client Characteristics Source of Referral . Previous Record Evidence of Mal- Private physician. « + +» « +» + 7% treatment Hospital : « « + ov wu 217% None . vv «27% Social service agency. om un «20% Previous record/evidence : & 23% School i + + + «vs vu =» » » 5% Law enforcement. . . . . . . . 3% Demographic Information Courts « + 4 + + sw ov» « » + 8% Average number children in Parent . + « « + +» +5 » =» » =» 35 Family: = « « 0» 0% 5 «5 & 2nd SIDING. + +» » o = 5 v 5 f-5 go= Families with preschoolers . .65% Relative . . . . + = »10% Families with one adult. . . .34% Acquaintance/neighbor. PEER Families with no high school SOY v4 on ew vow ow + = 220% degree. , + + + + + + wv x +» +70% ANONYMOUS, . « « « « «+ + » » « 1% Families with no minority. . .81% Other agency « « + s.x + + » .12% Families with no one employed.42% Average family income. . . . .$6000 Type of Naltpsatment Families with <$5500/year. . .69% Potential abuse or neglect . Families with teenage parent .60% only: + » «+ » . » vw» +18% Average age of mothers . . . .26 yrs. Emotional maltreatnent only. .19% Average age of fathers . . . .28 yrs. ums a } ) } } } : a Problems in Household Leading Physical neglect . . . . . . .16% to Maltreatment Physical abuse § neglect . . . 6% Marital. . . . . +. +. ..« . . .40% . Job-related. . . . . . . . . .24% Soverisy of Asssuls Alcoholism . . + . « « « + . . 5% Not serious. . « + +» « +» » + 408% Drugs. .- . ele v0 w sie 75 SOXIouS.: « « + +» 4 x x x wv « «32% Physical health. rine aw. 4 Sa vid Mental health. . . . . . . . .13% Responsibility for Maltreatment New baby « - ERE Mother . o . v x & oo » ww 49% Argument/ fight ee ee ak Father . . 4» « +» « + » +» » « +16% Financial problems . . . . . .€5% Both. ov « + +s» o7% «= =34% Mental retardation of pazent . 1% Other. . « « vw + vv « «» vw». + 1% Pregnancy. . . . . . 5% Heavy, continuous child care .51% Physical spouse abuse. . . . .10% None . . . ii ww ow ow ww w15% overcrowded housing. . . . . .10% Court hearing. . wee ow +539 Abused as child. . . . . . . .38% Reported to mandated agency. .24% Normal method of discipline. .31% Social isolation . . . . . . .19% Recent relocation. . . . . . .36% Legal Actions Taken (N=93) X.30 The Quality of Case Management In general, the Panel's case management practices were adequate. As shown on Table 2, for almost half the cases, the first contact occurred on the same day as the referral. And in close to 90% of the cases, contact was made with the referral source to obtain background information about the case, and almost as frequently to provide reports on case progress. Treatment plans were developed at that time and treatment services began within two weeks. Multidisciplinary team reviews were provided to only one-fifth of the cases, however, and case conferences were used for less than half the cases (typically during treatment). Consultants were rarely used for case management purposes although in one-fifth of the cases the client participated in either treatment planning or progress review. Although three-quarters of the cases had the same case manager throughout treatment, in close to half of the cases a person other than the case managet took primary responsibility for intake. Clients typically re- ceived services from three to five Panel staff members and from other agen- cies as well. The Panel, unlike many projects, systematically conducted at least one follow-up visit with terminated cases. The major problems in the case management practices were the relatively inadequate records kept by the project and the lack of interdisciplinary input into treatment planning for most of the cases. X.3} Table 2 Case Management Characteristics* Time Between Referral and First Client Participation Shien: fonsest Client presence at MDTs and/or Same day. « + + + 2 vs 5» v.58 » «47% case conferences . . . . . . . .22% 1-3days. « + » « vw lv 3 9» » «5% 4-7 days. . . . cv 0 0 00. . J14% Contact With Referral Source Within two weeks. . . . . . . . . 9% : : Within one month. . . . . . . . .20% for background information. . . gi Over one month. . . . . . . . . . 5% Or Progress reports. + +. + vu 470% Number of Client Contacts (after Responsibility for Intake initial contact) Before Treatment Current case manager. . . . . . .77% Plan Other staff member. . . . . . . .23% NOB: ov vw ov « oo = » = = 5 = +» » 239% ONE . + v « =» « =» = » =» « « « +» +158% Number of Case Managers TWO . « « « 5 © » = ow wu ow » «1 +33% OBE vv nm vw wie wns www ey 280 Three-five. . . . . . . . . . . . 8% TWO ov ow ww w % wd a vo» & « v18% Over flve . . . « « + v +» « + + = 0 More than two . . . . . . . . . . 2% Time Between First Client Contact Reason for Two or More Case Managers and First Treatment Service Joint management. . . . . . . =0 Within two weeks. . . . . . . . .69% Staff turnover. . . « . «+ +» . N= A Two weeks to one month. . . . . .22% Staff unavailability. . . . . = 2 Over onemonth. . . . . . ... . 5% Lack of success with client . =1 No services given . . . . . . . . 5% Other = +. .5. 5 % 5 w.% # a= = 1 Use of Multidisciplinary Review Number of Treatment Providers in Team Project (other than case manager) At least one review . . . . . . .20% Noti@. + + 5 +» oo s.0' = wu ou 5 & 9.2% Review during intake. . . . . . .16% ORE = = 5 + & & = » saw uw on 420% Review during treatment . . . . .16% THO o 5 5 5 « a % 5 & v % u » wv «19% Review at termination** . . . . . 2% Three-five., « + + + v.5 + « + +» «50% Over five . . . . . . . +. . . . . 2% Use of Case Conferences (staffings) Services From Outside Agencies. .80% At least one conference . . . . .47% Conference during intake. . . . .21% : : : : Conference during treatment . .43% Evidence of Commmication With ¢ : : 0 Outside Agencies. . . . . . . . .82% Conference at termination . . . .13% N=32 Use of Consultants None: « « « = oo. vo vs + +» = » 291% (Table 2 continued on following Snr Reanil biehis diets dolien-2) page) SPT Three-Five. . « « =» « v = +» » «» »14% Over Five . . +. ¢ + « +o +» +» » « 2% X.32 Table 2 (continued) Frequency of Contact by Case Managers Once per week or more . . . . . .41% Once or twice per month . . . . .27% Less than once per month. . . . . 8% Once or twice only. . . . . . . .13% Varied over time. . . . . . . . . 9% NONE: ov. o #6 +» # © #5 » » 5 » + 2% Follow-Up Contacts** At least one contact (client/ other agency). . . . . . . . .35% Two or less with client . . . . .93% Three-five. . . . . . . . . . . . 2% Over FIVE . « « + » + « = » » 5 » 9% Length of Time in Treatment** Up to three months. . . . . . . .12% 3-12 mONLAS + + « + « « +» + + + +74% JZ VOATS . 5 + vv 5 vw + vw uw 214% Over two years. . . « « «+ + + « . 0 Total cases = 45; total terminated cases = 42. * Owing tc rounding, percentages may not sum to 100%. * % Terminated cases only. X.33 XI. COMMUNITY IMPACT Summary The child abuse and neglect system in Pierce County, Washington has improved in several ways since the Panel for Family Living became a fed- eral demonstration program. The changes can be traced in part to the Panel's activities, which began several years prior to the federal grant award. It is not possible to know to what extent the Panel's federal grant activities, versus those that were already set in motion by this volunteer group, are responsible for the changes. One can conjecture, however, that the changes would have occurred much more slowly had the Panel's activities not been significantly increased as of May 1974. Perhaps the most significant improvement is increased communication, understanding and familiarity among those individuals and agencies consti- tuting the county's child abuse and neglect system. Well over 80 individuals, representing some 25 agencies, are active in the Panel's activities. Mini- mally, this involves attendance at the Panel's monthly breakfast meetings; for many, however, it means committing 8-10 hours per month for committee meetings, speaking engagements and the like. Regardless of the form of participation, the result is that those individuals working with child abuse cases know each other, and are aware of each other's resources. Referrals can be made to someone already known, and problems can be discussed infor- mally, as can individual cases. Resources in the community can be used more cleverly. While coordination between agencies was not a problem prior to May 1974, coordination seems to have impruved as a result of improved communication. X.34 The second most significant improvement is multifold, in part growing out of a reorganization within the local Children's Protective Services Department. In 1975, the department, which previously had about 15 social workers all handling intake and treatment, developed a special intake unit with six social workers, leaving the remaining social workers to carry out the treatment services. The impetus for the change came most directly from the fact that CPS was overloaded, social workers felt overworked, often inappropriate cases were kept for six months because intake was inadequate, and very few cases received treatment services. The fact that the two CPS supervisors actually brought about a change may well be in part due to the fact that they had both been active in Panel activities, becoming increas- ingly concerned with how the whole system functioned. The founding of the Panel itself was a response to the unacceptable situation CPS was in and thus may have served to highlight the problem. The results of the change include: quicker and more thorough intake by CPS, more appropriate handling and referring of cases by CPS, increased communication among agencies coming in contact with CPS and increased respect for, and thus desire to work with, CPS. Other important changes in the system include: expansion of service capability primarily through the Panel's services (which may well decline when the Panel's federal funds run out), ana expansion of the numbers of agencies concerned with abuse and neglect in the county, in part because of the Panel's activities. In general, one can say that the Pane! has helped to spark interest in the abuse/neglect problem in the community 6 has been an important source of new ideas and concerns about the problem and has helped to generate a X.35 spirit of cooperation and coordination rarely seen in this field. System Operations The child abuse and neglect system in Pierce County appears to be func- tioning better in many areas than it was prior to the Panel for Family Living's receipt of federal funds. The Panel's activities helped influence these changes, as did the reorganization of the local Children's Protective Services (CPS). The system is not completely centralized, but it appears to be more so than three years ago. CPS serves as the focal agency in the system. Although not all cases are channeled through CPS, relatively recent revi- sions in the state law which mandate that protective services be provided to all cases, whether identified by law enforcement or protective services (previously cases identified by law enforcement were not included in this mandate), undoubtedly resulted in a greater percentage of identified cases being channeled through CPS than in the past. CPS handles many of the functions of a model system, often in concert with other agencies. Identification of cases is handled by CPS, the police and sheriff's office, the schools, and other service agencies as well as the general public. Only recently have health professionals started to identify and report cases, and only recently has the school system begun a program of training teachers in identification. Investigation and Diag- nosis is the joint responsibility of CPS and law enforcement agencies; reporting between these two agencies and joint investigations seem to have increased since revisions in the state's reporting law. When appropriate, the court system becomes involved in investigations. Treatment planning for abuse and neglect cases is primarily handled by CPS; in cases where X.36 the juvenile court becomes involved in treatment decisions, court workers often rely on recommendations from CPS workers, perhaps more now than previously. Smaller scale efforts at treatment planning occur at other service agencies working with abuse and neglect cases, including the Panel's outreach/counseling workers or the Panel's Diagnostic Team while it was in existence. Even Mary Bridge Children's Hospital, through its SCAN team, now does treatment planning and case review, even after a child has left the hospital. A CPS worker is often involved in these activities. Many agencies in the community actually provide Treatment services to abusive and neglectful families, yet the majority of identified (i.e., labeled) cases receive treatment through CPS. A second provider of services to abusive and neglectful families has been the Panel, which has served approximately 100 parents a year (less than 10% of the number served by CPS). The local community mental health center, the public health nurses, and Mary Bridge Hospital's Maternal and Child Health Program are examples of other agencies that have been providing services to abusive and neglectful families; it appears that these agencies are all more aware of the fact that they have abusers and neglectors in their caseloads than previously. The amount of Referrals among agencies seems to have increased; CPS in particular is referring many more cases elsewhere than previously, although at the same time CPS has developed an interest in expanding the types of services offered in-house. All agencies seem more aware of the services existing in the community and are likely to make more thoughtful referrals. Placement continues to be handled by the foster care units in the Department of Social and Health Services. Termination is determined by those agencies handling cases. At CPS, termination decisions are now made more frequently X.37 on the basis of the clients' best interests, not the workers (this is due to the CPS reorganization which reduced the long-term treatment workers' caseloads and thus reduced the pressure to close cases prematurely). The Pierce County system has not developed any notable activities in the areas of Outreach, Prevention or Follow-Up, with the exception of some of the Panel's community education activities. The system does not seem to have any significant tracks or subsystems. Almost all identified cases are channeled through the same agencies, with the same procedures. This is probably more true now than previously because the system in general has become more coordinated. A few private agencies in the county appear not to report non-severe cases that they hear about or identify, and instead appear to provide services to these cases them- selves, As mentioned above, the system does not have any well developed out - reach, prevention or follow-up activities. In addition, the county has no specialized services for abused and neglected children, no 24-hour counseling hotline and limited services for sexual abusers.* The system has become more complete than prior to the Panel's receiving federal fund- ing. The Panel has expanded the community's parent education class and group therapy capacity, as well as adding a parent aide program and a multidiscipiinary diagnostic team, both of which have small but not insig- nificant service capacities, and a centralized Speakers Bureau to conduct * % The only service available now is a new series of group therapy ses- sions offered by CPS. The County has established a Task Force on sexual abuse, which to date has sponsored a well-attended conference, and which may be instrumental in the future in rectifying this gap in service. X.38 community and professional education sessions. Most of these activities, however, may well disappear after Spring 1977. The county system has few duplications in functions. The only dupli- cation of any consequence is that on occasion CPS and law enforcement separately investigate cases; this appears to occur less often now than three years ago, perhaps because of the revised reporting law and improved relations between these agencies. At the time the Panel was funded by OCD/SRS, the community system had several serious bottlenecks. Most importantly, CPS had an overburdened staff, with caseloads that were too large, and with little time to con- duct adequate intakes. Delays between the time of initial reports and actual investigations and diagnoses were often considerable. With the reorganization of CPS, this problem in the system was virtually eliminated. The new Intake Unit is able to respond more quickly and more thoroughly to referrals; cases needing services receive them more quickly and ave actually receiving services rather than mereiy being open cases in a worker's caseload. A second bottleneck in the system had to do with the ease and timing with which cases were seen in the Juvenile Court. The problems seemed to be tied to the Juvenile Court Judge. Since this judgeship is an annually rotating position, the problem appears or disappears as different judges accede to the bench. Caseload Size and Case Outcomes It is not possible to determine whether there have been changes in the total numbers of abuse and neglect cases reported in Pierce County and X.39 the dispositions of those cases since the demonstration program began because of the lack of data from all key agencies. However, data gathered from Children's Protective Services, the Juvenile Court and the sheriff's depart- ment provide a good indication of the changes likely to be occurring in other agencies in the county. Table 3 displays the CPS caseload data from January 1974 through Decem- ber 1976, Table 4 displays the Juvenile Court data for the same period, and Table 5 displays data from the Sheriff's office for 1975 and 1976. It is apparent that all three agencies have handled more abuse/neglect cases over the three-year period. CPS showed approximately a five percent increase in reports received, the Juvenile Court approximately a 25 per- cent increase (primarily in numbers of abuse cases), and the Sheriff's office a 16 percent increase. The reason for these increases may be the expanded awareness on the part of the community about what constitutes abuse and neglect cases and the reporting requirements; the state's revised report- ing law also may have influenced the rather dramatic increase in the number of abuse cases referred to the courts; and finally, some theorize that worsening economic conditions locally may have resulted in increased num- bers of actual cases. The data from CPS indicates that the number of reports where no abuse or neglect is found to exist has increased by 11 percent in 1975, and has decreased by 10 percent in 1976. The CPS staff suspect that with increased attention to child abuse and thus increased publicity about CPS, more people reported to CPS in 1975 and many of these reports were inappropriate. The formation of a special Intake Unit in CPS during 1975 allowed certain social workers to undertake more thorough investigations, resulting in the X.40 detection of these inappropriate cases. The intake workers have been care- fully providing referral agents with feedback about the cases they have been referring; perhaps the reduction of inappropriate referrals as well as the general reduction in number of referrals reflects the fact that referral agents are now more sophisticated about those cases which are appropriate to refer. In addition to the intake workers' activities, the Panel's education activities undoubtedly help to explain these changes. A study of the sources of reports to CPS, the Juvenile Court and the Sheriff's office reflects only modest changes. In general, CPS is receiv- ing reports from the same sources with three notable differences: more reports are being received from health agencies than previously, far fewer reports are coming from neighbors than in past years, and a greater percent of the reports are anonymous. The Juvenile Court is also receiving reports from essentially the same sources with two exceptions; a substantially larger percentage of reports are being received from CPS and other social agencies, and spouses and other relatives are reporting fewer cases. And, the most notable changes in source of referrals to the sheriff are an in- crease in reports from CPS and schools and a slight decrease from hospitals and neighbors. The conclusions derived from these data are that health agencies are more aware of child abuse and neglect problems than previously, perhaps because they have been provided education in this area, in part from the Panel, and are now more likely to report directly to CPS than to law enforcement; and CPS is more likely to report cases to the Juvenile Court, perhaps because of the revised reporting law. No information is currently available to explain tlie reduced reporting by neighbors and rela- tives, nor the increased numbers of anonymous reports. X.41 Table 3 Caseload Data, Children's Protective Services, 1974-1976 1974 1975 1976 Total number of reports 1977 1299 1355 Percent reports where no abuse/neglect exists 22% 33% 23% Percent families referred to juvenile court for removal of the child 1.6% 2.5% 3.2% Source of Reports: Court 1% 3% 3% Law enforcement 5% 3% 5% Schools 12% 11% 12% Private physicians 2% 2% 3% Health agencies 2% 7% 9% Local offices 10% 5% 5% Other social agencies 6% 6% 5% Relatives 15% 17% 16% Neighbors 32% 28% 18% Anonymous 3% 6% 10% Other 10% 14% 15% X.42 Table 4 Caseload Data, Remann Hall Juvenile Court, 1974-1975 1974 1975 Volume of Reports: Abuse 161 222 _Neglect 72 82 Unknown 8 -- Total 241 304 Source of Referral: Protective services/other social agencies 16% 32% Private physician - = Hospital 2% 1% Law enforcement 44% 47% School 3% 1% Court 7% 2% Self referral 7% 9% Spouse 13% 5% Sibling —— se Relative 8% 1% Friend/neighbor -- -- Anonymous se i Other 1% 1% Unknown a - Selected Court Dispositions: Commitment 0.5% 0.5% Probation 0.5% 0.5% Permanent ward 3.0% 1.0% Temporary ward -- for supervision 14.0% | 14.0% Temporary ward -- for placement 27.0% | 26.0% Continuance 3.0% 2.0% Referred to DSHS/CPS 19.0% | 12.0% X.43 Table 5 Pierce County Sheriff's Department: Juvenile Division 1975 1976 Total number reports received 49 57 Percent abuse 61% 44% Percent neglect 39% 56% Percent of total reports substantiated 53% 72% Source of Referral: Protective services 37% 44% Physician -— -- Hospital 10% 4% Law enforcement 4% 4% Schooi 4% 9% Relative 12% 11% Acquaintance/neighbor 24% 19% Anonymous 2% 4% Self-referral -- 2% Other/unknown 4% 5% X.44 The selected dispositions of cases from the Juvenile Court data sug- gests that child abuse and neglect cases coming to the court's attention do not fare any differently than previously; however, when interviewed, court workers suggest that whether or not the same number of children may be placed out of the home or minimally receive court supervision as in the past, more and more of these placement or supervision decisions are volun- tary on the part of the parent and are negotiated with the parent prior to a court hearing. Legislation and Community Resources Legislation. The Washington State Child Abuse and Neglect Reporting Law was revised during the time of the Panel's functioning as a demonstra- tion. The main change in the law concerns the reporting of cases and pro- vision of protective services. As previously, law enforcement agencies and protective services are mandated to receive reports. However, with the new law, law enforcement must provide protective services to those reports received, necessitating the referral of those reports to protective services, and protective services must now report cases to law enforcement as well as the Prosecuting Attorney. These cases cause protective services to be more clearly a focal point of the system then previously. The law addi- tionally includes the following provisions: the child at risk must now be assigned a Guardian ad Litem; hospitals can now detain a child until the next court day without consent; clergymen need not now report but all other professionals must continue to do so. Members of the Panel actively campaigned for certain changes in the law, but in general, not those that passed the legislature. X.45 Community Resources. Pierce County has experienced modest expansion in the resources committed to abuse and neglect during the demonstration period. Most of the expansion has been accounted for by the Panel's own programs; this will likely change when the Panel's federal funds run out. Key agencies with staff members specifically committed to abuse and neglect include: Children's Protective Services, with approximately 15 full-time social workers; the County Sheriff's Office, with the equivalent of one officer 60 percent time; the Tacoma city police, with one officer 60 percent time; the County Juvenile Court with five dependency workers at approximately 50 percent time and six intake workers at approximately 25 percent time; and Mary Bridge Children's Hospital with a very much part- time SCAN team and two part-time social workers. These staff commitments have not substantially changed during the last three years with the excep- tion of the Sheriff's office, which previcusly assigned abuse/neglect cases to any juvenile officer, and Mary Bridge Hospital which previously had no SCAN team or social workers. The schools essentially have no personnel specifically assigned to work on abuse or neglect, although awareness is high and school social workers, nurses and teachers do iden- tify and work with cases of abuse and neglect. When surveying resources from most of the service agencies in the county, it appears that the county has close to a full complement of desirable adult services, although not necessarily enough of them, with the exception of a 24-hour counseling hotline. Children's services are much more scarce, with no agency in the county specifically serving abused and neglected children. X.46 The Panel has contributed several new staff resources and many more services to Pierce County in addition to the Panel's five full-time paid professional staff members (which include a training specialist, a com- munity relations specialist, and two treatment workers, as well as the director). Non-paid staff resources have included parent aides (approxi- mately eight), parent education teachers and group therapists skilled in working with abuse and neglect (approximately eight and four, respectively), and the Diagnostic Team members skilled in reviewing child abuse and neglect cases. All but some of the parent education teachers and the group thera- pists are resources to the community generated after the Panel received federal funding. (It is not known yet how these resources will be utilized once the Panel's federal funds run out, although some of the parent education teachers have begun classes elsewhere). Although the Panel was providing some education prior to federal funding, as a demonstration project the Panel has brought to the community greatly expanded educational and training acti- vities, including a centralized Speakers Bureau. Community System Coordination While the Pierce County child abuse and neglect system was more coor- dinated than most communities' systems prior to the federal funding of the Panel, it appears that the system has improved during the demonstration effort. All agencies perceive greater cooperation and coordination between themselves and others in the system. The changes seem to result directly from a reorganization of Children's Protective Services as well as from some of the Panel's activities. Coordination mechanisms between Children's Protective Services, the local police and sheriff's office, hospitals and the County Juvenile Court X.47 have existed informally for a long time, dating back to the founding of the Panel several years before it became a demonstration project. As dis- cussed earlier, Children's Protective Services reorganized in 1975, creating an intake unit to handle all reports, investigations and diagnoses, and a treatment unit to provide services to cases on a long-term basis. The result of the reorganization was that a small number of CPS workers, rather than all 16, conduct the majority of interactions CPS has with other agen- cies in the community. Because other agencies only have to relate to a small number of CPS workers, they report that it has been much easier to estab- lish informal working relationships with CPS, the focal agency in the sys- tem. (It does not appear that the Panel had any role in the CPS reorganization although those CPS supervisors who made the reorganization decision were active members of the Panel.) In addition to the improved informal relations between agencies, several formal and informal arrangements have emerged within the last two years. CPS and the Panel established a formal written agreement on the referral of cases between the two agencies; following this, and perhaps as a cata- lytic response, CPS developed a similar formal written agreement with Madigan military base. CPS has also established agreements with the schools and local hospital with respect to standarcized reporting. The Panel itself also developed formal agreements with Parents Anonymous and Mary Bridge Children's Hospital. And finally, as a result of the revised state report- ing law, CPS and law enforcement have a formalized reporting relationship with the prosecuting attorney, in addition to the previously mandated reporting relationship between CPS, law enforcement and the Juvenile Court. X.48 Interagency collaboration appears to be more typical in Pierce County than in other communities, and has grown during the past three years. Different agencies are concerned with eliminating duplication and working together, particularly on individual cases, and on preserving each other's autonomy in certain functional areas. This spirit, which one encounters in all the key agencies, is very likely due to Panel activities. The Panel, through its membership meetings and Committee activities, provides forums for workers in the community to get together, learn more about each other's functions and work, and perhaps most importantly, to get to know each other. Many staff members from all key agencies participate in Panel activities and the friendships developed among individuals in these different agencies seem to have enhanced the agencies' desires and abilities to work together. A good example of efforts to collaborate is the Panel's Education Committee's High School Teachers Workshop series, a two-year planning effort by indi- viduals not only from the schools but from all key agencies in the community which finally took place in April of 1976 and was repeated in March of 1977. And, the Panel's Speakers Bureau has come to be regarded as the central re- cipient of most speaking requests; individuals from all key agencies serve as speakers for the bureau. The nature of the collaborative arrangements between agencies is encouraging. There is more information sharing on cases; agencies seem to trust each other's conclusions on cases more readily; and joint investi- gations (between CPS and law enforcement) seem to go more smoothly. How- ever, it does not appear that concerted efforts have been made to iron out all inefficiencies in the system. Some gaps and duplications remain. One can assume that if those aspects of the Tarel's activities that serve to bring different community agencies together continue, some of these more X.49 difficult aspects of collaboration may be worked out. As a final note on coordination, it should be pointed out that while a community-wide task force on child abuse and neglect existed in Pierce County under the auspices of the Panel, prior to the Panel's federal fund- ing, the infusion of additional monies has been very directly responsible for the impressive expansion of this task force (from about 20 to over 80 active members) and for the diversification of the task force's activities. Education and Public Awareness The amount of education and training on abuse and neglect for both professional and community people in Pierce County has increased substan- tially during the past three years. While the national attention to the child abuse and neglect problem may in large part account for the increased demand for such education, the provision of this education has been pri- marily by Panel staff and Panel members. All key agencies state that staff members have received substantially more abuse/neglect education during the past three years than in prior years. It is felt that the variety, amount and quality of the training has resulted in a much better informed group of professionals working with abuse and neglect, and thus higher quality of services being offered. Also, the training has helped to break down stereotypes about different agencies; for example, police officers are not seen as ''the bad guys" as they once were. In addition, all key agencies state that they have received more requests for training and thus have been providing more training to others, often through the auspices of the Panel's Speakers Bureau, than before. The education and training provided has not been 'planful," i.e., directed X.50 at identified target groups, but rather has been on a request-received basis. The Panel itself has done significant education and training. With over 300 separate training and education sessions given in 1975 and 1976, and with an average of 25 people per session, the Panel reached well over 7000 people. Most of these sessions were directed toward students, usually of high school age, but a wide range of professional groups have been addressed as well. (Professionals in the community have additionally re- ceived some education from planned activities at the Panel's breakfast meetings.) The Panel also provided over 30 TV, radio or newspaper educa- tional activities directed at the general public. The main topics covered in the educational activities include the etiology and dynamics of abuse, the state reporting law and the functions of the Panel. Although more and more individuals, representing different agencies and groups (including Parents Anonymous) have bacome involved in providing education and training, the organizing responsibility for providing these activities has increasingly become that of the Panel's paid staff. Agen- cies in the community regard education as a primary role of the Panel and appear to be interested in channeling many of the requests that they re- ceive for education through the Panel's Speakers Burcau. Although the courts, for example, would not refer a request from a school for a talk on the role of the court to the Panel, requests for more general talks on abuse and neglect would be referred. X.51 XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS The way project resources (both time and dollars) were allocated to different activities and services are good descriptors of the Panel's pro- gram. Table 6 depicts the average allocation of both time and dollars for the year 1976. As can be seen on the Table, a total of 11.9 person-years (or 24,660 hours) were used by the project, including the time of both paid staff and volunteers and consultants as well. The corresponding budget for a year, not including the dollar value of donated resources, was $155,820. Most of the project's resources were utilized for other than direct treatment services. Twenty percent of the time (and 17% of the budget) was used for community and professional education; another 14% of the time (and 10% of the budget) was for coordinative activities; and 33% of time (and 48% of the budget) was for general overhead functions including staff develop- ment and training, program planning, and day-to-day management. The dis- crepancies between the time and dollar percentages reflect the added resources of volunteers used extensively in education and coordination acti- vities. Although not shown on the table, datz from a sample of months in 1975 and 1976 indicates that these resource ailocations were quite stable over time, reflecting few or no changes in this aspect of the program. Less than one-quarter of the project resources went directly to the service program. Table 6 also shows how time and dollars were allocated to specific treatment activities, the typical monthly volume of units offered in each treatment service category and the average unit costs. As discussed else- where, the Panel's mix of services included: intake and initial diagnosis (with a monthly average of seven); case management (with a monthly caseload X.52 of 42); multidisciplinary team review (with a monthly average of three); individual counseling (with 114 contacts per month); lay therapy counseling (with 18 contacts a month); couples counseling (58 contacts a month); group therapy (20 person-sessions a month); and parent education classes (29 per- son sessions a month). Additionally, the Panel offered modest amounts of crisis intervention, transportation and babysitting. The unit costs of most of the Panel's activities were stable over time; the most dramatic change was in the cost of a review by the multidisciplinary review team, which dropped substantially over time due to decreased participation by both staff and consultants. The dollar cost of several of the service units increased substantially when one includes the dollar value of volunteers and unpaid consultants. Multidisciplinary team reviews, for example, cost the project, on average, $23 per review, but "cost" the community $88 in terms of total resources used. Likewise, the unit cost of parent aide counseling goes from $15.75 per contact to $19.25, and parent education classes go from $13 per person-session to $16.75. Table 6: Project Resource Allocation and Service Costs Resource Allocation to Volume and Unit Costs of Services Activities Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation Allocation |Average Monthly Volume | Unit Cost | to Community Community Education 12% 9% Professional Education 8 8 Coordination 14 10 Legislation/Policy 1 1 Staff Development/Training 17 10 Program Planning/Development 4 4 General Management 11 33 Project Research 8 BPA Evaluation pL 2 Qutreach -- -- 7 cases 6.75 7.50 Intake/Initial Diagnosis 1 8 intakes 16.25 17.00 Case Management/Review 6 42 average caseload 14.50 15.50 Court Case Activities -- -- 4 cases 16,75 18.25 Multidisciplinary Team Review 2 1 3 reviews 23.00 88.00 Individual Counseling 4 3 114 contacts 3.00 3.50 Parent Aide/Lay Therapy 3 2 18 contacts 15.75 19.25 Couples Counseling 2 2 58 contacts 4.50 5.00 Group Therapy 2s 2 20 person-sessions 13.25 13.50 Parent Education Classes 3 3 29 person-sessions 13.00 16.75 Transportation/Waiting -— -— 12 rides 2.50 2.50 Psychological/Other Testing -- -- 10 tests 29.00 122.50 Total Annual Person-Years/Budget 11.9 $155,820 Average monthly caseload = 42 €S'X —m—— 1 x . “ I - ) Ll . : rt BN [= . H H 1 1 i ) | . 1 - # I } - - n - - I 1: rl r a . B a - Xxr.1 PROTECTIVE SERVICES DEMONSTRATION PROJECT: UNION COUNTY, NEW JERSEY I. COMMUNITY CONTEXT Union County is in the most heavily populated section of the most dense- ly populated state in the nation. It is in the northeast part of New Jersey, adjacent to New York City, and is characteristic of highly populated, urban- ized, rapidly changing areas of industrialized states. It contains both aging and densely populated cities of moderate size (such as Elizabeth and Plainfield) and very affluent suburbs. Blacks represented 11.2% of the 543,067 county population (1970 Census). However, in Elizabeth, blacks constituted over 15%, and in Plainfield over 40%, of the population. Over 60% of the families in the county had incomes below $10,000 in 1970. 11. HISTORY With the advent of the Dodd Law, the Division of Youth and Family Ser- | vices (DYFS) became the mandated agency to receive reports of abuse and neglect. Within months the number of referrals had increased. Concern had arisen in the Union County office of DYFS about protective services, both in terms of the handling of these many new cases and the lack of ade- quate treatment resources for all referrals of child abuse and neglect. Many of these cases were going into the juvenile court system, whose orientation DYFS considered to provide only a limited understanding of the problem. The Assistant Prosecutor was asking for held in developing a bet- ter method of handling cases. DYFS realized that it was quickly becoming XI.2 a crisis-oriented service; it was focusing on the worst cases, and was capa- ble of giving other cases only superficial or ineffective treatment. This concern led to the formation of a voluntary group, consisting of a psychologist, psychiatrist, visiting nurse and a supervisor from DYFS, whose objective was to improve the treatment process. The group developed its role "as it went along,' meeting one afternoon a month to go over cases and, often with the family present, making recommendations for case handling. In effect, this group was operating as a diagnostic team. Group members began to develop an approach to working with the "resistive'" client. They realized this was essential in dealing with child abuse and neglect cases, since the mental health model, in which the client must be motivated to recog- nize his or her problem and seek help voluntarily, does not often apply in abuse and neglect situations. In these cases, the resistive parent must be accepted for treatment, and the treatment process itself should lead to motivation. The group identified certain problems in its work with child abuse and neglect cases in Union County: (1) a lot of "pre-work'" was needed simply to get clients to come to the team; (2) the team was hampered by an inability to adequately follow through with services -- it suffered from the lack of available rescurces, and the lack of a responsible coordinator to follow up with ser- vice delivery; (3) the team lacked a meeting place and secretarial staff; (4) because the team operated on a volunteer basis, the time members had available was limited. XI.3 At this point, the team began looking for funds to develop a proposal for improving the delivery of services in child abuse and neglect cases in Union County. This coincided with the issuance of HEW guidelines for propo- sals for the demonstration program in child abuse and neglect. Thus, DYFS as one member of the team, proposed a service strategy based on the exper- ience of the 'diagnostic team,'" and built on the focal role of DYFS as the sole legally mandated agency in New Jersey for receiving reports of and pro- viding services in child abuse and neglect situations. The strategy called for extensive use of contracts with voluntary community agencies to purchase needed treatment services, such as day care, lay therapy, homemaking, and family counseling, to supplement the agency's counseling and case manage- ment ability. | The proposal was developed through the Bureau of Research, Planning and Program Development in the state Division of Youth and Family Services. The model developed in the proposal was viewed by the agency as having poten- tial for impl-mentation throughout the state, once tested in Union County. Consequently, the proposal called for significant state contribution to the total budget for the effort. In May of 1974, about a year-and-a-half after the initial mobilization of the group's concern, the Union County Protective Services Demonstration Project was funded by HEW. III. SUMMARY OF ACTIVITIES First Year Summary Once the grant had been received, while the core staff existed as part of the Protective Service Unit of DYFS in Union County, a project director XI.4 was needed. She was hired in September and began to work with community agencies to establish contracts for purchased services. Completion of staf- fing took several months, with the planner-trainer (the director's assistant) hired in December and hiring of some case workers in late winter. In fact, staff turnover had begun by then, and a new supervisor and worker were hired in June. In late fall, the first meeting of the Advisory Board was held, and representatives of a range of public and private agencies formed subcommittees to address the various issues of concern to the project. The Diagnostic Team became operational in January, with members serving on a voluntary basis pending finalization of purchase of service contracts with the agencies represented. The major start-up effort of the project director was the development of contracts with service agencies. The first contracts were signed in early spring, and the contracting agencies began offering services on a limited basis in April and May. While several contracts had still not been final- ized by the end of the first year, interim arrangements with several agencies enabled the project to offer some of the needed services on a referral or purchase basis. In addition to the coordination activities with private and public agen- cies, community and professional education represented a major effort in the first project year. The last few months of the first year saw the project focusing on inter- nal operations, an area of concern because of the high rate of emergency referrals to the project. Staff felt response to emergency calls was hin- dering ongoing case service, and reorganization seemed in order to better serve both emergency intakes and regular caseloads. The project held a XI.5 two-day staff "retreat" during April, discussing needs for internal improve- ments, and the second year, it was hoped, would see a reorganized casework staff, with special units for responding to intake calls and for handling ongoing cases. Second Year Summary The project's second year can best be described as a major learning experience, fraught with frustration and struggles and very little obvious progress. While the project continued to serve clients, it was also, through trial and error, trying to improve the functioning of their ambitious and complicated program. One of the major learning areas was how to coordinate and work with contract agencies. Developing a public/private partnership in service delivery is no easy task and proved especially difficult for the project. Many of the contracts had been signed with the private agencies during the first year, but missing in these contracts were operational guidelines. What were appropriate clients for referral to the agencies? How were the project staff and private agencies going to ccordinate their services with each other? Further, how was the project to evaluate the contract agencies’ performance? But even more, the private agencies had to be trained to work with multi-problem, unmotivated clients. These problems were dealt with, but satisfactory solutions did not emerge until much later in the second year. The second major learning problem was how an innovative project lives in a bureaucracy. Many features of the project, i.e., emergency funds, use of consultants and staff training were modified by the state office to fit the state's organizational structures. Paper work requirements, a long XI.6 accepted evil in bureaucracy, were imposed on the project along with two research efforts, each requiring extensive record keeping duties. The pro- ject staff were not given a reprieve from standard bureaucratic paperwork. Meeting these requirements thwarted the original intent of the program and was disruptive to service delivery. Just as significant, the project expended energy struggling with the state bureaucracy when that energy could have been more profitably exerted in delivering services. The third major area of struggle was project management and organiza- tion concerns. Turnover was high (45%) requiring constant efforts to recruit and train new workers. The organizational structure had to be modified several times to find more effective ways to serve clients, handle intakes and crisis situations, while also monitoring clients served by contract agencies. Near the end of the second year a new organization was implemented that seemed compatible with program activities (see Organization section). But even with a new, good structure, staff training needs, job designs, and coordination/communication channels needed to be smoothed out, requiring several more months before the benefit of the new organization could be realized. Rutgers Protective Services Resource Institute agreed to write an operation manual to help facilitate these operating probiems, but the manual was not completed until the third year. During the second year the district offices state-wide began a special after-hours response unit in November 1975. Volunteers were recruited from the project staff and social workers in the local district. This unit pro- vided emergency coverage and after-hours investigation of intake reports. The staff was trained and supervised by the project planner/trainer and were given a special after-hour salary. With the implementation of this XI.7 unit, the project staff, who had felt overworked by after-hour coverage, were provided with much needed support. Third Year Summary During the third year, the project was making progress. The public/ private partnership was now bearing the fruits of two years of labor. All contracts were renewed with the exception of one family service agency. New contracts were signed for the parent line and visiting homemakers. Coordi- nation procedures between project and contracting agencies had been developed and were working effectively. There now exists a healthy partnership between the project and its contracting agencies, with only minor disruptions caused by occasional staff changes. One symbol of this improved relationship is the Union County Child Protection Council. The project Advisory Board disbanded during the summer of 1976 and reorganized into a community council composed of professionals in both pri- vate and public agencies and citizens concerned about children and improv- ing the services delivered to them. This body is very supportive of the project and has expanded its efforts to county-wide concerns and lobby ef- forts with the state legislature on behalf of the project. The project's internal operation has also improved. Staff has stabil- ized and the project organization seems to be operating fairly effectively, with a few exceptions. Shortcomings in the project operation are due to a vacancy in the major supervisor/case manager position and planner/trainer position, requiring the remaining two administrative persons to juggle two jobs each, i.e., supervision and administration, and the periodic increases in crisis and serious abuse cases that tend to overwhelm the intake unit. XI.8 There is also improvement in relations between the project and the state bureaucracy. Emergency funds procedures have been worked out, fund- ing for consultants has been allocated, and the requested staff changes and positions have been confirmed. Some of these improvements can be attributed to the leadership of the new project director who took over the management of the project in April 1976 and exercised stronger accountability regarding staff performance, but also gave support, trust and guidance. Disagreements with the contract agency were resolved in a forthright, diplomatic manner. Communication/ coordination in the project improved. By the third year, one felt a sense of pride and excitement from the staff and private agencies in their joint project. This does not mean that all problems in the project have been re- solved, but what it does infer is that there is now an effective process | and leadership to assure resolution of difficulties. During this third year the project began to demonstrate that a state agency in partnership with community private agencies could improve ser- vice delivery to clients. It has become a model for other district offices to imitate. The state has been pleased with the project's performance, and there is hope that it will be refunded by state monies when federal funds are terminated. IV. ORGANIZATION/STAFFING Basically, the demonstration project is a special unit of the Union County District Office of the Division of Youth and Family Services, hand- ling abuse and neglect cases. Although there had been a protective services unit in the district, the new project is housed in different offices and X1.9 represents a substantially expanded unit in terms of its staff, its addi- tional services, and its emphasis on community education and coordination with other agencies. The project director reports to the District Office supervisor, who is responsible, through regional linkages, to the state agency. All abuse and neglect reports are received by the Screening Unit of the district office. This unit screens out inappropriate referrals and then immediately refers suspected abuse (physical, sexual, emotional), severe neglect and self referrals. The response unit in the project does the in- vestigation and assessment on all intakes. This may take two to six weeks. The case is reviewed by a mini-team review, composed of the public health nurse and psychological consultant and appropriate staff members. One to two weeks after referral the investigation may not yet be completed. Deci- sion making still rests with caseworker and supervisor. When the assessment is completed the case may be referred to the appro- priate geographical unit or to the liaison unit if the client is a likely candidate for services offered by any of the contract agencies. If a deci- sion is made to refer the case to the supervision unit, this unit has the option of referring the client to the liaison unit at a later date should a family situation change or when services are more relevant. In addition, clients may receive active project supervision and a contract service, such as teaching homemaker or lay therapy. Figure 1: ORGANIZATIONAL CHART Project Director Response Unit I { Administrative Assistant Trainer/Legal Analyst Planner/Casework Manager Position 1 ] 1 Plainfield Supervision Elizabeth Supervision Liaison Unit (with Unit Unit contracting agencies) Assistant Supervisor Assistant Supervisor Four Workers Four Workers; One Lay Therapist | Assistant Supervisor Assistant Supervisor Four Workers Three Workers 01" IX XI.11 V. PROGRAM COMPONENTS The project has several components related to improving the community service network and provides a range of treatment modalities -- some directly by project staff and others through purchased services from the contracting agencies. Each of these components is described below. Community Education Project staff participate in speaking to a wide range of community groups, including high school and college students and citizens groups. They encour- age troubled parents to seek help, inform the public about the services avail- able to families, advise the public of the legal mandate to report cases of suspected abuse and neglect, and educate the community to help shape construc- tive attitudes about the problems and treatment of abuse and neglect. Professional Education Project staff provide training for professionals in the community in approaches to working with abusive and neglectful families. Training staff members of the voluntary agencies that contract to provide services to the project's clients is emphasized. Coordination Much energy, particularly in the early months of the project, has been devoted to developing contacts and coordinating with other agencies in the community, both public and voluntary. The major focus of the project's coor- dination efforts in the first year was the development of working relation- ships with private service agencies in the county so that contracts for purchasing needed services for project clients could be arranged. Family service agencies, day care centers, visiting nurse associations, homemaker XI.12 service agencies, hospitals and a hotline provider were all involved. Con- tracts were eventually secured for most of these services. In addition, coordination efforts resulted in development of interagency referral pro- cedures with several agencies who would not be involved in actual contracts but wished to work with the project in other ways. Coordination with public agencies included working with the county pro- secutor, court, schools, hospitals, and law enforcement bodies. Coordina- tion was usually combined with educational presentations, especially concern- ing the new child abuse law and effective procedures for the agencies to use in implementing the law's requirement to report cases to DYFS. Because the project is part of a larger state agency, intra-agency coordination was, and continues to be, an important element of the project's efforts. Extensive coordination with several state bureaus, particularly the purchase of service bureau and the fiscal bureau, has been necessary to achieve the project's goal of obtaining contracts for counseling and other services provided by private agencies and needed by the project's clients. Legislation and Policy Late in 1974, a new child abuse law was passed in New Jersey and was implemented on January 1, 1975. Project staff spent considerable time work- ing with other agencies to discuss the bill's interpretation and ramifica- tions, and to develop procedures based on the new bill. The Legislative Committee of the Advisory Board reviewed proposed amendments to the bill and has been seeking a definitive interpretation of the role of hospitals in providing medical evaluation of cases. X1.13 Project Research A staff member from the state DYFS Bureau of Research, Planning and Program Development is assigned to the project on a part-time basis, and has developed a research design for measuring the impact of project services on the families it serves. Case record forms have been devised for collecting data on clients served. The project social workers use these instruments to collect the needed data. The forms also function as part of the case management/review process. Diagnostic Team The team is composed of five members: a psychiatrist, a psychologist, pediatrician, visiting nurse and a social worker who is one of the coordi- nator/case managers from the project. The team reviews the more serious or complicated cases at intake and/or during treatment. When a family is re- ferred to the Team, an initial evaluation has been done by the primary social worker, supervisor, and team nurse or possibly by the psychologist. Parents, as well as children, attend the review and are involved in the team's develop- ment of a service plan. In the third year this team was reorganized into a "mini-team" comprised of the public health nurse and the psychologist con- sultant, the project case manager, and the appropriate supervisor and work- ers. Now this team reviews all incoming cases and other priority cases. Individual Counseling The project's social workers provide individual counseling to the clients in their caseload (average caseload is about 15 to 20 families), each worker seeing his or her clients in person at least once a month, and some clients more often. Some workers see each client at least weekly, with serious cases being seen more frequently, especially during initial crisis intervention. XI.14 Counseling can also be arranged as a purchased service through one of the three family service agencies contracting with the project. Lay Therapy The three family service agencies contracting with the project provide lay therapy. Lay therapists have been hired by each of the agencies on a full-time basis to work specifically with cases referred by the project. Unlike many volunteer lay therapist models used elsewhere, these lay thera- pists are paid a full time salary. The therapists make frequent home visits, and the therapist develops a supportive relationship with the parent, attempt- ing to fill some of the vacuum in the parent's other adult relationships and providing the kind of emotional support that the parent may have been seeking inappropriately from the child. In addition, the therapist provides '"advo- cacy" services, helping the parent deal with the many agencies with which he or she may be involved (welfare, court, etc.). Recently, the project has added one lay therapist to its staff to work in the Plainfield supervision unit. Couples Counseling, Family Counseling, Individual and Group Therapy These are provided, when needed, by the family service agencies con- tracting with the project. Each of these agencies is able to serve between 25 and 40 cases. Some workers currently provide couples counseling at the project. However, the project's treatment does not emphasize the psycho- analytic approach. Rather, the primary services are meant to be lay therapy and concrete services such as day care, homemaking, and parent education. The counseling and more traditional therapy services are reserved for those cases where the caseworker feels it appropriate. X1.15 24-Hour Hotline Counseling A contract was developed for an existing community hotline to expand its service to include a Parent Line, for supportive listening to parents in moments of crisis. The project and the hotline director trained the hot- line staff. This service began in late fall of 1976. Parent Education Several mothers' groups have been provided for mothers with young child- ren, focusing on parent education. The first group was led by the project director and case coordinator, with participation by the nurse from the diag- nostic team. The planner-trainer and a caseworker began a second group in Plainfield. This group has been taken over by the family service agency and has become a therapy group with the caseworker continuing as co-therapist. A variety of other project staff have led various groups, often with com- munity help, such as a group for Spanish-speaking mothers led by a Spanish- speaking project caseworker and a local mental health social worker. Crisis Intervention The project social workers spend much of their time responding to emer- gency or crisis calls, sometimes from parents already part of the project's caseload, but more often initial intake calls, where the referral was pre- cipitated by a crisis situation. Developing the most effective approach to responding to these crisis situations has been a prime concern of the pro- ject and is discussed in the later section on implementation issues. Day Care Day care is provided on a purchase of service basis. Three contracts have been signed, providing 5-7 pre-school slots each. The project plans XI.16 to arrange day care in various parts of the county, making this service more accessible to clients. The project also plans to include infant care in its contracts. Each contracting day care center must add an additional staff person to provide the special help that abused and neglected children require, especially in the area of child development. In addition to contracts, the project provides day care for clients on a vendor payment basis or Title XX slots with existing centers. DYFS also has its own center in the county. Play Therapy This is provided by the contracting family service agencies, as needed. Homemaking Homemaker services are provided through contracting agencies to assist parents in child care and home management, and to provide instruction 11° End1d rearing, household management, nutrition, shopping, budgeting and hygiene. The service was provided on an interim arrangement with a profit-making agency, until a contract with a voluntary agency was arranged. Child Care During the weekly meeting of the first ycung mothers' parent education group, child care was provided by a volunteer child care consultant for the project and later by a lay therapist experienced in nursery school education and child development. Primarily, volunteers or day care centers are used to provide this service to children of mothers in groups. Transportation Project social workers provide transportation for clients in their case- loads, and often use this as an opportunity for counseling. Transportation X1.17 is also provided by lay therapists and by students working part-time with the project. Emergency Funds Because economic crisis can be a precipitating factor in child abuse and neglect, the project offers emergency funds of up to $200 per year per family for immediate needs, including food, rent, clothing, etc. Vi. IMPLEMENTATION/OPERATION PROBLEMS Purchase of Service Contracts The basis of the demonstration in Union County is a combination of ex- panded social work staff for counseling and case management, and the expanded availability of treatment resources through contracts with voluntary agen- cies in the community. However, establishing working contracts has been a difficult process. Voluntary agencies were reluctant to become involved in a project operated by a public agency, especially a project with a federal component. The voluntary agencies wished to remain autonomous. Furthermore, each contracting agency was required to provide ''seed money' to be eligible for a contract under Title IV-A for purchase of services. A third problem in implementing the contracts was the compiicated bureaucratic network that had to be dealt with in the state agency in order to negotiate a formal con- tract. Finally, the purchase of service concept is difficult to implement. Contracts must be based on a specified volume of service, but determining in advance the amount of services that will be required by the project's clients was difficult; community resources for particular services have not always been available in the quantity or quality desired -- this has been a XI.18 particular problem with homemaker services and day care. Once contracts have been established, procedural problems of interagency relations must still be worked out. (How will referrals be made? Who will complete what parts of the case record? Who supervises whom?) The solutions to these problems have come primarily through time and careful attention to each matter. Because the previous project director had worked for a private agency, she was able to understand and deal with con- cerns of contracting agencies. Procedures and policies were developed jointly with them that both assured them of the autonomy they felt necessary and assured the project of the control it desired over services. In response to the coordination and accountability problems a liaison unit evolved within the project. This new unit of workers were assigned to work exclusively with project clients that were served by contracting agencies and facili- tate resolution of any difficulties between all involved providers. Also, the project directly promptly schedules meetings when conflicts emerge. By the end of the second year the program was running more smoothly. Although implementation of this system has been arduous, the staff believes that the end result is worth the effort because of the involvement of all community resources in serving the problems of abuse and neglect. Civil Service Hiring Hiring of project staff had to be done through the normal Civil Service procedures. Delays that occurred because of the complicated processes in- volved resulted in the project's losing potential staff members, including a Spanish-speaking candidate for a supervisor position, who took another position in the interim. Salary negotiations have been hampered by the XI.19 necessity to adhere to Civil Service scales which, in this case, do not give as much credit for relevant experience outside the agency as for experience inside the agency. This has jeopardized the hiring of persons desired for several positions. In addition, some present staff members are vulnerable to "bumping" since they have not yet had the opportunity to take the Civil Service exam, and could be bumped by any qualified person who has taken the test and wants the position. Coordination within the State Bureaucracy The project must work with many separate bureaus and agencies within the state, and has found coordination very difficult. Many delays and prob- lems in project implementation resulted from the complexity of bureaucratic requirements. The many people who must be involved in decisions about the project operations are, physically, far apart. The complicated bureaucratic problems have had ramifications in terms of hiring and contracting for ser- .vices, as described above, as well as in obtaining approval for various expenditures and activities. The procedures established for a permanent agency are not always applicable to a special demonstration project and, unless waived in certain cases, can impede efficient progress for such a project. Fieldwork Transportation Although the state determined that the project needed 10 cars, only eight state cars have been available to the workers for use in the field. The cars are shared by 17 workers; this allows only two days a week in the field for each worker. Prior to the implementation of the demonstration pro- ject, workers had three days per week in the field. Fewer days in the field XI.20 reduces the ability of the workers to do intensive casework. Workers have questioned whether a demonstration project, designed to provide more inten- sive services, can operate with fewer days in the field than the original protective service unit had. Previously, procedures set by the state agency for obtaining gas for the cars were time consuming (workers had to drive half an hour to Newark) and further cut into the limited time available in the field. Now gas credit cards are available which has helped improve this problem. In the second project year the social work staff reorganized into geo- graphic units, with each worker handling cases in a defined area of the county. The reorganization helped to alleviate the transportation problem by limiting the area a worker needed to cover in field visits. However, a long-term solution requires additional cars for the project. High Rate of Referrals and Emergency Calls The early months of the project involved extensive community education and coordination efforts with other agencies in the community and, as a result, the number of cases referred to the project increased dramatically at times. Workers who had transferred from the original protective services unit were still carrying cases from their original caseloads and found that, with the large number of cases coming in, it was impossible to do anything but crisis intervention. There was some feeling that perhaps the community education efforts of the project were ''too good,'" or that more attention should have been given to internal procedures before lauching a major public relations effort. In addition, many of the referrals coming in have been emergency calls. A rotating assignment of workers to emergency coverage X1.21 had not been working, and workers found themselves falling further into a ""crisis-response'' mode, unable to provide intensive, ongoing services to clients already in the caseload. As a result of these problems, the pro- ject made internal reorganization the focus of its second year. Community education received lower priority; the workers were reorganized into two geographic units and one unit for handling initial calls, and a policy and procedures manual was developed. VII. FUTURE PLANS The project's future, as with many of the other joint demonstrations, is uncertain and primarily a 'waiting game.' There is reason to be optimistic. The state has been impressed with the project's performance and is already funding more than half of its yearly budget. The pubis components have just been recontracted at the current levels by Title XX monies for this next year and continuity of their services is assured. Some of the consul- tants' positions, the public health nurse and the psychologist, have also been refunded. Unfortunately, the psychiatrist and pediatrician will not be continued. In addition to the continuance of the contract agreements, the project director and district supervisor are writing a proposal to the state asking that the project also be continued intact. Their argument is that the project needed the 2-1/2 years to implement the program and is now operating smoothly at capacity; three more years are required to demonstrate the model's effectiveness in serving clients. They are helpful that the state will honor its commitment to the original grant to continue the pro- ject after federal funding. There are also many reasons to be pessimistic about the state's willingness to refund the project. The state director Xy.22 of the Division of Youth and Family Services, who has been committed to the abusc/neglect program, has just resigned. A new election occurs this year and the present governor will probably be defeated. Finally, there have been a number of scandals associated with the department at the state level. The Union County Child Protection Council will lobby on the project's behalf to prevent its termination, but a new administration, with different priori- ties, may not be susceptible to their influence. If the state chose not to refund the project, most of the staff and purchase agreements would be absorbed into the district office operation. Many workers have stated that they will not work at the district office and are looking for other jobs. If the project loses its staff, its unique con- tribution to the local district in trained and experienced manpower will be lost. VIII. PROJECT GOALS The current goals of the Union County Demonstration Project are as follows: (1) to focus on improving the quality of services provided by casework staff through improved communication, better supervision, and clari- fication of effective casework and program procedures; (2) to achieve better delivery of services for abuse/neglect clients; (3) to establish and/or use effective training programs to improve services and maintain them at a high level; (4) to have parents and other agencies view DYFS as a helping agency, rather than punitive, legalistic, or for crisis intervention only; X1.23 (5) to develop and explore various service modalities and assess their effectiveness; (6) to educate society, including professionals, in child rearing methods and in the causes of abuse and neglect. The goals presented in the original grant proposal were formalized somewhat differently, with several specific process and evaluation objec- tives listed under a two-part overall goal: To insure the safety and welfare of Union County, and to do so by (a) improving and strengthening the reporting, investigating, diag- nostic and treatment capacities of the Union County Protective Service System; (b) providing expanded, meaningful programs of aid and support to troubled families in which abuse and neglect have occurred. The expanded goal listing, reported above, developed by project staff during the first year, does not represent any divergence from the originally proposed goals. Specific goals to be met in order to achieve the overall goal are more clearly delineated. Goals 2 through 6 are articulated through- out the original proposal, albeit not listed specifically as goals. The first goal listed above was, in fact, newly articulated toward the end of the Purse project year. It arose out of staff members' concern that they had substantially devoted their energies to community education, development of a service network through voluntary agencies, and coordination with other public agencies, while failing to have devoted concurrent energy to increas- ing the project's capacities and improving staff capabilities. Thus, the project planned to achieve this goal through better communication, better supervision, and clarification of effective casework and program procedures. XI.24 Union County accomplished their project goals by surmounting handicaps of staff recruitment and turnover, shortcomings in the state bureaucracy, and communication difficulties with the local private agencies. With few exceptions, the project met their expectations and accomplished what they intended to achieve. They improved their internal management and organiza- tion, making service delivery more efficient. They provided training and education to the workers that was relevant to improving services to clients. There has been an increased service capacity with the implementation of ser- vice contracts with private social agencies. The project also allotted time in this busy schedule of activities to perform education and training with many relevant commmity groups. There are still shortcomings. One of these is the problem of increasing worker monthly visitations to families. To do this, the agency will have to deal with transportation and paperwork require- ments that now interfere with the number of direct contacts made with clients. One can feel optimistic as the project enters its fourth year that many of these difficulties will be resolved. Goal 1: To focus on internal project workings in order to function more effectively as a project, particularly with regard to improving communication, improving the quality of supervision, and establishing standardized program procedures. During the first year, the Union County project's management processes, communication, supervision, and program procedures were neglected because emphasis was placed on developing and implementing treatment service contracts with community private agencies. Staff morale and the project general manage- ment received secondary attention. The first goal stated the staff's inten- tion to refocus the project's priority from the community to the internal X1.25 management of the project. The project has more than adequately satisfied the necessary steps to achieve this goal and there is indication, with few exceptions, that communi- cation and supervision have improved and program procedures have been re- fined and are more explicit. As a result, staff morale has improved and the project operation is more efficient. The entire staff preceded many of these changes with a retreat in early 1975. In the two day seminar, many of the differences among the workers and the administrative staff were aired and dealt with. Specific plans for improving the internal management were proposed. Mechanisms for communication have now been established. The entire staff now meets at least once a month to handle all administrative business and to coordinate activities among the administrative staff, response unit, supervisory units and the liaison unit. Over 85% of the staff attend these meetings, a marked improvement over the first year. In addition, the project director has begun meeting weekly with the entire supervisory and coordina- tive staff as a group. This cuts out the number of individual meetings and provides for more direct communication and input among all workers. The supervisors in turn meet weekly with their unit, either as a group or with individual workers. In these meetings, administrative information is shared with all workers. Another improvement in the communication process was provided by the staff newsletter, initiated and published by several of the workers. The. newsletter prints administrative changes and program procedures of importance, ‘coverage of staff activities, and spotlights a worker each month, to give everyone a formal introduction to each staff member. XI.26 Supervision in the project has also improved. In the administrative staff meeting, the project director meets with all supervisory and coordi- native personnel. This meeting includes specific training and modeling of group decision making and peer group supervision, that is to be practiced between the supervisor and his treatment unit. In addition to this exper- iential training, a group work expert from Trenton gave eight sessions in peer supervision to all project supervisors. Supervision faltered in the third year because the case management supervisor position was vacant for many months. Another form of supervision, case reviews, has also been implemented. The case review system began in May of 1975. On the average, 22 cases have been reviewed each month. Since January 1976, the average number of reviews increased to 29 cases. These case reviews are attended by the worker, super- visor, planner/trainer or project director, and the psychologist or nurse consultant to the project. In addition to the project case review, a multi- disciplinary team was started in July 1975. The team reviews approximately five cases each month. These case reviews have tended to improve the workers’ diagnostic and treatment planning skills. Recently, the team has decided to begin reviewing all cases at intake and have reorganized into a mini-team, consisting of the psychologist, visiting health nurse, case manager and other consultants as relevant. This will give the workers more support and consultation with difficult clients at the most critical point in the treat- ment process. There is now a rough draft of a procedures manual available to all workers. In its present form it is not being used by the staff, so the pro- ject received technical assistance from PSRI in redrafting the manual to X1.27 make it more readable and helpful to the staff. This manual has been com- pleted in the third year and distributed to staff. The project director believes that there has been a 100% improvement in the staff performance and project operation since the staff retreat. Evidence of this improvement has been reduced staff turnover, emergency fund requests being properly completed, intake and crisis situations usually handled promptly, and improvement in the quality of case management. During the spring quality site visit, the staff complained they still did not feel that they were given enough emotional support from their supervisors. This concern was given more attention in the second year and both supervisors and project director are struggling to improve this situation. Staff report a greater confidence in the project leadership and improved morale during the third year. An observer notices the improved spirit and camaraderie among the staff. Goal 2: To achieve better delivery of services for abuse and neglect clients. The project met their second goal through a reorganization of the inter- nal management of cases and through the augmentation of services for clients with service contracts with private agencies and agreements with several public agencies to give service priority to project clients. In the second year the project reorganized into (1) a response unit that works with all intakes, (2) two supervisory units, divided into geo- graphic areas, that do the ongoing case management with clients, and (3) a liaison unit which works with project clients referred to community con- tract agencies for services. At this time, all intake cases are investi- gated by the response unit and all but 10% of the cases have been assigned XI.28 to workers by geographical areas. One problem that interfered with service delivery to clients was that too few state cars were available to workers to do field visiting. This remains a problem for the project. In New Jersey state employees are not permitted to transport clients in private cars. So in the past, workers have been unable to schedule field visits for more than two days per week. The project now has three more cars but needs another two cars to allow for three field days per worker. However, the project cannot document its need for more cars, because the present method of assigning them is inefficient and all cars are not used. Due to this transportation problem, most workers are only in the field two days a week, so there has not been an increase in coverage of clients as was intended. Workers have been given permission to use their own cars if they are not transporting clients, but workers claim they need three days in the office to complete paper work and have not taken advantage of this new rule. The project also intended to improve service delivery by making avail- able to each treatment unit a case aide or volunteer who would assist the worker with direct service, e.g., transportation. In actuality, the project had one case aide assigned to work 1-1/2 days a week for only a two month period and 1-2 CETA case aides during the summer. The project was quite successful in increasing its service capacity to clients by operationalization of contracts with community family service agencies and negotiating priority with other agencies for project clients. These agreements are a major achievement, and represent a new model for com- bining the public and private agencies into a partnership to provide services X1.29 to clients. Because the BPA client forms have not been analyzed as yet we are un- able to report whether the project's reorganization or increased service capability has meant an improvement in client functioning. One nagging concern despite this progress is the fact that the workers’ monthly visitation reports have not improved and in fact decreased for some workers. This may be due to the limited cars or other statistical errors but will be given careful scrutiny by the project director if the project is refunded. Goal 3: To establish and/or use effective training programs to improve services and maintain them at a high level. The project has more than satisfactorily met the steps necessary for meeting this goal. Since there have been no staff surveys or reports regard- ing how this training has improved their work with clients, we must be satis- fied with reporting the extensive amount and kind of training provided to the Union County project staff and their contract agencies from January 1975 to April 1977. In this period of time, over 100 training sessions were pro- vided to the staff by the planner/trainer or other project staff. There were over 75 training sessions provided to the staff by outside paid con- sultants. Two series, 10 sessions each, on assertiveness training were offered to the staff on a voluntary basis. Ten staff members attended each series. The staff has taken advantage of at least 18 training workshops offered in the community. Nearly one-half of the staff are either enrolled in a master's program or attending classes and seminars offered at the com- munity colleges. Often the project reinforces staff initiative in getting training by reimbursement for outside learning. XI.30 The training sessions cover a wide range of topics including informa- tion on legal procedures, emotional abuse, hostile and resistive clients, drama therapy, family counseling, alcoholism and assertiveness training. The project staff also provided training to the contracting agencies. Over 60 training sessions were provided to the lay therapists, family ser- vice social workers, teaching homemakers, parent line volunteers, and group leaders. This training included an orientation to the project and the legal system as well as offering peer supervision to the agency group leaders, and specific training about unmotivated clients. Goal 4: To have parents and other agencies view us as a helping agency, rather than punitive, legalistic, or for crisis intervention only. The project staff worked very hard to improve the project's image as a helping agency rather than a punitive, legalistic agency. As evidenced by their community education efforts and coordination agreements, they have accomplished much during the last two years cf the project in establishing coordinative agreements with the police, courts, prosecutor, schools, hospi - tals, family service agencies, day care agencies, and other mental health services. At times, this seemed like an uphill battle due to the differences in agencies' needs and philosophies. The family service agencies and mental health agencies are now supportive of the project and its special mission to deliver services to clients, but some of the schools and hospitals remain skeptical of the project and its activities. This skepticism is due to past communication problems regarding referrals and investigations of mutual clients. x1.31 The project's relationship with the police, courts and prosecutor has improved. All parties are now trying to work together with individual clients. This success is due largely to the efforts of the legal analyst, who is able to relate to both the project and the legal system. Some evidence of the project's success has been the creation of a Union County Child Protection Council (UCCPC). During the summer of 1976 the Advisory Board reorganized into this council, independent of the project, but supportive of the project's purpose. The council has broadened member- ship to include all agencies working with children and concerned slidusny, and is performing an educational and advocacy function in the county on behalf of children. Another indication that the project has improved its image in the com- mmity is the increased number of referrals to it by other agencies for services to families rather than for the removal of children. Goal 5: To develop and explore various service modalities and assess their effectiveness. The project successfully met this goal, as indicated by the discussion of the second goal. Since the project began, at least nine new services are offered to project clients. These services are parent education classes, lay therapy, teaching homemakers, diagnostic team reviews, group therapy, individual therapy, day care, visiting health nurses, transportation, housing assistance, parent line, and other mental health services. Since these ser- vices have been offered, parent education classzs have been held serving over 50 different clients; on a monthly average, 50 clients have received lay therapy services; 30 clients have received teaching homemaker services; 100 clients have been given individual therapy; 15 clients have received group therapy; 17 slots have been made available for day care services to clients; and clients now have 35 hours of visiting nurse services available .to them each week. In addition, clients have ready access to Red Cross transportation services, housing authority assistance, welfare, and mental health services. At this time, client functioning and impact data are not available to determine the effectiveness of these services. This data will be analyzed by the end of the third year. The project is planning to complete a client satisfaction follow-up study this fall and information regarding clients’ i perceptions of the services should also be available in the third year. Goal 6: To educate society, including professionals, in child rearing methods and in the causes of abuse and neglect. The Union County project is primarily a service delivery agency, but they have also performed an outstanding function of community education and ‘training. Initially, the project staff tried to cover all requests for edu- cation, but as project management required more energy, the staff had to set priorities among the educational requests. Since the project began they have reached over 1500 people through various speeches and workshops. It is difficult to assess the impact of the project's educational efforts, but it seems apparent to the project that the recent improvements in working relationships with community agencies and the legal system, as well as the recent increase in the referral of preventive cases, are evi- dence that the project's educational efforts have been fairly successful. X1.33 IX. PROJECT MANAGEMENT AND WORKER SATISFACTION The Union County project is the largest project among the eleven demonstrations in the number of full time staff, client caseload and average monthly budget. The project employs a staff of 29 members, 25 of whom are full time, and serves an average monthly caseload of 294 clients. The average monthly budget is $44,898. The project's organizational structure is highly complex. In addi- tion to the six different disciplines actively involved in the project, it maintains intra-organizational contracts with private community agen- cies to deliver services to their clients. This multi-agency involvement in the project requires complex negotiations within the state bureaucracy including the Contracts Office and State Treasury. The project is an extension of the local district office of protective services and is aheratore highly formalized. The project must comply with carefully specified civil service requirements that dictate recruitment, hiring and promotion practices, and is subject to the formalized rules and procedures of the state and local district offices. However, within the ‘project, because of its evolutionary nature, employees perceive the agency to be highly informal. Until recently, there were no written job descrip- tions or an operating manual that described how the staff was to relate to the contracting agencies or specified arrangements for communication among the various sub-units in the project. The project is highly centralized in decision making related to pro- gram planning and policies. Ultimate decisions rest with the supervisor “in the local district office, who in turn must get clearance from her ‘superiors. The project is fairly decentralized in decisions regarding XI.34 internal work activity and daily operating procedures. Some workers report that staff participation in decision making has tended to vary depending upon the project director's preference. Many feel that they have had too little to say about decisions which directly affect their jobs. Management The Union County project, according to many observers and project staff, has had management and morale problems since its inception. Turn- over started within the first six months, when a supervisor and a social worker left the project. The management survey results tend to verify these early assumptions about the project's functioning. Over 46% of the. ‘project staff report themselves highly dissatisfied with their jobs. The project burnout rate is also very high -- over 59% are very burned out and nearly 41% are moderately burned out. The project rated the following management dimensions as being moderate to low: peer cohesion, task orien- tation, clarity, innovation and control. Job involvement, staff support, job autonomy and work pressure are ranked as moderate to high. There is no consensus regarding the ''goodness' or ''badness' of project leadership and communication. Relative to the overall mean for the eleven demonstra- tion projects, Union County is below mean on all the above management variables, with the exception of staff support and leadership, which were both on the mean. Interviews with project staff and management help illuminate the many factors that contributed to the consistently low staff morale and the workers' perception that their project, at least for most of the three years, was poorly managed. The problems that were consistently reported by the staff deal with burearcracy, project management, leadership, X1.35 communication, supervision, lack of support, and the pressure and diffi- culty in working with abusive parents. Instead of the opportunity to do innovative work with clients, staff spent, on the average, three days of a week in a maze of paperwork and bureaucratic red tape. Part of the frustration and length of time were due to the lack of information and instruction about what was required. There was no single instruction book. Rules and regulations changed regu- larly and staff were not always informed about changes. Supervisors did not have the answers. Consequently, workers learned as they went -- a painfully slow and unproductive process. Even if workers completed their paperwork in less than three days, there was no guarantee that they could spend more time with clients. Workers were required to use state cars while transporting and visiting clients. Workers who used their own cars were not always reimbursed in a timely fashion. Unfortunately, the project had only 4-6 cars available for the nearly 20 workers serving 294 clients. To add to these frustra- tions, workers were expected to visit all their clients at least once a month. Workers found it impossible to comply with visitation requirements when overwhelmed with paperwork and transportation scheduling problems, and became very discouraged and cynical. Much of the frustration and dissatisfaction evidenced among project management was related to bureaucratic civil service requirements that prevented them from hiring professionally trained workers. Because it vas nearly impossible to get special permission to employ non-civil ser- vice applicants or adjust salary scales, young and inexperienced workers were given job preference over social workers skilled in the field of XI.36 child abuse. This meant that management spent much of their time training and educating new workers. Frequently, after being trained and gaining some experience, these young workers requested transfers to other depart- ments, i.e., foster care or adoptions. Management believed that the pro- ject would have been more effective if they had been free to recruit appropriate manpower. In addition to these bureaucratic constraints, staff felt that project management was also a precipitating factor in job dissatisfaction. Many workers complained that because the first project director had to give so much attention to the community agencies in establishing contractual arrangements, she had to ignore the internal management of the project. Implementing these community service contracts required much of the direc- tor's time, but there was no effort to delegate more of the project manage- ment responsibilities to the coordinators or assistant positions. Conse- quently, many workers did not perceive an effective structure for project operation; rather, they felt the project was in perpetual crisis and dis- ruption. Because there were no job descriptions, because lines of authority were not clear and patterns of communication and working together were not specified, workers were often confused and angry about what appeared to be vague and contradictory information. Workers were further confused because they faced jobs that required investigation and supervision, but perceived that they were expected to do therapy and treatment with their clients since this was the major focus of training. The issues of work roles and dissatisfaction with project management were never addressed directly by the workers in staff meetings. X1.37 Supervision was another continuing source of frustration to the work- ers. Staff never felt that anyone knew what they were doing with clients or that they were given good direction and feedback in their work with clients. The quality of supervision tended to decrease when supervisors were under additional pressures from upper management. It appeared that supervisors spent more of their time monitoring paperwork than in develop- ing cohesive work units and providing direct guidance and assistance for working with clients. The supervisors themselves complained that they had never been given adequate supervision, training or support in doing their jobs. In fact, they often felt overly criticized and under-appreciated. Everyone in the project felt the need for more support and positive feedback. Workers were not particularly cohesive or supportive. Since the workers are divided into specialty sub-units, there was little time or opportunity for sharing with each other. There was no organized way for supervisors to give each other support. Many workers who burned out in this job attributed the lack of support and sharing as a critical ele- ment in their demise. Finally, many of the workers reported that working with angry, hos- tile clients day after day was an important factor in burning out. This was particularly true of the intake workers who found their work grueling, working with 5-10 intakes a week, many of which were difficult physical and sexual abuse cases. There seemed to be no time to rest because the unit was always short a worker. Other workers felt that the work with abuse clients was very traumatic. They were making decisions that directly affected the future life of the child and the family. Due to limitations in supervision and support, some social workers acted without the confidence XI.38 that they were ''making the right decision" and often felt guilty about re- moving children or taking a family to court. Another aspect of working with clients that frustrated workers was the amount of time and energy needed to deal with public agencies and the struggle of getting needed services for clients. Many times there just were no resources. Many workers found this work discouraging and left the agency. While many of these management problems continued to nag the project for the full three years, all workers interviewed reported that project leadership and staff morale improved in the third year. During the second and third year the new director began to build a structure for internal project organization. Staff communication improved. There were now regu- larly scheduled staff meetings in which workers' gripes were aired and information was shared clearly and directly. Some group decision making was encouraged. All supervisors met with middle management for program planning and to make decisions that directly affected project operation. Supervisors began to work more closely with their units and case reviews were regularly scheduled. Despite the fact that many bureaucratic con- straints remained, workers were more excited about their jobs and the work they were doing with clients. To many, it was very sad that as the project began to resolve many of its internal problems and was able to operation- alize its model program, federal funding was ending. X1.39 X. ANALYSIS OF CLIENT DATA Client Flow The process for identifying, diagnosing and managing cases has evolved over the three-year period. While there have been only a few structural changes in the client flow process, refinement and clarification of the process has tended to facilitate client movement through the system. During the last year and one half, the process was generally as follows. The initial referrals, received primarily from schools, hospitals and police, go through the screening unit, which is part of the original Union County District Office. Upon determining that a referral is a possible abuse or neglect case, the screening worker refers it to the project's Response Unit Super- visor, who in turn assigns it to a response worker for investigation and assessment. A home visit is made immediately if the case appears to in- volve a crisis situation (or within 72 hours in other situations), and needed services, such as emergency funds, can be provided at this point. All abuse and neglect cases are reported to the Central Registry, sub- stantiated or not (unsubstantiated cases are identified as such). After the initial assessment and investigation has been completed, the case is reviewed by the Mini-Team (consisting of the visiting health nurse, psycho- logist, project case manager, and relevant consultants) and the appropriate project staff. A treatment plan is developed. The case may be transferred to a worker in one of the supervision units appropriate to the client's geographical area in the county, or assigned to the liaison unit to be served by one of the contracting agencies. Clients may receive counseling from the project worker or family service agency workers, and/or one or more of the services available through the contracting agencies, including XI.40 homemaking, day care, and lay therapy. Some cases receive counseling only; some receive counseling and other services; some cases are effectively "transferred" to one of the contracting family service agencies. Such cases are considered to be "inactive with the project and are only moni- tored" by the liaison unit. The contracting agency becomes the primary worker on the case. Regardless of whether the primary worker is on the project staff or part of a contracting agency, all cases are reviewed at a quarterly con- ference attended by the primary worker, the supervisor, and possibly other consultants. If the case had been assigned to a family service agency, that worker along with the project liaison staff member and supervisor will be involved in the review. Before termination, all cases are reviewed by the worker's supervisor and ultimately by the case manager to deter- mine conformance with the project's termination criteria. The project has no specific follow-up policy or procedures for reviewing client status after termination; however, individual workers often make one or more tele- phone calls as follow-up on terminated clients. Client Characteristics As can be seen on Table 1, cases were referred to the project from a variety of sources, most notably hospitals (19%), social service agen- cies (17%), schools (15%), law enforcement (11%), and other agencies (14%). Private physician referrals accounted for only 1% of project intakes. Thirty-two percent of these referrals had a previous record or evidence of maltreatment. The characteristics of these referrals seem to conform to the project's criteria of serving all physical abuse referrals and ex- tending services to potential abuse/neglect cases when possible. The XI.41 greatest proportion of the project's caseload was physical abuse (27%) and neglect (28%). About 23% were potential abuse or neglect. Thirty-three percent of the cases were categorized as cases in which serious maltreat- ment had occurred, but only 5% of the project's cases received court hear- ings. This seems consistent with the project's goal of working with the families and reducing court intervention to extreme cases. In 52% of the cases the mother was the reported abuser; in 22% of the cases both mother and father were thought to be abusers. Only 9% of the abusers reported being abused as a child. In 37% of the cases there is only one adult in the family. The aver- age number of children per family was 2.7, but in nearly 30% of the cases there were four or more children. About two-thirds of the families had preschoolers in the home. Interestingly, only 27% of less than one-third of the families reported heavy, continuous child care as a problem. Inadequate education and low income were both consistent project caseload characteristics. In almost 75% of the families, neither the mother nor father had a high school degree. The average yestly income was $7500, but 67% of the families had an average income of $5501 or less. In 38% of the cases no one in the household was employed and the family received public assistance. In addition to the above economic and epLovaent problems, 33% of the families experienced marital difficulties, 29% had mental health problems, 24% experienced social isolation, 15% had physical health problems, 15% experienced alcoholism, and 12% of the families had overcrowded housing. Most of the cases referred to the project received services. Of those 10 cases rejected for services, five were outside the project guidelines, five were unconfirmed reports, and three could not be located. XI.42 of these cases were referred to other social agencies. Table 1 Client Characteristics Source of Referral Private physician . « « « . « Hospital. . . Social service agency * School. « + « + + Law enforcement . Court . v EEA ER Parent. « « + 3 « ww « ® © = » Sibling . Relative. a Acquaintance/neighbor ; Self. _ Anonymous . . . . . . Other agency. . . . . Type of Maltreatment Potential abuse or neglect only Emotional maltreatment only . . Sexual abuse. Physical abuse. Physical neglect. . . : Physical abuse & neglect. Severity of Assault Not serious . . . . . Serious . Responsibility for Maltreatment Mother. . . . . . . . Father. Both. Other . Legal Action Taken None. . . . coe ov Court hearing ‘ : : Reported to mandated agency . 1% 119% 17% .15% 11% 3% 0, 0 7% « 5% .14% .23% .14% . 5% 27% .28% 0 0 .67% .33% .52% .22% .22% Only two Previous Record/Evidence of Maltreatment None, . . . . e vw 408% Previous record/evidence. v vw w32% Demographic Information Average number of children in family . . . . . . . . . . 2.7 Families with preschoolers. . . .65% Families with one adult . .37% Families with no high school degree . . . . . «ow .71% Families with no minorities . . 39% Families with no one employed . .38% Average family income . . . . .$7500 Average age of mother . . . »31 yrs. Average age of father . v +36 yrs, Problems in Household Leading to Maltreatment Marital . + + » 035% Job related . Zz 47 .10% Alcoholism. .15% Drugs . . : . 8% Physical health : .18% Mental health . ’ sv +29% New baby. . # s vv wv 9% Argument /fight. . v «+ 18% Financial problems. s » vw » » 485% Social isolation. . . .24% Overcrowded housing . a «12% Heavy continuous child care . 27% (N=370) XI.43 The Quality of Case Management In general, the project's case management practices were adequate. As shown on Table 2, for almost 40% of the cases the first contact occurred on the same day as the referral. And in close to 90% of the cases, contacts were made with the referral source to obtain background information about the case, and almost as frequently to provide reports on case progress. In almost 30% of the cases no contact was made with the referred client for at least a month. In a majority of the cases, the treatment plan was begun after the first or second contact. Less than one-quarter of the cases received a multidisciplinary review, but 34% of the cases re- ceived a case conference at least once, typically during treatment, In a majority of the cases no consultant was used to develop the treatment plan. In about one-fifth of the cases clients participated in the multi- disciplinary team review or case conference. For most of the cases reviewed (75%), there was only one case manager throughout treatment, but in close to half of the cases a person other than the case manager took primary responsibility for intake. In 45% of the cases, only the case manager provided services to the client, but in 32% of the cases at least one extra worker provided treatment services, and in 21% there were two extra workers providing treatment to the family. Eighty-eight percent of the clients received two or less follow-up visits or contacts after termination. The quality case reviewers reported that the Union County project is doing a good job of case management in light of bureaucratic require- ments and large caseloads. Many cases are being carried that are not really protective service in nature, but are preventive or potential abuse and neglect cases that are so designated in order to quality for necessary XI.44 purchased services. Consequently, workers tend to be overwhelmed by large caseload sizes. Despite this, the project maintains well written, coherent records (although BPA forms are often not completed); the response to re- ferrals is quick, and service and information from outside providers are well coordinated by project workers. Follow-up after termination is carried out by many workers, but is an individual decision since the agency has no follow-up policy. There were a number of specific problem areas in the project's case management. The sample of cases indicated a long time lag between comple- tion of intake and transfer to services. However, the recent project re- organization is designed to improve this problem. The diagnostic team is not being used to its full potential, nor are outside consultants being used. Cases are often terminated without an evaluation as to the appro- priateness of such action. Some of these case management problems are due to the lack of scheduled formal meetings for supervision and communication problems. As a result, social workers often must rely on themselves of peers for support and consultation. XI.45 Table 2 Case Management Characteristics* Time Between Referral and First Client Contact Same day, . « + « « « + o . 39% 1-333Y8. + + « 2 5% 2 5 & x » 215% 4-7 dAYS. v + ss « 5» ow 5 » x « 4 2% Within two weeks. . . . . . . . . 6% Within one month. . . . . . .11% Over one month. . . . . . . .28% Number of Client Contacts (after initial contact) Before Treatment Plan None. . . dumm. .28% ONG + vv oo oo « 5 « & 5» .36% THO + ov 5.0 & ow « «oa » 5 » «235% Three-five. . . . . . . . . . . . 4% Over five . «. = « « = ov = » » » « 9% Time Between First Client Contact and First Treatment Service Within two weeks. ¢« © 8 41% Two weeks to one month. . . . . .18% Over one month. . . . . . . . . .16% No services given . .25% Use of Multidisciplinary Review Team At least one review . .14% Review during intake. . . . . . . 5% Review during treatment . .13% Review at termination** . . 9% Use of Case Conferences (staffings) At least one conference . .54% Conference during intake. . . . .31% Conference during treatment . .45% Conference at termination** . 41% Use of Consultants None. . . . . . . . . ... 77% One . . . . . « «vv vv vv... 4% Two . . . . . . . . .......0 Three-five. . . . . . . . . 12% Over Five . ¢ ov » o » « » ow .« =» = 8% Client Participation Client presence at MDTs and/or case conferences . . . . . . . .14% Contact With Referral Source For background information. .84% For progress reports. . . . . . .68% Responsibility for Intake Current case manager. . . . . .58% Other staff member. . . . . . . .42% Number of Case Managers ONE 's o wu 0 & su 4 wu # .76% TWO « = © & + © # u & « ».& & "17% More than two . . . . . . . . . . 7% Reason for Two or More Case Managers Joint management. . . . . . . .N= 2 Staff turnover. . . . . . . . .N=5 Staff unavailability. . . . . .N= 2 Lack of success with client . .N= 4 Other «. « + + + a ss un = » » » N= 3 Number of Treatment Providers in Project (other than case manager) None. . 4 + « « + 6% wt wu vw & .45% One « « 5% « + 5s ¢« » » u » & ». 052% Two . v wm vw Ee 21% Three-five. . . . . . . . . . . . 2% Over five . v + v« 5 v v 2 « wo +» 0 (Table 2 continued on following page) XI.46 Table 2 (continued) Services from Outside Agencies. .78% Follow-Up Contacts** Evidence of Communication With At least one contact (client/ : : other agency). + « + « «+ = » « «39% (rtside Agencies. + » . + + Lon Two or less with client . . . . .88% - Three-five. . . . . . . . . . . .12% Frequency of Contact by Case Over five . . « . « ¢ + + + 4 « 3.0 Managers Length of Time in Treatment** Once per woek OF MOTE « uw o + » +22% Up to three months. . . . . . . .12% Once or twice per month . . . . .25% 3-12 months 5 + « vs +» 2 5 & + = +70% Less than once per month. . . . .14% : : 1-2 Years . « « + + + +» +» » +» » =18% Once or twice only. . . . . . . «12% Over Two VesTd 0 Varied over time. . . . . . . . .18% oY tern nnn ne None. « » « + » s « = « » » +» «10% Total cases reviewed = 51; total terminated cases = 44. * Owing to rounding, percentages may not sum to 100%. * % Terminated cases only. XI.47 XI. COMMUNITY IMPACT Summary The Union County demonstration project began to operationalize the cen- tralized child abuse system mandated in the Dodd Law, and began to give meaning to the law's intention that 'the best interests of children be pro- tected by both the courts and social service agencies." They accomplished this by developing a network of services available to families that relate to the social-economic needs as well as emotional needs of families. The protective service agency has become a funnel through which clients are directed to therapeutic services in the community without having to nego- tiate the system alone. Consequently, as the community agencies have become more involved with the project and increased their awareness of the abuse and neglect problem, they are playing more aviive roles in advocating for both the project and clients to ensure an ongoing financial and philosophical commitment from the state. In addition, the coordinative relationships between the project and the police, courts, and prosecutor's office have improved, making investi- gation and court presentations smoother and more considerate of children's best interests. The legal analyst has also assisted protective service workers in better documenting of court presentations. As a result, the judges feel that they can make better decision for the children's futures. Formerly through the project's advisory board, and now through the Union County Child Protection Council, there exists a forum for coordinating the community effort in addressing the shortcomings in the community system and an impetus for social change. XI.48 As the project struggles to gain state refunding, there seems to be a commitment from the community to upgrade the nature and quality of services that are provided to clients through the protective service mandate. In many ways this growing involvement from the community has been sparked by the project's image of a public and private partnership that could meet the needs of families and children in the community. Community System Operation The 1974 New Jersey State legislature passed the Dodd Law, designating protective services (DYFS) as the primary agent for investigating, diagnos- ing, and treating children who have been abused or neglected. The Dodd Law was implemented on January 1, 1975 and provides for greater protection by allowing police, probation officers and DYFS workers to remove children with- out parental consent or court order in cases of imminent danger. It also provides for legal representation for parents and children, and provides for therapeutic services (homemaker, day care, etc.). Prior to the revision, multiple agencies, primarily the police, prosecutor's office, courts and DYFS, operated in the identification and investigation of abused and ne- glected children. The hospitals and schools, upon identification of a pos- sible abuse or neglect situation, notified one or more of the above agents. Among these investigative agents, only DYFS provided treatment to the parents. This treatment usually consisted of social work counseling, case management, advocacy and ancillary services, i.e., day care, food stamps and welfare assistance. With the advent of the Dodd Law, the reporting system was centralized, all persons were to refer suspected cases of abuse and neglect to DYFS, who XI.49 would, in turn, investigate and do all treatment planning and supervision of the family. Because protective services had only five full-time workers assigned to assist these families, staff was unable to deliver the kind and quality of intervention intended by the law. The Union County district office wrote a grant requesting funds from the federal government to demon- strate the level of programming needed to comply with the revision require- ments. When the project was funded, it was given the responsibility for investigation, case management and treatment provision for abused and ne- glected children in the county. Since the project's inception, a number of major changes have occurred in the child abuse system's functioning. Now, due to the project's manpower resources, the centralized structure for reporting, investigation and treat- ment planning, described in the Dodd Law, is being implemented in Union County. All major reporting agencies, including police, courts, schools and hospitals, recognize that the project is responsible for investigation and case management and are now referring most of their cases to the dis- trict office's screening unit to be routed to the project. Occasionally, the police accompany the DYFS worker during investigation of severe cases. For all substantiated abuse/neglect cases the DYFS worker tries to include the reporting agencies in the treatment planning process. Despite the increased manpower available through the project to work with child abuse clients, some agencies report that problems still exist with the investigation process. The hospitals report that there are delays between reporting of a case to DYFS and the project's response and investi- gation. The project believes that the delays are due primarily to the dis- trict office's screening unit and the system's mechanics for client flow XI.S0 to the project. Therefore, in those situations when speedy investigations. are required, the hospital social worker will call the prosecutor's office or the police. The prosecutor's office and the police state that they then contact DYFS regarding the hospital's referral, but often time has elapsed. Thus, there is some slippage and cases get lost. A particular problem with this reporting arrangement between the prosecutor and the project is the difference in the criteria used in judging whether a case should be crimi- nally prosecuted or referred to DYFS for treatment intervention. Consequently, if cases are reported directly to the prosecutor's office and then reported to DYFS, they are subjected to the discretion of the prosecutor and may not be referred to protective services immediately. Due to the educational and coordinative efforts of the project's legal analyst, many of these differences in definition and criteria regarding case investigation and disposition with the police and prosecutor are being resolved. A new DYFS policy was imple- mented during the third year in which all DYFS workers must report abuse cases that meet certain criteria, as defined in a formal policy agreement between DYFS and the statewide Prosecutor's Association, to the prosecu- tor's office. Another factor that had contributed to delays by DYFS in investigation of referrals was the amount of time spent in commuting between Elizabeth and outlying areas in the county. This was specifically a problem with referrals from Plainfield. Although the project has the use of an office in the United Family and Children's Society in Plainfield, it is not well utilized. In the third year DYFS established a Plainfield office that houses its own screening unit, and response and supervision workers on a rotating basis from the project. This new facility has solved the problems of delay in X1.51 investigation caused by commuting distances. One improvement in the Union County child abuse system has been to in- crease treatment resources for all clients who receive services from the demonstration project. Through partnership agreements with local private social agencies, the following services have been made available: indi- vidual, couples, family or group counseling; lay therapy; day care, home- maker services; visiting nurse services; crisis intervention; 24-hour hot line, 24-hour coverage; parent education classes; medical care; temporary placement of children; parent line; and advocacy services. In addition to these services, the project began a multidisciplinary team in Elizabeth to review difficult cases and to improve diagnosis and treatment planning by project staff. | Outreach and prevention efforts with high risk or potential child abuse families are almost non-existent in Union County. The project's own minimal efforts in the areas of prevention and outreach have been mostly educational speeches with community groups, schools, colleges and local agencies on iden- tification, etiology of child abuse, and increased knowledge of the project's purposes. The Elizabeth public school system operates an exciting preven- tive program providing day care and education to children of high school students, preventing high school dropouts and also modeling health parenting skills to teenage mothers. Currently, there are no plans by any other com- munity agency to develop outreach and preventive activities. As resources have become more scarce in New Jersey, agencies are struggling just to main- tain current program levels and the community seems to have little capacity for developing preventive programs. XI.52 Caseload Size and Case Outcomes It is difficult to determine from available data the actual increase in reported incidence of child abuse and neglect cases in Union County. Unfortunately, the data collected for the years 1973, 1974 and 1975 are not comparable. For example, 1973 and 1974 data represent numbers of children reported and 1975 data represent number of families reported. The follow- ing table, however, indicates that there is definitely some increase in reporting, although probably not the exact increase shown. Table 3 Numbers of Referrals to Protective Service Agency, 1973-1976 1973 1974 1975 1976 Total number of referrals* 380 372 547 na * The referrals include abuse, neglect, and other miscellaneous problems. Data available to state-wide evaluators indicate that Union County has had the most significant increase in reports and referrals of any county in New Jersey. These increases may be a reflection of the intense educational and coordinative efforts by the project with the schools, hospitals, police, prosecutors, and community agencies regarding the etiology of abuse and neglect, reporting procedures, and information about the project's purposes and services. XI.53 Legislation The Dodd Law on child abuse was passed in 1974 and implemented January 1, 1975, and established DYFS as the mandated agency to reccive all reports. Under the earlier law, the prosecutor's office had played part of this role. The law has not changed since the inception of the project. A legislative committee of the project's advisory board was appointed to review the Dodd Law and to draft recommendations for amending the law. This amendment is still pending. Many sections of the law were vague and confusing, the defi- nitions of abuse and neglect were subject to wide interpretations, and reporting requirements and responsibilities were unclear. One bottleneck in the legislative area has been a recent change in policy by a local hospital, which, responding to its legal advisor's recom- mendations, refused to examine or treat any child without parental consent or court order. This action was motivated by a growing concern about poten- tial lawsuits. The project legal analyst has negotiated arrangements for special phone court orders to be made available to the hospital in those situations where parents refuse permission for examination and treatment of their children. The hospital has agreed to perform exams on children that are placed in the shelter, but otherwise the hospital has not relented on its legally protectivist stand. This incident has strengthened the commit- tee's motivation to make the law's intention more explicit. The committee drafted a tentative revision to the law and sent it to the Citizen's Committee for Children of New Jersey, the original task force that advocated more services to children. The project legal analyst is a member of its Public Policy Committee, which reviews legislation regarding children. A bill was also drafted to amend language in the Dodd Law to give hospitals the right to examine and treat children without parental con- sent. In the meantime, the county prosecutor, with the endorsement of the legislative committee, drafted his own bill to the state legislature, re- quiring all doctors to report to the prosecutor's office directly. When the bill did not pass, a new policy was implemented that required all DYFS workers to report all cases of abuse to the local prosecutor's office. Community Resources Increases in manpower resources assigned to work with abuse and ne- glect clients in the last three years have been the addition of the 19 pro- ject staff members and a lay therapist, and a specially trained juvenile police officer to work closely on an informal basis with project response workers doing investigations in Elizabeth. Because of the project, average abuse and neglect caseloads have been reduced from 25-30 cases to 15-20 cases, creating the potential for clients to receive more individualized attention. The other major increase in manpower resources allocated to work with abuse and neglect clients has been among the private agencies contracted by the project. Through their participation with the project, the equiva- lent of four MSW social workers, eight lay therapists, one public health nurse, six teaching homemakers, and day care slots have been added (17 at one point; currently 10 PRS slots). More difficult to estimate are the increased staff contributions from other agencies in the community who are seeing the abuse/neglect clients whenever requested through informal agreements with the project. X1.55 The hospitals, schools and courts have not significantly changed the number of staff assigned to work with abuse and neglect clients during the last three years. These agencies depend on the protective service project to provide treatment and case management services for most abuse and neglect clients. In addition to these manpower changes, many new services for abuse and neglect clients have become available in Union County since funding of the demonstration project. Most of these have been added by protective services, but other community agencies are also now providing additional services, as indicated in Table 4. Comparison of Services to Abuse/Neglect Clients, Before and After XI.56 Table 4 Initiation of Union County Demonstration Project in 1974 Protective Other Services Services Court | Police| Hospital | Schools | Agencies Investigation x, + + X, + XxX, + Outreach Diagnostic team case review x Social work counseling Xx, ¥ X, + X, + Parent aide/lay therapist X Group counseling X X Parents Anonymous Individual/couples counselin X X 24-hour reporting Xx, + Crisis intervention X X Child management classes X X Provide referrals to others xX, + XxX, + x, + Homemaking X Outpatient care xX, + Medical care xX, + Public health nurse Xx X Residential care Xx, + Day care (Title XX, purchased)| x, + X Therapeutic day care X Crisis nursery Removal of child x, + Xx, + X, + Foster care x, + Advocacy/ancillary service X, * Follow-up Protective service X Transportation X X CODE: + = services provided before project x = services provided since project X1.57 Community System Coordination Coordination of social services, as in many communities, has always been a major problem in Union County. In order to implement the intent of the Dodd Law, the DYFS project was faced with improving coordination and referrals to the project as well as developing a network of services for clients supervised by the project. The target agencies most associated with referrals to the project were courts, schools, police, prosecutor's office, and hospitals. The legal ana- lyst and project director developed formalized agreements and procedures for referral and mutual handling of cases with the prosecutor's office, courts and police. Informal agreements have been made with several indi- vidual schools and hospitals throughout the county. Although there have been problems between the project and these agencies in the past, e.g., the hospitals had been dissatisfied with she delays by project staff in investi- gation of referrals, and there are differences in philosophy between the prosecutor and the project staff, most agree that many of these conflicts have been resolved by the recent effort ta have more frequent communication among all concerned parties. All agencies enthusiastically report that the project has made much progress in improving community relations. In the past, the Union County Protective Services Unit of DYFS lacked a network of agencies to which they could refer their clients with any guar- antee that services would be delivered. Now, after three years of project operation, there has been a substantial increase in the number and kind of services available to the project as described above. Coordination between private agencies and the project was developed partially by contracting with private agencies to deliver both the counseling XI.58 and concrete services to the project's clients. Homemakers, visiting health nurses, day care, family service agencies, Red Cross transportation and Kean College parent line were among the agencies the project contracted with. To facilitate coordination, a legal analyst, administrative assistant and the liaison unit were assigned within the project to oversee the daily work- ing relationships with all contract agencies. Through the creative use of private social services in the community, the project has minimized dupli- cations of services in the community and has made it possible for local, traditional agencies to become involved in delivering meaningful services to multi-problem families. Another area in which the project enhanced coordination with private agencies was through their advisory board, made up of representatives fron all the major social agencies in the community. The advisory board has been the forum for airing many of the problems associated with tying together public and private agencies, e.g., agencies' accountability, budget issues, disagreements regarding territory and responsibility, referral procedures, and sclection of appropriate clients for services. Education and Public Awareness Over five years ago, the Citizens' Committee for Children of New Jer- sey began a campaign to increase the community's knowledge and awareness of child abuse and to expose the gross deficiencies in community services available for children. Due to the impetus created by their campaign and continued vigilance in educating the community, the project receivec commun- ity support to develop a new model for protective services which could make available more intense advocacy and treatment services to families and children in trouble. - Since the project's beginning three years ago, the staff, along with the Citizens' Committee, continued the commitment to increase the community awareness and included educational efforts as part of the project's respon- sibilities. The project spent a great deal of time in the first year speaking with schools, courts, police, community groups, college classes, hospitals, day care organizations, mental health agencies, and other pro- fessional groups, trying to increase the knowledge of the participants in the areas of stress factors leading to abuse and neglect, the detection and reporting procedures outlined in the law, and the project's efforts to pro- vide treatment alternatives to prosecution or removal of children from homes. In the project's educational focus they have concentrated on increasing the community's trust in protective services as a therapeutic intervention with families. In keeping with their commitment, the project staff has conducted or participated in over 15 TV appearances, five radio spots, three press con- ferences, one open house, one county-wide conference run by the project, and over 150 separate educational presentations. Of these educational pre- sentations, about 50% were concerned with improving the knowledge of the etiology of abuse, about 20% focused on increasing reporting knowledge, and about 30% emphasized the project's purpose and operation. Most of these educational efforts took place during the first and third years. During the second year the project concentrated on improving inter-agency coordination and education. However, the project director, legal analyst, planner-trainer, and community liaison continued to speak with community groups, police, schools, day care providers, and college classes. XI.60 During the second year, the project increased the amount and diversity of in-service staff training, and used these opportunities to invite pro- tective service workers from other offices and welfare workers in the county to participate with them. During the third year, a greater variety of project staff, at various levels, became involved in public education and speaking engagements. This increased the total number of community education requests that could be filled and also offered a welcome respite from case management responsibili- ties. The police department has also participated in some of the workshops offered by the project, and has invited the project's legal analyst to attend their sestings and talk with the officers regarding the problems of abuse, reporting procedures, and coordination efforts. Two of the officers in the juvenile division have attended a special workshop on abuse and neglect, and are considered to be the department's '"experts' on child abuse. The police in turn give talks to the community, primarily the elementary grades of school and civic groups, in which they incorporate information about abuse and neglect. The hospitals have intensified their efforts to educate the doctors and nurses regarding child abuse, detection and reporting. Recently the community hospital in Elizabeth set up a new educational department which will be responsible for educating the staff and community groups. Muhlenberg Hospital, a teaching facility, is also increasing the level and depth of education to residents and staff doctors regarding abuse and neglect and the proper procedures for handling cases seen in the hospital. XI.61 XII. RESOURCE ALLOCATION AND SERVICE VOLUME AND COSTS The allocation of the project's resources, time and dollars are good descriptors of program activities. Table 5 depicts the average alloca- tion of both time and dollars for the year 1976. As is evident in the table, a total number of 23.72 person years, or 49,344 hours, were used by the project. The project's average monthly caseload was 294 cases. The corresponding budget for the year, not including the dollar value of donated resources, was $669,744. About one-third of the project resources were utilized for other- than direct treatment services. About 3% of the time and 2% of the budget was allocated for community and professional education activities, and 3% of the budget and time was allocated to community coordination. General overhead functions account for 30% of the time and 33% of the budget. These activities included staff development and training, program planning, and day-to-day project management. Table 5 also shows how time and dollars were allocated to specific treatment activities, the typical monthly volume of service units offered in each treatment service category, and the average unit costs. Over 57% of the project budget and 50% of the staff time was spent on direct ser- vices, intake and initial diagnosis, individual and group counseling, case management and referrals to contract and community agencies. The most fre- quently offered services were case management (with a monthly average of 294) and individual counseling (with a monthly average of 354), but other services offered consistently as part of the project's range of services included intake and initial diagnosis (with a monthly average of 30), multi- disciplinary team reviews (with a monthly average of 49), lay therapy a Al .D<& Table 3: Project Resource Allocation and Service Costs B Resource Allocation to Volume and Unit Costs of Services Activities Average Average Annual Annual Average Average Time Budget Annual Unit Cost Activity Allocation | Allocation | Average Monthly Volume | Unit Cost | to Community fT Sere ry 3S TL EER. T Sra Community Education 1% 1% Professional Education 2 1 Coordination 3 3 Legislation/Policy go — Staff Development/Training 11 12 Program Planning/Development 2 1 General Management 17 20 Project Research 3 BPA Evaluation 5 3 Outreach 1 40 cases $ 7.55 $ 7.55 Intake/Initial Diagnosis 5 3 30 intakes 48.78 48.78 Case Management/Review 24 18 294 average caseload 33.36 33.70 Court Case Activities 4 2 6 contacts 238.64 238.64 Crisis Intervention During Intake 1 1 68 contacts 3.57 3.37 Multidisciplinary Team Review 3 2 49 reviews 22.33 23.65 Individual Counseling 7 4 354 contacts 6.25 6.25 Parent Aide/Lay Therapy 1 5 119 contacts 21.96 24.14 Couples Counseling -- 2 22 contacts 45.61 47.32 Family Counseling 1 2 31 contacts 37.29 39.06 24-lour Hotline -- -- 31 calls 1.40 1.40 Individual Therapy -- 4 48 contacts 43.30 46.49 Group Therapy -- -- 28 person-sessions 10.39 10.39 Parent Education Classes 1 -- 36 person-sessions 6.58 6.58 Crisis Intervention After Intake 1 3 181 contacts 10.14 10.14 Day Care -- 3 492 child-sessions 4.11 4,11 Child Development Program -- 3 7 child-sessions 197.43 197.43 Play Therapy -- -- 1 child-session 135.00 135.00 Special Child Therapy -- 1 7 contacts 69.75 69.75 Homemaking -- 4 191 contacts 12.99 12.99 Medical Care 1 1 64 visits 7.65 7.65 Babysitting/Child Care 1 1 11 child-hours 4.78 4.78 Transportation/Waiting 3 3 148 rides 10.51 10.61 Emergency funds -- -- 11 payments -- -- Psychological/Other Testing -- -- 3 person-tests 39.46 39.46 Follow-Up -- -- 3 person follow-ups 80.47 80.47 Total Annual Person Years/Budget 23.72 $669,744 Average Monthly Caseload = 294 EE ———— XI.63 counseling (with 119 contacts a month), couples counseling (22 contacts a month), group therapy (28 person-sessions a month), and parent education classes (36 person-sessions a month). Additionally, the project offered 181 crisis intervention contacts, 11 units of babysitting and 148 transpor- tation contacts. These service units tended to be under-reported because many of the services were provided by contracting private agencies in the community, and these agencies did not always keep precise counts of the number of individual contacts or attendance at their groups. The project costs tended to be stable over time with several excep- tions. Due to delays in activating the use of emergency funds, more was spent in the last year than in the first two years of the project. Also, there were fluctuations in the budget when contracts for the hotline and homemakers were finalized in the last year, increasing costs from those of the first two YSaTS. Other changes in costs over time are due to cost reporting procedures becoming more accurate in the later cost accounting periods. The only donated time, 140 hours or $581 dollars, was devoted to the area of project research. U.C. BERKELEY LIBRARIES C022341571