Child Abuse Review Vol. 5: 91-102 (1996)

Child Protection Decision-Making

The effects of interagency collaboration on risk assessment in child protection practice were analysed in respect of the decision-making processes in child death inquiries. Universal features in the assessment of risk as identified in psychological literature were applied; in particular, the concepts of ‘groupthink’, the ‘certainty effect’ and ‘group polarization’. It is suggested that case conference decisions are inherently more risky than those taken by professionals with individual responsibility because of the way in which cases are framed in terms of losses.

KEY WORDS: risk; decision-making; case conferences; groupthink; certainty effect: group polarization; losses; gains

hild protection practice in the UK has developed C largely in response to the recommendations of public inquiries into the deaths of children already known to child care workers. Although these deaths may be atypical of child abuse generally (Hallet and Birchall, 1992); clusters of inquiries, most particularly that of Maria Colwell (DHSS, 1974) and the London inquiries, have been extremely influ- ential in focusing public and professional concern on who was most culpable and what lessons needed to be learned.

While complaining about the blame attached to them, social workers have been remarkably acquiescent in sub- scribing to the remedies prescribed. These remedies have been mostly concerned with increasing interagency colla- boration so that perceived deficits in informational flow could be removed and, by implication, risk prediction therefore made more accurate. Coordination and collabora- tion have been uncritically characterized as beneficial and essential, the result being a plethora of government guide- lines and training packages (see, for example, Adcock, White and Hollows, 1991; Lewis, Shemmings and Thorburn, 1992). Despite the establishment of an elaborate bureau- cratic procedural system, in practice little seems to have changed, as child deaths remain at the same level as previously (Central Statistical Office, 1994). Additionally

Address for correspondence: Ms Nancy Kelly, School of Human and Healrh Sciences, Universiry of Huddersfield, Huddersfield HDI 3DH, UR. Tel: 0484 422288, EXI. 2572. Fax: 0484472794.

Nancy Kelly Judith Milner School of Human and Health Sciences University of Huddersfield

‘Deaths may be atypical of child abuse generally’

‘ A plethora of government guidelines and training packages’

CCC O952-9136/96/020091-12 @ 1996 by John Wiley & Sons, Ltd.

Accepted 15 November 1995

92 KelIy and Milner

Hallett and Birchall (1992) contend that interagency col- laboration is problematic and difficult to implement.

Social work literature to date has identified a number of factors that may contribute to these difficulties, most notably problems around the exchange and use of appropriate information (DHSS, 1974; Reder, Duncan and Gray, 1993). The implicit reasoning behind the implementation of interagency collaboration seemed to be that improved informational flow would necessarily improve the assess- ment of risk. However, assessing risk is central to all organizational decisions and therefore has universal features. Potentially useful psychological explanations of decision processes that occur regularly in situations involving poten- tial losses and gains can be applied to the child protection context. Their possible influence on child protection decision-making is described below.

The first stage of the research attempted to identify an appropriate psychological model outlining group decision processes, which was then applied to the decisions as detailed in case conference minutes. Case conference minutes were chosen because of their centrality in child protection procedures (Home Office, 1991; DOH, 1992). The detailed minutes most readily available were those contained in several death inquiry reports: most notably those of Maria Colwell (DHSS, 1974), Tyra Henry (London Borough of Lambeth, 1985), Jasmine Beckford (London Borough of Brent, 1987) and Kimberley Carlile (London Borough of Greenwich, 1987). The Auckland and Orkney inquiries (DHSS, 1975; Secretary of State for Scotland, 1992) were also studied, but these do not contain sufficient verbatim detail to meet the requirements of the chosen methodology.

Documentary analysis (Hakim, 1987; Scott, 1990; Forster, 1994) was chosen as a method of non-intrusive investigation. I t is a technique which can be used when applying a different perspective to the research topic; further, it is a method that makes full use of contextual information already collated (Hakim, 1993). It is also particularly relevant for research in decision-making as potentially the actions of powerful people are under investigation. This constitutes ‘researching up’ and therefore the more traditional interviewing/semi- structured interviewing methods would have had limited usefulness (Walford, 1994).

‘The research attempted to identzyy an appropriate psychological model outlining group decision processes’

‘ Documen tary analysis was chosen as a method of non- intrusive investigation’

Groupthink

The first hypothesis was that the concept of ‘groupthink’ might provide an explanation for the processes and

Child Protection Decision-Making

decisional outcomes in child death inquiries. Janis (1982, 1989) developed this concept to explain foreign policy fiascos such as the Bay of Pigs and the Cuban missile disaster. He used the term ‘groupthink’ to describe a form of defective decision-making which he found in high-powered decision contexts. He characterises groupthink as:

‘. . . a mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when members’ striving for unanimity overrides their motivation to realistically appraise alternative courses of action’ (Janis, 1982)

Case conference proceedings showed strong evidence of the symptoms of groupthink; most notably, shared rationaliza- tions to support the first adequate alternative suggested by an influential group member; a lack of disagreement; a belief in unanimity and cohesiveness; direct pressure on dissenters and a high level of confidence in the group’s decision. For example, the Beckford Report (London Borough of Brent, 1987) shows evidence of a cohesive group of social services professionals discounting information presented at the first case conference. The initial case conference discussed the injuries to Jasmine and contained several members who were ‘hawkish’ in that they did not envisage Jasmine returning home to her parents. The social workers alone held another meeting 2 weeks later at which they decided that in future:

‘a smaller meeting would be adequate, and only those will be invited that it is felt necessary should attend’ (London Borough of Brent, 1987)

Similarly, at this meeting, although the adoption and foster care representative stated ‘that the children could be fostered [long term] almost immediately [moving on to adoption in due course]’, the words in square brackets were Tippexed out of the minutes (London Borough of Brent, 1987). In the Tyra Henry case (London Borough of Lambeth, 1985), concurrence-seeking behaviours were high in the small group meeting at the third case conference. At this meeting, the probation officer supported an emerging majority view that Tyra should stay with her mother by asserting that as Andrew Neil (Tyra’s father) had previously injured Tyrone (Tyra’s brother) when he was a difficult baby, he would not constitute a risk to Tyra now that she was a toddler. That this information was selective is evidenced by the fact that Tyrone was not a difficult baby and that Andrew Neil’s probation history showed that he had a record of uncontrollable violence over a range of situations.

It is also tentatively suggested that groupthink may be one of the factors involved in the successive reduction of

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‘Case conference proceedings showed strong evidence of the symptoms of group think’

The successive reduction of numbers of allied professionals that attend case conferences’

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‘The group may efsec tively counteract any attempt at correctives’

numbers of allied professionals that appear to attend case conferences. For example, in the Carlile case (London Borough of Greenwich, 1987), at the third meeting of social services in the Wirral in April 1985, none of the health services personnel were invited to attend, although the nursing officers and health visitors were the people who had registered concern about the children’s welfare at the two previous conferences. A result of their absence was that worries about Kimberley’s development ‘vanished from the social workers’ minds’ (London Borough of Greenwich, 1987).

It seems then that the concept of groupthink is a useful diagnostic tool in understanding what is occurring at a particular stage in the decision-making sequence; however, the correctives proposed by Janis and Mann (1977) seem to have limited applicability with respect to improving infor- mation flow. The proposed correctives include holding second chance meetings, appointing a devil’s advocate and bringing in independent chairs (see, for example, Lewis er al., 1992). Paradoxically, if the group is subject to the symptoms of groupthink, then the group may effectively counteract any attempt at correctives. In the Orkney inquiry (Secretary of State for Scotland, 1992), there is evidence of an attempt to challenge the original decision-making group by bringing in a group of experts from the mainland. When they arrived on Orkney they were promptly sent on a sightseeing tour while the original group held a further meeting at which they reaffirmed their original course of action. The experts’ group was left holding its own meetings in hotel rooms at which they expressed their frustrations at not being able to communicate their doubts about being involved in a plan of action which they felt to be less than ideal.

The Concept of Framing

It seems necessary then not only to ask the question of how group processes contribute to decision-making but also to address the question of why, and when, a decision-making group commits itself to a particular course of action. There are insufficient details for a complete analysis in the Auckland Report (DHSS, 1975), but it is clear that from a very early stage the professionals involved perceived the case in terms of Mrs Auckland’s domestic incompetence. This meant that at John Auckland’s trial in 1968 (following his murder of Marianne) the judge recommended that M r s

Child Protection Decision- Making

Auckland should be given some training to enable her to become a more competent housewife (DHSS, 1975). One psychological concept that explains how the initial percep- tion of a situation determines the decisions made is that of ‘framing’ (Kahneman and Tversky, 1982). The initial framing of the Auckland case persisted despite subsequent input from other concerned people. In order to explore this phenomenon, psychological theories of framing, most particularly that of prospect theory, were applied to other (more detailed) child death inquiry reports.

This theory may have considerable attraction for the analysis of child protection decision-making as it attempts to explain how decisions will follow either a risky or a cautious route depending upon the way in which the decision-maker/s perceive/s the original situation. The critical influence on decisions according to prospect theory is whether the decision-maker frames the problem in terms of losses or gains. A simplified example of how this operates can be illustrated by asking people two questions:

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1. If you have to make a choice between incurring (a) a certain loss of €50 or (b) a 50/50 chance of a f 100 loss or no loss at all, which would you choose?

2. If you have to make a choice between incurring (a) a certain gain of f50 or (b) a 50/50 change of a f 100 gain or no gain at all, which would you choose?

The odds are identical in these decisions. However, people opt most commonly for the riskier course of action when the question is framed in terms of losses, i.e. question 1. Conversely, they usually opt for the more cautious course of action when the question is framed in terms of gains, i.e. question 2 (Kahneman and Tversky, 1979).

The most important part of this theory is the ‘certainty effect’. This is the process by which individuals become risk- seeking when decisions are framed in terms of choices between losses, exaggerating the distastefulness of losses that are certain (f50) relative to those which are less sure (f 100). The operation of the certainty effect can be illustrated by reference to the Kimberley Carlile case, in which a variety of professionals had identified a number of possible and actual losses to the children. These included:

0 Marked behavioural problems (all three children) 0 Speech and physical developmental delay (Kimberley) 0 Need for a hearing test (Kimberley) 0 Weight falling below the third centile at 2 yr (Kimberley) 0 Low standard of care by mother (all three children) 0 Not attending school/nursery (all three children)

‘Whether the decision -maker frames the problem in terms of losses or gains’

‘Professionals had identz.ed a number of possible and actual losses to the children’

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‘Risk assessment was framed primarily in terms of the potential eflects of violence in the home’

‘Potential losses to the welfare of the individual children became subsidiary considerations’

0 Medical appointments not kept (Kimberley) 0 Bruising, ulcers on leg (Kimberley) 0 High levels of violence in the household 0 High levels of debt in the household, mother not managing

finance despite previous payments by Social Services Depart- ment

0 Lack of consistency of care due to mother’s repeated arrests for theft

The report suggests that the risk assessment by the social workers was framed primarily in terms of the potential effects of violence in the home:

‘the primary concern of the social workers was the extremely violent home environment, exposure to which was having a marked effect on the three children’ (London Borough of Greenwich, 1987)

The framing of risk in terms of violence rather than in terms of violence and neglect meant that the workers were able to avoid a certain loss:

‘the sole focus of their consideration was the future of the three children collectively.. . the main if not exclusive obstacle to discharging the voluntary care was the hovering presence of Mr Carlile. Once he was firmly out of the picture and would not be involved with the children’s lives, and once Mrs Carlile was properly housed no other consideration was alive to forestall the reunion of the three children to their mother (London Borough of Greenwich, 1987, our emphasis)

Avoidance of the certain loss of the mother-children relationship determined that the potential losses to the welfare of the individual children became subsidiary con- siderations. This had the effect of moving the focus of the case from the welfare of the children to the needs of the whole family. As the report outlines, the social workers suggested:

‘Three factors weighed against anything more drastic than voluntary care. They were, the children had not suffered any physical harm; the periods of voluntary care had been short; and “there is little hard evidence that the children are disturbed in their behaviour”’ (London Borough of Greenwich, 1987, P* 53)

The comment about the short periods of voluntary care may illustrate the possible existence of a strong belief on the part of the social worker about the necessity for children remaining with their mother. This belief constitutes a framing of the situation which conflicts with the possible losses previously identified and listed above.

The notion of the certainty effect has potential in an analysis of child protection decisions because choices are

Child Protection Decision-Making

invariably between unattractive courses of action, all of which involve some degree of potential loss. There is no definition in the Children Act 1989 of what constitutes the welfare of the child in terms of gains, the threshold criteria for an order being the possible losses or ‘significant harm’ in comparison with a ‘similar child’. There is no mention in the Act of what might constitute ‘significant well-being’. Additionally, the nature of child care knowledge means that the certain loss usually considered in child protection practice is the potential loss to the child accruing from mother-child separation. The emphasis in the Act on parental participation forces social workers to consider the needs and welfare of thefamily as a whole rather than the welfare of the individual children. The possible gains for children in child protection work are therefore uncertain, confused and unclear. As Blom Cooper tellingly comments in the Beckford Report:

‘The issues involved are rarely simple, and the choice facing social workers is often not between a wholly satisfactory family setting and an idyllic alternative, but that the choice is between two imperfect and uncertain options’ (London Borough of Brent, 1987)

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Group Polarization

Case conferences were specifically established to monitor and counteract the potential for risk in child protection practice (Home Office, 1991). However, there is substantial evidence in psychological literature which suggests that groups do not necessarily improve decision-making. A major reason that has been put forward is that of ‘group polarization’ (Moscovici and Zavalloni, 1969). This concept proposes that when individuals within the group initially tend towards a cautious position then the group will polarize around a more extreme cautious decision, and when individuals within the group initially tend towards a risky decision then the group will polarize around a more extreme risky decision. The certainty effect can predict what the individual preference might be in terms of risk or caution and, because of group polarization effects, there is no reason to consider that a group will substantially alter that initial preference.

The question in terms of case conferences is therefore one of which direction the group will polarize towards-risk or caution? At any initial case conference there will be a proportion of professionals who frame their views in terms of

‘Parental participation forces social workers to consider the needs of the family as a whole rather than the welfare of the individual children

‘Groups do not necessarily improve decision- making’

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Kelly and Milner

gains for the children and those who frame their views in terms of losses for the whole family. It is argued that the certainty effect, additionally influenced by legislative imperatives and mother-child ideology, will set the tone for the decision-making process. Consequently, this means that non-case-holding professionals may find it difficult to argue consistently from a gains perspective. Group polariza- tion will encourage rather than counter early framing effects. Dissenting case conference members will then: stop attend- ing case conferences; continue to register their dissent; or not be invited to case conferences. Although the experience of dissent in case conferences often seems to involve the expression of opinions by powerful professionals, in practice dissent seems to be largely ineffective. For example, the chairman of the second case conference in the Kimberley Carlile case explicitly expressed the view that everyone in the conference should consider care proceedings for the children until they were 18. Clearly, by the next case conference, this recommendation had been ignored. Although the case conference has the mandate to assess risk and formulate a care plan, and to re-evaluate the effectiveness of that plan, the processes of framing, group polarization and groupthink mean that the group is unable to act as an effective check against initial framing effects.

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‘Group polarization will encourage rather than counter early

‘Subsequent re- evaluations will commit more resources to the same failing

~ course of action’

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Discussion-A Model to Explain Practice

Separately, the three psychological processes outlined above may not explain the entire decision-making sequence of case conference proceedings in child protection practice. One integrating model offers an explanation of high-risk deci- sion-making and lists a sequence of stages and events which shows how decision-making processes unfold from the original point of choice and commitment of resources (Whyte, 1989). When the choice is framed in terms of losses, the course of action is inevitably shifted towards risk and the effects of group polarization mean that subsequent re- evaluations will commit more resources to the same failing course of action or will engage in even more risky behaviour. Although other losses may be realized, group pressure for conformity and the effects of groupthink ensure that the initial dominant position in the group will emerge as the group choice. How this unfolds in child protection practice may be illustrated by reference to the Tyra Henry case.

At the case conference held in December 1982, a few days after Tyra’s birth, when she and her mother were still in

Child Protection Decision-Making 99

hospital, three possible options were considered. These were: 0 Permanent removal under a care order 0 A care order with Tyra placed with her mother in the maternal

grandmother’s home, father excluded 0 Informal supervision

Option one was rapidly dismissed, as conference members considered that the circumstances did not warrant such a course of action. Option three was dismissed on the grounds of impracticality. It would seem, therefore, that option two was chosen by default. However, this option enabled practitioners to avoid the certain (and distasteful) loss of the mother-child relationship. At this stage the model suggests there will be a preference to commit new resources to the same course of action or otherwise engage in high-risk behaviour if the potential exists for the mother-child relationship -to continue. The next case conference demon- strates how these processes operate so that the group exaggerates its and the social worker’s original decision.

This case conference was held in October 1983, by which time there was evidence that the agreed course of action was failing, although a family aide and day nursery place had been offered to the mother. The domestic circumstances in the maternal grandmother’s house were deteriorating and neither the maternal grandmother nor the professionals had managed to gain the wholehearted cooperation of Tyra’s mother. There was evidence that Tyra’s father was on the scene. However, the most pressing problem to all parties was the housing situation of the maternal grandmother and her family. It can be seen by this point that various potential losses to all family members were becoming realized. This case conference did not explicitly discuss these losses in terms of risk to Tyra, although the doctor expressed the reservation that continuing with this course of action would allow the mother to re-establish a relationship with Tyra’s father. This process then committed the professionals not only to the same failing course of action but also to even higher-risk behaviour.

The next stage involves the pressures for conformity/ majority processes which will ensure that the dominant initial frame within the group will emerge as the group choice. A polarizing effect of group discussion will occur and this serves to exaggerate risk preference. This stage of group polarization is only too apparent in the case conference of May 1984, where attendance was low. It is significant that absent members included those who had expressed most reservations previously. The group had increasingly

‘The group exaggerates i ts and the social worker’s original decision’

‘The group had increasingly committed themselves to risky decisions’

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‘The case conference did not provide the means by which risk could be re-

Kelly and Milner

committed themselves to risky decisions and, at this final conference, the only real remaining option was one which further continued the same failing course of action. The social worker with day-to-day management and responsi- bility for the case shifted the focus of the potential discussion by asserting that there was no risk that the mother would hurt the child. Hence the recorded decision was that Tyra should remain on the at risk register for the present but that this would be reviewed in 6 months with a view to removing her name from that register. Shortly after this case conference Tyra died at the hands of her father.

Whyte’s (1989) proposed structure could have predicted such an outcome in that he maintains that group preference will converge around behaviour even more risky than that which an isolated individual would prefer if faced with the same alternatives:

‘Two heads. . . are not better than one when it comes to framing decisions. Groups suffer from framing effects more frequently than individuals and with more serious consequences’ (Whyte, 1991)

It is argued that the key social worker would not have engaged in such risky decision-making had she worked in isolation but that her initial framing of the options before the first case conference (avoiding mother-child separation) was bolstered by subsequent group processes. The case conference did not provide the means by which risk could be re-evaluated nor did it monitor the losses which were being increasingly accrued by all family members.

The inquiry reports talk about the decisions in the cases they outline being made in terms of drift, which seems to imply at the very least some sort of passive participation by professionals in the sequence of events and decisions. They prescribe more training for participants and emphasize the need for more case conferences , which, it is proposed, will merely lead to more practice overload. However, it seems from the above analysis that Whyte’s model may not only explain how the sequence of events in cases is driven by the initial framing of the problem and subsequent group processes, but may also provide the key to understanding the sense of frustration that professionals seem to experience once they are locked into a predetermined unfolding course of decisions.

Using Whyte’s model also seems to make explicit the fact that possibIe alternative courses of action reduce with subsequent case conferences. Potential losses become actual losses as the original framing of the problem inhibits re- evaluation. It is suggested that this can explain the seemingly

Child Protection Decision-Making

inappropriate decisions to close cases which, with hindsight, display obviously high degrees of risk and dangerousness.

While a complex psychological model may prove inacces- sible to a child protection practitioner with a heavy caseload, it is suggested that a simplified way of attempting to apply the model can be achieved by explicitly looking for and labelling the consequences of decisions at each stage and for all family members in terms of losses and gains. As the case progresses, the worker can then identify the objective out- comes for all family members. This exercise in itself can constitute an aid to reflexive practice without recourse to more training or the development of a checklist mentality.

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Acknowledgement

The authors would like to thank their colleague, Wendy Marshall, for her constructive comments on earlier drafts of this paper.

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