Factitious Illness by Proxy: Understanding Underlying Psychological Processes and Motivations

Children are put at risk of emotional and physical harm when parents seek unnecessary medical care. Understanding why parents seek medical interventions that create risk for their children requires us to consider how past experiences, and the mental representations of these experiences influence current behaviour. Past experiences of danger affect how parents interpret ‘dangerous’ situations in the present and how they organise protection of their child. This article demonstrates how the notion of mental representations (that dispose parents to act in particular ways) can assist in engaging, assessing and treating parents who display factitious illness by proxy behaviour. When classified using the Dynamic‐Maturational Method, the Adult Attachment Interview (AAI) allows both assessment of implicit and explicit representations and also understanding of the developmental process through which parents have learnt to attribute meaning to information and to organise their behaviour. In this case study, psychosocial assessment of the family included an AAI with each parent. The use of this assessment tool both aided the therapy team in the process of case formulation and intervention planning, and had therapeutic value in and of itself. We argue that treatment is more likely to be effective if the parents and professionals have a shared understanding of the parents' intentions and the developmental process that led to unsafe behaviour, which requires change.     

A science-based strategy for ecological restoration in South Florida

The Everglades and associated coastal ecosystems of South Florida are unique and highly valued ecosystems. One of the world's largest water management systems has been developed in South Florida over the past 50 years to provide flood control, urban and agricultural water supply, and drainage of land for development. However, this system has inadvertently caused extensive degradation of the South Florida environment, resulting in the loss of more than half the historical Everglades system and elimination of whole classes of ecosystems. The U.S. Man and the Biosphere Program (US MAB) instituted a project to develop ecosystem management principles and identify requirements for ecological sustainability of South Florida. A strategic process developed by the US MAB Project illustrates how ecosystem management and ecological risk assessment principles apply to South Florida, including the development of societal goals and objectives of desired sustainable ecological condition, translation of these goals/objectives into scientifically meaningful ecological endpoints, creation of a regional plan designed to meet the sustainability goals, and development of a framework for evaluating how well the plan will achieve ecological sustainability of South Florida. An extensive federal, state, and tribal interagency process is underway to develop a restoration plan for restructuring the regional management system, essentially following the elements in the US MAB project process. The Florida Governor's Commission was established as an institution to reflect societal values and define regional sustainability goals. The U.S. Army Corps of Engineers is developing a science-based plan for Congressional approval to restructure the water management system to achieve the societal goals. Thus, South Florida may become the prototype example of successful regional-scale ecosystem management.     

Helpful actions seen through the eyes of parents of children with disabilities

Parents of children with disabilities interact with a wide range of service providers in order to assure appropriate services for their children. While some actions performed by professionals are viewed as helpful, many are viewed as obstructive. Surveys completed by over 120 parents identified past actions perceived to be helpful and those thought to be unhelpful as well as identification of professionals associated with those actions. Using the critical incident technique, narrative responses were based on actual experiences that parents described. Parents were also asked to articulate specific actions they would like professionals to take in the future. Over half of the responses request desired relationships with professionals that focus on respect, collaboration, communication and information sharing. Implications for pre-professional training are discussed.     

Screening for trauma exposure, and posttraumatic stress disorder and depression symptoms among mothers receiving child welfare preventive services

The role of parental trauma exposure and related mental health symptoms as risk factors for child maltreatment for parents involved with the child welfare (CW) system has received limited attention. In particular, little is known about the extent to which mothers receiving CW services to prevent maltreatment have experienced trauma and suffered trauma-related psychopathology. This study examined screening data collected from 127 mothers receiving CW preventive services. There were high levels of trauma exposure among screened mothers and their young children. Among mothers, 91.6% experienced at least one traumatic event (M = 2.60) and 92.2% reported their children had been exposed to one or more traumas (M = 4.85). Mothers reported high levels of trauma-related symptoms: 54.3% met probable criteria for posttraumatic stress disorder (PTSD) or depression (61.7%). Nearly half (48.8%) met criteria for co-morbid PTSD and depression. The large majority of the clients with trauma-related disorders were not receiving mental health services. Latina women had significantly more severe PTSD symptoms than African American women. Case planners reported that the screening process was useful and feasible. These findings underscore the feasibility and importance of trauma screening among parents receiving CW preventive services.     

Perceptions of sources of sex education and targets of sex communication: sociodemographic and cohort effects.

As part of a larger survey study on young adult sexuality conducted over a 17-year period at a Midwest U.S. university, more than 6,000 college students completed questions on the sources of their sex education and the degree to which they have communicated about sex with various types of individuals. Participants reported receiving more sex education from peers and media than from parents (and mothers more than fathers). Respondents also reported communicating more about sex with peers than with parents or any other categories of individuals. Differences were found in the degree of sex education from various sources and in communication with various targets based on gender, ethnic background, and social class. Furthermore, changes were found over the 17-year period. More recent cohorts of students perceived that they received more sex education from media, peers, and professionals, and communicated more about sex with professionals, relative to earlier cohorts.     

Perceptions of Sources of Sex Education and Targets of Sex Communication: Sociodemographic and Cohort Effects

As part of a larger survey study on young adult sexuality conducted over a 17-year period at a Midwest U.S. university, more than 6,000 college students completed questions on the sources of their sex education and the degree to which they have communicated about sex with various types of individuals. Participants reported receiving more sex education from peers and media than from parents (and mothers more than fathers). Respondents also reported communicating more about sex with peers than with parents or any other categories of individuals. Differences were found in the degree of sex education from various sources and in communication with various targets based on gender, ethnic background, and social class. Furthermore, changes were found over the 17-year period. More recent cohorts of students perceived that they received more sex education from media, peers, and professionals, and communicated more about sex with professionals, relative to earlier cohorts.     

Lessons learned from children who have experienced homelessness: what services need to know

Children who accompany their parents or guardians during a period of homelessness make up 37% (more than one in three) of all people accessing the Supported Accommodation Assistance Program (SAAP) services. This paper describes an Australian qualitative study that explored the experiences of children who accompanied their families during periods of homelessness. It focuses particularly on what children and young people say they want from the services that they come in contact with; particularly specialised homelessness services such as housing support services and refuges. Key themes that emerged from the research include: the need for services to engage with children as individuals in their own right, to listen to and acknowledge their stories, to have services that meet their individual needs, to act and respond when children feel unsafe and for workers who can provide support to children to talk to parents about what is going on. Children and young people wanted workers to know that they felt their parents were doing their best to keep them safe. They focused on what their parents could do and did do rather than what they were not able to provide. They called on the human service system to do the same.     

Parent Management Training, Relationships with Agency Staff, and Child Mental Health: Urban Foster Parents' Perspectives

Many foster parents are ill prepared to meet the behavioral needs of children placed in their homes. Research suggests they lack training in evidence-based behavioral interventions and feel unsupported by child welfare professionals. Given the complex needs of foster children and increased rates of placement disruption for foster children with behavior problems, implementation of effective interventions is essential. However, little is known about foster parents' receptivity to these types of interventions. In this qualitative study, we examine urban foster parents' perceptions of the specific elements of parent management training (PMT), an evidence-based treatment for disruptive behaviors that teaches parents to improve desired behaviors and decrease oppositional behaviors by rewarding positive behaviors (positive reinforcement) and responding to negative behaviors with mild, consistent punishments such as timeout or a privilege removal. We present data from four focus groups (N = 38). While the questions focused on parent's perceptions of PMT, responses often related to parent interactions with agency staff. Four strong themes emerged from the data. First, foster parents discussed a need for more support and training in how to address children's behaviors, but also had concerns that some PMT discipline techniques would be ineffective based on their past experiences with foster children. Second, they described how staff communication skills and allegations of child abuse could affect parents' motivation to continue fostering. Third, they expressed a need for more detailed information about children's histories and visits with biological families as the lack of information contributed to difficulty in meeting foster children's needs. They suggested that joint training of foster parents and staff in the intervention could improve their ability to work together to support the child's positive behaviors. Finally, parents reported little involvement in child mental health services and doubted the effectiveness of the mental health services their foster children received.     

Parent perspectives on adoption preparation: Findings from the Modern Adoptive Families project

Preparing prospective adoptive parents for receiving a child into their family is an important task for child and family professionals. This study uses data from the recent Modern Adoptive Families survey to understand parent perspectives on their preparation for adoption. Logistic regression (n = 917) and qualitative thematic analysis of adoptive parents' comments about their adoption preparation were conducted to understand aspects of the preparatory experience that were satisfactory (n = 623) or dissatisfactory (n = 283). Child emotional and behavioral problems significantly predicted parent dissatisfaction with adoption preparation. Major themes for satisfactory aspects of preadoption services included receiving information about adoption in general and, more specifically, about clinical and special populations, and parenting tools and strategies. In addition, parents identified opportunities to connect with others touched by adoption and access to specialized post-adoption services as helpful. Conversely, parents expressed dissatisfaction when information was lacking or withheld, when they had quality concerns with the worker or agency, and when there was a dearth of services and supports following adoption. Implications of these findings include the need for adoption mental health competent training for adoption professionals to better support families preparing for or experiencing adoption.     

Evaluation of the Children’s Advocacy Center Model: Efficiency,Legal and Revictimization Outcomes

This study compares the Children’s Advocacy Center (CAC) model with more traditional child protection services on several important outcomes such as substantiation of abuse, arrest and prosecution of the perpetrator, the efficiency of the multidisciplinary process and child revictimization rates. One hundred and eighty-four child abuse and neglect cases from a large metropolitan area in Florida comprised the sample. Cases were selected over a five year-period from three different modes of child protection services including a CAC. Similar outcomes were found between the CAC model and the Child Protection Team (CPT), a multidisciplinary model, which was first developed in Florida in 1978. In comparison with traditional child protective investigation, these models were associated with improved substantiation rates and investigation efficiency. Results are discussed in terms of the utility of CACs above and beyond the aspect of multidisciplinary coordination and whether the goals of the CAC model need to be redefined. Recommendations for further research in the areas of multidisciplinary team decision–making, the long-term impact of the CACs and the role of supportive professionals on the multidisciplinary team were made.     

Steps in the Right Direction,Against the Odds,An Evaluation of a Community‐Based Programme Aiming to Reduce Inactivity and Improve Health and Morale in Overweight and Obese School‐Age Children

The study describes an evaluation of a 48‐week physical activity and nutritional education programme for overweight/obese school‐age children using quantitative and qualitative methods. The majority of participants were obese or severely obese when enrolled, and while some improvements in body mass index, self‐esteem and engagement in a range of physical activities were noted, difficulties in evaluating a complex community‐based intervention were highlighted. Children, parents and health professionals described a range of benefits from attending the programme but more intensive services are likely to be needed for the most seriously obese children and for those families resisting intervention.     

Parent-perceived Attitudes of Professionals: Implications for Service Providers

While parents' reactions to a diagnosis of disability in their child have been well documented, less is known of parents' reactions to the professionals who provide the diagnostic and support services used by parents. This study identified four major parameters within which the attitudes of professionals are perceived by parents of children/teenagers diagnosed as intellectually disabled. Comments of the 131 mothers and fathers interviewed helped to shed light on what they have expected of service providers, and suggest adjustments that may need to be made by professionals to the attitudes they convey in interaction with parents.     

Grandparent-Headed Families in the United States

Abstract

Grandparents are returning to the role of parents in ever-increasing numbers. Custodial grandparents often find themselves isolated from sources of support as they face unique emotional, physical, and financial challenges on a daily basis. Nearly half are grandparents without partners and the majority are caring for two or more young children. Children in the care of grandparents are more likely to experience cognitive, emotional, and physical challenges. Their early traumatic experiences may lead to difficulties in communication and forming attachments.

The Parent Topics Questionnaire is a standardized assessment measure designed to provide parent education group facilitators with specific information about needs, desires, and expectations of participants. Administration of this instrument to four parent groups revealed a high readiness for information among the custodial grandparent population. Based on information obtained from this measure, a holistic program was developed which simultaneously provided services to care-giving grandparents, their young grandchildren, and educational professionals.

Grandparent and grandchildren's groups met weekly and emphasized topics and activities aimed at meeting common needs within these populations. Educational professionals participated in a series of inservice meetings aimed at increasing awareness of needs and strengths of grandparent-headed families, modifying curriculum to more effectively meet grandchildren's needs, and enhancing knowledge of existing resources. Pre- and post-test analysis demonstrate significant positive effects for all involved populations. Grandparents were found to increase in parenting knowledge, perceived levels of social support, willingness to utilize existing resources, and enjoyment of time with their grandchildren. Levels of isolation and perceived depression were decreased. Participating grandchildren demonstrated increased abilities to interact effectively with peers and adults and perceived their interactions with grandparents more positively. Educational professionals reported feeling more informed about custodial grandparent family issues, more confident about interacting with grandparents, and more knowledgeable about existing resources.     

Multidisciplinary Child Protection Decision Making About Physical Abuse: Determining Substantiation Thresholds and Biases

The current study examined the threshold at which multidisciplinary child protection team (CPT) professionals substantiate physical abuse allegations and the extent that they utilize potentially biased constructs in their decision making when presented with the same case evidence. State legal definitions of child maltreatment are broad. Therefore, the burden of interpretation is largely on CPT professionals who must determine at what threshold physical acts by parents surpass corporal discipline and constitute child physical abuse. Biased or subjective decisions may be made if certain case-specific characteristics or CPT professionals' personal characteristics are used in making physical abuse determinations. Case vignettes with visual depictions of inflicted injuries were sent to CPT professionals in Florida and their substantiation decisions, personal beliefs about corporal discipline, and coercive discipline were collected. Results of the study demonstrated relatively high agreement among professionals across vignettes about what constitutes physical abuse. Further, CPT professionals strongly considered their perceptions of the severity of inflicted injuries in substantiation decisions. Although case specific characteristics did not bias decisions in a systematic way, some CPT professional characteristics influenced the substantiation of physical abuse. Practice implications and future directions of research are discussed.     

Evidence-based practice in family group decision-making for Anglo, African American and Hispanic families

This study addresses the need and gap in the literature on evidence-based practice in family group decision-making services by reporting on the Texas Department of Family and Protective Services' Family Group Decision-Making study, conducted between December 2003 and July 2005 with Anglo, African American and Hispanic families throughout Texas. These services are compared to standard practice by assessing satisfaction, child well-being and exits from care. Findings indicate that both parents and relatives are more satisfied with family group decision-making conferences than standard practice on a number of dimensions, with relatives reporting feeling more empowered than parents. Children are reported to be less anxious if their families participate in a conference, and they may be more adjusted when they are placed with relatives following a conference. Finally, exits from care are faster if families participate in family group decision-making conferences, and exits to reunification are increased; this may be especially true of African American and Hispanic children.     

Decision-Making processes in the child protection system: A comparative study between students and professionals in Portugal

Abstract

This research aims to achieve a better understanding of factors that influence the assessments and decisions of professionals and students about the possibility to remove a child at risk from her birth family. The study also analyzes the influence of the attitudes of the child’s mother on that decision. It was used a questionnaire based on a case vignette of alleged child maltreatment. Compared with students, professionals were more pro-removal, more in favor of reunification and parents’ participation in the decisions, and had a higher assessment of emotional abuse, and emotional and physical neglect. Mother’s wish did not show to have any impact in the two samples regarding maltreatment, risk assessments, and intervention recommendations.     

Met needs and unmet needs, and satisfaction among Social HMO members

This article reports on a survey of 800 members of four Social HMO demonstration sites, who were receiving home-based, community-based, and short-term institutional services under the demonstration's expanded community care benefits. The survey asked whether members needed help in 11 areas, whether they received help in each area from an informal caregiver, whether they wanted more help from the Social HMO, and whether help provided by both was adequate. Satisfaction with the program and with service coordination was also assessed. The adequacy of informal care differed by problem area, as did the help desired from the Social HMO and its responsiveness. Members were less satisfied when they had weaker informal care, were African American, and when they received inadequate help from the plan with ADLs, transportation, medical access, and managing money. Members were more satisfied when they were professionals, home owners, knew their service coordinator's name (or how to contact her), and received help with their problems. The findings point to the importance of clarifying divisions of labor with informal caregivers, as well as possible expansions in responsibilities for service coordinators and benefits beyond traditional boundaries.     

Child welfare supervised children's participation in center-based early care and education

Research suggests that early care and education (ECE) services, particularly center-based ECE, may help prevent child maltreatment and also mitigate some of the negative developmental outcomes associated with child maltreatment. There is also preliminary evidence to suggest that ECE could reduce the likelihood that maltreatment allegations will be substantiated by child welfare authorities and/or result in children being placed in out-of-home care. However, little is known about rates of ECE participation among children receiving child welfare services, nor the factors that determine ECE participation for this population. Data from the first wave of the National Survey of Child and Adolescent Wellbeing II, a nationally representative sample of children referred to the United States (U.S.) child welfare system (CWS) for suspected maltreatment, were used to measure the frequency with which 0–5 year olds participate in center-based ECE. Additionally, logistic regression analyses explored the effects of maltreatment type, substantiation, and children's living arrangements (i.e., with parents, relatives, or foster parents) on this outcome, controlling for a range of child and family covariates associated with ECE participation in the general population. Results indicate that less than a third of 0–5 year olds receiving child welfare services in the U.S. are participating in center-based ECE. Among the various categories of maltreatment type measured, being reported to the CWS for suspected physical abuse was associated with decreased odds of center-based ECE participation; however, other types of maltreatment, substantiation, and living arrangement were unrelated to center-based ECE participation. These findings suggest that, despite recent efforts by the U.S. federal government to promote ECE participation for CWS-supervised children, the vast majority of young children in the U.S. CWS are not receiving center-based ECE, and physically abused children are particularly disadvantaged when it comes to accessing these services.