March/April 2013 Issue

Multidisciplinary Child Protection Teams — The Social Worker’s Role
By Jennifer Van Pelt, MA
Social Work Today
Vol. 13 No. 2 P. 26

Clinically diverse professional teams identify and treat child abuse, and a social worker is often the team coordinator.

Last year’s media attention to the high-profile Jerry Sandusky child abuse case at Penn State University brought deficiencies in child abuse recognition and reporting into the spotlight and under the microscope. Government officials, educators, social services, and law enforcement acknowledged that existing procedures were seriously lacking in the educational setting.

In hospital settings, however, multidisciplinary child protection teams were established approximately 50 years ago to more effectively handle suspected cases of child abuse presenting in the emergency department (ED) or referred to the hospital. A 2012 survey report by the National Association of Children’s Hospitals and Related Institutions (NACHRI) indicated that 96% of acute care children’s hospitals have child protection teams in place to handle child abuse cases. These multidisciplinary clinical teams are critical in ongoing efforts to identify and prevent child abuse in the communities serviced by their hospitals. While a medical director, usually a pediatric physician who is board certified in child abuse pediatrics, leads the team, the social worker is a key member, serving as the clinical and team coordinator. 

“The social worker is the glue that holds a team together,” says Debra Schilling Wolfe, MEd, executive director of the Field Center for Children’s Policy, Practice & Research, a collaboration of child abuse experts from the University of Pennsylvania’s School of Social Policy & Practice, the Penn School of Law, the Penn School of Medicine, the Penn School of Nursing, and The Children’s Hospital of Philadelphia (CHOP) that combines the efforts of multiple disciplines and perspectives to address critical issues facing the child welfare system. According to Wolfe, by virtue of their training and perspective, social workers are adept at working with multiple disciplines and across multiple systems to direct team efforts.

Hospital-based child protection teams face numerous unpredictable challenges, most of which are emergencies. “The social worker brings the ability to multitask and balance, skills that are endemic to social workers,” Wolfe says.

The ED often is the first entry point into the system for abused children in crisis and the first opportunity for clinical diagnosis of child abuse. When a child presents to the ED with suspected abuse, the urgency and severity of injury means that many clinical specialties have a role in diagnosis and treatment, including pediatrics, trauma, nursing, psychology, and social work.

It is the hospital’s responsibility to coordinate a response regarding suspected child abuse cases not only internally but to external organizations involved in child welfare. “The social worker has the important role of coordinating reporting processes and the team effort involved in prospective child abuse cases,” Wolfe notes.

“Our team wouldn’t be a team without the social workers,” says Cindy W. Christian, MD, director of Safe Place: The Center for Child Protection and Health at CHOP, which provides clinical emergency, inpatient, and outpatient care to hundreds of abused and neglected children each year, conducts research in the field of child abuse, educates in child abuse pediatrics, and leads advocacy efforts in the city and state.

Christian leads the CHOP multidisciplinary child protection team, which includes other pediatric physicians, two social workers, and a psychologist as core members. Nurse practitioners and other clinicians, such as trauma physicians and child life specialists, also work with the team. One social worker serves as a liaison to families and outside agencies, provides psychosocial assessment, and ongoing family support. The other social worker provides therapy and counseling services.

“In my first years with the child abuse team, much of what I learned was at the side of a social worker, including how to talk to families and children,” Christian says.
Because child abuse always is a medical/social diagnosis and a family crisis, the medical team must work in partnership with social workers and rely on their expertise in family interaction, Christian explains. “Having a new diagnosis of child abuse results in a family being shell-shocked. Counseling and communication from the social worker is vital for family support,” she says.

Most importantly, the social worker ensures effective communication throughout diagnosis and treatment of child abuse cases, especially when the family or staff is uncomfortable with the abusive situation, as is common with sexual abuse cases, Christian explains. “As physicians, we don’t always have enough time to build trust with families. Our social workers get to know the families best and can identify when they may need extra communication from the medical staff,” she says.

In addition to assessing the child and supporting the family, social workers on child protection teams field calls from outside entities, arrange visits from child welfare and law enforcement, interface with citywide and countywide child abuse programs, and coordinate with prosecuting attorneys. “If we didn’t have a social worker on the team, we would face enormous roadblocks,” Christian emphasizes.

A Well-Oiled Machine
Social workers often function as the lynchpin on hospital-based child protection teams and provide a valuable diagnostic assessment of the child, which then informs all team recommendations for treatment.

Scott Snider, LCSW, a clinical coordinator for Duke Children’s Hospital & Health Center Child Abuse and Neglect Medical Evaluation Clinic in Durham, North Carolina, coordinates team efforts and conducts the diagnostic interviews of children who are suspected victims of sexual or physical abuse. “I provide the diagnostic interviews of children as part of their medical evaluation for suspected abuse. As such, I contribute expertise in child interviewing and language development in order to obtain accurate histories. My team can then use this history to direct appropriate medical care as well as referrals for other needed services, such as abuse-focused mental health treatment,” he explains.

After an initial diagnosis of child abuse, collaboration and synergy among clinicians who may participate on a multidisciplinary team also is essential. Other clinicians on Snider’s team include two physicians who are board certified in child abuse and a doctorate-level nurse practitioner. “Each discipline obviously brings their respective skills, and an effective multidisciplinary team can greatly enhance the child’s outcome,” Snider notes.

At Duke, the child protection team helps inform the department of social services and law enforcement regarding a child’s injuries and account of alleged abuse. The team’s diagnosis and recommended treatment strategy then helps determine service needs from mental health, child protective services, primary and specialty medical providers, and the criminal justice system.

In addition to benefiting the child, multidisciplinary teams are advantageous for hospitals (see sidebar on page xx). “Our medical center has come to rely heavily on our child protection team in numerous ways,” Snider says. The team provides 24-hour consultation to the ED and inpatient clinics as well as satellite outpatient clinics.

Since Snider’s facility is a specialty medical clinic for assessing alleged child abuse, its team not only provides expertise in medical diagnosis and treatment for the child and interacts with child welfare services and law enforcement but also handles referrals from other medical clinics and expert court testimony. “Our team helps defer unnecessary visits to the emergency department and provides our medical facility staff with much-needed support in addressing the complex issues associated with alleged child abuse,” he explains.

Maintaining and Improving Effectiveness
Few studies have been conducted on the effectiveness of multidisciplinary protection teams. However, in 2010, the first study proposing expert consensus on child protection team performance and effectiveness was published (Kistin, Tien, Bauchner, Parker, & Leventhal). This study surveyed professionals working on or with hospital-based child protection teams and reported that a collegial atmosphere and interdisciplinary collaboration are major keys to effectiveness.

For experienced teams like Christian’s and Snider’s, which operate at specialized children’s hospitals, such collegiality and collaboration are second nature when team members have worked together and with outside agencies for years. For smaller children’s hospitals with only basic services or nonchildren’s hospitals, child protection teams may not exist or may not function successfully. The researchers found that the factors most detrimental to team success were members not working well with other team members, poor communication, and the lack of a collaborative atmosphere.

To maintain or create successful team functioning for less experienced hospital teams, Wolfe advises that team members and hospitals understand that the team is not stagnant, and roles and responsibilities may shift from case to case or as the team evolves. “For a team to grow and thrive, each individual should acknowledge his or her own role in their disciplines and be respectful of the roles of others, both on and off the team,” she notes.

For example, a child welfare case worker and law enforcement personnel are mandated to conduct an investigation any time child abuse is suspected. The hospital team must understand and support those mandates, even if they conclude that child abuse did not occur. “Every multidisciplinary team is a work in progress, whether due to longstanding issues between agencies or to new membership through staff turnover and attrition. The most effective teams strive towards open communication with agency members and mutual respect for the roles and expertise other team members bring to the table,” Snider says.

In such situations, keeping the child at the center can be challenging, Wolfe says. “Team members should not lose sight that the child is the client first and foremost while meeting the individual needs of multiple disciplines and outside involved parties.”

For experienced teams, every child abuse case is an opportunity for learning. According to Snider, his team has learned that, in general, many cases of child abuse, particularly sexual abuse, can be prevented through basic measures, but ultimately the solution is more complex. “For example, many children are left with inappropriate caregivers or with people engaged in high-risk behaviors such as substance abuse. However, while commonsense approaches may appear simple, actually changing caregiver behavior, improving parenting skills, and improving the psychosocial factors that placed the child at risk often involve significant efforts and service intervention,” he says.

The aforementioned study on child protection team success found that the opportunity for education regarding child abuse, primarily from discussing cases and lessons learned from each case, is a variable associated with team success.
Resources are available to assist children’s hospitals with teams that have functional issues, children’s hospitals that currently offer only basic response services, and larger hospitals that serve adults and children. The NACHRI has published guidelines for developing and operating multidisciplinary child protection teams. While the guidelines focus on children’s hospitals, the NACHRI urges other hospitals and community organizations to examine and define their role in the “complicated and interdependent system of child abuse response and prevention.”

Dedicated children’s hospitals comprise only 5% of all hospitals in the United States, which means that most child abuse victims enter the healthcare system elsewhere. In hospitals without a dedicated child protection team or coordinated child abuse response service, hospital social workers will likely take the lead in handling suspected child abuse cases. The NACHRI guidelines provide recommendations for hospitals that treat children regarding the handling of suspected child abuse, noting that basic services should include a full-time clinical social worker.

When budgeting and staffing issues prevent the social worker from being dedicated to child protection, the NACHRI recommends that the social worker at least have some training in the dynamics of child abuse, its assessment and management in a hospital setting, child abuse reporting laws, and appropriate interventions and support. The guidelines also distinguish between clinical and therapeutic social work. A clinical social worker provides diagnostic assessment in addition to administrative/coordination duties, whether or not the hospital has a dedicated child protection team. Therapeutic social workers have a distinct role supporting medical and clinical social work by providing ongoing therapy that complements crisis intervention, according to the NACHRI.

The updated NACHRI guidelines mean that child abuse treatment and prevention work at hospitals will continue to expand. Recent public health research and statistics indicate that child abuse may be even more prevalent than what is documented. This, coupled with the Affordable Care Act provision for funding of home visit programs, will amplify the importance of social work involvement in child abuse prevention and multidisciplinary child protection teams.

— Jennifer Van Pelt, MA, is a freelance writer based in Reading, PA, and a frequent contributor to Social Work Today.

Best Practice Benefits More Than Just the Child
There is a growing emphasis on multidisciplinary approaches across child welfare services in general with a focus on the child, says Debra Schilling Wolfe, MEd, executive director of the Field Center for Children’s Policy, Practice & Research. Professionals have recognized that children live in the real world where they go to school, live at home or at a caregiver’s home, and have behavioral health and/or medical issues, all of which reach across disciplines.

Clinicians may tend to look only within their discipline for treatment, Wolfe notes. To best serve children and their families, a child-centered approach must be employed, allowing the child’s life to be viewed from a 360-degree perspective. Ultimately, a child-centered approach results in better outcomes for the child and family members. It also has systemic benefits.

According to Wolfe, this child-centered approach also benefits hospitals and involved agencies by doing the following:

• providing a coordinated joint response to child welfare services and law enforcement from multiple clinical disciplines;

• facilitating cooperation across clinical disciplines, preventing unintentional working at cross purposes;

• allowing for consistency of messaging and services from case to case;

• eliminating duplicative efforts in a time of dwindling resources; and

• improving the system’s efficiency.

— JVP

Reference
Kistin, C. J., Tien, I., Bauchner, H., Parker, V., & Leventhal, J. M. (2010). Factors that influence the effectiveness of child protection teams. Pediatrics, 126(1), 94-100.