Contents lists available at ScienceDirectChild Abuse & Neg

Contents lists available at ScienceDirect
Child Abuse & Neglect
journal homepage: www.elsevier.com/locate/chiabuneg
Research article
Clout or doubt? Perspectives on an infant mental health service
for
young children placed in foster care due to abuse and neglect
Fiona Turner-Hallidaya,⁎ , Gary Kaintha, Genevieve Young-
Southwarda,
Richard Cotmoreb, Nicholas Watsona, Lynn McMahona, Helen
Minnisa
a Institute of Health & Wellbeing, University of Glasgow,
Glasgow, UK
b NSPCC, London
A R T I C L E I N F O
Keywords:
Infant mental health
Decision-making
Foster care
Evidence
Social work
Child abuse/neglect
A B S T R A C T

Despite knowledge about the profound effects of child abuse
and neglect, we know little about
how best to assess whether maltreated children should return
home. The effectiveness of the New
Orleans Intervention Model (NIM) is being tested in a
randomized controlled trial where the
comparison is social work ‘services as usual.’ The future trial
results will tell us which approach
produces the best outcomes for children; meanwhile qualitative
process evaluation is generating
intriguing findings about the perceived impact of NIM on
decision-making about childrens’ fu-
tures. Interviews and focus groups were conducted with social
workers, foster carers, legal de-
cision-makers and the NIM team (n = 63). Data were analysed
thematically. Findings suggest
that NIM is seen as bringing greater influence (‘clout’) to
decision-making due to its depth of
focus, provision of treatment for the family, health professional
input and perceived objectivity.
Simultaneously, the NIM approach and the detailed information
it produces potentially throws
judgments into doubt in the legal system. Clout/doubt
perceptions permeate opinions about NIM
and are inter-related with a historical discourse about ‘health
versus social’ models of information
gathering, with implications for assessment of child abuse and
neglect that extend beyond the
study context. The juxtaposition of ‘clout versus doubt’ both
highlights and is strengthened by an
intense focus among social workers and legal professionals on
how evidence will be regarded
within legal fora when making decisions about children. There
is continuing uncertainty in the
child welfare system about the best ways of assessing

maltreated children, underscoring a con-
tinued need for the trial.
1. Introduction
1.1. The need for quality assessment in the complex world of
child abuse and neglect
Research continues to document the profound personal and
societal costs of childhood abuse and neglect (e.g., Caspi et al.,
2016;
Centre for Disease Control and Prevention, 2017). We know
that one of the key factors in establishing a child’s resilience to
such
effects is positive and emotionally responsive caregiving post-
maltreatment (Dozier, Bick, & Bernard, 2011; Dozier,
Zeanah, & Bernard, 2013). What is less well known, however, is
how best we can make the complex decision about whether a
child
http://dx.doi.org/10.1016/j.chiabu.2017.07.012
Received 21 February 2017; Received in revised form 30 June
2017; Accepted 23 July 2017
⁎ Corresponding author at: University of Glasgow, House 1,
Room 311 (Academic CAMHS), 1 Horselethill Road, Glasgow
G12 9LX (Twitter: ACE_centre2016).
E-mail addresses: [email protected] (F. Turner-Halliday),
[email protected] (G. Kainth),
[email protected] (G. Young-Southward), [email protected] (R.
Cotmore), [email protected] (N. Watson),
[email protected] (L. McMahon), [email protected] (H. Minnis).
Child Abuse & Neglect 72 (2017) 184–195

Available online 17 August 2017
0145-2134/ © 2017 Elsevier Ltd. All rights reserved.
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should return home or not after they have been taken into care.
Robust assessment is crucial if decisions are to be beneficial for
the child, but there are many challenges in measuring mal-
treatment and in disentangling cause from effect (Dinkler et al.,
2017; Glass, Gajwani, & Turner-Halliday, 2016; Pritchett et al.,
2016). Decision-makers know that there are potential pitfalls in
either reunifying children with their parents or in deciding on
permanence via long-term foster care or adoption. Half of
maltreated children who return back home will be maltreated
again within
two years (Luke, Sinclair, Woolgar, & Sebba, 2014). This has to
be balanced against the knowledge that, for young children
under
five, disruptions in their relationships with primary caregivers

can be particularly problematic (Dozier et al., 2013) and foster
care
can lack a focus on their specific needs (Zeanah, Shauffer, &
Dozier, 2011). Ensuring the best outcomes for these chil dren
necessitates
a research spotlight on how to generate the best quality
assessment information upon which to base the life-changing
decision of
reunification with their parents or permanence.
1.2. The introduction and testing of a new model of assessment
In this paper we report on the introduction of a new multi -
disciplinary infant mental health service for children aged 0–5
in
Glasgow, Scotland, who have been placed in foster care due to
concerns about abuse and/or neglect. This service is based on
the New
Orleans Intervention Model (NIM) (Minnis, Bryce, Phin, &
Wilson, 2010; Turner-Halliday, Watson, & Minnis, 2016;
Zeanah et al.,
2001), which was developed by the Tulane University Infant
Team and is made up of psychologists, social workers and a
psychiatrist.
NIM is being implemented internationally in the US, Australia
and England. It has had some encouraging results in the US
(Zeanah
et al., 2001), however we still know little about its
effectiveness. For the first time, NIM is being compared to
social work ‘services as
usual’ (SW-SAU) in a Randomized Controlled Trial (RCT) in
Glasgow, Scotland (Minnis, 2016; Pritchett et al., 2013; Turner -
Halliday
et al., 2016). This means that all children who come into care
due to suspected abuse and or/neglect, aged 0–5 in Glasgow, are
randomized to NIM or SW-SAU and researchers at the

University of Glasgow measure child outcomes across three
different time-
points (baseline, 15 months and 2.5 years after the child has
been placed in foster care).
The trial (known as the Best Services Trial: BeST?) exemplifies
the notorious challenges in carrying out RCTs of complex inter -
ventions: the existence of multiple outcomes, multiple partners
working across multiple settings and agencies, the interventions
(both
NIM and SW-SAU) comprising multiple elements and a need for
flexibility and adaptability in the delivery of the programs
(Craig
et al., 2008). However, as in any large randomized controlled
trial, we expect a good balance across the two groups with
regards
known and unknown factors (e.g., age, gender, family size) so
that only the interventions should differ. NIM and SW-SAU
represent
different lenses of assessment, different professional skill mixes
and different timescales. Both NIM and SW-SAU include a
three-
month assessment of the family, but the NIM intervention
additionally includes a six to nine month trial of treatment that
aims to
improve family functioning, child mental health and maximize
the family’s chance of having the child home, where in the
child’s best
interests. In Scotland, there is no legal timeframe for decision-
making, unlike in England where placement decisions have to
be made
within a maximum of twenty-six weeks.
NIM (called the Glasgow infant and family team – GIFT – in
Glasgow) offers a detailed assessment of all of the child’s
attachment

relationships using standardized measures followed, where
possible, with the trial of treatment that uses interventions such
as Circle
of Security, Parent-Child Psychotherapy and Video Interaction
Guidance (VIG) (Turner-Halliday et al., 2016). SW-SAU do not
offer
formal in-house treatment but do reflect on their naturalistic
observations with parents and can refer parents onto external
services,
e.g., substance misuse counselling, if required. In the United
Kingdom (UK), SW-SAU usually involves regular contact with
families to
assess their likelihood of having the child home. Because
preventative social work is well developed in the UK, often this
will entail
thorough scrutiny of past social work involvement with the
family and observation of the quality of child-parent contact.
The aim of
both services is to make a timely recommendation concerning
the child’s future placement based on the perceived best
outcome
possible for the child, be this reunification with their birth
family or adoption. Fundamentally, we do not yet know how a
new multi-
disciplinary infant mental health model will fare in the Scottish
context in comparison with the long-standing expertise of
traditional
social work judgement.
1.3. Using process evaluation to explore the context of NIM
The results of BeST? are due in 2021 when we will hopefully
learn whether NIM or SW-SAU is the most cost-effective
service, but
in the meantime there is much to be learned about how an infant
mental health model is perceived in the child welfare system

and, in
particular, how the infant mental health mode of decision-
making is perceived in comparison with decisions made by
social workers.
A realist process evaluation is embedded in the trial and allows
us to track the ways in which perceptions of both NIM and SW-
SAU in
the system context are operating (Turner-Halliday et al., 2016).
This is important because we know that contextual factors can
moderate outcomes and that, rather than receiving interventions
passively, participants interact with interventions in ways that
are
influenced by their subjective attitudes and beliefs as well as
cultural norms. This means that those in the context may
respond to an
intervention in ways that cannot be predicted (Moore et al.,
2014). Such subjective reaction, rather than lying dormant, can
actively
affect what happens in practice. The well known ‘placebo
effect’ in trials (re-constructed as a ‘meaning response’ by
Moerman and
Jonas, 2002) is a classic example of perception affecting
outcome. So too is the effect of differing subjective opinions on
relationships;
for example, conflicts between agencies in the child welfare
system can cause delays for children and their families (Johnson
& Cahn,
1995). The relationship between perception and practice, in the
wider context of an intervention, is circular; Pawson and Tilley
(2004, p. 5) remind us that “successful interventions can change
the conditions that made them work in the first place.”
In this paper, we unpack the views and understandings of those
involved in, or affected by, NIM’s implementation – especially
F. Turner-Halliday et al. Child Abuse & Neglect 72 (2017) 184–

195
185
their views on its impact on decision-making in the child
welfare system. Using inductive qualitative methodology, the
process
evaluation we report here has allowed us to move beyond the
normal confines of the RCT, where the focus is very much on
the
success or otherwise of the intervention. By exploring the
context of NIM, we aim to generate explanatory power to
explain why NIM
may, or may not be, effective in Glasgow. This is particularly
important in a trial of a complex intervention where – following
an
iterative process – the contextual and perceptual impacts on
both the intervention and control are captured as they happen;
for
example the evolving legal landscapes and changing perceptions
of NIM as it embeds in the system.
This study’s use of realist process evaluation embedded in an
RCT is an example of a growing awareness of the necessity to
integrate process and outcome data to maximize our ability to
interpret results. This represents a movement beyond the
historical
discourse of ‘quantitative versus qualitative’ methods and
beyond the preoccupation only with “does it work?” (Oakley,
Strange,
Bonell, Allen, & Stephenson, 2006). Process evaluation is
providing insight into the contextual and systemic differences
between the
UK child welfare context and New Orleans (where NIM was

originally developed). These identified differences unders core
that the
RCT question of ‘which service is best in Glasgow?’ is a very
genuine one. NIM in Glasgow may not generate the same
apparently
positive results as have been suggested in New Orleans because
Glasgow may be dealing with fundamentally different families
in a
different system.
Contextual differences between the two settings include the fact
that New Orleans does not have the thorough preventative social
services that we do in Scotland so that parents in Glasgow are
more likely to have been involved in intervention efforts to
prevent
maltreatment in the first place. Consequently, the parent group
who comes into NIM may have more entrenched problems and
their
children may have greater attachment insecurity due to going
back and forth between their family and foster care. Glasgow
does not
have a system like New Orleans that legally endorses parents’
engagement in NIM, making it possible that Glasgow parents
may have
higher instances of non-engagement. Instead, Scotland has an
internationally unique legal system for children – the Children’s
Hearing System – a key pillar of which is the involvement of
Children’s Panels of specifically trained lay people who make
decisions
about children in the child welfare system, although certain
decisions (such as long-term orders for adoption or permanence)
are still
made by judges (Sheriffs) in the Sheriff Court. Unlike in the US
and England, however, judges do not routinely impose
timescales
around children’s permanent placement decisions, leaving

uncertainty and interpretability over what are the most timely
decisions
for the child. Although the Children’s Hearing System has the
Welfare Principle (where the welfare of the child should be of
para-
mount consideration) as its foundation, it has become more
adversarial in recent years with increasing involvement of
lawyers
(Porter, Welch, & Mitchell, 2016). Our realist process
evaluation is finding that parents receive varying advice from
lawyers in
relation to NIM with some being advised not to engage; an
example of the increasing challenges for Children’s Panels in
making
decisions when faced with conflicting opinions (Walker,
Wilson, & Minnis, 2013). Exploring such legal tensions will be
a new focus
for the process evaluation as the trial moves forward.
Furthermore, there are differences between New Orleans and
Glasgow in relation to the care system. In addition to a concern
about instability in the Glasgow care system (Minnis et al.,
2010), children in the UK routinely go into emergency and
short-term
foster care (a pathway that sometimes results in multiple
placements) while decisions are made about their future. If it is
decided that
adoption is the most suitable outcome, the child will usually
move to new adoptive parents. In New Orleans and many other
parts of
the US, foster carers are dually registered as prospective
adopters so that, if a child cannot return home, their foster carer
routinely
becomes their adoptive parent (Turner-Halliday et al., 2016).
This means that, for children who are not able to return home,
NIM in

the US is able to work with the child’s long-term caregiver
whereas there are challenges for NIM in Glasgow in not being
able to work
on long-term attachment relationships with such children.
1.4. Using process evaluation to explore the impacts of NIM on
decision-making
The introduction of NIM into the child welfare system marks
the first time that an infant mental health model has been in-
corporated into social work systems. The multiple challenges of
multidisciplinary working in other fields have already been
docu-
mented (e.g., Robinson & Cottrell, 2005; Satterfield et al.,
2009), but not previously in this context. Realist process
evaluation allows
us to explore this novel interaction between a health and social
approach in assessing cases of maltreatment. It also heightens
understanding about the way that NIM generates information
upon which to base decision-making, and how the resulting in-
formation is received in a child welfare system where there is a
longstanding tradition of social work processes.
We already know that health and social care differ in terms of
their approaches to generating information upon which to base
decision-making. Healthcare practitioners consider RCTs to be
the gold standard research methodology. These – like BeST? –
are
predicated on a foundation of uncertainty about whether the
intervention (NIM) or the control (SW-SAU) produces the most
fa-
vorable outcomes (Greiner & Matthews, 2016). The process of
randomization to intervention or control in order to even out all
known
and unknown differences (confounders) between the two groups,
except for the intervention that they receive, is fundamental

since it
is the most robust way of preventing selection bias (Craig et al.,
2008.) In health, there is a notable congrue nce between the way
that
medical assessments, for example, are performed and the way
that an RCT gathers evidence: both have starting-points of
uncertainty
where the task is an inquisitive, bottom-up approach, to
information gathering. This approach, followed by NIM, may be
at odds with,
and undermine, the values of social work where common sense
representations and reflexive understanding of what is going on
in a
family are used to contextualize and locate work. In other
words, social workers are much more likely to make use of their
pro-
fessional autonomy during data-gathering. Rather than a purely
information-gathering approach to decision-making, it is argued
that
social workers are operating within a “limited rationality” that
is curtailed within legal and organizational requirements (Webb,
2001, p. 57).
The uptake of “evidence-based practice”, therefore, has varied
across professions. Medicine has adopted evidence-based
practice
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186
into its culture in a way that public policy, for example, has not
(Macintyre, Chalmers, Horton, & Smith, 2001). This can be

linked to
varying values between professions in terms of what constitutes
the nature of ‘evidence’ and the position of ‘certainty versus
un-
certainty’ in particular. For example, in the legal system, there
is value placed on the professional expertise and autonomy of
lawyers
and judges in a way that also values an assumption of “certainty
as to the ‘right’ answer” (Greiner & Matthews, 2016, p. 303). In
contrast, in health, an ethical pre-requisite of RCTs is
“equipoise,” defined as a “balance of forces or interests”
(Oxford Dictionaries) –
in other words, uncertainty as to the outcome of the study.
1.5. This paper – aims and objectives
Whilst the BeST? trial continues, we seek to examine how NIM
– and its style of decision-making – fits into Glasgow’s child
welfare
system by gathering qualitative data from a range of
participants in our process evaluation (Turner-Halliday et al.,
2016). This
inductive analysis to date has unearthed a key overarching
theme around the perceived impact of NIM on decision-making
in the
Scottish legal system. The theme represents an apparently
contradictory position amongst participants about NIM’s abili ty
to make
effective decisions, with implications for decision-making and
the nature of ‘evidence’ beyond the trial or the Scottish context.
These
views have permeated the qualitative data gathered from a range
of participants throughout the course of the trial and indicate
the
value in identifying and unpacking unpredictable reactions to a
new intervention in the system (Moore et al., 2014). In our

discussion
of the data, we aim to contextualize this theme by linking it
with the aforementioned theories of evidence-gathering in
health/social
models and by proposing what the findings means for the trial
and the assessment of cases of abuse and neglect more
generally.
2. Methods
Data were collected as part of the qualitative process evaluation
embedded in BeST,? which follows a realist evaluation
approach
(Pawson & Tilley, 2004) and uses an inductive qualitative
analysis to explore NIM’s context. Realist evaluation asserts
that pro-
grammes are embedded in open social systems, which are
active, and that can change and evolve. One of the key tasks for
evaluation,
therefore, is to unpack the complex social reality in the context
of an intervention in order to understand how interventions
function.
Realism assumes that programmes will vary depending on
context and what is contextually significant may not only relate
to locality
but also to systems of interpersonal and social relationships. It
is proposed that certain contexts will be supportive to the
programme
theory and some will not, which necessitates a key task in
sorting one from the other.
As one aim of the larger task of conducting a realist evaluation
over the course of the trial, this paper is focussed on NIM as
embedded in a social system and, by collecting data from
participants across the child welfare system, we aim to
understand per-

ceptions in that context and the ways in which such thinking
may be interacting with practice – with possible influences on
outcomes.
There is growing acceptance that, in the evaluation of complex
interventions, evaluations need to understand this complexity to
inform future intervention development, or the application of
the same intervention in another setting (Craig et al., 2008).
Qualitative work in the first part of the trial focused on the
implementation and delivery of services from the perspectives
of key
stakeholders; social workers, foster carers, NIM and SW-SAU.
The main data collection method for this purpose was focus
group
discussions, which were repeated throughout the trial in order to
track changes and developments over time. The exception was
data
collection with foster carers; it was found that they preferred
the more personal and private nature of an individual interview.
The second phase of the process evaluation, although still
tracking the development of issues gleaned in the first phase,
adopted
case study methodology to focus more specifically on the
impact of NIM and SW-SAU on a selection of children and
families enrolled
in the trial. This narrower focus allowed a more in-depth
investigation into the experiences of the birth family, foster
carers, social
workers and health professionals when a case of maltreatment is
under assessment by NIM or SW-SAU. The primary
methodology for
this part of the process evaluation was individual interviews.
For the aspect of the larger process evaluation that we focus on
in this paper, we used interviews and focus groups with 63

participants falling into the categories of a) SW-SAU, b) NIM,
c) Foster Carers, d) Children’s Hearing System: 19 interviews,
and 11
focus groups. Interviews: 6 SW-SAU individual interviews, 5
NIM individual interviews, 8 foster carer individual interviews.
Focus
groups: 3 SW-SAU focus groups (11 participants) 5 NIM focus
groups (12 participants), 3 Children’s Panel focus groups (26
parti-
cipants). Whereas the NIM and SW-SAU focus groups were
with the same teams over different time-points in the ongoing
trial, the
individual interviews with NIM and SW-SAU were with
selected team members for conducting the case studies. The five
participants
in NIM individual interviews also took part in the NIM focus
groups and so are not counted twice. Ethical approval was
obtained from
West of Scotland Research Ethics Committee.
Sampling was purposive: all members of NIM and SW-SAU
teams were invited to take part in the process evaluation based
on their
ability to provide views about the models being implemented.
Similarly, social workers were invited to take part in focus
groups if
they were aligned to any of three local area teams representing
the geographical spread of area team social work services across
Glasgow. Panel members were purposively recruited from six
sectors across Glasgow to provide views that represented the
spread of
panels across the city. The foster carers all had children being
assessed by either NIM or SW-SAU at the time of data
collection. For the
case studies, sampling was both purposive and random; NIM
and SW-SAU identified a number of cases where there were

indications,
during the process of assessment, about the nature of the final
recommendation and the process evaluation, then we randomly
selected two cases from each service where it looked likely that
there would be opposing outcomes; one case from each service
where
indications were suggestive of the child/ren being rehabilitated
home, and one case from each service where it looked likely
that a
recommendation would be made for permanency. Participants
were invited to take part in case study interviews based on their
involvement in the case and their ability to provide a view on
the child from their specific perspective; that is, from the angle
of the
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parent, the foster carer, the area team social worker and the key
workers involved in the case from either NIM or SW-SAU. All
participants received study information forms and had the
opportunity to ask questions before consenting to take part.
The focus groups and interviews used topic guides that evolved
iteratively from thematic analysis during the process of stake-
holder engagement prior to the start of the trial and continue to
develop as the trial unearths key issues as it progresses.
Interview and
focus group topic guides were semi-structured so that pre-
defined issues were explored whilst allowing for new issues and
topics to
emerge as introduced by the participants. The general focus of

all interviews and focus groups was the introduction of NIM
into the
system. Interviews and focus groups lasted approximately sixty
minutes and were audio recorded then transcribed verbatim. All
data
was stored securely and confidentially and participants were
anonymized for the purpose of reporting.
A thematic analysis (Braun & Clarke, 2006) was employed
where each transcript was examined in detail, noting reflections
and
preliminary themes. Transcripts were read numerous times to
identify repeating patterns and/or differences between
transcripts, and
any new themes identified at this stage were noted. Lists of
identified themes were then organized: themes that were found
to relate
to each other were clustered together and became a group of
themes divided into sub-themes with an overall theme heading
that
captured the essence of each category. In this first round of
analysis, FT-H identified that many of the categories of themes
linked to a
key overarching premise running throughout the data about the
impact and influence of NIM on decision-making. This
prompted the
formulation of a research question about NIM’s influence and
impact on decision-making in comparison with SW-SAU.
With this more specific research question in mind, it was
decided to conduct a second round of analysis through the lens
of the
emerging overarching theme. In order to enhance reliability of
the analysis, this second round involved a second researcher
(GY-S)
who independently analyzed the data. Analyzes were compared

and an overall level of agreement between researchers was
found,
with the exception of each researcher identifying a few different
minor sub-themes that were later identified by both researchers
to be
out-with the realm of the research question. These were omitted
from the overall frame of themes for the paper so that the final
themes were aligned only with the research question.
3. Findings
The overarching theme identified in the primary analysis of the
data was that which we have termed as ‘clout/doubt;’ a phrase
representing a set of conflicting views about the impact of the
evidence that NIM generates in cases of abuse and neglect.
‘Clout’
(influence or power) refers to the view that the information
produced by NIM is held in higher esteem than that which is
generated
from SW-SAU. On the other hand, ‘doubt’ refers to the view
that the NIM approach, and the evidence it produces, has the
potential to
throw into question (create uncertainty around) assessment
services’ recommendations about a child when that
recommendation is
viewed by the legal system.
In the second round of analysis (the more specific focus on
clout/doubt), the theme was found to be multi-faceted and,
although
we later explain that clout and doubt are essentially ‘two sides
of the same coin,’ the clout/doubt themes and their sub-themes
are
presented separately for the purposes of reporting:
3.1. The clout of mental health assessment

The ethos of a mental health focus when assessing wellbeing in
maltreated children was largely seen as positive and it was this
that made some feel that the model may better meet the needs of
both children and parents. However, there was a stronger focus
amongst SW-SAU and Children’s Panel members on the impact
of NIM’s evidence in the legal system than on the model itself.
One
strand of this perceived impact was that NIM was perceived to
have greater influence (clout) than SW-SAU.
Three main themes were interpreted from the data as being
pivotal in relation to perceptions of NIM’s clout:
3.1.1 NIM’s health professional input and position in the
system;
3.1.2 NIM having an in-depth assessment focus;
3.1.3 The information gleaned from giving parents a trial of
treatment.
3.1.1. NIM’s health professional input and position in the
system
NIM reports were perceived to be more influential than those
from SW-SAU due to a combined effect of the type of
professionals
involved in the service and where NIM sits in the system
comparative to SW-SAU.
The presence of psychologists and psychiatrists when presenting
NIM evidence was perceived by SW-SAU as adding an element
of
clout to judgment and opinion. SW-SAU reported that the
Children’s Panel, in particular, saw health professionals as
providing an
additional level of expertise, which often strengthened SW-
SAU’s recommendation:

“The fact that a child psychotherapist was sitting there [at the
Children’s Panel] saying the same thing about contact that I was
saying…I
wouldn’t have just won it on my own, but because a child
psychotherapist from GIFT [NIM] was there, saying the same
thing, it was a done-
deal then” (Area team 2 social worker).
Mental health professionals were perceived to bring with them a
“medical model,” which is thought by SW-SAU to hold
particular
credibility with the Children’s Panel:
“[NIM] seems more like a medical model almost, and panels
respond much better to medical models and they tend to trust
doctors and
psychiatrists and psychologists. They don’t tend to trust social
workers and people who aren’t, you know, medically trained”
(Area team
social worker, case study 3).
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188
Coupled with the perceived credibility of the team, NIM was
repeatedly referred to as “external” to SW-SAU, particularly by
SW-
SAU and panel members. Whereas SW-SAU were seen as
having a past relationship with the family (often being
responsible for
removing the child/ren from home as well as assessing them)

NIM was seen as having a more objective and fresh perspective
of the
case:
“I think that the reports carry a lot of weight, especially if you
are presenting that as part of an evidence to panels, because
panels −
whether we like it or not − sometimes maybe think that the
social work or area team are not as objective, but they see them
[NIM] as being
external…and not just based on social work bias” (Area team 1
social worker).
The combination of NIM’s perceived objectivity and level of
expertise appeared to ease decision-making by panels:
“[NIM] come in independently … it is uncomplicated that these
people, who are experts, have come in and their
recommendation is such
and such, and you would put a lot of weight on that” (Children’s
Panel member).
The trade-off of NIM’s professional clout for SW-SAU,
however, was that their own professional credibility could feel
undermined:
“I think we believe we should have more professional
credibility than we sometimes have. I think probably people
have got an anxiety that if
we disagree with the GIFT [NIM] assessment and then you get
two conflicting assessments going to family court, our
assessment will be seen
as the lesser…I don’t know whether that has happened, but I
think it would be interesting to see if that happened” (Area team
1 social
worker).

This resulted in a perspective that – inadvertently – SW-SAU
may enhance NIM’s clout by translating their own feelings of
comparative inferiority into the wider system. Some social
workers therefore voiced a need for more displays of confidence
amongst
SW-SAU when presenting evidence in the legal system.
3.1.2. NIM’s in-depth assessment focus
A mental health lens was seen as providing a more detailed
assessment of need, thereby enhancing NIM’s clout. In one case
study,
SW-SAU felt that NIM had identified a child’s developmental
issues that may otherwise have been missed:
“When you do have a case like that with a child who has got
additional needs, things can be masked, like her development.
GIFT [NIM]
had picked up on the clinical side of it, which has given us a
much better and thorough assessment” (Area team social
worker, case study
4).
NIM’s detailed assessment information about a case appeared to
further aid panels’ decision-making. The detail was seen as
“scientific” evidence, particularly in relation to decisions about
the frequency of contact sessions between children and their
birth
parent/s:
“To have a scientific basis upon which to consider the
difference between having contact twice a year and six times a
year would surely be
very, very helpful…I am quite frustrated that social work maybe
say that they want to make less contact because it is not going

very well…
and you say, well that’s not really enough information, what do
you mean by ‘it’s not going very well?’ But on that [NIM] case
there was a
whole list of things” (Children’s Panel member).
NIM assessments were also seen as more detailed in relation to
information about parents. Although SW-SAU assessments were
viewed to take account of parents’ history and own experiences
of maltreatment, NIM was seen as better examining the
implications
of a parent’s past trauma on current functioning:
“It [NIM’s assessment report] is very detailed and really goes
into the case history in terms of the trauma for mum and dad
and picking up
on things that maybe perhaps in our own integrated assessments
have just been skimmed over…but they have had the
opportunity to really
unpick that and work out why the parents are functioning the
way they are now, as opposed to just all the historical stuff all
the time” (Area
team 1 social worker).
Again, however, the perceived clout of NIM’s assessments had
a counter point in that it can make SW-SAU feel that their pro-
fessional expertise is being called into question:
“I feel as if we are undermined at times because we are trained
social workers, our job is to assess…social workers are skilled
to assess, they
do have the skills to do that, and they can come to some kind of
judgment” (Area team 2 social worker).
3.1.3. A trial of treatment
NIM‘s treatment component offers interventions that focus on

the parent–child relationship. These interventions can have a
secondary effect of addressing difficulties for parents that relate
to their own experiences of being parented. This is contrasted
with
SW-SAU where parents would usually be referred to external
services (if available) for such interventions. While carrying out
treatment takes longer, it aims to improve the accuracy of the
recommendation made at the end by maximizing the parent’s
chances
of changing whilst demonstrating clarity in relation to any lack
of change:
“If we get to the point where we say that we would not
recommend this child to go home, we have done it having had,
you know, the best
possible assessment, the best possible intervention. And in the
end we have to work in the best interest of the child - on that
really sound
foundation of what we know and what we have tried to do”
(NIM team member).
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Improving accuracy was essentially seen as making the best
decisions about the child in the long-term. For children who
return to
their parents, there was a view that undergoing treatment will
make it less likely that they will end up coming back into care:
“There are some cases where there would probably be that

process where the child might have returned home, but
potentially would have
come back into care without the right support, and that feels
like a real strength of what we are doing” (NIM team member).
For children who cannot be returned home, the evidence
generated from the treatment phase was felt to add clout to the
recommendation being proposed, even although the lengthier
timescale of the process is often seen as a caveat:
“People who have gone through the [NIM] process though by
the end of it are saying ‘well actually it is worth it’ because the
evidence is
there in terms of parent incapacity… I think people get very
frustrated with the timescale, you know, and there is no getting
away from
that” (Area team social work service manager).
Those who saw the treatment phase as adding clout to decision-
making generally saw the lengthier timescale as necessary
payment for improved accuracy. A view of there being
‘differential suitability’ for the NIM model, however, was
unearthed and this
depended upon whether the case warranted a lengthier
timescale. For foster carers, treatment (and a lengthier time to
make a
recommendation) was particularly suited to cases where
previous reunification had subsequently resulted in the child/ren
coming
back into care:
“I do not want these children to go back to their parents if it is
not done properly because these kids were in care before and
went back to
their mum and dad and they failed within six months…I am not
saying that I don’t want them to go back to their mum and dad, I

don’t
mean that, but what I mean is they need to be spot on this time
and I feel that this long assessment, because it is like a three-
month
assessment and then a further six months, is the right road for
this family” (Foster carer F2).
For other children, however, the treatment phase and lengthier
timescale was not perceived to be warranted – this is where
views
of doubt become visible, which are now outlined in the
following section.
3.2. The doubt created by a mental health approach
The ‘flip side’ of NIM generating evidence that is perceived as
more influential is that it was seen as having the potential to
throw
into doubt the claims and recommendations made after
assessment. In our data, doubt perceptions were isolated to
cases where it was
perceived that a child should not return to the care of their
parents. In such cases, fears were expressed that the mental
health element
of NIM would reflect more favorably on parents than a SW-
SAU assessment because: a) it involves a more intricate
assessment of
child-parent interaction that can be open to interpretation and
legal challenge; b) it has a current focus on family functioning
that
may miss wider information about the child’s social context that
SW-SAU often glean; c) it offers parents a trial of treatment,
which
may convey a perspective that change is possible in families
where SW-SAU believe it is highly unlikely.

These views are explicated in three sub-themes:
3.2.1 The intricate focus on child-parent interaction;
3.2.2 NIM’s lack of historical relationship with the family;
3.2.3 NIM’s trial of treatment.
3.2.1. The intricate focus on child-parent interaction
The detailed focus on intricate child-parent interactions that
NIM typically assess was thought by SW-SAU to reflect more
fa-
vorably on parenting capacity than their more naturalistic
observation of the relationship. The difference in focus was
seen as
“psychological versus practical:’
“I think because there are health professionals there at GIFT
[NIM], they certainly assess it in a much more thorough way I
would say….no
“thorough” is not the right word…they go into the ‘nitty gritty’
a bit more…they video it, they analyze very small snippets of
contact, for
example. If they see one thing positive − like very good eye
contact where there was maybe issues with attachment − they
would say ‘well
we might have something to work with there.’ So they would
assess it or they would judge it in a slightly different way
whereas social work
are looking through two-way mirrors and they are just looking
generally at the contact and whether mum does have the
capacity to meet the
child’s needs; for example, can mum change a nappy when the
child’s nappy needs to be changed? Does she recognize that? Is
she able to
stimulate them by getting the right toys? Able to feed them?
You know, the practicalities rather than going into some of the
psychological… I

think you can look at that more optimistically rather than just
looking at the way that a social work would assess it” (Area
team social
worker).
In cases where SW-SAU felt that reunification should not be
recommended, they feared that the intricate-level data produced
by
NIM could also reflect an unrealistically positive view of
parents in the legal system by providing more room for
interpretation and
challenge by family lawyers:
“It [intricate-level evidence] lends weight but it also gives them
[family lawyers] more things to challenge” (Area team social
worker).
3.2.2. A lack of historical relationship with the family
There is also a feeling that NIM can miss both a historical and a
wider social context about the child. In many cases, SW-SAU
has a
long history of working with the children and the families
concerned and there is a fear that NIM may miss much of the
arcane
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knowledge that social work has acquired. Social workers saw
NIM’s focus as being primarily on current functioning as
sometimes

presenting a more favorable picture of parental capacity:
“I think it is different because we [SW-SAU] are not just doing
the contact assessment…we are assessing the kind of dynamics
in the house,
and all the stuff that is provided in that…we are looking usually
before they are removed so it is home environment that we are
assessing
rather than just the contact once the kids have been removed”
(Area team 2 social worker).
NIM’s focus on current functioning was sometimes seen as
presenting an unrealistically positive picture of parenting
capacity that
would not be maintained. Some social workers feared that this
focus would create doubt in the legal system over parental
incapacity,
resulting in children being sent home to parents who would be
unable to maintain behavior change:
“I am not saying they [NIM] are unrealistic, and they will still
say what the concerns are as well, but I am thinking that this is
all a bit
artificial…mum and dad are doing okay just now, but, you
know, that certainly wasn’t my experience, for example, when I
had the
children registered for a year…and weekly visits and
everything, but now… they are able to pull some of that
together, and my anxiety is
that once the assessment phase is over, and if that child is
returned home, that things would revert back to the previous
behaviors” (Area
team 1 social worker).
3.2.3. NIM’s trial of treatment
Two angles of this theme were identified in the data:

3.2.3.1 That NIM’s treatment phase makes it appear that some
parents were given a chance when SW-SAU reportedly knew
from
the outset that reunification was not possible:
3.2.3.2 That a lack of synchronicity between the NIM timescales
and those in the wider system can render NIM evidence as more
‘doubtful’ than it would have been if there had been a better fit.
These two angles are now described:
3.2.3.1. Conveying a false possibility of change. SW-SAU held
the view that there are certain families where it is clear early on
– and
often based on a historical perspective – that the parents are
highly unlikely to ever achieve a level of sufficient parenting.
NIM’s
implementation of the treatment phase in such cases, where
NIM later recommends non-reunification, is seen as a
superfluous
consideration of an unachievable outcome:
“It’s commonplace for social workers, and particularly social
work managers, to say to us ‘we wouldn’t be doing this
[continuing to work
with the family] if you [NIM] weren’t involved - there would be
no talk of these children going home’ - and that’s the
commonest difference”
(NIM worker, case study 4).
Implementation and/or continuation of treatment are perceived
to weaken the case, legally, for non-reunification; that is, the
treatment approach is felt to create doubt by conveying a sense
of optimism that the parents could provide adequate care with
the
right intervention:

“It was quite clear, to me, that there should have been no
rehabilitation plan from the evidence that was there, but
certainly GIFT [NIM]
were reluctant to make that decision at that time because they
were saying they hadn’t gone through the whole assessment.
There was
support after support went on…there wasn’t any evidence of
change at that point and I just felt that we were flogging a dead
horse, you
know, and giving some false hope to mum as well…and if you
go to court with that it puts doubts in people’s mind that maybe
mum can
come through this and maybe she can parent her child or her
children. So, I just think that kind of thing needs to be teased
out a bit…
certainly when there are cases were it does appear obvious that
the children shouldn’t go back home at an early stage” (Area
team 2 social
worker).
Again, a view of there being a differential suitability for NIM
was apparent, with these apparently clearer-cut cases viewed as
less
aligned with NIM than those where decision-making takes
longer. In this perspective, perceived early and clear indicators
of non-
reunification (only one example was given: repeated and failed
previous attempts to improve parenting capacity) remove a need
for
improving the accuracy of decision-making through a trial of
treatment. This contradicts NIM’s position where decision-
making based
on “early” indicators without thorough assessment is
questioned, as is ascertaining the clarity of such indicators
without a trial of

treatment. NIM aims to give parents a chance to change in
response to treatment, where it is in the child’s interest and
where parents
can meet the conditions of treatment (e.g. attend regular
appointments.) SW-SAU did not refer to NIM’s treatment phase
also being
based on a rationale that parents whose children cannot safely
go home at the end of NIM treatment are less likely to maltreat
children from subsequent pregnancies. Due to the stage of the
trial, we do not yet know whether NIM is more likely than SW-
SAU to
recommend reunification, nor whether the trial of treatment has
an effect on reunification rates.
3.2.3.2. The doubt over undefined timescales. The debate over
whether NIM should be implementing or continuing treatment is
often
based upon a central question about ‘how long is enough?’ when
it comes to giving parents opportunity to change. Not having an
imposed legal timeframe in Scotland, even although court-
imposed timescales lack an evidence-base, means that
appropriate
timescales – and whether parents will continue to change in this
timescale − is open to interpretation. From the perspective of
SW-
SAU, parents demonstrating progress in treatment, but taking
too long to reach a “good enough” level of care, introduces
doubt over a
later recommendation of non-reunification:
“At the end of the NIM process, they [NIM] had said that mum
was now at the place where we would have wanted her to be,
like a few
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191
months ago, but I think that inevitably leads to the question
then why not give her a few more months then and see? Well
she is at a place
now where she has moved, but not enough to send the children
home, so it leads to the legal argument of ‘give her more time”'
(Area team 2
social worker).
The need to make decisions in a timescale that is right for the
child was discussed within all avenues of the data, with SW-
SAU
seeing NIM as sometimes lengthening the process beyond an
optimal time-point and NIM pointing to delays in the wider
system as
creating the most barriers to a timely process. A lack of a legal
framework that supports congruence between the timeline of
NIM and
processes in the wider system was seen as sometimes diluting
the clout of NIM reports; for example, a delay between NIM
making a
recommendation in their final report and a Children’s Hearing
being arranged. In such cases, doubt over whether NIM
information
was still relevant sometimes replaced former clout:
“When I was on the hearing I was still thinking ‘but that [NIM
report] was in June and things had moved on’ and so I felt that I
couldn’t put
the same weight on it and I felt very guilty about that because I
felt all the work had been put in [by NIM]” (Children’s Panel
member).

4. Discussion
4.1. Overview of clout/doubt and relation to study aims
The teasing apart of clout and doubt perceptions in the child
welfare system leads us to conceptualize the theme as a two-
sided,
but inter-related, concept – a ‘double-edged sword’ – with
neither clout or doubt existing as separate entities. Fig. 1
diagrammatically
represents the perception that NIM is seen as having more clout
in the system yet, in contrast, it is also seen to generate
evidence that
can be doubted. On the other hand, SW-SAU is seen as having
less clout but perceptions are that their assessment information
is also
less likely to evoke doubt. There are clear dilemmas for
assessors trying to generate evidence that will be heard, yet
perceiving that
the trade-off may be an increased risk of legal contest and the
chance that their recommendation is not upheld. These are
challenging
positions for those who face the complex task of making
recommendations about child welfare in the context of abuse
and neglect.
Ironically NIM’s ‘clout factors’ (its involvement of health
professionals, perceived objectivity, depth of focus and its trial
of
treatment) are the very same aspects of NIM that are seen as
having the potential to evoke doubt. Firstly, the health
professionals in
the NIM team, although being a key source of clout, were
perceived by SW-SAU to lack a wider social and historical
picture of

maltreatment. Rather than this being specifically about their
health professional expertise (as is the case with clout), the
doubt
generated by health professionals was about their alignment
with a current-day approach to assessment. The flipside of
NIM’s
proposed objectivity is a perceived inflation of some parents’
abilities in an unrealistic way by overlooking past history.
NIM’s depth
of assessment focus and resulting intricate-level evidence is
seen as being open to challenge in the legal system in a way that
SW-SAU
evidence is less likely to be. Lastly, the trial of treatment for
some parents, as well as being seen as having the potential to
improving
accuracy of decision-making, is thought to convey a message to
the legal system that change is possible in cases where SW-SAU
felt
that it was clear at an early stage that reunification was
unachievable. This message is seen as a factor that will lead to
legal contest if,
after treatment, a recommendation is made that the child should
not go home.
In research terms, clout/doubt suggests that the BeST? trial
maintains equipoise. More broadly, our findings evidence
genuine
uncertainty in the child welfare system about the best way of
assessing cases of child maltreatment: should assessment
measure
intricate-level interactions through a mental health lens or a
more general, and perhaps a more contextualized, overview of
the
parents’ ability to respond to a child’s needs? Should it have a
current or historical focus and should this focus be on the child,
the

parents or the relationship? Should there be a treatment
component implicating a lengthier timescale or a shorter
timescale with no
formal and routine treatment?
Until we know the results of BeST,? these questions remain
unanswered in terms of the impact of NIM and SW-SAU on
child
mental health. It is clear that the perceived answers to such
questions, however, are inextricably linked with the notion of
evidence
impact and not just evidence quality. In other words, there is a
driving focus on generating evidence that is most likely to be
heard and
NIM – high clout,
high doubt
SW-SAU – low
clout, low doubt
The ideal – high
clout, low doubt
Fig. 1. The relative impact of NIM versus SW-SAU evidence.
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to withstand legal contest. However, according to our data, this
ideal (see Fig. 1) appears unachievable because the assessment
approach that leads to being heard (having clout) in the system

is perceived to simultaneously increase the likelihood of legal
contest
(doubt) about the resulting recommendation.
4.2. The context and creation of clout/doubt: an adversarial
legal system
Clout/doubt perceptions appear to be born out of an adversaria l
legal context in which child welfare assessors and decision-
makers are immersed. Participants in SW-SAU and the Hearing
System answered open questions about the general impact of
NIM
with a central (and more specific) focus on how the new model
will be viewed legally, suggesting that consciousness about how
recommendations might play out in the legal system is highly
influential. This leads to questions about whether an
increasingly
adversarial legal consciousness surrounding cases of abuse and
neglect is shaping the assessment of maltreated young children
as
assessors attempt to pre-judge the ways in which the legal
system will react to the evidence that they present. Whether this
jeo-
pardizes assessment that should be driven more
straightforwardly by the needs of the child is a resulting and
concerning question.
Whereas clout appears to resonate with a general known
difference between the power and influence of health versus
social
models (e.g. Robinson & Cottrell, 2005), the doubt theme
encapsulates findings that shed a particular and novel light on
the legal
context of maltreatment. There is an irony in NIM attempting to
enhance the quality of assessment evidence by providing depth
of

focus and a trial of treatment, yet (according to SW-SAU) it is
these very aspects that may lead to the potential for NIM re-
commendations about a child not being upheld in legal contest.
The immersion of clout/doubt in presumptions about NIM’s
legal impact underscores the influence of context on perception.
It is
clear that perceptions about NIM construct it in a way that often
contradicts the way in which it was originally conceived. For
example, NIM was referred to as a “medical model,” whereas it
is multi-disciplinary with professionals from a social work
background
making up half of the team. In addition, the health professional
mix is dominated by those who would not be classed as
“medical,”
such as psychologists. Similarly, NIM was cited as being
“external,” whereas the NIM team sees itself as being embedded
within the
child welfare system. Perceptions of NIM as “medical” and
“external” are potential barriers to its integration into social
work systems
– an example of how perception of a model can impact on the
actual relations between agencies. Yet these potential barriers
are those
features of NIM to which clout is attributed. NIM’s clout looks
at least partly constructed on the basis of widely held traditional
beliefs
about the relative power of a mental health “medical” model in
the ‘health versus social’ dichoto my (Beresford, 2002). It is
possible
that, in this context where there is an emphasis on legally
impactful evidence, the health/social dichotomy becomes more
visible. In
other words, when the child welfare system is looking for
evidence that has clout in the legal system, the traditional power
and

influence attributed to health models fits this aim. In turn, the
perceived power difference between health and social care
becomes
reinforced.
4.3. Decision-making timescales: clout/doubt and ‘certainty
versus uncertainty’
SW-SAU in this study convey a sense that they are able to
establish the right decision about some children much earlier
than at the
concluding point of the NIM model, thereby reducing the time
the child spends in care before a decision about their future is
reached.
For cases where SW-SAU feels that non-reunification is the
only option from the start, NIM treatment was seen as
superfluous and a
delay for the child in moving onto adoption or long-term foster
care. There was a concern too that legal decision-makers could
also
argue for a lengthier timescale for parental change that is not in
the best interest of the child. This is weighted against the
counter-
point that NIM’s treatment phase may improve accuracy of
decision-making, reduce the likelihood of a child returning into
care if
they return home and decrease the chance of children from
future pregnancies being maltreated. Essentially, the
controversy over the
NIM treatment phase reflects a broader debate in the child
welfare system, and a lack of evidence, about timescales that
are in the
best interests of the child. Such debate also spans into
controversy over which parts of the system create the most
delays for children
and the timepoint at which it can be confidently decided that

parents are not going to progress adequately enough to be able
to be re-
unfied with their children.
Debates about timescales resonate with issues of evidence-
gathering and professional autonomy. For SW-SAU, being able
to make
a judgment without a treatment phase exemplified a core value
of using professional experience as a key tool for decision-
making. A
further facet of SW-SAU experience was their reported ability
to draw on their involvement with a family in the home setting
and
often prior to the child’s removal from that setting. According
to social workers, however, their professional experience felt
un-
dermined in Children’s Panels by the clout attributed to health
professionals from NIM. This appears to contradict the position
of
Greiner and Matthews (2016), who theorize that the legal
system would value such professional experience in comparison
with an
evidence-gathering approach (as NIM is based on). However,
Greiner and Matthews (2016) specify this position as being
related to
judges and lawyers and we know less about how such theory
translates to other facets of the legal system like the Hearing
System in
Scotland. We have yet to collect data with lawyers and judges
to explore whether social work predictions about the legal
reaction to
NIM evidence actually reflect the perspectives of the legal
profession.
In an alternative interpretation, it is possible that health
professional status, and related themes of clout (e.g., expertise

and
objectivity) may translate into a perceived notion of
professional autonomy. In other words, NIM reports may be
seen as being based
on health professional opinion rather than from evidence-
gathering by what is in fact a multidisciplinary team. Indeed, it
was the
voice of health professionals from the NIM team at a Children’s
Panel – the actual presence of that professional – that was given
as an
example of clout impact in the findings. If this is the case,
Greiner and Matthews’ (2016) theory about the legal system
favoring this
type of evidence is instead supported.
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193
Further research should also explore the potential differences
that might occur between health professionals’ presentation of
evidence verbally, such as in the Hearing System, versus a more
traditional legal system pondering written evidence. It is a
limitation
of this current study that we cannot say more about the relative
weights of different forms of evidence in different legal fora,
given
that participants often spoke generally about “the legal system”
without specification. It is plausible that, in court situations, a
key
feature of NIM’s clout – the presence of the health professional
in presenting evidence – may be diluted as the focus shifts onto
documented intricate details – a key feature of NIM’s doubt. It

is possible, therefore, that NIM recommendations about a case
are
more likely to be upheld by the Hearing System but contested at
court-level.
5. Conclusions and future directions
The quantitative results of BeST? are eagerly awaited and there
is continued uncertainty (a position of equipoise) about whether
SW-SAU or NIM offer the best approach to analyzing cases of
maltreatment. This is important, not only because it underscores
the
ongoing need for the trial, but because of the bidirectional
relationship between subjective opinion and practice. The
clout/doubt
theme is applicable beyond BeST? and beyond Scotland; it
suggests a central influence of the legal context on the
construction of
perceptions about what is the ‘best’ assessment evidence upon
which to base crucial child welfare decisions.
It will be interesting to witness how the clout/doubt theme
evolves over time. If it transpires that NIM really does face
more legal
challenge than SW-SAU, perceptions of clout/doubt may be
affected. Similarly, as SW-SAU is proven ‘right or wrong’ in
relation to
their projections about NIM’s impact, views about clout/doubt
may alter. This might be particularly true in relation to the
perspective
that NIM reflects more favorably on parents than SW-SAU; it is
feasible that, over time, this view may be strengthened or
diluted as
the conclusions of cases are learned. Calls amongst social
workers about a need to demonstrate a greater sense of
confidence in their

judgments have the potential to change and re-balance clout
perceptions between NIM and SW-SAU. Conversely, it is
possible that
social workers will – by feeling undermined – inadvertently
contribute to panels’ views of NIM’s clout if they convey a
comparative
lack of certainty.
Clashing timescales between NIM and processes in the wider
system also renders clout/doubt a changeable theme; for
example,
when there is a delay between the production of a NIM report
and a Children’s Hearing, the clout of the report can flip over to
be
replaced by doubt about it’s relevance to current day. The
passage of time also may alter the clout/doubt theme as
experiences of
congruence and conflict between the judgments of NIM and
SW-SAU are reflected upon. In cases where conflict between
the services
exists, there is a rationale for further research adopting a case
study approach to explore the process by which opposing
opinions are
managed and the impact that they have in the legal system.
This study provides a novel example of the merits of embedding
qualitative process evaluation into RCTs in such complex areas
of
study. Not only will it provide explanatory power to the future
results of this particular trial, but it also provides an
exploratory
platform to analyze how health and social work models sit
together in a vital area of public health interest. Tracking the
journey of
NIM’s introduction into the system allows us to capture how the
health/social relationship may evolve over time and the way it

might
inter-relate with any effects of NIM in the wider system. We
therefore endeavor to continue to explore the context of NIM
and the
potential fluidity of clout/doubt as the trial continues.
Funding and acknowledgements
This work was funded by the National Society for the
Prevention of Cruelty to Children (NSPCC) [grant numbers
20130913, IID/
1/010449942]; the Chief Scientist Office [grant number
CZH4629]; and the National Institute of Health Research [grant
number 12/
211/54]
We thank the participants in this study for the time taken to
share their views in interviews and focus groups.
References
Beresford, P. (2002). Thinking about ‘mental health’: Towards a
social model. Journal of Mental Health, 11(6), 581–584.
Braun, V., & Clarke, V. (2006). Using thematic analysis in
psychology. Qualitative Research in Psychology, 3(2), 77–101.
Caspi, A., Houts, R. M., Belsky, D. W., Harrington, H., Hogan,
S., Ramrakha, S., et al. (2016). Childhood forecasting of a small
segment of the population with large
economic burden. Nature Human Behaviour, 1, 1–10 0005.
Centre for Disease Control and Prevention (2017). Adverse
childhood experiences (ACEs). Retrieved 09/02/2017, from
https://www.cdc.gov/violenceprevention/
acestudy/.
Craig, P., Dieppe, P., McIntyre, S., Michie, S., Nazareth, I., &

Petticrew, M. (2008). Developing and evaluating complex
interventions: The new Medical Research
Council guidance. British Medical Journal, 337, a1655.
Dinkler, L., Lundström, S., Gajwani, R., Lichtenstein, P.,
Gillberg, C., & Minnis, H. (2017). Maltreatment-associated
neurodevelopmental disorders: A co-twin control
analysis. Journal of Child Psychology and Psychiatry, 58(6),
691–701.
Dozier, M., Bick, J., & Bernard, K. (2011). Intervening with
foster parents to enhance biobehavioral outcomes among infants
and toddlers. Zero Three, 31(3), 17–22.
Dozier, M., Zeanah, C. H., & Bernard, K. (2013). Infants and
toddlers in foster care. Child Development Perspectives, 7(3),
166–171.
Glass, S., Gajwani, R., & Turner-Halliday, F. (2016). Does
quantitative research in child maltreatment tell the whole story?
The need for mixed-methods approaches to
explore the effects of maltreatment in infancy. The Scientific
World Journal, 1869673.
Greiner, D. J., & Matthews, A. (2016). Randomized control
trials in the United States legal profession. Annual Review of
Law and Social Science, 12, 295–312.
Johnson, P., & Cahn, K. (1995). Improving child welfare
practice through improvements in attorney-social worker
relationships. Child Welfare, 74(2), 383.
Luke, N., Sinclair, I., Woolgar, M., & Sebba, J. (2014). What
works in preventing and treating poor mental health in looked
after children? NSPCC.
Macintyre, S., Chalmers, I., Horton, R., & Smith, R. (2001).
Using evidence to inform health policy: Case study. British
Medical Journal, 322(7280), 222–225.
Minnis, H., Bryce, G., Phin, L., & Wilson, P. (2010). The spirit
of New Orleans: translating a model of intervention with

maltreated children and their families for the
Glasgow context. Clinical Child Psychology And Psychiatry,
15(4), 497–509.
195
194
http://refhub.elsevier.com/S0145-2134(17)30267-3/sbref0005
https://www.cdc.gov/violenceprevention/acestudy/
https://www.cdc.gov/violenceprevention/acestudy/
Minnis, H. (2016). The Best Services Trial (BeST?):
Effectiveness and cost-effectiveness of the New Orleans
intervention model for infant mental health. Lancet Protocol
D-15-06090R1, ClinicalTrials.gov Identifier: NCT02653716.

Moerman, D. E., & Jonas, W. B. (2002). Deconstructing the
placebo effect and finding the meaning response. Annals of
Internal Medicine, 136, 471–476.
Moore, G., Audrey, S., Barker, M., Bond, L., Bonell, C.,
Cooper, C., et al. (2014). Process evaluation in complex public
health intervention studies: The need for
guidance. Journal of Epidemiology and Community Health,
68(2), 101–102.
Oakley, A., Strange, V., Stephenson, J., Bonnell, C., & Allen,
E. (2006). Process evaluation in randomized controlled trials of
complex interventions. British Medical
Journal, 332, 413–416.
Oxford Dictionaries (2017). Definition of equipoise in english.
Retrieved 09/02/2017, from
https://en.oxforddictionaries.com/definition/equipoise.
Pawson, R., & Tilley, N. (2004). Realist evaluation. Retrieved
30/11/2016, from
http://www.communitymatters.com.au/RE_chapter.pdf.
Porter, R., Welch, V., & Mitchell, F. (2016). The role of the
solicitor in the children’s hearings system: Centre of excellence
for looked after children in scotland.
Pritchett, R., Fitzpatrick, B., Watson, N., Cotmore, R., Wilson,
P., Bryce, G., et al. (2013). A feasibility randomised controlled
trial of the New Orleans intervention for
infant mental health: A study protocol. The Scientific World
Journal 838042.
Pritchett, R., Hockaday, H., Anderson, B., Davidson, C.,
Gillberg, C., & Minnis, H. (2016). Challenges of assessing
maltreated children coming into foster care. The
Scientific World Journal, 5986835.
Robinson, M., & Cottrell, D. (2005). Health professionals in

multi-disciplinary and multi-agency teams: Changing
professional practice. Journal Of Interprofessional
Care, 19(6), 547–560.
Satterfield, J. M., Spring, B., Brownson, R. C., Mullen, E. J.,
Newhouse, R. P., Walker, B. B., et al. (2009). Toward a
transdisciplinary model of evidence-based practice.
The Milbank Quarterly, 87(2), 368–390.
Turner-Halliday, F., Watson, N., & Minnis, H. (2016). Process
evaluation of the New Orleans Intervention Model for infant
mental health in Glasgow. Working with infants and
their carers after abuse and neglect. NSPCC.
Walker, H., Wilson, P., & Minnis, H. (2013). The impact of a
new service for maltreated children on Children’s Hearings in
Scotland: A qualitative study.
Adoption & Fostering, 37(1), 14–27.
Webb, S. A. (2001). Some considerations on the validity of
evidence-based practice in social work. British Journal of Social
Work, 31(1), 57–79.
Zeanah, C., Larrieu, J., Heller, S., Valliere, J., Hinshaw -
Fuselier, S., Aoki, Y., et al. (2001). Evaluation of a preventive
intervention for maltreated infants and toddlers in
foster care. Journal of American Academy of Child and
Adolscent Psychiatry, 40(2), 14–21.
Zeanah, C. H., Shauffer, C., & Dozier, M. (2011). Foster care
for young children: Why it must be developmentally informed.
Journal of the American Academy of Child
and Adolescent Psychiatry, 50(12), 1199–1201.
195

195
https://en.oxforddictionaries.com/definition/equipoise
http://www.communitymatters.com.au/RE_chapter.pdf
http://refhub.elsevier.com/S0145-2134(17)30267-
3/sbref0150Clout or doubt? Perspectives on an infant mental
health service for young children placed in foster care due to
abuse and neglectIntroductionThe need for quality assessment
in the complex world of child abuse and neglectThe
introduction and testing of a new model of assessmentUsing
process evaluation to explore the context of NIMUsing process

evaluation to explore the impacts of NIM on decision-
makingThis paper – aims and objectivesMethodsFindingsThe
clout of mental health assessmentNIM’s health professional
input and position in the systemNIM’s in-depth assessment
focusA trial of treatmentThe doubt created by a mental health
approachThe intricate focus on child-parent interactionA lack of
historical relationship with the familyNIM’s trial of
treatmentConveying a false possibility of changeThe doubt over
undefined timescalesDiscussionOverview of clout/doubt and
relation to study aimsThe context and creation of clout/doubt:
an adversarial legal systemDecision-making timescales:
clout/doubt and ‘certainty versus uncertainty’Conclusions and
future directionsFunding and acknowledgementsReferences
Child sexual abuse remains a problem in
society, often resulting in the long-term
placement of children in the foster care
system. In Kentucky, children placed in
foster care due to sexual abuse spent more
time in care when compared with children
removed for any other reason (AFCARS,
2013). Given the cost of long-term foster
care placement in both human and eco-
nomic terms, few studies have specifically explored if any
factors
help to predict why this vulnerable population spends signifi -
cantly more time in foster care. The overarching goal of this
exploratory study was to use binary logistic regression to
investi-
gate whether any child demographic or environmental character -
istics predicted the discharge of a child placed in Kentucky’s
foster

care system for child sexual abuse. Results indicated that
children
in the most rural areas of the state were over 10 times more
likely
to be discharged from foster care during the federal fiscal year
than
those residing in the most urban areas. Given this stark reality,
a focus must be allocated in understanding this phenomenon.
Future research must examine whether the results speak to the
necessity of systematic improvement in urban areas or if they
are
illustrating a unique strength found in rural areas.
Child Sexual Abuse and the Impact of
Rurality on Foster Care Outcomes:
An Exploratory Analysis
Austin Griffiths
Western Kentucky University
April L. Murphy
Whitney Harper
57
Journal_Vol95_1R2_July_Aug 2007 6/1/17 3:40 PM Page 57
In federal fiscal year (FFY) 2014, 3.6 million child abuse and
neglectreferrals were made alleging the maltreatment of 6.6
million children
in the United States. Of these, approximately 3.2 million

(48.5%)
received either an investigation or alternative response,
resulting in
702,208 (21.6%) victims of maltreatment (U.S. Department of
Health
and Human Services, 2016). A majority (75.0%) of these
children suf-
fered neglect, followed by physical abuse (17.0%), sexual abuse
(8.3%),
other types of abuse (6.8%), and psychological abuse (6.0%)
(U.S.
Department of Health and Human Services, 2016).
Approximately
one-fourth of all cases investigated by child protective services
are sub-
stantiated (Walsh & Mattingly, 2012), resulting in difficult
decisions
about whether or not the child can remain safe in their current
home
environment. At times, decisions are made to seek court
intervention
and children are placed in foster care. While many studies have
con-
sidered factors pertaining to reasons for placement, little to no
research
has been published on factors impacting the length of stay in
placement
specifically for children experiencing sexual abuse.
Child abuse is costly, in both economic and human terms. Wang
and Holton (2007) have estimated the annual financial cost of
child
abuse and neglect was $103.8 billion. However, this annual
calculation
of direct costs from hospitalizations, mental health services,
child wel-

fare services, and law enforcement is a conservative estimate,
only
accounting for the costs related to the victims (Wang & Holton,
2007). Although the economic costs associated with child abuse
and
neglect are substantial, it is essential to recognize the prevailing
“intan-
gible losses” that can impact the individual, such as pain,
suffering, and
reduced quality of life. Although difficult to quantify, these
losses may
represent the largest component of violence against children and
should be taken into account when allocating resources (Miller,
1993).
Seeking insight into areas to improve the foster care system and
its
relationship with the young lives depending on it, it is
important to
explore any factors that may explain longer stays in foster care
and if any
variables can be found that help children to achieve timely
permanency.
58
Child Welfare
Vol. 95, No. 1
According to Child Welfare Information Gateway (2013),
children who
have been sexually abused have had both their physical and

emotional
boundaries violated, possibly resulting in a lack of trust and
safety
(Wang & Holton, 2007). The adverse consequences for
children’s devel-
opment often are evident immediately, encompassing multiple
domains
including physical, emotional, social, and cognitive. These
children
experience significant disruptions in normal development, often
having
a lasting impact and leading to dysfunction and distress well
into adult-
hood (Hall & Hall, 2012). The purpose of this study was to
specifically
examine child sexual abuse in the state of Kentucky. The
research ques-
tion guiding this study was exploratory in nature and aimed to
identify
any factors that may influence the probability of whether a child
who
was placed in foster care for sexual abuse in the state of
Kentucky will be
discharged from the child welfare system.
Literature Review
Although the substantial reports of child sexual abuse are
dishearten-
ing, they must be understood in context. For example, the
aforemen-
tioned only reflects the children who have been placed in foster
care.
Further, not all abuse is reported. If child sexual abuse does get
reported,
child welfare practitioners often find that it is “easier” to
protect a child

by meeting a different standard of evidence in court (e.g.
neglect).
Doctors and other health professionals may question whether
CPS
intervention is likely to benefit the children and their families
or
instead cause harm. Levi and Portwood (2011) found that it is
factors
such as these that introduce significant variability in reporting
and are
also compounded by the absence of a clear standard to report
suspect-
ed child abuse. Nonetheless, child sexual abuse does occur and,
accord-
ing to Townsend and Rheingold (2013), about one in 10
children will
be sexually abused before the age of 18. Although systematic
chal-
lenges continue to limit the possibility of accurately quantifying
the
occurrence of child sexual abuse, individuals continue to be
impacted
by the consequences of this behavior.
59
Griffiths et al. Child Welfare
Investigating disparities in child maltreatment is important.
Dispari-
ties in foster care have been well documented when it comes to
race

(Derezotes, Poertner, & Testa, 2004; Font, 2013; Putnam-
Hornstein,
Needell, King, & Johnson-Motoyama, 2013; Summers, 2015;
Wells,
2011); however, regional location may also matter. Specifically,
do the
distinct differences of living in a rural community provide
valuable
insight when compared with the life experiences of living in an
urban
area? Although one may posit that both rural and urban areas
can be
fraught with common risk factors of abuse (e.g. family
stressors, men-
tal health problems, alcohol dependency, history of family
violence),
the Carsey Institute Report (Walsh & Mattingly, 2012)
identified
important substantiation differences emerging between rural and
urban areas in the United States. Higher income children (that
is, in
families with incomes greater than 200 percent of the federal
poverty
level) in rural areas are significantly more likely to have a
report sub-
stantiated than they are in urban places. Older children in rural
places
are more likely to have a report substantiated (35%) than those
in
urban areas (23%) (Walsh & Mattingly, 2012). Children in rural
areas
whose caregivers are either experiencing active domestic
violence or
have cognitive impairments are more likely to have a case
substantiated
than similar urban children (Walsh & Mattingly, 2012).

Child sexual abuse remains a problem in society, often resulting
in
the long-term placement of children in the foster care system.
The crit-
ical examination of the child’s demographic and environmental
charac-
teristics may provide insight into understanding what predicts
longer
placements in foster care for children who have experienced
sexual
abuse, and if any factors can help to predict a timely discharge
from
care. This study will specifically focus on exploring these
variables in
Kentucky, as this state’s regional differences may help to
further iden-
tify any prevailing concerns for consideration related to this
challenge.
Child Sexual Abuse in Kentucky
Kentucky Revised Statute (KRS) 600.020 defines a child as
being
maltreated when “his or her parent, guardian, person in a
position of
60
Child Welfare
Vol. 95, No. 1
authority or special trust, as defined in KRS 532.045, or other

person
exercising custodial control or supervision of the
child…commits or
allows to be committed an act of sexual abuse, sexual
exploitation, or
prostitution upon the child; creates or allows to be created a
risk that
an act of sexual abuse, sexual exploitation, or prostitution will
be com-
mitted upon the child” (KRS 600.020 (1)(a)(5-6)). There are
several
terms inherent in this definition that warrant further
explanation.
Child sexual abuse “includes but is not necessarily limited to
any con-
tacts or interactions in which the parent, guardian, person in a
position
of authority or special trust…uses or allows, permits, or
encourages the
use of the child for the purposes of the sexual stimulation of the
per-
petrator or another person” (KRS 600.020 (58)). Sexual
exploitation
“includes but is not limited to a situation in which a parent,
guardian,
person in a position of authority or special trust…allows,
permits, or
encourages the child to engage in an act of obscene or
pornographic
photographing, filming, or depicting of a child as provided for
under
Kentucky law” (KRS 600.020 (59)).
Child sexual abuse is unique, often eliciting a visceral public
response. The specifics of such an act, complicated by the
perception

of a trusted caretaker willingly taking the innocence of an
underage
victim, generally create an overwhelmingly adverse community
reac-
tion. However, it continues to happen. There were 22,269
children
maltreated in FFY 2014 with 3.9% being victims of sexual
abuse in the
state of Kentucky during FFY 2014 (U.S. Department of Health
and
Human Services, 2016).
Foster Care in the United States
Foster care is temporary, a step in the process of achieving
permanency
for children who have experienced maltreatment. In FFY 2014,
there
were 415,129 children in foster care in the United States (Child
Welfare
Information Gateway, 2016), with 7,506 children specifically
from the
state of Kentucky (Annie E. Casey Foundation, 2016).
Conditions
influencing high levels of foster care placement speak to the
current
61
climate of poverty, inequality, and social injustice in America.

Macro-
level challenges faced by social systems, such as child welfare,
perpetuate
family violence and delinquent behavior, resulting in broken
families
and communities (Agnew, Matthews, Bucher, Welcher, &
Keyes,
2008; Snyder & Merritt, 2014). When placed in out-of-home
care,
families are obligated to work with protective service agencies
to iden-
tify the prevailing high-risk behaviors and develop a plan to
minimize
the potential for reoccurrence.
A prominent federal law guiding child welfare practice is the
Adoption and Safe Families Act (ASFA) of 1997 (P.L. § 105-
89).
ASFA directs the development of the child’s permanency plan,
contin-
gent upon timelines and the safety of the child. According to
ASFA,
the five options for permanency are: return to parent, adoption,
referral
for legal guardianship, permanent placement with a fit and
willing rel-
ative, and other planned permanent living arrangement. This
federal
law was enacted to implement a consistent system of oversight
to expe-
dite permanency and keep children from becoming “lost” in the
system.
When children are placed in foster care, the initial goal is return
to
parent (reunification). However, ASFA allows the agency to

request to
change the child’s permanency goal after placement in foster
care for
15 of 22 months or through the uncommon finding of
“reasonable
efforts” before meeting this timeframe. For example, if a child
was
placed in foster care due to child sexual abuse, the agency is
mandated
to work to reunify the family. After 15 months, the agency can
petition
the court to change the child’s formal permanency goal to
adoption. If
this formal request is granted, the agency can now move toward
termi-
nating parental rights, which opens new avenues for the child’s
perma-
nency. With the clear and unquestionable ramifications of not
making
expedient progress to reunify the family, ASFA guides practice
and
shapes the social landscape of this country. States receiving
Title IV-E
funds are obligated to comply with federal guidelines largely
due to
ASFA. Federal oversight creates a culture of compliance,
influencing
procedures and policies when agencies work with families and
children.
Given this reality, compliance with continuous federal
evaluation is a
62
Child Welfare
Vol. 95, No. 1

Figure 1. Conceptual framework
driving force behind service delivery and agency program
implementa-
tion. Acknowledging the varying interests and the critical
importance
of children staying in foster care, it is valuable to understand
any factors
that may contribute to a child’s stay in foster care.
Conceptual Framework
Research has identified factors influencing foster child
outcomes for
decades. However, differences in research purpose may create a
chal-
lenge when attempting to generalize the findings. It is suspected
that a
number of variables may influence the outcomes of children in
foster
care, including child demographic characteristics, permanency
charac-
teristics, and environmental characteristics (McDonald,
Poertner, &
Jennings, 2007; Akin, 2011; Snowden, Leon, & Sieracki, 2008;
Sinclair
& Wilson, 2003; Smith, Stormshak, Chamberlain, & Whaley,
2001).
Few studies have specifically examined factors leading to
children who
have experienced sexual abuse resulting in longer placements in

the
foster care system. If one can better understand the factors that
predict
63
discharge from foster care for this unique population, one can
inform
practice and policy reducing time in placement for these
children. As
a result of the wide range of focus in the literature, this study
exam-
ined the impact of the child’s demographic characteristics,
permanency
characteristics, and environmental characteristics on length of
stay in
foster care for children who have experienced sexual abuse in
the state
of Kentucky in the FFY 2013 (see Figure 1).
Child’s Demographic Characteristics
Age matters, as the older a child gets the less likely they are to
exit to
any type of permanency (Barth, 1997). In a longitudinal study,
Connell,
Vanderploeg, and colleagues (2006) found that a child’s age
was the
primary characteristic associated with risk in placement change,
as the

older a child gets the more likely they were found to have a
change in
placement. Furthermore, a common finding is that as a child’s
age
increases, their probability of being adopted significantly
decreases
(Snowden, Leon, & Sieracki, 2008; Connell, Katz, Saunders, &
Tebes,
2006). Age as a risk factor in increasing days in care is an
important
variable to consider with this population.
Race and ethnicity are critically important factors, especially
related to the experience of minority populations in foster care.
Becker, Jordan, and Larsen (2007) found that non-white
children
were less likely to exit foster care successfully than white
children.
Also, Barth (1997) found that the reunification of African
American
children was less likely than that of White or Latino children.
Further,
African American children were found to be less than half as
likely to
achieve permanency as a White child (Kemp & Bodonyi, 2002).
When considering the specific permanency option of adoption,
African American children were found to be notably less likely
to be
adopted than Latino or White children (Barth, 1997).
The impact of a child’s sex does not appear to be as clearly
under-
stood. When studying factors associated with the speed of
reunification,
Fernandez and Lee (2011) found no difference when considering
the

64
Child Welfare
Vol. 95, No. 1
child’s sex. In a six-year study with 3,873 children, Barth
(1997) found
no sex based effects when examining the likelihood of a child
being
adopted or remaining in long term care. Also, Becker, Jordan,
and
Larsen (2007) did not find sex as a significant predictor when
exploring
variables that contribute to a successful exit from foster care.
On the
contrary, Kemp and Bodonyi (2002) found boys to be 32% less
likely to
achieve permanency than girls. Harris and Courtney (2003) also
found
that boys were significantly less likely than girls to achieve
reunification.
Permanency Characteristics
Permanency characteristics have long been posited to influence
the
experience and the outcome of children in foster care.
Specifically relat-
ed to child sexual abuse, Connell, Katz, Saunders, and Tebes
(2006) uti-
lized a longitudinal study and found that children who were

placed in
foster care for child sexual abuse had a consistent delay in
establishing
permanency. Additionally, Nalavany, Ryan, Howard, and Smith
(2008)
found that children with pre-adoptive histories of sexual abuse
were at a
greater risk of difficulties related to permanency (adoption
disruptions,
inconsistent parental commitment, moves while in care).
Regardless of
the child’s permanency outcome, individual level difficulties
may be
apparent for children who have been placed in foster care for
child sex-
ual abuse. For example, Yampolskaya, Armstrong, and McNeish
(2011)
studied risk factors for foster children in Florida and found a
significant
association between being placed in care for sexual abuse and
involve-
ment with the juvenile justice system.
Environmental Characteristics
Environmental characteristics, such as geographic location,
remain an
important consideration in child welfare literature. However,
the impact of
one’s geographic location has been conflicting. In their study,
Glisson and
colleagues (2000) found that children residing in urban areas of
Tennessee
were 50% more likely to be discharged from the system than
those

65
children residing in rural counties. On the other hand, Becker
and col-
leagues (2007), found that rurality may serve as a protective
factor. Given
the importance of a child’s environment on outcomes and the
uncer-
tainty of its impact, it is an important factor to consider in any
model.
It is understood that children who have been sexually abused
repre-
sent a unique population with specific challenges and critical
needs.
Yet, previous research focuses on the child’s reason for removal
as an
independent and predictive variable, rather than as population
for the
sample. There are a number of studies that examine the effects
of child
sexual abuse on future adjustment (e.g., depression, sexual
abusing own
children, etc.). However, no studies were located that explicitly
exam-
ined children who were placed in foster care by the court due to
child
sexual abuse and the impact on foster care outcomes (i.e.,
discharge).

Method
Procedure
This exploratory study utilized secondary data, Adoption and
Foster
Care Analysis and Reporting System (AFCARS), obtained from
the
National Data Archive on Child Abuse and Neglect (NDACAN).
AFCARS is a federally mandated reporting system that requires
each
state to electronically submit semi-annual data for the purposes
of pol-
icy development and state foster care and adoption analysis. It
contains
case specific information on children who are covered by the
protection
of the Social Security Act (Title IV-B/E). This study was
reviewed and
approved by the University’s Institutional Review Board (IRB).
Data were taken from the 2013 AFCARS Foster Care file, which
was
composed of all children in foster care in the United States in
the fed-
eral fiscal year (FFY) of 2013 (October 1, 2012 through
September 30,
2013). Data were downloaded into the Statistical Package for
the
Social Sciences (SPSS), Version 23. In order to address the
aforemen-
tioned research question, only child sexual abuse cases in the
state of
Kentucky were selected for inclusion in this study.
66

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Measures
Outcome Variable
The outcome variable in this study was whether a child had
been dis-
charged from foster care at the end of the FFY 2013. This was
deter-
mined using the “Discharge Reason” variable in the AFCARS
dataset.
Ultimately, this variable was recoded using a dichotomous
coding
structure (i.e., 0 = not discharged; 1 = discharged).
Predictor Variables
Predictor variables fell into two main categories: (a) child
demographic
characteristics; and (b) environmental characteristics.
Demographic
characteristics included the child’s sex, race/ethnicity, and age.
Child’s
sex was recoded into a dummy variable (1 = female) where
males
served as the reference category. Child’s race/ethnicity was
recoded
into a dummy variable (1 = non-minority) where minority
served as

the reference category (see Table 1 for included groups).
Child’s age
was a continuous variable and represented the child’s age on the
first
day of the FFY 2013. Number of placement settings was also a
con-
tinuous variable representing the number of placement settings
during
the current foster care episode.
Environmental characteristics included the rural/urban
continuum
code. The rural/urban continuum code was an ordinal variable
ranging
from 1 (Metro) to 9 (Rural); therefore, higher scores would be
indica-
tive of more rural settings.
Analysis
Data were downloaded into the SPSS, Version 23. Descriptive
statis-
tics were conducted to describe the sample included in this
analysis.
Then, a binary logistic regression was conducted in order to
determine
the probability of discharge for children who experienced
sexual abuse
in the state of Kentucky during FFY 2013.
67

Results
Sample Characteristics
There were 430 children who entered foster care as a result of
sexual
abuse in the state of Kentucky during the FFY 2013. Of the 430
chil-
dren included in this analysis, a majority (67.7%) were female
(n = 291)
and Caucasian (77.0%, n = 331). The child’s age on the first day
of the
FFY 2013 ranged from 0 to 18, with an average of 10.6 (SD =
4.8).
Number of placement settings for children in foster care as a
result of
child sexual abuse ranged from 1 to 24, with an average of 2.9
(SD= 3.2)
(see Table 1). With regard to rurality, almost half (49.7%)
resided in
metro areas (n = 214), 34.0% resided in non-metro areas (n =
146), and
16.3% resided in rural areas (n = 70) (see Table 1).
Logistic Regression
A binary logistic regression was conducted in order to
determine the
likelihood of a child being discharged from foster care within
FFY
2013. Block 0 reported that 158 (36.7%) children had been
discharged
and 272 (63.3%) were still in foster care at the end of FFY 2013
in

Kentucky. The initial -2 Log Likelihood score was 565.519 and
the
overall percentage correctly classified was 63.3%. Adding the
predic-
tors (i.e., sex, race, age, number of placements, rural/urban
continuum)
produced a lower -2 Log Likelihood of 531.536 and the
Omnibus Chi-
Square score represented a statistically significant difference
between
Block 0 and Block 1 (X
2
= 33.983, p < .001). Further, the Hosmer and
Lemeshow test indicated a goodness of fit between the predictor
vari-
ables and the dependent variable (X
2
= 12.153, p = .145).
Overall, results indicated that there were four statistically
significant
predictors of discharge from foster care (i.e., race, age,
rural/urban con-
tinuum, number of placements). Sex was the only predictor that
was
not a statistically significant predictor of discharge. Results
indicated
that Caucasian children were about half as likely to be
discharged from
foster care than non-white children (OR = 0.544, p = .015). For
every
68

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