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Home > Crisis Intervention in Child Abuse and Neglect > Crisis Intervention in Child Abuse and Neglect: Crisis Intervention Assessment
Crisis Intervention in Child Abuse and Neglect
User Manual Series (1994)
Crisis Intervention AssessmentIntroduction Different personalities of individuals, the divergent environments in which they reside, the variety of psychological and biological make-ups, and the varying family structures in which they live lead to a broad range of responses to stress. Consequently, it becomes difficult to predict human behavior.27 Yet it is necessary to make an attempt to assess the risk of abuse within families in order to protect family members. People in crisis need, and are more responsive to, immediate intervention. (Rapport, necessary for family assessment, is more readily established by offering immediate emotional first aid and support when the family is frightened, confused, and experiencing emotional pain.) A case of father-daughter incest illustrates the stages of crisis intervention. The multidisciplinary team learns that a hazardous event occurred when the father lost his job and received criticism from his wife. He felt or perceived himself to be in a vulnerable state, with the family not respecting him. He turned to a child in the family who seemed most understanding and least likely to reject him. Sexualizing his needs and feelings for the child, he misused his power by sexually fondling the child (precipitating factor) who, in turn, told a friend (hazardous event) who told a school authority. The case was reported (vulnerable state), followed by an investigation (another precipitating factor). By this time, the family was in an active state of crisis.28 Note that there can be several, cumulative precipitating factors and successive crises in one family. (In no way does this example imply that sex abusers are not fully responsible for their perpetration.) Total Family Involvement Since families are systems, what affects one member of a family affects other members. Considering this dynamic, interactional pattern, it makes sense to involve the entire family in crisis-intervention assessment. This is especially true in child abuse and neglect cases where the interactional pattern is dysfunctional, and change is critical to protecting the child. Even in incest cases or illegal drug sales, in which the offender is removed but reunification may occur, intervention is done with remaining family members but coordinated with professionals who are treating the offender. For an intervention to be most effective, all family members require both individual and group attention. Each member needs to feel special and separate, yet an integral part of the family group. Individual and family value orientations, communication styles, and roles must be understood. It takes hours of listening for the crisis worker to understand implicit family rules and beliefs, how messages are communicated and received, and who relates to whom and how, within the family. All family members need the opportunity to give their opinions about the family's primary problems. Different opinions help the crisis worker get a picture of the antecedents to the crisis. The involvement of the total family may facilitate the following intervention. When family crisis intervention is implemented, the specific steps that follow—similar to the generic stages of individual or group crisis counseling—should be taken. Appropriate efforts should be made to involve family members in each phase, which are to: (1) search for the precipitating event and its perceptual meaning to the family members; (2) look for the coping means used by the family and appraise the extent to which these have or have not been successful; (3) search for alternative ways of coping and the resources that might improve the situation, while actively soliciting suggestions from family members; (4) review and support the family members' efforts to cope in new ways, with evaluation of results in terms of day-to-day living experiences; (5) move toward early termination that was planned in the initial contract with the family; and (6) plan and conduct at least one follow-up or "booster-shot" session. Throughout this process, the crisis worker should actively define the goals of the family crisis session and the means that can be used for goal achievement, while energetically focusing on the relevant issues.29 Assessment While making an assessment, an crisis worker pays special attention to the initial contact with the family, what events precipitated the crisis, family interactions and conditions, and the family's perceived needs. With such understanding, crisis workers can more adequately assess risk to the child or children. Making the Initial Contact Before making contact with families, crisis workers should not pre-judge them, no matter what information is available from other sources. By keeping an open mind, crisis workers may see and hear things never perceived by other "helpers" and start afresh. The initial contact capitalizes upon the family members' search for answers to the crisis. Intervention must occur before the family members find rigid, maladaptive ways to defend themselves against the outside world. At this point, they are ready to receive open-minded, honest, trustworthy crisis workers. Kinney, Haapala, and Gast, experienced crisis workers, suggest the following approach during the initial contact:
Careful listening will usually facilitate understanding without trapping the crisis worker in initial judgments. Identifying the Precipitating Event Frequently in crisis intervention, the CPS investigation may be the precipitating factor for a new crisis for the family. But, prior to that, the precipitating factor, or presenting problem, was the physical abuse, sexual abuse, or neglect of a child, or possibly a child's observation of violence between adults. The crisis worker from CPS or another crisis intervention program needs to explain why he or she is there, what information he or she has been given, and explain that he or she is there to listen and help, not to blame or accuse. Consequently, the crisis worker may get new information, both current and past, regarding the crisis and its antecedents. The family can thereby set goals for resolving the current crisis and preventing similar crises in the future. Observing Family Interactions and Conditions Observation skills are critical tools for the crisis worker. The most important observational skill is that of seeing a crisis through the eyes of the client. This means that the worker has objective, nonjudgmental empathy. Much attention is given to nonverbal communication, and an attempt is made to understand family members' feelings toward each other and toward the crisis worker. Good observers try to determine more than surface appearance. For instance, the poorly kept house or unkempt person may signify depression or even physical illness. An orderly existence may be impossible for overworked parents who have several young children. Such conditions do not indicate whether or not there is appropriate affection between family members. A nurturing attitude may be of greater value to children than a clean living room! A hostile client may be reacting to negative experiences with social agencies in the past. The crisis worker must understand child care practices in various cultures.31 Crisis workers from middle-class backgrounds must try to understand the stresses of living in poverty, including the fear of violence in the ghetto and the temptation to sell drugs to support the family. A crisis worker's being naive or not being "street wise" can interfere with his or her observations. There may be signs of child sexual abuse, drug dealing, spouse abuse, or mental illness that are subtle or different from the crisis worker's experience. For purposes of getting supervision or consultation from other team members, the good observer merely describes with detailed objectivity the what, when, where, and how of the home visit. Good descriptive material is always clear, whereas use of labels and conditions such as "rigid," "resistive," and "paranoid" are subjective and potentially biasing. In fairness to crisis workers, good listeners and observers are not able to recall every important occurrence or statement that comes forth during several hours of emotional intensity, but a good listener and observer does remain objective. Determining Family Needs Traditional therapies and casework tend to determine what the family's problems are and what the family members must do to change. In contrast, crisis intervention encourages families to determine what their problems are, what they want help with, and how they want to go about making changes. The family chooses a limited number of goals, hopefully no more than four, from a more extensive number of possibilities, and determines action steps for achieving the goals. The crisis worker helps the family stay focused to achieve these goals. To be successful in focusing families, crisis workers need to have a sense of compassion, flexibility, and responsiveness to slight changes in focus. Rigidly adhering to a course of action brings greater pain and disappointment. For instance, a family member may have chosen to search for employment outside the home but can only find minimum-wage work that barely pays for transportation, clothing, child day-care, lunch, and other job-related costs. Consequently, the goal may need to change, such as doing piecework at home, possibly arts and crafts, or switching to a goal for part-time work when a spouse or relative can provide child care. Misperceptions of clients and what they need can create new crises. For example, lack of understanding of Native American culture has created unnecessary removal of children who, in turn, became disconnected from their culture and yet not integrated into any other culture.32 With any family, not just culturally different or minority families, an insensitive crisis worker can make incorrect assumptions. Personal values and past experiences can bias one's perception of families and limit recognition of possible interventions. Ultimately, crisis workers must listen closely to the family members' perceptions and respond to their needs, not their own personal needs or wishes. Assessing Risk Risk is defined as the likelihood of maltreatment occurring in the future. Safety is the determination regarding the immediacy and severity of the risk. Therefore, crisis workers must first determine whether the maltreatment is likely to occur again, and then determine if the child is safe. Extensive information on risk assessment is provided in another User Manual Series publication, Child Protective Services: A Guide for Caseworkers.33 In evaluating a family, the child's safety is of uppermost importance. Can the child be protected while crisis intervention services are being delivered? At the end of crisis intervention, will the child be in imminent danger? Is the criminal behavior in the family so prevalent that the child can only identify with criminal activity? Is addictive behavior such that the child only sees immediate gratification through drug use, sex, gambling, and other addictions? Are the addicted members willing to enter drug treatment? Are the addictions, drug dealing, and other criminal behaviors more important to the family than the children are? Realizing that the children may be removed, do the adults still refuse to cooperate in looking for mutually acceptable goals for change? Can the crisis worker engage just one adult in the assessment and planning? If so, there is still hope for change. If it is determined that the child is not safe in the home, then it is incumbent upon the crisis worker to determine first whether crisis intervention will assure the child's safety in the home. If it cannot be assured in the home, then the child must be removed for his or her own safety. For instance, removal of a sex abuser may not assure a child's safety if the remaining parent has been intimidated by the offender and will not protect the child or other children. Nonoffending parents who were sexually abused as children may have low self-esteem, dependency, or even flashbacks that reduce their ability to protect children or themselves. Another way to look at risk assessment is to see it as determining whether the child is happiest with extra protection in the home or removal from the home. Many children are reluctant to leave home or to want removal of the abuser because they fear the unfamiliar. If a child asks to be removed, careful assessment is needed. Is the child truly in danger, or has the child learned to manipulate away from discipline, believing there is less or almost no discipline in out-of-home placement? In the latter instance, parents may need help in applying consistent, firm, nonviolent discipline such as time-out, grounding for short periods, consequences for inappropriate behavior, and other good behavior-management approaches.34 Nevertheless, when a child asks to be removed, thoughtful consideration must be given. A more specific criterion is that of sadistic or torturous maltreatment, which suggests that parental rights may need to be terminated. This is true in other cases with parents who have made no significant changes in 6 to 12 months of intervention and treatment as well.35 Of course, these parents should not be blamed for ineffectual therapy. From the beginning, they deserve, and should have, well-trained, solution-focused professionals. If this kind of effective treatment system is absent, the parents and children may deserve a further chance to avail themselves of treatment. From a practical standpoint, removal of a child does not always assure safety. Some youths are physically or sexually abused in out-of-home placements. Others are so distressed that they run away or act out in other ways. Their hurt and their rage are misunderstood and require careful evaluation. Most children and families just need better-trained crisis workers. Program models, such as those described in the "Family-Centered Crisis Response Models" chapter of this manual, report between 70 and 90 percent success in keeping youth safe in their homes. This suggests that only the most severe, most sadistic abuse requires removal of the abuser or the victim, with the victim being removed only when the severe abuser breaks court orders and returns home or threatens to harm the child. Screening Instruments Great caution and professional judgment are warranted in the use of any risk-assessment protocol. Generally, a constellation of risk factors, rather than only one risk factor, suggests that the child is not safe or that vigilant monitoring is advised. When used properly, screening instruments such as the Child Abuse Potential Inventory for parent screening and treatment evaluation or the Child Maltreatment Interview Schedule can be helpful. Training in the use of such instruments is required, however, to assure that misinterpretations do not occur.36 There are both general and specific forms and lists that have been developed but require much further research. For instance, there is the Family Assessment Form (FAF), designed to assist in-home workers in determining what intervention is needed.37 The risk variables are measured by the Family Risk Scales, a total of 26 scales with sub-variables, and "emphasize parental characteristics and family conditions that are believed to be predictors or precursors of child maltreatment or other harm to children."38 It also incorporates six of the Child Well-Being Scales, referenced below, which are believed to be most useful for risk assessment. Even though general risk-assessment checklists must be used with caution, they may be helpful as reminders of the great variety of possibilities to be studied in determining risk in cases of child abuse and neglect. They are of benefit in preparing for supervision and consultation as well, assuming that the crisis worker's listening and observing take precedence over the rigid filling out of checklists. Since checklists tend to identify weaknesses in families, crisis workers are cautioned to work harder at finding strengths and building on those, while seeing family weakness as potential goals or action steps in reverse. An example is that of the parents' lack of nurturing or quality parenting skills. If parents feel that they want to improve in this area, a goal becomes: "Parents will develop positive nurturing and parenting skills." Action steps may be: (1) "Attend child development sessions once weekly" or "Spend 30 minutes daily with crisis worker learning child development stages;" (2) "Learn and practice behavioral management techniques with crisis worker;" (3) "Learn how to express appropriate, nonsexual affection and practice in presence of worker." Parents' desire to work toward such parenting goals is a positive indicator during the assessment period. Some authors emphasize tendencies of abusive parents. When assessing the risk of maltreatment, they focus on parents who are more likely to pose a danger to their child because they:
Child abuse and neglect assessment is an attempt to calculate the probability of risk, knowing there is no fool-proof approach to protecting all children. But risks of harm are greater when certain factors come together. For instance, David Finkelhor's "Eight Risk Factors for Sexual Abuse" indicate that children in the following situations are vulnerable to being sexually abused:
Crisis workers can assess whether the above factors are present and whether offsetting safeguards are in place. Further examples of risk scales are the "Child Well-Being Scales" for child neglect,41 and "The Wife Abuse Inventory,"42 and the "Substance Abuse Subtle Screening Inventory."43 Assessment of Other Special Issues Crisis workers improve services to families by studying and assessing the presence or absence of suicide potential, post-traumatic stress disorder, and sex offenders' amenability to treatment. Suicide Potential Both victims and abusers have been known to commit suicide when they perceived no other appropriate solutions. Any past suicidal gestures or current statements require careful consideration by the crisis worker. Likewise, any family member who seems despondent or overwhelmed by anxiety needs specific assessment of suicide potential. Individual family members whose affect is inappropriate for the circumstances may need evaluation as well. Because more children and adolescents are committing suicide in this country than in the past, professionals need to be sensitive to these tendencies during a crisis.44 There are various suicide scales which should be part of the intervention team's repertoire for assessment.45 Post-Traumatic Stress Disorder Children who have been abused or have witnessed abuse in the family often suffer from post-traumatic stress disorder (PTSD),46 which requires a four-step approach to intervention:
Sex Offenders' Ability to Change Assessment of a sex offender's honesty, remorse, denial, minimization, use of force, premeditation, family enmeshment, substance abuse, past victimization, empathy or motivation for change, and age is necessary in determining the appropriate interventions for the offender, victim, and family members.48 Total family involvement is required for successful intervention. Chronic offenders need long-term monitoring and strict supervision. Risk to the child is very high when the mother doubts the child's story of victimization. When Assessment Indicates a Lack of Safety for Children When children cannot be protected in their homes, one solution is to obtain a court order requiring that the adult leave the home. If other family members and the abuser are likely to collaborate in defying the plan, putting the children at risk, then removal of the children from the home is necessary. Another option is to bring protective relatives to the children's home while their parent(s) leaves the home. In certain instances, such as when both parents are on drugs and have to be removed temporarily and protective relatives are not available, a 24-hour homemaker and crisis worker may be needed in the home. Until a decision is made about whether the parents have the potential and desire to care for the children, it is best to keep the children in the familiar environs of home. There are various options for accomplishing this, such as asking the abuser to leave the home or bringing 24-hour caretakers to the home. Removing children from the home is traumatic for parents and children, even when all agree it is best. In fact, removal creates a new crisis for everyone involved. Techniques of crisis intervention, described in the next chapter, are beneficial in reducing the separation anxiety which accompanies emergency placements. If the parents are available, try to involve them in the decision to leave the home or to place the children in emergency placement. Likewise, to the extent possible, children deserve to be involved in the decision, based on their age and ability to assess their situation. Many maltreated children can feel reasonably good about being placed with caring and protective families, but will need a great deal of support and reassurance about what the future appears to be. Young children and severely intimidated youth may be unaware of their rights. They may not understand that nonintimidating lifestyles are possible. They may want to cling to the abusive family even when it is chaotic and incapable of protection or nurturance. With the dramatic increase in the number of children being placed with relatives, crisis workers must exercise caution to assure children's safety, as relatives may have come from similarly dysfunctional backgrounds. Furthermore, children in kinship care deserve the same supports that are afforded to children in the legal custody of the State. Children's anxiety and loneliness are greatly reduced when they can be placed along with siblings, familiar toys, clothes, bedclothing, animals, and other familiar objects. Crisis workers can advocate for such consideration of the children's feelings.49 Because children are prone to blame themselves for abuse and separation from the family, they need much reassurance that they are not to blame. To the extent possible, the crisis worker should review the anticipated happenings of the next few days and how the child's safety and protection will be managed. Children need reassurance that they will return to their parents when, or if, it is safe. It is important for crisis workers to find strengths in the parents even if their behaviors are unacceptable. Crisis workers need to listen to the parents' frustrations and anger and help them choose reasonable goals for reunification with their children. Plans for supervised visitation with the children and an agreement for ongoing counseling are desirable after the parents have expressed and learned to cope with their anger toward the child placement agency. Summary If possible, crisis-intervention assessment involves all family members, both individually and as a group, to determine family interactions, conditions, and events that precipitated the crisis. Having no preconceived notions, the openminded crisis worker allows the family to determine their needs and their goals for change. Immediately and longitudinally, the safety of the children and other family members is considered. Although there are no foolproof screening instruments or checklists, such tools can assist in calculating the probability of risk for additional abuse or neglect and the presence of individual and family strengths for change.
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