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Keynote presentation at 'What Works? Evidence Based Practice in Child and Family Services,
Association of Children's Welfare Agencies (ACWA), Biennial Conference
2-4 September, Bondi Beach, NSW
Abstract
In the first half of the twentieth century the patronage of eminent practitioners and academics was commonly deemed sufficient to ensure the development and funding of interventions to improve health and wellbeing and/or to reduce social ills (Crouch 1998). Since the development of formal, statutory services following the modern 'discovery' of child abuse and neglect, the development of new policies and practices in child protection has also been influenced by a growing body of research evidence. In general however, significant shifts in Australian child protection practice have resulted from the utilisation of overseas research, such as the Messages from Research set of studies developed by the UK Department of Health (Dartington Social Research Unit 1995) and US risk assessment studies (e.g. English & Pecora 1994).
Australian research into aspects of child protection practice has been hampered for a number of reasons, including a low investment in research in this area (i.e. a relative lack of funding by the child protection sector). Despite overseas interest in the lessons that might be learned from Australian child protection practice, there appears to have been a failure to value 'homegrown' research by governments, child protection departments and the wider professional sector. As a consequence, relatively few Australian studies of child protection have been completed, and thus, inform policy and practice. Investment in research has also been hampered by: agency and professional defensiveness; the difficulties associated with investigating such complex, highly sensitive, real-world phenomena; along with researchers' failure to translate findings into a form that is useful for the child protection sector.
It is not possible within this paper to fully explore the range of child protection-related research that has been undertaken in Australia. However, Australia has made quite useful contributions to some of the current key areas of child protection research.
These include:
Despite this body of work, and evidence of a degree of strategic research planning, a clear, coordinated, statutory child protection research program has not yet been enacted. No doubt this has been hampered by child protection services being a state rather than national responsibility. Unfortunately, most State/Territory child protection departments have also not developed their own research frameworks, nor have they (in the main) developed strong collaborative relationships with external research institutions. 1
A key question for the child protection field for the future is: how can an evidence-based approach be cultivated to better inform practice?
Evidence-based practice can be defined as:
'the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individuals' (Sackett, Richardson, Rosenberg and Haynes 1997:2).
More specifically, it involves:
'integrating individual practice expertise with the best available external evidence from systematic research as well as considering the values and expectations of clients' (Gambrill 1999:346).
The 1960s heralded not only the modern 're-discovery' of child abuse via Kempe and colleagues' work on the 'battered child' syndrome (Kempe et al. 1962), but also the first empirical (or experimental) tests of the effectiveness of health and welfare programs. This heralded the dawn of the program evaluation era, and with it, the expectation that public sector programs should be able to objectively and scientifically demonstrate program success and client satisfaction (Rist 1997).
This shift has eventuated partly as a consequence of a growing focus on demonstrating service cost-effectiveness and cost efficiency (Rees 1994; Cooper 1997), and ongoing concerns regarding the social cost of poorly performing programs (Weiss 1988; Stevens 1999). The validity of the latter has been demonstrated with respect to child abuse and neglect, by the continuing toll of child maltreatment deaths (Stevens 1999), high rates of re-abuse and repeated child maltreatment reports to statutory child protection services, and the continuing high incidence of child maltreatment in the community.
Curtis (1997) argues that it is the 'the seductive appeal of absolute certainty' thought to result from the use of quantitative, economically-focused performance criteria that has led to the domination of 'scientific' or experimental evaluation methods, an appeal that has been strengthened by the absence of other viable alternatives. Thus, in the 1990s, following a trend evident across a variety of fields, including medicine, welfare, education, there was a growing shift to adopting an 'evidence-based approach' to child protection practice. Based on the view that 'formal rationality of practice based on scientific methods can produce a more effective and economically accountable means of social service' (Webb 2001:60), the intention is to make policy and practice decisions informed by a critical appraisal of the best evidence available rather than merely 'accepting famous ideas just because they are famous' (Sheldon 2001:803).
Empirical evaluation can be defined as involving the conduct of a 'true experiment' (Fink and McCloskey 1990). This requires pre- and post-test comparisons of matched control ('no treatment') and experimental ('treatment') samples. Overall, the intention is to evaluate with large sample sizes over time, enhancing the potential for future replication.
Of all experimental approaches, it is randomised control trials (RCTs) that are considered to be the 'gold standard' or best practice research (Fink & McCloskey 1990; Smith 1999). Such designs involve the random allocation of participants to either an experimental group or a control group, enabling the researcher to overcome a variety of potential sources of bias and provide the best chance of determining an unbiased estimate of the effect of participation in a particular program (Chalk & King 1998).
Unfortunately, many have taken evidence-based practice to mean:
'that practice should be based upon the evidence of randomised control trials alone, and that all other practice is either not evidence-based or of a lower quality...... This narrow approach, whilst not one envisaged by the original proponents of evidence-based medicine (Sackett et al. 1996), is a common misunderstanding of the paradigm' (Ramchandani, Joughin & Zwi 2001:60).
In actuality:
'the phrase evidence-based practice (EBP) draws attention to the kind of evidence needed to rigorously test different kinds of practice-related claims. What is needed to critically appraise data regarding a question depends on what kind of question it is (e.g. question concerning effectiveness, validity of a measure, predictive accuracy of a risk assessment measure) (Gambrill 1999:344).
Thus, although generally grounded in controlled, experimental studies, this does not mean that only RCT research should be accepted as valid. Rather, the development and use of the evidence base involves developing as complete a picture as is possible, critically assessing the most reliable and valid information available. RCTs can therefore be seen as an important, (but not the only), component of a research base. Because as Lewis notes:
'there are problems in trying to apply (RCTs) - to social interventions, as many such interventions are not amenable to research designs involving RCTs' (Lewis 1998:136).
Despite its ability to demonstrate clear cause and effect relationships with regard to program or practice outcomes, a randomised control design (RCT) or even quasi-experimental approaches are often not possible in situ (in the real world context), or even desirable in every instance. First, they are not particularly sensitive to local and contextual factors that may affect practice and professional decision making (e.g. Webb 2001). Second, only a small proportion of published research - even in medicine, the home of the RCT - is able to be based on RCTs as it is often too difficult and too expensive (in terms of time and money) to be utilised.
It is important therefore, to recognise that there are a variety of research methods that can provide a degree of experimental control, reliability and validity. The trick is to tailor the methods to the research question being investigated and any situational constraints.
For those reasons the use of a multiple methods (or triangulation) approach is advocated. Combining quantitative and qualitative methods, and not necessarily excluding RCTs, this approach can provide a better understanding of applied social phenomena, such as child maltreatment and child protection work (Lewis 1998; Tomison 2000).
What is also required when creating an evidence base, is the development of a comprehensive picture of what works. Research should consist of a hierarchy of steps that builds to a comprehensive evaluation of policy and practice, not merely a measure of outcome or 'success' which does not tell us why a particular initiative is successful. A research program is therefore the equivalent of a basic program evaluation model, and should include the following stages in order to fully assess an issue (Tomison 2000:
Baseline (or input) stage: where the question to be addressed is documented, aims, objectives etc. reported and the development of the program or initiative described.
Process (also known as implementation or formative evaluation): The extent to which a program or initiative is operating as intended via the assessment of ongoing program elements and the extent to which the target population is being served. That is, how the program is achieved, any modifications undertaken, which program elements have led to a successful outcome.
Outcome (impact): The extent to which a program or intervention affects participants on a set of specified outcomes, variables or elements; the effect on clients, workers, wider society. Outcome studies are often the focus of research where a primary aim is to demonstrate success to funding bodies.
Overall, to develop an evidence-base requires an investment in a research base that supports comprehensive investigation and evaluation. Determining why something works is just as important as determining whether it works at all.
However, Lewis contends that to develop a truly comprehensive assessment regarding a particular issue, undertaking input and process analyses in combination with impact/outcome assessments, is only part of the process. It is also important to give consideration to what types of information can be incorporated into the assessment. Lewis contends that a wide range of information should be drawn upon, in addition to research data, such as 'experiential knowledge, common sense, practice wisdom, user perspectives - rather than simply statistical correlations, important though these can be' (Lewis 1998:136).
Taking as a 'given' the general disparity between the levels of funding available and the need for research in this field, other issues require addressing if both the conduct and use of research are to be facilitated.
First, as noted above, substantial changes to policy and practice in child protection systems have often been implemented without careful, evidence-based consideration of the effectiveness of existing systems, or proof that the new initiative will have a significant, positive impact. This tendency has been exacerbated by the crisis-led approach to development in child protection.
Child deaths and regular, adverse media coverage on a variety of aspects of child protection practice (leading many workers and services to feel that when making decisions or taking action they are 'damned if they do, damned if they don't') have helped to create a climate where it is at times more important to be seen to be making some form of response to alleviate concerns, rather than taking the time to plan a considered response (so-called 'policy by media', Goddard and Saunders 2001). As a result, changes to policy and practice have often not resulted from the careful consideration of evidence-based practice.
Further, the absence of strong research knowledge has hampered attempts to make considered strategic decisions. In order to minimise the tendency of 'quick fixes', child protection departments require the resources (time and funds) that will enable them to develop a research plan able to adequately assess service limitations and the implications of advocated policy and practice changes. This will require a cessation in 'innovation-led' policymaking (the desire to be seen to be taking action and adopting new approaches) and the common practice of only funding pilot programs of limited duration. Such policies impact negatively on the ability to adequately trial programs and to determine their efficacy (Tomison 2000).
However, addressing such issues leads to a Catch 22 situation. Research evidence is required to provide an alternative to crisis-led, 'quick fix' or innovation-led policymaking. Yet to obtain that evidence requires the development of a body of knowledge that can only eventuate if governments and/or departments invest in programs and research with timelines that allow adequate assessment and a slower approach to the implementation of changes to practice. Making that investment appears to be more likely when departments are not in crisis and governments do not have to make quick responses to child protection scandals.
Even allowing for some regional or statewide differences in populations, community needs and service infrastructures, the challenges and solutions facing the different child protection sectors are remarkably similar. Thus it should be that research findings are also, to a large extent, generalisable.
Generalisability would be being further enhanced by the State/Territory child protection services moving to adopt uniform definitions of maltreatment, case outcomes and data collection processes (although this would require legislative changes). In recent years, despite attempts by the Australian Institute of Health and Welfare and Standing Committee of Community Services and Income Security Administrators (SCCSISA 1998) to develop uniform data definitions that would enable the collection of uniform community services data from across the country, child protection systems appear to be becoming more divergent in their approaches, such as the introduction of the New Directions 'case streaming' model in Western Australia (Tomison 1996a). Such trends have hampered the generalisability of research investigating child protection systems and will reduce (to an extent) the value of any national research plan of action.
Child maltreatment is a complex phenomenon that may reflect the degree of underlying social problems in a family, community or society (Melton & Flood 1994). The adequate prevention of child maltreatment requires that an holistic approach be adopted in order to address what are often multiproblem, disadvantaged, dysfunctional families. It has been demonstrated that attempts focusing primarily on remedying a single family problem are often not as effective as approaches that utilise a multivariate, holistic approach. Such programs target the influence of constellations of family factors and/or problems, often working in collaboration with other services (Tomison 1996b; Durlak 1998).
There are clear associations between a variety of social ills and child abuse and neglect. There are similarities between the risk and protective factors underpinning the development of a range of social ills. Over time, a high degree of congruence has developed between the prevention of the various forms of violence and/or social ills, in terms of the priorities and strategies for action that have been proposed and undertaken. Clearly therefore, the prevention of child maltreatment and other social ills, and the enhancement of the professional systems would be facilitated by greater cross-sectoral collaboration and coordination from government, researchers and non-government agencies from policy-level linkages down to the enhancement of relationships between sectors and agencies at the service provision level. In research terms, this could be facilitated by the development of a cross-sectoral research group (see below).
In order for statutory child protection services and non-government child welfare and family support agencies to make the most of research opportunities, to develop an evidence base and/or evidence-based practice, a number of issues should be addressed, some of which are discussed below.
To achieve these steps, a number of 'agency' issues need to be addressed.
Parton (1985) described defensive practice as professional and agency self-protection, where child protection professionals are not prepared to take risks in case management or decision making for fear that they may make an error and subsequently be vilified or sued. This may lead to an inflexibility with respect to child protection investigation, or the minimisation of abusive concerns; either practice may in turn create harm for children and families (Satyamurti 1981; Jones 1991; Hallett & Birchall 1992).
Certainly, the regular criticism of child protection departments in the media (and to be fair, often in research publications) has led, at times, to a highly defensive stance by workers and department managements. This has translated into a reluctance to expose departments to further criticism via research unless it (and the dissemination of findings) are able to be entirely controlled by the department. It is becoming common for research to be contracted on the basis that a department has full intellectual ownership of the work and veto rights over dissemination and publication of the results.
Restrictions on intellectual property is a major issue for research bodies, who if they cannot publish the results of research they undertake, are unable to justify the time and academic resources expended. For those relatively few studies that are being undertaken, or that are proposed, the 'ownership' issue is beginning to seriously impact on what can be undertaken and achieved. First, a body of evidence is not seeing the light of day, in some cases even where the results are predominantly positive. Thus, the ability to learn from these studies Ð in research and practice terms Ð is substantially reduced. Second, overly restrictive contract terms means that researchers will be deterred from applying to undertake contracts. The withdrawal of such research expertise has the potential, over time, to affect the quality of the research that is able to be produced.
There is a clear need for a change in the ways in which research is undertaken Ð whether it be independent or contract research undertaken for a department or agency. Despite the risks of, (once again), having practice errors, or flaws in service delivery systems being highlighted, departments require research to inform practice.
Admittedly, this needs to be undertaken in a manner that does not merely 'catastrophise' 2 the system, but provides a balanced picture, creates learning's and provides a means of enhancing or guiding policy and practice development. It must also be done in such a way as to enable researchers to disseminate their work within the department and the wider child protection field. The issue of partnerships in research is discussed further below (see Researchers below).
There is a need to develop a research-friendly culture within child protection departments, such that research is valued as a means of better understanding child maltreatment and of determining the most effective professional responses. Research has indicated however that child protection workers generally fail to keep up with research knowledge and instead rely on 'practice wisdom' as the main means of informing their (e.g. Gambrill 1999). While practice wisdom is a vital component of an agency's knowledge, at times some sections of the child protection and/or family support sectors appear to operate under the assumption that their views and experience, in isolation, provide an accurate, comprehensive assessment of practice that can adequately inform changes to service delivery. That is, there appears to be a feeling that 'we think this is what's happening - therefore it is'.
Such attitudes can lead research to be perceived as a waste of valuable resources that will, at best, merely confirm practice wisdom. Thus, the costs of participating or undertaking research are not seen as being offset by a significant increase in knowledge. Hence, overcoming agency defensiveness and developing an agency culture where research and evidenced-based practice is valued should be key features of corporate planning.
In addition, training programs are required that can teaching workers' the value of using research to inform practice. Specifically, such courses will need to teach the process of evidence-based practice: identifying a question and the information required; knowing the information that is required to answer the question; the critical review and assimilation of information; and the ability to determine the implications for practice. Workers will also need to be educated on how to access and use the information resources of specialist research agencies (e.g. National Child Protection Clearinghouse) and academic libraries to supplement their knowledge (Ramchandani et al. 2001).
As an indication that researchers and practitioners are recognising the need to train staff in evidence-based practice techniques, Darlington & Osmond (2001) reported on their recent development of the Using Knowledge in Practice (UKIP) project. This system is designed to assist child protection workers to make better use of research-based knowledge in making practice decisions. The project was piloted with the Queensland Department of Families, Youth and Community Care in 2001.
In addition to a general promotion of an evidence-based approach, a key feature of the shift to a research culture should be the development and empowerment of agency staff in research roles. That is, utilising staff experience, practice wisdom, and awareness of agency culture in combination with research expertise in order to facilitate the conduct (internal and external) and adoption of research knowledge. [The latter may incorporate the development of worker training programs.]
Appropriately trained staff provide an in-house expertise or capacity to conduct rigorous research, enable agencies to conduct highly sensitive research while avoiding issues of client confidentiality (e.g. legal responsibility to keep client information within the department) and/or enable research ownership in circumstances where a department may not wish to publicise any results.
The development of specialist in-house expertise is also vital as a means of ensuring that when research is done, particularly research involving external researchers, it is based on accurate information about the department, agency culture and practices. It is contended that researchers produce more balanced findings if they seek out, or are able to obtain practitioners' interpretations of the findings. An internal research cadre is best placed to provide an insider's view of the results, or to ensure practitioners are able to provide their interpretation of the data. Thus, such staff could assist in bridging the research-practice gap, such that external experts' research benefit from the interpretation and assistance of those 'at the coalface', thus increasing their ecological validity.
Importantly this would also enable academic and practice concepts to be more accurately translated, ensuring a better understanding of practice and ensuring that research findings are produced in a form that encourages adoption or use by practitioners. It would also minimise the publication of ill-considered conclusions that merely result in the scapegoating of practitioners.
Knowledge has to be available if it is to be used. Once research is completed it is vital that the results are used and disseminated widely so as to inform practice. This can be facilitated in a number of ways. First, agencies should encourage researchers (internal and external) to produce academic publications. This provides status for the research and also contributes to the dissemination of knowledge to the field from a source that is considered reputable (that is, books, refereed journals etc.).
Second, it is vital that the research is translated for practice. Researchers have an obligation to assist internal 'experts' to use research findings to develop material or training programs as a means of disseminating the research findings effectively through the child protection system - that is, to contribute to practice wisdom. It would be particularly beneficial if researchers devoted time to developing research syntheses or meta-evaluations - rigorous reviews designed to encapsulate knowledge of a particular issue and presented in a form enabling easy access and comprehension by practitioners and policymakers (Gambrill 1999).
Unfortunately, although many researchers would be pleased to work more effectively with child protection agencies, particularly if it became a condition of access to information, it is currently the case that very few researchers are currently requested to develop practice materials or to provide seminars or training sessions for practitioners or policymakers.
Overall then, as part of any research undertaking, it is strongly recommended that a publication/dissemination plan be developed (allowing the agency a period of confidential review of the results prior to publication or use). This should incorporate both academic and professional practice publications (including meta-analyses if practicable) and training schedules.
In summary, it is recommended that child protection and/or family support agencies should:
It is generally acknowledged that child protection work is exceedingly difficult and that no matter what decision is made, a child protection worker is liable to have that decision criticised by other professionals, the media and wider community. It should also be acknowledged that child protection work is typically not done under ideal situations Ð workers must contend with involuntary, uncooperative and/or hostile clients, a lack of resources, high workloads etc. (e.g. Tomison 1999). Thus, when investigating aspects of child protection practice it is often the case that the focus is on understanding practice and identifying elements of the system that may benefit from alternative approaches. That is, the research is often focused on identifying less than optimal performance (and hopefully offering some solutions).
While researchers should not cease to document the realities of practice - 'warts and all' - it is apparent that a proportion of the research that is produced is perceived by workers as merely scapegoating them, offering what they perceive to be a biased representation of their experience. Although this may be the case in some instances, most researchers are genuinely attempting to develop as accurate a picture as possible of the realities of child protection practice. As was noted above, it is argued that some of the so-called 'bias' or perceptions that research is not an accurate depiction of practice, is based in a failure (or a lack of opportunity) to adequately incorporate workers' or the agency's perspective. That is, it represents a failure to take into account agency cultural issues and the language of practice. This emphasises the importance of an 'action research' approach, where researchers have access to practitioners perspectives on aspects of practice and/or their interpretation of the research findings.
The identification of service deficits or areas requiring improvement provide vital data for researchers if they are to ensure their findings are utilised and translated into practice. Yet it is important that a problem focus or 'catastrophising' does not become the primary means of information-sharing. The way results are presented - balancing negative and positive aspects of practice, ensuring that the language used, and the understanding of what has occurred, is congruent with workers' perspectives - will improve the utility of the research. Although a researcher may maintain a different interpretation of the findings, giving workers a voice is important for ensuring that the results are perceived as balanced and objective. It facilitates the acceptance and use of research findings in child protection systems and ensures that the researcher is able to make the most of the collected data. The tension inherent in such a process however, is avoiding being too influenced by practitioner views such that important findings are minimised or inappropriately modified merely to avoid conflict.
Overall, to conduct research with the child protection departments requires entering into an agreement based on mutual trust. From the researcher's perspective, the benefits of engaging in a collaboration relate to: enhanced access to the field; ensuring the most accurate depiction of child protection practice; and thus ensuring the work is a valuable addition to the research and practice fields. The only possible downside is that rather than being more balanced, the research process and interpretation of the results may become too influenced by agencies or practitioners such that important, less positive findings are minimised. With care however, the potential benefits of getting the support/advice and wisdom of the system's 'insiders' far outweigh the risks.
In the past year at least two national associations of researchers have been developed to create a national agenda for research on children and more specifically, an agenda for research on the out-of-home care system (the latter being discussed at this conference). A sub-committee of one of these committees, or another national body, is required to focus specifically on research investigating child protection practice. Such a group, perhaps linked in with the Australian Research Council, should also include government policy makers and non-government service provider representatives.
The group would be able to regularly advise on new developments in child protection-related research and practice. More importantly, the group should be charged with the development of a national research strategy. Such a framework or 'master plan' would work to ensure uniformity of purpose, clarity of mission, and enable large-scale cross-sectoral research initiatives (with pooled funding), while also forming a base for sector-specific interventions. The group would also ensure communication was maintained between the various sectors and states, and enable the sharing of new research and lessons from practice.
Although making some useful contributions to child protection knowledge, Australia is currently failing to adequately invest in developing a child protection research base. However, there are some promising signs of change - greater recognition of the benefits arising from adopting an evidence-based approach, and some recognition of the need to create better research-practice partnerships in order to get the most from the research that is undertaken. In creating further opportunities for change it is contended that the three principles for conducting and using research - from the perspectives of both researcher and practitioner - should be:
Educate (on evidence-based practice)
Evaluate (critical appraisal of the data and investment in ongoing research investigations)
Disseminate (informing the field using both academic and practice-oriented material)
1. However are moving to establish closer links with the research sector. Queensland for example, appears to have developed close links between the Department of Families, Youth and Community Care Queensland and the Department of Social Work, University of Queensland.
2. The latter term was picked up while the author was working with a child protection manager. She defined the term, in child protection vernacular, as presenting the most negative or pessimistic perspective when describing the child protection system.
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