Preventing child abuse: Changes to family support in the 21st century
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Increased demand for assistance from families and communities has led to a substantial reinvestment in a rapidly changing family support sector. In this paper, a number of central themes in the development and provision of family support are explored,particularly as they apply to the prevention of child abuse and other family violence in the twenty-first century.
During the final decades of the twentieth century, the general social and economic context in which families existed changed radically in Australia, as in other postindustrial countries (McGurk 1997). Like many Western countries, Australia made significant progress in enhancing the health and wellbeing of its citizens. For example, there was a lowering of non-Indigenous infant mortality rates, increased participation in education and health programs, and a reduction in the levels of physical and intellectual disability (AIHW 1998; de Looper & Bhatia 2001).
However, not all changes to families and the wider society have been positive. Families, communities, services and governments have had to cope with the recognition or discovery of a variety of new issues or problems that may impact on families and communities. The societal discovery of child abuse, high youth suicide rates and the high rate of drug abuse, are some examples. There has also been an increase in the incidence of a number of pre-existing social problems, such as generally higher levels of unemployment and poverty (Harding, Lloyd & Greenwell 2001; Vimpani, Patton & Hayes 2002).
Further, the social benefits thought to accrue through strong economic growth do not appear to have been fully realised (Weeks & Quinn 2000). Despite periods of strong economic performance, relatively high levels of violence, poverty and unemployment have occurred in a society where an increasing number of its members have been marginalised and excluded (Weeks & Quinn 2000).
In the 1990s, the American psychologist, James Garbarino (1995), ably captured the situation, arguing that there was a toxicity of some social environments similar to the toxicity of the physical environment, and that these social environments were particularly toxic for children. Garbarinos toxic factors included: violence in all its forms, poverty, unemployment, poor housing and an under-resourced education system. He argued that the management of socially toxic environments needed to be similar to the management of a physically toxic environment receiving a similar, if not greater, level of perceived urgency by the public.
THE IMPACT ON FAMILIES
Given the complex nature of families, and their sensitivity to economic and social change in their wider environment, it is perhaps not surprising that families themselves have experienced significant changes to their structure (McGurk 1997; Weston & Stanton 2002). The changing patterns of family structure and formation [such as] the formation of marriage-like relationships, changes in childbearing and fertility patterns, revisited gender roles, the intrusion of work into family life and family breakdown (McGurk 1997:v), have been interpreted as evidence of both the decline of the family as we know it and, alternatively, as evidence of the ability of families to adapt to changing circumstances. With regard to the latter, it is the familys durability and adaptability that are seen as evidence that families (albeit different sorts of families) will continue to remain as the basic social unit of society (McGurk 1997).
THE CHANGING NATURE OF FAMILY SUPPORT
The increasing expansion and identification of social ills or issues (such as child abuse and parenting problems, youth suicide, bullying, domestic violence, substance abuse, relationship breakdown etc.), combined with a greater focus on the quality of family life and the health and wellbeing of family members (Tomison & Wise 1999), have produced significant demand for assistance as families and communities seek external support to assistAdam M. Tomison them in achieving and maintaining a reasonable standard of living, health and wellbeing. This has occurred as traditional forms of support provided by extended family and/or friends and neighbours appears to be decreasing (Bittman & Pixley 2000).
As a consequence, families have turned to governments and a range of family support services to assist them in dealing with the changing nature of society and the specific issues they may face. These family support services can be broadly defined as seeking to benefit families by improving their capacity to care for children and/or strengthening family relationships (AIHW 2001:xi). Typically, such services have focused on the provision of parent support, knowledge and skills development, and have been provided via centre-based group programs and/or as home visitation services (e.g. Tomison & Poole 2000). [For an overview of parent education, see Tomison 1998; for recent analyses of the effectiveness of such programs, see Chalk & King 1998, and Shonkoff & Phillips 2000.]
In the last decade there has been a substantial reinvestment in a rapidly changing family support sector (Tomison 2001), and growing recognition of the need to work strategically to ensure the best response for families and improved societal health and wellbeing. In this paper, the intention is to explore a number of central themes in the development and provision of family support services, particularly as it applies to the prevention of child abuse and other family violence in the twentyfirst century.
Despite various attempts to protect children from harm through the ages, the organised prevention of child abuse could be said to have originated as part of the general assistance beginning to be provided by child welfare agencies to families living in poverty in the late-nineteenth century.
In Australia, the earliest form of child protection began within weeks of the first white settlements being established in New South Wales (Gandevia 1978), in response to what would today be defined as neglect. The settlements abandoned and neglected children, or children whose parents were considered socially inadequate, were initially boarded out with approved families or later resided in orphanages, the first of which was established on Norfolk Island in 1795 (Liddell 1993).
Over the next century a strong voluntary or non-government child welfare sector was developed in Australia (and overseas) (Picton & Boss 1981). The Christian churches became involved in running orphanages and secured prominent positions within the non-government child welfare system positions that are still held today.
In the mid-1800s, at a time when institutionalisation (residential care of children) was still the main response to child welfare problems (Liddell 1993), New South Wales and Victoria experienced a significant increase in the number of abandoned and neglected children as a consequence of the gold rushes and as a proportion of overall population increases (Liddell 1993). However, there was also increasing concern over the conditions experienced by children in care, and the deprivation they suffered as a result of having no family life (Liddell 1993). Thus, by the end of the nineteenth century, boarding out had become the most popular form of child welfare activity throughout the Australian states (Liddell 1993), a form of foster care that was probably the best model of foster care in the world at that time (Scott 1998:5).
The child protection pendulum
Since the 1800s, the provision of alternative care has oscillated between the housing of children in institutional settings or in some form of family-based care, such as foster care. This trend provides one of the earliest examples of what has become a continuing issue in child protection and child welfare the regular oscillation between (and revisiting of) child protection and child abuse prevention service models or approaches (Dale 1998), often as a response to public outcry at perceived failures in protecting children from harm (and child deaths in particular) (Scott 1995; Goddard 1996; Parton 1997).
Fuelled by evidence of the further abuse and neglect of children in institutions, the alternative care pendulum has continued to swing between institutional and familybased care to this day. Australian State and Territory governments are still reflecting on the degree to which institutional care should be used under a system that has favoured family-based care for much of the past 40 years.
Family support in the 20th century
By the 1890s, most Australian states had established a Childrens Court and legislation to protect children from the more obvious forms of child maltreatment. Anumber of voluntary child rescue organisations were also formed at this time: for example, the Victorian Society for the Prevention of Cruelty to Children (1894), later to be known as the Childrens Protection Society (Liddell 1993).
The development of such agencies strengthened the role of the non-government sector in carrying out early forms of child protection work. The end of the nineteenth century saw child protection as largely invisible, subsumed within the emerging and amorphous field of child welfare (Myers 2002:563). The period also saw the development of early family support services, such as forms of parental respite, and set the foundation for the child welfare/family support sector of the 1990s (Liddell 1993).
The modern discovery of child abuse
The first half of the twentieth century was not notable for changes to child welfare practice, but it did see the state taking greater responsibility for looking after childrens welfare, and the increased use of legislation to enforce appropriate standards of care (Liddell 1993). It is generally agreed that modern professional (and subsequently public) interest in child maltreatment, sometimes known as the second wave of the child rescue movement (Scott 1995), was prompted by the publication in 1962 of Kempe and colleagues seminal work on batteredchild syndrome (Kempe, Silverman, Steele, Droegemuller & Silver 1962). Subsequent public concern for the welfare of children and the need for expertise in the assessment and treatment of cases of child abuse and neglect led most communities to develop some form of distinct, professionally staffed, child protection service, located within social service agencies or government departments (Jenkins, Salus & Schultze 1979). According to some sources (for example, American Humane Association 1992), the development of child protection services as part of larger welfare departments was part of a commitment to maintaining families, rather than treating child abuse as a crime.
The role of family support services
In addition to a continued role in providing alternative care for children removed from their families, the church agencies, child rescue societies and other non-government agencies that constitute the family support service sector, have spent much of the last 40 years maintaining and expanding their role in supporting children and families at risk of harm. Although it was not always explicitly acknowledged as such, the work of supporting at risk families, maltreating families who sought assistance voluntarily, and statutory child protection client families, has been vital in not only avoiding the recurrence of maltreatment, but in reducing the risk or preventing maltreatment and enhancing child and family wellbeing (Tomison 1999; 2001).
Throughout the 1980s, a range of family support services provided a variety of therapeutic supports to families in need. These services included nurse-based home visiting services, where there was some recognition by governments and practitioners that infant welfare nurses could play a greater role in identifying and supporting at risk families. At this time, adequate resourcing and lower service demand meant that many services were able to counsel, treat or support not only statutory child protection clients, but many voluntary client families where identified child maltreatment concerns were deemed suitable for a community case plan (Tomison 1999). In addition, many families who voluntarily sought assistance for more general family dysfunctions or issues, and/or who were at risk of maltreating their children (that is, secondary prevention cases), were also able to be provided with supports, although these were often of a short-term nature (Tomison 1999).
Reframing child protection service provision
In the 1990s, statutory child protection services in the Australian States and Territories, like those in other Western countries, struggled to cope with ever-increasing numbers of reports of suspected child maltreatment and fewer resources (Tomison 1996c). These pressures, some caused or exacerbated by an over-emphasis on cost-effectiveness and bureaucratic structures at the expense of professional practice, led governments and child protection services to seek alternative approaches for managing child abuse and neglect.
It became apparent that a substantial proportion of the child maltreatment allegations referred to child protection services did not involve concerns deemed by the statutory services as requiring their involvement (Audit Commission 1994; Dartington Social Research Unit 1995; Tomison 1996c). Many of the reports involved families who had not maltreated their child but who had more generic problems, such as financial or housing difficulties, an incapacitated caregiver, or serious stress problems. Although such at risk families may require assistance, it has been argued (Tomison 1996c) that they do not require child protection intervention. Further, their labelling as cases of child abuse or neglect was placing an additional burden on what were generally limited child protection resources (Tomison 1996c).
Despite the fact that legal action was not taken for the majority of families with whom child protection services were involved, it was argued that the style of intervention for all families had become forensically driven (Tomison 1996c; Armytage, Boffa & Armitage 1998). This adoption of a forensic or legalistic approach produced a number of negative consequences.
First, it led to the shifting of scarce child protection resources away from the provision of support to families where there was confirmed or substantiated child maltreatment (tertiary prevention) to enable the conduct of investigations. Similar problems were identified in the United Kingdom (Audit Commission 1994; Dartington Social Research Unit 1995) and the United States. The US Advisory Board on Child Abuse and Neglect (1993) concluded that the adoption of a forensic approach meant there was no realistic hope of meaningful treatment or family support to prevent a recurrence of child abuse and neglect, or to ameliorate its effects. As Kaufman and Zigler noted: currently, investigation is the only "service" provided in response to many child abuse and neglect reports (1996:235).
Second, an under-resourced family support system was swamped by referrals from child protection services, effectively ending the bulk of the secondary prevention work that had been done with at risk families and creating substantial waiting lists for all but the most severe child abuse cases (Tomison 1996c; 1999). In effect, the focus on child protection investigations at the expense of prevention and treatment services was the same as having a health system in which ambulances and casualty departments are increased while immunisation programs and surgical wards are closed (Scott 1995:85).
Third, there was an emphasis on child protection services as the expert, and an alienation of essential non-government family support agencies and professionals from a partnership approach with statutory services with regard to the prevention, support and protection of children (Armytage, Boffa & Armitage 1998). Finally, the shift to forensic investigation also raised general questions in relation both to child protection services screening or gatekeeping practices and the nature and availability of broader child welfare and family support services in the community. Within this, the dilemma was described as one of distinguishing child protection problems from broader welfare concerns and, in all instances, delivering an appropriate response matched to the needs of the client children and families.
In developing alternative service models as a response to these critiques, attention therefore focused on the operation of both child protection services and the broader child and family welfare system that statutory child protection services operate within (Dartington Social Research Unit 1995). Most Australian State and Territory governments subsequently adopted new models of child protection and family support (Tomison 1996c), based predominantly on the recommendations proposed in the UK Department of Healths Child Protection: Messages from Research report (Dartington Social Research Unit 1995).
Such approaches were often not new, but involved a revisiting or recapitulation of solutions previously tried and tested since the development of child protection services. One of the major differences was that there was now substantial formal recognition of the vital role played by the broader child and family welfare system in supporting families, and thus in preventing the occurrence and recurrence of child abuse and neglect.
Valuing family support
As Scott noted:
child protection services are merely one component in a complex web of child and family services at the primary, secondary and tertiary levels of prevention. The child protection service is heavily dependent on this broader infrastructure of statutory and non-statutory services . (1995:85)
One of the primary aims of the family support approaches described above was to re-balance the respective roles of statutory child protection services and family support services. Taken to its logical conclusion, the aim was to ensure that statutory intervention would no longer drive the child protection system, rather that it would be integrated as one important facet in an overall welfare or needs assessment of the family (Dartington Social Research Unit 1995; Parton 1997). Thus, good practice and adequate child protection would emerge from adopting a wider perspective on child protection such that the underlying problems in a family that may put a child at risk, or have a detrimental effect on the childs long-term welfare, would be addressed (Tomison 1996c). That is, it was recognised that merely conducting an investigation and applying the label child abuse to a family would not do much to reduce the risk of further harm to children. The priority would be on supporting children and parents to reduce any risks to the child, and to keep policing, surveillance and coercive interventions to a minimum (Parton 1997:3).
Clearly there has been a renewed focus on addressing family ills holistically, and to resource services to support children and families in order to prevent the development or recurrence of child abuse and neglect. With regard to statutory child protection services, child protection workers have been provided with a greater range of options to select from when responding to a report. These differentiated responses provide workers with more scope to tailor the assessment process to the perceived family needs and the level of risk to the child (Tomison 2002). Thus, a case that appears to be mainly about a need for general family support than the occurrence of actual child maltreatment, may receive a less intrusive assessment involving non-government family support agencies, while a serious child abuse concern continues to receive a more authoritarian response from child protection workers, at times in the company of police officers (Tomison 1996c, 2002).
The perceived cost benefits
Some researchers and practitioners raised concerns that the new models may not adequately protect children (Tomison 1996c). Child protection departments were already being criticised by some for failing to intervene in cases where children were at risk of harm (Tomison 1996c), with the perceived failure to intervene being exacerbated by the impact of a substantial increase in the number of reports. The fear was that the child protection pendulum had already swung too far towards the preservation of families. Thus, the danger of adopting a family support approach would be that this may encourage a stronger shift to family preservation and addressing the families needs as a whole, while further compromising the safety of children.
In contrast, the benefits of the new systems are that, in principle, families are not unduly stigmatised or traumatised by inappropriate or unnecessary investigations, and are therefore more likely to accept assistance. In addition, family problems can be comprehensively assessed and (in theory) appropriate services put in place to address them, thus preventing the development of maltreating behaviour, or reducing conditions detrimental to a childs long-term development (Tomison 1996c).
Equally importantly, the models recognise the need for effective collaboration between child protection services and other family support agencies in order to more effectively assess family needs and to provide a response that can positively affect family wellbeing and ensure the protection of children from abuse and neglect. Such models, if appropriately resourced, enable family support services to regain prominence in preventing child maltreatment and the early detection of at risk children, a role which many services were unable to perform substantially in the 1990s because of a lack of resources exacerbated by the high demands for services that accompanied the recession of the late-1980s and early-1990s (Tomison 1996c; Armytage, Boffa & Armitage 1998).
FAMILY SUPPORT IN THE 21ST CENTURY
Notwithstanding the dramatic resurgence of interest in family support in the 1990s, interest in the prevention of child abuse and neglect has increased substantially over the last 20 years. This trend has been due in part to the humanitarian desire to remedy or prevent the suffering of children, as noted above. It was boosted, however, by the recognition that the investigation-driven child protection response of the early 1990s would ultimately fail without adequate family support and other prevention services that could actually work with families to address their needs and to reduce any risks to childrens health and wellbeing.
However, there have been other reasons for the renewed interest in prevention. Harrington and Dubowitz (1993) contended that the greater interest resulted from the professional communitys discovery of the harmful and expensive outcomes that can result from child abuse and neglect. Such outcomes included physical and emotional harm, the transmission of abusive or violent behaviour through the generations from parent to child, and delinquency and/or adult criminal behaviour (see Widom 1992). Further, a small but growing body of evidence that prevention programs can produce greater social and economic benefits compared with crisis services, has also given impetus to a more prevention-focused service philosophy (e.g. Barnett 1993; Colorado Childrens Trust Fund 1995).
In the often-quoted Perry Preschool study, Barnett (1993) calculated that by the age of 27 years, for every dollar taxpayers spent on the preschool children enrolled in the Perry Preschool early intervention program (developed in the 1960s), there had been a subsequent saving of over seven dollars in health, welfare, criminal justice and social security expenditure. Such cost-benefit analyses have resulted in a revitalised attitude towards the effectiveness of such early intervention programs, given that not only were they able to assist the nation to attain educational targets, but they were lucrative social investments (Zigler & Styfco 1996:144; Vimpani, Patton & Hayes 2002).
In the last decade, in addition to the reinvestment in family support, there have been three clear, interrelated prevention trends evident in policy and practice, with respect to the response to a number of social ills including crime, substance abuse, domestic violence and child maltreatment. These are: the renewed popularity of early intervention prevention approaches, particularly those targeting the first three years of life; the concomitant development of health promotion and initiatives designed to enhance child and family health and wellbeing; and whole of community approaches.
Early intervention services
Early intervention initiatives are allied with the promotion of health and wellbeing. A range of early intervention strategies and programs have been developed to create growth-promoting environments for young children whose development is threatened by biological vulnerability or adverse life circumstances (Shonkoff & Phillips 2000:32).
The primary intention with an early intervention approach is to intervene to influence childrens, parents or families behaviours, in order to reduce the risk or to ameliorate the effects of less than optimal social and physical environments. The approach also aims to increase the chances of a:
more favorable developmental trajectory for each child. This is accomplished by attempting to identify and mitigate the influence of existing risk factors, as well as to identify and enhance the buffering capacity of available protective factors . (Shonkoff & Phillips 2000:32)
Although early intervention approaches to prevent child maltreatment or other social ills may be beneficial from birth to adulthood, the early years of life in particular have become the predominant focus for intervention. Infancy is a period of developmental transition that has been identified as providing an ideal opportunity to enhance parental competencies and to reduce risks that may have implications for the lifelong developmental processes of both children and parents (Holden, Willis & Corcoran 1992; Keating & Hertzman 1999; Shonkoff & Phillips 2000).
Interest in early intervention approaches has been strengthened by growing empirical evidence that early exposure to chronic violence, a lack of nurturing relationships and/or chaotic and cognitively toxic environments (Garbarino 1995), may significantly alter a childs neural development and result in a failure to learn, emotional and relationship difficulties and a predisposition to violent and/or impulsive behaviour (e.g. Pynoos, Steinberg & Wraith 1995; Shore 1997; De Bellis et al. 1999). That is, if a childs sensory, cognitive and affective experiences are significantly below those required for optimal development, such as may occur in a chronically violent environment, the brain may develop in ways that are maladaptive in the long term (see Shonkoff & Phillips 2000, for an excellent overview).
Specifically, the child may develop a chronic fear response, such that neural systems governing stress response will become overactive, leading the child to be hypersensitive to the presence of cues signalling a threat. Alternatively, a child experiencing a violent environment may become unresponsive and overly withdrawn. In either case, although this survival reaction may be an important adaptation for life in a violent home environment, it can be maladaptive in other environments, such as school, when the child needs to concentrate and make friends with peers.
When used as a preventative measure, early intervention approaches should incorporate both the promotion of health and wellbeing, and the prevention of social ills like child maltreatment (LeGreca & Varni 1993). It should be noted that there has been some recognition (e.g. Zigler & Styfco 1996; Tomison & Wise 1999; Brooks-Gunn 2003), that early intervention strategies, particularly if used in a limited way or in isolation, do not offer a magic solution to remedying the social problems that may impact on children, such as poverty.
However, early intervention approaches, often closely linked with universal services, are generally perceived to be one of the most effective ways to ameliorate the effects of maltreatment (Widom 1992; Clark 1997; Tomison & Wise 1999). Family support services carrying out an early detection role, especially home visiting services, have been particularly noted for their success in identifying families at risk of maltreatment prior to the concerns reaching a level that would require protective intervention (Olds et al. 1986a; Oldset al. 1986b; Olds et al. 1997; Chalk & King 1998).
Whether they be similar to the Home Visitor service operating in the United Kingdom child protection system, the universal maternal and child health nurses of Scandinavia, or Australias infant welfare nurses, home-visiting programs are an important facet of a cohesive child abuse prevention strategy. Ideally they offer a universal primary preventative service with the flexibility to cater for the needs of at risk or maltreating families (Vimpani et al. 1996). Where resources allow, such services are able to support and educate parents, and are more likely to detect problematic changes in family functioning (Drotar 1992). These services are also able to divert/refer families to the most appropriate support and can often alleviate the family situation without the necessity of statutory child protection services involvement.
The value of the preventative role played by the non-government sector, including early detection services, in preventing child abuse and neglect was relatively unacknowledged and undervalued during the recession of the late-1980s and early-1990s, particularly by governments intent on cost-cutting (Tomison 1999). It was not until the shift to a family support model of child protection practice in the mid- to late-1990s, and the publication of empirical evaluation studies, that the benefits of home visiting and other early intervention programs were recognised. Since then, governments have begun to reinvest in early intervention programs.
Back to the future
Much of the current approach to child abuse prevention results from a revisitation and extension of the programs and tenets of early intervention programs that were first begun in the United States 30 years ago (Tomison & Wise 1999). The US Civil Rights movement provided the impetus to develop new ways of thinking and to overhaul the existing social structure. Education was seen as the key to eliminating social and economic class differences (Zigler & Styfco 1996; Ochiltree 1999) and resulted in attempts to improve the cognitive and social competence of disadvantaged young children.
Early intervention programs like Perry Preschool (Barnett 1993; Zigler & Styfco 1996), Head Start (Zigler & Styfco 1996), and the Elmira Prenatal/Early Infancy Project (Olds et al. 1986a; Olds et al. 1986b; Olds et al. 1997) have demonstrated some improvement in disadvantaged childrens lives, and may reduce the number of at risk or maltreating families who will require more intensive support in order to reach an adequate level of parenting and overall functioning. Early intervention is therefore a vital, costeffective component of any holistic approach to preventing social ills or promoting social competence (Barnett 1993; Emens et al. 1996; Zigler & Styfco 1996).
In Australia, the renewed interest in early intervention approaches has led to the creation of the National Investment For The Early Years (NIFTeY) organisation (Vimpani 2000). NIFTeY is dedicated to promoting the development, implementation and evaluation of strategies in the early years of life that advance the health, development and wellbeing of all children in Australia.
Strengthening families and communities promoting resiliency
Strengthening families and communities has become a major component of efforts to prevent a variety of social ills, including child maltreatment. Researchers investigating the risk factors that may heighten childrens vulnerability to social ills such as child abuse and neglect, have consistently identified some children who are able to achieve positive outcomes in the face of adversity children who are resilient despite facing stressful, high-risk situations (Kirby & Fraser 1997). Resilience appears to be determined by the presence of risk factors in combination or interaction with the positive forces (protective factors) that contribute to adaptive outcomes (Garmezy 1993).
The enhancement of protective factors or strengths has become a key facet of prevention strategies. Governments are now using it as the basis for Australian communitylevel interventions, and as a valued part of a policy of promoting family and community health and wellbeing. For example, the Stronger Families and Communities Strategy (Department of Family and Community Services 2000), announced by the Commonwealth in April 2000, invested $240 million to help support and strengthen Australian families and communities.
The Strategy takes a prevention and early intervention approach to helping families and communities build resilience and a capacity to manage problems before they become severe. It recognises the importance of the local community and the wider social and economic environment for the wellbeing of citizens, the special protective role that strong communities can have for the very young, and the importance of supporting families to care for their members.
The Strategy focuses on the importance of early childhood development, the needs of families with young children, improving marriage and family relationships, balancing work and family responsibilities and helping young people in positive ways. It also includes new initiatives to encourage potential community leaders, to build up the skills of volunteer workers, and to help communities develop their own solutions to problems and promote a can do community spirit.
Overall, much of the current focus of family support services is on taking a whole of community approach to improving the health and wellbeing of children and families. The aim is to ensure that when faced with adversity or stress, communities are better equipped to cope and respond in a non-destructive way. This approach goes beyond direct prevention of maltreatment and is better described as a wellness or health promotion approach (Prilleltensky & Peirson 1999; Tomison & Poole 2000).
It also appears that a similar trend has begun among professionals working in the child protection and child welfare arenas. In family support work, many agencies have begun to re-focus their work with families to empower clients, focusing on a familys potential for change (rather than on their problems), and attempting to engage family members in a truly cooperative venture to find solutions to their issues. A strengths-based or solution-focused approach to practice is based on the development of an effective collaborative relationship with children and their families (De Jong & Miller 1995). The underlying tenet of this perspective is that all families have strengths and capabilities. However, as Durrant notes, a focus on strengths does not deny shortcomings it suggests that focusing on the shortcomings is often not a helpful way in which to address them (cited in Scott & ONeill 1996:xiii).
Although significant benefits may accrue through the adoption of a health promotion approach, it is contended that in order to prevent child maltreatment and other social ills more effectively, strategies are required that focus on both reducing risk factors and strengthening protective factors that foster resiliency (LeGreca & Varni 1993; Tremblay & Craig 1995; Cox 1997). As Cox notes:
truly ecological approaches that are developmentally attuned demand concurrent programs that work on protective as well as risk factors and that reflect and impact on processes working within and across various domains of the childs world (1997:253).
Such an approach has already been adopted to prevent other social ills. For example, Tremblay and Craig (1995:15657) describe developmental prevention, a key component of crime prevention strategies, as interventions aiming to reduce risk factors and increase protective factors that are hypothesised to have a significant effect on an individuals adjustment at later points of development.
Whole of community approaches
The African proverb, It takes a village to raise a child, epitomises the importance of the role of the wider community in raising children and young people. The larger socio-economic system in which child and family are embedded can influence family functioning, child development and the availability of helping resources, such as universal child and health services, within communities and neighbourhoods (Martin 1976; Garbarino 1977; US Advisory Board on Child Abuse and Neglect 1993; Hashima & Amato 1994).
The importance of community has undergone a resurgence of interest (Korbin & Coulton 1996), with governments and the child welfare and family support sectors redesigning services to become more community-centred, and forging alliances with local communities to help improve the physical and social environment of communities (Cohen, Ooms & Hutchins 1995; Argyle & Brown 1998) and to develop social capital (Coleman 1988; Fegan & Bowes 1999).
Until recently, despite the development of ecological theories of child maltreatment (for example, Garbarino 1977; Belsky 1980), researchers, policy makers and practitioners working to prevent child maltreatment have often perceived such structural forces as being beyond the scope of prevention. The tendency has been to tailor prevention activities to run within environmental or structural constraints (Parton 1991; Garbarino 1995). However, there has been growing recognition that preventing child maltreatment requires the development of the means to address the societal factors underpinning child maltreatment and other family violence (Altepeter & Walker 1992; Tomison 1997).
This, in turn, has led to the adoption of holistic prevention strategies with a focus on whole of community approaches and early intervention strategies designed to influence a broad network of relationships and processes within the family and across the wider community (Wachtel 1994; Hay & Jones 1994; US Advisory Board on Child Abuse and Neglect 1993; Tomison 1997; NSW Child Protection Council 1997; National Crime Prevention 1999).
With a few exceptions, such as the Australian national audit of child abuse prevention programs undertaken by the National Child Protection Clearinghouse (henceforth to be known as the Australian Audit) (Tomison & Poole 2000), there has been a dearth of information available on the role and nature of family support services operating across the nation. However, in 2001, on behalf of the Australian Community Services Ministers Advisory Council (CSMAC), the Australian Institute of Health and Welfare (AIHW) published a report describing the family support services funded and/or delivered by the Commonwealth and State and Territory governments (AIHW 2001). Anumber of service trends were evident.
- As noted above, crisis services addressing issues such as family violence were increasingly being complemented by services that built on family strengths (capacitybuilding) and the creation of resiliency using a solutionfocused approach (Dunst, Trivette & Deal 1988; De Jong & Miller 1995). This approach was linked to the development of social capital (Coleman 1988) and creating family and community capacity to address and/or manage their own needs.
- There was a clear focus on the creation of innovative service solutions that were locally designed and delivered to meet the needs of specific communities. Further, services were being tailored to meet the needs of specific sections of the Australian population, including Indigenous Australians, culturally and linguistically diverse communities, people with disabilities or mental health issues, and rural and remote communities. Such services were set up to complement the more traditional generic family support services.
- Family support services were generally taking into account the wider community-level factors that might impact on service delivery, tailoring support programs to acknowledge the wider social and physical environmental context.
- A strong investment in early childhood and early intervention programs was evident.
- There was an increased focus on service integration or interagency coordination, and a greater focus on measuring outcomes and evaluating program impact or outcomes.
- Finally, there was recognition that to be effective, family support services must attempt to address holistically the needs of the family, including key members of the extended family.
In the following sections, building on the trends identified by AIHW (2001), some of the key issues or trends facing family support services in the twenty-first century are described.
Overcoming a legalistic approach engaging with families
It has been argued that in the 1990s, a legalistic framework and rules of evidence were increasingly determining the facts of a child protection case, and whether abuse or neglect concerns were serious enough to warrant protective intervention (Mitchell 1996; Stanley 1997). It is contended that a focus on legalistic issues has pervaded child protection practice and usurped attempts to address the therapeutic needs of the child and family (Tomison 1999).
For example, one consequence of the adoption of a legalistic approach is that attempts have been made to restrict definitions of maltreatment in order to limit coercion and the stigma associated with being labelled as maltreating to those families where a child is at significant risk. This approach conflicts with the therapeutic concern to widen definitions of what constitutes maltreatment, and to increase the identification of both at risk and maltreating families in order to offer support (Hallett & Birchall 1992).
Afurther consequence of the law becoming the standard by which cases are judged and maltreatment defined, is that cases with legal consequences are, by definition, more likely to be singled out for attention (Lynch 1992). Emotional abuse or neglect, typically more difficult to prove legally, may therefore be less likely to receive adequate attention (Stanley 1997). In addition, there is a danger that maltreated children may receive less care and protection as a function of a lack of evidence, or until the evidence is such that the case is able to be dealt with under the legal system (Stanley 1997).
Finally, the evidential standards required by courts may permeate the work of non-judicial agencies, thereby setting the parameters for practice (Besharov 1985). This may lead to forensic issues dominating case investigations, with child protection concerns subsumed by criminal concerns and therapeutic work hampered (Mouzakitis & Varghese 1985).
A focus on voluntary engagement
It has been argued that there is a need to shift both research and service delivery away from determinations of guilt and risk to focus more on the development of comprehensive needs assessment and the provision of services to support children and families (Kaufman & Zigler 1996). The key issue for preventing child abuse is therefore not the achievement of legal sanctions, but the determination of what governments and the wider community may do to prevent or reduce the harm done to children (US Advisory Board on Child Abuse and Neglect 1993). The US Advisory Board on Child Abuse and Neglect concluded that:
the most serious shortcoming of the nations system of intervention on behalf of children is that it depends upon a reporting and response process that has punitive connotations, and requires massive resources dedicated to the investigation of allegations. State and county child welfare programs have not been designed to get immediate help to families based on voluntary requests for assistance . If the nation ultimately is to reduce the dollars and personnel needed for investigating reports, more resources must be allocated to establishing voluntary, nonpunitive access to help . (1990:80)
In recent times, using differentiated child protection systems, there has been some evidence of a shift in practice such that the focus is on service delivery and, more particularly, the encouragement of at risk and non-statutory maltreating families to seek and accept assistance. Statutory intervention is kept as much as possible for use with those for whom family support, by itself, is inadequate, and there is a need to intervene to ensure a childs safety (Tomison 2002). Many services have therefore adopted practice principles that promote cooperation between workers and families in order to achieve greater levels of parental cooperation and, subsequently, a better outcome for children and families (Tomison 1996c).
The importance of cooperation
The degree to which parents or caregivers cooperate with professionals has been identified as a factor affecting a variety of child protection case management decisions, such as whether to employ legal interventions in order to protect the child (e.g. Dalgleish & Drew 1989; English et al. 1998; Karski 1999). That is, parents who fail to recognise that there is a problem in the family, who exhibit hostility and/or who hinder professional involvement represent a higher risk to the child, as do parents who lack potential or motivation for change (Tomison 1999).
Some studies have suggested that cooperative parents make up a significantly smaller proportion of cases where legal protection is sought, than do cases where the parents are uncooperative (Craft & Clarkson 1985; Karski 1999). Other researchers have indicated that uncooperative parents fail to engage in therapeutic interventions, and thus are more likely to receive minimal intervention strategies (Goddard & Hiller 1992). Many child death inquiries have indicated that uncooperative parents have managed to avoid further protective investigations and professional case monitoring until after the child has died (e.g. Goddard & Hiller 1992; Reder, Duncan & Gray 1993).
From the findings of a large-scale tracking study of 295 suspected child abuse and neglect cases within a Victorian regional child protection network (Tomison 1999), it was apparent that the majority of substantiated cases and cases where legal action was taken involved parents whose level of cooperation was described as ambivalent at best. Further, families rated as uncooperative by workers, but who were engaged as voluntary clients, at times derailed case plans by failing to work with professionals and refusing referrals to services for assistance. As statutory intervention was generally considered to be inappropriate with these cases, the uncooperative or ambivalent caregivers were frequently left with the responsibility for their childs care and protection, effectively without professional supervision or support. These grey cases (Jones et al. 1987; Dalgleish et al. 1999) would be left to either improve to an adequate level of caregiving or to be renotified with similar or more serious concerns. Workers could perhaps then enforce cooperation through legal means.
The study therefore provides an insight into some of the difficulties faced by workers when attempting to work with families: in particular, the difficulties faced when working with families for whom there is insufficient evidence to take statutory action, or where the maltreatment concerns have been deemed suitable for remedy via voluntary work with the wider family support sector. The findings also support the move of family support services to adopt strengthbased or solution-focused approaches to casework. Under this approach, the positive engagement of families and a focus on pre-existing family strengths and capabilities would appear to offer a better chance of promoting family change and reducing the risk to the child (De Jong & Miller 1995; DePanfilis & Wilson 1997; Turnell & Edwards 1999).
Access to services
One area becoming increasingly the focus of discussion is clients access to services. Why is it that those most in need of assistance often appear to fail to gain access to services? Why do a proportion of the families with significant support and child safety needs, who manage to access services, disengage prior to completing the program?
Clearly, the demand for services by maltreating families (generally referred by child protection services) or those in crisis, has often swamped services operating with a prevention/ early intervention focus (see above). It is also apparent that this situation can create more demand, not less, as at risk families unable to gain assistance when problems first arise may present again with more serious child maltreatment concerns (Tomison 1996c).
Overall, there is growing recognition that to be truly effective, service sectors need to investigate this issue and develop methods of enhancing accessibility. It is apparent that governments have moved to enhance accessibility as part of their efforts to develop family and community capacity-building. A range of funded community development projects incorporate attempts to engage with local communities and to provide families with the skills to recognise a need and to seek out services before their problems reach crisis point (e.g. Department of Family and Community Services 2000).
Unfortunately, accessibility issues have not yet been explored fully, as research investigations of accessibility issues are still quite rare. The National Child Protection Clearinghouse is presently analysing the results of an exploratory study designed to gain further understanding of the issues around how families with a child at risk of being maltreated access programs designed to prevent maltreatment (Stanley & Kovacs, in press). Issues being explored include: how program design and implementation impact on accessibility for the service user; factors associated with the service users, such as knowledge of a programs existence and design; and the means by which identified barriers to accessibility may be overcome.
Access for all
Anumber of specific sections of the Australian population have been identified as being at greater risk of child abuse and neglect (Tomison & Poole 2000). Typically, these include young (adolescent) parents; Aboriginal and Torres Strait Islander communities; some culturally and linguistically diverse communities; families where a parent or child is suffering from a physical or intellectual disability; families where a parent or child is suffering from a mental disorder; and rural and remote populations. Each sub-population brings with it particular engagement and access issues.
For example, the development of culturally-sensitive prevention programs specifically targeting Aboriginal and Torres Strait Islander or culturally and linguistically diverse (CALD) communities appears to be necessary to ensure access to services (Tomison & Poole 2000). Aboriginal and Torres Strait Islander peoples often prefer to attend services that offer culturally-relevant programs staffed and managed by their own communities (Wilson 1995; Tomison 1996b). Where there is inadequate access to such Indigenous services, families are more likely to fail to seek assistance.
Unfortunately, the availability and number of culturally appropriate services is relatively low. In the Australian audit of prevention programs carried out by the National Child Protection Clearinghouse, Tomison and Poole (2000) reported that although 16 per cent (296) of the 1814 prevention programs collected were reported to target Aboriginal and Torres Strait Islander peoples, only 23 per cent of these programs (68 of the 296) appeared to have been specifically developed or tailored for the Indigenous population.
In order to enhance Aboriginal and Torres Strait Islander access to culturally appropriate services, a number of approaches have been put into place (Tomison & Poole 2000). First, there has been much work done around the provision of cross-cultural awareness training (for example, Deemal-Hall & McDonald 1998; Firebrace 1998), to ensure that non-Indigenous workers are sensitive to the needs of their Indigenous clients.
Second, cultural issues and sensitivities (for Indigenous and non-English-speaking communities) have been incorporated into a variety of programs, such as the Barnardos Family Work program that operates in a number of centres across New South Wales. Aboriginal and Torres Strait Islander communities have also been given a voice in the development of culturally-appropriate materials via representation on a range of decision-making bodies.
Finally, in an attempt to develop more Indigenous services, a number of government and non-government agencies have developed Aboriginal or Torres Strait Islander teams, or employed Indigenous workers to work with local communities. The Commonwealth, for example, as part of the National Rural Health Strategy (Department of Health and Aged Care 1996), has funded initiatives that support the funding and training of Aboriginal health education officers and other means of increasing Aboriginal and Torres Strait Islander involvement in the delivery of culturally- appropriate services and in the management of health services. The Government has also undertaken to accelerate the development of education programs for Aboriginal health workers, and to pilot various service delivery models to encourage and support nurses and Aboriginal and Torres Strait Islander health workers operating in rural and remote areas that are under-supplied with medical services.
Tailoring support to family needs
Just as attempts to engage with the range of Australian families requires the development of tailored solutions, any understanding of family support needs to be:
informed by an awareness of the diversity of family forms and recognition of the different responses of family members to challenges along their life course . (McGurk 1997:v)
It therefore follows that an effective family support system requires the flexibility to meet families needs (both therapeutic and physical), particularly if a collaborative, solution- focused approach is to be effective. Further, the adoption of a systems approach to family issues needs to be balanced against meeting the needs both of individual families, and individuals within families. This is clearest when considering the provision of support to children and young people.
Addressing childrens issues
A traditional assumption made in Western societies (and thus, in Western family policies) is that childrens needs will be met as dependants within the family context, with adults mediating their needs (Makrinoti 1994). While this may broadly be a correct assumption, there will often be times when the needs of the individual child or young person will require a tailored response (e.g. child abuse trauma; bullying; post-family breakdown) (Tomison 1997).
A number of authors, such as Makrinoti (1994) and Mason and Steadman (1997), refer to the ideology of familism and its relationship to the oppression of children. The term familism is used to describe the ways by which policies targeting children are frequently subsumed under other policies (Mason & Steadman 1997). Childhood is fused with the institution of the family such that children and their needs cannot be defined independently of the family. Children, therefore, do not exist as a distinct social entity, but are conceptualised as family dependants (Makrinoti 1994).
The question is, can childrens needs be met via the provision of generalised support to parents or the family as a whole?
In the last decade a range of child focused services have been identified (Tomison & Poole 2000), where the focus of the program is predominantly on children and young people without the involvement of, or with a minimal focus on, their families. Child-focused programs constituted 19 per cent (342) of the 1814 programs identified in the Australian Audit, and were comprised of:
- adolescent parent support programs (mainly for young mothers);
- respite and substitute care services for children and families requiring time out or emergency assistance;
- generalist support and counselling programs for at risk and maltreated children and young people;
- school-based health promotion and resiliency programs;
- services for young people at risk of homelessness; and/or
- programs run in sexual assault centres or womens refuges for children who had witnessed domestic violence.
It should be noted that many of these programs were not designed to replace or supplant family-focused programs that is, in general they did not attempt to explicitly address childrens needs as part of a wider parent or family- focused support program. Rather, the programs aimed to provide a specialist support service and/or support for children and young people estranged from their family. The general standard of the evaluations that were completed for the programs precluded a reliable assessment of their effectiveness (Tomison & Poole 2000). Overall then, is a child-focused approach effective? Does the adoption of a focus on an individual family member (child focus) preclude a family-centred focus? What is the impact on the provision of family support?
In 2001, Wise reported on an independent assessment, undertaken with colleagues, of an attempt to emphasise childrens needs within family support programs. This was achieved via the trial implementation of the UK Children in Need approach (Department of Health (UK) 2000) within an Australian family support system. Designed for use by service providers in cases where statutory child protection intervention was not required, the Children in Need system comprises a conceptual framework and accompanying practice tools that assist family support staff to adopt a systematic "child-in-family" practice focus (Wise, in press).
Using worker feedback and other data sources, it was reported that some workers felt that a systematic child focus within the context of family support would undermine the familys trust (because of its similarity to child protection risk assessment processes), and thus negatively impact on engagement and service provision. However, it was also acknowledged by workers that careful practice would probably reduce the potential for family disengagement. Overall, Wise concluded that it still needs to be determined whether more deliberate and systematic attention to individual childrens needs within family services leads to better outcomes for children and their families (Wise, in press).
Yet it was apparent that workers judged the Children in Need approach to be a useful framework for providing family support tailored to the needs of children and parents. What appeared to be required to adequately test the approach was the provision of better training for workers in child and family assessments, and appropriate service resourcing that would permit smaller worker caseloads and enable workers to focus on the needs of children and families, rather than deal with parental needs in isolation.
Generic or tailored family support
As noted above, the issue of generic versus specialist programs is perhaps most evident when assessing the needs of particular Australian communities. While tailored, culturally- sensitive prevention programs may be required for Aboriginal and Torres Strait Islander or culturally and linguistically diverse communities, it appears that flexible, generalist prevention programs may provide a suitable means for catering to the needs of children and families where a disability or mental disorder is present (Tomison 1996a). For these families, it is the provision of adequate resources that enable services to be provided for as long as families require them, rather than the development of specialist services to meet particular family needs, which appears to be the crux of service provision. Unfortunately, existing family support services appear to be unable to provide the services required on an indefinite basis, and rationing of services is a common result (Tomison 1996a; Scott 1998; Tomison & Poole 2000).
Financial flexibility wrap-around services
Restrictive funding practices, such as the traditional allocation of block funds for specific services and/or client groups, have been identified as impacting detrimentally on the ability to support what are often multi-problem families by constraining therapeutic action and reducing the effectiveness of cross-sectoral or interagency work (Coughlin 1984; Cocks 1993).
In recent years there has been a growth in the number of wrap-around services that tailor an individualised support package to a familys needs (Ainsworth 1999; Tomison, Burgell & Burgell 1998). Wrap-around services can be defined as services:
where the use of flexible funds allow service coordinators to wrap the services around children and their families, rather than forcing children into existing service programs . (Karp 1996:299)
Under such an approach, funding is allocated on a per client basis, enabling workers to develop a case plan and purchase a range of services or practical supports for children and families that are tailored to meet their individual needs (Audit Commission 1994; Dollard et al. 1994; Karp 1996; Tomison, Burgell & Burgell 1998; Edgar 1999). It should be noted that given the flexibility and potentially multifaceted nature of the support package, intensive service coordination is an essential ingredient to the success of individualized, wrap-around services (Karp 1996:300301). Further, most wrap-around models are based on the adoption of solution-focused or strengthsbased approaches to practice, where the client family is engaged in identifying needs and developing potential solutions (e.g. Dunst, Trivette & Deal 1988; De Jong & Miller 1995).
Adopting an holistic approach
In order to address the needs of what are often multiproblem, disadvantaged, dysfunctional families, effective family support requires the adoption of an holistic approach to assessment and service provision. It has been demonstrated that attempts focusing primarily on remedying a single family problem are often not as effective as approaches that utilise a multifaceted, 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). Further, despite being able to make observable improvements to wellbeing and resiliency, it is important to recognise that no one program or activity has been entirely successful in enabling children and young people to develop optimally when the larger child rearing environment is not a conducive one. For example, in discussing the success of Head Start and the Perry Preschool program, Zigler and Styfco note that:
thirty years of experience with early intervention have yielded a clear but unwelcome truth: such programs cannot overpower poverty in shaping a childs developmental outcome . although children do better than they would have without the [preschool program experience] they still do not approach the achievements of middle-class students . Such findings lead to the sobering conclusion that early childhood intervention alone cannot transform lives. (1996:152)
Nor can it be expected that any program, in isolation, can deliver a once-off inoculation that ensures childrens healthy development (Brooks-Gunn 2003). To adequately prevent child maltreatment (or to effectively support families), it is important that a range of programs are instituted and coordinated under a comprehensive strategy. This strategy should be comprehensive, child-centered, family- focused and neighborhood-based (US Advisory Board on Child Abuse and Neglect 1993:16, as cited in Melton & Flood 1994), and one which takes children seriously as individuals (US Advisory Board 1993:17, as cited in Melton & Flood 1994).
The 1994 UK Audit Commission report identified the development of regional or area strategic childrens services plans as a key aspect of an effective family support system. Under this approach a range of coordinated, flexible, non-stigmatising services are developed that can make best use of limited resources. Edgar (1999) proposed the development of similar family resource zones in Australia.
Child and Family Centres
At the service level, the adoption of an holistic, multidisciplinary approach is exemplified by the continued development and refinement of Child and Family Centres. Child and Family Centres, frequently referred to as onestop shops, are multi-service community centres that adopt an holistic approach to preventing child maltreatment and promoting healthy communities, providing support to families on a number of dimensions (Tomison & Wise 1999).
Similar programs, known as Family Resource Centers in the United States, or multi-component community-based programs in Canada (Prilleltensky & Peirson 1999), have been operating for some time (Tomison & Wise 1999). Designed to be non-stigmatising and easily accessible, such one-stop shops offer highly integrated services that promote child and family wellbeing rather than allowing family problems to develop to the extent that secondary or tertiary prevention becomes the focus of centre activity.
The intention is to engage children and families in the local community, to promote health and wellbeing, and to encourage families proactively to seek assistance in order to ameliorate a variety of family problems prior to the development of a crisis. While retaining the flexibility to cater for more traditional preventative strategies, the centres are ideally placed to take early intervention and health promotion approaches, underpinned by their holistic service philosophy. The centres are also well placed to facilitate a sense of community and the development of social support networks within neighbourhoods.
Involving the wider professional community: cross-sectoral partnerships
As noted above, a developmental prevention approach (the enhancement of protective factors in combination with a reduction in risks) (Tremblay & Craig 1995) has been adopted in order to prevent a variety of social ills. As part of a developmental preventative strategy, most sectors have adopted universal early intervention and health promotion approaches to prevent social ills, and many of these interventions and initiatives share the same underlying philosophy and constructs. It is becoming common for complex health and social issues to be managed by a number of professionals (Jones et al. 1987). Within the Australian child welfare and family support systems, a variety of government and non-government agencies and professions are involved with different aspects of support and treatment.
Taking into account the need to consider and address a variety of sector-specific issues, what is apparent is the current high degree of congruence 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. Thus, the prevention of a range of social ills and the promotion of health and wellbeing would appear to be facilitated by increased cross-sectoral collaboration and coordination from government, researchers and non-government agencies, from policylevel linkages down to the enhancement of relationships between sectors and agencies at the service provision level. As Durlak notes:
those working with prevention in different fields must realize that the convergence of their approaches in targeting common risk and protective factors means that the results of their programs are likely to overlap . We are just beginning to learn how this occurs. Categorical approaches to prevention that focus on single domains of functioning should be expanded to more comprehensive programs with multiple goals. Future prevention programs, therefore, will need to be more multidisciplinary and collaborative. Also needed are comprehensive process and outcome assessments of how risk and protective factors influence outcomes in multiple domains . (Durlak 1998:518)
Child abuse and domestic violence
Aclear example in the Australian audit of child abuse prevention programs of the growth of holistic, cross-sectoral approaches, was the finding that the majority of the 1814 programs collected had attempted to address domestic violence, in combination with the various forms of child maltreatment (Tomison & Poole 2000). Two-thirds of all programs were reported as being designed to address issues of both domestic violence and the various forms of child maltreatment.
A more detailed assessment of family support programs revealed that 72 per cent (106) of the 148 family support programs addressing the recurrence of violence (that is, tertiary prevention), addressed issues of violence holistically (i.e. child maltreatment and domestic violence). Further, one-third of these programs (35) were being run in womens refuges/shelters and other adult crisis or assault services. Thus, agencies traditionally not occupying a central child abuse prevention role had developed strategies and programs to prevent not just exposure to domestic violence, but wider child maltreatment concerns.
A failure to recognise the potential for cross-sectoral impact
A first step to further the development of cross-sectoral work, however, is to ensure that service providers recognise the role (or potential role) they may play in preventing various social ills. Services need to be aware of the potential for them to collaborate with various sectors under a broad developmental prevention approach. In the Australian Audit, attempts were made to access those agencies or community groups not traditionally considered to be part of the child abuse prevention network, who might be involved in child abuse prevention work. Such groups included: child care services; neighbourhood community centres; community nursing services; drug and alcohol services; disability services; and migrant resource centres (Tomison & Poole 2000).
A substantial number of these agencies were identified as operating programs that were clearly aimed at (or had an impact on) the prevention of child abuse and neglect (for example, they ran a parent education program). Yet frequently, the agencies staff did not view their work as child abuse prevention. This finding appeared mainly to be a reflection of services differing priorities and/or the adoption of a primary focus on other social ills or populations based on block funding agreements (for example, substance abuse prevention or general health surveillance). It appeared that the prevention of child abuse was a secondary objective, or an accidental or unforeseen benefit of a program that was relatively unrecognised by some service staff.
The failure to articulate or acknowledge child abuse prevention as an aim within services, particularly in urban areas where service networks are more dissipated, is likely to impact on the extent to which services access interagency support, receive feedback on the value and relevance of their work, and contribute to the development of the child abuse prevention field as a whole. Further, the reduction of any sense of shared purpose between agencies in a local network will reduce opportunities to disseminate information both within and between agencies and the potential for collaborative and/or cross-sectoral work (Tomison & Poole 2000).
Thus, one option to facilitate the development of cross-sectoral work would appear to be assessing the extent to which child abuse prevention is formally (and informally) acknowledged as an objective of various services across the health, welfare, education and criminal justice sectors, and then identifying mechanisms to ensure that the potential for child abuse prevention is acknowledged, and the opportunities for interagency networking and information sharing are enhanced.
Overall, despite the greater recognition of cross-sectoral issues and the benefits of collaborative approaches, the potential benefits offered by involvement in interagency and, particularly, cross-sectoral collaborative partnerships still remain relatively untapped.
Interagency coordination and collaboration
Interagency (and interprofessional) coordination and communication1 have been well-documented as having the potential to enhance or undermine family support work. Ensuring effective interagency (or interprofessional) cooperation and coordination has been a common theme and an ongoing, significant issue for the provision of child protection and family support services for many years (e.g. Hallett & Birchall 1992; Morrison 1998).
Acoordinated response to the problem of child abuse and neglect can produce more effective interventions, greater efficiency in the use of resources; improved service delivery by the avoidance of duplication and overlap between existing services; the minimisation of gaps or discontinuity of services; clarification of agency or professional roles and responsibilities in frontier problems and demarcation disputes; and the delivery of comprehensive services (Hallett & Birchall 1992; Morrison 1998). Overall, the generally accepted objectives of a coordinated child protection response are to achieve: a comprehensive perspective in case assessment; comprehensive case plans or interventions; support and consultation for the workers involved in child protection; and the avoidance of duplication or gaps in service delivery (Hallett & Birchall 1992).
However, as Reid noted in 1969, interagency coordination is not a natural state of affairs and does not result merely from good intentions. While there would appear to be overall agreement that coordination in child protection is a necessary and valuable practice, effective coordination is difficult to achieve (for example, Jones et al. 1987; Morrison 1998). The desire for a coordinated response to child protection is often asserted, rather than demonstrated, and [may be] taken to be self-evident (Hallett & Birchall 1992:18).
Conversely, service coordination problems, especially where many services are involved, have often been cited in the literature as leading to less than optimal case management (Jones et al. 1987; Hallett & Birchall 1992; Morrison 1998; Tomison 1999). There is the potential for children and families to miss out on services, or to become victims of duplicated services or incompatible treatments, potentially causing the child and family more distress (Hallett & Birchall 1992). Poor coordination and cooperation have also been mentioned as contributing factors in a number of child abuse death inquiries (e.g. Goddard & Hiller 1992; Reder, Duncan & Gray 1993).
Inaccurate information, the failure to receive relevant case information, interagency disputes and/or ignorance of the role of other professionals involved in a cases management, all reduce the ability of professionals to make informed decisions when dealing with suspected or substantiated child maltreatment cases. For these reasons many social scientists have argued for a clearly structured teamwork approach to child abuse case management (eg. Jones et al. 1987; Tomison 1999), and stressed the importance of the participating services being coordinated by a designated key worker and/or agency.
The mechanisms of coordination
There is the potential for agencies to develop a large variety of inter-organisational (or interprofessional) links for the purpose of coordinated service delivery. These may range from low-key, unstructured, informal links between workers from different agencies, to the formalised interrelationships which may occur with agencies or professions in (and between) particular organisational networks, to highly formalised, centralised coordination structures (Challis et al. 1988; Hallett & Birchall 1992).
The formal structures or mechanisms that commonly facilitate interagency and interprofessional coordination are referral protocols, case conferencing, and the development of multidisciplinary teams. In Australia, formal referral protocols between statutory agencies, and mandatory reporting legislation (Goddard et al. 1996; Tomison 1999) are perhaps the primary formal means of communication in most States and Territories. In addition, although not mandated as they are in the United Kingdom, case conferencing is also a significant means of interagency coordination and communication in Australia.
However, a number of authors have highlighted the important role that informal professional relationships and communication paths can play in combination with formal child protection structures (e.g. Challis et al. 1988; Morrison 1998; Tomison 1999). Although an over-reliance on informal communication methods and the circumventing of formal coordination and communication mechanisms may lead to the variety of interagency communication problems identified above, strong informal linkages operating in conjunction with more formal communication structures appear to lead to a more effective interagency network (Morrison 1998; Tomison 1999).
To be effective, interagency and interprofessional communication and collaboration should be based on formal structures, such as referral protocols, case conferencing procedures and the placement of substantiated cases onto a central register. The underlying formal structure can then be supplemented or enhanced by the development of informal links or working relationships . (Tomison 1999:353)
Interagency work in Australia
In the Australian Audit (Tomison & Poole 2000), service providers involved in approximately one-quarter (450) of the 1814 programs could be said to be working collaboratively or in partnership with another agency. These partnerships generally involved a generic family support agency working with another, more specialist agency (for example, a drug rehabilitation service). However, in general, the partnerships involved only limited liaison between the agencies in order to refer cases and/or to share knowledge as a means of enhancing their services response to particular groups of client families. Most of these arrangements did not appear to constitute cross-sectoral working arrangements.
For example, the providers of health education and a variety of universal, community development programs appeared to recognise and attempt to address a number of social ills and/or to promote general health and wellbeing. In general, these programs were not truly cross-sectoral in that they did not involve the pooling of shared resources or the collaborative development of programs by services from a variety of sectors. Given that most prevention work has traditionally been done by agencies (or sectors) in isolation, focusing primarily on addressing one form of violence or social ill (Rayner 1994), the lack of a truly cross-sectoral response is perhaps not entirely surprising.
In order to create an environment that enhances crosssectoral, interagency or multidisciplinary work, some Australian States and Territories have adopted some form of joint investigation or formal multidisciplinary teams approach to assessment and case planning. Some of the more important interagency structures (where there is a basis in family support rather than purely forensic investigation) are described here.
Suspected Child Abuse and Neglect (SCAN) Teams Queensland
SCAN teams were developed in 1980 via the then Queensland Coordinating Committee on Child Abuse, in order to provide a formal mechanism to coordinate the activities of various government departments responses to child maltreatment. They have been described as a best practice model for the investigation, management, treatment and prevention of child abuse and neglect (Cameron, Roylance & Reilly 1999).
The statewide system of SCAN teams is designed to ensure an effective, coordinated, multidisciplinary response to notifications of suspected child maltreatment, particularly by the three government departments with statutory responsibility for child protection in Queensland (Department of Families; Queensland Police Service; Queensland Health), although a number of the teams have also permanently co-opted members from the education and mental health sectors.
SCAN teams are predominantly involved with the investigation and management phases of the child protection process, although they may be consulted about any aspect of child protection work. SCAN teams undertake to provide an interagency forum for case discussion and planning to ensure:
- the safety of the child;
- that assistance is available to the family and child;
- that intervention is effective and coordinated. (Cameron, Roylance & Reilly 1999:8)
The teams also provide a forum for formulating recommendations for action, including the actions to be undertaken by the three statutory departments; and have a review role such that the effectiveness of the SCAN team recommendations made are assessed in terms of meeting the needs of the child and family (Cameron, Roylance & Reilly 1999). In 199697, SCAN teams discussed approximately half of all substantiated child maltreatment cases in Queensland (one in six of all notifications received) (Cameron, Roylance & Reilly 1999).
The SCAN teams do not, however, have a formal role in monitoring or sanctioning the actions of the statutory departments; rather, the focus is on case planning and case coordination. The team determines the best course of action for each case via consensus, but individual agencies retain the statutory and/or professional responsibility for their own actions. Each agency does, however, have an obligation to report back on the outcomes of the actions taken. Further, if an agency decides not to implement a team plan, they are expected to refer the matter back to the SCAN team for further deliberation (Cameron, Roylance & Reilly 1999).
Why is the model effective?
- the SCAN teams have a focus on the holistic management of cases, not just the investigation process;
- they ensure information is shared between agencies in an effective manner;
- they are a professional forum, allowing all participants to voice their concerns and to hear others perspectives;
- each member is informed of the views and plans of other members;
- each participant agency retains its statutory obligations and powers.
The teams also play a key role in identifying regional education and training needs, and initiating activities to meet those needs.
New South Wales area child protection committees
A number of attempts have been made in various Australian jurisdictions (with and without government mandate) to promote interagency coordination and collaboration through the development of interagency area committees operated via government agencies or non-government professional forums.
New South Wales currently has the strongest, legislated interagency coordination mechanisms. For more than a decade the NSW Department of Community Services, which has the statutory responsibility for child protection, has been required to consult at the highest levels with the Police, Education and Health departments, and peak family support and child welfare bodies, when developing policies and contemplating changes to service delivery, in order to develop effective, coordinated cross-sectoral case practice (Tomison & Wise 1999).
In 1985, the government created the NSW Child Protection Council to coordinate the Governments child protection response. In addition to leading (or being the vehicle for) much of the senior interdepartmental contact, the Council also had responsibility for the establishment of formal interagency guidelines (updated regularly) and for developing and supporting a series of regional interagency Area Child Protection Committees, which were set up across the State. The NSW Child Protection Council provided information, training and support to local agencies and professionals via the Area Committees. These Committees became a key mechanism for imparting knowledge and training, and for the identification of local issues or needs that the Council then attempted to respond to.
Through enactment of the Children and Young Persons (Care and Protection) Act 1998, the NSW Government legislated for strengthened interagency partnerships, developing a series of clauses specifying the mutual obligation of the government departments in responding to child abuse and neglect. The Act explicitly states that Health, Education, the Police Service and the non-government sector all share the responsibility for child protection and are expected to share some of the burden of responding to maltreating families.
In 1999, in part as a response to the findings of the 1996 NSW Legislative Council Standing Committee on Social Issues Inquiry into Childrens Advocacy (Parliament of NSW, Legislative Council 1996), and the 1997 (Wood) Royal Commission Inquiry into Paedophilia (Wood & James 1997), the NSW Government set up a Commission for Children and Young People, which replaced the NSW Child Protection Council. The Commission took on many of the duties of the Council, including some responsibility for interagency coordination. The Commission released an updated version of the New South Wales Interagency Guidelines for Child Protection Intervention (NSW Commission for Children and Young People & Bruce Callaghan and Associates 2000).
Strengthening Families Victoria
The Department of Human Services Victoria has created a service that provides another perspective on both case planning and case coordination for at risk families and/or those where there are minimal protective concerns. It highlights the coordinated wrap-around service model, where a key worker or designated service acts as a case coordinator and service broker, supervising and purchasing supports for a multi-service case plan. As Karp notes:
the coordinators role is multifaceted: marshalling resources, developing a mutually agreed-upon interagency plan, ensuring coordination across agencies, and being ready when and if crises or problems arise . (1996:300-301)
The Strengthening Families program, initially piloted as the Brimbank Family Outreach Service (Tomison, Burgell & Burgell 1998), was designed to provide support and advice to at risk families not currently identified as maltreating. The aim of the program was to prevent these families from becoming abusive or neglectful, and thus becoming clients of statutory child protection services. In order to achieve this, the Outreach Service team engaged with identified at risk families. They would then provide case planning, service brokerage and interagency coordination functions for the client family within a defined network of local family support services.
That is, child protection services or other professionals would refer at risk families to the Outreach Service team. Using strengths-based approaches, a worker would then approach the family and seek to engage them in developing solutions for their practical and/or therapeutic needs. Having developed a case plan, the worker would then purchase and coordinate service delivery by local agencies.
In an evaluation of the pilot program, Tomison, Burgell and Burgell (1998) found that the Outreach Team did appear to enhance professional attempts to engage with, and address, the needs of at risk families. It was reported by a range of service providers that the service had generally enhanced interagency relationships. Specifically, the Team had improved case recordkeeping and information sharing between agencies, while reducing service duplication and the number of inappropriate reports received by local child protection agencies. Further, the staff were able to develop and provide effective support for these client families, decreasing the probability of the families becoming abusive (at least in the short term) and entering the statutory child protection system. The individualised, coordinated case plans were perceived by other service providers, and the families themselves, as being effective.
In conclusion, it is worth noting that in situations where the development of multidisciplinary teams is not a possibility, it is important that professionals have access to training in cross-sectoral issues and the methods of creating interagency or interprofessional linkages. The opportunity to interact and develop working relationships with other professionals, and if possible regular access to specialist advice, is a vital component of effective practice. For example, unless specially trained, relationship counsellors confronted by couples where domestic violence is present (or the potential for violence has been identified), are likely to require access to specialist supports to deal effectively with the familys concerns.
RESEARCH AND EVALUATION
Melton (2002) is the latest in a long line of authors to note the significant gaps in knowledge regarding child maltreatment, and the relatively small research investment that has been made, given the magnitude of the problem and the size of the professional response (e.g. National Research Council 1993; Melton & Flood 1994; Tomison 1997).
Child protection policy (and that of the wider family support movement) rests on a myriad of largely unstudied assumptions . (Melton 2002:577)
the absence of knowledge related to policy issues must not be allowed to obstruct necessary policy construction. Some social conditions are so severe and pressing as to warrant policy construction or immediate pragmatic action even in the absence of a consensual body of data. When this occurs, the efforts made need to be based on wise judgement, well informed by scholarship, with provisions for the evaluation and revision of programs as needed . (Hall, Kagan & Zigler 1996:5)
That is, under a general Public Health model, once the underlying etiological or risk factors associated with a problem are understood (Willis, Holden & Rosenberg 1992) and a problem is clearly defined, the next stage in developing an effective prevention strategy is to trial and evaluate various prevention initiatives. Based on the results of such trials, successful family support programs can then be implemented on a wider scale (Tomison 1997).
Unfortunately, relatively little is known about the effectiveness of current child abuse prevention or family support initiatives, mainly because of a failure to conduct careful program evaluations (Harrington & Dubowitz 1993; Melton & Flood 1994; Tomison 2000). This failure has been exacerbated in the past by the relatively low priority given to prevention programs by governments and other institutions, and the common tendency of funding only short-term demonstration or pilot projects (Melton & Flood 1994). Given the limitations of current child abuse prevention program evaluations, evidence-based practice may offer a means of establishing a reasonable body of research upon which to base a prevention strategy (MacDonald & Roberts 1995; Clark 1997).2
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).
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 and education, there was a growing shift towards adopting an evidence-based approach to child protection 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 et al. 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).
Unfortunately, many have taken evidence-based practice to mean only the use of evidence from randomised control trials. All other practice is perceived as either not evidence- based or of a lower quality. Such a narrow approach was not envisaged by Sackett et al. (1997), but is a common misunderstanding of the paradigm (Ramchandani, Joughin & Zwi 2001:60). In reality:
[T]he 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 evidence-based practice will generally be grounded in controlled experimental studies, this is not the only form of research that should be accepted as valid (Tomison 2000). Rather, the development and use of the evidence base involves developing as complete a picture as is possible of the effectiveness of particular interventions, by critically assessing the literature to identify the most reliable and valid information available. Thus, randomised control trials will be an important, but not the only, component of a research base.
As Lewis notes: there are problems in trying to apply [randomised control trials] 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 trial, or even quasi-experimental approaches, are often not possible in situ (in the real world context), or even desirable in every instance. First, such approaches 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 is able to be based on a randomised control design as it is often too difficult, too expensive (in terms of time and money) and too problematic ethically (e.g. withholding treatment from control group participants) to be utilised (see Tomison 2000 for a more detailed analysis).
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 then, 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 randomised control designs, this approach can provide a better understanding of applied social phenomena, such as child maltreatment, child protection and family support work (Lewis 1998; Tomison 2000).
Developing a comprehensive picture
What is required when creating the evidence base is the development of a comprehensive picture of what works in family support. To achieve this, 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.
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). The argument is that deficits in methodological rigour are therefore compensated for, in part, by the richness and quantity of the data gathered (Tomison 1997).
The past 50 years have seen significant changes to Australian families and communities, the identification of a variety of new social issues and, consequently, substantial expansion and changes to the family support system. At present, child protection and wider family support services across Australia continue to struggle to provide an effective response for children and families. Despite the renewed interest in developing greater supports for at risk and maltreating families in order to prevent child abuse and neglect, it is clear that the need for assistance remains high and that services continue to struggle to meet demand.
It would appear that the provision of professional family support will remain a driving force in the prevention of child maltreatment and other social ills, in conjunction with strong government interest in strengthening families and communities (that is, developing family and community resiliency). In many ways this can be considered a reclamation of the prominent role held by such agencies for much of the nineteenth and twentieth centuries (Tomison 2001).
What then are the key issues that will drive the provision of family support in the next decades?
First, given the growing focus on evidence-based practice, greater investment in research should lead to an expansion of current knowledge of the social and economic benefits of a range of early intervention, prevention and family support services. Hopefully, this will provide a more accurate picture of the sorts of interventions and models of service provision that can produce the greatest social benefits and best meet the needs of Australian families.
Second, there is a clear need for the continued development of multifaceted, comprehensive strategies designed to enhance the health and wellbeing of Australian families and communities. Early intervention approaches have demonstrated that they are a cost-effective means of supporting families and improving health and wellbeing. While such programs are clearly an important part of any strategy, they are not a panacea. No one initiative, in isolation or at only point in time, can be expected to support families adequately.
Such strategies will need to include the means to ensure strong coordinated cross-sectoral planning and service provision. The development of regional or area childrens services plans, as proposed in the UK Audit Commission report (1994), is one model worth exploring further. Further, despite the inherent difficulties in achieving effective coordination with complex service structures, there is a need to continue the shift towards greater professional interagency coordination and collaboration.
Third, the ongoing development of localised interagency collaboration or teams approaches is vital, particularly given the likelihood of a continuation of the current trend towards flexible service provision and the development of individualised support packages for children and their families. Service provision is also likely to be characterised by a greater emphasis on ensuring access to services, especially by those families most in need. It is to be hoped that any service expansion will include the provision of long-term monitoring and tailored support packages for families, particularly those with ongoing chronic problems, such as a disability or chronic neglect. This is a serious gap in the existing family support system (Tomison 1999).
Fourth, a greater emphasis on community capacity-building, health promotion and efforts to develop resiliency should be monitored to ensure that they do not detrimentally affect efforts to reduce risk factors and to prevent social problems. The adoption of a developmental prevention approach, where the aim is to reduce risk and to promote protective factors (Tremblay & Craig 1995) would appear to offer the best way forward. Afocus on resiliency without a continued focus on reducing risk factors is, in effect, only a partial solution. Effective family support requires a truly holistic approach where risk and resiliency continue to be acknowledged as interrelated, and solutions are developed to address the former and to promote the latter.
Fifth, as noted above, traditional forms of support provided by extended family and/or friends and neighbours have been decreasing (Garbarino 1995; Bittman & Pixley 2000). Peoples networks of social support have shrunk considerably, with more and more people reporting that there is no-one to whom they can turn for support in an emergency (Garbarino 1995). As further information becomes available as to the benefits (and limitations) of community participation, it will be important to maintain a balance between community and professional supports. That is, efforts to enhance childrens and families engagement and involvement with their wider communities, should occur together with the continued resourcing of the service sector. It is important that families who require more than informal community-based support are able to access appropriate professional assistance.
Balancing child protection and family support
Finally, perhaps the issue in the provision of family support in the twenty-first century is the effective integration of statutory child protection services within the wider family support system. The introduction of the family support approach to child protection in Australia has enabled some child protection services to successfully re-focus their resources towards dealing with the more severe cases of child abuse and neglect (e.g. Parton & Mathews 2001). Further, the importance of working in partnership with an effective, better-resourced, non-statutory family support system has been recognised, and the services have been reintegrated more firmly into the wider family support system. However, it is apparent that at this stage the legalistic approach (forensic investigation) still continues to hold primacy in dealing with child maltreatment cases.
With a continued focus on prevention and family support (and if greater resourcing of family support services can demonstrate therapeutic success and reduction in service demand), there is likely to be a continuation of the current de-emphasis on the government run statutory child protection response. Much like the service ideal proposed by proponents of the current family support child protection models (e.g. Dartington Social Research Unit 1995), only a small number of families families that health surveillance, early intervention and family support services are unable to help will experience the statutory child protection response. In many ways such a system could look much like it did before the rise of statutory child protection agencies in the 1970s, with a strong focus on general child welfare and family support. Such an ideal system may also lead to greater attention (and resources) being placed on addressing the structural forces that impact on families.
The danger is that the critics of the family support approach to child protection will be proved correct. That is, that the family support approach may lead to a failure to protect substantial numbers of children who are being maltreated through the adoption of a minimal intervention approach. Given that the historical pattern of change in child protection is for radical shifts driven by child abuse tragedies (e.g. Reder, Duncan & Gray 1993; Goddard 1996; Parton 1997), the danger is that the resultant policy change will swing the child protection pendulum too far. Child protection may go from a family preservation approach to a strongly interventionist approach, thus beginning another cycle of extreme policy shifts.
Rather than engage in a further round of dramatic policy shifts and the probable revisitation of historical approaches, it is to be hoped that policymakers will be able to withstand the fallout from any child abuse tragedies, and instead draw on the evidence base to inform a considered response. It is recommended that any change is of an incremental nature, designed to better balance and integrate child protection and wider child welfare and family support needs, rather than the sort of radical policy shift that has failed to work in the past.
1 Interagency coordination can be defined as different agencies working together at an organisational level, while interprofessional collaboration is committed individuals from different disciplines working together (Morrison 1998:6).
2 A full discussion of current knowledge about what works in the provision of family support and methodological approaches is beyond the scope of this paper.
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