Ad hoc conferences of hospital and community professionals in cases of hospitalized physically abused children
Pergamon Child Abuse & Neglect, Vol. 22. No. 1, pp. 63-68, 1998 Copyright 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0145-2134/98 $19.(R) + .00 PII S0145-2134(97)00124-5 BRIEF COMMUNICATION AD HOC CONFERENCES OF HOSPITAL AND COMMUNITY PROFESSIONALS IN CASES OF HOSPITALIZED PHYSICALLY ABUSED CHILDREN JERRY G. JONES, TOSS WORTHINGTON, AND FLO HAWKS Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital. Little Rock, AR, USA SUSAN O. MERCER Graduate School of Social Work, University of Arkansas at Little Rock, Little Rock, AR, USA BEVERLY W. JONES Arkansas Department of Human Services, Little Rock, AR, USA LELENG WOON Graduate School of Social Work, University of Arkansas at Little Rock, Little Rock, AR, USA ABSTRACT Objective: Although community interagency child protection teams are common and well described in the literature, they may not meet the needs of investigating agencies when children are hospitalized in tertiary medical facilities some distance from their homes. Sometimes, the communities in which they live do not have effective teams, or the information to be conveyed is highly technical. This report describes and assesses ad hoc multi-agency conferences with varying hospital and community agency participants, each conference devoted to a single hospitalized child suspected of having been abused. Method: A questionnaire devised by the authors was administered by telephone to 22 former conference participants from state social agencies, law enforcement units, and prosecuting attorney's offices. Results: Most of the surveyed participants reported the case-specific conferences to have been helpful, meeting their goals and affecting the outcomes of their cases. Conclusion: The conferences appear to have been worthwhile. Although they were associated with some disadvantages for the involved professionals and the sponsoring hospital, the disadvantages appeared to have been offset by the potential benefits for the children, families, participants, and hospital. 1997 Elsevier Science Ltd Key Words~onferences, Multi-agency, Child maltreatment, Hospital. Received for publication January 30, 1997; final revision received June 30, 1997; accepted June 30, 1997. Reprint requests should be addressed to Jerry G. Jones, M.D., Arkansas Children's Hospital, 800 Marshall Street, Little Rock, AR 72202-3592. 63 64 J.G. Jones et al. INTRODUCTION INTERAGENCY CHILD PROTECTION committees or teams commonly exist in cities and rural communities throughout the United States. The participants reflect a variety of disciplines, including mental health, social work, law enforcement, prosecution, medicine, and nursing. They commonly meet on a regular basis, reviewing several cases at each session. Their goals may include sharing of information and enhancement of decision-making by the participants. The agency representatives commonly are from the community in which the child resides or the alleged abuse occurred. Committees such as these have been well-described, and the results of a survey of state social agency participants in such a program have been published (Bross, Krugman, Lenherr, Rosenberg, & Schmitt, 1988). In this article, we will describe and assess another type of interagency meeting, one that has occurred on an ad hoc basis for hospitalized physically abused children at Arkansas Children's Hospital (ACH) for the past 10 years. This case-specific conference (CSC) is a product of two conditions unique to tertiary medical facilities. First, the abused children often reside far from the hospital, and thus hospital professionals are not part of the community multidisciplinary teams of those areas of the state. In ACH, 57% of the hospitalized victims of suspected physical abuse or neglect are from a county different from that of the hospital, Second, the evidentiary hospital evaluation tends to be quite technical, involving the observations of a variety of professionals, presentation of complex physical findings, discussion of the results of laboratory tests and radiologic procedures, explanation of mechanisms of injury, and dealing with issues of morbidity and mortality. The perceived effectiveness of the conferences by the participating agency members had been difficult to ascertain on an informal basis. The authors developed and implemented a survey instrument to obtain this information, and the responses of participants are reported in this article. METHODS When physical abuse was suspected in a child admitted to ACH, the suspicion was reported to the mandated state agency. When most of the evidentiary evaluation was completed, an ACH child protection team social worker, nurse practitioner, or physician determined whether a CSC was appropriate. The criteria for offering the conference to community professionals typically was as follows: (1) it was requested by a community professional; (2) a community agency was having difficulty synthesizing or utilizing the available hospital information; (3) a case was highly complicated; or (4) the local community was some distance from ACH and thus not a part of the hospital's weekly Child Protection Committee meetings. Each conference was established and conducted similar to the model described by Boatwright and Crummette (1987). The involved hospital and community professionals were invited to attend a CSC at a mutually convenient date and time. The hospital personnel commonly included nurses, social workers, physicians, mental health professionals, child life specialists, and the attorney member of the hospital child protection team. The physicians commonly were radiologists, general and subspecialty pediatric surgeons, general and subspecialty pediatricians, and pediatric resident physicians. The community profes- sionals were investigators and attorneys from the mandated state social agency, law enforcement officers, and prosecuting attorneys. A single case of a physically abused hospitalized child was presented and discussed. The goals were similar to those of community child protection commit- tees, which included the sharing of information and enhanced decision making. Each conference was usually led by a member of the hospital child protection team. The inpatient pediatric team physician usually began with a brief history including chief complaint, reason for admission, and a basic review of the child's hospital course to date. Other physicians who were Conferences of hospital and community professionals Table 1. Responses of the 22 Participants n % Conference was Helpful 21 95 Conference Helped Determine Outcome of Case 14 64 Participant Had Goals Which Were Met 18 82 The Needed Hospital Professionals Were Present 19 86 The Needed Community Professionals Were Present 17 77 Participant Would Want to Attend Such Conferences in the Future 20 91 65 consulted followed with their reasons for involvement and clinical findings. The team social worker discussed the family assessment, social interactions, and family or investigational needs. Often, a nurse from the inpatient unit presented observations of patient/family interactions. Each participant had an opportunity to provide input. No decisions were made by the group as a whole in regard to the child's medical care, social or law enforcement disposition, or court involvement. Agency professionals made decisions in accord with their respective mandates and responsibilities. How- ever, coordination of efforts to meet the needs of the children, families, agencies, and hospital often occurred. Following the meeting, a brief summary was recorded in the medical record. A survey of community participants in approximately 28 case specific conferences held during the previous 20 months was performed. A questionnaire prepared by the authors was administered via telephone by a graduate student research assistant unaffiliated with ACH or the child abuse program. She was able to contact 22 of the participants who attended 15 of the conferences, and they became the subjects of the study. Conference participants who could not be reached or were no longer employed by the represented agency were excluded from the study. Fourteen (64%) of the subjects were from one of the two state agencies charged with investigating child abuse (10 caseworkers and four attorneys), six (27%) were law enforcement officers, and two (9%) were prosecutors. RESULTS The results of the survey are summarized in Table 1. Twenty-one (95%) of the participants indicated the conferences were helpful, with only one responding that the conferences were not helpful. When asked to rate the degree to which the conferences were helpful, 15 of the 21 participants who gave positive responses (71%) indicated that they were exceptionally beneficial, six (29%) indicated they were moderately helpful, and no one indicated they were only slightly helpful. When asked how they were helpful, the participants had a variety of responses. Many felt the conferences aided them in obtaining the needed medical information, including the possible causes of the injuries and their ages, Others were able to compare the medical information with the history given by the parents in order to understand whether the history was consistent with the injuries sustained by the children. Many responded that the conferences gave them opportunities to have their questions answered regarding medical information. A few gave responses that were specific for the agencies represented, indicating the conferences helped in determining the safety of returning a child to the home (caseworker), allowed for the evaluation of potential court witnesses (prosecuting attorney), and provided an opportunity for informal discovery (state social agency attorney). Fourteen (64%) of those surveyed reported that the case specific conferences they attended helped determine the outcomes of their cases. Five (23%) indicated the conferences did not affect the outcome, some noting that the outcome had already been determined prior to the conference and others indicating their cases were still pending. All but one subject, who did not respond, believed the conferences were worth the trip to ACH. 66 J.G. Jones et al. Nineteen (86%) of those surveyed had set goals for the conferences. Their goals correlated with the aspects of the conferences they found helpful. All but one of them reported their goals were accomplished. That one responder expected to speak with all of the physicians involved with his case, which did not occur. Nineteen (86%) believed the needed ACH professionals were in attendance. Seventeen (77%) believed the needed community professionals were present, and five (23%) gave no response. All but two participants, who did not give responses, related that they would want to attend case specific conferences in the future. The subjects were asked how the conferences could be improved, Suggestions included tele- conferences, phone conferences, having physicians stay through the entire conference, and requir- ing all requested physicians to be present. Other suggestions were that ACH professionals be more understanding of the position of the state social agency and less biased against th e parents of the victims. One attorney of the social agency believed the presence of the defense attorney would have been helpful, and one police investigator believed inclusion of the parents would have been beneficial. Actions taken by agencies in these cases included four protective services cases opened, with the children remaining in their homes. The opening of a protective services case occurred when the state social agency worker determined that credible evidence of abuse was present but the child would be safe in the home with close monitoring of the family and use of such modalities as parenting classes, psychological evaluations and counseling, and day care. Four cases resulted in the children being taken into state custody, and five cases resulted in guilty pleas and/or convic- tions. Three cases were still pending, the involved agencies' plans uncompleted at the time of this survey. No actions were taken in two cases, because either the child was considered safe by the state social agency or arrest and prosecution of a perpetrator was considered improbable by the law enforcement organization. One participant said the conference assisted him in obtaining a confes- sion from an alleged perpetrator. DISCUSSION The ACH child protection team is consulted on all hospitalized children suspected of having been abused. The team has evaluated children in whom abuse has unquestionably occurred; in some instances, perpetrators have even disclosed their actions. Other cases, however, are clouded by ambiguity. In such cases, the hospital-acquired evidence of abuse often is considerable but requires detailed explanations of the significance to the investigating community agencies. The agencies must receive, understand, and process how to utilize the available information in order to act appropriately. Case specific conferences can enhance the acquisition and assimilation of informa- tion by investigators from community agencies in difficult cases. The results of the survey appear to support the value of the conferences. Almost all believed them to be helpful, and most reported the conferences helped determine the outcomes of the cases. The value typically was specific to the disciplines of the participants. Attorneys indicated the usefulness in selection of witnesses and their potential testimony, and investigators noted the value of presentation of the hospital-acquired evidence. Suggestions for improvement included more use of video and telephone conferences and greater efforts to make available all appropriate hospital participants. A limitation of this study was the ability to contact only 22 community professionals who participated in the conferences. This difficulty reaffirmed the mobility of professionals in the field of child abuse investigations. Some case specific conferences have not progressed as smoothly as anticipated. For example, a few parents were told of the scheduled conferences and wished to attend or learn the outcomes of the meetings, Although they were advised that the conferences were not for decision making, some Conferences of hospital and community professionals 67 parents remained unhappy. Occasionally, interactional problems occurred between participants, especially if a defensive stance had been taken regarding reasons why certain actions had or had not been taken. The conference must be redirected, reminding members of the need to work cooperatively and effectively. One or two participants sometimes had attempted to dominate the discussions, causing the meetings to be extremely lengthy. The conference appeared intimidating to others, preventing them from feeling comfortable enough to ask their own questions. A survey of ACH participants regarding their feelings about the worth of the conferences was not performed. The ones who attended generally appeared to accept that effective communication with community agencies was part of their patients' health care. However, they sometimes expressed frustration when the plans of the social agency differed from their expectations. Some other ACH professionals usually were unavailable to attend the conferences in spite of vigorous attempts to accommodate their schedules. Perhaps they had less interest in disorders with strong psychosocial components, a wish to avoid court, or very full schedules. That some professionals would wish to avoid dealing with child abuse is unlikely to surprise professionals in this field. These conferences are expensive in terms of professional time, with each conference lasting more than an hour. Third party reimbursement is poor. However, the conferences have potential advantages for the children, families, sponsoring hospital, and participants. These advantages include the following: 1. Better outcomes for victims of child abuse are likely when the appropriate community agencies have the information needed to adequately investigate and make decisions regarding safety of children and support of families. 2. Education of hospital personnel occurs when a cohesive clinical picture and plan for a family develops by collaboration of hospital and community professionals. 3. These conferences avoid the inconvenience of community professionals trying to reach hospital personnel individually at inappropriate times or when the personnel are not prepared. 4. They have increased the likelihood only the appropriate hospital professionals will be subpoe- naed to court, rather than personnel with information of little value to the court or that could be given equally well by others. 5. They can prevent one person, often the hospital child abuse professional, from carrying the burden of testimony regarding the hospital-acquired evidence single-handedly and often inap- propriately. 6. The conferences reinforce the hospital as a resource for referral and collaboration by community agency professionals. Thus, the conferences may be relatively cost effective in addition to benefiting the children, their families, and the participants. This study does not provide objective evidence that the six potential benefits of the case specific conferences actually occurred in the cases discussed. The responses of the participants were subjective. Establishment of a control group of cases, in which the conferences would be denied in order to compare outcomes, appears untenable. A method to confirm the value of the conferences to the satisfaction of third party payors is elusive. However, health care providers must continue to try to determine the effectiveness of their roles in the societal response to child abuse. REFERENCES Boatwright, D., & Crummette, B. D. (1987). How to plan and conduct a patient care conference. Nursing, 17, 64. Bross, D. C., Krugman, R. D., Lenherr, M. R., Rosenberg, D. A., & Schmitt, B. D. (1988). The new child protection team handbook. New York: Garland Publishing. 68 J.G. Jones et al. R I~SUME Objectif: Bien que les 6quipes communautaires inter-disciplinaires soient gEnEralisEes et bien dEcrites dans la littErature, elles ne rEpondent pas aux besoins des agences sociales lorsque les enfants sont hospitalisEs dans des unites mEdicales tertaires h une certaine distance de leur domicile. Les communautEs darts lesquelles les enfants vivent n'ont parfois pas d'Equipe efficace ou l'information ~ faire pssser est trop technique. Ce rapport dEcrit et Evalue des conferences multidis- ciplinaires ad hoc avec plusieurs participants de l'hEpital et d'autre agences, chaque conference 6tant centrEe sur un seul enfant hospitalisE suspect d'avoir 6tE maltrait& M~thode: Un questionnaire rEalisE par les auteurs a 6t6 prEsentE par tEtEphone ~t 22 anciens participants aux conferences, issus d'agences sociales de l'Etat, des unites de police et des bureaux des procureurs. REsultats: La plupart des participants interrogEs ont estimE que les conferences autour d'un cas spEcifique Etaient utiles, rencontrant leurs objectifs et influenqant le suivi de leurs cas. Conclusions: Les conferences semblent avoir Et6 utiles. Bien qu'elles aient 6tE associEes ~ quelques dEsavantages pour les professionnels impliquEs et pour I'hEpital sur le plan financier. Ces dEsavantages ne present pas lourd dans la balance par rapport aux bEnEfices potentiels pour les enfants, les families et les participants de l'hEpital. RESUMEN Objetivo: Aunque la literatura ha descrito con fYecuencia los equipos comunitarios intersectoriales de protecci6n infantil, puede que lestos equipos no satisfagan las necesidades de las agencias/servicios de investigaci6n, cuando los nifios/as son hospitalizados en centros medicos de atenci6n terciaria alejados de sus hogares. A veces, las comunidades donde viven estos nifios/as no tienen equipos suficientes, o la informaci6n que se requiere es muy tEcnica. Este artfculo describe y evalfia reuniones multisectoriales ad hoc, en las que participan diferentes miembros del hospital y de las agencias/servicios comunitarios. Cada reuni6n se dedica a un 6nico nifio/a hospitalizado a causa de las sospechas de que ha sido vfctima de abuso. M~todo: Los autores de este estudio elaboraron un cuestionario, que fue administrado telef6nicamente a 22 profesionales de agencias/servicios sociales estatales, policfa, y fiscal/a, que habfan participado en este tipo de reuniones. Resultados: La mayoria de los sujetos entrevistados sefialaron que las reuniones de caso habfan sido fitiles, habian cumplido sus objetivos, y habfan influido en 1o que hab/a pasado con sus casos. Conelusiones: Las reuniones parecen haber sido 6tiles. Aunque presentaban algunos inconvenientes para los profesionales implicados en elias y para el hospital que las organizaba, los inconvenientes pareclan compensarse con los beneficios potenciales para los nifios/as, las familias, los participantes en las reuiones, y para el hospital.