Double dilemma

    Vicki Whitfield talks to Mike George about how she approached a
    case involving a mother with parenting problems and her twin
    teenage daughters, one of whom is profoundly disabled while the
    other exhibits very challenging behaviour.

    Messy, and apparently intractable situations are part and parcel
    of many frontline social workers’ caseloads. To work effectively
    staff usually have to employ persistence and often a degree of
    professional dexterity, plus an ability to live with dilemmas and
    uncertainties.

    They may also be potentially high-risk situations, so risk
    assessment and management is a continuous feature of the work.

    All of these factors have featured heavily in Vicki Whitfield’s
    work with Florence Brown (not her real name) and her twin teenage
    daughters.

    All three have significant needs and the family situation is
    tense and risky. Brown has for many years appeared to be unable or
    unwilling to parent adequately, which has put one of her daughters,
    who is profoundly disabled, at increasing risk. Meanwhile, Brown’s
    relationship with her other daughter is dysfunctional to say the
    least, as the daughter exhibits very challenging behaviour towards
    her mother, and exerts considerable control over her.

    The family has been supported by social services for many years,
    and Brown has been offered a range of services, such as the
    provision of hoists and other aids and training in their use, and
    home care assistance. But despite this there has been no
    appreciable improvement.

    About a year ago Whitfield, who has a specific remit for
    disabled children, took over the case, because Brown’s inadequate
    parenting, and the other daughter’s behaviour were leading to an
    increase in the risks facing the disabled daughter.

    Whitfield explains that despite numerous attempts to train and
    give advice to the mother she still appeared unable or unwilling to
    use proper handling techniques when dealing with her disabled
    daughter, putting her at risk of injury. In addition, she did not
    accept advice on how to stimulate her.

    Meanwhile, the other daughter had begun to associate with a
    group of young people who showed no concern about the need to
    protect her sister. This situation was becoming potentially
    serious, as more of them began to visit the family home at all
    hours, unsupervised, and sometimes leaving the front door open, she
    says.

    In addition, visiting occupational therapists and
    physiotherapists noted that some of the disability equipment had
    been damaged, and that the family’s Motability-financed car had
    been rendered unusable. Whitfield had been trying to engage with
    Brown, but says that she was often not available, and that when she
    was, she always avoided dealing with the consequences of her
    actions and relationships with her daughters. So Whitfield convened
    a meeting of all the professionals involved, to focus on their
    concerns about the family. “Basically, we agreed about the physical
    and emotional home environment, and the mother’s neglect of her
    profoundly disabled daughter’s needs,” she says.

    They also agreed that Whitfield should start searching for a
    suitable residential placement for the disabled daughter, and after
    consultations within social services she began to do so.

    “My manager and I then met with the mother to explain why we
    were taking this step, and to explain our duty to protect the
    child. Meanwhile, because of the other daughter’s increasing
    involvement with a peer group who abused alcohol and who appeared
    to be moving towards an offending lifestyle, I contacted the youth
    offending team and the police’s family unit,” she adds.

    Then the housing department informed Whitfield that because of
    the activities of this group of teenagers, they were on the brink
    of serving the mother with a notice warning her that if the
    situation did not improve, proceedings could be taken to evict
    her.

    This was followed by the police telling her that they had found
    stolen property in the family’s home. Consequently, she and her
    manager made more attempts to persuade her to take seriously her
    duty to care for her children, but she always refused to listen or
    act. As a result, the twins were placed on the child protection
    register, on the grounds of severe neglect, and a lack of adequate
    parenting.

    Brown then attempted suicide, and Whitfield and her colleagues
    decided they had no option but to accept the one offer of a
    residential placement which she had received by this time, and
    urgently. “I had hoped to be able to explore other residential
    possibilities, but there was absolutely no time available, for
    example it would have taken time to arrange aids and training for
    foster carers,” she explains.

    So far, the placement appears satisfactory, though Whitfield
    continues to monitor her progress. She is also starting to explore
    a supported living option for the daughter with behavioural
    problems, because, she says, when she is away from her mother her
    behaviour improves dramatically. “It has been striking how her
    difficult behaviour occurs almost solely in the context of her
    relationship with her mother. I suspect that what started as
    sibling rivalry and attention-seeking behaviour escalated over the
    years, though the relationship between this and her mother’s
    inadequate parenting is not clear.

    “This case has highlighted major dilemmas. Firstly, while it
    might seem self-evident that the twins were suffering from neglect,
    it is not a straightforward issue, and I had to check carefully
    with my colleagues from other agencies before starting child
    protection procedures on these grounds. Secondly, all three have
    significant and intertwined needs, but in the end my first duty was
    to protect the daughter who was most at risk; although the
    prognosis and outcomes could have been very different if these
    long-term problems had been tackled earlier,” she concludes.

    Case notes

    Practitioner: Vicki Whitfield.

    Field: Social worker in a children and families team.

    Location: Cambridgeshire social services.

    Client: Florence Brown (not her real name) is in her forties,
    and has twin daughters in their mid-teens. One daughter has
    profound disabilities, the other has substantial behavioural
    problems. Brown and her daughters have been known to social
    services for many years, and numerous interventions have been made
    over the years, particularly, but not solely, to support the
    disabled daughter.

    Case history: Whitfield, who has a specific remit for disabled
    children, started work with the family a year ago, when concerns
    were increasing about the safety and well-being of the disabled
    daughter.

    Her mother seemed unwilling or unable to parent adequately,
    while her other daughter’s behaviour was indirectly putting her
    sibling at risk.

    Despite home carers assisting the disabled child, there were
    visible signs of neglect in the family home.

    Whitfield, with other professionals, arranged for an assessment
    of the mother, but there was no clear conclusion about the reasons
    for her inability to parent, or her unwillingness to take
    professionals’ advice about how to keep her disabled child safe.
    Whitfield began searching for a residential placement for this
    daughter. Meanwhile, both children were placed on the child
    protection register. Brown then attempted suicide, so an emergency
    placement was found for disabled daughter, and after urgent
    inquiries by Whitfield, a suitable residential placement was found
    for her.

    Dilemma: All three members of the family had significant needs,
    but priority had to be given to the child who was most at risk.

    Risk factor: If the disabled daughter had continued to live at
    home, the risks to her health and safety, and development, would
    have almost certainly escalated further.

    Outcome: The disabled daughter is now safe.

     

    Arguments for risk

    The family received services from occupational therapists,
    physiotherapists, a paediatrician, home care staff, and Whitfield,
    so there was continuous monitoring.

    Brown had sisters who kept in close contact, although they were
    frustrated about their inability to improve the situation.

    Now that the disabled daughter is no longer in the home, it is
    possible that the relationship between the other daughter and her
    mother might improve.

    However, the other daughter tends to exhibit challenging and
    disruptive behaviour mainly when she is with her mother.

    Brown has very low self-esteem, and intensive self-assertion
    work with her might enable her to improve her parenting.

    Arguments against risk

    Brown has consistently, over many years, avoided issues
    concerning her parenting skills, and has also been unable or
    unwilling to utilise the handling, parenting and other skills she
    has been taught.

    Similarly, she has for many years disengaged from interventions
    designed to support and care for her disabled daughter, and appears
    to have no insight into the risks her behaviour posed.

    She has effectively handed over control within the family to her
    other daughter, and so has few means of protecting either herself
    or the twins.

    She has refused help offered by members of her wider family, and
    by all the professionals with whom she has been in contact.

    She did not appear to react when told that her daughters were
    being placed on the child protection register, nor when one of them
    was placed in residential accommodation.

    The other daughter appeared to have no insight into, or concern
    about the risks her behaviour posed to her sister.

    Her destructive behaviour appears to be entrenched in the
    family’s dynamics.

    This daughter is in danger of adopting an offending
    lifestyle.

    Independent comment

    It is now widely recognised that disabled children are at
    increased risk of abuse and neglect, writes David Miller. This
    family highlights the potential complexity of risk assessments
    involving disabled children. Behaviour, mood and even injuries are
    sometimes presumed to be a consequence of the child’s impairment in
    the absence of a more considered evaluation.

    Challenging behaviour can be seen as a problem to be contained
    rather than as a consequence of underlying causes, including
    possible abuse.

    Professionals need to disentangle issues that arise from a
    child’s impairment from those of their social and emotional
    situation. Over-emphasis on the provision of practical support to
    maintain a disabled child with their family can shift the focus
    away from the child’s welfare, especially their emotional needs.
    This can lead to a delay in the early recognition of abuse or
    neglect. In this family the mother’s attitude needs to be seen in
    the context of the child’s emotional as well as physical needs.

    Direct work with disabled children can significantly inform an
    assessment of risk although the views and experiences of disabled
    children are frequently not sought. This represents a challenge to
    professionals as a level of communication can usually be achieved
    through careful planning, creative thought and time.

    Network meetings can provide an essential mechanism for
    information sharing, identification and clarification of areas of
    need and concern. The pooling of knowledge from a potentially wide
    range of professionals and other support staff will provide a
    context within which individual concerns can be placed.

    Difficulties that are frequently encountered in locating
    suitable placements for disabled children should not be allowed to
    compromise any risk assessment. Disabled children have a right to
    protection and to fulfil their full potential.

    David Miller is project manager, services to disabled
    children and their families at the NSPCC.

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