DARE

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2 Developing assessment tools incorporating risk and evidence to support professional judgement in social work Dr Brian Taylor

3 Professional decisions (D) require: 1. Effective engagement of clients & families in assessment (A) 2. Accurate, relevant data about the client & family (A) 3. Analysis of that data so as to make sense of it (using knowledge - E) 4. Deriving pointers regarding the future to inform decisions in uncertainty (R)

4 Assessment tools should support Effective engagement of clients & families in considering risks, values & evidence Gathering & ordering of appropriate client & family data Analysis of this data MORE LATER Decisions in uncertainty regarding future client behaviour & possible service intervention MORE LATER DARE 2010

5 Evidence in Assessment Tools DARE 2010 To what extent do our assessment tools incorporate best professional knowledge? : Research? Theory that has stood the test of time? Best practice in engaging children, clients, families?

6 Risk in Assessment Tools To what extent do our assessment tools give us pointers regarding the future to inform decisions? The best predictor of future behaviour is past behaviour BUT Some people do change markedly Our client & family information is not complete Prediction of human behaviour is far from perfect How will we evaluate client motivation?

7 I n t e g r a t e d Assessment Systems Being developed widely across Britain & Ireland E.g. Single Assessment Process in adult care & CAF & UNOCINI etc in child care AIMS: Assessment proportionate to need Gather information once Capture all relevant perspectives Structure information from multiple sources Simplify access to information Promote integrated professional working Standardise data gathered for service development DARE 2010

8 Integrated Assessment Systems DARE 2010 Aim to integrate wide diversity of processes across health & social care, education, justice, housing etc Benefits in improved client data, inter-professional communication, recording, monitoring BUT How effectively do integrated assessment tools inform professional judgement & decision making?

9 NISAT - an integrated assessment system DARE 2010 Specialist Assessment Contact Screening Core Assessment Complex Assm t GP and Medical Practitioner Report Carer s Support and Needs Assessment

10 A key question DARE 2010 What is the role of the Social Worker if another health and social care professional is the care (case) manager or coordinator of care? In family & child care also: What specialist assessment(s) might Social Workers properly & usefully undertake? Essential element in further development of professional competence & credibility Potential for development of social work profession as expert witnesses

11 Assessing parenting in child protection 1. Systematic literature review of available tools 2. Questionnaires completed by 17 (more interested & enthusiastic?!) Social Workers on each tool they have recently used [included senior practitioners & family centre SWs as well as field work team SWs] 3. Development process with Principal Practitioners & 2 other experienced SWs to compare 1 & 2, to categorise tools & draw out recommendations DARE 2010 Charlene Brown & Brian J Taylor (2008) Tools for assessing parenting in child protection: Literature review and staff survey, Ballymena: Northern Health and Social Care Trust

12 Assessing parenting in child protection DARE 2010 Findings 14 tools in use, as well as various models Particular expertise amongst family centre SWs Wide variety of tools & models used Impressive initiative amongst some professionals Tools in use gave limited support for analysis of the data gathered from children & parents Wider range of tools potentially available: 24 tools for use with children & young people 33 tools for use with parents [3 for both]

13 Categories of tools for use with children & young people (24) to assess parenting Attachment(7) Abuse (3) Behaviour & Development (6) Impact of Events & Trauma (6) Resilience (1) Views of Children (1)

14 Categories of tools for use with parents (33) to assess parenting Abuse & Neglect (5) Attachment (4) Behaviour (2) Change (1) Domestic Violence (1) Family Functioning (3) Parenting (6) Parental Mental Health (5) Social Supports (3) Trauma & Childhood Experience (3)

15 Selecting a manageable range of specialist assessment tools, e.g. Family functioning: genograms & ecomaps Social supports for parents: Arizona Social Support Scale Parenting & home environment: HOME scale Engaging parents re neglect: GRADED Care Profile Vulnerable parents of children with disabilities: Parent Assessment Manual Attachment risks & parent child interaction: CARE Index Change in families: Parental Motivation to Change tool

16 Setting strategic priorities in developing assessment practice? All SWs in Family Support & Intervention Teams should be trained to use tool A to assess B All SWs in Family Centres should be trained to use tool C to assess D Each locality should have at least one Social Worker trained to use tool E to assess F

17 Predicting Harm what can we do & how best can we do it? We want to predict harm so as to focus scarce resources on those most likely to come to harm We particularly want to predict the most serious (and less frequent) harms BUT predicting rare events is particularly problematic

18 Intuitive prediction based on: My own life experience as a child? My own life experience as an adult? Relevant similar cases in my working life? My understanding of research(?!) My understanding of theories (e.g. stigma, attachment, bonding, loss & bereavement)?

19 Limitations to intuitive prediction My own life experiences provide only a limited experience from which to generalise My past and present caseload provide only a limited experience from which to generalise The feedback on the success of my efforts with clients & families is generally limited My perceptions may be influenced by vivid or more recent events, workload pressures, personal crises & pressures My judgements may be unduly influenced by the media, peers, political pressure DARE 2010

20 Developing a more scientific approach to predicting harm in social work IF we knew how often the undesirable event occurred in the past AND the relevant characteristics of the situations where it occurred We could use that knowledge to assist in predicting how often the event might occur in the future = actuarial prediction = method used by insurance companies

21 Risk Factors = The factors that correlate with a particular event [usually an undesirable or harmful event] Re-offending by serious offenders Homicide by people with mental health problems Suicide Admission to long-term nursing home care Child abuse & neglect

22 Risk factors - example DARE 2010 First 4 weeks after disch. from psychiatric hospital male *200 First 4 weeks after disch. from psychiatric hospital female *100 history of parasuicide *10-*30 alcohol abuse *20 drug misuse *20 Samaritan client *20 current or ex-psychiatric patient *10 prisoner *5 doctor *2 farmer *2 unemployed *2 Some suicide risk factors (England and Wales) (Gunnell, 1994)

23 Actuarial [vs Clinical ] Prediction Establishes the base rate of factors known to correlate with incidence of the particular harm Increases reliability & consistency of prediction Increases accuracy of prediction BUT May give a false sense of security Is far from infallible >>

24 Prediction using risk factors Predictive assessment tools are not perfect There are four possibilities: DARE correctly predict the harm (called a true positive because the tool correctly identified the thing that we want to predict); or 2. indicate that harm will not occur, but it does (a false negative); or 3. correctly predict that harm will not occur (a true negative); or 4. indicate that harm will occur, but it does not (a false positive)

25 eg Predicting suicide DARE suicide rate for Northern Ireland : 227 male and 64 female = approx 300 suicides in population of 1.5 million, i.e. 2 in 10,000. Could we use a screening (assessment) tool incorporating risk factors with 90% accuracy to identify these people so as to target services? TOOL: REALITY: Yes harm No harm Total Yes harm No harm 149,970 1,349,730 1,499,700 Total 150,240 1,349,760 1,500,000

26 Limitations to predicting DARE 2010 The problem is not so much the false negatives BUT the false positives where we intervene unnecessarily ISSUES: A false positive = a child taken wrongly from a family, a person wrongly detained or wrongly not detained in psychiatric hospital etc Labelling if there is an issue of stigma Human rights Resources, masking the real referrals Many risk factors are static we can do nothing about them; need to focus on dynamic risk factors

27 An example of actuarial scoring Past sex offences conviction OR 1 to 2 charges 1 2 to 3 convictions OR 3 to 5 charges 2 4+ convictions OR 6+ charges 3 Age Less than 25 1 Victim gender Any male 1 Relationship to victim Any non-related 1 [Thornton tool example courtesy of Martin Calder]

28 A validity test DARE 2010 Score No in group % recidivism at 5 yrs % recidivism at 10 yrs (20%) 4% 7% (31%) 8% 11% (29%) 14% 21% (13%) 25% 37% (5%) 33% 49% 5 52 (2%) 50% 73% Total % 20%

29 Tool validity The scoring system correctly predicts the increase in re-offending Although no confidence intervals are given here, the increase is consistent and large, particularly for 10-year re-offending

30 Knowing your risk factors Using tools predictive of harm We in social work need to learn to understand & use this type of data so as to make better informed decisions Inquiry reports implicitly if not explicitly seem to assume that risk factors will be taken into account by professionals in safeguarding roles Courts & the educated public are increasingly likely to expect this

31 Predicting rare events DARE 2010 Predicting harm in social work is like expecting an insurance company to predict precisely WHICH young drivers will have an accident! BUT REMEMBER that most of the research shows that (actuarial) prediction using risk factors is more accurate than (intuitive) professional judgement THE ISSUE is predicting when the base rate (incidence) is low, not the actuarial vs clinical method The causal routes to extreme harm are varied, so even good (simple) use of risk factors (as by insurance companies) is difficult. Macdonald G & Macdonald K (2010) Safeguarding: A case for intelligent risk management, British Journal of Social Work, 40(4):

32 Prospects for using risk factors in assessment DARE 2010 screening FROM AMONGST THOSE REFERRED will probably be more accurate than attempting to predict from amongst the general population Predicting RE-abuse or RE-offending from amongst previous abusers or offenders is likely to be more accurate than predicting first time events USE risk factors to INFORM current modes of unaided professional judgement

33 Alternative analyses DARE the AIM assessment tool for young people who sexually abuse others 4 domains: - Offence - Developmental - Family or Carers - Environment E.g. Developmental Domain includes resilience factors, health issues, experience of abuse or neglect, witnessing domestic violence, quality of early life experiences, history of behaviour problems, sexual development and interests Morrison, T and Henniker, J (1999) Building a comprehensive interagency assessment and intervention system for young people who sexually harm, in Erooga, M and Masson, H (eds) Children and Young People who Sexually Harm Others: Current Developments and Practice Responses. London: Routledge

34 AIM assessment tool DARE 2010 high strength low concern low strength high strength high concern low strength low concern high concern Each quadrant has established indicators of likely key issues & possible service responses Then identify: - 5 most important strengths - 5 most important concerns - 5 most important unknowns

35 Assessment tools to support analysis Gather & collate data Analyse data Decision-making systems

36 Summary DARE 2010 Integrated assessment systems (A) Much progress; some benefits; some problems Predicting harm (R) Many pitfalls but we must begin to venture Risk factors (E) Need to be knowledgeable Need analysis of data to provide this knowledge Assessment tools (A) Need to appraise & use existing tools more Need to develop tools that support analysis Decisions (D) Need development of R, A, & E

37 Assessment tools as an integral part of D.A.R. & E. to improve professional practice so as to benefit clients & families

38 Key features Links theory to current practice Looks at how to make difficult decisions Tackles issues around risk and judgement Features include critical reflection points and analysis Find out more...

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