“You can make all the referrals that you wish…” Menka Tsantefski

“You can make all the referrals that you wish…” Menka Tsantefski University of Melbourne Department of Social Work

Acknowledgements The University of Melbourne, Department of Social Work • Dr. Lynda Campbell • Professor Alun C. Jackson • Professor Cathy Humphreys The Royal Women’s Hospital, Women’s Alcohol & Drug Service: • Veronica Love • Antoinette Amy • Mary-Catherine Tobin • Sue Krzanich • Victorian DHS, Child Protection Service Staff • The twenty-women who participated in this study

Infants within the VictorianService System • Victoria receives approximately 4,500 annual notifications of infants under 2 years of age • At least 50% of notifications involve parental substance-misuse • 32% of these mothers report drug use during pregnancy • In the absence of other concerns, substance use is insufficient grounds for notification to Child Protection (CP) in Victoria • Victoria has a complex service system with diversionary strategies to prevent entry to CP

“Who’s Holding the Baby?”: Child Death Inquiry Analysis Report2000 • VCDRC examined 28 deaths of infants known to Child Protection (CP) from 1995 to 1999 • 23 under one year; remaining 5 between one and two years of age • Role of broader health sector and linkages to CP of particular concern; finding prompted analysis of the intersectoral relationship between Maternity Services and CP • Evidence of multidisciplinary involvement • The critical coordinating role was missing • Responsibilities not clarified • Referrals not followed through • Lack of protocols led to poor outcomes

VCDRC findings 2001-2008: Family and infant factors • Approximately 50% of deaths occurred in infants under six months • Most deaths occurred in the investigatory stage or shortly after case closure • Co-occurring familial factors present in the majority of cases: • parental substance-use (44%) • mental illness (44%) • domestic violence (88%) • and transience • A pattern of women resuming relationships with violent men is evident

Identification of High Risk Infants • Early identification reduces crisis driven intervention • Improves case planning including alternative pathways to service provision • Particularly difficult in prenatal notifications based on prediction of future parenting problems, particularly for first-time parents • Obstetric services play a critical role in early identification and risk assessment

The Women’s Alcohol & Drug Service(Women’s ADS) • The major provider of services to substance-dependent women in Victoria • Obstetric care including pharmacology • Counselling • Frequent appointments/consistent staff • Close collaborative links with CP High Risk Infant (HRI) program • Approximately 50% of women have CP involvement (pre or postnatal notification)

The Research Questions The Women’s ADS sought to know: • The outcome of notification to CP • The factors in ‘a good outcome’ The two questions combined: • What (formal and informal) support do women accessing the Women’s ADS receive?

Study Aims • Examine the referral process between Women’s ADS & CP • Report the extent of shared risk assessment between the Women’s ADS and CPS • Evaluate collaboration between Women’s ADS and CP • Analyze the service response at a critical point in time: discharge from hospital to home or to alternative care • Review pathways to service provision

The Study Aims Cont. • Identify the primary sources of support to substance-dependent women • Identify the type of support considered most helpful by mothers • Report the helpfulness of services from the perspective of service users • Examine the lived experience of substance-dependence and early parenting • Examine the variables in ‘a good outcome’ for mothers and infants

Methodology • Longitudinal Study in 3 Phases • Infant age 6 weeks; 6 months; and1 year • Data mining of the Women’s ADS Client Assessment Tool: demographic data, maternal, infant and family variables • Structured interview with Women’s ADS (phase 1) • Structured interviews with CP staff (all 3 phases) • Interviews with mothers (and fathers) (all 3 phases) • Administration of the Norbeck Social Support Questionnaire and the Social Network Map

Women’s ADS: Risk assessment Decision making Extent and quality of collaboration DHS CP: Legal outcomes Service provision outcomes Extent and quality of collaboration Surveys: Based on Protocol between Drug Treatment Services and DHS Child Protection and Juvenile Justice Branch (2002)

Methodology cont. Interviews with mothers: • Experience of obstetric care • Service use • CP involvement • About the baby • The social network • Drug use and parenting • Domestic violence

Participant recruitment • 22 women recruited from Women’s ADS over six month period • 1 baby died (SIDS) before first interview • 1 baby transferred to RCH (not included in study) • Data available for 20 women and infants • 10 notifications by Women’s ADS • 8 postnatal; 2 prenatal (4 prenatal meetings held) • 2 women had pre-existing CP involvement • Total number of women with CP at Phase 1=12 • Total number of women with CP at study end =15

Risk Assessment-Women’s ADS Reasons for notification to CP by frequency: • Continuing drug use • Domestic and other violence • Unstable accommodation/homelessness • Children out of mother’s care • Lack of support • Parenting concerns • Mental health issues Note: With 1 exception, all mothers with older children had prior CP involvement (n=8)

Collaboration: From Women’s ADS Perspective • Confirmation of outcome of notification forthcoming in all cases • Feedback ranged in quality from ‘good’ and ‘sufficient’ through to ‘excellent’ • I described as ‘shocking’ (contact with mother limited to telephone interview) • In all cases, CP informed Women’s ADS of planned action • “DHS put really good supports in place. They really tailored the action plan to the women’s needs; I think it’s great they were so flexible”.

Collaboration: From CP Perspective • All referrals considered timely • Usefulness of information and quality of collaboration ranged from: not good (1) to excellent (3) • “Clear direction for planning was provided. This enabled DHS to work collaboratively with parents instead of a crisis model”. • Liaison limited to infant discharge from Royal Women’s Hospital

Collaboration: Women’s ADS & CP - Mothers’ Perspectives • “It seemed like they were working against me, I think. Like everybody was ganging up on me. That’s how I felt, because I wasn’t really informed about the process; it happened behind my back”. • “They worked rather well together. We had to meet (CP worker) before she was born. She’s nice…anything I need, I ring her up”.

Women’s ADS referrals: Housing (9) Family support (8) Financial aid (6) Domestic violence (4) Drug/alcohol counselling (5) Phase 1 service use 4 3 0 0 1 (linked to pharmacotherapy) Service Provision Outcomes

Service use at Phase 1 • Patter of referrals mirrored frequency of issues recorded on Women’s ADS Client Assessment Tool • Most referrals did not result in continuous service provision • Little use of MH or AOD beyond perinatal period • AOD referrals generally for pharmacotherapy and did not result in other treatment • Numerous referrals for housing and financial assistance to meet women’s immediate survival needs

Phase 2 Housing 2 Family Support 4 Financial aid 2 D/V counselling 1 D/A counselling 3 Note: all women accessing D/A and D/V services had current or historic CP involvement Phase 3 Housing 2 Family Support 4 Financial aid 2 D/V counselling 1 D/A counselling 1 Note: 2 women lost to follow-up after infant removal by CPS Phases 2 & 3 Service Provision

Referrals to Early Parenting Centres: Phases 2 & 3 Referrals by CP Other referral I referral to early parenting centre by community midwife • Parenting Assessment Skill Development Service (PASDS) (6) • In-home (1) • Banksia House X 2

Service use at 12 months • Service use not sustained by majority of women • Service use higher among women with current or historic CP involvement • Most women did not maintain engagement with AOD or DV services regardless of CP involvement • 3/4 women attending family support programs had CP involvement • Unanimous acceptance of the MCHS • Prescribing doctors often only other professional to see infants

Why don’t they engage? • Lack of self-determination • Unresponsive to women’s needs • Assessment & support or more monitoring? • Poor collaboration and service unavailability • Stigma, guilt and shame • Fear of scrutiny and infant removal

Referrals from mothers’ perspectives • “I asked for relationship counseling; they didn’t do that. I asked for drug counselling; they didn’t do that. They could have made the referrals. They could have made the suggestions”. • “Well, they (CP) were supposed to link me with support services…I couldn’t have one dollar to get up and do it. I was too sick and into the dope at that time to walk up there. I don’t remember the word they called me; they called me lazy that I didn’t go there, right, and they were too shit frightened of Cameron to come over”.

Contributing professional factors • Poor communication and collaboration, especially after discharge from hospital leading to delays and gaps in service provision • Lack of role clarity and responsibilities • Minimal use of case conferences and case planning after pre-birth notifications • Lack of family-centred practice especially after infant removal • Exclusion of and difficulty in engaging men • Full circle to Who’s Holding the Baby Report

From a HRI Manager • “Unfortunately with services, you can make all the referrals that you wish, but they want to hear directly from the client themselves…Those services in the community don’t actively outreach. They are dependent upon the client reaching out to them for services and support”.

What do mothers want? • Financial assistance • Improved housing • Respite care • Referral to other services • Counselling esp. home-based • AOD services sensitive to women as mothers (counselling, detox, rehab) • Parenting education for self & partner

Concluding comments • Traditional segregation of adult-focused e.g. AOD, MH, DV and infant/child focused e.g. CP & FS, continues to characterize the service response • CP is an important gateway to AOD treatment (Jeffreys et al, 2009) • Study findings confirm anecdotal reports that engagement by Australian women in specialist AOD services is not sustained in the postnatal period (Butler, 2007) • Need professional collaboration with assertive outreach and relationship-based practice to engage parents, family and other network members

Thank you

Poor collaboration and service unavailability • “It’s getting to the point where I don’t really need them”. • It’s taking so long. Like, it’s causing stress between Anton and me.

Fear of scrutiny and infant removal • “I haven’t accessed services perhaps because I think they’ll want to get DHS involved or anything like that could happen. They’ll start saying I’m a bad mother”. • “What I really need is, I’d like to be upfront with Human Services but I’m too scared they’re going to take him away. I need to go into detox but I don’t want to tell them because I don’t want them to take him away because I know that once they get him they won’t give him back”.

Collaboration-Family Support: Mothers’ Perspectives • It’s a little bit scary ‘cause I’ve heard her talking on the mobile phone, and yeah: she’s like a spy for the Human Services, so I don’t trust her; and I’ve heard her talk about other families on the phone.

Lack of self-determination • “They (Women’s ADS) did push me to go there, didn’t they? Yeah, you have a counsellor but I haven’t, for some reason, I’ve lost touch with him, but while the baby was in hospital, he was ringing me, and stuff”. • “I have to go for the next nine months. It doesn’t do me any good. It sets me off. I start thinking about it more”.

Responsive family support • “We go swimming and whatever I need to do; shopping or what ever it is. (Worker) visits about once a week. She might say, ‘Okay, we’ve got to make an appointment to take her to day care’: two days a week; that’s all I need. I’ve got one support letter for a housing transfer. They gave me a voucher to buy clothes from the op-shop. We’ve done a parenting course with them and everything like that, you know. I’ve benefited from it”.

Phase One Referrals and Access

“You can make all the referrals that you wish…” Menka Tsantefski