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RE: good ! question?
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<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>Margaret,<o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>You raise two really interesting points. One is the issue of
what we use for outcomes (in this instance, referrals, substantiations and
removals ---we try to use injury when we can, but most systems don’t
reliably collect that information). The reason we always test tools on each of
these measures is that each one has limitations with respect to how “real
world” they really are. If we had knowledge certain that abuse/neglect
occurred we’d only need the one outcome measure. Lacking that certainty,
if we relied solely on re-referrals we’d include as “recurrence”
many families who did not maltreat after the assessment, but were reported. If
we relied solely on substantiation, we’d miss families where maltreatment
occurred, but could not be substantiated. There is plenty written and discussed
these days about how substantiation decisions can vary pretty wildly for
reasons that have little to do with whether a child was maltreated. Removals as
an outcome suggest a pretty good indicator not only that something happened,
but that it was severe enough to result in removal. There are false positives
and false negatives in each outcome. Each is imperfect, but when the risk level
has a strong correlation with each, it helps mitigate the potential bias in any
one outcome measure. <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>The rates of re-referral, re-substantiation and removal within
each risk category will always decline from measure to measure: there will be
more referrals than substantiations and more substantiations than placements.
What is interesting is that the relative proportions also seem to vary by risk,
with a higher ratio of substantiations to referrals and removals to
substantiations in high risk groups. For example… <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>Low risk has a re-referral rate of 28%, re-substantiation=9% and
removal=.6%. So, for every 100 low risk families someone reports, about 32 will
be substantiated and less than 1 will be removed.<o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>Very high risk has a re-referral rate of 74%, re-substantiation=46%
and removal =22%. So, for every 100 very high risk families someone reports, 62
will be substantiated and almost 30 will be removed. <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>This suggests that higher risk families not only have increased probability
of ANY future maltreatment, but also that it is more likely to be severe. <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'>The 22% removal rate among very high risk families might strike
us as low unless we think about risk and safety as distinct notions. The risk
tool is just one component of decision making, and it’s our position that
a child should never be removed based on risk. When there is high risk, there
is an opportunity to provide services that will reduce risk. Safety assessment
should be the basis for removal decisions (and even there, upon identifying a
threat to safety, the first consideration is whether an in-home safety plan can
be developed with the family to mitigate the danger). There is a correlation
between safety and risk, as we would expect. But risk alone can be addressed
with services. <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:11.0pt;font-family:"Calibri","sans-serif";
color:#1F497D'><o:p> </o:p></span></p>
<div>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>Raelene Freitag, MSW, Ph.D.</span><span style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>Director</span><span style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>Children's Research Center</span><span style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>426 S. Yellowstone Dr. #250</span><span style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>Madison, WI 53719</span><span style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal><span style='color:#1F497D'> <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>608-831-1180<o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:10.0pt;font-family:"Arial","sans-serif";
color:#1F497D'>www.nccd-crc.org<o:p></o:p></span></p>
<p class=MsoNormal><span style='color:#1F497D'> <o:p></o:p></span></p>
<p class=MsoNormal><span style='font-size:7.5pt;color:#1F497D'>Please do not
send any identifying or confidential information (such as names,
birthdates, social security numbers) via e-mail. It is possible
for third parties to intercept information transmitted in
an e-mail. Identification numbers (such as case or
referral numbers) may be included where necessary. Intercepting persons
cannot use these numbers to identify a client unless they have access
to the host application or database.<o:p></o:p></span></p>
<p class=MsoNormal><span style='color:#1F497D'> <o:p></o:p></span></p>
</div>
<p class=MsoNormal><span style='color:#1F497D'> </span><span
style='font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497D'><o:p></o:p></span></p>
<div>
<div style='border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0in 0in 0in'>
<p class=MsoNormal style='margin-left:.5in'><b><span style='font-size:10.0pt;
font-family:"Tahoma","sans-serif"'>From:</span></b><span style='font-size:10.0pt;
font-family:"Tahoma","sans-serif"'> bounce-2250391-6833790@list.cornell.edu
[mailto:bounce-2250391-6833790@list.cornell.edu] <b>On Behalf Of </b>M. W.
Sullivan<br>
<b>Sent:</b> Wednesday, January 16, 2008 7:34 AM<br>
<b>To:</b> Child Maltreatment Researchers<br>
<b>Subject:</b> Re: dumb question?<o:p></o:p></span></p>
</div>
</div>
<p class=MsoNormal style='margin-left:.5in'><o:p> </o:p></p>
<div>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'>Unless I'm mis-reading. This graph
seems to show that increasing risk on the assessment is associated with
incrementally more referrals and nearly doubles the rate of substantiation from
moderate risk. Unclear whether highest risk results in more
home removal---were these differences significant?</span><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'> <o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'>It seems that this data is useful to show
that reffals and substantiation rates are valid--ie reflect some
"real-world" status. Home removal is more equivocal---why isn't
the rate much higher?</span><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'> <o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'>Margaret W. Sullivan, Ph. D.<br>
Professor & Associate Director<br>
Institute for the Study of Child Development/Pediatrics <br>
UMDNJ-Robert Wood Johnson Medical School<br>
97 Paterson Street<br>
New Brunswick, New Jersey 08903-0019<br>
"The approach to the problem is more important than the
solution." <br>
Telecommunications: <br>
Phone: 732-235-7164 FAC:732-235-6189 <br>
Link: www2. umdnj.edu/iscdweb/index.html<o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'> <o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'><br>
<o:p></o:p></p>
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<div>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'>----- Original Message ----- <o:p></o:p></span></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in;background:#E4E4E4'><b><span
style='font-size:10.0pt;font-family:"Arial","sans-serif"'>From:</span></b><span
style='font-size:10.0pt;font-family:"Arial","sans-serif"'> <a
href="mailto:RFreitag@mw.nccd-crc.org"; title="RFreitag@mw.nccd-crc.org">Raelene
Freitag</a> <o:p></o:p></span></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'><b><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'>To:</span></b><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'> <a
href="mailto:child-maltreatment-research-l@list.cornell.edu";
title="child-maltreatment-research-l@list.cornell.edu">Child Maltreatment
Researchers</a> <o:p></o:p></span></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'><b><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'>Sent:</span></b><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'> Tuesday, January 15, 2008 12:00 PM<o:p></o:p></span></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'><b><span style='font-size:10.0pt;
font-family:"Arial","sans-serif"'>Subject:</span></b><span style='font-size:
10.0pt;font-family:"Arial","sans-serif"'> RE: dumb question?<o:p></o:p></span></p>
</div>
<div>
<p class=MsoNormal style='margin-left:.5in'><o:p> </o:p></p>
</div>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:11.0pt;
font-family:"Calibri","sans-serif";color:#1F497D'>Sheri,<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:11.0pt;
font-family:"Calibri","sans-serif";color:#1F497D'>It’s a good question.
The term “risk” is often used quite loosely, and is used rather
impressionistically. Sometimes it has likert-type scale definitions or anchor
points so there is a relative increase or decrease. Alternatively, there are
actuarial risk instruments that have very specific outcome data for families in
various risk levels. For example, a recent study of over 5500 California family
risk assessments conducted by workers in the field was used to construct a risk
assessment instrument that creates 4 levels of risk. The known rates of each
outcome measured are presented below:<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><!--[if gte vml 1]><v:shapetype
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font-family:"Calibri","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
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<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>Raelene Freitag, MSW, Ph.D.</span><span
style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>Director</span><span
style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>Children's Research Center<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>So, when a worker in California
describes a family as high risk, they are saying that the family shares
characteristics with families that are very likely to be re-referred in the
next two years (74.8%--and often this will occur multiple times), have about a
50-50 chance of having at least one new substantiation, and more than 1 in 5 (22.1%)
will end up in foster care. In contrast, low risk families are unlikely to be
re-referred, more than 90% will not be re-substantiated, and only about half a
percent will end up in foster care. It’s really important to note that
risk assessment is good for classification, but not prediction. It should not
be used as a basis for decisions about whether to remove a child (safety
assessment should be used for that). But a reliable and valid risk tool can be
very effective at identifying families who would benefit from services to
prevent maltreatment. It’s also important to note that we see virtually
the same recurrence –by-risk distribution whether or not the CURRENT
referral is substantiated. It’s helpful to think about serving higher
risk families regardless of whether the current incident is substantiated or
not. <o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>You are completely right about
the importance of balancing statistical information with clinical judgment.
It’s my argument that we can’t ignore the evidence that for some
things like estimating probability of future events simple statistical models
typically outperform human judgment. We also can’t ignore that even the
most robust risk tool can’t predict the future, or take every variable
into account. I encourage our profession to move past “either/or”
thinking about this and take a “both/and” approach. It’s
important to advance our skill at integrating data-driven information such as
risk assessments into the human relationships between worker and family.<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>If you want to learn more about
actuarial risk, you can get several publications, including some of the risk
studies, from our web-site below. Follow the link to CRC, then publications,
and look for risk-related publications there. Best wishes.<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='color:#1F497D'>Raelene
Freitag, MSW, Ph.D.<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>426 S. Yellowstone Dr. #250</span><span
style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>Madison, WI 53719</span><span
style='color:#1F497D'><o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='color:#1F497D'> <o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>608-831-1180<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='font-size:10.0pt;
font-family:"Arial","sans-serif";color:#1F497D'>www.nccd-crc.org<o:p></o:p></span></p>
<p class=MsoNormal style='margin-left:.5in'><span style='color:#1F497D'> <o:p></o:p></span></p>
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<p class=MsoNormal style='margin-left:1.0in'><b><span style='font-size:10.0pt;
font-family:"Tahoma","sans-serif"'>From:</span></b><span style='font-size:10.0pt;
font-family:"Tahoma","sans-serif"'> bounce-2239133-6833790@list.cornell.edu
[mailto:bounce-2239133-6833790@list.cornell.edu] <b>On Behalf Of </b>D F
MCMAHON<br>
<b>Sent:</b> Monday, January 14, 2008 5:10 PM<br>
<b>To:</b> Child Maltreatment Researchers<br>
<b>Subject:</b> dumb question?<o:p></o:p></span></p>
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<p class=MsoNormal style='margin-left:1.0in'><span style='font-size:10.0pt;
font-family:"Tahoma","sans-serif"'>I don't know if it is or it isn't. Child
welfare--in the legal system and in the child welfare system per se--is rife
with terms that indicate scale--degrees of risk (low, medium, high for
example); imminent risk of harm; etc etc.<br>
<br>
To what extent does either the child welfare system or the legal system
quantify these concepts? For example, if a risk assessment indicates high risk
for abuse/neglect (with abuse/neglect definitions including additional
quasi-quantitative concepts pertaining to likelihood of serious physical
or emotional harm as a consequence)--does this basically mean a reasonable
person would have the willies (scale) or that there is actually a range of
probability that can be applied to the risk (e.g. 1% risk of serious physical
or emotional harm)? <br>
<br>
I'm asking not to challenge, but to try to better understand the framework
here--yet it is also the case that 1) human beings are not very good at
assessing degree of risk--there may be consistency, but not necessarily
accuracy--e.g. if you ask people to state the likelihood that X will occur
given Y there are many examples in which groups of people pretty consistently
say the odds are Z even though the odds are actually far greater or less--and
2) perceived risk is affected by sociological factors (e.g. different attitudes
about the risk of germs depending on whether you are talking to a family
running a small dairy farm where the kids are in 4-H and raise rabbits and
chickens, vs. an affluent couple in the suburbs who have one child). <br>
<br>
It strikes me that child welfare in our society entails a pretty significant
tension between a statistical, sort of public-health aspect and an individual
aspect ("if just one life is saved" then all else is justified).
Since I am not a professional or a theoretician in this area are there things
one can read regarding this or are there observations anyone might have? Say,
someone who is knowledgeable (genuinely knowledgeable) about child welfare but
also able to identify underlying philosophical notions and, perhaps, conflicts?
<br>
<br>
(If you understand the question but can state it more clearly, please feel free
to do so)<br>
<br>
Sheri McMahon<br>
<br>
<br>
<br>
<o:p></o:p></span></p>
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