Stress responses and decision making in child protection workers faced with high conflict situations

Abstract

Introduction

The assessment of children at risk of abuse and neglect is a critical societal function performed by child protection workers in situations of acute stress and conflict. Despite efforts to improve the reliability of risk assessments through standardized measures, available tools continue to rely on subjective judgment. The goal of this study was to assess the stress responses of child protection workers and their assessments of risk in high conflict situations.

Methods

Ninety-six child protection workers participated in 2 simulated scenarios, 1 non-confrontational and 1 confrontational. In each scenario, participants conducted a 15-minute interview with a mother played by a specially trained actor. Following the interview, the workers completed 2 risk assessment measures used in the field at the time of the study. Anxiety was measured by the State-Trait Anxiety Inventory at baseline and immediately following the completion of each interview. Physiological stress as measured by salivary cortisol was obtained at baseline as well as 20 and 30 minutes after the start of each interview.

Results

Participants demonstrated significant stress responses during the 1st scenario, regardless of whether the interview was confrontational or not. During the second scenario, the participants did not exhibit significant cortisol responses, however the confrontational interview elicited greater subjective anxiety than the non-confrontational scenario. In the first scenario, in which the workers demonstrated greater stress responses, risk assessment scores were higher on one risk assessment tool for the confrontational scenario than for the non-confrontational scenario.

Conclusion

The results suggest that stress responses in child protection workers appear to be influenced by the novelty of a situation and by a parent's demeanor during interviews. Some forms of risk assessment tools appear to be more strongly associated than other with the workers’ subjective and physiological stress responses. This merits further research to determine which aspects of risk assessment tools are susceptible to the emotional elements of intake interviews.

Introduction

Throughout the western world, child protection services are struggling to manage the overwhelming number of reports of child abuse and neglect. In the US alone, there were almost 2 million investigations for child maltreatment in 2008 (USDHHS, 2010). Concurrent with the high demand for protective services investigations, there has been a rising public concern that children at risk are not adequately protected from abuse and violence. Recent years have been fraught with high profile inquiries throughout North America, Europe, New Zealand and Australia into the deaths of children under the supervision of child protection services and attempts to hold child protection workers and their organizations responsible for the abuse and deaths of children through the criminal and civil courts (Alexander and Alexander, 1995, Kanani et al., 2002, Mansell, 2006, Munro, 2005, Regehr et al., 2002b).

It is not surprising that child protection services throughout the western world are moving towards highly standardized risk assessment models in an effort to ensure that children are safe from harm and that clinical decisions are based on the best available evidence (Camasso and Jagannathan, 2000, DePanfilis and Zuravin, 2001, English and Pecora, 1994, Johnson and L’Esperance, 1984). The assumption of standardized risk models is that the provision of systematic checklists will result in uniform assessments of risk to children, thereby allowing workers to consistently ensure their safety. This belief rests on the premise that all workers assess situations and complete measures in the same manner. What is not clear is the degree to which professional judgment fluctuates based on contextual factors in any given situation, such as the distress (subjective and physiological) experienced by the worker in response to the situation (Gambrill & Shlonsky, 2000).

Risk assessments made by child protection workers often occur during high stress encounters. Protection workers enter family homes in response to a report alleging suspected abuse or neglect. They must confront parents with the allegations, while simultaneously assessing their validity (Mansell, 2006). Thus, the influence of acute stress responses in the face of high stress confrontations is a critical issue to consider in child protection and the assessment of future risk of harm. Considerable data exist that the high conflict situations that child protection workers encounter frequently lead to threats of violence (Littlechild, 1995, MacDonald and Sirotich, 2005, Newhill, 1996, Rey, 1996). For instance, a previous study of 175 child protection workers in a large urban agency in Canada revealed that approximately 20% of staff had been victims of assault on the job and almost 50% of staff had received verbal threats (Regehr, Leslie, Howe, & Chau, 2005). A large national survey in the United States revealed that 67.7% of social workers in child protective services experienced verbal abuse, and 38.5% were physically threatened (Jayaratne, Croxton, & Mattison, 2004). This exposure to threats and violence has far reaching effects on the emotional and mental health of workers and on the functioning of the organization (Littlechild, 2005, Regehr et al., 2002a, Regehr et al., 2004).

Workers’ ability to make competent and consistent judgments may be influenced by the perception of personal risk experienced in any given clinical context. Horwath (2007), in a study of social workers in England required to make decisions about child neglect, suggested a number of individual factors that may contribute to disparate decisions regarding risk. These factors included fear of verbal and physical aggression by the parent; fear of making the wrong decision; concerns about lack of skill to identify child neglect; guilt in breaching client trust; and sympathy for families in situations of hardship.

Researchers in other fields have observed that people's interpretation of the world around them tends to reflect their current emotional state. Both state and trait anxiety, even when mild, are associated with an increased likelihood of interpreting ambiguous stimuli (facial expressions, social situations, heard homophones [“tear” vs. “tier”]) as threatening (Blanchette and Richards, 2003, Richards et al., 2002). In addition to this bias in interpretation of ambiguous information, individuals demonstrate a more rapid detection of and a preference towards information that is congruent with their current mood (Dolan, 2002, Nabi, 2003, Niedenthal and Setterlund, 1994). For example, if a person is experiencing anxiety in a social situation, that person will be more attuned to and will be quicker to detect other people's negative expressions and behaviors. Finally, emotions also influence people's risk taking tendencies. For example individuals in depressed moods are significantly less willing to take risks than are individuals in neutral or positive moods. In fact, they appear to assess the risks in a particular situation as being higher than do individuals in neutral or positive moods (Yuen & Lee, 2003).

Much of the work to date on the effects of emotions on risk perceptions have been focused on anxiety. In the stress literature, the physiological response to stress has emerged as having an important effect on cognitive functioning. When individuals are faced with situations that are appraised to be dangerous or as outweighing their resources, a very specific biological system (the hypothalamic-pituitary-adrenal or HPA axis) is activated. This results in the increased release of the hormone cortisol in the blood, which is then diffused to the saliva and excreted into the urine. Increased cortisol production is most likely to occur when stressors are uncontrollable, ambiguous, novel, of long duration, or contain an element of psychosocial evaluation (Kemeny, 2003). Cortisol elevations have been associated with impairments in verbal, social and declarative memory and in selective attention (Dickerson and Kemeny, 2004, Takahashi et al., 2004). This suggests that a stress response experienced by workers when assessing violent families and children at risk may influence their appraisal of risk for the child. However, there has been no study directly aimed at investigating the relationship between cortisol stress responses and risk assessments.

The goal of this project was to assess the stress responses of child protection workers and their assessments of risk when exposed to confrontational parents during a simulated inquiry into the possible abuse of a child. Studying the effects of stress in the natural work environment is particularly challenging for practical and ethical reasons. First, stress responses in the natural setting are difficult to predict, and there are many confounding factors in the real world setting that make it difficult to isolate the effects of stress. Second, it would be unethical to manipulate workers’ stress levels as they perform actual risk assessment purely for the sake of research. As such, we have opted to use high fidelity simulation, with actors trained to portray realistic parents, for the purposes of this study. Simulation has been used quite consistently in the medical setting to study the effects of acute stress on performance, and the levels of subjective and physiological stressed induced in these studies (Harvey, Nathens, Bandiera, & LeBlanc, 2010) are within the range of those that are inducted in the laboratory setting (Lupien et al., 1997). In this study, we hypothesized that both subjective (anxiety) and physiological (cortisol) stress responses of workers would be greater in confrontational than in non-confrontational interviews with simulated parents. Secondly, we hypothesized that the workers would make higher assessments of risk when exhibiting stress responses.