Decisions and Disparities: Disentangling Sources of Inequity John D. Fluke, Kempe Center for Children, University of Colorado School of Medicine February 7, 2013 Shubert Center for Child Studies, Case Western Reserve University
Content • Brief Overview of the DME • A Framework for Thinking About Disparities • Decision Making Ecology: Placement Decision Analysis with the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS)
The Decision-Making Ecology Donald J. Baumann, Ph.D. Saint Edwards University Len Dalgleish University of Sterling, UK John D. Fluke, Ph.D. Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine
Overview • Key Issues • The Decision Making Ecology • General Assessment and Decision Making (GADM) and Thresholds • Example Studies
The Continuum of Intervention ASSESSMENT Child protection Screening Assessment Placement Reunification Decisions/Actions • Assessments and decisions are made at key points along the child protection continuum • Each key decision point requires a specific decision and action
Some Key Issues • The Context of Decision-Making in Child Welfare • Child Welfare and the Problem of False Positives • General Research Concerns with Assessment and Decision Making • Making Sense of Feedback and Decision Making Consequences
Making Sense of Feedback and Consequences How do we make progress in integrating and improving clinical/professional judgment in the assessment process? What and whose consequences are we actually most concerned about? What are the best ways to influence decision actions?
DECISION-MAKING ECOLOGY (DME)
Decision Making Ecology (Baumann, Dalgleish, Fluke &Kern, 2011) Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
Decision Making Ecology Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
Case Factors • Type Maltreatment • Pattern of Maltreatment • Risk of Harm • Safety • Child and Family Characteristics
Decision Making Ecology Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
Organizational Factors • Resources and Caseloads • Bureaucratic Distractions • Support & Unit Cohesion • Policy
Decision Making Ecology Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
Decision Maker Factors • Experience • Skills • Values • Comfort with Casework • Orientation (protection vs. preservation)
Decision Making Ecology Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
External Factors • Law • Critical Events • Funding • Community Engagement
Decision Making Ecology Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
GENERAL ASSESSMENT AND DECISION MAKING (GADM) MODEL: THE PROCESS OF DECISION-MAKING
Risk assessment and decision making • In many jurisdictions risk assessment is used as a way to summarise the case information. • How is this assessment turned into a decision about a course of action? • In general, the risk of harm has to be sufficient to warrant taking protective action.
Assessment and decision making are difficult tasks • Assessments and • There are structural decisions are and resource based on constraints, media information that is interest, often unclear, noisy unpredictability of and uncertain. outcomes. • Sometimes made • This is: under time Decision making pressure in a highly under uncertainty. emotional atmosphere.
Crucial points: The general model for assessment and decision making. Separates: The assessment of the situation. From: The decision to something about it. – Qualitatively different factors influence assessment and decision making. Distinguishes: The person ’ s ability to detect the need to take action (how good they are). From: The person ’ s willingness to take action (their threshold).
The Big Problem in Making Decisions Under Uncertainty: An Illustration Using the Receiver Operator Characteristic Curve- Risk Assessment Accuracy Estimate
Research and Risk Assessment What Do We Know about What is Tied to Risk? – Prior History of – Younger children Maltreatment – Domestic Violence – Child Disability – Family Stress – Type(s) of – Lacking Social Maltreatment Supports – Severity of – Inability to Use Maltreatment Resources – Substance Abuse – Provision of Services
Child Welfare and the Problem of False Positives N = 210,642 Sensitivity (true positive) High threshold Low threshold
Effect of Thresholds on False Positives The assessment has an Area Under the Receiver Operator Curve = 63%: Prevalence assumed to be 10%: Applied to 100,000 children LOW THRESHOLD HIGHER THRESHOLD
Assessments and thresholds are influenced by different factors • • The Risk Assessment From Theory, the Threshold derives from case for Action derives from the information on the Child, experiences and history of the Family and the nature the worker. of the current and past – Possible consequences concerns. for the different • Information organized stakeholders. into operationally defined – How the worker values factors. the consequences. E.g. A comprehensive system Dalgleish and Drew (1989)
A General Model for Assessing the Situation and Deciding what to do about it - Dalgleish Assessment Dimension: e.g. Risk or ‘ Level of Concern ’ HIGH Factors Factors Influencing Influencing Assessment Threshold Assessment. Information from for Action Current situation Information from Threshold being Assessed. Experiences and The Case Organizational Factors. Factors) LOW If the Assessment is ABOVE the Threshold , then ACTION is taken. If the Assessment is BELOW the Threshold , then NO ACTION is taken .
The Process of Decision Making: The Threshold Concept High • If threshold low, W 1 needs little evidence Threshold before taking action. W 2 No If threshold high, W 2 needs W 2 W 1 much evidence before Assessment. Assessment. taking action. Yes Even if they agree on the Threshold assessment, W 1 they disagree about taking Low action. Assessed level of risk or need *From Len Dalgleish, 2000
Decision Making Ecology Case Factors Organizational Factors Decision Outcomes Making External Factors Decision Maker Factors Influences Decisions Outcomes
Outcomes/Consequences • Children – Safety – Permanence – Well-Being • Workers/Supervisors – Satisfaction – Turnover – Corrective Actions – Reorganization – Redefinition of Functions • External – Public Anxiety – Media Scrutiny – Legislative Scrutiny
The Continuum of Intervention and Hypothesized Threshold Structure ASSESSMENT Child protection Screening Assessment Services Placement Reunification Decisions & Actions
33 Incidence?
34 Enumerating Disparities and Disproportionality in Decision Points • Population Based Denominator Ratios – Based on data from one child welfare decision (e.g., new placements/population) – Easiest to obtain • Decision Based Denominator Ratios – Based on data from at least two child welfare decisions (e.g., new placements/opened cases) • Relationship Population Based Denominator Ratio= e ( ∑ ln(Decision Based Denominator Ratio))
Comparison of Population and Decision Based Disparity Ratios - Colorado 2009 African American Children with Respect to White Children 2.69 2.42 2.34 2.34 2.16 1.35 1.03 0.89 Population Denominator Decision Points Decision Denominator
Comparison of Population and Decision Based Disparity Ratios - Colorado 2009 African American Children with Respect to White Children 2.69 2.42 2.34 2.34 2.16 1.35 1.07 1.03 0.89 0.89 0.86 0.79 Population Denominator Decision Points Decision Denominator Poverty Adjusted Population Denominator
Questions About Where to go Next • Exploration of Explanatory Factors – What are the source of Disparities? • Explanatory Factors are Likely to be Different for Each Decision Point • Use the Decision Making Ecology (DME) Framework (Baumann, et al., 2011) and the Explanatory Factors to Frame Research Questions • Poverty Indicators or Proxies in Administrative Data – Are Decision Making Errors (False Positives, False Negatives) Disparate? – Some examples 37
Disentangling Substantiation: The Influence of Race, Income, and Risk on the Substantiation Decision in Child Welfare Donald J. Baumann, Ph.D. Alan J. Dettlaff, PhD, MSW Texas Department of Family & Protective Jane Addams College of Social Work Services University of Illinois at Chicago John D. Fluke, Ph.D. Stephanie L. Rivaux, PhD Child Protection Research Center Texas Department of Family and American Humane Association Protective Services Joan R. Rycraft, Ph.D. University of Texas at Arlington
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