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The social ecology of treatment: Case study of a service system for maltreated
children

Article  in  American Journal of Orthopsychiatry · January 1992

DOI: 10.1037/h0079313

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 Ecology of Treatment, p. 1

Crittenden, P.M. (1992). The social ecology of treatment: Case study of a service system for
maltreated children. American Journal of Orthopsychiatry, 62, 22-34.

The Social Ecology of Treatment:

A Case Study of Child Abuse and Neglect

Patricia M. Crittenden*

University of Miami

Address for Correspondence:

Department of Pediatrics
University of Miami
P.O. Box 016820(D-820)
Miami, FL 33101

1
 Ecology of Treatment, p. 2

Running Head: Ecology of Treatment

2
 Ecology of Treatment, p. 3

Abstract
Difficulties in improving services for maltreated children can be attributed, in part, to
misunderstanding of how the forces determining service availability and procedures operate. This
paper 1) applies social ecological theory to the issue, 2) provides a case study of an attempt to
modify one service delivery system, and 3) offers recommendations for improving services to
families.
 Ecology of Treatment, p. 1

During the last 30 years the study and treatment of child abuse and neglect have grown
exponentially. This growth has involved the establishment of professional bureaucracies to
respond to the problem as well as the generation of a substantial body of research regarding the
nature of maltreatment. The bureaucracies were established at a time when child abuse was
defined in terms of individual psychopathology. The research of the last decade, however, has
increasingly pointed to an ecological model of the etiology of child maltreatment (Belsky, 1980;
Bronfenbrenner, 1979; Garbarino, 1977). This model postulates that maltreatment is the result
of a nested hierachy of influences including cultural, subcultural, political, community, family, and
individual factors. Socioeconomic and familial factors, in particular, have been identified as
central to the occurence of maltreatment (Gelles, 1980).
In order to understand service delivery systems, this perspective needs to be applied both
conceptually and practically to treatment. Doing so requires understanding the social ecology of
treatment as thoroughly as that of causation. This paper will first describe the social ecology of
treatment from a theoretical perspective, then provide a case study of an attempt to modify one
treatment system, and lastly recommend ways in which systemic functioning can be modified and
improved.
The Social Ecology of Treatment

The conceptual model. Bronfenbrenner describes the influences on individuals' development

in terms of four types of systems (Bronfenbrenner, 1979): a) microsystems of individuals with
whom a person has direct contact, e.g., family, friends, co-workers, and professionals; b)
mesosystems of which the person is not a member but which directly affect the person, e.g.,
sibling subsystems which affect parental functioning, supervisors who affect the course of
therapy without meeting the client; c) exosystems of bureaucratic structures which affect groups
without there being knowledge of the specific individuals affected, e.g. legislative bodies that
make funding decisions, administrators who decide what services to offer, court precedents; and
d) macrosystems of cultural and subcultural influences which affect individuals and institutions
through values, traditions, and role expectations.
There are three important features to this conceptual model. First, the model is dynamic; all
systems are adjusting all of the time to both internal and external influences. Second, it is
interactive; each person is not only influenced by the systems of which he is a member, but each
also influences the systems in return. Third, the systems are highly interconnected not only
vertically (micro to macro systems) but also horizontally (members of one microsystem are
members of other microsystems). Application of this model to treatment suggests that, although
treatment is often construed (using a static, unidirectional model isolated from extra-individual
influences) as something which clients accept or resist, treatment systems may, actually be far
more dynamic and complex.
The application to treatment. The social ecology of treatment can be described from a
number of perspectives. Because service providers are the most direct representatives of
treatment systems, their perspective will be used here. Professionals offering treatment are
 Ecology of Treatment, p. 2

members of a) microsystems of clients, colleagues, supervisors, and family and b) mesosystems

of supervisors, administrators, and clients' families. All of these systems influence the course of
treatment. Powerful exosystems include governmental and legislative bodies, agency
administrations, the media, interagency councils, funding sources, professional organizations, and
training institutions. All operate within the context of macrosystem values regarding the relation
of individuals to their communities, the extent of individuals' responsibility for their own welfare,
the perceived importance of different groups of people, and community attitudes toward people
whose behavior conflicts with community standards. Although this list is not exhaustive, it is
suggestive of the breadth of influences affecting treatment as it is delivered by professionals to
individuals.
Such a system is dynamic in that change occurs constantly. Changes at any one level affect
other levels, thus, highlighting the relations among components of the system. For example,
changing eligibility criteria affects clients' resources, professionals' work-loads, interagency
relationships, legislative bodies, the media, etc. When changes are highly discrepant with current
practice, greater reverberations through the network of systems may be expected. Using these
notions, a case study will be examined to identify aspects of systemic functioning influencing the
service delivery system for maltreated children and their families.
A Case Study
The context

Florida provides a particularly instructive example of some of the issues regarding the social
ecology of treatment. Florida has historically been in the forefront of states in responding to the
problem of child abuse (macrosystem value). This has led to the establishment of a number of
(exosystem) institutions. Florida was among the first states to institute a mandatory reporting law
and to establish a central registry. When in 1984 a sexual abuse scandal in a daycare center
occurred, the state legislature met in a special session to consider legal strategies to protect
children; the outcome was a fingerprinting law for all childcare workers. In addition Florida is
the only state to have a central system of multi-disciplinary Child Protection Teams which provide
expert consultation to the Intake and Protective Service Units that are mandated to receive and
investigate all reports of abuse.
On the other hand, Florida's very early response to child protection issues has in some ways
hampered its ability to keep up with recent advances in research and practice. Florida's major laws
and institutions were advocated by the medical profession in the late 1960's and early 70's; the
approaches taken were in line with the then accepted medical/legal model of child abuse. The
effect of this early and lasting (macrosystem) influence has been to institutionalize the belief that it
is individual parents who are responsible for child maltreatment. Additionally, the strong
medical influence lead to an emphasis on child abuse as opposed to child neglect.
Florida is also of interest because the state is very conservative in its support of low income
families (macrosystem values expressed through exosystem institutions and regulations). Florida
consistently ranks among the three or four least generous states in the amount of social funding
overall, unemployment payments, and AFDC payments (Grant Thornton, Inc., 1986; Whited,
1991). In addition, Florida typically spends almost 80% of its funds for dependent children on
investigation, prosecution, and out of home placement whereas only 15% are spent on supervision
and treatment and a miniscule 4% on prevention (Florida Center for Children and Youth, 1988,
1989, 1990). Current knowledge regarding the relation between socioeconomic status, stress, and
maltreatment suggests that states which offer little support to low income families and which have
few prevention programs will have relatively high rates of family dysfunction as compared to
states with more comprehensive support (Emery, 1989).
Bureaucracies represent a necessary compromise between current knowledge and beliefs
(macrosystem) and political realities (exosystem) at the time that they are established. Once
established, however, the micro- and mesosystems created tend to resist change. The challenge in
Florida was to institute change in a state 1) with a strong committment to protecting children but
also 2) with a bureaucracy which was medically and legally oriented, and 3) with a tendency not
to fund prevention, treatment, and support programs for low income families.
New policies and procedures
In an effort to foster change, the University of Miami, which administered the Miami Child
Protection Team (CPT) serving a third of the population of Florida, chose to use the CPT as a
demonstration program for improving service to maltreated children and their families. They
sought 1) to institute diagnostic and evaluation procedures and treatment planning procedures
that focused more on family relationships and resources than on child injuries, 2) to advocate for
prevention and treatment programs, and 3) to use Team experience to improve future service to
maltreating families. The changes, ranging from internal procedures to interagency relationships,
will be described briefly below, followed by a discussion of the process of change and the social
ecology of treatment.
Family assessment. Rather than continuing the practice of investigating allegations of
maltreatment by interviewing children and, sometimes, mothers in the hospital, CPT staff were
asked to make home visits. In keeping with current knowledge regarding the familial quality of
dyadic violence (Kalmuss, 1984; Meredith, 1986; Straus & Gelles, 1986), every member of the
family participated in the evaluation; this necessitated home visits in the evening and on weekends
when school-aged children and employed adults were at home. Finally, the use of a standardized,
multi-method assessment protocol focusing on a range of individual and family competencies was
instituted to permit empirical evaluation both of family needs and strengths and of treatment
recommendations.
Time use. Relationships among professionals also needed modification. CPT staff reported
spending only 11% of their time with families whereas they spent 29% with their CPT colleagues
and 20% with colleagues in other agencies. (The remainder was spent on paperwork.) Clearly the
balance needed to change in ways that favored direct contact with families.
Neglect. Child abuse cases predominated in the CPT case load. Research, on the other
hand, indicated that neglect was more prevalent, more detrimental to child development, and
more resistant to intervention than abuse (National Center on Child Abuse and Neglect, 1988).
Changes in policy to enable the CPT to provide more in-depth consultation for neglect cases were
instituted.
Written treatment plans. Records of case work were kept in hand-written, running-record
form. Formal summative reports were instituted to improve communication among professionals
as well as to permit evaluation of the relation 1) between family needs (and strengths) and
treatment recommendations and 2) between recommendations and the implementation of
treatment.
Matching family needs to treatment recommendations. A review of treatment plans
indicated that most plans were essentially the same. The typical plan consisted of: 1) protective
services, 2) foster care for injured children, 3) day care for young children in the home, 4)
counseling, and 5) parent education, plus an assortment of family-specific fiscal and medical
services. Generally, the more severe the child's injuries, the more services were included in the
plan.
The fit of this "standard plan" to the range of maltreating families was unknown. Moreover,
it was not clear whether severity of injury was the best indicator of the severity of family
dysfunction or whether more services were better than fewer services. Overall, it seemed unlikely
that planning was sufficiently attuned to individual family's needs. Instead it was likely that:
1) families varied in their needs;

2) families varied in their ability to benefit from services;

3)services varied in the types of families for whom they could be effective;

4) families could only change in a few ways at once.

By ignoring individual differences, plans were designed that not only failed to meet family needs
but also wasted valuable community resources.
A Level of Family Functioning Scale (LFF) was devised to assess both families and services
(see Figure 1). Services were evaluated in terms of the level for which they were most
appropriate. Families were assigned to a level after assessment and before development of a
treatment plan. This procedure was intended to help CPT staff to match families to appropriate
services.
---------------------------
Insert Figure 1 about here.
---------------------------
In order to assess the validity of the Level of Family Functioning scale, data from the family
assessment protocols of 281 maltreating families seen by the Child Protection Team and 111
normative families of a similar income level were analyzed. One hundred and three families were
Hispanic, 35 were Haitian, 166 were black (non-Hispanic and non-Haitian), and 98 were white
(non-Hispanic).
There were no differences among families at the five levels of family functioning in maternal
age, the mother's age at her first preganancy, the number of moves the family had made, or family
income. There were differences in the number of partners that the mother had had, marital
status, stressful life experiences, family coping strategies, maternal depression, evidence of
physical neglect, and conflict tactics (see Table 1). Differences reflected a descending linear
trend from "Independent and Adequate" to "Inadequate" families. This pattern of differences
suggests that families assigned to different levels were, in fact, different in functioning.
--------------------------
Insert Table 1 about here.
--------------------------
 It was hoped that, when staff matched family LFF to service LFFs, there would be fewer
cases where inappropriate services were offered. Instead, this procedure increased staff
frustration; there were not enough long-term, intensive services for the number of families
assigned to the Restorable and Supportable levels.
A study of Intake and Protective Service Units throughout the state of Florida indicated
that this problem was not unique to Miami. One hundred and five Intake and Protective Service
supervisors, working in groups of 4-7 individuals from the same geographic area, classified the
services in their districts by LFF. Overall 51% of services in Florida were considered
appropriate for "Vulnerable to Crisis" families, 28% for "Restorable" families, and 16% for
"Supportable" families. These workers were then asked to estimate the percentage of maltreating
families in their district in each Level of Family Functioning. The supervisors estimated that only
20% of maltreating families were "Vulnerable to Crisis" whereas 40% were "Restorable", 30%
"Supportable", and 10% "Inadequate". The data on 281 CPT families in Miami were similar (see
Table 2). Clearly the range of services available did not match the range of services needed by the
families. Workers, through a lack of appropriate services, were assigning seriously troubled
families with deeply rooted, chronic problems to (available) preventive or crisis-oriented services.
They were also "temporarily" removing children from families that could not realistically be
expected to function in a minimally adequate manner.
--------------------------
Insert Table 2 about here.
--------------------------
Implementing treatment recommendations. Conducting two- and six-week follow-up
investigations of the provision of services in Miami documented what "everyone knew": families
were not receiving the services prescribed in their treatment plans. Less than 50% of
recommended services had been initiated within six weeks of the acceptance of the plan by the
court. The reasons were, however, unexpected. In 33% of cases, the professional had been
too busy to make the referral. In 38% of cases, the receiving agency had a waiting list. In only
29% of cases was the family the problem.
Examination of family problems indicated that in many cases the treatment plan itself was
not feasible. Some families lacked transportation or caretakers for children left at home.
Others were unable to maintain the schedules implied by the plans: monthly visits by protective
service workers, weekly parent group meetings, weekly counseling sessions, daily childcare,
intermittently scheduled medical appointments, etc. Provisions for parental visits to children in
foster care were almost never included in the plans. Moreover, families were often confused by
the array of services and service providers. In the absence of intensive case management,
however, it was the families' responsibility to integrate the various services.
The plans themselves indicated little understanding of how change occurs. Most plans
indicated that all services should be initiated as soon as possible; families were expected to find
adequate housing, seek medical care, learn new parenting skills, gain additional income, and
improve their interpersonal relationships. At once. Realistically, it was rarely possible to
accomplish so many changes at one time. In fact, the effect on family members of such rapid and
massive change was sometimes further disintegration of already attenuated family relationships.
Finally, even when families completed the treatment program, there was often the belief
among professionals that insufficient change had been made to warrant the return of the children
or the termination of protective services. The lack of documentation of either improvements in the
home or the inability/unwillingness of parents to make necessary improvements led judges to keep
children in out-of-home placements far beyond federal guideline time limits. Florida was censured
by the federal government for this practice; in Miami, the worst offender, out-of-home placements
averaged 53.4 months at the time of the censure and increased in the following year (Tobocman,
1985).
It appeared that treatment was offered to families the way multiple repairs would be made
on a car: all at once and without reference to other aspects of the system. Treating families,
however, involves helping their members to learn new patterns of behavior as well as to change
inappropriate patterns. Because learning is progressive and builds on previous steps, learning
occurs most easily when it is based on strengths. In all cases, however, there are limits to how
much can be learned or changed at once. Moreover, the more foreign the information or
behavior to be learned, the more difficult and lengthy the process of learning. Finally, if the
learner is preoccupied or under extreme stress, the process of change will be slower yet.
Maltreating families, of course, face all of these impediments to learning. In addition, changes in
any member's functioning are inextricably tied to changes in other members'.
To improve the quality of treatment plans, a protocol for writing developmental family
treatment plans was instituted. The protocol had five main components:
1. Family condition and needs were assessed systematically in terms of both strenghths and
weaknesses; a summary of the assessment was included in the plan.
2. Temporal priority of service components was defined in terms of four categories: a) immediate
resolution of safety or health crises, e.g., foster care; b) short-term crisis services intended to
reduce the potential for violence, e.g., intensive crisis counseling; c) long-term services to change
patterns of daily life, e.g., behavior management skills, marital counseling, money management; d)
future services which were neither critical for the resolution of current crises, nor best addressed
while the family was unstable, e.g., further education, job training.
3. Feasibility, in terms of daily family life, was considered, e.g., the number of concurrent changes
and meetings; arranging feasible service plans often extended the time frame of plans further.
4. Accountability and evaluation were built into plans. In order to determine when services could
be reduced or withdrawn, plans were to specify what individuals were to learn or to do rather
than simply stating the services to be received. The plans stated a) what the family needed, b)
what objective behavioral change would demonstrate that the need had been met, c) the time
frame within which needs should be met, and d) the specific responsibilities of family members
and of professionals for meeting the objectives in the plan. Appropriate agencies were then
suggested.
5. Responsibility for case management was assigned to specific agencies and individuals.
The process of change
Although it might be expected that the effects of these changes would be expressed in terms
of outcomes to families, in this case, the effects have to do with changes in the professional
system. (Desirable as information on families might have been, there were no funds for
follow-up studies. Use of program funds to explore these issues was not permitted.) The changes
affected the entire hierarchy of the treatment system.
 The microsystem. The early changes (i.e., making home visits, carrying out a standard
assessment protocol, writing summative reports) applied almost exclusively to the microsystem of
the Team and were deemed undesirable by current Team members. Staff who had worked
exclusively in the hospital were afraid to visit clients at home; in addition their own families
(related microsystems) did not want them absent during evenings and weekends. The use of a
standardized protocol was seen as a waste of time which interfered with clinical interviewing
(influence of the exosystem of training systems). Similarly, assessment of family strengths and
written reports were perceived as additional time and paperwork. Visiting homes reduced time for
consultation with colleagues (other microsystems), thus, making jobs less satisfying. Within six
months of implementing the new procedures, all Team members had found new jobs.
Hiring of replacement staff was strongly influenced by the exosystem of professional training
programs. Applicants with psychology backgrounds were comfortable with a standardized
assessment protocol, but were uncomfortable with home visits. Applicants with social work
training were willing to work in homes, but felt constrained by the assessment protocol. Most
nursing applicants were uncomfortable with the emphasis on family functioning. Moreover, most
applicants believed that their role was to apprehend abusers and protect maltreated children from
their parents; few expressed macrosystem values of compassion, understanding for the parents,
and maintenance of family unity. In the end, young applicants who had high intelligence and
motivation but little training or experience were hired; their intelligence, enthusiasm, and
dedication were balanced against their lack of experience. Supervision, extensive pre-service
and in-service training, and use of the formal assessment protocol became ways of reducing these
liabilities.
Mesosystems. Interdisciplinary co-operation, which historically had been very difficult to
achieve within the Miami service delivery system, became even more fraught with conflict as
agencies reacted to the perceived threat to their status among the hierachy of service providers.
The attempt to structure the provision of services so that fewer were offered at once and so that
one agency would exercise power as case manager disrupted multi-agency relationships
(micro- and mesosystems). No discipline or agency wished to yield power or authority to any
other. In the end, the compromise among agencies was based on mutual recognition of the
validity and importance of each discipline's or agency's contribution without negotiation of
priorities. Because each discipline/agency independently assessed clients' needs and offered
those of its services which it deemd appropriate, decisions regarding which agencies to include for
each case became the primary means of regulating agency relations. The result was often a
degree of safe "cronyism" and a functional lack of central case management to limit, order, and
integrate services.
Ultimately, many organizations from the local to the state level were affected by changes
in CPT policy and procedure. Changes in CPT staff time use reduced availability of CPT staff in
hospital emergency rooms and pediatric wards. Their absence made it clear that they had been
fullfilling roles that inadequate hospital funds could not cover. The medical agency that funded the
CPT believed that limited funds were wasted by assessing siblings of reported children and
partners of perpetrators. In addition this agency, concerned that the assessment protocol was
really a ruse to carry out research, forbid analysis of the assessment data by CPT staff or with
CPT funds. Courts officers complained that CPT staff less frequently than before provided
unequivocal recommendations for removal of children. Only the Intake and Protective Service
Units were pleased by the changes; they respected CPT staff for going into homes and working
with the entire family and appreciated the written reports which provided the kind of detailed
information that they did not have the time to gather.
The exosystem. The review of treatment plans and service needs in Florida, if it had been
revealed and substantiated, might have created even more furor. The inability of professionals in
many agencies to deliver appropriate treatment in a timely manner would have been exposed.
Even more serious was the discrepancy between the service needs of families and the range of
available services. Either new funds for service to chronic, multi-problem families were needed
or present funds needed to be reallocated from short-term services, such as parent education, to
long-term, intensive services. In either case, open acknowledgement of the discrepancy between
family needs and service delivery could affect many of the treatment providers. The delicate
balance of power and access to funding among agencies and disciplines would be challenged in a
context of very scarce resources and limited public and legislative support. Moreover, the public's
hope of an inexpensive, short-term solution to maltreatment would be denied. As a
consequence, legislators would have to make tougher assessments of constituents' values and
implement their conclusions as funding decisions.
In fact, the evidence regarding the ineffectiveness of the treatment system was not
presented to the relevant individuals and organizations in Florida. Instead, the funding agency
required the immediate return of the CPT to its former medical approach. Concurrently, other
problems in Miami's treatment system were exposed by the deaths of several children. The media
coverage was very condemning of the local and state bureaucracy. Many of the problems
addressed by changes in the CPT were identified and exposed. In the wake of a change in the
governorship in Florida, a state level reorganization took place; administrators at the state and
local levels were replaced. In a series of media exposes, administrators at the local level were
replaced several times more during the following years.
Ironically, Florida's response to the problems within the treatment system was almost
identical to the state's response to maltreatment. Individual administrators were held responsible
for problems which they did not create and which were far beyond their power to resolve. These
administrators were fired; those who replaced them entered a system which was inherently
unsound. The problems continued and the new administrators were replaced, but the values,
procedures, and resources underlying the hierarchy of organizations remained unchanged.
The basic problems of how one defines maltreatment, where responsibility for maltreating
families' plight lies, and the extent of the public's commitment to providing adequate resources for
prevention and treatment remained untouched. The public heard little about the problems faced
by most low income families. Instead they heard horror stories about bad parents and negligent
professionals. Legislators struggled to create highly visible solutions without spending more
money or challenging the balance of power among the disciplines and agencies.
The macrosytem. Underlying all of the problems were the serious philosophical issues
(macrosystem) of the extent and nature of society's responsibility to troubled families. The effort
to identify and remediate life-threatening harm to children reflected the social belief that children
were innocent and deserving of society's protection. On the other hand, the failure to provide
adequate services and a protective standard of living along with the pressure to criminally
prosecute and punish purpetrators reflected the opposing social value that one's quality of life
must be earned.
The CPT reforms were based on different responses to these issues than those guiding
most of the treatment (and political) systems in Florida. Because of this lack of macrosystem
synchrony, the changes had disrupted, and were disrupted by, microsystems of professionals,
mesosystems of administrative hierarchies, exosystems of training institutions, legislators, and the
media, and macrosystems of social values.
Treatment Systems
This study reports a specific set of circumstances around the problem of child maltreatment
in one state. Its purpose, however, is not to focus solely on the treatment of child abuse and
neglect or to justify a specific set of changes. Rather the purpose is to provide an example of
how treatment systems can be analyzed and modified. In other settings the players and situations
would be different. The dynamic influence of a hierarchy of systems on the availability and
suitability of treatment services would, however, remain unchanged.
Four major conclusions regarding the nature of treatment systems can be drawn from this
case study. First, it is apparent that the social ecology of treatment is very complex and includes
far more than recipients of treatment or or the professionals who deliver services. In fact, the
needs of recipients are only one of many factors influencing the nature of the treatment system.
Two forces seem predominant.
One is public policy which embodies the "consensus" of public opinion, media attention,
and legislative priorities. Although the manner in which public policy is formed is far beyond the
scope of this report, it is clear that policy and funding decisions expand, constrain, and/or direct
the type and availability of treatment services. Because priorities must be established among the
many problems facing voter-sensitive governmental bodies, public opinion (and the media
attention which often molds it) is critical to the decision-making process. Unfortunately, in Florida
the public's wish to resolve problems without either increasing taxes or reducing services tended
to favor the implementation of symbolic services, i.e., the fingerprinting law. The complexity of
underlying problems could not adequately be addressed by such superficial and poorly
coordinated approaches.
The other major force is professionals. Through their training institutions, professional
organizations, and agency hierarchies, professionals define the problems to which they will
respond as well as the nature of that response. Problems that do not fit professional definitions
receive little or no treatment regardless of their impact on individuals. For example, when
maltreatment is defined as a parent's problem, both family distress and the role of socioeconomic
status in designating groups of at-risk individuals are overlooked.
In addition, the bias toward continuing to do what one knows how to do and is expected by
others to do is strong. New approaches challenge both individuals and agencies. Consequently,
implementation of new procedures is not only difficult for the individuals learning new skills or
ways of thinking, it also implies changes within the network of "client agencies" that exchange
referrals. Finally, changes in service threaten existing boundries (i.e., "turf") between agencies.
"Comprehensive service delivery" can be viewed as encroachment on another's territory.
Consequently, such moves are made cautiously. The point is that the complexities of
interdisciplinary relations, particularly the interdependencies among agencies, can make change
difficult to conceive or implement. The power of these forces is real, but not usually offered as
explanations for why treatment services are as they are.
Second, even simple changes in microsystems can have major ramifications in the network
of related micro-, meso-, exo-, and macrosystems. These ramifications can either greatly impede
the process of change or they can speed and facilitate it as in the case of "an idea whose time has
come." In the case study presented here, change was not co-ordinated across and among levels of
influence. Nor was it reflective of a group consensus that change was needed. Given the conflict
in values, such consensus was unlikely. In its absence the many effects upon other entities within
the treatment system were unexpected, misunderstood, and perceived as threatening. Such a
climate reduced greatly the chances of successful change.
Third, where there is macrosystem dyssynchrony, it becomes very difficult to implement any
effective treatment policies. In Florida, conflicting values and needs in a state with subpopulations
differing widely in urbanization, ethnicity, and political representation resulted in the lack of
coherent and stable social policy. Instead, media-aroused voters pressured legislators at all levels
of government to respond immediately to "new" crises. Treatment policy, thus, was the result of
successive waves of political deals. Not surprisingly, the "system" failed, leaving the public
doubtful of governmental competence and unwilling to risk either further money or the delegation
of authority necessary for a true overhaul. Ad hoc responses to pressure groups representing
dyssynchronous values became the primary means of doing business.
Dyssynchrony can occur among parts of systems, e.g., professionals versus the public, or
within the conflicting values of one part of the system, e.g., a belief in the value of preserving the
family combined with the belief that abusers should be punished. In Florida, the dyssynchrony
pervaded the treatment system; the lack of awareness of values and of conflict among values made
consensus and change almost impossible.
Fourth, empirical data analysis is critical for evaluation of treatment effectiveness.
Although such evaluations are an on-going expense, they are less expensive in terms of both
money and human suffering than continuing to deliver outdated or ineffective services. In this
case, data were available to test some of the assumptions underlying the attempted policy
changes. The importance of assessment of all family members was supported by analyses of the
functioning of siblings of reported children. Among the siblings, 58% experienced maltreatment
(with an additional 38% reported as being "at risk"). Moreover, 75% of siblings showed
distortions of development. In fact, there were no differences between siblings and reported
children on any variable except severity of injury at the time of the report (Jean-Gilles &
Crittenden, 1990). Other analyses indicated that severity of psychological maltreatment rather
than either severity of physical injury or extent of poverty accounted for most of the variance in
outcomes to young maltreated children (Claussen & Crittenden, 1991). Analyses of the data are
continuing; hopefully, the results will provide additional evidence supporting the types of changes
which were attempted with the CPT.
Nevertheless, empirical evidence is only one aspect of the decision-making process.
Interpretation of the meaning of the results of analyses depends upon philosophical perspectives.
At present, Florida is both caught between contradictory values and also trapped by inadequate
means of resolving conflict. Recognition of that contradiction is a necessary first step to resolving
the conflict. As limited monies are spread increasingly thinly over prevention, rehabilitation, and
prosecution, it becomes essential that a coherent, cost effective strategy guide policy. Effective
solutions to the dilemma of inadequate childrearing require both accurate knowledge of the
situation and contingencies upon it (which good research can provide) and also recognition of
how values are embedded in decisions. Empirical knowledge, along with openly acknowledged
and carefully considered values, should guide our choice of treatment policies and procedures.
Changing Treatment Systems
A strategic approach. When problems seem to be approaching a desperate state and
improvements can be envisioned clearly, there is a strong tendency to begin implementing changes
as immediately and as widely as possible. This was done with the CPT in Miami. In a modified
metaphor, this was like treating a symptom of illness without first examining the whole person. In
the case presented, the CPT was not independent of the system in which it operated and the
"treatment" of the CPT was in conflict with the functioning of the remainder of the system. Effort
was wasted.
Instead, a strategic approach to analysis and remediation of the problem was needed.
Because the CPT's problems were rooted in the political macrosystem of Florida, change needed
to be directed toward that structure. Any effort to accomplish change in local microsystems,
without first addressing the issue of macrosystem dyssynchrony, should have been limited to that
which could be accepted without disruption to interlocking micro- and mesosystems. Although
such an approach is more conservative than that which was attempted, it would have increased
the probability that those changes which were attempted would be effective.
In other contexts, where underlying value systems are coherent and political systems are
effective, effort can be focussed on developing new policies which reflect these values. In the
context of such macrosystem synchrony, exosystem committees, panels, and study groups
(representing the many components of treatment micro- and mesosystems) can draft
recommendations which may be expected to change policy effectively.
In situations in which macrosystem values are coherent and exosystem policies are
appropriate, but techniques are outmoded and/or financial support is insufficient, more direct
action at the level of microsystems can be taken. If more advanced intervention strategies exist,
support for demonstration and integration of new techniques into treatment services can give
professionals the resources and opportunities that they seek while meeting both the public's and
client's need for improved service. If the needed techniques do not yet exist, research can be
instigated to develop the needed knowledge. If expansion of resources is needed, research to
document needs and advocacy efforts involving the media and governmental representatives may
be undertaken.
Managing change. Most efforts to institute change in treatment systems are directed toward
advocacy of new techniques or resources. What becomes clear from this evaluation of the
treatment system in Florida is that identifying desirable changes is not enough especially when
inadequate resources create intense competition among agencies with similar goals. Knowledge of
the functioning of entire treatment systems is essential to identifying the roots of problems. If
causal conditions are not changed, processes dependent upon them cannot be substantively
improved.
Because states such as Florida provide woefully inadequate services to children and families,
the temptation to struggle directly with service provision is great. The lesson of this case study,
however, suggests that long-term outcomes would be enhanced by greater attention to the broad
context, i.e., the macrosystem, in which change is needed.
From this perspective, Florida is an unusual state. It is both among the wealthiest of states
and among those with the lowest tax rate. Moreover, it is in a process of extremely rapid
demographic change and growth as its southern, predominantly rural population is modified by
increasing numbers of relatively wealthy senior citizens and relatively impoverished, culturally
diverse immigrants with children. The widely disparate values, goals, and needs of these groups
and their unequal political influence and representation (Fiedler, 1991) almost guarantee a
mismatch of needs to resources.
This case study of Florida's system for treating cases of child abuse and neglect
demonstrates the complexity of the social ecology of treatment. In particular, it demonstrates the
influence of macrosystem dyssynchrony on microsystem and mesosystem functioning. To assist in
understanding this complexity, an approach to analyzing the state of treatment systems has been
offered. Based on the outcome of that analysis, a guide to identifying where change efforts might
best be directed has been outlined. In those states with general consensus regarding values,
policies embodying those values, and reasonably sufficient public resources, change can
productively be focussed directly on treatment microsystems. In other states, more preliminary
work involving macro- and exosystems may be necessary to prepare a basis for change in
treatment micro- and mesosystems. In all cases, recognition of the many factors contributing to,
and impinging upon, treatment systems should be considered. Attention to the hierarchy of
systemic influences affected by change efforts can both reduce the disruptive impact of change
and maximize its positive impact on related parts of the system.
 References
Belsky, J. (1980). Child maltreatment: An ecological integration. American Psychologist, 35,
320-335.
Bronfenbrenner, U. (1979). The experimental ecology of human development. Cambridge, MA:
Harvard University Press. Claussen, A.H. & Crittenden, P.M. (1991). Physical and psychological
maltreatment: Relations among types of maltreatment. International Journal of Child Abuse and
Neglect, 15, 5-18.
Emery, R.E. (1989). Family violence. American Psychologist., 44, 321-328. Fiedler. T. (1991).
Black leaders plan for more seats of power. Miami Herald, May 5, 1, 31A.
Florida Center for Children and Youth (1989,1988,1987). Budget report: Programs for children
and families. Legislative wrap-up: Statutory changes affecting children. Tallahassee, FL: Florida
Center for Children and Youth.
Garbarino, J. (1977). The human ecology of child maltreatment: A conceptual model for research.
Journal of Marriage and the Family, 39, 721-736.
Gelles, R.J. (1980). Violence in the family: A review of research in the seventies. Journal of
Marriage and the Family, 42, 873-884.
Grant Thornton, Inc. (1985). Public spending in Florida. Chicago: Grant Thornton.
Jean-Gilles, M. & Crittenden, P.M. (1990). Maltreating families: A look at siblings. Family
Relations, 39, 323-329.
Kalmuss, D. (1984). The intergenerational transmission of marital aggression. Journal of Marriage
and the Family, 47, 11-19.
Meredith, W.H., Abbott, D.A., & Adams, S.L. (1986). Family violence: Its relation to marital and
parental satisfaction and family strengths. Journal of Family Violence, 1, 299-305.
National Center on Child Abuse and Neglect (1988). Executive summary: Study of the national
incidence and prevalence of child abuse and neglect: 1988. (DHHS, OHDS, ACYF). Washington,
D.C.: US Government Printing Office.
Straus, M.A., & Gelles, R.J. (1986). Societal change and change in family violence from 1975 to
1985 as revealed by two national surveys. Journal of Marriage and the Family, 48, 465-479.
Tobocman, S.L. (1985). The child on the outside. Florida Bar Journal, LIX, 35-38.Whited, C.
(1991). Land of plenty shortchanges kids in poverty. Miami Herald, May 5, 1B.
Table 1
Family Variables by Level of Family Functioning
______________________________________________________________________________
_ Level of Family Functioning
_____________________________________________________

Variable Adequate Vulnerable Restorable Supportable Inadequate

F1____________________________________________________________________________
___Child age/mo. 53 54 62 50 50 .88
Birthorder 1.1 2.0 2.2 3.1 1.5 7.93**
Maternal age/yr. 29 30 28 28 32 1.49 2
Firstpregnancy 18 19 18 19 22 .97*
Percent married 40 32 23 12 43 21.61 3
# of moves 3.8 3.5 4.0 3.9 7.6 1.60
#ofpartners 1.0 1.3 1.4 2.1 1.7 12.64***
Life stress 4.5 5.0 5.5 5.7 4.6 4.17*
Coping strategies 105 106 104 99 86 6.30**
Maternaldepression 3.1 3.9 5.5 7.0 4.4 17.59***
Physicalneglect 14.2 13.8 13.0 11.9 10.1 43.60***
Maternal cooperation 4.6 4.6 3.6 2.4 .6 56.39***
Maternal defensiveness .4 .5 1.2 2.3 3.5 86.21***

Maternal withdrawal .3 .5 1.1 1.5 1.8 27.92***

Family violence 7.2 10.2 10.3 14.9 25.7 6.07**
______________________________________________________________________________
1
weighted linear trend.
2
group difference.
3
Chi-square statistic.
* p < .05; ** p < .01; *** p < .001.
 Table 2

The relation of family needs to types of servics in Florida

___________________________________________________________________________

Level of Family Services Families Families

Functioning in Florida1 in Florida1 in Miami3
___________________________________________________________________________
Vulnerable 51% 20% 24%
2
to Crisis (35-80%) (10-40%)
Restorable 31% 40% 48%
(6-43%) (30-70%)
Supportable 18% 30% 24%
(8-28%) (10-40%)

Inadequate 5% 10% 3%
(2-10%) (5-30%)

___________________________________________________________________________
1
Estimates of 105 Intake and Protective Services supervisors in Florida.
2
Ranges of estimates from the supervisors.
3
Actual data from 281 families evaluated by the Miami/Dade County Child Protection Team.
 Figure 1. Levels of Family Functioning
I. Independent and Adequate

Families in this category are able to meet the needs of their children by combining their own
skills, help from friends and relatives, and services which they seek and use. Such families, like
all families, face problems and crises. It is their competence at resolving these problems which
makes them adequate.
II. Vulnerable to Crisis

Families in this category need temporary, i.e., six months to a year, help resolving unusual
problems; otherwise the family functions independently and adequately. Examples of common
precipitating crises include birth of a handicapped child, divorce, loss of employment, death of a
family member, entry of a handicapped child into school, and sexual abuse in day care of a child.
Because each of these crises could result in chronic problems, it is the nature of the family's
response, not the nature of the crisis, which results in the Vulnerable classification.
III. Restorable

Families in this category are multi-problem families who need several types of training in
specific skills or therapy around specific issues. Following intervention, it is expected that the
family will function independently and adequately. The period of intervention can be expected to
last 1-4 years and require active case management to organize the sequence of service delivery
and to integrate the services.
IV. Supportable
There are no rehabilitative services which can be expected to enable these families to
become independent and adequate. With specific on-going services, the family can meet the
basic physical, intellectual, emotional, and economic needs of their children. Services, and
management of those services, will be needed until all the children are grown. Examples of
supportable families include those with a mentally retarded mother, a depressed mother, or a
parent who abuses alcohol or drugs chronically.
V. Inadequate

There are no services sufficient to enable these families to meet the basic needs of their
children, now or in the future. Permanent removal of the children should be sought.

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