key: cord-0958715-gnqn5rpy authors: Fogarty, Alison; Jones, Andi; Evans, Kirsty; O’Brien, Jacquie; Giallo, Rebecca title: The experience of the COVID‐19 pandemic for families of infants involved with Child Protection Services for maltreatment concerns date: 2021-08-25 journal: Health Soc Care Community DOI: 10.1111/hsc.13555 sha: e6091a76492173be52efc02d744bce324ee0b6b7 doc_id: 958715 cord_uid: gnqn5rpy The COVID‐19 pandemic and associated physical distancing restrictions have exacerbated social, economic and health disadvantage within our communities. With increases in mental health difficulties and family violence already being seen, there is concern that the risk of child maltreatment risk may also be increased. The current study aimed to explore the experience of the COVID‐19 pandemic for families identified to be at risk of child maltreatment in Victoria, Australia. Understanding the experiences of the pandemic for families already at risk is essential in identifying how to best support vulnerable parents and young children during this challenging time. Interviews were conducted with 11 parents currently involved with Child Protection Services, and nine clinicians working within a child and family health services, supporting clients with child protection involvement. Parents and clinicians described a range of pandemic related stressors including employment and financial stress, worry about infection and changes to service access. In addition, parents with children in out of home care discussed decreased access to their children resulting from physical distancing restrictions. Parents and clinicians perceived the pandemic to be having a negative impact on parent mental health, parenting stress and isolation. Although parents raised minimal concerns about the impact of the pandemic on child well‐being, clinicians expressed concerns about the rise in risk factors for child maltreatment. Parents discussed a range of coping strategies which they perceived to be helpful during the pandemic, and clinicians and parents described the need for additional mental health support and support to access basic needs. The study highlights the importance of ensuring at risk families have access to parenting and mental health support throughout the pandemic and the importance of ensuring children within at‐risk families are sighted and their safety assessed. The COVID-19 pandemic is creating challenges for families worldwide. Those experiencing social disadvantage may be disproportionately at risk of adverse health and well-being outcomes during the pandemic (Abrams & Szefler, 2020; Burström & Tao, 2020) . Families at risk of child maltreatment are among the most vulnerable groups in our communities, often having experiences of socioeconomic disadvantage, poor housing conditions and low educational attainment (Drake et al., 2006; Marcal, 2018) . Pre-existing physical and mental health difficulties are also common, with higher rates of intellectual and learning disabilities, substance use, depression and intergenerational trauma often present in this population (Canfield et al., 2017; Jenkins et al., 2018; Slayter & Jensen, 2019) . Pandemic related stressors may result in an exacerbation of pre-existing social and economic disadvantage (Abrams & Szefler, 2020; Burström & Tao, 2020; McNeely et al., 2020) . Consequently, there is great concern that the COVID-19 pandemic may further increase risk factors for child maltreatment for families already at risk (Bradbury-Jones & Isham, 2020; Fegert et al., 2020) . Emerging research suggests that the pandemic's impact on mental health is considerable (McGinty et al., 2020; Pierce et al., 2020) . Parents of young children may be at particular risk with two recent studies noting an increase in rates of post-natal depression and anxiety compared to non-pandemic norms (Cameron et al., 2020; Pierce et al., 2020) . Parenting stress is also a concern (Fegert et al., 2020; Griffith, 2020) , with many parents experiencing a decrease in access to usual support and parenting respite (e.g., parent groups, childcare and family support) which can buffer maltreatment risk (Griffith, 2020) . Early reports, and evidence from prior pandemics and disasters point to the use of maladaptive coping strategies to manage mental health and increased stress including substance use, interparental conflict and family violence (Bradbury-Jones & Isham, 2020; Campbell, 2020; Chodkiewicz et al., 2020; Neill et al., 2020) . Such strategies are significant risk factors for child maltreatment (Duffy et al., 2015; Victor, Grogan-Kaylor, Ryan, Perron, & Gilbert, 2018) and have been associated with harsh and hostile parenting (Fulu et al., 2017; Grasso et al., 2016) . The increased risk of child maltreatment and increased rates of family violence pose a serious threat to the health and development of children residing within these vulnerable families. Specifically, infants and young children make up a large proportion of child protection notifications relating to child maltreatment in Australia (AIHW, 2020) . There are concerns about the visibility of young children to mandatory reporters during the pandemic with considerably fewer face-to-face opportunities for child protection, maternal child health nurses, and childcare workers to meet with families (Baron et al., 2020) . The consequences of this are beginning to be seen with reported drops in child protection notifications during the pandemic (Jonson-Reid, Drake, Cobetto, & Ocampo, 2020) . Given the substantial and long lasting impact of maltreatment on health and well-being (Afifi et al., 2017) , minimising maltreatment risk and promoting child well-being and safety during the COVID-19 pandemic is paramount. To appropriately support families of infants and young children with maltreatment concerns, it is necessary to understand how the pandemic specifically affects them and their support needs during these unprecedented times. This qualitative study interviewed parents with infants at risk of child maltreatment who had attended a child and family health service and the clinicians working within this service. The study aimed to explore: (1) the experience of the COVID-19 pandemic for families with child maltreatment concerns, (2) the perceived impacts of the pandemic on parent and infant wellbeing; and (3) perceptions about support needs during and following the pandemic. The current study utilised a qualitative design with ethics approval obtained from the Royal Children's Hospital Human Research Ethics Committee. The participants were parents of infants referred to a child and family health service by Child Protection Services for concerns of child maltreatment, and clinicians working within the parenting assessment and skill development service. To be eligible for the service, parents had to have current involvement with Child Protection Services and display significant risk factors for maltreatment such as parenting difficulties, mental health difficulties, family violence, parent-child relationship What is known about this topic? • The COVID-19 pandemic is affecting families across the world • Those families already experiencing disadvantage may be most at risk to negative social, economic and health outcomes. • Rates of family violence have increased since the pandemic began, and experts are concerned about a heightened risk of child maltreatment. • This paper sheds light onto the experience of the COVID-19 pandemic for some of the most vulnerable in our community. • It highlights the concerns clinicians hold for child safety during the pandemic. • This paper highlights that continued access to parenting and mental health support and assessment during the COVID-19 is paramount. difficulties, lack of parental supervision, physical health difficulties. Parents and clinicians were invited to participate in the study by the service manager. Those who consented were contacted by a member of the research team who further explained the purpose of the study and re-confirmed consent. The interviews were conducted approximately 1-5 months into the pandemic in Victoria Australia. At this time, a broad range of public health restrictions were being implemented to suppress the virus. At the time of the interviews, stay at home orders were in place with only four permitted reasons to leave the house: (1) buying food and other essential items, (2) daily exercise, (3) to obtain or provide care, and (4) to attend school or work if you are unable to do this from home. Over the study period, 20 parents consented to participate. Nine withdrew prior to participation or were unable to be contacted. Of the 11 parents who participated, the majority were female (64%), Australian born (64%) and from English speaking backgrounds (82%). Most parents had not completed high school (73%) and were not in paid employment at the time of the interview (91%). The mean age of parents and infants was 24 years and 5 months, respectively. Most parents were in a relationship at the time of the interview (91%) and had their children in their care (81%), with two parents reporting to have a child in out of home care. Nine clinicians (of 14) consented to participate. They were involved in the delivery or management of the service. They held formal qualifications in nursing, social work, psychology, and/or early childhood development, were predominately female (67%), and on average had 21 years' experience working with families. Semi-structured interviews were conducted by a registered psychologist from the research team. Interviews occurred over the phone, were 32-69 min in duration, and audio-recorded. Interview questions were open-ended and centred around the parents' perceptions of impact of the pandemic on daily life, health, well-being and development. Example questions in- How has the pandemic impacted your child and their development? The semi-structured nature of the interview enabled the interviewer to probe participants on their responses and ask additional questions relating to individual circumstances. Parents who participated were provided with a $50 supermarket voucher as reimbursement for their time. Interview transcripts were analysed using thematic analysis, allowing for the identification of key themes occurring within and across the parent and clinician interview data. This enabled triangulation of findings across multiple informants. NVivo Version 12 was used to aid the analysis process (QSR International, 2018). The analysis followed steps outlined by Braun and Clarke (2006) whereby interview transcripts were read thoroughly by two researchers to increase familiarity with the data before initial codes were generated. Themes and sub-themes were determined independently through refinement and analysis of these codes. To increase the rigour of the qualitative analysis, transcripts were coded independently by two researchers. Once initial coding was complete, researchers then met regularly to compare codes and themes, and discuss the refinement process. Data collection and analysis occurred concurrently to determine when saturation had been met (the point at which no new themes were emerging). To increase trustworthiness and credibility of the findings, themes and subthemes were presented to, and discussed with a sub-sample of clinicians from the study (N = 4) at a key stakeholder meeting. Final themes and sub-themes were agreed upon by both researchers and discussed with the broader research team. This process included a discussion around the accuracy of themes and subthemes, discrepancies within the data and the presence of any potential researcher bias. Each transcript was allocated a pseudonym to protect the identity of participants. The thematic analysis revealed key themes relating to: (1) pandemic related stressors; (2) pre-existing vulnerabilities; (3) parent wellbeing; (4) child well-being; (5) coping strategies; and (6) support and service needs. Figure 1 displays these themes and corresponding sub-themes. Quotes demonstrating key themes are presented alongside participant pseudonyms. Parents and clinicians described a range of pandemic stressors impacting on families. Financial stress and employment were noted to be a key concern. Parent: We are struggling to cover the rent, and bills, and food. Clinician: We're working with clients who have lost their jobs, rents in arrears; they're struggling. (Clinician 04) COVID-19 restrictions and social distancing orders had changed the lives of families with limited opportunities to visit places in the community (e.g., playgrounds) and see extended family members. Parent: It is a bit frustrating…I mean, we can't go out and do -do normal things. Can't take him to parks or anything. Can't really take him anywhere. (Kim) Not being able to see family members, not being able to just go out and look in shops. Having to just sit at home all day, every day. (Megan) Worry about infection of COVID-19 for themselves, their child and/or a family member was common. Parent: I would love to be able to go for a walk but everyone else is doing it and I don't want to get that close to people with it needs to be understood that it is affecting them as well. Parents and clinicians described considerable changes in the way in which they accessed services. Some families were not able to access certain services during lockdown periods, and all families experienced a reduction of face-to-face services and an increase in use of telehealth The clinicians reflected that many families were experiencing high levels of disadvantage prior to the pandemic, and the pandemic had added another layer of disadvantage. Clinician: Definitely, social isolation has been much greater. We already work with families who are vulnerable and isolated, and it's had impacts on their mental health, how they're actually functioning as a family. (Clinician 04) This theme was further supported by a small number of parents noting that the pandemic and public health restrictions did not lead to F I G U R E 1 Key themes and subthemes relating to the experience of COVID-19 pandemic for families with child maltreatment concerns. Note: p Indicates theme was present in parent data only, C Indicates themes was present in clinician data only, *Indicates themes present in both parent and clinician data considerable changes in their lives due to pre-existing social isolation. This is reflected in the following parent's response when asked how things have changed for them and their family. Parent: Well, a little bit. Not a lot, 'cause we didn't exactly go out heaps beforehand. Despite noting limited changes to daily life as a result of the restrictions, these parents still went on to describe challenges to well-being. Parents and clinicians both noted the substantial impact pandemic related stressors were having on parent mental health and well-being. Specifically, they described considerable experiences of social isolation resulting from, or exacerbated by the restrictions. Parents and clinicians also noted parenting stress to be a concern, with few opportunities to take a break. The impact of the pandemic on the well-being of children was not a prominent theme for parents. However, parents reflected upon their children's emotional experience of the pandemic. For instance, some parents noted their children to be cautious around strangers and busy locations. Others had noted disruptions to children's sleep due to fewer opportunities to 'burn off energy' through play and stimulation. Parent: We can't take the kids out to the park, or anything like that, which is sort of difficult, because then you've got to find ways at home to sort of burn their energy, which is difficult because we don't have a lot at the moment. We don't even have any play equipment or anything in the backyard. (Elise) Clinicians noted considerable concerns for the safety of children during the pandemic, noting that restrictions and increased stress on families may increase children's risk of maltreatment. Clinicians also noted that the extent of this impact remains to be seen, commenting on the limited visibility of children to both healthcare and child protection workers. Parents identified a range of things that were helping them to cope throughout the pandemic. Keeping busy and occupied by focusing on their child, and engaging in activities such as cooking, gaming and watching movies were reported as helpful. Parents and clinicians reflected on the support needs of families during the pandemic in Victoria. Both noted that families required additional support to access basic needs such as food, baby supplies and medication. Parents also noted that financial counselling and support was needed. Reduced access to community and/or family sources (e.g., parks, playgrounds, childcare centres, family to support childcare) were noted as a concern by parents within the study. Although these restrictions were experienced by all families across Melbourne, the absence of these resources were likely to have the most detrimental impact for families experiencing social and economic disadvantage. Such community resources have been identified as important factors buffering the risk of parenting stress and developmental delays, providing important cognitive stimulation and opportunity for physical exercise which may not be available within the home environment due to lack of play equipment and toys, and parent engagement with play (Milteer et al., 2012; Votruba-Drzal, Levine Coley, & Lindsay Chase-Lansdale, 2004) . Additional stress and hardship can contribute to, or further exacerbate, mental health and parenting difficulties during the pandemic (Conger & Conger, 2008) . Parents in the current study described a sense of isolation, having a low mood, and experiencing more stress and frustration. They spoke about stress specifically related to parenting, and fewer opportunities to receive some respite due to limited access to usual supports such as childcare and family support. This is of concern due to the well-established link between parent mental health difficulties, parenting stress and child maltreatment risk (Doidge et al., 2017; Mikolajczak et al., 2019) , and that respite opportunities can be protective against child maltreatment (Maguire-Jack et al., 2018) . Clinicians also reflected on the heightened risk these factors presented for child maltreatment, however, noted the challenge which health, social care and child protection services have in identifying child maltreatment risk and occurrence given the low visibility of children during this time. Telehealth services offer important parenting support during this time, however, are limited in their ability to accurately assess risk (Racine et al., 2020) . The visibility of children is dependent on the use of videoconferencing (rather than telephone services) and the openness of parents to have the child in view of the camera during sessions. Clinicians highlighted this as a serious concern, noting the need for "more eyes on children" and supports for families at risk during this time. Research furthering our understanding of what works in developing and maintaining strong therapeutic alliances via telehealth platforms whereby parents feel more comfortable to facilitate the visibility of children during sessions will be a vital step in this process. However, in many cases, COVID-19 safe face-to-face contact with families may be necessary to occur alongside telehealth to ensure the observation and assessment of child safety. Despite the considerable concerns for child safety raised by clinicians, parents reported minimal impact of the pandemic on their child's well-being. Some parents reflected on their child's emotional reactions to pandemic related situations (e.g., seeing people wearing masks, or reacting to being in busy locations), however, did not comment on concerns around long-term impacts. Although experiences of trauma were not collected during this study, adverse childhood experiences are common in parents with child protection involvement (Giallo et al., 2020; Madigan et al., 2019) . Given research demonstrating that parents with complex trauma can experience higher levels of discomfort in response to children's emotional distress (Berthelot et al., 2015; Lieberman, Ippen, & Van Horn, 2015) , it is possible that experiences of trauma among parents in the current study may have increased their sensitivity and distress to changes in their children's emotional reactions to these pandemic related stimuli. It is also likely that histories of complex trauma among participants may have impact on their capacity to reflect fully on their child's experience and long-term impacts. In addition, all parents from our sample were involved in child protection at the time of interviews and had recently undergone a parenting capacity assessment. This recent experience may have contributed to parents being more cautious and reserved in talking about their child's well-being and parenting experience, particularly when speaking with an interviewer who they did not have a prior relationship with. Despite these concerns, it is important to acknowledge the coping skills and capacities of families. Parents noted that keeping busy by focusing on their children and engaging in enjoyable activities such as cooking and watching movies, were important way of coping throughout the pandemic. Support from a partner to assist with parenting and enable time-to-self was also critical for some parents. This is particularly important as coparenting support and time-toself have been associated with fewer mental health difficulties in the early years of parenting (Feinberg, 2003; Woolhouse et al., 2016) . It is promising to see this theme arise within this study and highlights the strengths of the families involved. It is important to note, however, that the pandemic may have exacerbated the strain on couple relationships and parenting partnerships for some families -particularly for those with pre-existing relationship difficulties and limited personal and social resources. Such families may benefit from interventions which go beyond parenting skill development to focus on specific skills to strengthen the co-parenting relationship. Whilst continued access to services had been important for parents, both parents and clinicians highlighted greater need for mental health support as well as financial support to access basic needs including food and baby supplies. For parents whose children were in out-of-home care, restrictions meant they were unable to see and maintain a meaningful relationship with their children and work towards reunification. Considerable distress was expressed by these parents, highlighting their need for mental health support and opportunities for access visits with their children during the pandemic. Lastly, clinicians' concern regarding parenting stress and child safety highlight that continued provision of services which support families to increase parenting capacity and monitor risks of child maltreatment are critical. Importantly, this study captured the voices and experiences of one of the most disadvantaged cohorts of families in our communities during the COVID-19 pandemic, and this was complemented by the experiences of clinicians working closely with these families. However, it is important to note that the study findings were likely impacted by the openness of participants to share their experiences, particularly related to the challenges faced by their family during the COVID-19 pandemic. All parents who participated in interviews were involved with Child Protection Services at the time of the interview, and many noted negative experiences with services in the past. The interviewer was not known to participants prior to contacting them, and there were limited opportunities to build trust and rapport. As a result, some participants might have chosen not to share some of the challenges they were facing during the pandemic due to mandatory reporting concerns. The discrepancy noted within this study between clinician and parent reports on the impact of the pandemic on child well-being highlights the complexities of conducting research on sensitive topics with parents involved with child protection services. Future research with similar populations could seek to use strategies to build trust and rapport prior to discussion of sensitive topics such as use of prolonged engagement, multiple interviews and use of videoconferencing platforms or face-to-face interviews. It is important to note that there was considerable heterogeneity among parents within our sample, including country of birth and language background. Moreover, although most parents had their child in their care at the time of time interview, two parents did not. It is likely that there were considerable differences in experiences across these groups which may have been more pronounced if our sample was larger. It is important that future research attempt to understand the experience of the pandemic for specific populations of families such as those from migrant and refugee background, families identifying as Aboriginal and/or Torres Strait Islander, and those with children in out of home care. In addition, the COVID-19 pandemic is likely to remain in families' lives for some time, with the period of recovery likely to be most enduring for those hardest hit by its social and economic impacts. A key area for future research is to work with organisations to develop and evaluate innovative ways to provide services to at risk families in a way that ensures children are seen and are provided with the support and protection they need. Infants are highly vulnerable to the long-term impacts of maltreatment (Cicchetti & Rogosch, 2012) and understanding how to best support parents during the COVID-19 pandemic is critical. This study highlighted the importance of continued access to mental health support, childcare and other respite options to minimise parenting stress and parent mental health difficulties, and therefore, reduce child maltreatment risks. COVID-19 physical distancing restrictions have created challenges for services to provide flexible and accessible care to all families. Many services have pivoted rapidly to telehealth options, enabling continued provision of services, however, it is also important that barriers to identifying and monitoring risk to child safety, and to accessing safe and high-quality telehealth, such as access to electronic devices, stable internet and confidential spaces, are addressed. These efforts are critical to ensure an environment to promote parent mental health, child safety, and family preservation and reunification during the pandemic crisis. All authors significantly contributed to this publication. AF contributed to study conceptualisation and design, conducted qualitative interviews, and led the analysis of data and write up of the manuscript. AJ made substantial contributions to study conceptualisation and design, participant recruitment, was part of the broader research team reviewing the data analysis, and was involved in the drafting and revising of the manuscript. KE and JO were both involved in the study's conceptualisation and in the revising of the manuscript for important intellectual content. RG was the study's Principal Investigator, leading the study design and conceptualisation, assisted with data analysis, and involved in the drafting and revising of the manuscript. The authors would like to acknowledge the study participants for generously sharing their experiences of this challenging time. This project was funded by Department of Health and Human Services, the Victor Chiodo Foundation, and Morgan Stanley. Murdoch Children's Research Institute received funding from the Victorian Government Operational Infrastructure Support Program. 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