Friday, 31 January 2014

Human Factors in Child Protection (2): Decision-making

Decision-making is central to child protection. Is this a child protection case? Is this child at risk of significant harm? Is emergency action required to protect this child? Is a child protection plan necessary? Should we start care proceedings? Each of these questions represents a step requiring someone or some group to make a decision, often a weighty one.

Wrong decisions can have momentous consequences. A case may be closed prematurely. A child may be returned home to suffer further abuse. A professional may wrongly decide that her or his concerns do not amount to a concern of abuse or neglect. As a result a child may be harmed, or worse.

So how do we take decisions? Psychologists [2] distinguish between different types of decision making. Below I look at each of these in turn.

Rule-based decision-making involves the decision-maker following procedures which determine the outcome. These often take the form "If X do Y". They may look straightforward, but problems often arise in determining how to interpret the procedure. For example Lord Laming recommended a procedure following the Victoria ClimbiƩ tragedy along the following lines: "If a child's first language is not English, an interpreter must be used ..." [1]. But what do we mean by a "first language" (first language learnt, most fluent language, language spoken at home, language spoken at school etc.) and who can be an interpreter (qualified professional interpreter, fluent speaker, person with some knowledge of the language, member of child's community, member of child's family)? And what happens where the child prefers to speak in (say) English, but is more fluent in another language, or where it is very difficult to find a qualified interpreter in a language not much spoken locally?

Clearly having procedures is a good idea in simple situations, where ambiguity and uncertainty do not apply. Procedures are actually useful in clear, simple and predictable situations. However, for complex situations procedures rapidly become too elaborate and eventually become unworkable. Highly involved procedures can result in unacceptable delays in action. Where procedures are too complex they can be difficult to understand and steps may be missed. Sometimes the wrong procedure for a given situation is applied. And sometimes the procedures themselves contain 'error traps' because the person who drafted the procedure did not foresee some particular set of circumstances. Last, but by no means least, complex procedures which make the task more difficult often result in people developing informal 'work arounds' to get the job done. These can have disastrous consequences, not least because managers may naively think that a procedure is being followed, when it isn't.

In contrast intuitive decision-making relies on the expertise of individuals. An experienced practitioner can spot patterns in situations and react rapidly and very often appropriately. This type of intuitive decision-making, or 'pattern-matching', is necessary where there is insufficient time to generate lists of options or to carry out any kind of detailed analysis. It is often essential in emergency situations. Often the response is 'workable' but not ideal and it is usually quick. This type of decision-making is suitable for 'first responders' in most types of emergency situations, but experienced practitioners are required. It is by no means infallible. Pattern 'mismatches' are always a danger and some very serious accidents have involved very experienced people making the wrong intuitive decision. Intuitive decision-making is not suitable for dealing with new circumstances or situations which are not well understood. It is not suitable for use by inexperienced people, especially novices.

Analytical decision-making involves identifying options, analysing each and selecting the best. Typically the decision-maker thinks through the consequences of each option, exploring the various scenarios, possibly identifying positives and negatives of each and comparing likely outcomes. As much relevant information as can be marshalled to inform the decision is the ideal. It is also important to identify and analyse the 'do nothing' option.

Clearly analytical decision-making is likely to produce optimal solutions more often than other methods and it is well adapted for complex situations. However, it requires a lot of time and effort and places a heavy burden on staff. It is not appropriate for emergency situations and difficult working environments, especially where a response is required quickly.

Creative decision-making involves coming-up with new and untried solutions to unfamiliar situations. It requires inventiveness and high levels of resourcefulness. It is very time consuming and makes very heavy demands on those who undertake it. It is also inherently risky. However, it is sometimes unavoidable when decision-makers are faced with completely new and novel situations about which little is known.


In child protection we need to use rule-based decision-making sparingly, only in situations where it is appropriate. Procedures will only work for simpler processes. In the past there has been a naive assumption that procedures could be extended more or less indefinitely to cover a wide variety of complex situations. This has resulted in large complex procedural manuals, not better child protection decisions.

In child protection work we should rely on intuitive decision-making only where it is absolutely necessary to provide a quick response, for example when considering emergency action to protect a child. This type of decision-making is suitable only for very experienced staff, but in Britain there has been an unfortunate tradition of providing first contact child protection services using recently qualified or agency social workers. No matter how experienced the decision-maker, intuitive decision-making requires careful review at the earliest opportunity, when time permits.

We need to recognise that much decision-making in child protection will be analytic. This requires good working conditions and staff have to be given the space, time and resources to analyse and assess options and to come to an optimal conclusion.

Creative decision-making in child protection should be avoided unless it is absolutely necessary to deal with new and challenging phenomena. It needs to be recognised that creative decisions in child protection will always be risky and should be avoided if possible.

No approach to decision-making is without a downside. Many decisions in child protection are inherently risky. Decisions should be reviewed where possible using the analytic approach, but where this is not possible the risks need to be realised. Reviewing decisions is time consuming and hard work, but it has to be recognised that it is frequently necessary.

Briefing and de-briefing can be used to support decision-making in child protection. De-briefing the team after an important piece of work can be an ideal opportunity to review the success or otherwise of the decisions taken. What went right and what went wrong? How can we do it better next time?

In a briefing we can identify and plan for likely outcomes before a significant piece of work is undertaken. In this way a well organised briefing can reduce the pressure to produce rapid decisions in a new and challenging situation.

Much decision-making in child protection is undertaken in groups, rather than by individuals. Planning or strategy meetings, reviews and child protection conferences all involve several people, often representing a range of agencies. Decision-making in groups has some advantages but also carries risks. I will be writing a further post of this subject in February.  


[1] Lord Laming, The Victoria Climbie Inquiry Report  CM 5739, HMSO, Norwich, Jan 2003. Recommendation 18, Paragraph 6.251

[2] See for example Flinn, R et al Safety at the Sharp End, Ashgate, 2003, Chapter 3.