One in Ten

Multidisciplinary Teams: What's the Secret Sauce?

November 25, 2021 National Children's Alliance / James Herbert Season 3 Episode 16
One in Ten
Multidisciplinary Teams: What's the Secret Sauce?
Show Notes Transcript Chapter Markers
In today’s episode, we speak with Dr. James Herbert, senior research fellow at the Australian Center for Child Protection, the first Children’s Advocacy Center (CAC) in Australia. Now, for those of us in the CAC movement or on multidisciplinary teams (MDTs), we sometimes take our work together for granted. The teamwork, the support—the conflict!—and the difficult decisions we make together to protect children. But imagine for a moment coming to that work completely fresh and as a research scientist, as Herbert did, and truly trying to unpack what makes it work.

Now, we know that research has established that MDTs create better outcomes in child abuse cases. But what is that secret sauce that does make it work? How do teams make their decisions in these high-stakes cases? And what research is still needed to help us better leverage the combined knowledge and skills of the team? Most importantly, how does improving the understanding of the MDT model help us better serve abused children?

 Topics in this episode:

  • Getting into child abuse research (1:33)
  • A lack of research on multidisciplinary teams (7:20)
  • Current research on MDT effectiveness (9:34)
  • Barriers to service (what caregivers say vs. what CACs say) (21:35)
  • Government funding for child advocates (27:47)
  • Other research needs (31:24)
  • The EU and the Barnahus model (42:47)
  • Our next episode (45:12)
Links:

James Herbert, Ph.D., is a senior research fellow at the Australian Centre for Child Protection at the University of South Australia

Better together? A review of evidence for multi-disciplinary teams responding to physical and sexual child abuse,” Herbert, JL & Bromfield, L (2019), Trauma, Violence, & Abuse, vol. 20, no. 2, pp. 228–15.

Barnahus model

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at NationalChildrensAlliance.org. Or visit our podcast website at OneInTenPodcast.org. And join us on Facebook at One in Ten podcast.


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Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “Multidisciplinary Teams: What’s the Secret Sauce?” I speak with Dr. James Herbert, senior research fellow at the Australian Center for Child Protection. And that is the first CAC [Children’s Advocacy Center] in Australia. Now, for those of us in the CAC movement or on multidisciplinary teams [MDTs], we sometimes take our work together for granted. The teamwork, the support, oh the conflict!, and the difficult decisions we make together to protect children.

But imagine for a moment coming to that work completely fresh and as a research scientist, as James did, and truly trying to unpack what makes it work.

Now, we know that research has established that MDTs create better outcomes in child abuse cases. But what is that secret sauce that does make it work? How do teams make their decisions in these high-stakes cases? And what research is still needed to help us better leverage the combined knowledge and skills of the team? Most importantly, how does improving the understanding of the MDT model help us better serve abused children?

I know you’re going to be as interested as I was in James’s take from halfway around the globe. Take a listen.
 

Teresa Huizar:
Hi, James, welcome to One in Ten

James Herbert:
Hi, Teresa. How are you?

Teresa Huizar: 
I’m great. And I know it’s bright and early where you are and it’s evening where I am, but I’m looking forward to our conversation today. And, you know, I just want to start the conversation where I do every one of these, which is to say, how did you come to this work? Especially that work around looking at effective responses to child abuse. 

James Herbert: 
It kinda was a bit serendipitous in that I was really interested in evidence-based policy and that was sort of the thing I was pursuing as a research interest. And, you know, I’d worked in corrections and a few other things and sort of got really interested in, you know, all right, we do this research. How does it sort of rumble around these big organizations and actually have an impact? And yeah, I guess maybe I got a bit jaded and cynical based on the experience of working in corrections. So I did some work looking at the impacts of evaluation after the fact.

So, really big scale evaluations. And just by chance, they happened to all be early intervention child protection programs. So when I sort of finished up and was applying for jobs, one of the jobs that came up was at the Australian Centre for Child Protection. Then it actually was really just down to that sort of what brought me into researching into multi-agency responses was the postdoc was specifically kind of embedded within the development of a new Child Advocacy Center in Perth, Western Australia, which is my hometown.

I was living in Sydney at the time. So yeah, I kind of had the opportunity to move back to Perth, which was really great as well. Yeah, be embedded in and I guess support this new thing that was happening in Western Australia. They were, you know, really excited about it. And it had taken a really long time to get all the different police and everyone else on board.

But, yeah, it was a really awesome experience of just sort of being dropped in, you know, not only doing the research and understanding what’s going on broader in the field, but actually sitting within one and watching it sort of develop around me and, and even seeing the way police and child protection and interviewers and things changed the way they interacted with each other as they became more familiar. Yeah, it was a really powerful experience. It really reinforced the, I guess the meaningfulness of inter-agency collaboration when it’s at that very personal. 

Teresa Huizar:
Well, and interestingly enough, because you were watching them while researching them, it was a little bit, I don’t know, sociological too.

James Herbert:
“Watching them while researching them” sounds a little ominous.

Teresa Huizar:
It’s interesting. But you know, one of the things that you had, the benefit of which—you know, you’d have to go back in our history 35 years to find something similar—is you were, even though I know that there had been multidisciplinary efforts in Australia for some time—this really was the first Children’s Advocacy Center model developed there. And so there weren’t any sacred cows about how you went about that, really. You had the benefit of bringing fresh eyes to that. And I’m just wondering as a researcher, I know that the place you start is looking at the existing literature and sort of delving into it. What does it tell us is effective? What’s there?

Were you surprised that, while there is a fair amount of research about Children’s Advocacy Centers and the various disciplines within them, there really wasn’t much about what made multidisciplinary teams effective?

James Herbert: 
I guess there’s a few things to unpack with that. So we sort of came in and had the advantage of, alright, we agree that a more holistic response is needed.

What does that look like in the context of our local system? And, obviously Child Advocacy Center, you know, it’s an approach, and you know states and jurisdictions have the ability to sort of adapt it and tweak it for their own systems, within the principles, of course. They were able to start from a broader position of saying, “Hey, what’s going to make a difference? What’s actually—well, one: How do we work within the existing legislation and the mandates that particular government workers have? But also, how do we sort of like tighten this thing up and make it all work?

And, yeah, it was really exciting sort of being around for them having those conversations where, you know, anything was possible that we’re really motivated to try and give a better experience for children coming into the system and to link them into the services they need, because that was the issue they really understood.

And I guess the point you were making about starting from scratch but also having some things sort of floating around is part of what was driving our research and at, at the very start was: All right, we’ve got this evidence base for Children’s Advocacy Centers. You know, primarily a lot of the studies are from the early 2000s. They’re sort of reflecting at a time in the U.S. where you’re comparing a sort of informal interagency response versus, you know, massive Child Advocacy Centers. Like, I think it was Dallas and, you know, Huntsville [Alabama], and Philadelphia, like those really, really developed, centralized clusters of resources.

So it was sort of different for us because we had professionalized interviewers that were delivering an evidence-based protocol. We had you know, a rough inter-agency system that was more or less about having an initial meeting about a case content. So for our research, we sort of had to start to think about and start to unpack: Alright, if you are only implementing some of these things, what are the things you’d expect to see as a result of it? So that sort of prompted us to try and I guess unpack, you know, multi-agency responses or CACs as an intervention to say: Hey, if you’re only doing some of these things, if you already have some of these other things, what other reasonable things or the reasonable outcomes that you’d be wanting to evaluate to see whether you’re having the effect?

Teresa Huizar: 
I remember the first time I read some of your research about this, one of the things that really struck me about it is that when you’re delivering a complex intervention, sometimes you can make assumptions about what makes the difference. And then that can turn out not to be the central factor that does. You know, it’s an interesting thing that you can have assumptions about what’s this, you know, what’s the special ingredient in the secret sauce that makes all the difference? But those are just assumptions until they’re tested. And I really appreciated the fact that you were—along with other researchers—exploring that question about what is it that makes the difference in the MDT response.

And I’m just wondering, you know, you had this experience of looking through the literature, crafting the study, and at the same time, observing the team that was sitting, you know, right down the hallway from you and what hypothesis did you really have—or hypotheses—going into that? And how did your own experience with the team that you were working with daily, how did it shape that?

James Herbert: 
I am by my nature, a bit of a cynic, but I think some of the special sauce is less, and maybe this is part of the intervention that’s less studied as well is some of the cultural aspects and the exchange and the learning that happens at a really deep level between these different disciplines that are often coming at things with different knowledge and different experiences and different values.

Yeah. You know, whether informally they can get together and resolve those things and make good decisions in the context of the case mutually, or whether you need a protocol or a set of procedures that helps to, I guess, mediate those different mandates and responsibilities.

I think that’s really the special sauce. And I think everything else is sort of like layered on top. But yeah, they’re absolutely, you know, really complex interventions that have a lot going into them. So I think maybe the culture piece is maybe something we miss all the time. Like, we’re really sort of focused on intervention bits we can see like implementing interviewing protocols or co-locating people and that sort of stuff.

Teresa Huizar: 
Well, related to that, I know that you have a current research interest in multidisciplinary team deliberations. And can you talk a little bit about what interested you in that and sort of what you’re hoping to explore? 

James Herbert: 
The work on the Child Advocacy Center here was really sort of built around a postdoc. And so that finished, I think, in 2018. From then, I’ve really sort of like funneled down into a few different content areas that are still definitely within the realm of multi-agency responses, but yeah, one of them, and one that I’m really interested in, and one that I think has really broad applications to lots of different types of interventions, is thinking about MDT deliberations.

Obviously MDTs, lots of them are very different. Some of them are sort of arrive at a group decision. Some are not, some are sort of more information sharing and that sort of thing. And, I’ve sat in lots of them. Like I’ve sat in some that really have those arguments and bang the table.

And, you know, I’ve seen this before: “It’s really important that we intervene,” and you know, that sort of stuff, but I’ve also been in ones they just sort of are exchanging information and, someone’s sort of reading off a sheet and it’s being added to a PDF and I’m thinking, “Gee, this really could have been an email” or really a technological solution that could have achieved the same thing.

It sort of has got me thinking about what happens in these MDTs and whether they arrive at a different decision than they would otherwise. So. It is a bit of a sort of, you know, confected scenario. It’s a bit of an experimental situation, but we’re developing a project to look at MDT deliberation in the sense of: Are people changing their minds from the point of initially coming in, through the deliberation process, and at the end? So the idea would be, we would test people’s assessment of risk and recommended actions on a number of vignettes. We’d have them as a group deliberate an unstructured way. So it’s sort of up to them and, you know, ideally working within their existing group deliberation structure, have them arrive at a group decision and then at the end see whether anything’s changed.

And now from that you learn a few interesting things. One one hand you will learn whose assessment of risk counts more. Who’s got the sort of juice in the situation? Whose assessment of things is most powerful in forming the group consensus? You get a sense of whether people are actually changing their minds.

So are people sort of—you know, because they have to work in these teams day in, day out—are they not dying on particular molehills? Are they sort of agreeing to group assessments but have a different personal opinion? I think this is sort of a starting point and where I’d like to be, is starting to unpack and look at the dynamics of some of these MDTs.

Teresa Huizar: 
So I’m wondering James, you know, thinking about these deliberations and what you’re trying to understand about them, which sort of ties back to your interest in culture as well, because you’re trying to explore how much sort of interpersonal differences or persuasion or lots of other variables affect the decision-making of teams, do you have a thesis? Do you have a sort of theory about, “This is sort of what I’m expecting to see”? 

James Herbert: 
I’m open-minded at this stage and I mean, there have been some forerunners of this work and so we have a rough idea. I guess there’s been some qualitative stuff looking at, particularly in the UK where they have these safeguarding boards, they have a lot of local level inter-agency collaboration happening. And I guess the observation there has been that there is often a tendency to not challenge each other and not raise difficult questions within teams. And so we think that we’ll observe a bit of that. But I also think it will be conditional on different types of cases. And I think that’s where it gets really interesting is the types of cases that really sort of trigger different disciplines’ risk antenna.

They’re sort of like, “Well, we’ll see things and be like, well, we need to elevate this as higher risk.” And that’s sort of, I think, where we’re really interested in understanding, what is the nature of these cases? What’s the nature of the deliberation and these differences that’re going on?

This is primarily a quantitative project and looking at the differences, but the other thing we’re really interested in is the deliberation. So we’ll be recording those and analyzing this sort of discourse and discussions and persuasion that’s happening in cases where there’s big attitude change compared to ones where there’s a little attitude change.

So I think that that’ll be really interesting, but I guess the other challenge for that, Teresa,  is we are probably going to be looking at three or four teams. And so with that, we won’t be able to quite get into the culture of the teams quite as much, because we won’t have the level of variation that someone doing this in the U.S. and looking at Child Advocacy Centers could get where you could look at the wide variety of teams that are out there and sort of develop a bit of a measure of the culture within the teams. Who’s dominant and who’s sort of driving decision-making within those teams.

Teresa Huizar: 
You know, I was just thinking, as you were talking, about some case review that I observed in Tennessee, where as a part of their—they call them CPIT [Child Protective Investigative Teams], but as a part of their CPIT meetings, which are, I believe by statute led by the prosecutor, but the team itself has to come to a consensus about the next step, and there has to be an actual vote about it.

And what was interesting about that is, in those that I observed, there was much more robust debate then in case reviews, which are far more common, in which there would never be a vote. Do you know what I mean? It’s just people talk around the table and some sort of consensus sort of emerges and people may or may not ultimately agree with that.

But I thought that was interesting that the fact that they had to vote in front of their peers seemed to make a difference to the amount of debate. Now, of course, you know, that’s an N of what, you know the small handful of those I observed, but I just remember being very struck by that even years ago, when I observed them, I was like, that is fascinating how much that changed the dynamic. It’s almost like I would want before having them scoring these, sort of how they get along and in their deliberations on agreeableness as a personality trait. I think more agreeable people are going to go along just generally, you know? And so how does that impact what happens in MDT deliberations? When you have lots of people in the room who are prone to be highly agreeable, what does that mean for the level of debate and discourse that actually occurs?

James Herbert: 
Wow. I think I need a social psychologist in my team.

Teresa Huizar:
You might!

James Herbert: 
Yeah. That’s really interesting. I think there’s so many things that come into play, you know, the relative power—

Teresa Huizar:
Yes.

James Herbert:
—and the agreeableness, also some of the gender dynamics as well. Like my observations of sitting in a Child Advocacy Center is the really gendered nature of some of the different job roles and how those dynamics sort of play out.

It’s all really interesting stuff. And I think really ripe for further exploration and looking at. Some of this work has been done in, I guess multidisciplinary medical teams, but that’s quite the different way when everyone starts from the premise of being a medical subdiscipline or a medical specialist. And maybe at the other end you might have a social worker or something like that. But having disciplines so different and with such different values and mandates as police prosecutors, child and family advocates, that sort of thing. I think that it just introduces a whole new level of complexity about how people interact and how they ultimately, I guess, arrive at a decision they can all live with. Because, you know, part of what this is all about is, one, you’re hoping that they arrive at a better decision than you would get individually.

But the other thing is, all these people have to sort of like live and continue day by day on these decisions. And if there’s something that is bothering them and is challenging their ability to continue to work in that same, like that’s a real issue. 

Teresa Huizar: I do think that healthy teams are ones that normalize and have normal ways of coping with conflict, you know? And so there’s not the sense of, “We’ve got to go along to get along on everything.” I think where that exists, it’s not just that case review and that type of team deliberation is not as good as it could be, but I think you just see that kids are sort of inevitably getting short shrift because people do not want to have the more difficult conversations that need to be had. And so, I’m very interested, not only in your research around MDT deliberations, but I’m just interested in this idea about how teams cope with conflict and how that ties to the quality of the decisions that they make.

So I just feel like, you may be relatively early in your career, but there’s an unlimited number of subjects that you can research over the next 40 years or whatever.

James Herbert: 
Oh yeah. If I’m hopefully 40 years, that’d be a pretty substantial career. Yeah. Look, I guess the other area I wanted to bring in with that I’ve been in pursuing is really about the take-up of therapeutic services from the point of the forensic interviews. And that’s part and parcel of the Child Advocacy Center model is, you know, having the child and family advocate, that’s sort of addressing some of those barriers and might be doing a bit of psycho-education and education on trauma to try and facilitate those referrals. I guess what I’ve been really interested in is the contribution of that to a successful engagement and completion.

And again, you know, these are prerequisites to benefiting from therapy, but my observation is sometimes within the system here, things are really sort of a bit based on more of a consumer model. So they’re sort of based on the premise that if they want a service, they will present to the service provider and they will tell us what they need, and that sort of stuff. And I just think that that’s not the population we’re talking about. We’re talking about people that have often a lot of challenges, and I just really like the idea of the child advocate that’s working to address— you know, sometimes these might be really minor barriers. Sometimes they’re more substantive and complex, but often these are just, being intimidated and wanting to keep them, you know, going to a service, and someone coming with them makes all the difference and potentially is that sort of “sliding doors” moment between someone actually engaging and completing a course of therapy and making that step towards recovery versus joining the ranks of people with untreated trauma out in the community that come and manifest themselves in various ways later in life.

Teresa Huizar: 
You raise a good point. And I think it’s naive to think that people who are sometimes at the point of most crisis they’ll experience in their life are a sort of normal type of consumer, you know, they can weigh all the pros and they can weigh all the cons of doing something very, very calmly and sort of decide what they’re going to take up in that way. You know, we forget when there’s a child sexual abuse allegation in a family, especially it’s like a bomb going off in that family. And so I think that when you think about just how disruptive that is, we can’t expect that caregivers are going to make the same decisions they necessarily would even six weeks later, four weeks later.

I think that one of the things that interested in NCA [National Children’s Alliance] in this, because we’ve been doing a fair amount of work more recently around family engagement, is we a few years ago included in our census—which is a survey we do of all Children’s Advocacy Centers about their programs every couple of years—we asked them questions about what CACs’ perceived as the greatest barriers for kids and families taking up services, particularly mental health services. It was pretty interesting. People listed all the things you would expect: transportation and child care and waiting lists and all of these things. And they ranked those types of very practical barriers very high. 

Then when you look at our Outcome Measurement Survey, where we’re asking caregivers directly about those things, those practical barriers actually rated much lower than what parents said, which basically was: I didn’t think my child needed it.

That was the number one barrier, was this perceptual barrier. So sort of perceptual and attitudinal barriers. This isn’t about trying to blame parents for that or say, “Well, I can’t believe you don’t understand why they need this.” Quite to the contrary. It really pointed us in a much more effective way to say, “Well, you know, if the problem is that a parent doesn’t believe their child needs therapy, and we can see from their trauma symptoms that they do, then there are two things here. One, we need to make sure that we’re doing some psycho-education about the benefits of that. Two, we need to train family advocates in motivational interviewing and other techniques so that they really can have these conversations in a way to unpack what the [caregivers’] concerns or perceptions are. And three, you have to look at the issues of untreated trauma in the parents because—or a bad experience that they had had with a therapist—because that was driving some of that perception about they don’t need it, or it doesn’t really help.

And so I think that this is an area in which Children’s Advocacy Centers have a lot of work to do ahead of us collectively, together as a movement, because we know that when you’re doing all of those things and you’re addressing these very real concerns that parents might have or perceptual barriers, it makes all the difference in seeing kids really see this uptake of services. And it was real shift, I mean, here in the U.S. moving from “Here’s your pamphlet or brochure, here’s a number to call” to “We’re going to really sit down and talk with you. We’re going to help make the appointment. We’re going to follow up with you about your concerns to make sure you actually get there. If you fail to show, we’re not just going to say ‘too bad, so sad.’ We’re going to follow up with you again to say, ‘Okay. Was there an issue? How can we help you those kinds of things and talk to you about it in a different way?’” 

That’s just a very much more extensive, I would, say family advocacy model, but what we’re seeing is that it’s really having substantial effects and it’s making family advocates feel more successful about their work. And they’re not just in an endless loop of trying to help, but never really feeling that they get to an outcome. So I think you’re really onto something and I’ll just be fascinated to see what research emerges.

James Herbert: 
Yeah. Look, I think monitoring who’s actually getting to services is really important. That was really interesting, the discrepancy between what providers were reporting where the barriers as opposed to what families were. But I think some of these things are, like, really idiosyncratic to the local context.

It’s sort of depends on, I guess, the thickness of the service environments, the complexity of the service environment. There’s a lot of things going on. One thing, you know, obviously I’m a data person, so I want to know this stuff. On the one hand, I think as well, there’s a piece about what is the contribution of the advocate to you know, I guess not to be biased, but the sort of conversion to actually completing therapy and potentially benefiting from it. I think that’s a case that we’ve had a lot of a challenge making here, which is convincing government departments that the advocate role is something worth funding.

So I think on the one hand is there’s a piece about demonstrating the value of that. I guess the other piece of it and pre pandemic they [Chicago] were nice enough to host me. I was really impressed with some of the work they were doing around sort of monitoring who is getting and who isn’t getting to services, which they monitored for a really long period of time, and then use that to generate solutions to those problems.

And so in that case, it was things like, you know, building motivational interviewing and professionalization of the advocates, but it was also sort of generating a centralized waitlist. You know, they had this problem of long wait lists and high dropout, and the solution to it was really, instead of people being on waitlists all around town, being on a centralized one but still being able to go out and try out different services and see whether they, I guess, develop that therapeutic alliance with anyone who could see them. I just found that really, really impressive, and really long-term thinking in terms of how to make the most of data and build that into not just the Child Advocacy Center, but into the local service system, because they were really talking about a network of therapeutic providers across Chicago.

So I just found that really impressive in terms of data use. 

Teresa Huizar: 
Oh, I agree. I mean, I think the Pathway Program overall is just so interesting and, you know, Char has been generous enough to present about it as has Wendy more than once. And I just think it’s an interesting thing to try to continue to explore all the ways to reduce these barriers. I do think, in terms of your comment about your government’s reluctance to maybe see the value of, or fund as much as you’d like, child or family advocates— 

James Herbert: 
To be fair, they’ve been getting it for free.

Teresa Huizar:
Yeah, no, I get it. I—

James Herbert:
They’re getting it for free, so that explains the need to convince them to pay for it. 

Teresa Huizar: 
Yeah, I know, I get it, I get it. I just think that a part of this is that there’s just not as much research about that role as other things. You know we found in—every five years, we commissioned an annotated bibliography around our Standards [National Standards of Accreditation for CACs], including all of these various services. And if you look at that and just thumb through the number of pages on recent research, around forensic interviewing, for example, or the medical response or mental health, I mean, it’s voluminous. But when you, when you get to victim advocacy, it’s thin, because there’s really not that much out there.

And I think that that’s a discipline that has been professionalizing and is still doing that in terms of setting up its sort of practice standards and testing those and seeing how that works. So I think here in the U.S. too, it’s, it’s an important role, but one in which often I think family advocates themselves feel that they’re having to argue and debate about the importance of their role, because it just doesn’t have the same level of evidence-base as some other things. And so I’m hopeful that researchers will begin to take more of an interest in that role and not just the flashier sorts of things that have gotten a lot of attention, in the U.S. anyway over the last 35 years.

James Herbert: 
Hmm. Yeah. And I don’t want to pretend that Western Australia where I am and where I was evaluating has the only multiagency response in the country. Like really, there are sort of other things that do look like that and do have an advocacy role built in. It might be called something else, or it might sort of sit in another way, but there’s really quite developed multi-agency responses in Victoria and even in New South Wales, which is much more of a government-led system, you know, with departments of health, much more involved. There are sort of things floating around that do have that role built in.

So it’s not so outlandish that they would consider paying for or supporting a child and family advocate linked to their forensic response. I think it’s for free as part of the trial and to sort of sweeten up to do a Child Advocacy Center approach. They’ve just gotten used to it. So yeah, I think that the next phase is really about demonstrating some of the—you know because it’s government, so it has to be economic benefits. So, pitching, pitching it that way. But I think also there is a more emotive piece and maybe a more rights-based piece about, “Hey, you know, equitable access to these, really important services, it’s what you would want for your children.”

As well as, you know, the economic argument about untreated trauma in the community and the long-term impacts of that. So I think probably the two-pronged approach is the way to go. 

Teresa Huizar: 
When you’ve talked to your colleagues around the world, you know, here in the U.S. and elsewhere, about developments in this model, and also research interests that are worth exploring, what do you see as research gaps that exist that you think—whether it’s you or anyone else—you’re like, “Somebody needs to research that”? 

James Herbert: 
We’ve covered some of them. Particularly the child/family advocate and the contribution to both, I guess, the child-centeredness of the experience—so the degree to which it’s a less distressing experience for the child and their family because of the advocate—but also, yeah, some of the sort of therapeutic outcomes in terms of: “Alright, you started addressing some of these immediate barriers or challenges the family’s having through your response that then facilitates them going into those services.”

I think that’s something really interesting. I have been looking for a good sort of site in Australia, too, to be able to compare between sort of the more, you know, “Here’s a sheet of services” compared to someone that’s getting an advocate. It is difficult because, you know, there tends to be state-based responses here. So things tend to be quite uniform across the state. But there are sort of pilots happening here and there. And if we get in at the right time, you can get some data that’ll tell you something interesting. 

I think as well, yeah, we talked about the culture piece and then how some of those teams operate and function, which I think is, is really interesting. The other bit of it. And I think probably where some of the big gaps is in, I guess, the types of services that are being connected to from the forensic response. So say you’ve got a Child Advocacy Center that they won’t have any in-house service. They might refer out to various services that are in the local area.

I think while there’s a lot of really good research and evidence about best practice treatments for, for trauma, and even, some really good research on complex trauma, I think the next question is about some of the standards that you want to see and the types of services that are being referred from Child Advocacy Centers. Bearing in mind that we’re primarily, I guess, you know, it might vary place to place, but my experience has been, we’re primarily talking about very complex cases with lots of things going on. Is it appropriate to then refer to services that are primarily still on treating basic trauma and not two systems approach? 

So I guess for me, some of the questions are about what are the appropriate services that should be connected to a Child Advocacy Center. What things can we get behind as being evidence-based and [appropriate for the situation]?

Teresa Huizar: 
Well, I think it’s interesting that you say that because I do think that, while there are lots of treatments and for that matter services that exist, once you really start drilling down into the evidence-based, you know, it sort of narrows the field considerably. And I think that, for us, we started getting this question some years back where people would be like, “Oh, okay. So what do you recommend as the evidence-based mental health treatment that we should offer?” 

And of course there’s not just one, right? There’s some, but actually the number of them that have solid evidence for the particular—not evidence for substance abuse treatment, not evidence for some other type of something someone might need, but specifically around trauma that relates to abuse. Actually, there’s a handful, you know, it’s not a large number. 

And so we set out to start, some years ago, just sharing that information. It’s like—because I think what CAC directors here felt was it was like sifting a needle in a haystack—you know, they would go on to our government’s website and start looking at all the evidence-based interventions that many of those didn’t apply to their population. So it just became overwhelming. How do I even begin to pick one of these? And one of the things that we can do and that research can do is help answer that question about: There’s not an unlimited amount of money to train clinicians, and there’s not an unlimited amount of money that Children’s Advocacy Centers have in terms of brokering services. So that being the case, what are those that are most promising and most likely to deliver the outcomes that we want to see for the population that we’re typically serving? I think that that’s really important and I’m delighted to hear you’re looking into that and hope others do. 

James Herbert: 
I do have to be critical of research in some respects in that often the evidence-base for things are based on really idealized samples. Ones that don’t necessarily apply very well to Children’s Advocacy Centers. So like when you’re doing a randomized control trial and you’re screening for ongoing domestic violence and substance abuse and those sorts of things, the group you’re testing, will look less and less like the actual clinical sample.

And I think that it gets very challenging about then applying it to different contexts. And I guess the other thing to say, and maybe it goes to your point, Teresa, is we’re more thinking now in terms of the context of complex trauma with lots of things going on is more of a matrix type approach, which is to say matching different symptomatology to different interventions and thinking about how you sort of combine them in that sort of formulation stage instead of dogmatically sort of applying a particular model. I mean, you might have a primary model as a base, but you would have a sort of assessment and diagnosis stage where you’d identify some of the key issues or key things to address, and then you’d be going, ideally going through a sort of matrix to match them to particular therapeutic approaches that would address that.

And I guess in the formulation stage, ideally within a therapeutic team, you’d be making some decisions about how to structure that and how those things could work in a complimentary way. And I think that’s really the only way to go with complex trauma at the moment. It’s just very, very difficult to apply the evidence-base to, I guess, the complexity of the lives of some of the children and the families that show up at Child Advocacy Centers.

Teresa Huizar: 
I think one of the benefits of the fact that we have so many Children’s Advocacy Centers here in the U.S., is so many of them over the years, especially some of the larger ones, have paired with research institutions, and now there’s more published research that was developed in the context of a CAC.

And I think that, for me, it’s critical that Children’s Advocacy Centers see themselves as partnered with researchers. So you don’t have this sort of disconnect that you’re describing, whereas you’re not like, “Okay, well, this was tested in an academic center with kids who had virtually no trauma at all. And now we’re trying to implement it somewhere else.” We’re seeing more published research where the entirety of the research study was conducted within the context of the CAC pool. So I hope that that continues to grow and continues to grow worldwide because I think that’s a critical point you’re making, is that there’s this real life effect too.

James Herbert:
Yeah. And look, I’ve seen that myself and undertaking literature reviews that it’s less now studies of “Do Child Advocacy Centers work?” and it’s more, “We’re doing this new intervention and it just so happens to be in a Child Advocacy Center.” I’d say we’re seeing a lot more of that.

I think that speaks to the next stage of things, which is the sort of tinkering and improving and thinking about how things work within that context, because that is the predominant context in the United States now. Which is really interesting. It sets some challenges for research.

And I know, and I sort of said, you know, wow, it’s sort of at a point where you couldn’t do a comparative study in the U.S. anymore because everyone, almost everyone, has some form of multi-agency response. You couldn’t do the multi-site.

Teresa Huizar:
With your control, right? Yeah.

James Herbert:
Yeah, the horse has bolted on that one. 

Teresa Huizar: 
Well, you know, we’ll have to look at our colleagues around the world who may be differently positioned, sort of looking at that ground again, which I think is always helpful. You know, we had one experience with it, but I think other countries may have another. And it’ll be interesting to see that.

I think you’re right though. It does mean that the research questions that are really to be pursued here maybe slightly different now than they would have been back when the multi-site evaluation was done. But that was such a seminal piece of research, you know, I think had that work not been done at the time it was done, as you point out it would be impossible to do. So I’m just wondering. We’ve talked about research directions. We talked about the things that you’re working on and hope to work on. What makes you feel hopeful about the future of these programs in your own context in Perth and the rest of Australia?

James Herbert: 
Hmm. 

Teresa Huizar: 
I realize I’m asking the cynic.

James Herbert:
Look, I think—

Teresa Huizar:
A self-avowed cynic.

James Herbert: 
Yeah, I am by nature, a bit of a cynic. But in the course of my research career, I’ve sort of endeavored to go from being an outsider—and part of being in a university is being an outsider. You know, you’re supposed to be an independent voice—to getting a bit more access to government and seeing how things work.

And I guess I’ve been impressed by the people within those agencies that, you know, previously, you know, when you’re outside, it’s very easy to say, “Oh, you know, they make dumb decisions all the time. They do dumb stuff, fund dumb things.” But once you’re in and sort of meeting these like really impressive, really knowledgeable people, I think, on the one hand you’re like, “Geez, how are they making these terrible decisions when they’ve got such incredible competence and clever people?” But on the other hand, I’m happy that they’re happy that they’re, doing what they do and are motivated to do things for the benefit of children in there particular state.

So I think that that’s maybe a source of encouragement for me that there are people within, I guess the more powerful institutions, who really know what they’re talking about and make really tough decisions—the best with the best knowledge they can. And yeah, I think dedicating ourselves to, I guess, connecting research to that policy making and that decision-making is really important and we can’t ask them to make the further step. We can’t ask them to walk all the way to us and run randomized trials and that sort of stuff. We have to—probably not halfway, probably a bit further than halfway—meet them. And make it easy for them to work with us and to give them the knowledge and the language from the broader literature and all the things we’ve learned from other places. So I think that’s—it’s a long answer—but maybe that’s the thing that encourages me. 

Teresa Huizar: 
So what question have I not asked you, or is there anything else you’d like to cover in the conversation, James?

James Herbert:
I’m always really excited to hear from NCA and all the things you’re up to. I know the survey work and all the sort of background material you provide. So always really handy to have a glimpse of what’s going on in the U.S.

Oh yeah, I actually do have an additional thing. Sort of adding on to what you were saying before. I’ve been making an effort to really connect to the Barnahus movement in the EU. I think this has really interesting things going on in terms of adaption of the models. So, you know, of course the EU: really, really varied contexts—you know, Bulgaria as opposed to France or Germany and really diverse countries with different legal systems as well.

And just hearing about how they adapt the model to fit their context. And I guess maybe in some ways there’s some better parallels to the west Australian context in terms of the split between how law enforcement works and prosecutors and things like that; this may be some better analogs for us to learn from. As well as the EU is said to have really good data and really good public health data on prevalence data and things like that. So I think that that’s a really exciting area and I really want to make sure I’m connected into that network and understanding what the developments are there across all the new studies that are happening over there. It’s really an exciting space at the moment.

Teresa Huizar: 
You know, it is so interesting to see how flexible this model is and how it plays out, effectively but differently in every country that it’s in. And so I just am always interested in research that comes from Children’s Advocacy Centers or Barnahus model or others, you know, around the globe.

Thank you so much for coming on One in Ten, and we’ll look forward to talking to you again after your next research is published.

James Herbert: 
No problem. Thanks, Teresa. You’re very high energy for 8 p.m. So thanks so much for staying up.

Teresa Huizar: 
Well, James, I just really appreciate you getting up at the crack of dawn to do this. Goodness, we owe you one.

James Herbert:
Oh, it’s not a problem.

[Outro]

Teresa Huizar:
Thanks for listening to One in Ten. If you like this episode, please share it with a friend. And we hope you’ll join our next episode exploring whether antipoverty programs actually do reduce child maltreatment. For more information about this episode and others, please go to our podcast website at www.OneInTenPodcast.org.

Becoming a child abuse researcher
A lack of research on multidisciplinary teams
Current research on MDTs
Barriers to service
Government funding for advocates
Other research needs
The EU and the Barnahus model
Our next episode