Intervention Methods in Secure Care: What Is Going on for Society’s Most Vulnerable Children?

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to read this article on intervention methods in secure care.  Overall, I think the piece is a valuable contribution to the literature, especially highlighting the professional reflections on how to provide treatment for children in secure care. It is important to document the lack of evidence-based interventions in secure care even though many interventions are being offered. I have some comments and suggestions on the piece, which I hope will help to strengthen the work.

 

I am concerned about the scope of the article, which aims to analyze how professionals reflect on children’s needs and understand interventions and propose a concept of ‘containment’ as a way of explaining the limited scope for interventions in secure care. The structure of the article needs to be altered to accommodate both arguments – or reduced to just one of them. Either the article must present the analysis of professionals’ perspectives and discuss these findings in light of the literature. Or, the concept of containment needs to be presented earlier – preferably before the methods and analysis and applied analytically. Currently the ‘discussion’ is not really a discussion of the findings, but opens up for a whole new argument. The sentence in the abstract (repeated in the first part of Discussion) “we believe the concept of “containment” in both therapeutic and restrictive forms is an integrated dimension of…” is very complex and need to be unpacked and explained better. As I read the paper, there are in fact two papers squeezed into one. Consider which argument to forefront.

 

There are a few clarifications that are needed for the international reader. Please explain what secure care in Scotland is used for – are the children there in custody, serving sentences (legal grounds) or for protection/secure care (social grounds). You write that the purpose of secure care is dual: rehabilitation and protecting the public (p. 1 l. 24). This may be the case in Scotland, while other jurisdictions can have different purposes. Please also elaborate on what a consultation meeting is and whether children/parents never participate in these deliberations, what is the purpose etc.

 

The section presenting key literature on secure care interventions and what we know about effects and challenges also presents some wider literature, which touch upon the effect of social work interventions, social work practice and decision-making. I would suggest rewriting this section to a more precise presentation of secure care/interventions in secure care literature. The structure is unclear and the literature needs to reflect the main argument of the article (which ever you chose to forefront).

 

A few clarifications in the methods section are also needed. Why do you consider the study to be retrospective? Usually this terms applies to studies looking back at past experiences, but this seems to be a study of present meetings dealing with present cases. Also, was the study conducted in one organizational context of ‘consultation meetings’? How are they organized – connected to one secure institution? In case you studied one locality you may consider how that reflects in your data/findings? What is the difference between researchers and project staff? Som clarification on what you mean by “project”/specialist project – is it the study?

 

I hope you feel encouraged to revise the article and I sincerely believe there is a valuable contribution to the literature in terms of understanding what society aims to accomplish in secure care – how do professionals understand these children and their needs, how do they identify relevant interventions and what are their expectations of improving children’s wellbeing and life chances. Also important to document that many children are not offered anything else than confinement and professionals show limited concern or interest in the effects of intervention. Thank you for this important work and I look forward to seeing how you progress.

Author Response

Many thanks for your comments. We have changed the article accordingly and believe it is more robust. The changes are noted below in italics with any additional comments in bold.

Reviewer 1

Thank you for the opportunity to read this article on intervention methods in secure care.  Overall, I think the piece is a valuable contribution to the literature, especially highlighting the professional reflections on how to provide treatment for children in secure care. It is important to document the lack of evidence-based interventions in secure care even though many interventions are being offered. I have some comments and suggestions on the piece, which I hope will help to strengthen the work.

I am concerned about the scope of the article, which aims to analyze how professionals reflect on children’s needs and understand interventions and propose a concept of ‘containment’ as a way of explaining the limited scope for interventions in secure care. The structure of the article needs to be altered to accommodate both arguments – or reduced to just one of them. Either the article must present the analysis of professionals’ perspectives and discuss these findings in light of the literature. Or, the concept of containment needs to be presented earlier – preferably before the methods and analysis and applied analytically. Currently the ‘discussion’ is not really a discussion of the findings, but opens up for a whole new argument. The sentence in the abstract (repeated in the first part of Discussion) “we believe the concept of “containment” in both therapeutic and restrictive forms is an integrated dimension of…” is very complex and need to be unpacked and explained better. As I read the paper, there are in fact two papers squeezed into one. Consider which argument to forefront.

Response- the ‘discussion’ section has been entirely restructured. The material on containment has been removed and replaced with material on discourse analysis to reflect more closely the findings from the study.

There are a few clarifications that are needed for the international reader. Please explain what secure care in Scotland is used for – are the children there in custody, serving sentences (legal grounds) or for protection/secure care (social grounds). You write that the purpose of secure care is dual: rehabilitation and protecting the public (p. 1 l. 24). This may be the case in Scotland, while other jurisdictions can have different purposes. Please also elaborate on what a consultation meeting is and whether children/parents never participate in these deliberations, what is the purpose etc.

Response – the following text has been added to explain the routes by which children in Scotland can be admitted to secure care

In Scotland children are admitted to secure care via the children’s hearing system due to welfare issues (e.g. protection of themselves or others) or the criminal justice system arising from offending behaviour. Whilst there are different routes into secure care [15], the policy framework - including Scotland’s Independent Care Review (the Promise) [16] and secure care pathway standards coproduced with children living within secure care [17] - makes clear that secure care is not designed as a punishment for a child but as a protective and therapeutic intervention.

Response- with regards to the purpose of the meetings it is stated in the methodology that:

Data for the study is obtained from a specialist project that provides consultation, advice and support to practitioners involved with children who present a serious risk of harm to others. The project is based in Scotland, within a university Social Work and Social Policy department, with its funding linked to the Children and Young People’s Centre for Justice with the department. The Children and Young People’s Centre for Justice provides operational oversight and governance. Referral to the project could be made from any source, with these predominantly coming from social work practitioners. The consultation meetings (hereafter, referred to as meetings) aimed to provide advice to those in attendance as to how best to support the child and their family. Discussion within meetings included consideration of the child’s development and early years, family dynamics, previous episodes of harm, relationships with peers and community, existing care plans, accommodation, mental health, education, and legal status.

 

Response - In terms of participation the following is noted in the methodology:

The project does not permit service users (children, family members or laypersons) to attend meetings. This might be considered problematic in terms of good practice around participation and involvement [42] however, the project’s rationale for excluding this cohort is to establish a practice forum where professionals have the opportunity to express their views and feelings in an open and explicit manner and with scope to argue and debate with colleagues. 

 

The section presenting key literature on secure care interventions and what we know about effects and challenges also presents some wider literature, which touch upon the effect of social work interventions, social work practice and decision-making. I would suggest rewriting this section to a more precise presentation of secure care/interventions in secure care literature. The structure is unclear and the literature needs to reflect the main argument of the article (which ever you chose to forefront).

Response- the more general material has been replaced with content specific to secure care, including children’s rights

From a children’s rights perspective the application of intervention methods in secure settings is not an optional aspect of care, but ought to be an integral feature of a child’s support and rehabilitation. Children often feel excluded from this process however, despite research pointing to features of care that they find beneficial [30, 31]. Secure care demands more than mere containment and requires care and support that is proactive and therapeutic in addressing the causes and consequences of children having their liberty taken from them. Article 37 of the United Nations Convention on the Rights of the Child (UNCRC) stipulates that any deprivation of liberty - such as placement within secure care - must only be used as a last resort and for the shortest appropriate time. Applying effective intervention methods is a fundamental way for professionals to adhere to Article 3 by acting in ‘the best interest of the child’ [32] and to ensure a child receives the necessary support whilst remaining in secure care. However, applying intervention methods that respect and uphold human rights within a secure setting is not without its challenges. In particular, the management of risk can be prioritised over more relational and therapeutic approaches, serving to marginalise and undermine children’s human rights [30, 33, 34]. This preoccupation with risk is part of wider neoliberal agenda that is reshaping welfare [35, 36] and contributes to increased use of out of home provision such as secure care [37, 38]. The disproportionate focus on risk highlights how intervention methods in secure care are shaped by wider political and structural factors ranging from early interventions [39] to the ‘national shortfalls’ that can adversely impact on safeguarding systems for children [40]. From a rights-based perspective the application of intervention methods and associated challenges is critical to constructing a more robust understanding of what professionals do with children whose liberty has been removed. Without effective intervention methods secure care can deny children fundamental rights and reinforce cycles of disadvantage, and fail to address the underlying factors that precipitated the child’s entry into the secure environment.

 

 

A few clarifications in the methods section are also needed. Why do you consider the study to be retrospective? Usually this terms applies to studies looking back at past experiences, but this seems to be a study of present meetings dealing with present cases. Also, was the study conducted in one organizational context of ‘consultation meetings’? How are they organized – connected to one secure institution? In case you studied one locality you may consider how that reflects in your data/findings? What is the difference between researchers and project staff? Som clarification on what you mean by “project”/specialist project – is it the study?

 Response- in terms if the location of the meetings:

Data for the study is obtained from a specialist project that provides consultation, advice and support to practitioners involved with children who present a serious risk of harm to others. The project is based in Scotland, within a university Social Work and Social Policy department, with its funding linked to the Children and Young People’s Centre for Justice with the department. The Children and Young People’s Centre for Justice provides operational oversight and governance. Referral to the project could be made from any source, with these predominantly coming from social work practitioners.

Response – retrospective:

The study is retrospective in that examines audio recordings from meetings that took place between five and eight years prior to this study.

I hope you feel encouraged to revise the article and I sincerely believe there is a valuable contribution to the literature in terms of understanding what society aims to accomplish in secure care – how do professionals understand these children and their needs, how do they identify relevant interventions and what are their expectations of improving children’s wellbeing and life chances. Also important to document that many children are not offered anything else than confinement and professionals show limited concern or interest in the effects of intervention. Thank you for this important work and I look forward to seeing how you progress.

 

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your work on this interesting and important article.  Although there is merit in this work it is necessary to make some very major revisions to prepare this for publication.  

1. You need to foreground the needs of these children and young people in your introduction -who are these 'interventions' for anyway?  They are for young people with (for the most part) very complex trauma histories who have often been failed by previous social work 'interventions'.  I know words are limited but without this the introduction feels cold.  
2. Your second research question perplexes me, given that your methods you cannot determine 'effectiveness'.  You can ask to what extent practitioners feel the intervention is 'effective' and what they mean by this.  Please modify.
3. What was the researcher(s) relationship to the 'project'?  Was this a practitioner led piece of research? Any ethical issues related to this need to be explored.  We also need a sharper description of the project.  It seems this was a consultation service to help professionals make decisions (which they had to self-refer to?).  Was this in relation to CYP reaching a certain level of risk within the service? Please clarify the arrangements, thresholds and referral mechanism for the service.  Also what was the agenda of the meeting - you mention broad aims but what things were routinely discussed?
4. You define intervention as 'For the purpose of this study intervention methods are considered to be any action or support that is part of a recognised programme or treatment plan involving the active
   participation of the child with one or more professionals.' This seems to exclude a lot of the day to day and relational/ life space work that goes on in secure residential.  A justification for this exclusion is required.
5. So this was not an ethnographic study? It is really not clear if researchers just worked with recordings?  How did they sense check this with practitioners if they were not there and again, what was their status (e.g. practitioner researchers etc.)?  The methodology needs grounded in methodological literature. What precident is there for such an approach?
6. Your analysis of the data focuses around the idea of 'precision' in the first section - because it is unclear the purpose of the meeting for practitioners it is not clear how much detail we would expect them to share.  If they had been interviewed you might get more detail about the intervention.  Essentially it is unclear to what extent your critique of the practitioners is fair - you need to contextualise your critique and ensure it is fair.  Later you say 'Despite the lack of clarity, there are no questions from other professionals in the meeting that might prompt a more in-depth account or analysis of the intervention. This is a common aspect to all of the interviews.' - so what can we conclude about what is going on here?  Might it be poor questioning rather than bad practice?  You need to be clear about the conclusions you are drawing and what they are based upon.
7. Your argument about containment does not flow from the empirical evidence you present.  The evidence you have seems to suggest that people are vague about the interventions being carried out and in some cases no formal interventions are in place.  This is an important and deeply concerning finding but you need to better explain the meetings that this data is drawn from and it seems there is scope to critique the project's approach if they were not eliciting and exploring the detail of interventions (and this was part of their role) then why not?  Overall the discussion is disconnected from the empirical findings and the conclusion.  The claims you make about barriers and resources (while unlikely to be untrue) are not substantiated in your data.  Your discussion of containment did not fit with the empirical data you present.  

 

Author Response

Reviewer 2

Many thanks for your comments. We have changed the article accordingly and believe it is more robust. The changes are noted below in italics with any additional comments in bold.

 

Dear Authors,

Thank you for your work on this interesting and important article.  Although there is merit in this work it is necessary to make some very major revisions to prepare this for publication.  

1. You need to foreground the needs of these children and young people in your introduction -who are these 'interventions' for anyway?  They are for young people with (for the most part) very complex trauma histories who have often been failed by previous social work 'interventions'.  I know words are limited but without this the introduction feels cold.  

Response- we have added a paragraph on children’s rights, so hopefully this helps.

From a children’s rights perspective the application of intervention methods in secure settings is not an optional aspect of care, but ought to be an integral feature of a child’s support and rehabilitation. Children often feel excluded from this process however, despite research pointing to features of care that they find beneficial [30, 31]. Secure care demands more than mere containment and requires care and support that is proactive and therapeutic in addressing the causes and consequences of children having their liberty taken from them. Article 37 of the United Nations Convention on the Rights of the Child (UNCRC) stipulates that any deprivation of liberty - such as placement within secure care - must only be used as a last resort and for the shortest appropriate time. Applying effective intervention methods is a fundamental way for professionals to adhere to Article 3 by acting in ‘the best interest of the child’ [32] and to ensure a child receives the necessary support whilst remaining in secure care. However, applying intervention methods that respect and uphold human rights within a secure setting is not without its challenges. In particular, the management of risk can be prioritised over more relational and therapeutic approaches, serving to marginalise and undermine children’s human rights [30, 33, 34]. This preoccupation with risk is part of wider neoliberal agenda that is reshaping welfare [35, 36] and contributes to increased use of out of home provision such as secure care [37, 38]. The disproportionate focus on risk highlights how intervention methods in secure care are shaped by wider political and structural factors ranging from early interventions [39] to the ‘national shortfalls’ that can adversely impact on safeguarding systems for children [40]. From a rights-based perspective the application of intervention methods and associated challenges is critical to constructing a more robust understanding of what professionals do with children whose liberty has been removed. Without effective intervention methods secure care can deny children fundamental rights and reinforce cycles of disadvantage, and fail to address the underlying factors that precipitated the child’s entry into the secure environment.

 

 

1. Your second research question perplexes me, given that your methods you cannot determine 'effectiveness'.  You can ask to what extent practitioners feel the intervention is 'effective' and what they mean by this.  Please modify.

 

Response- the second research question has been changed.  The research questions are now worded as follows:

This study examines the way professionals discuss intervention methods in multidisciplinary meetings in relation to children in secure care. The study is retrospective in that examines audio recordings from meetings that took place between five and eight years prior to this study. The study examines the:

 

1. extent to which intervention methods with children are discussed by professionals in a consultation meeting;

 

1. barriers that limit the application of intervention methods in a secure care context.

 

 

1. What was the researcher(s) relationship to the 'project'?  Was this a practitioner led piece of research? Any ethical issues related to this need to be explored.  We also need a sharper description of the project.  It seems this was a consultation service to help professionals make decisions (which they had to self-refer to?).  Was this in relation to CYP reaching a certain level of risk within the service? Please clarify the arrangements, thresholds and referral mechanism for the service.  Also what was the agenda of the meeting - you mention broad aims but what things were routinely discussed?

Response – one of the researchers was directly involved in this project, being part of the consultation panel in a small proportion of the consultations.  The other researcher had no role in the project.  Text has been added to the paper to highlight this.

Greater clarification as to the purpose and format of the project has now been included to highlight that this project was established to provide advice regarding the lives of children who were believed to pose a heightened risk of harm to others.  Referral could be made from any source, with these predominantly coming from social work practitioners, with the consultation aimed at providing advice to the practitioner as to how best to support the child and their family.  Discussion within consultation meetings included consideration of the child’s earliest years, family dynamics, previous episodes of harm, relationships with peers and community, existing care plans, accommodation, mental health, education, and legal status.

 

You define intervention as 'For the purpose of this study intervention methods are considered to be any action or support that is part of a recognised programme or treatment plan involving the active participation of the child with one or more professionals.' This seems to exclude a lot of the day to day and relational/ life space work that goes on in secure residential.  A justification for this exclusion is required.

Response- the following text has been added earlier to offer clarification on intervention methods.

In secure care settings staff may engage in a variety of activities and interactions that support and build relationships with children as part of daily routines, even though these activities may not be formally recognised or labelled as intervention methods. From this perspective secure care itself and many of the interactions that occur between children, staff and other professionals can be considered an ‘intervention’, but not an ‘intervention method’.

1. So this was not an ethnographic study? It is really not clear if researchers just worked with recordings?  How did they sense check this with practitioners if they were not there and again, what was their status (e.g. practitioner researchers etc.)?  The methodology needs grounded in methodological literature. What precedent is there for such an approach?

Response- the paper provides details which explains that the data is from the audio recordings, however we will make that more explicit. Whilst it would be really interesting to interview practitioners, but this was beyond the scope of this study. The methodology has been changed to include discourse analysis.

1. Your analysis of the data focuses around the idea of 'precision' in the first section - because it is unclear the purpose of the meeting for practitioners it is not clear how much detail we would expect them to share.  If they had been interviewed you might get more detail about the intervention.  Essentially it is unclear to what extent your critique of the practitioners is fair - you need to contextualise your critique and ensure it is fair.  Later you say 'Despite the lack of clarity, there are no questions from other professionals in the meeting that might prompt a more in-depth account or analysis of the intervention. This is a common aspect to all of the interviews.' - so what can we conclude about what is going on here?  Might it be poor questioning rather than bad practice?  You need to be clear about the conclusions you are drawing and what they are based upon.

Response- this is really interesting question to which we don’t really have an answer, hence didn’t want to speculate about in the paper. We only focussed on the audio recordings and our comments are based on that evidence. We hope it is fair and perhaps further research will offer a different viewpoint.

1. Your argument about containment does not flow from the empirical evidence you present.  The evidence you have seems to suggest that people are vague about the interventions being carried out and in some cases no formal interventions are in place.  This is an important and deeply concerning finding but you need to better explain the meetings that this data is drawn from and it seems there is scope to critique the project's approach if they were not eliciting and exploring the detail of interventions (and this was part of their role) then why not?  Overall the discussion is disconnected from the empirical findings and the conclusion.  The claims you make about barriers and resources (while unlikely to be untrue) are not substantiated in your data.  Your discussion of containment did not fit with the empirical data you present.  

Response- containment in the discussion section has been replaced with ideas on discourse analysis, which hopefully address the points you make.

 

Reviewer 3 Report

Comments and Suggestions for Authors

This is such an important topic and I commend you for addressing it as it has such huge human rights implications. Also the consequences for society in not responding  to these childrens' complex needs can be so serious.

I have made some comments on the paper and will highlight  some major  issues below:  

I thought the argument could have been more grounded in human rights discourse given the massive human rights implications of locking children up without a formal process of review.

You will note that I suggested that, rather than focusing responsibility  on the professionals involved for the obvious deficiencies in the process,  that management and clincal supervision practices need also to be implicated if not highlighted  

 I thought your model was introduced too late . Id move it before the examples to use as an explanatory tool 

Methodology - I would have liked a bit more theory around this what kind of perspecive are you taking? and more specific attention to the types of techniques to improe validity  aligned   with qual research - triangulation, follow up interviews etc  

Ive attached my comments - some are purely my opinion, offered in the spririt of collegial review  

Comments for author File: Comments.pdf

Author Response

Reviewer 3

Many thanks for your comments. We have changed the article accordingly and believe it is more robust. The changes are noted below in italics with any additional comments in bold.

 

This is such an important topic and I commend you for addressing it as it has such huge human rights implications. Also the consequences for society in not responding  to these childrens' complex needs can be so serious.

I have made some comments on the paper and will highlight  some major  issues below:  

I thought the argument could have been more grounded in human rights discourse given the massive human rights implications of locking children up without a formal process of review.

Response- a paragraph on human/children’s rights has been added at the beginning of the paper.

From a children’s rights perspective the application of intervention methods in secure settings is not an optional aspect of care, but ought to be an integral feature of a child’s support and rehabilitation. Children often feel excluded from this process however, despite research pointing to features of care that they find beneficial [30, 31]. Secure care demands more than mere containment and requires care and support that is proactive and therapeutic in addressing the causes and consequences of children having their liberty taken from them. Article 37 of the United Nations Convention on the Rights of the Child (UNCRC) stipulates that any deprivation of liberty - such as placement within secure care - must only be used as a last resort and for the shortest appropriate time. Applying effective intervention methods is a fundamental way for professionals to adhere to Article 3 by acting in ‘the best interest of the child’ [32] and to ensure a child receives the necessary support whilst remaining in secure care. However, applying intervention methods that respect and uphold human rights within a secure setting is not without its challenges. In particular, the management of risk can be prioritised over more relational and therapeutic approaches, serving to marginalise and undermine children’s human rights [30, 33, 34]. This preoccupation with risk is part of wider neoliberal agenda that is reshaping welfare [35, 36] and contributes to increased use of out of home provision such as secure care [37, 38]. The disproportionate focus on risk highlights how intervention methods in secure care are shaped by wider political and structural factors ranging from early interventions [39] to the ‘national shortfalls’ that can adversely impact on safeguarding systems for children [40]. From a rights-based perspective the application of intervention methods and associated challenges is critical to constructing a more robust understanding of what professionals do with children whose liberty has been removed. Without effective intervention methods secure care can deny children fundamental rights and reinforce cycles of disadvantage, and fail to address the underlying factors that precipitated the child’s entry into the secure environment.

 

 

You will note that I suggested that, rather than focusing responsibility  on the professionals involved for the obvious deficiencies in the process,  that management and clinical supervision practices need also to be implicated if not highlighted  

Response- the discussion section on discourse theory and over assessment now broadens out the analysis to include wider organisational and institutional practices.

 I thought your model was introduced too late. I’d move it before the examples to use as an explanatory tool 

Response- the model has been removed and replaced with ideas on Foucauldian discourse theory.

Methodology - I would have liked a bit more theory around this what kind of perspective are you taking? and more specific attention to the types of techniques to improve validity aligned   with qual research - triangulation, follow up interviews etc  

Response- we have added a paragraph on discourse analysis which hopefully gives a better grounding for the data analysis. As for follow up interviews, this would be really great to do with staff and the young people, however it is beyond the scope of this study.

Discourse analysis is employed to explore how professionals articulate the use of intervention methods when discussing children in secure care. Hardy et al. [43] argue that discourse analysis facilitates an understanding of written and spoken language in relation to the specific contexts in which it occurs. As such, it provides a means to examine the discussions of intervention methods for children within the distinctive environment of secure care. While there is no singular definition or methodology for discourse analysis, Potter’s [44] focus on the socially constructed and interpretative nature of reality underscores its relevance to this study: professionals play a central role in interpreting and implementing intervention methods. A notable feature of discourse analysis is its capacity to support the coding of language, enabling the identification of frequency and patterns between interactions [45]. This allows for the identification of key themes or issues within individual cases and across a broader cohort of children. The discourse analysis is applied to the 21 audio recordings, each relating to an individual child.

 

I’ve attached my comments - some are purely my opinion, offered in the spirit of collegial review  

These are very much appreciated.