A. Engaging And Joining With The Family

Child welfare workers begin engaging with families at their first contact, and initially, this may be somewhat challenging. Some family members may mistrust or resent the Department’s intervention in their lives, but this barrier can often be overcome by using a positive approach. A positive relationship with families can be facilitated by engaging them around the most important issues threatening their children’s safety, issues that are causing them the most pain, and issues that are most important to them.

Good interpersonal skills are needed to develop trust and an effective working relationship with a family. Workers must continue to use these skills as the ISP process continues in order to maintain and deepen the family’s engagement and trust in the change process which will assure greater safety, well-being, and permanence for their children.

B. Actively Involving The Family And The ISP Team In The Initial And On-going Assessment Process

A thorough assessment of family members’ strengths and needs is critical to the development of an effective ISP. The assessment process begins with child welfare workers engaging family members and assembling all available relevant information. In addition to obtaining information directly from family members, the worker must attempt to obtain any other relevant information about the family. This may be accomplished through consultation with other professionals serving the family as well as through a review of reports, evaluations, existing agency records, and case notes. Refer to policy section II. C. 2. for additional information related to consent for release of information.

1. Identifying Strengths

All children and families have strengths. Strengths are those positive attributes and characteristics that family members value about themselves and each other. Strengths may be “what is going well" or may be resources the family has available to them. Unfortunately, strengths may not always be obvious to family members, so one of the worker's tasks is to guide the family members in the identification and recognition of strengths within themselves and each other.

Initially, identifying strengths with family members may not be a familiar exercise for social workers. Traditionally, child welfare practice focused on pathology rather than on capacity. Family members can be helped to overcome obstacles and setbacks more effectively when workers are not drawn into focusing on deficits. Additionally, when acknowledging that there is a corollary strength to each identified need within all "crisis" situations, workers must begin to positively reframe what has previously been considered a deficit. For example, recognizing a parent’s love for a child as an important strength, instead of labeling the family as "enmeshed," can be more empowering for the family.

Children and families’ needs can be met more successfully when strengths are appreciated and included in a plan which ties intervention strategies directly to individual family members’ identified strengths. The identification of strengths and needs should occur in an environment that is more than conversational and less than formal assessment. An activity that drives the strengths identification phase of the process is the listing of strengths and individual family members’ interests according to the areas of family functioning (e.g., educational, developmental, vocational, medical/health, family). A series of visits may be needed to identify the strengths that will become the "starting point" of ISP teamwork. Visits can be held in any location where those present will be at ease (e.g., the homes of parents, extended family members or neighbors; local restaurants).

Helping families identify and reach agreement on their strengths and needs is a critical part of the ISP process. Individuals often feel appreciated, valued, and more capable when workers focus on the strengths that can be used to address the needs. Reaching agreement on strengths and needs increases the capacity of families to remain hopeful and motivated. Their "ownership" of the individualized service plan will also grow as they pursue steps to meet needs they themselves have identified.

The following tools, located in the Appendix, are available to assist workers in the strengths identification process.

• Family Strengths Assessment
• Sample Questions For Family Strengths Assessment

2. Identifying Risks

Child welfare workers interact with families during the initial assessment process to gather and analyze the issues or risk factors that are affecting the children’s safety and well-being thereby necessitating the family’s involvement with the Department’s system of care. These issues and factors may affect the children physically, mentally, and/or emotionally and can usually be tied to some form of maltreatment which is presently occurring or which may have occurred at some point in the children’s lives. As children’s life circumstances are altered (e.g., removal from home and entry into foster care), new risks may emerge.

As the assessment process continues, workers shall continue to focus on risk factors that may affect children’s safety, well-being, and permanence regardless of their living situation. To successfully affect change, needs must be tied to risks and ultimately address the causes or underlying conditions which have resulted in maltreatment.

3. Identifying Needs As workers gather and analyze information from and about families, strengths and problems are identified. Family members’ behaviors are often viewed to be problems as well. Rather than negatively labeling the information collected as ‘problems,’ the positive reframe for problems may be better understood as ‘needs.’ Needs identification can be accomplished in a positive manner if workers understand that families’ needs must be defined as how the family would like to change, grow or develop. Needs are also identified positively by empowering family members to define, in their own words, how their family would like to change, grow or develop to achieve desired outcomes.

The identification of needs occurs through interviews with the family and significant others, and observation of family members’ behaviors. Family-focused and solution-focused questions are effective tools to use as they can facilitate the gathering of information during the interviews. Workers must also remember that family members’ behaviors impact other family members, and observing the family as a system is an integral part of the assessment process.

It is important to remember that behaviors are expressions of need, and the issues that have caused or significantly contributed to maltreatment and/or a family’s crisis are the underlying conditions. These underlying conditions are needs that must be met to reduce or eliminate the risks in order to provide for the children’s protection, safety, permanence, and overall well-being. Workers and families will identify needs that should be tied to the identified risks for the children. This may result in an extensive list of needs, so prioritizing and targeting a limited number of those needs, particularly those that are most important to the family and safety of the children, will give focus to the ISP process and help families avoid being overwhelmed.

Workers’ preferences for recording strengths and needs during discussions with families will vary. Some may use a notepad to list strengths and needs, while others may use a blank ISP form or a form they have developed. Any approach is acceptable as long as families have input and feel heard during this discussion and identification process. Approaches will also differ for recording strengths and needs at ISP team meetings. Recording on flip chart paper, notepads or the ISP form are all options. Regardless of where this process takes place or how it is recorded, strengths and needs should be recorded using the family members’ actual words or words they understand and agree on. 4. Establishing The Desired Case Outcome Or The Permanency Goal

The worker and family members will discuss and agree upon an overall desired case outcome that is known as the permanency goal. This goal will meet children's safety needs, eliminate or significantly reduce the risks, and will support Decree goals. Permanency goal options are:

• remain with parent;
• return to parent;
• permanent relative placement with transfer of custody to the relative;
• permanent relative placement with DHR retaining custody;
• adoption by current foster parent;
• adoption with no identified resource;
• another planned permanent living arrangement, court approved; and
• adult custodial care.

C. Preparation For The Child And Family Planning Team Meeting

Discussions will be held with age-appropriate children, their families, and team members to prepare them for ISP meetings. Decisions made during this process will reflect the agreement of age-appropriate children and their families unless the children's immediate safety needs cannot be met through mutual agreement of those involved.

Age-appropriate children and their parents will be encouraged to attend and fully participate in all team meetings with assistance provided to help maximize their involvement. Strategies may include, but are not limited to, the following:

• workers’ use of interpersonal helping skills to engage families;
• coaching to enable families to identify feelings, articulate strengths and needs;
• role playing with families around what they want to do and say at the meeting;
• helping the family make notes or list things they want to remember or bring to the meeting (e.g., friends, advocates, family with similar life experience); and
• arranging day care or transportation, as needed.

Age-appropriate children and families are entitled to make decisions regarding the services they will be provided. They also have the right to refuse services unless such refusal places the child(ren) in danger or at risk of harm. When children and families refuse or do not access services as agreed upon, their reasons will be assessed with them, and new or modified services will be authorized by the child and family planning team. While services requested by the family may not always be delivered in the manner requested, service delivery will reflect joint planning efforts among the family, DHR and other ISP team members.

1. Preparing Age-Appropriate Children And Their Families

Before team meetings are held, workers must prepare the age-appropriate children and their families for participation. Preparation will include:

• Explanation of the meeting’s purpose, which is to obtain input about the strengths, needs, and goals they have identified in partnership with their worker and/or other members of the child and family planning team, and to determine steps and services to meet identified needs.
• Encouraging participation in the meeting, which includes verbalization of their strengths, needs, and desires regarding services to meet the identified needs.
• Encouraging them to ask questions in an attempt to increase their comfort level regarding the upcoming meeting. This may be accomplished by developing a list of the important issues they want to discuss, and if they indicate an interest in doing so, helping them articulate what they want to say.
• Exploring the best date, time, and location for the meeting as well as who will be invited as team members. Determining whom to invite to the ISP meeting may be accomplished by developing a list of anyone directly involved in service provision for the family and anyone the family wants to participate (e.g., supportive friends, advocates, relatives, school personnel, therapists, service providers, foster or adoptive parents).
• Discussing team members’ roles and responsibilities including those of the facilitator and recorder.
• Helping the family identify supports they will need to participate in the meeting (e.g., transportation, a reminder call, childcare, an interpreter) and developing a plan for providing the supports.
• Discussing confidentiality issues.

(a) Explain the Department's policy of protecting family members’ privacy while sharing information among those involved with them to promote teamwork and facilitate decision-making.
(b) Explain that Department staff and other team members will honor their requests for maintaining confidentiality, and that information will not be shared unless it is required:

• to protect a child;
• by court order; or
• to achieve attainment of Decree goals.

(c) Ask appropriate family members to sign needed release of information forms allowing school personnel, therapists, or other service providers to share relevant information previously provided by family members.

2. Preparing ISP Team Members

In addition to preparing families, it is also important to prepare the other team members for the ISP meeting in order to create positive expectations and avoid conflicting agendas. Team members are to receive verbal or written notification of the date, time, and location of the ISP meeting per policy section II. C. 3. The meeting's purpose, agenda, and who is invited to attend will be discussed with each team member prior to the meeting. New team members will also need a description of the process used during ISP meetings. Make sure they are aware that the focus will be on the family's strengths and needs rather than on deficits. Each team member should be also be asked to review their information on the family, identify the family's strengths and needs, and consider possible strategies for addressing the needs prior to attending the meeting.

As ISP team members, DHR staff must also prepare for team meetings. Prior to the meeting, the family’s worker will review the appropriate case materials and the family’s current situation to determine how the case will be presented and make arrangements for the availability of any items, tools or supports (e.g., release of information forms, flip chart and markers, interpreter, facilitator, recorder) needed during the meeting.

ISP team members have distinct roles and responsibilities as they work in partnership with age-appropriate children and families to plan and deliver services designed to achieve desired case outcomes. There are three (3) separate roles related to the meeting itself, and some ISPs will have team members filling each of the roles while in other ISPs, a team member may fill more than one role. These roles are (1) facilitator, (2) worker, and (3) recorder

Facilitators have three (3) major responsibilities during the ISP meeting. They build the team, direct the process, and facilitate differences. The facilitator helps the ISP team work together by recognizing the value of each person present, seeking participation from each team member, encouraging team members to speak directly to one another, and facilitating effective feedback among the team members. Facilitators are also responsible for directing the process. They help the team focus on the purpose of the meeting, which is planning and evaluating the delivery of services to meet the family’s identified needs in an effort to achieve safety, stability, and permanence in the children’s living situation.

The third major role is facilitating differences. Every family and ISP team will experience conflict or differences in opinions at some time or another. In some ways, examining what is occurring and what should change can help bring the team closer together. Facilitators must assess the situation and decide if the conflict should be addressed during or outside the ISP meeting. Some questions to consider when making this determination are as follows.

• Does the issue involve the whole team?
• Is the conflict pertinent to the development and implementation of the ISP as it relates to achieving safety, permanence, and overall well-being for the children?
• Is the whole team needed to help reach resolution of the issue?
• Is assistance or support needed from outside the team (e.g., a worker’s supervisor, a team member who is not present)?

Workers may fill one or all three of the roles specific to the ISP meeting depending upon their skill level and the complexity of the meeting to be held. The worker is responsible for presenting a case summary to the ISP team. Additionally, assigning someone other than the worker to record the participants’ input and decisions made during the meeting is helpful. Recorders list the strengths, needs, goals, steps and services as they are decided upon by the team. Recording may be done on a flip chart, a blank ISP form or on notepaper, whichever is more convenient or preferable for the recorder, for transference to the actual ISP document that is distributed to team members.

D. The Child And Family Planning Team Meeting

The ISP meeting has a process of its own with basic elements to be covered. This process may vary from meeting to meeting and may not occur in the order described. Areas to cover are described below.

1. Making Introductions And Explaining Purpose

ISP meetings typically begin with the facilitator inviting those present to introduce themselves. The facilitator explains the purpose of the meeting, confidentiality, and the need to sign the confidentiality statement if team members have not already done so. If there are written social summaries, assessments or other documents to be shared with team members, the facilitator should make sure they are shared and presented with consideration to the children and family’s right to be treated with dignity and respect as well as the need to meet confidentiality requirements.

The purpose of the meeting is to develop a plan based on the family's identified strengths and needs. The facilitator is responsible for maintaining the group's focus so the plan can be developed or revised in a reasonable period of time. Meetings should last no longer than 1 to 1 ½ hours, depending upon the complexity of the case and the needs and desires of team members. In some situations, the meeting may need to be continued at a later time to complete development of the ISP. Refer to policy section II. C. 3. b., Segmenting ISP Meetings, for additional information.

2. Summarizing The Case

Workers will present a concise (no longer than 10 minutes) verbal summary of the family’s case and its current status. Family strengths are to be emphasized and problem statements avoided. Workers will typically initiate the discussion of strengths and needs at the conclusion of the case summary. They may distribute a draft of previously identified strengths and needs, make a verbal presentation, or have them listed on a flip chart during the meeting. When reviewing the list, workers will clearly explain that the strengths and needs were identified in partnership with the family.

3. Discussing Strengths And Needs

Facilitators will encourage other team members to go beyond the worker’s presentation to provide any additional information they may have about the family’s strengths and needs. As they are added to the list, strengths and needs shall be simply stated and agreed upon by the team. Discussion may result in revising, deleting and/or adding strengths and needs. Changes should not occur without the family members’ agreement, unless the team's changes are directly related to a more successful provision of safety and permanence for the children. The facilitator is responsible for keeping the focus on strengths and needs, and directing the team away from a discussion of services until strengths and needs have been identified.

1. Selecting Needs On Which To Focus

The team will reach consensus around which needs are most important to the family and most critical to protection of the children. The number of needs to be addressed shall be small enough to allow planning and direction to remain clearly focused upon attainment of the desired case outcome (i.e., the permanency goal

When children are in foster care, the team shall always stress the importance of contact between the children and their families, and address the needs for maintaining and strengthening family attachments. The team shall discuss and agree upon how (and how often, when this is an issue) family contacts will occur. Any restrictions on visiting, phone or mail contact must be consistent with the related policies and clearly documented in the ISP.

5. Developing Goals

In order to achieve the desired case outcome, goals determined by the child and family planning team must be tied to family members’ strengths and needs. Goals will always reflect the desired change in the underlying condition and lead to the achievement of the permanency goal.

At least 1 goal shall be developed for each selected need, although some needs may generate more than 1 goal. Goals will describe the change that takes place when needs are met, and they may be short- or long-term goals. Goals will be reasonable, positively stated, achievable, and clearly described through the use of “action” verbs.

Goals are negotiable within the ISP process and their review is needed to determine if they have been achieved, should be changed or abandoned. Goals will be reviewed by the team on an as-needed basis and each time the ISP is reviewed and/or revised. Goals may change, be abandoned or revised, or new goals may be added when:

• new risks are identified;
• a more appropriate match of service to need is necessary;
• a more effective method of service delivery is needed; or
• the family progresses and/or achieves identified goals.

6. Brainstorming Strategies For Meeting Goals

The worker and facilitator (if different from worker) will help the team brainstorm strategies for meeting goals. Considered strategies will utilize identified and potential strengths to develop steps and identify services to meet the needs and achieve the goals. Creative ideas should be generated based on the family’s identified needs and should not be constrained by whether or not strategies are available or affordable. The focus should be on developing an extensive list of possible strategies that is not limited by consideration of only those services that currently exist.

The ISP team should be inventive and visionary as it plans. Members need to understand that non-traditional services may be more accessible, affordable, and effective for families. The success of a new, non-traditional service is largely dependent upon the family’s level of involvement in planning and developing the strategies to meet their needs. Brainstorming with family members often results in a service that represents familiarity, security, and safety for them.

Neighborhood or community supports, also known as “natural helpers,” may include church groups or neighbors, relatives or friends who function as aides, coaches, mentors, babysitters, respite care providers or transportation aides. These providers can be identified by children and/or their families and should be given first consideration as service providers.

Extended family, friends, and trusted neighborhood or community figures have the ability to begin beyond "square one" at the inception of service delivery because they already have an established relationship with the family. These individuals, however, may be at a disadvantage when utilized as service providers because they may lack professional experience and/or there may be some misconceptions about the demands that will be placed upon them in their new role.

Training and support must be in place for “natural helpers” so they have every opportunity to succeed in their partnership with children, families, and other ISP team members. If family members are honestly engaged in planning, and if the entire team is genuinely committed to supporting and training non-traditional providers, these services will rarely fail to deliver the desired outcomes.

Innovative ways of creating new services include, but are not limited to, the following:

• linking the family with other families who have complimentary strengths and similar needs, thus creating support groups;
• contracting with an individual agency or organization to create and provide needed services identified during ISP team meetings; and
• recruiting, training and supporting extended families and neighbors to craft needed services.

Examples of natural helpers being utilized to meet identified needs include:

• a "godmother" babysitting for a child may meet a need for respite;
• a karate teacher or art instructor at a community center may provide a service to meet a child's need to develop confidence and self-esteem;
• engaging a neighbor to check on the family during evenings and weekends may be an important part of meeting a child's safety needs;
• involving teachers in a behavior management plan to help a child remain in school;
• identifying and engaging other experienced families or foster parents to serve as "mentors" to a child's parents may meet the parents’ need for increased skill and patience in disciplining the child; and
• identifying a specific neighbor or family member who could be contacted to provide emergency respite or childcare could be part of a plan for handling future crises.

These and other similar possibilities should be explored and appropriate strategies selected.

7. Developing Steps And Matching Services To Needs

Based upon the list of strategies developed by the team during the brainstorming session, the facilitator will guide the team to decisions on steps and services. Several steps may be developed and implemented before children or family members actually access a service. Services must be acceptable and accessible to the family, and compatible with their ethnic and cultural background. Both steps and services will reinforce family members’ strengths and meet identified needs, thereby enabling children to attain Decree goals.

The type, number and mix of services must be individualized to the children and their families. Needed services will be created if they do not exist or are not accessible to family members. Traditional services may be chosen to meet identified needs; however, a non-traditional, creative approach to service development and delivery is encouraged if this type service will be more acceptable and accessible to the famil

Once specific services have been determined, the child and family planning team will develop steps to address the identified needs, and authorize, implement and monitor service delivery. The steps will be:

• designed in a sequenced order that is understandable to the famil
• worded in a manner that specifically identifies who is involved, what is to be accomplished, and within what timeframe
• designed to enable family members to experience success in a short period of time;
• developed as small, measurable, and time-limited; and
• able to move family members toward achievement of the goal while increasing their ability to function independently.

The steps must also include the following information related to service delivery:

• Specific services to be provided including methods of delivery, duration, frequency and intensity.
• Target dates and actions to be completed prior to service implementation.
• Methods and team members responsible for monitoring implementation.
• Methods and team members responsible for evaluating the plan.

8. Conclusion

At the conclusion of the child and family planning team meeting, the facilitator should acknowledge the team’s efforts, contributions and cooperation in developing the plan. Team members responsible for implementation and monitoring of steps and/or services should be reminded of those responsibilities. An approximate or definite date for reviewing the plan will also be determined at this time. The date of the review will depend on the type plan developed (i.e., initial or review), the intensity of the children and families’ needs, and/or the nature of services to be implemented. Reviews may be requested by any of the current team members.

A written copy of the ISP will be provided to age-appropriate children and their parents as well as all other team members at the conclusion of the meeting. If this is not feasible, the facilitator or worker will advise the team that their copies will be provided within ten (10) working days. Team members will be informed that they should review the ISP document and immediately bring any discrepancy they may note or confusion they may have regarding the written plan to the DHR worker’s attention.

9. Follow-Up Activities

ISPs are to be distributed to team members within ten (10) working days following the meeting. If a team member notes any discrepancies from what was agreed upon during the meeting or does not understand the goals and steps detailed in the written plan, the DHR worker is responsible for responding to the particular issues. Minor issues (i.e., issues which do not impact anyone other than the team member who is noting the discrepancy or needing clarification) that can be resolved or corrected without full team involvement should be dealt with informally.

Issues which involve more than one (1) team member and which are not controversial, may be resolved by a conference call, individual telephone calls or in-person discussions with the other team members. Any issues raised which are potentially controversial or are complex and involve several team members may be handled by a conference call with all the involved team members participating. When a conference call is not feasible, a team meeting should be held for clarification and resolution. Worker insight and discretion, along with supervisory concurrence, must be used in making decisions regarding the most appropriate method for resolving the issues. When the ISP must be revised based upon the aforementioned circumstances, a revised copy is to be distributed to each member of the ISP team.