Journal articles on the topic 'Montana. Child Protective Services Program'

Sleep-related infant deaths, including Sudden Infant Death Syndrome (SIDS), are the number one cause of death in infants between 28 days and one year of life. Nearly half of families experiencing a sleep-related infant death in Kansas were involved with the Department of Children and Families Child Protective Services (CPS), making CPS staff a priority for safe sleep training. This study assessed the impact of the two-day Kansas Infant Death and SIDS (KIDS) Network Safe Sleep Instructor (SSI) train-the-trainer program on CPS staffs’ knowledge of the American Academy of Pediatrics safe sleep recommendations. Training was attended by 43 participants, 27 (63%) of whom were employed by CPS. CPS staff had significantly lower baseline knowledge on the 10-item pretest (t = 3.33, p = 0.002), but both CPS and other attendees showed significant improvement by posttest (t = 8.53, p < 0.001 and t = 4.44, p < 0.001, respectively). Following SSI certification, CPS SSIs provided more safe sleep training to professionals than other SSIs (1051 vs. 165, respectively), and both groups of SSIs were able to significantly increase the knowledge of their trainees. Overall, the KIDS Network SSI training was successful. The innovative partnership with CPS allowed for provision of training to a group not historically targeted for safe sleep education.

The author has been involved in running a training workshop for Department of Education staff on responding to suspected disclosures of sexual abuse. Many participants indicated that they felt uninformed and marginalised when dealing with other services in the community. A pilot study is under way whereby an experienced Student Welfare Coordinator acts as a contact person for accessing Department of Education requests for informal consultation regarding suspected sexual abuse in the region. A second workshop is currently being planned for workers from Protective Services and Child and Mental Health Services.

Residents of rural northeast Nevada lack many of the social services available in the urban parts of Nevada and the nation. One of the services lacking in Battle Mountain, Nevada is quality after-school child care. The University of Nevada Cooperative Extension and the Lander County School District collaborated to develop and administer an after-school program for at-risk elementary students, which addressed this need. The program was designed to provide an educational experience while at the same time providing students with some of the protective factors needed to help them lead more productive lifes. This paper details how the program was carried out and shows the results of the program's evaluation. In lean economic times, a collaborative effort such as this may be one way to address youth needs in rural areas. The result was increased community support for quality after-school child care.

The study examines whether the form of maltreatment experienced by the child moderates the effects of a parent training program (PTP) on the probability that the child’s case will be closed. This study involved 736 children on whom the Montreal child protective services (CPS) agency had an active file between 2007 and 2015. The experimental group was composed of all children with a parent who participated in the PTP Incredible Years ( n = 368). A control group was matched with the experimental group based on a propensity score. Cox regression revealed that once parents have participated in the PTP, the probability that their children’s cases will be closed increases more for children being followed because of neglect than for those being followed because of emotional maltreatment. Results show that a parent’s participating in a PTP is associated with an increase of the probability that his or her child’s CPS case will be closed and hence with a reduction of the length of time that the child must receive protective services.

Contemporary child welfare policies in the United States are well-suited for prevention of child abuse but fail to account for the relationship between family financial hardship and neglect, that is, the lack of safe and consistent care. We argue that rates of child neglect have been stagnant because of two failures: (1) lack of recognition of financial hardship as a causal mechanism of neglect and (2) federal policy that purposefully omits alleviation of financial hardship as a solution to the occurrence of neglect. Because U.S. antipoverty programs operate independently of one another, our siloed policy structure misses opportunities for the alleviation of child maltreatment and, worse, creates negative and unintended consequences in child welfare. We present a model for change: systems synergy for the promotion of safe and consistent care that makes reduction of child maltreatment the responsibility of every social service program in the United States.

Early Childhood Mental Health Consultation (ECMC) focuses on enhancing adults’ (e.g., parents) skills and abilities in order to improve children’s behavior. Limited research has examined parenting factors as mechanisms of change, which is important given the bidirectional nature of parent-child interactions. Parenting stress and its influence on children’s behavioral outcomes (behavior problems and protective factors) were investigated following the implementation of an Early Childhood Mental Health Consultation (ECMHC) program. Participants included parents that participated in the ECMHC program (n = 247) and a comparison group (n = 72) in the Midwest. Overall, parents in the ECMHC group experienced fewer dysfunctional parent-child interactions and less distress. Results indicated that parent-child dysfunctional interactions mediated the relationship between ECMHC and children’s behavior problems (CI = .001, .038) and protective factors (CI = -.061, -.001). Parental distress did not mediate the relationship between ECMHC and children’s behavior problems (CI = -.001, .016) or protective factors (CI = -.020, .001). Understanding the influence of stress and parent-child interactions is beneficial as these may be malleable and responsive to change if targeted in intervention. Examining mechanisms of change related to parents will allow for refinement of services and improved behavioral outcomes for children.

This study uses logistical regression to identify employee and organizational attributes contributing to the probability of voluntary turnover among child protective service caseworkers in a large children's services bureau. Variables which indicate the employee's stake in the organization (length of service, overtime hours), commitment to the profession (previous experience or internship with a human services agency), and level of education, were determinants of those who chose to remain or leave during times of high turnover and intense outside criticism and questioning of agency effectiveness. The agency's primary response to the problem, a special training program, did not significantly reduce the probability of turnover.

AbstractThis study examined the effects of the Nurse Family Partnership (NFP), a program of prenatal and infancy home visiting by nurses, on the timing of verified reports of child maltreatment. A sample of predominantly unmarried, low-income mothers and their first-born children were randomly assigned to receive either home visitation services by nurses beginning in pregnancy and lasting until the child was age 2, or comparison services. Previous studies have found that this program was effective in reducing the overall number of substantiated Child Protective Service reports by age 15. In the current study, survival analyses were used to assess temporal differences between nurse visited (n= 93) and comparison (n= 144) children's onset rates for maltreatment. The two groups' survival functions remained nearly identical until age 4, at which point the nurse-visited group's risk for onset began to significantly diminish. These results were more pronounced among the highest risk subgroup and among victims of neglect. The findings provide evidence that the NFP's success in reducing the number of maltreatment reports resulted in part from in its impact on the timing of the maltreatment process.

The mandatory reporting of intimate partner violence (IPV) is a controversial issue that is receiving increased attention. A related concern is whether children’s exposure to IPV constitutes child maltreatment, making it reportable to child protective services. These issues have been relatively unexplored within the context of home visitation programs. A secondary analysis of qualitative data collected from community stakeholders, clients, and home visiting nurses in the Nurse–Family Partnership program was carried out. Participants’ perceptions about mandatory reporting of IPV and reporting of children’s exposure to IPV are highlighted. Emergent themes and implications for research, practice, and policy are discussed.

Home visitation (HV) interventions may hold promise to improve parenting and prevent child maltreatment recidivism in families reported to child protective services (CPS) with young children, but this has rarely been studied. Findings are presented from an 18-month randomized controlled trial in which intact families ( N = 122) with at least one CPS report were provided with a facilitated connection to a paraprofessional evidence-based HV program or usual care services from child protection. Results are reported for changes in maternal stress, depression, and social support outcomes and repeat reports to CPS. No significant changes were found in maternal outcomes by group. Among nondepressed mothers or families without multiple CPS reports prior to study enrollment, HV was associated with a significantly lower likelihood of CPS report recidivism. These results indicate potential for HV to prevent maltreatment recidivism but suggest that higher intensity intervention is warranted for mothers exhibiting significant depressive symptoms or families with extensive CPS histories.

The Families First Pilot Program in the then Outer East metropolitan region of Melbourne began in mid-1991 as an intensive family preservation and reunification service for children on the verge of state care. The service offered was brief (4-6 week), intensive (up to 20 hours per week), home-based and flexible (24 hour a day, 7 day a week availability) and all members of the household or family were the focus of service even though the goals were clearly grounded in the protection of the child. This paper begins with some of the apprehension expressed both in the field and in Children Australia in 1993, and reports upon the now completed evaluation of the pilot, which covered the first 18 months of operation. The evaluation examined implementation and program development issues and considered the client population of the service against comparative data about those children at risk who were not included. The paper concludes that there is room for Families First in the Victorian system of protective and family services and points to several developmental issues.

This research note presents findings from a qualitative study exploring female, system-involved intimate partner violence (IPV) survivors’ perspectives on substance use disclosure in the context of research studies. The study sample includes 22 women who completed a court- and/or child protective services (CPS)–mandated IPV parenting program. Analyses revealed three key areas of participants’ perspectives on substance use assessment and disclosure: (a) administration setting/format and measurement clarity, (b) administrator characteristics, and (c) repercussions due to breach of confidentiality. Findings from the current study offer insights into barriers for survivors reporting their substance use and suggestions for researchers seeking to assess substance use among this population.

AbstractObjectivesDespite documented increases in emergency department (ED) mental health (MH) presentations, there are inconsistent findings on the characteristics of patients with repeat presentations to pediatric EDs (PEDs) for MH concerns. Our study sought to explore the characteristics of MH patients with repeat PED visits and determine predictors of return visits, of earlier repeat visits, and of more frequent repeat visits.MethodsWe examined data collected prospectively in a clinical database looking at MH presentations to a crisis intervention program housed within a PED from October 2006 to December 2011. Predictive models based on demographic and clinical variables were constructed using logistic, Cox, and negative binomial regression.ResultsA total of 4,080 presentations to the PED were made by the 2,900 children and youth. Repeat visits accounted for almost half (45.8%) of all presentations. Multivariable analysis identified five variables that independently predicted greater odds of having repeat presentations, greater risk of earlier repeat presentations, and greater risk of frequent repeat presentations. The five variables were: female, living in the metropolitan community close to the PED, being in the care of child protective services, taking psychotropic medications, and presenting with an actionable need in the area of mood disturbances.ConclusionsRepeat visits account for a large portion of all MH presentations to the PED. Furthermore, several patient characteristics are significant predictors of repeat PED use and of repeating use sooner and more frequently. Further research is needed to examine interventions targeting this patient group to ensure appropriate MH patient management.

Introduction: Circle of Security-parenting (COS-p) is a simplified, relationship-based programme with the intention of developing parents’ observation and inferential skills related to understanding their child’s needs, increasing sensitivity to their child, aiding in emotional regulation, as well as decreasing any of their negative attributions to their child. COS-p is a widely used parenting programme that is gaining global popularity, as it is currently being delivered across several continents. Despite being one of the most frequently used interventions in Norwegian child protective services (CPS), no research has been conducted on this programme’s effectiveness when used in the CPS context. This study therefore aims to establish a systematic overview of the programme’s effectiveness for families within the CPS system, regarding both caregivers and benefits for the children. Method: The database searches were originally conducted in June 2018 and updated in April 2020, encompassing 13 international bibliographical databases. The search for grey literature was conducted, and the generated articles these were then manually searched. A non-statistical narrative approach was used to analyse the studies due to the heterogeneity of the outcome measures. Research studies on the effectiveness of COS-p intervention, where the participants reported a minimum of two specifically defined risk factors, were included for further analysis. Results: Seven studies met the inclusion criteria. The studies included in the review focus on a diversity of separate and isolated factors concerning caregivers but not the effect of the accumulation of risk factors and how this may or may not influence the potential effectiveness of COS-p. The findings’ strengths include some improvements in reducing parental stress, increasing self-efficacy and parenting skills, and promoting an understanding of child behaviour. There is no conclusive evidence that COS-p assists in increasing the security of the parent-child attachment relationship. Discussion: Given the limited number of studies, further research is needed to examine if COS-p improves child behaviour, if its effects can be sustained over time and if it is more effective for particular populations.

AbstractThis investigation examined the impact of dimensions within maltreatment such as the severity, frequency, chronicity, and subtypes of maltreatment and their relationship with child outcome. Children between the ages of 5 and 11 who participated in a summer camp program were assessed on their social competence, behavior problems, and peers ratings of cooperation, disruption, and initiation of aggression. The 235 participants were all from low-socioeconomic status families; 145 children were from families with documented histories of child maltreatment, whereas 90 of the children had no record of maltreatment. The study found that severity of the maltreatment, the frequency of Child Protective Services reports, and the interaction between severity and frequency were significant predictors of children's functioning. Additionally, the chronicity of the maltreatment in the family significantly predicted peer ratings of aggression. Subtype differences emerged as well, with children in the sexual abuse group being more socially competent than other maltreated children, and children in the physical abuse group having more behavior problems than nonmaltreated children. Regression analyses with cooccurrence of multiple subtypes of maltreatment indicated that physical neglect, physical abuse, and sexual abuse made significant unique contributions in predicting child outcomes. The advantages of exploring multiple dimensions within maltreatment, the necessity of developing better operational definitions of these dimensions, and social policy implications of the findings are discussed.

ABSTRACT Background Little is known about the impact of food-assisted maternal and child health programs (FA-MCHN) on child wasting. Objectives We assessed the impact of Tubaramure, a FA-MCHN program in Burundi, on child (0 to 24 months) wasting and the differential impacts by socio-economic characteristics and age. The program targeted women and their children during the first 1000 days and included 1) food rations, 2) strengthening and promotion of use of health services, and 3) behavior change communication (BCC). Methods We conducted a 4-arm, cluster-randomized, controlled trial (2010–2012). Clusters were defined as “collines” (communities). Impact was estimated using repeated cross-sectional data (n = ∼2620 children in each round). Treatment arms received household and individual (mother or child in the first 1000 days) food rations (corn-soy blend and micronutrient-fortified vegetable oil) from pregnancy to 24 months (T24 arm), from pregnancy to 18 months (T18), or from birth to 24 months (TNFP). All beneficiaries received the same BCC for the first 1000 days. The control arm received no rations or BCC. Results Wasting (weight-for-length Z-score &lt;2 SD) increased from baseline to follow-up in the control group (from 6.5% to 8%), but Tubaramure had a significant (P &lt; 0.05) protective effect on wasting [treatment arms combined, −3.3 percentage points (pp); T18, −4.5 pp] and on the weight-for-length z-score (treatment arms combined, +0.15; T24, +0.20; T18, +0.17). The effects were limited to children whose mother and household head had no education, and who lived in the poorest households. The largest effect was found in children 6 to 12 months of age: the group with the highest wasting prevalence. Conclusions FA-MCHN programs in highly food-insecure regions can protect the most disadvantaged children from wasting. These findings are particularly relevant in the context of the economic crisis due to the coronavirus disease 2019 pandemic, which is expected to dramatically increase child wasting.

Background: Racial and ethnic minority infants and mothers have worse birth outcomes than Caucasian infants and mothers, specifically infant mortality. The purpose of this pilot study was to compare infant mortality rates from vital statistic data between mothers who participated in the Women, Infants, and Children (WIC) Program and the general population in Kansas. Methods: A retrospective secondary analysis of data received from the Kansas Department of Health and Environment (KDHE) was conducted. Data were provided on all mothers who delivered a child in the state of Kansas from 2009 to 2011. The data received from KDHE included maternal demographics, infant deaths, infant gestational age, infant weight at birth, and WIC program participation. Results: The overall infant mortality rate was 6.4 per 1000 births. Infant mortality for Caucasians was lower than for non-Caucasians. Infant mortality for blacks was greater than for non-blacks. Being Hispanic was not statistically associated with a difference in infant mortality. WIC program participation was associated with lower infant mortality in both blacks and Hispanics. After adjusting for WIC, infants born to black mothers were still more than twice as likely to die when compared with Caucasian infants. WIC services were not statistically associated with a reduction in infant mortality. Mother’s education showed a significant protective effect on the likelihood of infant death. Conclusion: The WIC program is associated with positive outcomes at the national level. However, widespread reductions in health disparities have not been reported. Differences in education levels between mothers affected infant mortality to a greater degree than WIC program participation alone in the analysis. The infant mortality rate for black and Hispanic mothers was lower for WIC program participants. The WIC program may be beneficial for reducing infant mortality racial disparities but program participation should be expanded to affect maternal health disparities at the population level.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. Cutcliffe JR, Stevenson C, Jackson S, et al. A modified grounded theory study of how psychiatric nurses work with suicidal people. Int J Nurs Studies 2006:43(7):791–802.16. Lakeman, R. What can qualitative research tell us about helping a person who is suicidal? Nurs Times 2010:106(33):23–26.17. Karman P, Kool N, Poslawsky I, et al. Nurses’ attitudes toward self-harm: a literature review. J Psychiatr Ment Health Nurs 2015:22:65–75.18. Carter B. ‘One expertise among many’ – working appreciatively to make miracles instead of finding problems: Using appreciative inquiry as a way of reframing research. J Res Nurs 2006:11(1): 48–63.19. Lieblich A, Tuval-Mashiach R, Zilber T. Narrative research: Reading, analysis, and interpretation. Sage Publications; 1998.20. Braun V and Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006:3(2):77–101.21. Kishi Y, Otsuka K, Akiyama K, et al. Effects of a training workshop on suicide prevention among emergency room nurses. Crisis 2014:35(5):357–61.

IntroductionOn their 18th birthday children in custody of provincial Child and Family Services (CFS) age out, and are adults in control of their own care. An additional extended transitional services program was introduced several years ago to address gaps in the provicion of, and access to, adult social services during this change. Objectives and ApproachUsing linked population based data from the Manitoba Population Research Data Repository, children in the custody of CFS who turned 18 during a 10 year study period were compared to children not in custody. For those in custody of CFS, we also compared individuals who participated in the extended transitional care services to those who opted out. Outcomes included use of health services and prescription drugs, social assistance, involvment with the justice system, living in social housing, and mental health outcomes. For most outcomes, the two year period prior to the 18th birthday and the two year period after were measured. ResultsDuring the study period, 4656 children in care of CFS turned 18 while in custody. There were 2811 permanent wards, of which 1663 participated in the extended transitional services program. An additional 1845 non-permanent wards also turned 18 during the study period. Permanent wards were much more likely to be long term wards (greater than six years, ~65\%) compared non permanent wards (~17\%). Opioid prescription rates more than doubled in the two years after their 18th birthday and were about 6 times greater than prescription rates for those not in care of CFS. Criminal accusation rates did not change after their 18th birthday, were about equal for permanent and non-permanent wards. For the majority of outcomes, the transitional services program appeared to have little impact. Conclusion/ImplicationsCompared to children not in care of CFS, rates of most outcomes were considerably higher for wards. Not all outcomes demonstrated a significant change over the transition period. By linking data from so many different government departments, extra attention can be focused on areas likely to have the greatest impact.

Summary While previous studies have offered insight into evidence-based practices that are effective in promoting safety and well-being, the underlying contextual implementation conditions that influence these outcomes in child welfare agencies are less understood. To address this gap, this study relied on organizational survey data collected from child welfare workers and supervisors during the process of implementing an evidence-based practice—the Positive Parenting Program—and merged those data with data gathered by the Parents' Assessment of Protective Factors survey. Findings Results showed a significant increase between baseline and termination of services in social connections and overall protective factors index scores. Parents who received services from organizations inclusive of supportive leadership experienced greater increases in social connections. Lower protective factors index scores were associated with workers’ perception that evidence-based practices were required; however, scores increased as supportive leadership increased. Parents who identified as African American experienced lower protective factors index scores compared to parents in other racial categories. Parents who were engaged with workers who felt evidence-based practices were appealing were likely to experience greater increases in protective factors index scores. Applications Intended client outcomes are more likely to be achieved when agency leaders (1) provide workers support to learn and use evidence-based practices and (2) rely on methods to increase evidence-based practice appeal rather than mandate implementation. Future research is needed to (1) understand why the implementation contexts or Positive Parenting Program itself are not as effective for African Americans as they are for oteher racial/ethnic groups and (2) validate findings in other agency contexts and with other evidence-based practices.

This study the author aims to explore the perceptions of doulas on single mothers’ risk and protective factors, and aspirations relative to child - birth in the postpartum care. The current study was conducted by semi - structured questions, case file reviews, field notes, and twelve home visits via utilizing Grounded Theory. These mothers receive social services through a family services agency in Pittsburg h, PA. There were three doulas and three single mothers in the sample group. Findings displayed four themes: (a ) doula program is helpful for single mothers relative to child - birth, ( b ) social exclusion is a risk factor in single mothers lives relative to leading to single motherhood; (c ) support system is a protective factor in single mothers ’ lives relative to child - birth; and (d ) pursuing education and applying for jobs are the aspirations of single mothers relative to child - birth.

Children known to child welfare are more likely to have poor health compared to the general population. Most children served by child welfare are served in their own homes. New Jersey implemented the Child and Family Nurse Program (CFNP) to provide nurse care coordination to address the health needs of children who remain in-home. Our study described: 1) families served by CFNP; 2) services provided to these families; and 3) family well-being outcomes. The study focused on the 304 families served by CFNP from 2016 to 2017. We used CFNP data to describe families served and services provided, and family baseline and follow-up surveys to assess change in family well-being over time. Families served by CFNP experienced improvements in family protective factors and health-related quality of life from baseline to follow-up. While more rigorous studies are needed to learn CFNP’s impact, it is a promising approach that merits consideration by state child welfare leaders.

Impacting 1 in 4 children in the United States, childhood exposure to domestic violence predicts myriad negative sequelae. Intervening post exposure is critical to help children and their protective parent heal and avoid long-term negative consequences. Children aged 2-17 and their mothers who were victims of domestic violence participated in a 12-week group program delivered by domestic violence agency staff that provides psychoeducation on the impact of trauma and domestic violence and aims to improve parent and child well-being. The impact of the Child Witness to Domestic Violence (CWDV) program was tested in an intervention group ( n = 69 children, 33 mothers) who participated in CWDV and control group ( n = 80 children, 39 mothers) consisting of children whose mothers received adult-focused domestic violence services but were not enrolled in CWDV or other child-focused services. Multiple regression analyses controlling for child gender, child age, mother’s age, and the outcome of interest at time 1 found that participation in CWDV program significantly predicted better child functioning as indicated by less hyperactivity ( B = –.85, p = .06), fewer negative emotional symptoms ( B = –1.14, p = .01), and fewer total behavioral difficulties ( B = –2.48, p = .02) as well as higher maternal hope ( B = .57, p = .03). These data provide promising evidence of the impact of a brief, replicable group intervention that promotes healing and well-being among children and parents exposed to domestic violence. Limitations include a quasi-experimental design and reliance on maternal report.

The differential treatment of youth of color in schools perpetuates disparities in academic outcomes. Alternative education programs may represent a constructive approach to preventing or mitigating these disparities. This study examines the outcomes of an urban alternative education program in the United States. Secondary analysis of demographic, psychosocial, and academic data from all program participants ( N = 232) during a 3-year study period was conducted. Descriptive statistics summarize demographic characteristics, and bivariate analyses examine the strength of association and interrelationships among individual variables, program retention, and educational attainment. Results show grade-level advancement, employability, and, therefore, decreased risk for justice involvement, regardless of students’ histories of lower academic performance, unemployment, behavioral health conditions, and justice system or child protective services contact. This evaluation offers a framework for replication and recommendations for future research examining alternative education programs.

Child abuse is a serious phenomenon that needs treatment to recover the victims. The present article aims at describing a training of giving treatments to recover children as victims from abuse and violence to show the students’ (participants) knowledge and service before they do internship program at an orphanage. The subject of research is 7th semester students of guidance and counseling program at Universitas Slamet Riyadi, Indonesia. The result of the research are the improvements of the college students’ knowledge and service in giving treatment for child abuse victims; they are familiar with six forms of treatment to recover the victims that consist of Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT), Parent Training and Multi-systemic Therapy, Project Support (Children’s Protective Services), Web-based parenting skills, Home Visiting Program, and School Based Mental Health Intervention for Children. The conclusion of the article is treatments in the form of collaboration between parents (caregivers), schools, and children (as victims) to recover child abuse and violence through a variety of phases to realize the purposes and children abuse as victims need appropriate treatment based on the condition of them and such six treatments as a choice and solution to recover the victims.

Introduction Most developed countries, including Australia, have a strong focus on national, state and local strategies for emergency management and response in the face of disasters and crises. This framework can include coping with catastrophic dislocation, service disruption, injury or loss of life in the face of natural disasters such as major fires, floods, earthquakes or other large-impact natural events, as well as dealing with similar catastrophes resulting from human actions such as bombs, biological agents, cyber-attacks targeting essential services such as communications networks, or other crises affecting large populations. Emergency management frameworks for crisis and disaster response are distinguished by their focus on the domestic context for such events; that is, how to manage and assist the ways in which civilian populations, who are for the most part inexperienced and untrained in dealing with crises and disasters, are able to respond and behave in such situations so as to minimise the impacts of a catastrophic event. Even in countries like Australia that demonstrate a strong public commitment to cultural pluralism and social cohesion, ethno-cultural diversity can be seen as a risk or threat to national security and values at times of political, natural, economic and/or social tensions and crises. Australian government policymakers have recently focused, with increasing intensity, on “community resilience” as a key element in countering extremism and enhancing emergency preparedness and response. In some sense, this is the result of a tacit acknowledgement by government agencies that there are limits to what they can do for domestic communities should such a catastrophic event occur, and accordingly, the focus in recent times has shifted to how governments can best help people to help themselves in such situations, a key element of the contemporary “resilience” approach. Yet despite the robustly multicultural nature of Australian society, explicit engagement with Australia’s cultural diversity flickers only fleetingly on this agenda, which continues to pursue approaches to community resilience in the absence of understandings about how these terms and formations may themselves need to be diversified to maximise engagement by all citizens in a multicultural polity. There have been some recent efforts in Australia to move in this direction, for example the Australian Emergency Management Institute (AEMI)’s recent suite of projects with culturally and linguistically diverse (CALD) communities (2006-2010) and the current Australia-New Zealand Counter-Terrorism Committee-supported project on “Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism” (Grossman and Tahiri), which I discuss in a longer forthcoming version of this essay (Grossman). Yet the understanding of ethno-cultural identity and difference that underlies much policy thinking on resilience remains problematic for the way in which it invests in a view of the cultural dimensions of community resilience as relic rather than resource – valorising the preservation of and respect for cultural norms and traditions, but silent on what different ethno-cultural communities might contribute toward expanded definitions of both “community” and “resilience” by virtue of the transformative potential and existing cultural capital they bring with them into new national and also translocal settings. For example, a primary conclusion of the joint program between AEMI and the Australian Multicultural Commission is that CALD communities are largely “vulnerable” in the context of disasters and emergency management and need to be better integrated into majority-culture models of theorising and embedding community resilience. This focus on stronger national integration and the “vulnerability” of culturally diverse ethno-cultural communities in the Australian context echoes the work of scholars beyond Australia such as McGhee, Mouritsen (Reflections, Citizenship) and Joppke. They argue that the “civic turn” in debates around resurgent contemporary nationalism and multicultural immigration policies privileges civic integration over genuine two-way multiculturalism. This approach sidesteps the transculturational (Ortiz; Welsch; Mignolo; Bennesaieh; Robins; Stein) aspects of contemporary social identities and exchange by paying lip-service to cultural diversity while affirming a neo-liberal construct of civic values and principles as a universalising goal of Western democratic states within a global market economy. It also suggests a superficial tribute to cultural diversity that does not embed diversity comprehensively at the levels of either conceptualising or resourcing different elements of Australian transcultural communities within the generalised framework of “community resilience.” And by emphasising cultural difference as vulnerability rather than as resource or asset, it fails to acknowledge the varieties of resilience capital that many culturally diverse individuals and communities may bring with them when they resettle in new environments, by ignoring the question of what “resilience” actually means to those from culturally diverse communities. In so doing, it also avoids the critical task of incorporating intercultural definitional diversity around the concepts of both “community” and “resilience” used to promote social cohesion and the capacity to recover from disasters and crises. How we might do differently in thinking about the broader challenges for multiculturalism itself as a resilient transnational concept and practice? The Concept of Resilience The meanings of resilience vary by disciplinary perspective. While there is no universally accepted definition of the concept, it is widely acknowledged that resilience refers to the capacity of an individual to do well in spite of exposure to acute trauma or sustained adversity (Liebenberg 219). Originating in the Latin word resilio, meaning ‘to jump back’, there is general consensus that resilience pertains to an individual’s, community’s or system’s ability to adapt to and ‘bounce back’ from a disruptive event (Mohaupt 63, Longstaff et al. 3). Over the past decade there has been a dramatic rise in interest in the clinical, community and family sciences concerning resilience to a broad range of adversities (Weine 62). While debate continues over which discipline can be credited with first employing resilience as a concept, Mohaupt argues that most of the literature on resilience cites social psychology and psychiatry as the origin for the concept beginning in the mid-20th century. The pioneer researchers of what became known as resilience research studied the impact on children living in dysfunctional families. For example, the findings of work by Garmezy, Werner and Smith and Rutter showed that about one third of children in these studies were coping very well despite considerable adversities and traumas. In asking what it was that prevented the children in their research from being negatively influenced by their home environments, such research provided the basis for future research on resilience. Such work was also ground-breaking for identifying the so-called ‘protective factors’ or resources that individuals can operationalise when dealing with adversity. In essence, protective factors are those conditions in the individual that protect them from the risk of dysfunction and enable recovery from trauma. They mitigate the effects of stressors or risk factors, that is, those conditions that predispose one to harm (Hajek 15). Protective factors include the inborn traits or qualities within an individual, those defining an individual’s environment, and also the interaction between the two. Together, these factors give people the strength, skills and motivation to cope in difficult situations and re-establish (a version of) ‘normal’ life (Gunnestad). Identifying protective factors is important in terms of understanding the particular resources a given sociocultural group has at its disposal, but it is also vital to consider the interconnections between various protective mechanisms, how they might influence each other, and to what degree. An individual, for instance, might display resilience or adaptive functioning in a particular domain (e.g. emotional functioning) but experience significant deficits in another (e.g. academic achievement) (Hunter 2). It is also essential to scrutinise how the interaction between protective factors and risk factors creates patterns of resilience. Finally, a comprehensive understanding of the interrelated nature of protective mechanisms and risk factors is imperative for designing effective interventions and tailored preventive strategies (Weine 65). In short, contemporary thinking about resilience suggests it is neither entirely personal nor strictly social, but an interactive and iterative combination of the two. It is a quality of the environment as much as the individual. For Ungar, resilience is the complex entanglements between “individuals and their social ecologies [that] will determine the degree of positive outcomes experienced” (3). Thinking about resilience as context-dependent is important because research that is too trait-based or actor-centred risks ignoring any structural or institutional forces. A more ecological interpretation of resilience, one that takes into a person’s context and environment into account, is vital in order to avoid blaming the victim for any hardships they face, or relieving state and institutional structures from their responsibilities in addressing social adversity, which can “emphasise self-help in line with a neo-conservative agenda instead of stimulating state responsibility” (Mohaupt 67). Nevertheless, Ungar posits that a coherent definition of resilience has yet to be developed that adequately ‘captures the dual focus of the individual and the individual’s social ecology and how the two must both be accounted for when determining the criteria for judging outcomes and discerning processes associated with resilience’ (7). Recent resilience research has consequently prompted a shift away from vulnerability towards protective processes — a shift that highlights the sustained capabilities of individuals and communities under threat or at risk. Locating ‘Culture’ in the Literature on Resilience However, an understanding of the role of culture has remained elusive or marginalised within this trend; there has been comparatively little sustained investigation into the applicability of resilience constructs to non-western cultures, or how the resources available for survival might differ from those accessible to western populations (Ungar 4). As such, a growing body of researchers is calling for more rigorous inquiry into culturally determined outcomes that might be associated with resilience in non-western or multicultural cultures and contexts, for example where Indigenous and minority immigrant communities live side by side with their ‘mainstream’ neighbours in western settings (Ungar 2). ‘Cultural resilience’ considers the role that cultural background plays in determining the ability of individuals and communities to be resilient in the face of adversity. For Clauss-Ehlers, the term describes the degree to which the strengths of one’s culture promote the development of coping (198). Culturally-focused resilience suggests that people can manage and overcome stress and trauma based not on individual characteristics alone, but also from the support of broader sociocultural factors (culture, cultural values, language, customs, norms) (Clauss-Ehlers 324). The innate cultural strengths of a culture may or may not differ from the strengths of other cultures; the emphasis here is not so much comparatively inter-cultural as intensively intra-cultural (VanBreda 215). A culturally focused resilience model thus involves “a dynamic, interactive process in which the individual negotiates stress through a combination of character traits, cultural background, cultural values, and facilitating factors in the sociocultural environment” (Clauss-Ehlers 199). In understanding ways of ‘coping and hoping, surviving and thriving’, it is thus crucial to consider how culturally and linguistically diverse minorities navigate the cultural understandings and assumptions of both their countries of origin and those of their current domicile (Ungar 12). Gunnestad claims that people who master the rules and norms of their new culture without abandoning their own language, values and social support are more resilient than those who tenaciously maintain their own culture at the expense of adjusting to their new environment. They are also more resilient than those who forego their own culture and assimilate with the host society (14). Accordingly, if the combination of both valuing one’s culture as well as learning about the culture of the new system produces greater resilience and adaptive capacities, serious problems can arise when a majority tries to acculturate a minority to the mainstream by taking away or not recognising important parts of the minority culture. In terms of resilience, if cultural factors are denied or diminished in accounting for and strengthening resilience – in other words, if people are stripped of what they possess by way of resilience built through cultural knowledge, disposition and networks – they do in fact become vulnerable, because ‘they do not automatically gain those cultural strengths that the majority has acquired over generations’ (Gunnestad 14). Mobilising ‘Culture’ in Australian Approaches to Community Resilience The realpolitik of how concepts of resilience and culture are mobilised is highly relevant here. As noted above, when ethnocultural difference is positioned as a risk or a threat to national identity, security and values, this is precisely the moment when vigorously, even aggressively, nationalised definitions of ‘community’ and ‘identity’ that minoritise or disavow cultural diversities come to the fore in public discourse. The Australian evocation of nationalism and national identity, particularly in the way it has framed policy discussion on managing national responses to disasters and threats, has arguably been more muted than some of the European hysteria witnessed recently around cultural diversity and national life. Yet we still struggle with the idea that newcomers to Australia might fall on the surplus rather than the deficit side of the ledger when it comes to identifying and harnessing resilience capital. A brief example of this trend is explored here. From 2006 to 2010, the Australian Emergency Management Institute embarked on an ambitious government-funded four-year program devoted to strengthening community resilience in relation to disasters with specific reference to engaging CALD communities across Australia. The program, Inclusive Emergency Management with CALD Communities, was part of a wider Australian National Action Plan to Build Social Cohesion, Harmony and Security in the wake of the London terrorist bombings in July 2005. Involving CALD community organisations as well as various emergency and disaster management agencies, the program ran various workshops and agency-community partnership pilots, developed national school education resources, and commissioned an evaluation of the program’s effectiveness (Farrow et al.). While my critique here is certainly not aimed at emergency management or disaster response agencies and personnel themselves – dedicated professionals who often achieve remarkable results in emergency and disaster response under extraordinarily difficult circumstances – it is nevertheless important to highlight how the assumptions underlying elements of AEMI’s experience and outcomes reflect the persistent ways in which ethnocultural diversity is rendered as a problem to be surmounted or a liability to be redressed, rather than as an asset to be built upon or a resource to be valued and mobilised. AEMI’s explicit effort to engage with CALD communities in building overall community resilience was important in its tacit acknowledgement that emergency and disaster services were (and often remain) under-resourced and under-prepared in dealing with the complexities of cultural diversity in emergency situations. Despite these good intentions, however, while the program produced some positive outcomes and contributed to crucial relationship building between CALD communities and emergency services within various jurisdictions, it also continued to frame the challenge of working with cultural diversity as a problem of increased vulnerability during disasters for recently arrived and refugee background CALD individuals and communities. This highlights a common feature in community resilience-building initiatives, which is to focus on those who are already ‘robust’ versus those who are ‘vulnerable’ in relation to resilience indicators, and whose needs may require different or additional resources in order to be met. At one level, this is a pragmatic resourcing issue: national agencies understandably want to put their people, energy and dollars where they are most needed in pursuit of a steady-state unified national response at times of crisis. Nor should it be argued that at least some CALD groups, particularly those from new arrival and refugee communities, are not vulnerable in at least some of the ways and for some of the reasons suggested in the program evaluation. However, the consistent focus on CALD communities as ‘vulnerable’ and ‘in need’ is problematic, as well as partial. It casts members of these communities as structurally and inherently less able and less resilient in the context of disasters and emergencies: in some sense, as those who, already ‘victims’ of chronic social deficits such as low English proficiency, social isolation and a mysterious unidentified set of ‘cultural factors’, can become doubly victimised in acute crisis and disaster scenarios. In what is by now a familiar trope, the description of CALD communities as ‘vulnerable’ precludes asking questions about what they do have, what they do know, and what they do or can contribute to how we respond to disaster and emergency events in our communities. A more profound problem in this sphere revolves around working out how best to engage CALD communities and individuals within existing approaches to disaster and emergency preparedness and response. This reflects a fundamental but unavoidable limitation of disaster preparedness models: they are innately spatially and geographically bounded, and consequently understand ‘communities’ in these terms, rather than expanding definitions of ‘community’ to include the dimensions of community-as-social-relations. While some good engagement outcomes were achieved locally around cross-cultural knowledge for emergency services workers, the AEMI program fell short of asking some of the harder questions about how emergency and disaster service scaffolding and resilience-building approaches might themselves need to change or transform, using a cross-cutting model of ‘communities’ as both geographic places and multicultural spaces (Bartowiak-Théron and Crehan) in order to be more effective in national scenarios in which cultural diversity should be taken for granted. Toward Acknowledgement of Resilience Capital Most significantly, the AEMI program did not produce any recognition of the ways in which CALD communities already possess resilience capital, or consider how this might be drawn on in formulating stronger community initiatives around disaster and threats preparedness for the future. Of course, not all individuals within such communities, nor all communities across varying circumstances, will demonstrate resilience, and we need to be careful of either overgeneralising or romanticising the kinds and degrees of ‘resilience capital’ that may exist within them. Nevertheless, at least some have developed ways of withstanding crises and adapting to new conditions of living. This is particularly so in connection with individual and group behaviours around resource sharing, care-giving and social responsibility under adverse circumstances (Grossman and Tahiri) – all of which are directly relevant to emergency and disaster response. While some of these resilient behaviours may have been nurtured or enhanced by particular experiences and environments, they can, as the discussion of recent literature above suggests, also be rooted more deeply in cultural norms, habits and beliefs. Whatever their origins, for culturally diverse societies to achieve genuine resilience in the face of both natural and human-made disasters, it is critical to call on the ‘social memory’ (Folke et al.) of communities faced with responding to emergencies and crises. Such wellsprings of social memory ‘come from the diversity of individuals and institutions that draw on reservoirs of practices, knowledge, values, and worldviews and is crucial for preparing the system for change, building resilience, and for coping with surprise’ (Adger et al.). Consequently, if we accept the challenge of mapping an approach to cultural diversity as resource rather than relic into our thinking around strengthening community resilience, there are significant gains to be made. For a whole range of reasons, no diversity-sensitive model or measure of resilience should invest in static understandings of ethnicities and cultures; all around the world, ethnocultural identities and communities are in a constant and sometimes accelerated state of dynamism, reconfiguration and flux. But to ignore the resilience capital and potential protective factors that ethnocultural diversity can offer to the strengthening of community resilience more broadly is to miss important opportunities that can help suture the existing disconnects between proactive approaches to intercultural connectedness and social inclusion on the one hand, and reactive approaches to threats, national security and disaster response on the other, undermining the effort to advance effectively on either front. This means that dominant social institutions and structures must be willing to contemplate their own transformation as the result of transcultural engagement, rather than merely insisting, as is often the case, that ‘other’ cultures and communities conform to existing hegemonic paradigms of being and of living. In many ways, this is the most critical step of all. A resilience model and strategy that questions its own culturally informed yet taken-for-granted assumptions and premises, goes out into communities to test and refine these, and returns to redesign its approach based on the new knowledge it acquires, would reflect genuine progress toward an effective transculturational approach to community resilience in culturally diverse contexts.References Adger, W. Neil, Terry P. Hughes, Carl Folke, Stephen R. Carpenter and Johan Rockström. “Social-Ecological Resilience to Coastal Disasters.” Science 309.5737 (2005): 1036-1039. ‹http://www.sciencemag.org/content/309/5737/1036.full> Bartowiak-Théron, Isabelle, and Anna Corbo Crehan. “The Changing Nature of Communities: Implications for Police and Community Policing.” Community Policing in Australia: Australian Institute of Criminology (AIC) Reports, Research and Policy Series 111 (2010): 8-15. Benessaieh, Afef. “Multiculturalism, Interculturality, Transculturality.” Ed. A. Benessaieh. Transcultural Americas/Ameriques Transculturelles. Ottawa: U of Ottawa Press/Les Presses de l’Unversite d’Ottawa, 2010. 11-38. Clauss-Ehlers, Caroline S. “Sociocultural Factors, Resilience and Coping: Support for a Culturally Sensitive Measure of Resilience.” Journal of Applied Developmental Psychology 29 (2008): 197-212. Clauss-Ehlers, Caroline S. “Cultural Resilience.” Encyclopedia of Cross-Cultural School Psychology. Ed. C. S. Clauss-Ehlers. New York: Springer, 2010. 324-326. Farrow, David, Anthea Rutter and Rosalind Hurworth. Evaluation of the Inclusive Emergency Management with Culturally and Linguistically Diverse (CALD) Communities Program. Parkville, Vic.: Centre for Program Evaluation, U of Melbourne, July 2009. ‹http://www.ag.gov.au/www/emaweb/rwpattach.nsf/VAP/(9A5D88DBA63D32A661E6369859739356)~Final+Evaluation+Report+-+July+2009.pdf/$file/Final+Evaluation+Report+-+July+2009.pdf>.Folke, Carl, Thomas Hahn, Per Olsson, and Jon Norberg. “Adaptive Governance of Social-Ecological Systems.” Annual Review of Environment and Resources 30 (2005): 441-73. ‹http://arjournals.annualreviews.org/doi/pdf/10.1146/annurev.energy.30.050504.144511>. Garmezy, Norman. “The Study of Competence in Children at Risk for Severe Psychopathology.” The Child in His Family: Children at Psychiatric Risk. Vol. 3. Eds. E. J. Anthony and C. Koupernick. New York: Wiley, 1974. 77-97. Grossman, Michele. “Resilient Multiculturalism? Diversifying Australian Approaches to Community Resilience and Cultural Difference”. Global Perspectives on Multiculturalism in the 21st Century. Eds. B. E. de B’beri and F. Mansouri. London: Routledge, 2014. Grossman, Michele, and Hussein Tahiri. Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism. Canberra: Australia-New Zealand Counter-Terrorism Committee, forthcoming 2014. Grossman, Michele. “Cultural Resilience and Strengthening Communities”. Safeguarding Australia Summit, Canberra. 23 Sep. 2010. ‹http://www.safeguardingaustraliasummit.org.au/uploader/resources/Michele_Grossman.pdf>. Gunnestad, Arve. “Resilience in a Cross-Cultural Perspective: How Resilience Is Generated in Different Cultures.” Journal of Intercultural Communication 11 (2006). ‹http://www.immi.se/intercultural/nr11/gunnestad.htm>. Hajek, Lisa J. “Belonging and Resilience: A Phenomenological Study.” Unpublished Master of Science thesis, U of Wisconsin-Stout. Menomonie, Wisconsin, 2003. Hunter, Cathryn. “Is Resilience Still a Useful Concept When Working with Children and Young People?” Child Family Community Australia (CFA) Paper 2. Melbourne: Australian Institute of Family Studies, 2012.Joppke, Christian. "Beyond National Models: Civic Integration Policies for Immigrants in Western Europe". West European Politics 30.1 (2007): 1-22. Liebenberg, Linda, Michael Ungar, and Fons van de Vijver. “Validation of the Child and Youth Resilience Measure-28 (CYRM-28) among Canadian Youth.” Research on Social Work Practice 22.2 (2012): 219-226. Longstaff, Patricia H., Nicholas J. Armstrong, Keli Perrin, Whitney May Parker, and Matthew A. Hidek. “Building Resilient Communities: A Preliminary Framework for Assessment.” Homeland Security Affairs 6.3 (2010): 1-23. ‹http://www.hsaj.org/?fullarticle=6.3.6>. McGhee, Derek. The End of Multiculturalism? Terrorism, Integration and Human Rights. Maidenhead: Open U P, 2008.Mignolo, Walter. Local Histories/Global Designs: Coloniality, Subaltern Knowledges, and Border Thinking. Princeton: Princeton U P, 2000. Mohaupt, Sarah. “Review Article: Resilience and Social Exclusion.” Social Policy and Society 8 (2009): 63-71.Mouritsen, Per. "The Culture of Citizenship: A Reflection on Civic Integration in Europe." Ed. R. Zapata-Barrero. Citizenship Policies in the Age of Diversity: Europe at the Crossroad." Barcelona: CIDOB Foundation, 2009: 23-35. Mouritsen, Per. “Political Responses to Cultural Conflict: Reflections on the Ambiguities of the Civic Turn.” Ed. P. Mouritsen and K.E. Jørgensen. Constituting Communities. Political Solutions to Cultural Conflict, London: Palgrave, 2008. 1-30. Ortiz, Fernando. Cuban Counterpoint: Tobacco and Sugar. Trans. Harriet de Onís. Intr. Fernando Coronil and Bronislaw Malinowski. Durham, NC: Duke U P, 1995 [1940]. Robins, Kevin. The Challenge of Transcultural Diversities: Final Report on the Transversal Study on Cultural Policy and Cultural Diversity. Culture and Cultural Heritage Department. Strasbourg: Council of European Publishing, 2006. Rutter, Michael. “Protective Factors in Children’s Responses to Stress and Disadvantage.” Annals of the Academy of Medicine, Singapore 8 (1979): 324-38. Stein, Mark. “The Location of Transculture.” Transcultural English Studies: Fictions, Theories, Realities. Eds. F. Schulze-Engler and S. Helff. Cross/Cultures 102/ANSEL Papers 12. Amsterdam and New York: Rodopi, 2009. 251-266. Ungar, Michael. “Resilience across Cultures.” British Journal of Social Work 38.2 (2008): 218-235. First published online 2006: 1-18. In-text references refer to the online Advance Access edition ‹http://bjsw.oxfordjournals.org/content/early/2006/10/18/bjsw.bcl343.full.pdf>. VanBreda, Adrian DuPlessis. Resilience Theory: A Literature Review. Erasmuskloof: South African Military Health Service, Military Psychological Institute, Social Work Research & Development, 2001. Weine, Stevan. “Building Resilience to Violent Extremism in Muslim Diaspora Communities in the United States.” Dynamics of Asymmetric Conflict 5.1 (2012): 60-73. Welsch, Wolfgang. “Transculturality: The Puzzling Form of Cultures Today.” Spaces of Culture: City, Nation World. Eds. M. Featherstone and S. Lash. London: Sage, 1999. 194-213. Werner, Emmy E., and Ruth S. Smith. Vulnerable But Invincible: A Longitudinal Study of\ Resilience and Youth. New York: McGraw Hill, 1982. NotesThe concept of ‘resilience capital’ I offer here is in line with one strand of contemporary theorising around resilience – that of resilience as social or socio-ecological capital – but moves beyond the idea of enhancing general social connectedness and community cohesion by emphasising the ways in which culturally diverse communities may already be robustly networked and resourceful within micro-communal settings, with new resources and knowledge both to draw on and to offer other communities or the ‘national community’ at large. In effect, ‘resilience capital’ speaks to the importance of finding ‘the communities within the community’ (Bartowiak-Théron and Crehan 11) and recognising their capacity to contribute to broad-scale resilience and recovery.I am indebted for the discussion of the literature on resilience here to Dr Peta Stephenson, Centre for Cultural Diversity and Wellbeing, Victoria University, who is working on a related project (M. Grossman and H. Tahiri, Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism, forthcoming 2014).

The ProjectThe Hand Up Linkage project focuses on the family as a communication context through which to explore the dynamics of intergenerational welfare dependency. In particular, it explores ways that creative life-course interventions might allow children in welfare dependent families to construct alternative realities for themselves and alternative views of their future. Formed through an alliance between a key Western Australian social welfare not-for-profit organisation, St Vincent de Paul WA (SVDPWA and also, in the context of volunteers, ‘Vinnies’), and Edith Cowan University, the project aims to address the organisation’s vision to provide “a hand up” (St Vincent 1) rather than ‘a hand out’, so that people can move forward with their lives without becoming dependent upon welfare. Prior to the start of the research, SVDPWA already had a whole of family focus in its outreach to poverty-impacted families including offering homework clubs and school holiday children’s camps run by their youth services division. Selected families supported by SVDPWA have been invited to participate in an in-depth interview for the project (Seidman), partly so that researchers can help identify “turning points” (King et al.) that might disrupt the communication of welfare dependency and inform more generalised intervention strategies; but also in order to explore the response to creative interventions within the children’s daily lives, including investigation of how strategies the child (and family) employed might help them to imagine alternative realities and futures for themselves. This paper closely examines the way that one 10 year old child from a non-English-speaking background family has employed alternative ways of viewing her life, through the camp program provided by the Linkage Partner St Vincent de Paul WA, and through reading novels such as Harry Potter and the Lemony Snicket Unfortunate Incidents series. Such activities help fuel hope for a different future which, in Snyder’s view has “two main components: the ability to plan pathways to desired goals despite obstacles, and agency or motivation to use those pathways” (Carr 96).The FamilyKani is a 10 year old girl living in a migrant sole parent family. The parents had moved to Australia from Bangladesh on student visas when Kani was 5 years old, however due to domestic violence the mother had recently separated from her husband, first into a women’s refuge then into private rental accommodation. The mother is in protracted negotiations with the Department of Immigration for permanent residency, which she had to recommence due to her separation. There are also family court negotiations for child custody and which restrict her leaving Australia. She receives no government benefits and minimal child support, works fulltime and pays full childcare fees for Kani’s 3 year old brother Adil and full primary school fees for Kani at a local religious school, given that Kani had experienced bullying and social aggression in previous schools. Kani was referred to SVDPWA by the women’s refuge and she began attending SVDPWA Kids’ Camps thereafter. (NB: Whilst the relevant specifics of this description are accurate, non-relevant material has been added or changed to protect the child’s and family’s identity.)Creative Life-Course InterventionsThe creative engagement that Kani experienced in the Hand Up project is constructed as one component in a larger model of creativity which includes “intrapersonal insights and interpretations, which often live only within the person who created them,” (Kaufman and Beghetto 4). Such an approach also acknowledges Csikszentmihalyi’s work on the concept of “flow”, whereby optimal experiences can result from positive absorption in a creative activity. Relevant Australian research such as the YouthWorx project has identified participatory engagement in creativity as one means of engaging with young people at risk (Hopkins; Podkalicka). The creative interventions in the Hand Up project take two forms; one is the predesigned and participatory creative activities delivered as part of the SVDPWA Kids’ Camp program. The second is a personalised intervention, identified by way of an in-depth interview with the child and parent, and is wholly dependent on the interests expressed by the child, the ability for the family to engage in that activity, and the budget restraints of the project.Reading as an Alternative RealityA key creative intervention embedded in the Hand Up Linkage project is determined by the interests expressed by the child during their in-depth interview. Also taken into account is the ability for the family to engage in that activity. For example, Kani’s mother works fulltime at a location which is an hour by public transport from home and does not have a car or driver’s license, so the choice of creative opportunity was restricted to a home-based activity or a weekend activity accessible by public transport. A further restriction is the limited budget available for this intervention in the project, along with an imperative that such interventions should be equitable between families and within families, and be of benefit to all the children in addition to the interviewed child. Fortunately, transport was not an issue because Kani expressed her interest very emphatically as books and reading. When asked what she liked doing most in life, Kani replied: “Reading. I like reading like big books, like really thick books and stuff. I have like 30 in my room. Like those really big books. And I'm starting to read Harry Potter now. Okay, the books that I like reading is Harry Potter, the entire set Roald Dahl books and the Baudelaire Orphans by Lemony Snicket. I like reading David Walliams. I like Little Women” (Kani). Her excitement in listing these books further animated the interview and was immediately emphasised because Kani took the interviewer (second author) and her mother into her room to demonstrate the truth of her statement. When asked again at the close of the interview “what’s a favourite thing that makes you feel good inside?” Kani’s answer was “Family and reading”. The energy and enthusiasm with which Kani talked about her reading and books made these the obvious choice as her creative intervention. However, participation in book-related courses or after-school activities was restricted by Kani’s mother’s transportation limitations. Taking into account how the financial constraints of her sole parent family impacted upon their capacity to buy books, and the joy that Kani clearly experienced from having books of her own, it was decided that a book voucher would be provided for her at a local bookstore easily accessible by bus. The research team negotiated with the bookstore to try to ensure that Kani could choose a book a month until the funds were expended so that the intervention would last most of the coming six months.What Kani was expressing in her love of books was partly related to the raw material they provide that help her to imagine the alternative reality of the fictional worlds she loved reading about. Kani’s passionate engagement in these alternative realities reflects theories of narrative immersion in one’s chosen medium: “One key element of an enjoyable media experience is that it takes individuals away from their mundane reality and into a story world. We call the process of becoming fully engaged in a story transportation into a narrative world” (Green et al. 311–12). Kani said: “Reading is everything, yeah. Like getting more books and like those kind of things and making me read more... ‘cause I really love reading, it’s like watching a movie. Do you know ... have you watched Harry Potter? … the book is nothing like the movie, nothing, they’ve missed so many parts so the book is more enjoyable than the movie. That’s why I like reading more. ‘Cause like I have my own adventures in my head.” This process of imagining her own adventures in her head echoes Green and Brock’s explanation of the process of being transported into alternative realities through reading as a result of “an integrative melding of attention, imagery, and feelings” (701).Constructing Alternative Realities for Herself and an Alternative Possible FutureLike many 10 year olds, Kani has a challenging time at school, exacerbated by the many school moves brought about by changes in her family circumstances. Even though she is in a school which supports her family’s faith, her experience is one of being made to feel an outsider: “all the boys and the girls in our class are like friends, they’re like ... it’s a group. But I’m not in their group. I have my friends in other classes and they’re [my classmates are] not happy with it, that’s why they tease me and stuff. And like whenever I play with my friends they’re like ... yeah”. The interviewer asked her what she liked about her special friends. “They’re fun. Creative like, enjoyable, yeah, those kind of things …they have lots of cool ideas like plans and stuff like that.” As Hawkins et al. argue, the capacity to develop and maintain good relationships with peers (and parents) is a key factor in helping children be resilient. It is likely that Kani also shares her creativity, ideas and plans with her friendship group as part of her shared contribution to its existence.A domestication of technology framework (Silverstone et al.) can be useful as part of the explanation for Kani’s use of imaginative experience in building her social relationships. Silverstone et al. argue that technology is domesticated via four interlocking activities: ‘appropriation’ (where it embraced, purchased, taken into the household), ‘objectification’ (where a physical space is found for it), ‘incorporation’ (the spaces through which it is inserted into the everyday activities of the household or users) and ‘conversion’ (whereby the experience and fact of the technology use – or lack of use – becomes material through which family members express themselves and their priorities to the social world beyond the home). Arguably, Kani ‘converts’ her engagement with books and associated imaginative experiences into social currency through which she builds relationships with the like-minded children with whom she makes friends. At the same time, those children feed into her ideas of what constitutes a creative approach to life and help energise her plans for the future.Kani’s views of her future (at the age of 10) are influenced by the traditional occupations favoured by high achieving students, and by the fact that her parents are themselves educational high achievers, entering Australia on student visas. “I want to be a doctor … my cousin wants to be a doctor too. Mum said lawyer but we want to be a doctors anywhere. We want to be a ...me and my cousin want to be doctors like ...we like being doctors and like helping people.” Noting the pressures on the household of the possible fees and costs of high school, Kani adds “I need to work even harder so I get a scholarship. ‘Cause like my mum can’t pay for like four terms, you know how much money that will be? Yeah.” Kani’s follow-on statement, partly to justify why she wants “a big house”, adds some poignancy to her reference to a cousin (one of many), who still lives in Bangladesh and whom Kani hasn’t seen since 2011. “Like I want to live with my mum and like yeah and like I live with my cousin too because like I have a cousin ... she’s a girl, yeah? And like yeah, she’s in Bangladesh, I haven’t seen her for very long time so yeah.” In the absence of her extended family overseas, Kani adds her pets to those with whom she shares her family life: “And my mum and my uncle and then our cat Dobby. I named it [for Harry Potter’s house elf] ...and the goldfish. The goldfish are Twinkle, Glitter, Glow and Bobby.”Kani’s mum notes the importance of an opportunity to dream a future into existence: “maybe she’s too young or she hasn’t really kind of made up her mind as yet as to what she wants to do in life but just going out and just you know doing stuff and just giving them the opportunity”. The SVDPWA Kids’ Camp is an important part of this “they [the refuge] kind of told us like ‘there’s this child camp’. … I was like yeah, sure, why not?” Providing Alternative Spaces at the SVDPWA Kids’ CampThe SVDPWA Kids’ Camps themselves constitute a creative intervention in offering visions of alternative realities to their young participants. Their benefit is delivered via anticipation, as well as the reality of the camp experience. As Kani said “I forget all about the things that’s just past, like all the hard things, you know like I go through and stuff and it just makes me forget it and it makes me like think about camp, things we’re going to do at camp”. The Kids’ Camps take place three times a year and are open to children aged between 8 and 13, with follow-on Teen Camps for older age groups. Once a child is part of the program she or he can continue to participate in successive camps while they are in the target age group. Consisting of a four day activity-based experience in a natural setting, conducted by Vinnies Youth and staffed by key SVDPWA employees and Youth volunteers, the camps offer children a varied schedule of activities in a safe and supported environment, with at least one volunteer for every two child participants. The camps are specifically made available to children from disadvantaged families and are provided virtually free to participants. (A nominal $10 enrolment fee is applied per child). Kani was initially reticent about attending her first camp. She explained: “I was shy, scared because I sleep with my mum so it’s different sleeping without Mum. I know it’s kind of embarrassing ‘cause, sleeping with my mum like, but I just get scared at night”. Kani went on to explain how the camp facilitators were able to allay her fears “I knew I was safe. And I had people I could talk to so yeah ...like the leader”. As one Vinnies Youth volunteer explains, the potential of offering children like Kani time out from the pressures of everyday life is demonstrated when “towards the end of every camp we always see that progression of, they came out of their shell … So I think it’s really just a journey for everyone and it’s understandable if they did feel stuck. It’s about what we can do to help them progress forward” (VY1). Kani was empowered to envision an alternative idea of herself at camp, one which was unexpectedly intuited by the research interviewer.When the interviewer closed the interview by expressing that it had been lovely to talk to Kani as she was “such a bundle of energy”, Kani grinned and replied “Do you know the warm fuzzies, yeah? [When positive thoughts about others are exchanged at the SVDPWA Kids’ Camp]. The bundle ... all the leaders say I’m a bundle of happiness”. The Kids’ Camp provided Kani with a fun and positive alternative reality to the one she experienced as a child handling the considerable challenges experienced by social isolation, domestic violence and parental separation, including the loss of her home, diminished connection to her overseas extended family, legal custody issues, and several school changes. Taking the role of cultural intermediary, by offering the possibility of alternative realities via their camp, SVDPWA offered Kani a chance that supported her work on creating a range of enticing possible futures for herself. This was in contrast to some commercial holiday camp experiences which might more centrally use their “cultural authority as shapers of taste and … new consumerist dispositions” (Nixon and Du Gay 497). Even so, Kani’s interview made clear that her experience with the SVDPWA Kids’ Camps were only part of the ways in which she was crafting a range of possible visions for her adult life, adding to this her love of books and reading, her fun, creative friends, and her vision for a successful future which would reunite her with her distant cousin and offer security to her mother. ConclusionUnderstandably, Kani at 10 lacks the critical insight required to interpret how her imaginative and creative life provides the raw materials from which she crafts her visions for the future. Further, the interviewer is careful not to introduce words like ‘creative’ into her work with the participant families, so that when Kani used it to talk about her friends she did so drawing upon her own store of descriptions and not as a result of having recently been reminded of creativity as a desirable attribute. The interview with this young person indicates, however, how greatly she values the imaginative and cultural inputs into her life and how she converts them in ways which help ensure access to further such creative currency. Apart from referencing her reading in the naming of her cat, Kani’s vision for herself reflects both the conventional idea of success (“a doctor”) and a very specific idea of her future living as an adult in house large enough to include her mum and her cousin.Kani’s love of reading, her pleasure in books, her choice of friends and her aspirations to scholarly excellence all offer her ways to escape the restricted options available to families who seek support from organisations such as SVDPWA. At the same time the Kids’ Camps themselves, like Kani’s books, provide an escape from the difficulties of the present. Kani’s appropriation of the cultural raw materials that she draws into her life, and her conversion of these inputs into a creative, social currency, offers her an opportunity to anticipate a better future, and some tools she can use to help bring it into existence.ReferencesCarr, A. Positive Psychology: The Science of Happiness and Human Strengths. 2nd ed. Hove, UK: Routledge, 2011.Csikszentmihalyi, M. Creativity: Flow and the Psychology of Discovery and Invention. New York: HarperCollins, 1996.Green, M., and T. Brock. “The Role of Transportation in the Persuasiveness of Public Narratives.”. Journal of Personality and Social Psychology 79 (2000): 701–21.———, T. Brock, and G. Kaufman. “Understanding Media Enjoyment: The Role of Transportation into Narrative Worlds." Communication Theory 14.4 (2004): 311–27.Hawkins, J.D., R. Kosterman, R.F. Catalano, K.G. Hill, and R.D. Abbott. “Promoting Positive Adult Functioning through Social Development Intervention in Childhood: Long-Term Effects from the Seattle Social Development Project.” Archives of Pediatrics & Adolescent Medicine 159.1 (2005): 25. Hopkins, L. “YouthWorx: Increasing Youth Participation through Media Production.” Journal of Sociology 47.2 (2011): 181–197. doi: 10.1177/1440783310386827.Kani. In-depth interview, de-identified, 2016.Kaufman, J. C., and R.A. Beghetto. “Beyond Big and Little: The Four C Model of Creativity.” Review of General Psychology 13.1 (2009): 1–12. <http://dx.doi.org/10.1037/a0013688>. King, G., T. Cathers, E. Brown, J.A. Specht, C. Willoughby, J.M. Polgar, and L. Havens. “Turning Points and Protective Processes in the Lives of People with Chronic Disabilities.” Qualitative Health Research 13.2 (2003): 184–206.Nixon, S., and P. Du Gay. “Who Needs Cultural Intermediaries?” Cultural Studies 16.4 (2002): 495–500.Podkalicka, A. “Young Listening: An Ethnography of YouthWorx Media’s Radio Project.” Continuum 23.4 (2009): 561–72.St Vincent de Paul Society (WA). St Vincent de Paul Society, Annual Report 2013. Perth, WA: St Vincent de Paul Society (WA), 2013. 5 Jan 2017 <http://www.vinnies.org.au/icms_docs/169819_Vinnies_WA_2012_Annual_Report.pdf>.Seidman, I. Interviewing as Qualitative Research: A Guide for Researchers in Education and the Social Sciences. New York: Teachers College Press, Columbia University, 2006.Silverstone, R., E. Hirsch, and D. Morley. “Information and Communication Technologies and the Moral Economy of the Household.” Consuming Technologies: Media and Information in Domestic Spaces. Eds. R. Silverstone and E. Hirsch. London: Routledge, 1992. 9–17.Snyder, C.R. Handbook of Hope. Orlando, FL: Academic Press, 2000.VY1. In-depth interview with Vinnies Youth volunteer, de-identified, 2016.

Photo by Anna Hecker on Unsplash ABSTRACT All people deserve the legal ability to outline their care decisions in advance and expect their decisions to govern during a pregnancy. However, until advance directives govern without pregnancy exceptions, people will not uniformly retain the ability to formulate autonomous decisions about their health care planning. INTRODUCTION In the last few years, states have passed increasingly restrictive laws regarding abortion and reproductive health care. Recent legislation in Alabama effectively banned the procedure altogether, while more than a dozen states have passed or are currently in the process of enacting so-called “fetal heartbeat laws,” which ban abortion at roughly six weeks post-conception after the detection of electrical activity in what could develop into fetal cardiac tissue.[1] While courts rarely uphold outright bans and broad sweeping legislation, they garner significant media and public attention.[2] In practice, however, often smaller legislative changes that garner the least attention have the most significant impact by steadily chipping away at healthcare rights. Few people realize the ethical impact of the poorly understood legal means by which a pregnant woman has already lost her right to make autonomous healthcare decisions over her body using an advance directive in nearly every state. BACKGROUND Advance directives are one of modern medicine’s most powerful yet underused tools. Most clinicians and patients think of advance directives as being only for the elderly or terminally ill. This association stems from the 1991 Congressional Patient Self-Determination Act that requires hospitals, nursing homes, and hospice agencies receiving federal funding to inform patients of their legal right to prepare an advance directive. The 2015 announcement by the Center for Medicare and Medicaid Services (CMS) to reimburse for advance directives without requiring a diagnosis code recognizes that all adult patients can benefit from advance directives regardless of illness or life expectancy.[3] Providers should be aware of a small but significant exemption found in most state advance directive laws. This exemption, commonly known as the pregnancy clause, invalidates the advance directive of a pregnant woman, negating autonomy. The pregnancy clause can lead to treatment against medical standards of care and places private interests over public health. Advance directive statutes are frequently amended, but currently, only eight states allow patients to write their pregnancy-related wishes into their advance directive and guarantee that their instructions will be followed. Eleven states automatically invalidate advance directives during pregnancy, while 18 states permit physicians to disregard a pregnant woman’s (or her proxy’s) wishes based on the likelihood of viability, pain, and suffering, or conscientious objector clauses. Thirteen states remain silent on whether an advance directive is binding during pregnancy or have contradictory statutes.[4] Viability has no standard definition for the purposes of the clauses and viability-based pregnancy clauses can lead to the same loss of rights as pregnancy clauses that invalidate advance directives due to pregnancy without any exceptions. Many may wonder about the clinical relevance of pregnancy clauses. The likelihood that a woman will need to effectuate an advance care directive while pregnant is higher than many people would realize. This situation is most commonly assumed to occur in instances of a brain-dead pregnant woman, of which there are a few cases reported each year. But brain death and persistent vegetative states are just two reasons to look to an advance directive. Advance directives more commonly apply to patients with dementia, strong religious objections to medical care, or during cancer treatments, surgery, or acute injury with temporary loss of capacity. In surgery or acute lapses of capacity, a proxy may be asked to make decisions if complications arise. The number of women potentially affected by pregnancy clauses is significant. Each year, 75,000 pregnant women will undergo non-obstetrical surgery;[5] one in 1,500 pregnant women will be diagnosed with cancer;[6] and an estimated 250,000 Americans will exhibit early-onset Alzheimer’s symptoms between the ages of 30 and 50.[7] ANALYSIS Though pregnancy clauses are a seemingly narrow focus, they can nullify an entire advance directive and restrict care not related to the fetus. By negating entire advance directives, the clauses negate proxy appointments, allowing decision-makers other than the intended proxy. Providers and proxies are left with little guidance over who can make decisions on behalf of the patient. Many states will appoint a biological family member as the surrogate decision maker if there is no designated proxy or the directive is invalid. The outdated language and assumptions about nuclear families found in these structures could significantly impact unmarried couples, same-sex partnerships, and relationships that do not meet state-defined partnership standards where the courts may appoint someone other than the woman’s significant other even when she designated them as a proxy.[8] Members of religious groups whose doctrines prohibit certain medical therapies must be informed that if they become pregnant, their autonomous ability to decide about medical care through an advance directive and their right to freely practice religion can be voided entirely. In addition to infringing on patient autonomy, pregnancy clauses also restrict how clinicians might practice medicine by mandating medically inappropriate treatments against the provider’s recommendations. For example, Illinois’s pregnancy clause stipulates that “if you are pregnant and your health care professional thinks you could have a live birth, your living will cannot go into effect.”[9] This clause places providers in a difficult position of sacrificing their therapeutic obligation to their patients. It may require them to use futile therapy against the patient’s best interest and without regard for prolonged pain and suffering. Pregnancy clauses are void of any consideration of the best clinical interest of the patient or the fetus and instead promote conservative rhetoric that all potential fetal life is paramount. Numerous medical and chromosomal conditions are incompatible with life or present significant potential disabilities that may be accompanied by pain and suffering. The same conditions also pose risks to the mother, including death. Accordingly, the medical profession recognizes that there are instances in which it may not be in the best medical interest of the mother or the fetus to continue the pregnancy. Yet providers are seemingly required by pregnancy clauses to violate codes of conduct and subject pregnant patients and their nonviable fetuses to treatments to which other patients would not be subjected. Without evidence of a patient’s clear and convincing intentions, states have an interest in protecting life, preventing suicide, and maintaining the ethical integrity of the medical profession that could interfere with the person’s ability to refuse care.[10] The legal defense of pregnancy clauses is that the state’s interest in fetal life is sufficiently important to override the mother. As established in Planned Parenthood v. Casey (1992), however, the state’s interest only exists for fetal life post-viability.[11] Therefore, to allow the state interest to override the person’s advance directive when the fetus is not yet viable violates Casey. Individuals have a legal and ethical interest in maintaining bodily privacy, integrity, and freedom from unwanted touching. They have the right to appoint a proxy or use a directive to govern care in the case of incapacity. Even when contemplating brain death, organ donation, and whether to be cremated or buried, there is an expectation that personal wishes will govern. Honoring an advance directive allows providers to uphold the integrity of the medical profession by respecting the principles of autonomy and beneficence. Pregnancy clauses are inherently unethical as their creation was not to further the integrity of the medical or legal profession, nor protect a state’s interest in the patient’s life. In 2016, the American College of Obstetricians and Gynecologists issued a committee opinion that pregnancy is not an ethical exemption to the right of capable patients to refuse treatment.[12] The right to direct treatment while pregnant is consistent with modern medical practice, while the legislative promotion of a singular abstract interest in potential fetal life to the exclusion of all other medical and ethical considerations is not in line with the profession’s values.[13] Many pregnancy clauses are politically motivated, reflecting anti-abortion legality lobbying efforts and attempts to win over conservative voters. When Alaskan Attorney General Harold M. Brown argued the state’s pregnancy clause was unconstitutional, Governor Bill Sheffield – a Democrat in a historically red state – enacted the bill anyway. Georgia’s Governor Bill Kemp narrowly won his election, with some crediting his aggressive messaging against immigration and abortion.[14] With either advance directives, proxies, or even friends and relatives who know what the person (if not incapacitated) would have wanted, courts and legislatures should not have leeway to force care that a person, if conscious, would have refused.[15] The ability to harness advance directive law to force invasive and unwanted treatment upon a pregnant patient’s body continues to occur out of the fear of legal uncertainty. The lack of uniformity between states in their pregnancy clauses further adds to the confusion. Many advance directive statutes create a conditional proposition: if a provider acts in accordance with the carefully drawn circumstances of an advance directive, the provider is granted protective immunity from accusations of malpractice or wrongful death for that conduct. It is neither illegal nor unethical to remove a ventilator, for example, from a patient who has directed such a course of action in an advance directive. A pregnancy clause may remove that immunity making the unethical act of ignoring the directive legal, but the ethical act of following it (removing a ventilator, for example) could subject the practitioner to liability.[16] Without a pregnancy clause, providers retain the ability to both follow an advance directive and to act in the best medical interest of their patient. Pregnancy clauses create confusion over the permissibility of medical acts in an attempt to coerce providers into making decisions that violate the rights of their patients and their own ethical codes of conduct. Pregnancy clauses are a fallacy of consequentialist ethics in which the morality of the outcome justifies actions. Under consequentialist reasoning, any violation to the woman is justified if the fetus develops and results in a live birth. This reasoning is further faulty as it incorrectly assumes that mechanically ventilating an unconscious, sick, dying, or dead body will result in a live birth. Consequentialist theories should be limited to situations with predictable ends. Ethical medical providers refute consequentialism in certain contexts because it treats patients as a means to an end to produce benefit for others. In pregnancy, ignoring advance directives to achieve the chance that a fetus might survive is not justified by consequentialism. Pregnancy clauses also fail through the lens of deontological ethics in which an action must be ethical in and of itself and not based on outcomes. The choice to respect autonomy through an advance directive should be followed uniformly absent special circumstances. Proponents of pregnancy clauses may argue that pregnancy is an appropriate exception because a woman “has chosen to lend her body to bring [a] child into the world.”[17] Minnesota and Oklahoma echo this belief in their statutes, which contain an unjustified rebuttable presumption that all female patients would want life-sustaining treatment if they are pregnant.[18] Pregnancy should not abrogate the rights of a person to assign a proxy for access to an abortion or to control her medical treatment. Pregnancy exclusions are not grounded in the ethical “best interest” standards for the mother or the fetus. Instead, they are rooted in outdated expectations of female gender roles, which reaffirm a legislative assumption that a pregnancy is more morally valuable than a woman’s autonomy. CONCLUSION All people deserve the legal ability to outline their care decisions in advance and expect their decisions to govern during a pregnancy. Providers and the government do not have to approve of a person’s care decisions or values, but medical practitioners must respect a person’s right to dictate their own health narratives. With the push for more patients to execute advance directives, providers and patients must be aware that their advance directives may succumb to the authority of pregnancy clauses. Until advance directives govern without pregnancy exceptions, people will not uniformly retain the ability to formulate autonomous decisions about their health care planning. Advance directive law will continue to be hijacked by politically motivated legislators. When seeking to address inequities in healthcare laws and access, it is essential to take a closer look at not only the headline cases but also the clauses and exemptions to laws seemingly designed to benefit patients. [1] For proposed and current abortion legislation and maps, see https://www.guttmacher.org/state-policy# and Anne Godlasky, Nicquel Terry Ellis, and Jim Sergent, “Where is Abortion Legal? Everywhere, but…” USA Today, May 15, 2019, updated April 23, 2020 https://www.usatoday.com/in-depth/news/nation/2019/05/15/abortion-law-map-interactive-roe-v-wade-heartbeat-bills-pro-life-pro-choice-alabama-ohio-georgia/3678225002/ [2] https://www.guttmacher.org/state-policy# (Many bills fail in legislatures and are not enacted.) [3] Department of Health and Human Services Centers for Medicare & Medicaid Services; 42 CFR Part 405, 410, 411, 414, 425, and 495; “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Final Rule.” [4] DeMartino, E. S., Sperry, B. P., Doyle, C. K., Chor, J., Kramer, D. B., Dudzinski, D. M., & Mueller, P. S. (2019). US State Regulation of Decisions for Pregnant Women Without Decisional Capacity. JAMA, 321(16), 1629–1631. https://doi.org/10.1001/jama.2019.2587; Villarreal, Elizabeth. “Pregnancy and Living Wills: A Behavioral Economic Analysis.” The Yale Law Journal Forum. Vol. 128 (2019); 1052-1076. [5] “Surgery During Pregnancy.” Intermountain Healthcare: Fact Sheet for Patients and Families, (2018). https://intermountainhealthcare.org/ext/Dcmnt?ncid=520782026 [6] Basta, P. Bak, A. Roszkowski, K. “Cancer Treatment in Pregnant Women”. Contemporary Oncology, 19, no. 5 (2015): 354–360 [7] “31-Year-Old Woman Fights Alzheimer's While Pregnant.” San Francisco Globe. 9 July 2015, sfglobe.com/2015/02/19/31-year-old-woman-fights-alzheimers-while-pregnant. [8] “Health Care Proxies.” Human Rights Campaign, https://www.hrc.org/resources/health-care-proxy. [9] Illinois Department of Public Health website, Statement of Illinois Law on Advance Directives and DNR Orders, http://www.idph.state.il.us/public/books/advdir4.htm. [10] In the Matter of Karen Quinlan, 355 A.2d 647 (1976); Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990); and In re Conroy 486 A.2d 1209 (1985). [11] Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992). [12] The American College of Obstetricians & Gynecologists Committee on Ethics, Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy, (2016). [13] Lederman, Anne D. “A Womb of My Own: A Moral Evaluation of Ohio’s Treatment of Pregnant Patient’s with Living Wills”. Case W. Res. L. Rev. Vol. 45:351 (1995); 351-377. [14] Tavernise, Sabrina. “The Time Is Now: States Are Rushing to Restrict Abortion, or to Protect It.” The New York Times, 15 May 2019. [15] Cruzan. [16] Mayo, T.M. “Brain-Dead and Pregnant in Texas.” The American Journal of Bioethics, Vol. 14, no. 8 (Nov. 2014); 15-18. [17] In re A.C., 573 A. 2nd 1244 (1990). [18] Johnson, Kristeena L. “Forcing Life on the Dead: Why the Pregnancy Exemption Clause of the Kentucky Living Will Directive Act is Unconstitutional.” Kentucky Law Journal. Vol. 100 (2011-12); 209-233.