The 'Toxic Trio' - Is it Time for a Rethink? - Antser

The ‘Toxic Trio’ – Is it Time for a Rethink?

By Simon Dean and Marianna Nicolaou

We recently set aside the time to have a discussion about the recent research carried out by the National Children’s Bureau as part of their Living Assessments programme. Their review examined the evidence to support the view that social workers should be particularly vigilant for three risk factors in family life: parental mental illness, parental substance misuse and domestic violence, especially when these issues occur in combination, in what has come to be known as ‘the toxic trio’.

“Understanding serious case reviews and their impact: a biennial analysis of serious case reviews 2005-07” first described how a ‘combination of these three problems can produce a toxic caregiving environment for the child’ as they sought to consider how risk factors might be linked to serious and fatal cases of maltreatment. Subsequent reviews have used the term cumulative harm instead. However, by then, the terminology Toxic Trio had found its way into children’s safeguarding practice.

In his article ‘Toxic Terminology’, Dr Peter Sidebotham, Emeritus Professor of Child Health at Warwick Medical School, identified that there is “no doubt that these three parental risk factors do feature prominently in cases of child maltreatment ”. He goes onto say that there are many other equally important factors have all been shown to increase the risks of maltreatment (including parental adverse childhood experiences) and that too narrow a “focus on domestic violence, parental substance misuse and parental mental ill-health can mask the very real risks posed by any of these and many other recognised risk factors”. Indeed, the 2011-2014 triennial review found that in 21% of cases, none of the trio were present. 

Dr Sidebotham was also concerned by the impact of the term ‘toxic trio’ as a label as “it is deeply stigmatising and does not help in appraising the real nature of any family dynamics, and of any support or protection needed for the child or family.” The National Children’s Bureau found parents reportedly feeling like they have been “unfairly questioned, judged and stigmatised by the focus on the toxic trio in risk assessments”.

Social care professionals are very careful in how they speak to children and families and would never use the word ‘toxic’, yet somehow it became entrenched within professional thinking. Language is important, and closer examination of the term and how it had come to be used highlights other factors too, with the underlying assumptions that may be made in the use of the term Toxic Trio.

Mental health problems are likely to affect significant numbers of the population at any one time and having a mental health problem as a parent does not mean that a child is at risk of maltreatment. The impact on the child will depend on how it is experienced within the family environment and other contributing factors. Substance misuse issues are more clearly a risk factor for child maltreatment, particularly where violence is involved, however if these are under control and/or well managed, it does not mean that a child is inevitably at risk of neglect or violence.

Domestic Abuse however not only means children are at risk of abuse, but are experiencing it at some level, even if they are not witnessing it. It is very challenging for practitioners to manage within a family environment and difficult to effect meaningful change; difficult but not impossible. There is yet to be detailed research that has been able to show how a combination of these factors directly increases the risk to children, although all are significant factors for the outcomes of children, but then so are many others.

It may be that following on from the deaths of Victoria Climbié and Peter Connelly, when agencies were asked to be extra vigilant, that there was a slight shift in how we thought about families.  There are a number of other terms from that time that could also do with closer examination.

It has been interesting to see another shift more recently, with a growth in social work models like Family Safeguarding that have improved families engagement with practitioners and have sought to support the needs of both children and adults, in order that, where possible, children can safely remain within their families.

As we hopefully come to the end of another period of lockdown, services are very aware of the significant impact this will have had within the home environment. The Government will need to urgently invest in services to respond to this unseen level of need, in order for children and adults to be kept safe and to receive the support services they need to recover from what has been a very challenging and, in some cases, devastating time for all.

Thanks to Professor Peter Sidebotham for his article ‘Toxic Terminology’ that prompted our discussions.

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