Administration and Policy in Mental Health and Mental Health Services Research

, Volume 37, Issue 1, pp 27–39

Improving the Mental Health of Children in Child Welfare Through the Implementation of Evidence-Based Parenting Interventions

Authors

    • The Department of Pediatrics and the Centers for Primary Care and Outcomes Research and Health PolicyStanford University
  • Patricia Chamberlain
    • The Center for Research to Practice & Oregon Social Learning Center
  • John Landsverk
    • Child and Adolescent Services Research CenterRady Children’s Hospital
    • School of Social WorkUniversity of Southern California
    • George Warren Brown School of Social WorkWashington University in St. Louis
  • Charlotte Mullican
    • Center for Primary Care, Prevention and Clinical Partnerships, Agency for Healthcare Research and QualityDepartment of Health and Human Services
Original Paper

DOI: 10.1007/s10488-010-0274-3

Cite this article as:
Horwitz, S.M., Chamberlain, P., Landsverk, J. et al. Adm Policy Ment Health (2010) 37: 27. doi:10.1007/s10488-010-0274-3

Abstract

Any comprehensive approach to children’s mental health should consider services systems such as Child Welfare that provide services to children with high rates of emotional and behavioral disorders. This paper will review what is known about efficacious parent-focused interventions that can improve the lives of children in Child Welfare and explore possible reasons why such interventions are rarely used by Child Welfare agencies. Data from a pilot study suggest key features for increasing the implementation of efficacious practices to improve children’s mental health.

Keywords

Child welfareImplementationEffective interventions

Introduction

Comprehensive approaches that address children’s mental health issues should include service systems, such as Child Welfare, that serve children at high risk for mental health problems. Each year in the United States there are more than 3 million allegations of child maltreatment involving over 6 million children. In 2007, over 780,000 children were served in the foster care system nationally, an estimate that has been stable over the past 5 years (USDHHS 2009). Studies show that children involved in the Child Welfare system, including both children in foster care and children remaining at home after a maltreatment investigation, are at high risk for multiple problems, including disproportionately high rates of behavioral and emotional disorders. These problems create significant challenges for their biological parents and/or foster caregivers and increase the possibility of unstable placements, putting these children at risk for further psychopathology. Although the relatively small proportion of children who are placed in foster care are more likely to receive individually focused mental health services, such services are rare for children remaining at home even though the overwhelming majority of children investigated by Child Welfare agencies remain at home. Even for those in foster care, the bulk of the therapeutic intervention is the foster home itself and, while training for foster parents is universally available, it is not evidence based. Services to the hundreds of thousands of children who remain in their homes come in the form of parent-focused services. Although there are numerous, efficacious parent-focused interventions that can change the family environment and improve the lives of children, research has documented that most of the parent focused interventions currently delivered to families in child welfare and most foster family training do not use treatment strategies with solid empirical support (Hurlburt et al. 2007; Barth et al. 2005).

Given that Child Welfare systems are mandated to deliver or facilitate the delivery of services designed to aid parents in retaining their children safely at home, prevent further maltreatment, and reduce costly restrictive placements and placement changes, it is surprising that these agencies have not commonly adopted one or more intervention models from the array of parent training models that result in strong, durable changes in parenting practices and reductions in children’s emotional and behavioral problems. Therefore, the purpose of this paper is to provide a limited review of efficacious parent-focused interventions, present a model to explain the likely reasons for the lack of adoption and examine the results of a pilot study designed to gather data on the elements in the model.

Efficacious Parent-Focused Interventions: Substitute Parents

As noted in the introduction, studies show that children in foster care are highly vulnerable to a variety of problems including disproportionate rates of mental health and related psychosocial and adjustment problems (e.g., Kortenkamp and Ehrle 2002; Landsverk and Garland 1999). Unfortunately, it is typical for the mental health needs of children in foster care to go unmet (Kerker and Dore 2006) and for these unmet needs to have long-term negative consequences for children and for Child Welfare systems. A number of barriers to adequate care have been identified: lack of resources, lack of interventions designed to prevent the development or escalation of problems, over-burdened caseworkers, and over-burdened and under-informed foster caregivers (Kerker and Dore 2006). Within the context of an over-stressed child welfare system, one effective and potentially viable solution is to improve foster caregivers’ abilities to provide meaningful interventions and supports to the children who are placed with them. Training foster caregivers to serve as therapeutic agents of change shifts foster care from a condition of maintenance to one of active intervention (Ruff et al. 1990; Kerker and Dore 2006; Chamberlain et al. 2008b). This shift capitalizes on using an existing workforce that ideally, would increase stability and permanency for children in foster care, thereby reducing their risk for many subsequent mental and behavioral health problems.

One of the most frequently cited explanations for a failed foster placement is the inability of the foster caregivers to manage a child’s behavior problems (Brown and Bednar 2006; Holland and Gorey 2004). Chamberlain et al. (2006) found that for each increase in the number of behavior problems (above six) that were reported to occur within in a 24-hour period, there was a 25% increase in the risk for a negative change of placement within the next 12 months. Compounding the challenges for foster caregivers in managing child behavior problems is the fact that most caregivers have the responsibility of caring for more than one child. There is evidence of a direct relationship between the number of children in a home and the number of behavior problems exhibited by the youth placed there (Moore et al. 1994).

Fortunately, there is a solid and growing body of research supporting the effectiveness of several treatments in reducing rates and severity of child behavior problems, especially those utilizing versions of a parent management training (PMT) model (Kazdin and Wassell 2000; Patterson 2005; Webster-Stratton et al. 2004). PMT interventions are based on numerous studies that have revealed developmental pathways to child and adolescent behavioral and emotional problems to be strongly associated with ineffective parenting practices (Gelfand and Teti 1990; Laub and Sampson 1988; Loeber and Dishion 1983).

Multidimensional treatment foster care (MTFC) is one such approach specifically designed for use in foster family settings, and has been tested with youth displaying severe emotional and behavioral problems, including delinquency (Chamberlain and Reid 1991, 1994; Eddy and Chamberlain 2000; Leve and Chamberlain 2004; Chamberlain et al. 2007). Given that MTFC studies showed that foster parents could be trained and supported to enhance positive outcomes for even extremely challenging children and adolescents, a next logical step was to examine the feasibility of using components of the MTFC model to address the needs of foster caregivers housing children with more moderate behaviors.

A large-scale effectiveness trial was conducted in San Diego County in collaboration with the San Diego Department of Health and Human Services, the Child and Adolescent Services Research Center, and the Oregon Social Learning Center. The trial, which concluded in 2006, tested whether weekly foster parent groups focused on PMT/MTFC principles could increase foster parent skills, reduce child behavior problems and increase placement stability. Seven hundred foster families receiving a new placement were randomized to KEEP (Keeping foster and kin caregivers skilled and supported, the PMT condition) or control (case work services as usual). A main effect for decreased child behavior problems was observed in the KEEP but not in the control condition, and the effect was partially mediated by improved parenting skills, specifically higher rates of positive reinforcement relative to discipline in KEEP participants (Chamberlain et al. 2008b). Participation in KEEP increased the chances of reunification with biological family and mitigated the risk-enhancing effect of having a history of multiple placements.

A full foster care service approach using parent management training mounted directly on this non-specialty service system has been described in a recent paper by Fisher et al. (2009). Their paper describes a framework for determining the types of programs needed for children with varying needs along a continuum that includes screening and identifying those who are functioning adequately in foster care versus those in need of supplemental services. The framework applies a graduated approach that uses increasingly intensive interventions based on risk levels. Those at low risk could be provided with ‘enhanced foster care’ with additional resources for families and children (Kessler et al. 2008). For those at moderate risk, interventions could be implemented that target specific problems such as disruptive behavior or school functioning, and for those at high risk, intensive therapeutic foster-care programming could be implemented (2009: 122). This framework (shown in Fig. 1) could be used as a precursor to the type of thinking that will need to be done in developing a systematic approach to addressing behavior problems presenting in children involved in this non-specialty sector.
https://static-content.springer.com/image/art%3A10.1007%2Fs10488-010-0274-3/MediaObjects/10488_2010_274_Fig1_HTML.gif
Fig. 1

A graduated approach to preventing placement disruptions in foster care

Efficacious Parent-Focused Interventions: Biological Parents

For children remaining in their homes there are a number of family based interventions that show promise according to the California Evidence-Based Clearing House (www.cachildwelfareclearinghouse.org).

SafeCare® provides in-home services for families at risk for child abuse and neglect, and is the one intervention with evidence that specifically addresses neglectful parental behaviors. The program is based on an Ecobehavioral model which proposes that child maltreatment stems from a combination of parent and family factors, parent–child-interactions, and also from factors within the broader culture and society in which the family lives (Edwards and Lutzker 2008; Lutzker 1984). SafeCare was developed as a streamlined alternative to Project 12-ways, a program implemented in 1979 by the Illinois Department of Children and Family Services. SafeCare focused on providing three of the most commonly used types of services from Project 12-ways, including information on infant and child healthcare, positive parent–child interaction skill and planned activities training, and home safety (Edwards and Lutzker 2008). In an evaluation of the original implementation, Gershater-Molko et al. (2002) compared families in the SafeCare program to families participating in a family preservation program who were matched on child’s age and geographical location. At 36 months, 85% of the SafeCare group had no further abuse reports compared to 54% of the Family Preservation group. SafeCare is currently undergoing evaluation using random assignment to treatment conditions. Although data have not yet been published, preliminary results are reported as promising (Edwards and Lutzker 2008; Hecht et al. 2008).

The Positive Parenting Program®, commonly known as Triple P, is a multi-level parenting and family support program developed in Australia which aims to prevent and address behavioral, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents. The five level system targets the different developmental stages of childhood and adolescence, while providing a comprehensive set of interventions that move from universal (level 1) to intensive family-level intervention (level 5) (Sanders 1999, 2008). The Triple P program offers extensive training and support through regional dissemination agencies to ensure fidelity to the model, and has begun being used in multiple locations in the United States.

Triple P has conducted extensive outcomes evaluations on the different levels of care and in multiple settings and populations, including 43 randomized controlled trials, 76 evaluation studies in total, and a recent meta-analysis (e.g., Bor et al. 2002; de Graaf et al. 2008; Morawska and Sanders 2006; Plant and Sanders 2007; Sanders 1999; Sanders et al. 2007, 2000, 2004, 2002; Sanders and McFarland 2000; Turner and Sanders 2006). These studies have shown lower levels of child behavior problems, lower dysfunctional parenting styles and a higher sense of competence in the groups receiving Triple P. A large scale trial, funded by the CDC, has been conducted in South Carolina. Eighteen counties, matched on child abuse rates, poverty, and population size, were randomly assigned to either Triple P or services as usual. Initial results show decreased rates of substantiated maltreatment and out of home placement in the Triple P counties (Prinz et al. 2009).

The incredible years (IY) is an extensively researched series of multifaceted, developmentally-based curricula for parents, teachers, and children designed to promote emotional and social competence and to prevent, reduce, and treat behavior and emotional problems in children. The parent training programs focus on strengthening parenting competencies and fostering their involvement in school through a videotape modeling format with role-plays and feedback on effective parenting practices. The child training programs focus on strengthening social, emotional and academic skills, such as understanding and communicating feelings, problem solving, anger management, and appropriate classroom behaviors.

Multiple randomized controlled group evaluations of IY have shown increases in parent positive affect, replacement of spanking and harsh discipline with non-violent discipline techniques, increased monitoring of children, reductions in parental depression, increases in parental self-confidence, and reduced child conduct problems (Baydar et al. 2003; Brestan and Eyberg 1998; Gardner et al. 2006; Gross et al. 2003; Reid et al. 2004, 2001; Webster-Stratton and Reid 2003). Current research is focused on extending the IY model into additional child populations (e.g., ADHD, developmental disorders) into multiple racial/ethnic populations and mounting IY on the Child Welfare system platform.

Parent–child interaction therapy (PCIT) is a treatment for conduct-disordered children, ages 3–6, that aims to improve the parent–child relationship through changing parent–child interaction patterns. Through PCIT, parents are taught skills to establish a positive relationship with their child while increasing their child’s prosocial behavior and decreasing negative behavior. Randomized controlled trials have shown that PCIT increased parent skills, decreased externalizing behaviors in children, and improved scores on the CBCL and ECBI (Bagner and Eyberg 2007; Nixon et al. 2004; Schuhmann et al. 1998). A randomized controlled study examining families entering the child welfare system due to physical abuse found that the PCIT group had significantly fewer re-reports of abuse and less negative parent behavior during the follow-up period, as compared to those receiving services as usual (Chaffin et al. 2004). A recent meta-analysis confirmed the effectiveness of PCIT in reducing child behavior and parenting problems (Thomas and Zimmer-Gembeck 2007).

Family connections (FC) is a multi-faceted, community-based neglect-prevention program that works with families in their homes and in the context of their neighborhoods. The goal of FC is to help these families meet the basic needs of their children and reduce the risk of child neglect. The individualized family intervention is geared to increase protective factors, decrease risk factors, and target child safety and well-being outcomes. The core components of FC include: (a) emergency services; (b) home-based family intervention; (c) service coordination with referrals targeted toward risk and protective factors; and (d) multi-family supportive recreational activities. An outcome study has been conducted in Baltimore comparing families assigned to 3 or 9 month versions of FC but without a control group. Pre-post evaluation showed that both groups improved on protective factors (parenting attitudes, parenting competence, and social support) and reduced risk factors for abuse and neglect (parental depression, parenting stress, life stress, children’s behavioral problems) after completing the program (DePanfilis and Dubowitz 2005; Girvin et al. 2007). There was little difference in outcomes between the 3 and 9 month groups. FC is currently being replicated in eight communities in the United States, all of which are using random assignment of subjects and an “intent to treat” analysis.

As this review indicates there are a number of promising interventions that could be used with families whose children remain at home after an investigation for child maltreatment. However, unlike the interventions for substitute parents developed by Chamberlain and colleagues, no framework for guiding the choice or sequence of interventions exists.

Developing a framework is a potentially creative method to mount a parent-mediated, evidence-based approach directly on the service platform of the child welfare system. Typically, Child Welfare has a culture that thinks of safety and permanence as their direct responsibility, while viewing child well-being as achieved through referral to outside service sectors such as medical and mental health. For example, the Child and Family Service Reviews measure accountability in this area by tracking whether children experiencing threats to their well-being (mental health, etc.) are referred to outside service sectors. The solution proposed here is to actually mount the well-being intervention on the Child Welfare platform, simultaneously addressing the need for well-being and the more classic Child Welfare goals of safety and permanence. However, the task of fitting and mounting these mental health interventions in Child Welfare, a non-specialty service sector, is not a trivial problem and the remainder of this paper explores reasons for this that can guide both the research needed on the process as well the eventual process itself.

A Model to Explain Non Adoption of Evidence-Based Parenting Interventions

Given that child welfare systems are mandated to deliver or facilitate the delivery of services designed to aid parents in retaining their children safely at home, prevent further maltreatment, and reduce costly restrictive placements and placement changes, it is surprising that these agencies have not commonly adopted one or more intervention models from the array of efficacious parent training models particularly in light of data from a recent MacArthur funded study showing that mental health service provider agencies are constantly experimenting with new practices (Schoenwald et al. 2008a, b). The reason lies in the problem identified in the NIH Roadmap Initiative and the NIMH report Bridging Science and Service, namely, our continued inability to implement evidenced based practices in routine services settings. In fact, as pointed out in the Kaufman Best Practices Project (2004), and by Chaffin and Friedrich (2004), two of the biggest obstacles for public child welfare agencies may be the ability to access research-based information on the appropriateness/effectiveness of parent-training programs and the level of involvement/comfort with the implementation process, also described as the initial phase of selection or adoption of new practices (Glisson and Schoenwald 2005). Unlike in mental or physical health where the discussions of evidenced-based practices have been common for almost two decades, such discussions in the social work literature were not common until 2004 or later when the Journal of Evidence-Based Social Work and the California Evidence-Based Clearinghouse for Child Welfare, as well as a number of reviews of evidence based practices for child welfare clients (Barth et al. 2005; Chaffin and Friedrich 2004; NAPCWA 2005; Kaufman Best Practices Project 2004) were published. Further, traditional social work education has not focused on evidence-based practices (Weissman et al. 2006), although there is a growing recognition of the importance to do so and some model programs do exist (e.g., Brekke at USC-Institute for the Advancement of Social Work Research 2007).

As described by Frambach and Schillewaert (2002), little is known about how different contextual, intervention, and person factors are related to stages of adoption and implementation. This likely occurs because most empirical studies of implementation focus only on a limited number of factors. Surprisingly little is known about early stages of the implementation process, specifically the initiation of the process to adopt an evidence-based program or service. Further, there are scant data on strategies to improve adoption, with a few isolated exceptions (e.g., Chamberlain et al. 2008a). Key features of this first stage are awareness of EBPs, attitudes towards EBPs and evaluation of the effectiveness and fit of EBPs (Frambach and Schillewaert 2002). Another feature of this early stage is the availability, understanding and use of data from scientific studies by an organization—a process we know little about, particularly in human service organizations (Davies and Nutley 2008). The data on this early stage of EBP adoption is particularly scarce with regard to Child Welfare agencies. A search of the extant literature found that some information was available about the impact of organizational structures/context/climate/culture on agency effectiveness (Yoo et al. 2007; Glisson and Hemmelgarn 1998) and on the implementation of specific EBPs (e.g., SafeCare, MTFC) (Aarons and Palinkas 2007; Palinkas and Aarons 2010; Chamberlain et al. 2008a). Other publications have reviewed the implementation process for Intensive Family Preservation (Homebuilders) (Adams 1994) and the approaches taken to implement the Family to Family Initiative sponsored by the Annie E. Casey Foundation (Fiester 2008), but the evidence base for these programs is less well established. Unlike for mental health or juvenile justice agencies (Raghavan et al. 2007; Ganju 2003; Torrey et al. 2003, 2005; Schoenwald et al. 2008a, b; Glisson and Schoenwald 2005) little research exists on characteristics related to the widespread adoption of EBPs in Child Welfare settings.

Regardless of what problem, issue or challenge is to be addressed by an organization through the use of a new or existing but previously unused practice or intervention, the process of change is one that moves, often somewhat chaotically, through a series of stages (Grol et al. 2007; Rogers 2003; Damanpour 1991; Greenhalgh et al. 2004) where numerous forces both within and outside of the organization determine whether or not the implementation of the innovation proceeds (Damanpour 1991). The first phase of this process, alternatively labeled knowledge/awareness/exploration/initiation or pre-contemplation (Grol et al. 2007) involves an awareness of either an issue that needs attention or of an improved approach to a challenge. However, perhaps due to the fact that the implementation literature is largely built on issues in business, agriculture or health where the adoption of innovation is driven by profit or science there is little attention to the first phase of the implementation process (Damanpour 1991).

Further, adoption of innovation in human services organizations is fundamentally different than business or agriculture due to the nature of the innovations and the variability of the clients (Damanpour 1991). Across human service organizations, those with a strong focus on development of new knowledge and understanding of best practices as well as incentives to adopt best practices like Medicine have embraced the need for innovation more strongly than those without either incentives or a strong focus on knowledge development like Education or Child Welfare (Chadwick Center Best Practices Report 2004; NAPCWA, Guide for Child Welfare Administrators on Evidence Based Practice 2005; Hemsley-Brown and Sharp 2003). However, even in Medicine with its strong scientific base and specific efforts to promote the adoption of best practices [e.g., Evidence-based Clinical Practice Centers Program (www.ahrq.gov/clinic/epc), National Guidelines Clearinghouse (www.guideline.gov)] there has been a tremendous lag in the adoption of evidence-based practices (Committee on Quality of Health Care in America, Institute of Medicine 2001) and there are data to suggest that physicians in practice do not frequently access evidence from research but rather rely on “collectively reinforced, internalized, tacit guidelines” developed by experience, colleagues, patients, opinion leaders and other sources (Gabbay and le May 2004).

Given that change is a process and that at each stage of the process the features influencing change might differ, it is important to examine each stage of the process individually. Since Child Welfare does not have a strong focus on knowledge development, examining the first stage in the implementation process is critical (Fig. 2). Beginning at the broadest level, the state and federal sociopolitical contexts as well as funding availability are potentially strong influences for the first phase of the implementation process, the exploration of innovative interventions or practices (Davies and Nutley 2008; Ganju 2003; Hoagwood 2003). Child Welfare is especially sensitive to social and political forces. At the national level, Child and Family Service Reviews mandated as part of the 1997 Adoption and Safe Families Act (PL 105-89) require Child Welfare agencies to monitor outcome indicators in the three key areas of safety, permanence and child wellbeing. Although all states have participated in at least one review, no state has achieved excellence in all areas prompting the development of Performance Improvement Plans (www.acf.hhs.gov/programs/cb/cwmonitoring/recruit/cfsrfactsheet.htm, accessed 6/5/09). These plans may provide an impetus for state Child Welfare agencies to explore evidence-based practices in areas requiring improvement.
https://static-content.springer.com/image/art%3A10.1007%2Fs10488-010-0274-3/MediaObjects/10488_2010_274_Fig2_HTML.gif
Fig. 2

Exploration phase: possible key features for child welfare

State legislatures often demand practice changes in response to both public concerns over issues such as abuse while in state-mandated out-of-home care or failure to find permanent homes in a timely manner or consent decrees and settlements arising from class action suits. Similarly, legislators may use funding in the form of special allocations to encourage the use of innovations. Conversely, severe budget restrictions discourage the exploration of innovations since exploration demands staff time which may be limited due to funding restrictions (Greenhalgh et al. 2004).

States may employ a number of other strategies to encourage exploration of evidence-based practices. In mental health, numerous states have set up offices for evidence-based practices to serve as resources to agencies interested in practice change. In California, the county mental health directors established the California Institute for Mental Health, a private, nonprofit public interest corporation established in 1993 to promote excellence in mental health services through training, technical assistance, research and policy development (www.cimh.org). For Child Welfare the California Evidence-Based Clearing House, funded by the California Department of Social Services, identifies and disseminates information on evidence-based practices relevant to Child Welfare (www.cachildwelfareclearinghouse.org).

Federal and State efforts are not the only social and political drivers. Private foundations, professional organizations and educational reforms all potentially can shape the context for exploration of evidence-based practices in child welfare. Two excellent examples are the Annie E. Casey initiative Family to Family started in 1992 and the educational changes proposed by the April, 2008 meeting on Partnerships to Integrate Evidence-Based Mental Health Research into Social Work Education and Research sponsored by the National Institute of Mental Health (www.nimh.nih.gov). The Family to Family initiative operates in 17 states and advocates for children remaining in their own families through redesigning foster care systems to partner with their communities to develop neighborhood-based foster care (Fiester 2008). The NIMH initiative was a joint effort with the Institute for the Advancement of Social Work Research and explored necessary changes in education to incorporate EBPs (Institute for the Advancement of Social Work Research 2007). Similarly, the 2006 University of Texas at Austin Symposium, “Improving the Teaching of Evidence-Based Practice” was also an early effort to explore EBPs as part of reforms in teaching and curriculum (Jenson 2007).

Unlike in mental health where consumer-based organizations such as the National Alliance on Mental Illness have significantly shaped the political, service and research agenda (www.nami.org), client organizations have been considerably less visible in Child Welfare. As noted by Hoagwood (2003), clients can be powerful advocates for system change through both their demands on individual providers and through their advocacy efforts with legislators. In child welfare, client advocacy has taken the form of organizations started by concerned individuals who were, most often, not child welfare clients. The most famous of these organizations, the children’s defense fund (CDF) grew out of the Civil Rights Movement 35 years ago and was started by Marian Wright Edelman, a lawyer, to promote policies that protect children from abuse and neglect, ensure access to health care, access to quality education and move them out of poverty (www.childrensdefensefund.org). CDF has an impressive record of change from separating children and adults in South Carolina jails in 1974, through facilitating PL #94-142, education for all handicapped children in 1975, to doubling the Child Tax Credit in 2002. Now with offices in several states, CDF has inspired the development of individual state advocacy organizations such as Connecticut Voices for Children, an organization heavily involved in promoting better practices in Child Welfare (www.ctkidslink.org).

Much of what has been written on the implementation of evidence-based practices is focused at the level of the organization or agency for, as stated by Ferlie and Shortell (2001), the bulk of health services are delivered in groups or teams. An “extra-organizational” feature of organizations that may encourage the implementation of EBPs is an organization’s inter organizational network (Frambach and Schillewaert 2002). Thus, if an agency or organization interacts with other organizations that employ EBPs, the agency may be more likely to explore adoption of EBPs. In Child Welfare, contracting with Mental Health or Juvenile Justice agencies that employ EBPs will both familiarize the Child Welfare Agency with EBPs and set the example that practice change is achievable. The community development team (CDTs) model which works with groups of agencies to implement EBPs adopted by the California Institute for Mental Health is a good example of the power of interorganizational networks (www.cimh.org; Chamberlain, Brown et al. 2008a, b).

As mentioned above, considerable information is available on the organizational characteristics that promote the exploration and eventual adoption of EBPs including an organization’s absorptive capacity, readiness for change and receptive context. Organizations that start with good knowledge/skills, can incorporate new knowledge, are highly specialized and have mechanisms in place to spread knowledge throughout the organization, are much more likely to explore EBPs and eventually initiate them (Ferlie and Shortell 2001; Grol et al. 2007; Damanpour 1991; Greenhalgh et al. 2004). Child Welfare agencies suffer from a number of defects in this area. They often have a work force with varied levels of education and considerable workloads, have multiple responsibilities ranging from investigations to direct delivery of parent services and have few readily available venues for knowledge sharing (Yoo et al. 2007).

The organizational context has received the most attention in child welfare due largely to the work of Glisson and colleagues (Glisson and James 2002; Glisson and Hemmelgarn 1998; Glisson and Schoenwald 2005). As noted by Glisson and James 2002, both culture (the normative beliefs and shared expectations of the organization) and climate (psychological climate is the individual’s perception of the psychological impact of the work environment on his/her well being) greatly impact the adoption of EBPs. Thus, individuals who do not view the climate of their organization as welcoming innovation and organizations whose cultures do not promote exploration of practices in response to challenges are highly unlikely to explore the use of EBPs (Simpson 2002; Klein and Sorra 1996; Damanpour 1991). In fact, to assist Child Welfare agencies in changing the climate for innovation, Glisson and colleagues have developed an organizational and community intervention model (Glisson and Schoenwald 2005; Glisson et al. 2006). Additionally, characteristics of the organization such as leadership, clear goal setting and prior success in undertaking practice change all have been linked to the likelihood that an agency will explore the use of EBPs (Greenhalgh et al. 2004; Damanpour 1991).

At the most micro level, characteristics of individual adopters are important determinants of which agencies will and will not explore or initiate the use of EBPs. In reviewing the literature, three features of individual adopters appear to be important: values and goals, social networks and the perception of the need to change. Values and goals have received considerable attention in the research literature. Labeled as early adopters (Rogers 2003) these individuals are seen as trend setters—comfortable with innovation and highly professional. They engage in ongoing education, usually follow the professional literature in their fields and are well-networked (Berwick 2003; Grol 2001). Unfortunately, Child Welfare unlike Medicine does not have a strong research base (NAPCWA 2005), the discussion of the use of EBPs in Child Welfare is reasonably recent (Barth et al. 2005; NAPCWA 2005; Chadwick Center Kaufman Best Practices Project 2004) and traditional social work education has not focused on evidence-based practices (Weissman et al. 2006) although there is a growing recognition of the importance to do so (Jenson 2007).

Finally, perception of the need to change in response to a challenge is critical if EBPs are to be explored. Such perceptions come from the ability to identify a problem and feeling empowered that change can occur. However, as noted by Yoo et al. 2007, the bulk of the research attention on Child Welfare workers has focused on burnout and turnover. This is unfortunate since, as suggested by Chaffin and Friedrich 2004, two of the biggest obstacles in implementing EBPs for public Child Welfare agencies may be the ability to access research-based information on the appropriateness/effectiveness of EBPs and the level of involvement/comfort with the implementation process. This dearth of information, however, presents an unparalleled opportunity for investigation.

Is Child Welfare Challenged in the First Stage of the Implementation Process? Data from a Pilot Study

To investigate whether the Child Welfare agencies were challenged with respect to the availability and use of research data on evidence supported parent training programs and to prepare for a second Caring for Children in Child Welfare Survey, we developed an interview based on the original NIMH funded Caring for Children in Child Welfare (CCCW) interview by Landsverk and colleagues (Leslie et al. 2003), the Child Mental Health Clinic Director’s Survey from the MacArthur Foundation Network by Schoenwald et al. (2008a), and the organizational readiness scale developed by investigators at TCU. The interview contained questions to gather data on the broad areas of the model displayed in Fig. 1. Using many of the Child Welfare agencies originally employed in the CCCW pilot test, we interviewed individuals in six Child Welfare agencies to ascertain their ability to access research-based information on EBPs, barriers to the adoption of EBPs and their level of comfort with and involvement in the implementation of EBPs. These agencies were initially chosen because they were not selected as part of the National Survey of Child and Adolescent Wellbeing sample but shared characteristics in common (size, urbanicity, state) with sampled agencies. Results from this small pilot study suggest that, as identified by Schoenwald et al. (2008a), most agencies (5/6) have adopted at least one new practice in the past 5 years. When asked what the major barriers to the practice change were, 4/5 agencies replied staff resistance (Individual Adopter Characteristics) due to fear of the unknown/change or job loss. The most important drivers for exploring/adopting EBPs were largely Socio-Political such as funding, state/federal mandates and interest of leaders in improving practices. Financial benefits were cited as very important by 4/5 programs that had explored practice change as was staff interest. As postulated from the literature review, advocacy groups were never mentioned as an important driver. EPBs that were considered most likely to be adopted were those that were consistent with the agency’s current practices and philosophy and those that were most likely to benefit clients. Only 2/5 agencies mentioned that being evidence based had influenced whether a new practice was adopted (Table 1).
Table 1

Features affecting implementation

New program or practice in last 5 years

5/6

83.7%

Major barrier to adoption

4/5

80%

Features important for practice change

Outer context

 Sociopolitical

  State policies/funding

4/5

80%

  CFSRs

3/5

60%

 Client interest

2/5

40%

Inner context

 Organizational characteristics

  Leadership

5/5

100%

  Staff support

4/5

80%

 Innovation/organizational fit

  No financial risk rather benefit

4/5

80%

  Matched agency’s practice/philosophy

5/5

100%

  Matched agency’s mission-client benefit

5/5

100%

Characteristics of the innovation

 Evidence-based

2/5

40%

All six agencies provided parent training programs to biological, foster and adoptive families but only 3/6 provided at least one evidence based program and only two agencies described a process for exploring new programs that included reviewing the research literature (Professionalism). Surprisingly, only two agencies had heard of and only one had accessed the California Evidence Based Clearing House for Child Welfare. Only two agencies had used federal or foundation technical assistance (Table 2).
Table 2

Parent training programs and agency characteristics

Availability of parent training program

6/6

100%

Parent training programs mentioned had adequate level of research support for efficacy

3/6

50%

Procedure for choosing a new parent training program mentioned reviewing/reading the literature

2/6

33%

Knowledge or use of the California evidence-based clearing house for child welfare

2/6

33%

Received technical assistance for parent training/other programs from an organization other than their state

2/6

33%

Delivery of parent training

 Child welfare agency staff

1/6

16.7%

 Contractors

2/6

33.3%

 Contractors/community agencies

3/6

50%

Agency characteristics

 Electronic database

6/6

100%

 Computerized client records

0/6

0%

 Child outcomes collected

6/6

100%

 Child functioning as an outcome

0/6

0%

Staff characteristics

 Mostly BSWs or below

6/6

100%

 Problems hiring staff

2/6

33%

 Continuing education paid for (this is only if state mandated)

2/6

33%

 Continuing education release time

6/6

100%

 Very interested in EBPs

1/6

16.7%

Moving to characteristics on the more micro level, all agencies had electronic data bases but only for administrative data. No agency had client records electronically available and no agency collected child functioning as an outcome (Absorptive Capacity). Agencies used a variety of arrangements to deliver their parent training. Finally, agency staffs are trained at a Bachelor’s level or below making them exempt from any continuing education requirements in at least nine states. Continuing education, unless state mandated, was rarely paid for and only one agency director reported his or her staff as very interested in EBPs (Professionalism) (Table 2).

Conclusions

Highly efficacious parent training programs are available, have been tested in child welfare agencies and a range of programs are available. Hence, the lack of evidence-based parent training programs in Child Welfare is a missed opportunity to improve the lives of hundreds of thousands of children. The need to assist Child Welfare agencies with the exploration/initial knowledge of EBPs was confirmed in this very small pilot study. Given that federal and state mandates as well as interest of agency/regional leadership appear to be very important in beginning the implementation process, testing interventions at this level to increase adoption of EBPs would be an important initial step, as would a broader survey of child welfare agencies that documented additional factors that may be driving forces for the implementation of evidence-based parenting practices, such as interagency networks and use of research data for decision making. The importance of financial benefits from EBPs argues for attention to cost-effectiveness analyses when presenting arguments in favor of practice change and for research focused on developing decision analytic models capable of assessing the costs and benefits of system wide changes. Similarly, the importance of match to agency philosophy/congruence with current practices implies that support for agencies as they explore possible EBPs, much like that provided by the Community Development Teams in California, may increase the adoption of EBPs. Ideally, a number of agency models should be developed and tested to determine the most effective interventions for agencies of various sizes, geographical locations and specific challenges. Finally, agency personnel are critically in need of information about EBPs if they are to be widely adopted. Innovative continuing education programs based on adult learning techniques, conveniently delivered, as well as social work education curriculum reform, could be important drivers for change, particularly if high quality evaluations identify that these changes encourage the use of evidence-based practices. Testing interventions to improve each of these deficiencies and mobilizing community and parent advocacy groups potentially could greatly improve the adoption of EBPs.

Acknowledgments

This work was supported by funding from the NIMH (P30-MH74678-01A2; PI: Landsverk). The findings and conclusions are those of the authors and do not necessarily reflect those of the Agency for Healthcare Research and Quality.

Copyright information

© Springer Science+Business Media, LLC 2010