Youth involved in child welfare may benefit from programming that enhances their relationship skills given their susceptibility to engaging in high-risk interpersonal behaviors that can lead to challenges such as, engaging in or experiencing violence, housing and job insecurity, and poor physical and mental health. This research explored the feasibility of implementing an evidence-based healthy relationships program, the Healthy Relationships Plus Program - Enhanced (HRP-E), with youth involved in child welfare. Over 9 months, four HRP-E groups were facilitated at a Children’s Aid Society in Ontario, Canada, involving 28 youth. Interviews were conducted with facilitators (n = 5) and youth (n = 13) to examine their views of the program. Facilitators also completed surveys that evaluated the facilitation of each session and overall program implementation. A thematic analysis of the data was conducted and results indicated that the HRP-E was perceived as a valuable program that is relevant and useful for youth involved in child welfare. Participants highlighted trauma-informed practices and organizational resources that are required when facilitating the HRP-E within a child welfare context. The present findings address the theory-to-practice gap by illustrating the practical application of trauma-informed program facilitation. The outcomes of this study contribute to understanding considerations and best practices for implementing a healthy relationships program with youth involved in child welfare.
Youth involved in child welfare are more susceptible to engaging in high-risk interpersonal behaviors (e.g., engaging in violence, difficulty setting boundaries, poor communication skills) than their peers due to factors such as experiences of maltreatment and insecure relationships with caregivers (Crooks et al., 2011; Ellis & Wolfe, 2009; Lansford et al., 2007). Healthy relationship programming has been recommended for youth involved in child welfare because these skills are crucial to the youths’ well-being, particularly as they transition into adulthood (Forenza et al., 2017; Osgood et al., 2010; Reilly, 2003). A scoping review found minimal research on social support interventions within child welfare and underscored the need for further research in this area given how important social supports are for youth when they are transitioning out of care (Okland & Oterholm, 2022). The present study addresses this gap in research by exploring the feasibility of implementing an evidence-based healthy relationships program with youth at an Ontario, Canada child welfare agency.
There is minimal research related to the implementation of evidence-based healthy relationships programs for youth involved in the child welfare system. When introducing an evidence-based program into a child welfare context it is crucial to make community-informed adaptations so the program meets the unique needs of the agency and consumers which in turn supports implementation success (Hanson et al., 2016). Literature has highlighted the need to examine implementation considerations of evidence-based programs in a child welfare context (Gopalan et al., 2019; Maher et al., 2009; Mildon & Shlonsky, 2011). Identifying an evidence-based intervention that fits the needs of a population is only useful if there is an understanding of how to successfully implement the program within the specific context (Mildon & Shlonsky, 2011). The present study adds to this body of research by outlining key considerations for implementing a healthy relationships program within a child welfare context.
This study also addresses the theory-to-practice gap by exploring practical steps to using trauma-informed practice (TIP) when implementing a healthy relationships program within a child welfare context. Child-service providers, including providers in child welfare, have noted that TIP is well understood as an ideology but there is a lack of concrete examples on how to execute TIP (Donisch et al., 2016). Dunkerley and colleagues (2021) found that there is a particular need to understand how to apply TIP within child welfare in light of the pervasive impact of trauma within this context. Given the competing demands faced by child welfare services, understanding concrete steps to practicing TIP is crucial to facilitate the implementation of this important approach (Jankowski et al., 2019). This research adds to the literature by providing further understanding on the application of TIP, and the feasibility and implementation of a healthy relationships program within a child welfare context.
Child Welfare Services
Child welfare agencies in Ontario are mandated by the Child, Youth and Family Services Act (2017) to care for children 15 years and younger, and youth ages 16 and 17 are eligible for services on a voluntary basis. Child welfare agencies investigate child maltreatment cases and provide protection, residential support, adoption services, and additional care required to ensure the safety and well-being of children and youth (Child, Youth and Family Services Act, 2017).
Given the wide-range of critical and, often, urgent services that child welfare agencies are mandated to provide, it may not always be feasible for child welfare staff to support youths’ healthy relationship skill development in a proactive manner. Experiencing maltreatment has been found to increase the likelihood of engaging in violent offences and experiencing relationship violence (Crooks et al., 2011; Lansford et al., 2007; Wekerle et al., 2009). Youth who have experienced maltreatment are also at high risk of forming friend groups with strong peer-group control, which further increases their likelihood of engaging in violent acts (Ellis & Wolfe, 2009). In a study by Forenza and colleagues (2017), youth involved in child welfare reported difficulties enacting skills they felt would contribute to a healthy relationship. Youth involved in child welfare are at risk of developing poor relationship skills, which can negatively impact their well-being.
Relationship skills such as, conflict resolution skills, boundaries and assertive communication, coping strategies and peer pressure resistance, are imperative for the transition from child welfare involvement to living independently as a self-supporting adult. Youth often struggle during the transition out of care as evidenced by their higher rates of unemployment or underemployment, housing insecurity or homelessness, financial insecurity, involvement with the criminal justice system, early parenthood, poor physical and mental health, and experiences of victimization during the transition (Kovarikova, 2017; Reilly, 2003). Youth in care report that the main struggle they experienced when transitioning from care to independent living was a lack of supportive relationships (Goodkind et al., 2011). Youth who had been in care reported that the ability to develop healthy relationships was crucial during the transition out of care and was more essential than other formal services (Geenen & Powers, 2007). Legault and colleagues (2006) found that youth involved in child welfare who had positive support networks had better psychological adjustment than those without such networks. Healthy relationship programming may support youth involved in child welfare to develop the skills required to create supportive relationships with adults and peers which will in turn improve their transition to adulthood.
Healthy Relationships plus Program – Enhanced
The Fourth R programs (Wolfe et al., 2006; Crooks et al., 2018; see www.youthrelationships.org for more information) include an array of evidence-based social and emotional learning programs that could support youth involved in child welfare to enhance their relationship skills. The Fourth R program is designed to foster healthy relationship skills, promote positive mental health, and reduce engagement in high-risk behaviors (Wolfe et al., 2009, 2012). The program takes a positive youth development approach and is built upon a practice of skill development and harm reduction. Youth participate in role plays to practice using their skills in real-life scenarios. This program develops the youths’ skills, critical thinking, and problem-solving ability (Crooks, et al., 2018) The Fourth R was created in collaboration with researchers, educators and psychologists (Crooks, Zwicker et al., 2017). The first version of the Fourth R aligned with the Ontario Ministry of Education’s health curriculum for Grade 9. The program has subsequently been adapted and evaluated in other contexts, including health curriculums for grades 7 and 8 (Crooks et al., 2015), First Nations communities (Crooks, Exner-Cortens et al., 2017), LGBTQ communities (Lapointe & Crooks, 2018), and vulnerable youth (Crooks et al., 2018).
Although the Fourth R program addresses a range of social-emotional competencies, the programs’ primary focus is the development of healthy relationships skills and experiences. Fourth R programs have been found to reduce dating violence, depressive symptoms, and the risk of violent offending for youth who have experienced child maltreatment (Crooks et al., 2011; Lapshina et al., 2019; Temple et al., 2021; Wolfe et al., 2009). In addition, research has found that the Fourth R programs improve youths’ recognition of abuse, awareness of sexual health, peer pressure resistance, and intent to obtain mental health support (Crooks et al., 2008; Exner-Cortens et al., 2019; Wolfe et al., 2012).
The Healthy Relationships Plus Program - Enhanced (HRP-E) could be useful for youth involved in child welfare as it is an adapted Fourth R program modified to meet the needs of vulnerable youth ages 12–18 years (Kerry et al., 2019; Townsley et al., 2017). This version of the Fourth R program addresses the needs of vulnerable youth by using a trauma-informed and harm reduction approach and includes higher-risk scenarios that match the experiences of vulnerable youth. In a mixed methods quasi-experimental evaluation of the HRP-E program in a youth justice context, youth reported that participation in the program promoted the development of social-emotional skills (Kerry, 2019). Based on multiple baseline and post-intervention surveys, youth reported significant increases in assertiveness, self-control, empathy, problem-solving efficacy, as well as a significant decrease in attitudes supporting peer conflict. Many of these improvements remained significant at a one-month follow-up (Kerry, 2019). Although this evaluation was in a youth justice context, these youths have similar risk factors to those involved in child protective services, and indeed, many youth are dually-involved. Notably, the experience of trauma is ubiquitous among both child protective and juvenile justice involved youth (Dierkhising et al., 2013; Wekerle et al., 2009).
A study on trauma-related symptoms experienced by child welfare-involved youth in Ontario found that 59% of youth experience minimal trauma symptoms, 30% moderate trauma symptoms, and 11% severe trauma symptoms (Gallitto et al., 2017). Considering this high prevalence, it is crucial that programming for child welfare-involved youth utilizes TIP. The Substance Abuse and Mental Health Services Administration (2014) defines that:
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. (p. 9)
Steele & Malchiodi (2012) outline that TIP requires all levels of service to understand the impact that trauma can have on individuals, families, and communities so they are aware of potential triggers and can reduce the risk of re-traumatization. Services need to be provided in a safe and respectful context that clearly defines roles and boundaries as trauma often occurs within relationships where boundaries are unclear or are not respected (Hopper et al., 2009). All aspects of service should aim to provide the client with autonomy and control, since trauma is often related to disempowering circumstances (Hopper et al., 2009; Steele & Malchiodi, 2012). Services that are trauma-informed provide a predictable environment and use a strength-based approach to facilitate a sense of control and empowerment (Hopper et al., 2009). TIP also promotes coordination across services to facilitate holistic care since trauma can impact one’s psychological, social, physical, and cognitive functioning (Steele & Malchiodi, 2012). Services that use TIP support opportunities for positive interpersonal experiences as they recognize that trauma is often relational and healthy relationships support the healing process (Steele & Malchiodi, 2012).
TIP is required to make services accessible for trauma survivors and to reduce the risk of re-traumatization (Steele & Malchiodi, 2012). While TIP is valuable for all organizations, given the widespread impact of trauma in society, it is essential for providers serving clients who have high rates of trauma exposure. The National Child Traumatic Stress Network (n.d.) highlights the importance of integrating TIP into the child welfare system considering the high prevalence of trauma experienced by children and families receiving services. The HRP-E is a promising program for child welfare-involved youth since it follows TIP guidelines to meet the needs of vulnerable youth who are more likely to be impacted by trauma. The present study identifies additional TIP approaches to use when implementing the HRP-E within a child welfare context.
Bowen and colleagues (2009) outline feasibility studies as aiming to understand whether an intervention is relevant and useful to a specific context and population, thereby informing whether further examination is warranted. The present feasibility study used an exploratory approach to investigate the following research questions:
1) How do youth and facilitators view the fit and feasibility of the HRP-E program with youth involved in child welfare?
2) What factors should be considered when implementing the HRP-E program with youth involved in child welfare?
A Children’s Aid Society (CAS) in Ontario, Canada facilitated the HRP-E program for youth 14–19 years of age who were or had been involved in welfare services. There was a wide age range of youth participants given that the only eligibility requirement was youth having sufficient supports and stability (see details below). There were four HRP-E programs delivered and participants were grouped into cohorts with similar aged youth. The program was co-facilitated by a staff member from CAS and clinical trainees from Western University in Southwestern Ontario, Canada. The clinical trainees were all PhD or post-doctoral level trainees, and each had a minimum of three years of clinical training. The staff member from CAS was hired through a grant held at the university by the second author through a subgrant process with the agency. She was assigned full time to work with the university team to adapt and implement the program in the child protection context. Her professional background includes a Child and Youth Worker diploma and over two decades of frontline child protection work. She met regularly with the research team and the clinical trainee facilitators to discuss strategies and approaches to facilitating the HRP-E program within the context of CAS. Her expertise was instrumental in some of the changes that were made over the course of the project, such as the development of inclusion criteria for the program, as noted below.
Purposive sampling was used for this study; the researcher recruited participants who were participating in or facilitating the HRP-E program at CAS. Social workers at CAS were provided with an overview of the HRP-E program and were asked to refer youth who would benefit from social-emotional learning. Following the first implementation of the HRP-E program at CAS, program facilitators identified the need to have additional eligibility criteria that assessed whether the youth had sufficient supports and the required stability to engage in the program. The life stability eligibility criteria required youth to have stable housing, have supportive relationships in their life, not be currently engaged in problematic substance use, and not have any recent hospitalization for mental health-related symptoms in order to participate in the HRP-E.
Four HRP-E program groups at CAS were recruited to participate in the research, involving 28 youth and five facilitators. Participants included five facilitators and 13 youth aged 14–18 years who had varying involvement with CAS. The youth were living in group homes, with a foster family, or with their biological family. One of the co-facilitators was involved in facilitating all four HRP-E groups and completed the measures and an interview for each group. The other co-facilitator changed with each group.
The HRP-E program has a recommended group size of 6–12 participants and consists of 16 sessions that are each 1 h, although in many cases, it is implemented in eight 2-hour sessions. The program uses a flexible implementation model. The skill-based activities focus on healthy relationships, violence intervention, high-risk sexual behavior, sexual exploitation, safety planning, mental health literacy, suicide prevention, substance use, help-seeking practices, and peer pressure (Townsley et al., 2017). To develop skills, critical thinking and problem-solving ability, participants engage in role plays and other interactive activities to practice using their skills in real-life scenarios.
The HRP-E program groups were delivered in 2019 with one in the spring, one in the summer, and two in the fall. Each group implemented the program in eight 2.5-hour sessions and scheduled two additional sessions for program introduction and finale. The spring and fall groups facilitated one session per week for a total of 10 weeks. The summer group facilitated a session every Tuesday, Wednesday, and Thursday for a total of 3 weeks and engaged in additional extracurricular activities following each HRP-E session.
Throughout the facilitation of the four HRP-E groups, modifications were made to program implementation and structure to meet the needs of the population and context. The changes seemed to have a positive influence on the retention of youth participants. Figure 1 outlines the evolution of the HRP-E program implementation and structure, as well as the retention rate of each group.
Evolution of the HRP-E Program Implementation, Structure and Retention
Descriptive Caption. This figure outlines the evolution of the HRP-E program throughout the implementation phases. There are 5 boxes with arrows after each box indicating that the boxes are consecutive and each box outlines different changes to program implementation. Box 1 outlines that the spring group engaged in a 10-week length program, retention rate was 20% and 2 out of 10 youth completed the program. Box 2 specifies that after the spring group modifications were made to the program to include transportation for youth to and from program and eligibility criteria was put in place that youth need life stability to participate. Box 3 then outlines that the summer group was 3 weeks long, there was a retention rate of 100% and 4 out of 4 youth completed the program. Box 4 explains that after the summer group, the program was lengthened so youth had time to practice skills, and the transportation and eligibility criteria changes were maintained. Box 5 outlines that the fall group was 10 weeks in length and there were 2 program groups. Group 1 had a 100% retention rate with 5 out of 5 youth completing the program. Group 2 had a retention rate of 55% with 5 out of 9 youth completing the program.
The purpose of this research was to achieve a comprehensive understanding of feasibility. The facilitators completed session tracking sheets after each HRP-E session to report on the activities that were completed, session modifications, and challenges and successes experienced during the session. Session tracking sheets included questions such as: ‘Was there a specific section or activity that was well-received?’ and ‘Was there a specific section or activity that was problematic?’.
Post-intervention, facilitators completed an online implementation survey that examined the HRP-E structure, retention, engagement, and the facilitator’s experience implementing the HRP-E. The implementation survey consisted of Likert-scale and open-ended questions such as: ‘To what extent was implementing the HRP Program a positive experience?’ and ‘Was there anything about the HRP Program that made it difficult to implement? Check all that apply’. The survey was adapted from previous implementation research with the Fourth R.
Following participation in the HRP-E program, youth and facilitators participated in semi-structured interviews to share their view of the program, resources required to implement the program, and the fit of the program within a child welfare context. Interviews took place at the agency where the groups were held. Facilitator interviews ranged in length from 30 to 60 min. One youth interview was 21 min in length, eight youth interviews were between 8 and 15 min in length, and four youth interviews were 6 to 7 min in length. Although some youth interviews were short, it was determined that the information still brought valuable insight into the program. Some of the youth provided direct statements about how they felt about the HRP-E program which contributed to shortened interviews that still provided useful data. The interviews were audiotaped and transcribed verbatim. The youth interviews included questions such as, ‘How was your experience participating in the Fourth R program?’ and ‘Did you learn any specific skills and strategies in the program? Have you used any of these skills or strategies?’. The facilitator interviews included questions such as, ‘What was your experience like facilitating the Fourth R program at the Children’s Aid Society?’ and ‘What resources do you think are required to implement the Fourth R program with youth at a child welfare agency?’. The participants received a $20.00 gift card as compensation for their participation in the interview. Interview protocols are available from the corresponding author.
Qualitative analysis of interviews and the open-ended questions from the implementation surveys was conducted through a multi-phase thematic coding process (Braun & Clarke, 2006). The transcriptions were uploaded onto Dedoose (V. 8.3.17), which is a web-based mixed-methods analytic software. The coding analysis was conducted on Dedoose through an iterative process of identifying, refining, and redefining codes. Data collection, code jotting, and the coding procedure were recorded through a memo process on Dedoose (Saldaña, 2016).
Data from facilitators and youth were analyzed together using the same process and codebook. The data were analyzed and organized using the codes-to-theory model for qualitative inquiry outlined by Saldaña (2016; p. 23). The codes were recorded and revised in a codebook and a three-row graph was used to organize each code by code definition, the key findings from the code’s excerpts, and the exemplar excerpts that reflected the code. The exemplar excerpts were edited for clarification. Each code graph was examined to identify cross-cutting themes, and a preliminary model was developed to describe the themes. The preliminary thematic model was reviewed and refined through consultation with the second author, graduate students and the staff research team. When there was intercoder variability, the team discussed and modified the code, theme, category or assertion until consensus was reached. Figure 2 outlines the final model that was developed with one overarching assertion, three themes, and a total of 12 categories.
The quantitative data from the implementation surveys and session tracking sheets were examined to clarify and triangulate the interview findings. These measures were also used to quantify views on program structure and content, retention and engagement, and program fidelity.
Impact of Unique Life Experiences on HRP-E Feasibility: Major Themes and Categories
Descriptive Caption. This figure outlines the model created to represent the research findings with 1 overarching assertion, 3 themes, and a total of 12 categories. The overarching assertion is unique life experiences. Under the overarching assertion the 3 themes are fit of program, trauma-informed facilitation and commitment of child welfare agency resources. Under fit of program there are 3 categories which are satisfaction, need and relevance and learning outcomes. Under trauma-informed facilitation there are 4 categories which are program and session structure, program content and activities, learning process and support. Under commitment of child welfare agency resources there are 5 categories which are intentional recruitment, transportation and program space, support personnel, program supplies and activities, and funding.
This research used qualitative methods that aim to establish trustworthy data that are credible, confirmable, and dependable (Shenton, 2004). The research applied data triangulation to support the credibility of the data. The triangulation of data was achieved by examining the experiences of youth and facilitators through different methods, such as interviews, session tracking sheets, and implementation surveys. To support the confirmability of the research results, the interviews were audio-recorded to ensure that the data accurately represented the participants’ responses to interview questions. The interviewer was independent from the intervention team to enhance the confirmability of the data. To increase both the confirmability and dependability of the research, the researcher kept an audit trail that details all research activities, data collection, and analysis. In addition, all coding processes were recorded and refined in a codebook throughout the collection of data (Saldaña, 2016).
The overall assertion identified by the researchers is that the feasibility of the HRP-E program with CAS-involved youth was inextricably linked to the unique life experiences shared by the youth participants; specifically, their involvement with child welfare services. All codes were organized into three themes that reflected the underlying primacy of understanding the unique life experiences of CAS-involved youth. As outlined in Fig. 2, the themes were organized into 12 categories that represent the key findings. The results are organized by theme, and we present the findings and exemplar excerpts of each theme and category below.
Fit of HRP-E Program with Youth Involved in CAS
The HRP-E appears to be a valuable program for CAS-involved youth. The unique life experiences of CAS-involved youth contributed to the HRP-E being a satisfying program as it filled a need and provided youth with relevant skills and knowledge.
Overall, youth and facilitators reported that they enjoyed participating in and facilitating the HRP-E program. Youth reported that their satisfaction with the HRP-E program was related to the peer connection and relationship-building. The unique experiences shared by youth, given their involvement with CAS, enhanced relationship-building and fostered a sense of peer connection. Facilitators and youth commented that being with peers with common experiences made it a non-judgmental space to explore their experiences, discuss sensitive topics, and learn. An example of this is from Facilitator 01 who shared:
I think for some of these youth they could really use a friend and I think this group really helped with that. It’s a group of people who are all involved in CAS, and they have that common experience. And I don’t know how often they get to embrace that identity with other people in their lives. It’s uncomfortable for them to talk about being involved with CAS or living in a foster home with peers at school.
When commenting on how they found being with a group of CAS-involved youth, Youth 06 stated that “…it’s better if someone has had the experience that you might have had, that it [makes it] easier to talk about.” Youth also described feeling more empowered to be themselves and share their views because of this sense of safety that derived from relationships developed in group.
Many youth explained that they felt understood by group members and that others cared about their experiences and views. For instance, Youth 06 shared this sentiment, “It felt like people actually cared about what I was saying; when I was talking, they were listening.“ This sense of being understood and cared for made youth feel less isolated with their experiences of pain and trauma. Youth 13 reported that the HRP-E discussions helped them recognize, “…that other people dealt with friends or family with mental health problems.” The HRP-E program offered a unique opportunity for the youth to both learn and experience healthy relationships.
Results indicated that most youth had a positive social experience in the group, and for some youth, this was a novel experience. For example, Youth 10 expressed having an unexpected positive social experience:
In the summer when they were trying to get me into this, I was like, this sounds really stupid... But once I met the people and gave it a chance, it wasn’t that bad. It was actually really fun. I’m sad it is ending because I’m going to miss my friends.
Need and Relevance
Youth and facilitators indicated that there is a need for the HRP-E program for CAS-involved youth and that the content was relevant for this population. Youth described that the HRP-E program provided them with opportunities to learn relevant skills and taught them new ways to navigate personal situations. Youth explained that they appreciated that the program discussed important and sensitive topics, such as mental health challenges and communication skills in relationships, that are often neglected and avoided in their personal lives. Youth 10 explained that they felt the program content was important even though it was challenging to talk about:
I think they [program content] are really important to talk about because it might not be the nicest thing to talk about, but it’s a reality. And it’s important to know that… these things are happening and what to look out for and how to be careful and keep safe.
Youth and facilitators reported that although the HRP-E topics were sometimes uncomfortable for the youth, they were nevertheless essential for their learning and growth. Youth 01 explained that to learn it is crucial to have these difficult conversations:
Well I liked it a lot. There were some triggering parts of it [the program] like talking about people who were going through stuff but you got to get through the triggers, you know, the pain, to learn. So I liked every bit of it [the program].
The HRP-E program provided youth with a space that felt safe, comfortable and validating to explore triggering material and learn new information and skills.
Considering that most youth had challenging family relations, they did not always have a guardian that could support them to learn healthy relationship skills. The HRP-E provided CAS-involved youth with a safe space to explore these topics. Facilitators commented that if the youth attended this program in the community without other CAS-involved youth, they might not have felt as comfortable to engage in the program content. Overall, the HRP-E provided youth with the opportunity to develop necessary skills in a unique environment where they felt safe and understood by their peers due their common involved with CAS.
The HRP-E supported youth to develop new skills and knowledge. For instance, facilitators and youth discussed how the youth used the new skills, felt better prepared for the future, were reinforced for existing skills, improved their ability to engage in perspective-taking, and considered how to integrate new skills into their life. Facilitators and youth reported that youth were using a variety of HRP-E skills they learned outside of the group, such as breathing techniques, assertive communication, active listening, respectful interactions, and peer pressure resistance techniques. For instance, Facilitator 05 explained:
I know one of the youth also used assertive communication to let their worker know that one of the strategies that’s on their IEP in their schools for coping doesn’t work. But she didn’t know how to communicate that to the worker or to the school teacher… She had mentioned it to me and we role played and rehearsed the script of them using our assertive communication techniques. And I followed up with her last weekend, and she used that communication skills to speak to her worker, and the worker is currently in touch with the school principal to get that going.
The youths’ high performance on the final HRP-E quiz activity also demonstrated that they all retained information from the program.
Many youth reported that the HRP-E program prepared them with skills and information to navigate future situations. When commenting on what they gained from the HRP-E program, Youth 10 stated:
Yeah, just like preparation and more knowledge. And that bad things can happen to anybody, and you never think it’s going to be you until it does. I think it’s good to realize that we are never perfectly safe, and you’re supposed to be in charge of keeping yourself safe.
Youth reported that practicing skills in the group made them feel equipped to address real-life situations. Specifically, Youth 11 described how practicing the skills in group was useful, “so if something were to happen in the real world, you’d know how to do it with strangers.” This new knowledge provided youth with new approaches to difficult situation, Youth 01 mentioned, “And it was like oh I could have done this…So if that ever happens again, I could do this instead of what I did because what I did wasn’t the best to fix the situation. So I did learn a lot.” It is clear that youth learned new approaches to life situations and this built their repertoire of skills for navigating interpersonal relationships.
The HRP-E also enhanced the youths’ confidence as they learned that the approaches they were already using in their life were useful and appropriate. This reinforcement was reassuring for the youth and made them feel more confident about their ability to navigate challenging situations, Youth 08 explained:
…It was definitely reassuring… Hearing my thoughts echoed throughout the group…The strategies that I normally apply, our facilitator, would mention… that it is a really good thing to do and would reconfirm what I’m thinking. So, there’s reassurance and boosting confidence.
Overall, youth developed new healthy relationship skills and felt more confident about their ability to navigate unhealthy relationships and challenges in relationships.
Need for Trauma-Informed Facilitation
The HRP-E explores content related to consent in sexual activities, healthy and unhealthy relationship dynamics, dating violence, the consequences of substance use, and other emotionally evocative topics. These topics parallel closely with the youths’ lived experiences and, it is essential to take a trauma-informed approach to facilitation in order to prevent re-traumatization. A TIP approach to facilitating the HRP-E was required in order to support youth while they explored sensitive topics. TIP recommendations can be applied to the program and session structure, the HRP-E activities and content, and to supporting the youths’ learning process and well-being.
Trauma-Informed Program and Session Structure
Youth and facilitators reported that the youth needed more time to process the program content due to the sensitive nature of the information for these youth. Facilitators from the Spring-Summer Groups shared on the Implementation Survey that program content“…Appears to be very triggering for them [youth participants]. Each topic has multiple layers that require more thought and processing.” This issue of program intensity was particularly salient for the summer group, which ran three days a week over a three-week period, in conjunction with recreational activities following each HRP-E session. Facilitator 02 confirmed this challenge:
I think time was a big challenge for us… I think this group required a lot of additional processing time… Then we’re trying to squeeze all this content in while also balancing the fact that they’re having these great discussions… And we don’t push content when they’re not in a place to receive it, so that I found was challenging at times.
The facilitators reported that having more time allocated to program activities and the overall session would allow them to provide a more predictable schedule while also supporting the youths’ needs. Youth also found that more time in sessions was required to cover the program content and that this would support a more predictable schedule. For example, Youth 02 explained, “I think with our group, in particular, it was a lot of content to cover in a very short period of time.” The sessions delivered two HRP-E topics which may be too much content for youth to process in one session. Facilitator 01 suggested lengthening the time allotted to activities so there would be a more predictable schedule, “If we had more time, we could plan it better. I know we did a pretty good job planning it out. But we had to rush through a few things because we took too long.” When delivering the HRP-E program for CAS-involved youth, facilitators should consider reducing the number of topics delivered in one session so there is sufficient time for information processing, debriefing and breaks which in turn may help create a more predictable schedule.
In some cases, youth seemed to understand the program content and gain new perspectives but had challenges applying the skills and knowledge. A lengthened program duration may provide more opportunities for youth to process information and practice skills within and between sessions. The program was lengthened after the summer group as they noted that delivering the program in three weeks may not provide the youth with enough time to process the information. Facilitator 03 reported that one youth in the short three-week program could:
…read the red Flags and she know the material, and she has all the correct information, but somehow she is not implementing it into her own life. And I think one of the downsides to having our program so quick, we were having six sessions a week, is it did not allow for the processing time.
Some youth may require more time to translate the knowledge to practice, but nevertheless contemplation is an essential first step for skill development. In order to have more time and reduce the amount of content covered in each session, facilitators and youth advised for the program to be delivered over a longer period of time. A lengthened program duration would provide more opportunities for youth to process information and practice skills within and between sessions. In accordance with TIP, the HRP-E structure should allocate more time for information processing, debriefing, and breaks in order for the session schedule to be more reliable and to support the youth while they explore sensitive topics.
Trauma-Informed Program Content and Activities
Trauma-informed considerations for program content and activities are outlined in the HRP-E manual. The youth and facilitators provided further insight on how to apply TIP principles in this context. Youth and facilitators suggested applying the following TIP principles to program content and activities: flexibility, language that eases information processing, a strength-based approach, and developmentally appropriate content.
The youth participants were typically coping with unpredictability within their lives due to changes to their living situation, experiencing stressful circumstances, and coping with mental health and trauma symptoms. These adversities meant that there was a constant need for facilitators to be flexible and individualize the session content and activities to meet participants’ flucuating needs. As explained by Facilitator 05:
…When you work with vulnerable populations, life is very unpredictable for them. Because life is unpredictable for them, what they bring to the sessions is also unpredictable. So you might have this plan, you’re really prepared… But they come in sometimes with their own life stressors and other challenges, and that changes the dynamic.... That challenged my own facilitation skills because I have to be innovative in ways to implement it.
Facilitators needed to be creative and flexible in their delivery of program content so they could attend to the youths’ fluctuating needs. For example, an interactive activity was altered to be sedentary because the group seemed unable to engage in something active due to their needs during that session. Overall, facilitators described the delivery of the HRP-E program within this context requires a balance between attending to participants’ needs and achieving program goals. Facilitators made modifications to program language to ensure the content was appropriate and relevant for CAS-involved youth. Facilitator 05 discussed their experience addressing the literacy levels in the group,
I had to be very cognizant about the language. The latest example I can think of is the questions from the trivia… My co-facilitator was stating the questions and all the youth were giving blank stares and they’re like, what does that mean? So I had to break it down to language that would be more accessible to them. And once you had broken down the language for them, they were able to give their responses really well.
It was crucial for facilitators to be aware of the language they were using so youth could engage in the program and feel understood.
Facilitators reported that they adapted program activities and content by integrating a strength-based approach. For example, facilitators modified the wellness activity to focus on the youths’ strengths and on building supports rather than having youth evaluate their current well-being. Facilitators commented that for CAS-involved youth, an evaluation of their well-being can often highlight the negative aspects of their life, and cause distress.
Lastly, program content and activities were adapted by facilitators to ensure they matched the youths’ experiences and developmental stage. Facilitators reported that it was essential for them to ensure that the youth were able to process the program content considering their developmental stage. Facilitators modified the program content to match the youths’ processing capacity to ensure the content would not be overwhelming and distressing for them. For instance, some youth had not been exposed to drugs, so the harm reduction activities were adjusted to align with the youths’ experiences and developmental stage. Facilitators modified program content and activities to ensure the program was trauma-informed by being flexible facilitators, using appropriate language, using a strength based-approach, and delivering developmentally-appropriate content.
Accommodate the Learning Process of the Group
Facilitators reported that a trauma-informed learning process was crucial for the youth participants, considering the sensitive nature of the program content. Facilitators stressed the importance of recognizing the impact of the youths’ previous experiences on learning, and the value of using a collaborative approach to learning.
The facilitators reported that the youth had predetermined views on some of the topics based on their experiences, which made them resistant to processing the perspectives and ideas presented in the HRP-E program. Facilitator 02 shared the challenge of addressing some predetermined views:
…Occasionally, it was tricky because we’d had these conversations and they would get the opposite conclusion… And you don’t want to end that session by being like you’re actually wrong… It is hard when you know your life experience told you one thing whereas in other groups, maybe they’ve never experienced it, so it’s easier to say, yeah, it would be wrong if someone would do that… than oh I’ve experienced that and it didn’t seem wrong, but it’s wrong? It’s a harder knot to unravel.
Facilitators described that these situations required them to balance respecting the youths’ views while also not validating unhealthy perspectives. In order to validate the youths’ experiences, facilitators emphasized the importance of having a collaborative discussion with youth rather than imposing the program views on the youth. For instance, Facilitator 05 discussed their experience with collaborative learning:
You always begin each activity by inviting the voices and opinions…of youth rather than this is what an unhealthy relationship… I think when you do brainstorming and you put in some scenarios, you invite them [youth participants] to be more critical thinkers. It helps because it’s not just me as an adult, I’m just going to push down this education on you. We know that…education is only effective when there is acceptability of that education. So, I think when we brainstorm together, we co-create the solutions for the scenarios… I felt there was a greater buy-in to this because it was not just me telling them this is what the youth in the scenario should be doing.
Youth and facilitators described how the collaborative approach to learning was more engaging for the participants because the youth felt that their perspectives were valued. A trauma-informed learning process for CAS-involved youth required facilitators to be aware of the complexity of processing sensitive topics, respect the youths’ experiences, and deliver the content in a collaborative manner.
Be Aware of Youths’ Needs and Provide Appropriate Support
Facilitators and youth reported that receiving emotional support from facilitators and other youth participants was crucial to the youths’ well-being while they explored sensitive program content. Facilitator 01 shared this example of the emotional support in group:
One example sticks out in my head. One of the youth was having a challenging time talking about mental health and how to support other people in their life with mental health issues… So they were getting fairly emotional talking about the activity and their experience and all the youth stood up and came over and gave her a hug. And I mean that was pretty explicit support.
The youth expressed that they felt well supported during the HRP-E program, for example, Youth 02 shared,
Some of the content was slightly triggering… So the facilitator said you can leave at any time if you find this too much and they even came out to help and support you if you did leave, that was a very nice thing to see.
Most youth reported that the support they received during the HRP-E group was sufficient and that they did not need external supports to cope with the program content.
Facilitators underscored the importance of being aware of the youths’ needs and well-being and, being flexible to meet these needs. Facilitators reported that having information on the youths’ current and past wellness and living situation allowed them to anticipate potential challenges and provide the youth with adequate support. However, facilitators cautioned that background information did not always predict the youths’ needs, making it essential for facilitators to actively monitor the youths’ well-being. Facilitator 02 shared that,
… The best advice [to facilitators]… would be to be super mindful of your youth always, and then being responsive to those needs as best you can… I think my biggest takeaway was you really… need to be much more intentional, …mindful, … flexible and…responsive than in a different group.
Overall, facilitators advised that HRP-E facilitators in this context need to be flexible in order to balance attending to the youths’ needs while also getting through program content.
Facilitators discussed the importance of providing support in a manner that distinguishes them as a facilitator and not a counsellor, given that the HRP-E was not designed as a psychotherapy program. This view was discussed by Facilitator 05 as requiring some thoughtfulness and nuance:
So, the idea is when you are providing a tier two psycho-educational design intervention with a vulnerable youth whose lived experiences may bring up very sensitive and vulnerable conversations… How are the facilitators inviting and providing a space for those discussions to happen, but it doesn’t become therapy… So, I think the responsibility goes back to the facilitators and their own preparedness to do this program because there are additional considerations for doing a program such as the HRP with vulnerable youth.
Facilitators recognized the importance of being aware of the scope of the program and clearly defining their role and boundaries with the youth and connecting the youth to other supports if required. Facilitators in the present study recommended that HRP-E facilitators have training in TIP as well as clinical experience supporting trauma survivors. The HRP-E is viewed as feasible for CAS-involved youth if facilitators are knowledgeable about TIP and are committed to integrating these approaches into the program.
Required Program Resources
Facilitators advised that in order to ethically implement the HRP-E program, child welfare agencies need to have the resources to engage in intentional recruitment, provide transportation and program space, personnel dedicated to supporting the program, program supplies and activities, and financial support. It would be potentially risky to implement a program that covers sensitive topics without securing adequate resources considering the vulnerability of CAS-involved youth.
Intentional HRP-E Recruitment
Facilitators recommended that agencies engage in intentional recruitment and define program eligibility criteria that aim to prevent problematic group dynamics and ensure that the youth have the emotional capacity and life supports to cope with the sensitive program content. For the first pilot group, youth were selected who were experiencing significant challenges, and 8 of the 10 youth who started the group did not finish it. Based on this first group, recruitment criteria were implemented that required youth to have stable housing, have supportive relationships in their life, not be engaged in heavy substance abuse, and not have any recent hospitalization for mental health-related symptoms in order to participate in the program. Facilitator 03 describes the challenges of retention prior to implementation of recruitment criteria:
In the first time around…we had really poor attendance, part of that was due to the nature of those participants. We had a lot of significant mental health and some addiction issues, lots of instability like housing instability, and so forth…We mitigated a challenge by having some criteria for participants.
Facilitators emphasized that the youths’ emotional stability and supports should be considered throughout the program to ensure the youth has the emotional resources to explore the sensitive program material. Intentional recruitment of youth seems to be necessary to support the well-being of youth by preventing potentially problematic group dynamics and ensuring the youth can cope with the sensitive program content.
Transportation and Program Space
Facilitators discussed the importance of coordinating the youths’ transportation to and from the group to make the program more accessible for this vulnerable population, and Youth 10 noted that this support was critical, “I feel like because they have drivers, it’s a good location… because there are many times that I would not have been able to get here or home if there wasn’t a ride.” Providing transportation is crucial to reducing the barriers that vulnerable youth experience to attend valuable programs like the HRP-E.
HRP-E Support Personnel
Significant staff time and energy were required to adequately support the facilitation of the HRP-E, beyond the actual program hours. Facilitators reported that support personnel are required to coordinate recruitment, logistics, facilitation, and the youths’ care. It was noted that having a co-facilitator enabled one facilitator to leave the room and follow-up with youth who removed themselves for a break. Being able to connect with the youth’s caseworker, particularly in situations where a youth was struggling, was an invaluable resource for supporting the youth’s well-being.
HRP-E Program Supplies and Activities
Facilitators suggested that child welfare agencies prepare HRP-E materials and supplies, making them readily available to facilitators and thereby reducing tasks that facilitators have to manage in session. Facilitators also recommended that child welfare agencies review program materials before implementation to make population-specific adaptations to the program handouts. The facilitators reported that the introduction of preparation time increased their capacity to attend to the needs of the youth because they had more time and energy available to manage group dynamics.
Financial resources were also important for supporting the group. Facilitators identified reinforcement and engagement supplies, such as food, gift card prizes, and fidget toys, as crucial to supporting youth engagement and information processing. Facilitators reported that organizing extracurricular activities for the youth was another valuable incentive, as well as being a relationship builder for the youth.
The results of this study highlight the need for and relevancy of a healthy relationships program for youth involved in child welfare. The HRP-E addresses essential healthy relationship skills that many of the youth identified as never having explored previously. These skills are crucial to supporting these youths with their transition to adulthood and their overall well-being. Literature has underscored the need for youth involved in child welfare to develop interpersonal supports as they transition to adulthood (Geenen & Powers, 2007; Osgood et al., 2010; Reilly, 2003). These skills are also valuable for youth involved in child welfare considering their elevated risk for involvement in relationship abuse and other violent offences (Crooks et al., 2011; Ellis & Wolfe, 2009; Indias et al., 2019; Lansford et al., 2007; Wekerle et al., 2009). While the HRP-E fit the needs of youth involved in child welfare, the feasibility of the program relied on facilitators using a trauma-informed approach and the child welfare agency having adequate resources to support the program.
Trauma-informed facilitation techniques identified in the present study demonstrate ways facilitators can apply the TIP model. The results acknowledged the importance of using trauma-informed techniques such as being strength-based and collaborative to facilitate client-centered care, a predictable and respectful environment, empowerment and autonomy, and opportunities for healthy relationship building (Steele & Malchiodi, 2012). Evidence-based programs should be adapted for implementation in child welfare contexts to ensure the intervention meets the unique needs and context of youth involved in child welfare (Maher et al., 2009). Specifically, Barkan and colleagues (2014) stressed the importance of making adaptations that consider the youths’ trauma-related symptoms, the unpredictability of their environment, and their vulnerability due to their age and life experiences. The results of this research highlights that these techniques should be applied to program and session structure, program content and activities, learning process, and support.
The session and program structure should allocate sufficient time for information processing, debriefing, and breaks for the session schedule to be more predictable, provide opportunities for relationship-building and to support the youth while they explore sensitive topics. In order to provide trauma survivors with an environment that feels safe, it is critical to have consistency and predictability (Steele & Malchiodi, 2012). Youth in the present study noted that they would appreciate having a more predictable session structure. To support consistency and predictability, the HRP-E session schedule needs to allocate a sufficient amount of time to accommodate for participants’ learning process and needs.
Program activities and content should be delivered with flexibility, using simple and concrete language that eases information processing, using a collaborative and strength-based approach, and delivering developmentally appropriate content. Trauma symptoms can impact and interfere with one’s capacity for information processing and thereby it is important to adjust the delivery of program content to align with the youths’ learning process (Steele & Malchiodi, 2012). The use of a strength-based approach facilitates empowerment by emphasizing the survivor’s skills and abilities (Kezelman & Stavropoulos, 2012; Steele & Malchiodi, 2012). Some of the activities in the HRP-E were adapted by facilitators to make them more strength-based as they acknowledged the importance of highlighting positive factors in the youth’s life. Facilitators also noted that they delivered the HRP-E content through collaborating with the youth rather than imposing the content on the youth. A collaborative and strength-based approach can support the development of a sense of agency and belief in one’s skills which can support healing trauma wounds (Kezelman & Stavropoulos, 2012; Steele & Malchiodi, 2012).
Appropriate support that makes trauma survivors feel emotionally safe is crucial, given that their emotional needs were not met in the past (Steele & Malchiodi, 2012). TIP requires facilitators to be aware of the youths’ needs and well-being, use flexible approaches to meet these needs, and demonstrate an awareness of the scope of the program by clearly defining their roles with the youth and connecting the youth to other supports if required. Services need to be provided in a safe and respectful context that clearly defines roles and boundaries as trauma often occurs within relationships where boundaries are unclear or are not respected (Hopper et al., 2009). TIP aims to facilitate opportunities for positive interpersonal experiences because trauma often occurs within unhealthy relationships, and positive interpersonal experiences can support the healing process (Steele & Malchiodi, 2012). To ensure facilitators can stay within their scope of practice, youth should have access to appropriate psychological supports outside of the HRP-E program, skilled facilitators should be recruited for program facilitation, and training about TIP should be offered to facilitators. It may be challenging for a child welfare worker to contain their scope of practice if they are both facilitating the program while supporting youth in a therapeutic role outside of the group context. Child welfare agencies should consider the risks and benefits of having child welfare workers having dual roles with youth. Boundaries in relationships develop trust and consistency, which are valuable for youth involved in child welfare whose relationships are often unstable and fraught with unclear boundaries (Kezelman & Stavropoulos, 2012; Hummer et al., 2010).
Access to resources is required to implement the HRP-E for CAS-involved youth. Considering the vulnerability of this population, resources are essential to ensuring that CAS-involved youth can safely navigate the sensitive HRP-E content. Facilitators in the present study highlighted that agencies need to have the capacity to provide staff support, coordination of care for the youth, resources for recruitment, transportation, and financial support. One specific consideration that organizations need to understand is that the time required for a facilitator to successfully implement the program is much greater than the sum of the program hours; consistent communication with youth and other stakeholders required significant and ongoing availability of the facilitator.
Lack of funding is perceived as a crucial factor that impedes the feasibility and sustainability of programs within the Ontario child welfare system (Weegar et al., 2018). Other child welfare locations have also found that the lack of resources and funding interfered with the implementation of programs within child welfare agencies (Gopalan et al., 2019; Schelbe et al., 2018). Child welfare staff reported that they have demanding responsibilities, which makes it challenging to prioritize supporting program implementation (Gopalan et al., 2019). The National Child Traumatic Stress Network (n.d.) underscored that a necessary component of a trauma-informed child welfare system is providing adequate support for child welfare staff. Child welfare staff need to be supported by child welfare agencies, so they can support the HRP-E program while also maintaining their well-being, given their demanding responsibilities. For the HRP-E program to be feasible and sustainable, adequate resources need to be granted to welfare agencies so they can support this valuable program.
The results of the present study identified that there is a need for healthy relationships programming for CAS-involved youth. CAS-involved youth benefit from learning social and emotional skills that support their well-being and prepare them for the transition to adulthood. As reviewed, child welfare-involved youth are susceptible to engaging in high-risk behaviours that do not support community well-being. It is essential that as a society, we allocate the necessary resources to support this vulnerable population to develop skills that promote well-being.
The study results provide a rationale for policy and system change to better meet the needs of CAS-involved youth by providing the resources required for programming. In order to make a healthy relationships program feasible and sustainable for CAS-involved youth, resources need to support program implementation within this context. Given the vulnerability of CAS-involved youth, the appropriate resources must be provided to ensure the program can attend to the well-being of the youth.
The results identified specific program resources required, including intentional, relationship-oriented recruitment; accessible and convenient program space; support personnel; program supplies and activities; and, most importantly, funding. The results contribute to the body of literature that illuminates the need for policies to support the allocation of resources to organizations caring for child welfare-involved youth. Future research that supports the advocacy for policy change by identifying the needs of CAS-involved youth and the resources required to meet the youths’ needs is recommended. Quasi-experimental research should be conducted to clarify the impact of healthy relationships programming on CAS-involved youth.
Trauma-informed facilitation techniques identified in the present study demonstrate ways facilitators can apply the TIP model. The findings underscore the importance of using trauma-informed techniques that facilitate client-centred care, a predictable and respectful environment, empowerment and autonomy, and opportunities for healthy relationship building. The results highlight that these techniques should be applied to program and session structure, program content and activities, learning process, and support. The identified techniques contribute to the body of literature on program implementation for CAS-involved youth. Given the unique needs of vulnerable youth, it is essential to understand how to implement a program for this population. Future research should continue to explore the implementation science behind programming for CAS-involved youth. Further understanding of implementation factors will improve the ability of organizations to facilitate programming within a child welfare context. Overall, the result of the present study contributes to understanding how to support the well-being of CAS-involved youth through providing appropriate programming.
The small sample size and qualitative design of the present study limit the generalizability of the findings. The present study is not generalizable to the diverse population of youth involved in child welfare given the small sample size. Furthermore, demographics and living circumstances were not collected in an attempt to increase confidentiality of participants. It is crucial that future research uses a larger sample size and collects and analyzes demographic information to clarify the feasibility and fit of the HRP-E with diverse youth involved in child welfare. Bernal & Sáez-Santiago (2006) highlight that research often neglects to include minoritized clients in the development of evidence-based programs which exacerbates the systemic barriers to accessing supports that meet the community’s needs. Diversity considerations are particularly important given that the Canadian child welfare system has an overrepresentation of specific racial groups including Black and Indigenous families (King et al., 2017; Sinha et al., 2013).
The present study contributes to understanding the need for, and fit of, a healthy relationships program for youth involved in child welfare and implementation factors to consider within this context. Despite the limitations of the present study, the results are useful to understanding how programs can meet the needs of youth involved in child welfare. In summary, the results found that the HRP-E program was perceived as a relevant and useful program for youth involved in child welfare, but required trauma-informed facilitation and commitment of child welfare agency resources to be successful. The findings contribute to understanding how to implement a program with youth involved in child welfare to support their development of healthy relationship skills. It is evident that healthy relationship programming is valuable for CAS-involved youth and has the potential to equip this vulnerable population with the knowledge and skills required to enhance their well-being.
Availability of data and materials
The datasets generated during and/or analysed during the current study are not publicly available to protect the privacy of participants and in accordance with the child protective services agency?s stipulations.
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The authors would like to express gratitude to the staff and youth at the Children?s Aid Society of London and Middlesex in Ontario, Canada for their time, efforts and dedication to this research project. We wish to acknowledge the team at the Centre for School Mental Health for their ongoing encouragement and support.
This research was supported by the Canada Graduate Scholarships to Honour Nelson Mandela from the Social Sciences and Humanities Research Council (B. Houston) and a grant from the Public Health Agency of Canada (C. Crooks; Grant # 1819-HQ-000052). This study is part of a larger research project funded by the Public Health Agency of Canada to examine the fit of the the Healthy Relationships Plus Program - Enhanced with vulnerable youth. This research project aims to address identified gaps in the area of violence prevention and mental health promotion programming for under-served populations through evaluating and developing effective programming.
Conflict of Interests
The second author is one of the developers of the program described in this paper.
Bridget Houston received research support from the Centre for School Mental Health at Western University and the Canada Graduate Scholarships to Honour Nelson Mandela from the Social Sciences and Humanities Research Council. Claire Crooks received research support from a grant from the Public Health Agency of Canada (C. Crooks; Grant # 1819-HQ-000052).
The Western University Non-Medical Research Ethics Board and the Children’s Aid Society in Ontario involved in the study approved all research procedures and materials.
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Informed consent was obtained from all individual participants included in the study.
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Houston, B., Crooks, C. Feasibility of a Healthy Relationships Program with Youth at a Child Protective Services Agency. Child Adolesc Soc Work J (2022). https://doi.org/10.1007/s10560-022-00886-w
- Child Welfare
- Healthy Relationships Program
- Violence Prevention
- Implementation Science
- Trauma-Informed Practice