Significance

The Infant Toddlers Court Teams (ITCTs) is a program for collaborative problem solving for families involved with child protective services with the goal to ensure that child and parent needs are identified and met quickly and effectively. This study compared services receipt among parents the year before the COVID-19 pandemic with the first year of the pandemic. Parents were able to maintain similar levels of services receipt within 30 days and within 14 days as before COVID. This success is notable given the significant disruption to the availability of services and barriers to accessing services caused by the pandemic.

Introduction

Parents involved with child protective services agencies (CPS) are required to complete a case plan listing the services they need to fulfill either to avoid the removal of their child from the home or to reunify with a child placed in out-of-home care. Studies based on the first two cohorts of the National Survey of Child and Adolescent Well-Being (NSCAW), the only nationally representative study of children investigated for maltreatment, demonstrate the high and co-occurring needs of CPS-involved parents including intimate partner violence, mental health problems, substance use problems, history of childhood maltreatment, high family stress, low social support, and difficulties paying for basic necessities (Casanueva et al., 2010, 2011; Ringeisen et al., 2011). Among parents in need, a fraction are referred to and access services (Casanueva et al., 2014; Dolan et al., 2011; Finno-Velasquez et al., 2016; Ringeisen et al., 2011). Even among parents with a substantiated maltreatment report involving substance use problems, less than 20% are referred to substance use disorder (SUD) treatment or other preventive services (Steenrod & Mirick, 2017).Footnote 1 Reducing the gap between service needs and receipt is critical, as parents who receive services are more likely to be reunified with their children (Lin et al., 2020; Ryan et al., 2017).

In response to decades of gaps between parents’ services needs and receipt, the CPS is undergoing a period of transformation as a result of the Family First Prevention Services Act of 2018 (H.R. 1892). This landmark legislation provides the direction and funding for the CPS to prioritize preventive services that strengthen families and keep children safely with their families to avoid the trauma that results from being placed in out-of-home care (ACYF, 2018; Wilson et al., 2019). The legislation expands and allows more flexible funding for preventive services to address SUD and mental health needs and provide in-home parenting interventions. The opportunity to provide preventive services offers a stark contrast to prior funding constraints that limited federal reimbursements to children who had already experienced maltreatment or were placed into foster care.

Infant-Toddler Court Teams (ITCTs) provide a two-level structure for collaborative problem solving for families involved with CPS. At the systems level, an “active community team” of stakeholders from across the prevention-to-treatment continuum engages in needs assessment and monitoring, facilitates multisector trainings, and advocates for policies and funding to sustain improved practices and increase systems integration. At the family level, professionals and parents work as a “family team,” meeting frequently to ensure that child and parent needs are identified and met quickly and effectively. These meetings are proactive and family-centered, empowering parents in the case planning process to create a climate of trust for information sharing and problem solving (AMCHP, 2021).

A unique role in ITCTs are a systems-building professional, the “community coordinator,” who strengthens linkages across systems so that services are better aligned and coordinated. Critical functions of this role include engaging and empowering the parents, driving a focus on holistic support for families that addresses the social determinants of health, and ensuring that services to strengthen the parent-child relationship are central in the case plan (AMCHP, 2021). ITCT sites receive implementation support from the National Resource Center for the Infant-Toddler Court Program, a program funded by the Health Resources and Services Administration’s Maternal and Child Health Bureau in the U.S. Department of Health and Human Services.

From the outset of the COVID pandemic, the Infant-Toddler Court Program worked with its network of sites to adapt to social distancing restrictions including shifting family team meetings to a HIPAA-compliant virtual context and identifying strategies to support families having access to technology. These efforts allowed ITCTs to continue to support children and their families consistently.

The current study examined parent services data collected at multiple ITCTs prior to and during the first year of the pandemic. Parents of children at ITCT sites with a case opened between April 2019 and February 2020 (pre-COVID group) were compared with families whose cases opened between April 2020 and February 2021 (COVID group). Since the impact of the pandemic varied across the country during March 2020, cases opened during this month (N = 7) were not included in the analysis. The goal of the study was to explore the impact of COVID, in the context of ITCT support, on parents’ access to services. Access to services follows the Institute of Medicine’s definition of access as “the timely use of personal health services to achieve the best possible outcome” (p.202) (Millman, 1993).

Specifically, the study examined the following research questions and hypothesis:

  1. 1.

    Were ITCT sites able to maintain access to services during the first year of COVID-19 compared to the previous year?

    We hypothesized that during the first year of COVID-19 compared to the previous year there was a decrease in access to all services that parents were referred to as part of their participation with the ITCT.

  2. 2.

    Did the time from referral to service receipt (within 14 and 30 days of referral) change during the first year of COVID-19 compared to the previous year?

    We hypothesized that during the first year of COVID-19 compared to the previous year for those families who were able to receive a service, time to service receipt improved as the Infant-Toddler Court Program provided support to ITCTs to transition to virtual platforms.

Subjects & Methods

The study received approval from WCG Institutional Review Board (WCG IRB: The Leader in IRB and IBC Review Services). ITCTs use a web-based HIPAA-compliant platform provided and maintained by the Infant-Toddler Court Program (ZERO TO THREE, 2021); community coordinators or data analysts at the site entered information about each family and each service need into the database. The dataset for April 2019 through July 27, 2021, was provided to an independent evaluation team—after all personal identifiers were excluded—for analysis of 11 ITCTs across seven states. The evaluation study was conducted following all ethical principles and approved by the Institutional Review Board. The dataset includes information on children’s and parents’ sociodemographic characteristics, reasons removed, placement status, service needs, and detailed information on monthly service access and completion.

Measures

Independent Variable

The main predictor was the family time of entry to the Infant-Toddler Court Programs. The variable has two values: entry the year before COVID-19 (between April 2019 and February 2020) and entry during the first year of COVID-19 (between April 2020 and February 2021).

Control Variables

Derived variables were produced to represent parents’ sociodemographic characteristics (age, gender, education, employment, housing), main setting during the first 6 months (setting in which the child spent most of the time: in-home if placement was with either parent, kin if the child was with a relative or fictive kin, or non-kin resource caregiver if the child was in care at a foster adopt home, therapeutic foster care, and other foster care). Child race/ethnicity is a derived variable that uses two variables: Spanish/Hispanic/Latino ethnicity (yes/no) and race (African American, Caucasian, Hawaiian/part Hawaiian, American Indian or Alaska Native, Asian). Very few parents were identified as Other, so the Hispanic and Other categories were combined for analysis.

Two derived variables were created to represent the types of alleged child maltreatment that was reported to CPS. If physical abuseFootnote 2 was included among the alleged types of maltreatment, then the physical abuse variable was coded as 1, otherwise this variable was 0. The neglectFootnote 3 variable was coded as 1 if neglect was among the alleged types of maltreatment included, otherwise the variable was 0.

Dependent Variables

As all families included in the study have a substantiated case of maltreatment (the alleged maltreatment was founded during the CPS investigation), all services represent tertiary prevention that focus on securing the safety of children after maltreatment occurs, which includes specialized services (e.g., for mental health, substance use disorders, and parenting) and ancillary services needed to reunify families after a child is removed (e.g., housing, transportation to services and family time) (Herrenkohl et al., 2016). Each service need was associated with a referral date, receipt, and completion. The following variables were derived:

Service need: The unit of analysis was a service need, not a parent or family. Each parent could have multiple instances of a need for the same service and a need for multiple services. Each need was associated with a referral date, receipt, and completion. Needs included access to services classified as health care, housing, transportation, employment, family support, parenting, mental health, substance use problems, medication assisted treatment, domestic violence, 12-step program, anger management, educational services, intensive case management, psychiatric or psychological evaluation, reunification services, or other. Every parent was included for each service that they were referred to, producing a total count of needs. The mean number of services needs per parent was 4.8.

Service receipt: This binary variable indicated if a service needed had a date for service receipt. If there was a date of receipt, service access was classified as 1, otherwise it was 0.

Time to services: Among those services identified as received, a derived variable was created using referral date and receipt date to calculate the number of days elapsed. For those services where the referral date was missing but the receipt date was present, the mean days to receipt among all parents receiving that type of service was used. Dichotomous variables were also created to indicate if the service was received within 30 or fewer days, and, to align with recent legislation in some states to improve faster access to services during COVID, a second variable was created to represent receipt within 14 or fewer days from referral.

The ITCP database does not collect information about parents’ insurance status; however, as all participants had an active child welfare dependency case, the CPS must provide services mandated in the case plan to all parents regardless of insurance status.

Parents

The study group included 187 parents: 72 with cases opened before COVID and 115 with cases opened during COVID. Most parents were between 20 and 29 years of age (57%), 35% were 30 years or older, and less than 10% were 19 years or younger. Over half of parents were female (59%). About a third of parents owned or rented their house (34%), while the rest were living in different household arrangements with relatives, friends, or did not have a place. Over half of parents had mental health needs (56%) and 74% of parents had substance use problems. During the first 6 months of participation in the ITCT, the main setting for 20% of children was in-home with parents, 38% with kin, and 42% with non-kin foster caregivers. Among the reasons for removal or CPS involvement (Child Welfare Information Gateway, 2019), close to 63% of children had neglect among the reasons, while 12% had physical abuse.

Three significant differences were found among sociodemographic factors between the pre- and during COVID groups. During COVID, the percentage of Hispanic/Other parents increased (from 5 to 25%), Black parents decreased (from 40 to 20%), and white parents remained similar (55–54%; overall race/ethnicity p < .001). During COVID, the percentage of parents employed decreased (from 39 to 25%, p < .05) and parents with less than a high school education increased (from 72 to 90%; p < .01).

Analysis

All analyses were completed using SAS statistical software (SAS, 2013). Descriptive statistics were used to characterize service use by parent, setting, and child welfare characteristics. Cross-tabulations and significance tests were conducted (Pearson χ2 tests for categorical variables, t-test for continuous variables) to test for differences by case opened period. Logistic regression models were used to test for differences pre- and during COVID, controlling for the following covariates: parent gender, age, race/ethnicity, education, employment, housing, main type of setting during the first 6 months, physical abuse, and neglect, substance use problems, and mental health problems. Models included interaction terms between the group variable (pre- or during COVID) and control variables.

Results

Parent Access to Services

Overall, 897 instances of services needs were analyzed, 411 pre-COVID and 486 during COVID. Of these 897 needs, 659 (76%) received services. Using logistic regression for all 897 parent service needs, service receipt was reduced during COVID (OR = 0.2, CI: 0.1–0.3, p < .0001). Across service needs overall, independently of COVID group (see Table 1), females were more likely to receive services than males (OR = 2.2, CI: 1.5–3.3, p < .001), parents aged 20 to 29 were less likely to receive services than parents 30 years or older (OR = 0.7, CI: 0.5-1.0, p < .05), and parents with substance use problems were less likely to receive services than parents without substance use problems (OR = 0.5, CI: 0.3–0.9, p < .05). Parents with a child where the reason for removal or involvement with CPS included physical abuse were more likely than parents without that reason to receive a needed service (OR = 1.9, CI: 1.1-3.0, p < .05) and this result was similar for parents of children that were identified as neglected compared to other reasons (OR = 2.5, CI: 1.8–3.6, p < .0001). Parents of a child placed with kin (OR = 0.4, CI: 0.2–0.6, p < .001) and non-kin foster (OR = 0.2, CI: 0.1–0.4, p < .0001) compared with parents with a child who remained in-home during the first 6 months were less likely to receive services.

Table 1 Parent access to services among families with a case opened during COVID compared to families with a case opened before COVID
Full size table

Significant interactions were identified between parents receiving services pre-COVID and during COVID by parent age, type of placement, and physical abuse. During COVID there was a small reduction in receipt of services compared to pre-COVID among parents less than 20 years of age (p < .001) and among parents 20 to 29 years of age (p < .001) compared to parents 30 years of age or older. During COVID a larger reduction in receipt of services was found when compared to pre-COVID among parents of a child placed with kin (p < .01) compared to parents of a child who remained in-home, and among parents who had a child for whom the reason for removal or involvement with CPS included physical abuse compared to parents without that reason (p < .01).

Receipt of Services Within 30 and 14 Days of Referral

For time between referral and receipt, the 659 needs that were received were analyzed, 359 pre-COVID and 300 during COVID. Of these needs, 409 (62%) were met within 30 days and 289 (44%) were met within 14 days. The mean time to receipt was 55 days pre-COVID and 43 days during COVID.

Across 659 needs that were received, there were no differences pre- and during COVID on receipt in 30 or fewer days and 14 or fewer days from referral (Table 2). Across services overall, independently of COVID group, Hispanic/Other parents were more likely to receive a service within 30 or fewer days (OR = 3.6, CI: 1.9–6.7, p < .0001) and within 14 or fewer days from referral (OR = 3.4, CI: 2.0-5.8, p < .0001) compared to white parents. Parents with more than a high school education compared to parents with less education were more likely to receive services within 30 or fewer days (OR = 2.3, CI: 1.4–3.8, p < .001) and within 14 or fewer days from referral (OR = 1.8, CI: 1.1–2.8, p < .05). Parents that owned or rented a house were less likely to receive services within 14 or fewer days from referral than parents without housing (OR = 0.6, CI: 0.4–0.9, p < .01). Parents of both children placed with kin and non-kin foster (OR = 0.6, CI: 0.4–0.9, p < .05) were less likely to receive services within 30 days compared with parents that had their children in-home during the first 6 months. Parents that had a child that reason for removal or involvement with CPS included physical abuse were more likely than parents without that reason to receive services within 30 or fewer days (OR = 3.4, CI: 1.9–5.9, p < .0001) and within 14 or fewer days from referral (OR = 1.8, CI: 1.1–2.9, p < .05). Parents with a child for whom the reason for removal or involvement with CPS included neglect were more likely than parents without that reason to receive services within 30 or fewer days (OR = 1.7, CI: 1.2–2.5, p < .01) and within 14 or fewer days from referral (OR = 1.6, CI: 1.1–2.4, p < .05). Significant interactions were found between parents accessing services within 14 or fewer days pre-COVID and during COVID by parents having housing. Parents that owned or rented a house were less likely to access services within 14 or less days than parents without housing during COVID compared to pre COVID (p < .01).

Table 2 Parent service access and receipt within 30 or fewer days of referral among families with a case opened during COVID compared to families with a case opened before COVID
Full size table

None of the logistic regression modeling of specific services, including models for mental health, substance use problems, and parenting services had an overall Wald Test that was statistically significant, indicating that the predictor variables were not explaining access nor receipt within 30 days or less and 14 days or less from referral. Bivariate analysis by type of service showed that for three services there were differences before and during COVID. During COVID, access to mental health service (90–58%; p < .001), parenting services (95–70%; p < .01), and SUD services (82–63%; p < .05) decreased. But, among parents that accessed a service during COVID, receipt in 30 days or less for mental health (33–67%; p < .01) and SUD services (39–76%; p < .01) improved. For receipt within 14 days or less, only SUD services improved during COVID (32–57%; p < .05).

Discussion

The devastation caused by the COVID-19 pandemic among service providers across communities due to layoffs, furloughs, community-based behavioral and mental health providers closing temporarily or permanently, and shortage of providers due to physical and emotional fatigue, had a large impact on access to services compared to the previous year (Aragona et al., 2020; Auerbach & Miller, 2020; Mark et al., 2021; Pagano et al., 2021; Radfar et al., 2021; Tucker et al., 2020). At the same time, during COVID, mental health and SUD needs increased severely across the general population (Ahmad et al., 2021; Czeisler et al., 2020; Mochari-Greenberger & Pande, 2021; Taylor et al., 2021). Nevertheless, this study found that parents participating in an ITCT were able to maintain similar levels of receipt within 30 days and within 14 days as before COVID. Moreover, bivariate comparisons showed that among parents that accessed services, a higher percentage of parents in need received mental health services in 30 or fewer days and SUD services in both 14 and 30 or fewer days during COVID compared to pre-COVID. This success is notable given the significant disruption to the availability of services and barriers to accessing services caused by the pandemic.

A key factor in ITCTs’ success in supporting parent and child access to services was the ability to transition rapidly from in-person to virtual hearings, family team meetings, and services. Another major driver was the strong existing networks of community partnerships at ITCT sites, which resulted in expedient access to smart devices and the internet for families and caregivers. The result was a buffering of the impact of COVID on parents’ access to services, such that parents participating in an ITCT received services within a similar time frame than before the pandemic despite the loss of service providers across communities.

Future studies are needed to demonstrate that the innovations developed during COVID to better support parents’ services needs and access show benefits as regular practice (e.g., telehealth) (Columb et al., 2020) and what changes in legislation, regulation, financing, accountability, and workforce development are needed to strengthen systems going forward (Goldman et al., 2020; Moreno et al., 2020; Pagano et al., 2021; Pfefferbaum & North, 2020). As summarized by a community coordinator when asked about responses developed during COVID:

One of the conversations we need to be having is what this looks like for the future. And if this is something that can continue, if they can continue to do therapy virtually, if transportation is challenging or if they can continue to do their substance [use disorders’ treatment] groups virtually, so that we are taking away some of those barriers for our families, not creating more hurdles than what are necessary for them to reunify with their children. If it works for a year or more, why can’t it work after this pandemic?

Conclusion

The scope of public child welfare interest is shifting toward a public health approach, moving away from a narrow focus on the physical safety of children to strengthening families, preventing children from being removed from their families, and a broader concern for the health and well-being of children and their families. Efforts to ensure receipt of appropriate services and supports that sufficiently build protective factors are identified and addressed as part of the shift from a focus on safety to one on family well-being and prevention. Timely services and supports that address the social determinants of health can prevent negative long-term physical, psychological, and behavioral outcomes for the entire family and strengthen families to prevent maltreatment recurrence, including with siblings or subsequent children. As this exploratory study demonstrated, the Infant-Toddler Court Program provided a robust platform for supporting the health and well-being of families with very young children even in the face of a severely reduced service landscape due to the COVID-19 pandemic (AMCHP, 2021; HRSA, 2022).