Strategies and Adaptations to an Integrated Substance Use and Infant Mental Health Treatment Program During COVID-19.

The COVID-19 pandemic resulted in increased parenting stress and substance use. At the same time that mental health and social service needs increased, access to services, including among those receiving treatment, decreased due to stay-at-home orders. Few programs were equipped or prepared to translate their interventions to a virtual format at the start of the pandemic. There is a critical need to identify effective adaptations to substance use and family-focused treatment during the COVID-19 pandemic. Effective program adaptations have continued relevance for the expansion of access to family-focused addiction services beyond the pandemic itself, particularly for rural or other hard to reach populations. Seventy-three semi-structured interviews were conducted with the five agencies participating in the implementation of the In-Home Recovery Program (IHRP), an in-home, substance use disorder (SUD) treatment program. Using a rapid analysis approach two coders analyzed interviews for recurring concepts and themes. Facilitators for adapting services included: (1) the introduction of virtual toxicology screens, (2) helping parents access technology, (3) assisting parents with non-identified children to decrease their stress, and (4) anticipating reoccurrences of substances during the pandemic. Barriers to adapting services included: (1) engaging young children in virtual treatment, (2) privacy, and (3) engaging in telehealth with parents experiencing domestic violence or reoccurrence of substances. Findings reveal virtual substance use treatment is possible. Facilitators to adaptation such as providing access to technology and virtual toxicology screens demonstrate the feasibility and acceptability of utilizing telehealth interventions for substance use. Barriers to adaptations were primarily related to the infant mental health component. Telehealth is likely not appropriate for children below the age of five. Individual sessions focusing on caregiving, rather than dyadic treatment may be more suitable to virtual formats.

A Relational Workforce Capacity Approach to Trauma-Informed Care Implementation: Staff Rejection Sensitivity as a Potential Barrier to Organizational Attachment.

This study explores the relationship between staff rejection sensitivity (a psychological concept grounded in histories of loss and trauma) and organizational attachment among mental health agencies transitioning to Trauma-Informed Care (TIC), which is currently outside the focus of most research. Specifically, this study examines: (1) whether staff rejection sensitivity predicts organizational attachment; (2) whether staff turnover intentions account for the association between rejection sensitivity and organizational attachment; and (3) whether those associations hold once taking into account staff demographic factors (gender, race and ethnicity, education, and income)? Around 180 frontline workers in three Northeastern U.S. mental health agencies responded to surveys collected between 2016 and 2019 using the organizational attachment, rejection sensitivity and turnover intention measures, and their previous TIC training experience. Rejection sensitivity was significantly associated with organizational attachment (ß = -0.39, p < 0.001), accounting for 6% of its variance in organizational attachment. The relationship between these variables retained significance, and staff education significantly predicted organizational attachment, with higher education predicting lower levels of organizational attachment (ß = -0.15, p < 0.05), accounting for 22% of its variance. This study concludes that TIC transitioning mental health agencies' staff with a higher rejection sensitivity are more likely to express lower organizational attachment and higher intent-to-turnover.

Expanding the Trauma-Informed Care Measurement Toolkit: An Evaluation of the Attitudes Related to Trauma-Informed Care (ARTIC-45) Scale with SUD Workers in PIMH.

Human service organizations (HSO) have increasingly recognized the value of employing trauma-informed care (TIC) in a variety of practice settings. Evidence suggests that effectively adopting TIC has shown client improvements. Organizational barriers to TIC implementation, however, exist. To improve TIC practice, the attitudes related to trauma-informed care (ARTIC) scale was developed to measure staff attitudes and beliefs towards TIC. The ARTIC has been widely adopted by researchers without evaluating its psychometric performance in diverse practice settings. The purpose of this study was to independently validate the ARTIC scale drawn from a sample of staff (n = 373) who provide services to substance-using parents. Psychometric tests were conducted to evaluate how the ARTIC performs with our HSO population. Results from a confirmatory factor analysis showed poor fit (X2 = 2761.62, df = 2.96; RMSEA = 0.07 [0.07, 0.08]; CFI = 0.72). An exploratory factor analysis was conducted to analyze how the data fit with our specific population, yielding 10 factors. Finally, a qualitative inter-item analysis of these factors was conducted, resulting in nine factors. Our findings suggest that measuring TIC attitudes and beliefs may vary according to field of practice and ethno-racially diverse workers. Further refinement of the ARTIC may be necessary for various services domains.

Creating a parallel process: A new methodological framework for conducting Trauma-Informed Evaluation and Research (TIER) in mental health settings.

New understandings of the pervasiveness of adverse childhood experiences and their attendant negative impact over the life course has led to a focus on the provision of Trauma-Informed Care (TIC) in mental health treatment. The Substance Abuse and Mental Health Services Administration operationalizes TIC through six key principles: 1) safety, 2) transparency and trustworthiness, 3) peer support, 4) collaboration, 5) empowerment and, 6) sensitivity to cultural, gender, and historical issues (SAMSHA, 2014). However, there has been little attention paid to how these principles should be operationalized in the context of evaluation. This methodological article first identifies the need for evaluation of TIC programs to mirror the core principles of TIC and then offers specific strategies for conducting research and evaluation in accordance with them. The goal of this work is to define a set of principles for research and evaluation that utilizes the process to reinforce key tenets of TIC and enhance trauma treatment.

An Ecological Model for High-Risk Professional Decision-Making in Mental Health: International Perspectives.

Mental health professionals are frequently presented with situations in which they must assess the risk that a client will cause harm to themselves or others. Troublingly, however, predictions of risk are remarkably inaccurate even when made by those who are highly skilled and highly trained. Consequently, many jurisdictions have moved to impose standardized decision-making tools aimed at improving outcomes. Using a decision-making ecology framework, this conceptual paper presents research on professional decision-making in situations of risk, using qualitative, survey, and experimental designs conducted in three countries. Results reveal that while risk assessment tools focus on client factors that contribute to the risk of harm to self or others, the nature of professional decision-making is far more complex. That is, the manner in which professionals interpret and describe features of the client and their situation, is influenced by the worker's own personal and professional experiences, and the organizational and societal context in which they are located. Although part of the rationale of standardized approaches is to reduce complexity, our collective work demonstrates that the power of personal and social processes to shape decision-making often overwhelm the intention to simplify and standardize. Implications for policy and practice are discussed.

All in the family: parental substance misuse, harsh parenting, and youth substance misuse among juvenile justice-involved youth.

PURPOSE: Research consistently connects parental and youth substance misuse, yet less is known about the mechanisms driving this association among justice-involved youth. We examine whether harsh parenting is an explanatory mechanism for the association between parental substance use and parental mental health and youth substance use disorder in a sample of justice-involved youth. METHODS: Data were drawn from the Northwestern Juvenile Project, a large-scale longitudinal survey of mental health and substance misuse in a representative sample of youth in juvenile detention. Harsh parenting, child maltreatment, youth alcohol and cannabis use disorder, and parental substance misuse and mental health were assessed among 1,825 detained youth (35.95% female) at baseline, three-year follow-up, and four-year follow-up. RESULTS: At baseline, over 80% of youth used alcohol and/or cannabis; at the four-year follow-up, 16.35% and 19.69% of the youth were diagnosed with alcohol and cannabis use disorder, respectively. More than 20% of youth reported their parent misused substances and 6.11% reported a parent had a severe mental health need. Black youth experienced significantly fewer types of harsh parenting compared to White youth. Multivariate path analyses revealed harsh parenting mediated the association between parental substance misuse and mental health on youth alcohol and cannabis use disorder. Harsh parenting that does not rise to the level of child maltreatment mediated the association between parental substance misuse and mental health on youth alcohol use disorder; in contrast, child maltreatment did not mediate these associations. Multigroup analyses revealed the effect of harsh parenting on youth alcohol and cannabis use disorder did not vary across sex or race-ethnic subgroups. CONCLUSIONS: Harsh parenting represents one mechanism for the intergenerational continuity of alcohol and cannabis misuse and should be regularly assessed for and addressed in juvenile justice settings.

That Which is Essential has been Made Invisible: The Need to Bring a Structural Risk Perspective to Reduce Racial Disproportionality in Child Welfare.

The racial and ethnic disproportionality and disparity in the child protective system (CPS) has been a concern for decades. Structural factors strongly influence engagement with the child welfare system and families experiencing poverty or financial hardship are at a heightened risk. The economic factors influencing child welfare involvement are further complicated by structural racism which has resulted in a greater prevalence of poverty and financial hardship for families who are Black, Native American or Alaska Native (Indigenous), or and Latino/Hispanic (Latino) and their communities. The multiple decision points within CPS are an opportunity to reify or correct for bias in child welfare outcomes. One major effort to eliminate racial disparities and disproportionalities has been to enact standardized decision-making procedures that aim to control for implicit or explicit bias in CPS. The Structured Decision-Making Model's (SDM) actuarial-based risk assessment (RA) is the gold-standard of these efforts. In this conceptual article, we ask (1) How are structural factors accounted for in assessment of risk within CPS? and (2) What are the consequences when structural factors are left out of risk assessments procedures? We posit that the exclusion of race, ethnicity, and economic factors from the RA has inflated the importance of variables that become proxies for these factors, resulting in inaccurate assessments of risk. The construction of this tool reflects how structural racism has been overlooked as an important cause of disproportionality in CPS, with interventions then focused on individual workers and cases, rather than the system at large. We suggest a new framework for thinking about risk, the structural risk perspective, and call for a revisioning of assessment of risk within child welfare that acknowledges the social determinants of CPS involvement.

The decision sampling framework: a methodological approach to investigate evidence use in policy and programmatic innovation.

BACKGROUND: Calls have been made for greater application of the decision sciences to investigate and improve use of research evidence in mental health policy and practice. This article proposes a novel method, "decision sampling," to improve the study of decision-making and research evidence use in policy and programmatic innovation. An illustrative case study applies the decision sampling framework to investigate the decisions made by mid-level administrators when developing system-wide interventions to identify and treat the trauma of children entering foster care. METHODS: Decision sampling grounds qualitative inquiry in decision analysis to elicit information about the decision-making process. Our case study engaged mid-level managers in public sector agencies (n = 32) from 12 states, anchoring responses on a recent index decision regarding universal trauma screening for children entering foster care. Qualitative semi-structured interviews inquired on questions aligned with key components of decision analysis, systematically collecting information on the index decisions, choices considered, information synthesized, expertise accessed, and ultimately the values expressed when selecting among available alternatives. RESULTS: Findings resulted in identification of a case-specific decision set, gaps in available evidence across the decision set, and an understanding of the values that guided decision-making. Specifically, respondents described 14 inter-related decision points summarized in five domains for adoption of universal trauma screening protocols, including (1) reach of the screening protocol, (2) content of the screening tool, (3) threshold for referral, (4) resources for screening startup and sustainment, and (5) system capacity to respond to identified needs. Respondents engaged a continuum of information that ranged from anecdote to research evidence, synthesizing multiple types of knowledge with their expertise. Policy, clinical, and delivery system experts were consulted to help address gaps in available information, prioritize specific information, and assess "fit to context." The role of values was revealed as participants evaluated potential trade-offs and selected among policy alternatives. CONCLUSIONS: The decision sampling framework is a novel methodological approach to investigate the decision-making process and ultimately aims to inform the development of future dissemination and implementation strategies by identifying the evidence gaps and values expressed by the decision-makers, themselves.

Negotiating child protection mandates in Housing First for families.

BACKGROUND: Housing First (HF) is an evidence-based service model that combines permanent housing and supportive case management premised on harm reduction and consumer self-determination to end homelessness for high-need individuals. Originally developed for use with single adults, this model is now being employed with families. Yet there is little empirical work on how HF is implemented with this particular population. OBJECTIVE: The aim of this study is to examine how frontline providers adapt and apply HF to formerly homeless or at-risk, families involved in child welfare. PARTICIPANTS AND SETTING: Frontline providers working in family HF programs (N = 59) were recruited from two states, across 11 organizations, and 16 program sites. The theoretical sample (n = 26) includes 13 participants working in programs that encouraged direct collaboration with Child Protective Services (CPS) in the program model and 13 participants from three non-CPS-aligned sites in a second state. METHODS: A grounded theory approach was used to analyze semi-structured, qualitative interviews. RESULTS: Frontline providers exercised street-level bureaucratic discretion when interpreting child protection reporting mandates and they found ways to adapt the HF model to this population. In doing so, they worked to juggle both their mandates to child protection and to principles of HF to create a "child safety-modified" form of HF. CONCLUSIONS: While our study shows that providers are modifying HF to address the needs of families involved in child welfare, it also raises questions as to the degree to which HF can be done with high fidelity when used with this population.

Contradictions and Their Consequences: How Competing Policy Mandates Facilitate Use of a Punitive Framework in Domestic Violence-Child Maltreatment Cases.

Research shows child welfare cases involving caregiver domestic violence (DV) continue to produce punitive consequences for non-abusive adult victims. This occurs despite the adoption of a supportive policy framework that emphasizes perpetrator responsibility for DV-related harm to children. Risk assessment procedures have been implicated in punitive outcomes, but we know little about how they shape child welfare workers' decision-making practice. Focusing on a state with a supportive policy framework, this paper uses grounded theory to examine how policy contradictions, procedural directives around risk assessment, and informal interventions produce punitive consequences for adult victims of DV and unmitigated risk to children. Data include state policy and procedural documents and interviews with child welfare workers describing decision-making in their most recent completed case and most recent case involving DV. Findings point to the need for active alignment of policies and procedures, greater integration of knowledge across practice areas, renewed commitments to differential response, and greater inclusion of DV specialists in child welfare settings.

Frontline Staff Characteristics and Capacity for Trauma-Informed Care: Implications for the Child Welfare Workforce.

BACKGROUND: Improved understanding of the lasting ways trauma can impact self-regulatory and relational capacities have increased calls for Trauma-Informed Care (TIC) for child welfare-involved families. Little is known, however, about how the attitudes and characteristics of frontline workers impact the implementation of TIC and job retention. This work fills an important gap in knowledge regarding the relationship between staff relational capacities, the implementation of TIC and staff retention. OBJECTIVE: To understand the relationship between staff characteristics, endorsement of TIC and intent to turnover. PARTICIPANTS AND SETTING: Three child and family serving agencies surveyed 271 staff from a populous Northeastern state. METHODS: Regression analyses were used to examine the relationship between staff characteristics, Attitudes Related to Trauma Informed Care (ARTIC) score, and intent to turnover. RESULTS: Higher levels of staff rejection sensitivity was associated with lower endorsement of Principles of Trauma-Informed Care (p < .05). Lower staff alignment with principles of TIC was associated with higher levels of intention to turnover and leave their organization (p < .05). CONCLUSION: Staff histories of relational loss and trauma may impact both workforce buy-in and readiness to implement TIC. Therefore, identifying staff sensitivity to rejection in the hiring process or after hire, and providing specific supports, such as reflective supervision, may enhance both service delivery and staff experiences' of their work. Additionally, using the ARTIC scale in the hiring process may also reduce staff turnover and burnout. Attending to staff relational characteristics is a critical component of promoting worker resilience.

Innovations in Child Welfare Interventions for Caregivers with Substance Use Disorders and Their Children.

Families who enter the Child Welfare System (CWS) as a result of a caregiver's substance use fare worse at every stage from investigation to removal to reunification (Marsh et. al 2007). Intervening with caregivers with Substance Use Disorders (SUDs) and their children poses unique challenges related to the structure and focus of the current CWS. Research demonstrates that caregivers with SUDs are at a greater risk for maladaptive parenting practices, including patterns of insecure attachment and difficulties with attunement and responsiveness (Suchman, 2006). Caregivers with SUDs have also often experienced early adversity and trauma. However, traditional addiction services generally offer limited opportunities to focus on parenting or trauma, and traditional parenting programs rarely address the special needs of parents with SUDs. This article details four innovative interventions that integrate trauma-informed addiction treatments with parenting for families involved in the child welfare system. Common mechanisms for change across programs are identified as critical components for intervention. This work suggests the need for a paradigm shift in how cases involving caregivers with substance use disorders are approached in the child welfare system.

Revenue, relationships and routines: the social organization of acute myocardial infarction patient transfers in the United States.

Heart attack, or acute myocardial infarction (AMI), is a leading cause of death in the United States (U.S.). The most effective therapy for AMI is rapid revascularization: the mechanical opening of the clogged artery in the heart. Forty-four percent of patients with AMI who are admitted to a non-revascularization hospital in the U.S. are transferred to a hospital with that capacity. Yet, we know little about the process by which community hospitals complete these transfers, and why publicly available hospital quality data plays a small role in community hospitals' choice of transfer destinations. Therefore, we investigated how community hospital staff implement patient transfers and select destinations. We conducted a mixed methods study involving: interviews with staff at three community hospitals (n = 25) in a Midwestern state and analysis of U.S. national Medicare records for 1996-2006. Community hospitals in the U.S., including our field sites, typically had longstanding relationships with one key receiving hospital. Community hospitals addressed the need for rapid AMI patient transfers by routinizing the collective, interhospital work process. Routinization reduced staff uncertainty, coordinated their efforts and conserved their cognitive resources for patient care. While destination selection was nominally a physician role, the decision was routinized, such that staff immediately contacted a "usual" transfer destination upon AMI diagnosis. Transfer destination selection was primarily driven at an institutional level by organizational concerns and bed supply, rather than physician choice or patient preference. Transfer routinization emerged as a form of social order that invoked tradeoffs between process speed and efficiency and patient-centered, quality-driven decision making. We consider the implications of routinization and institutional imperatives for health policy, quality improvement and health informatics interventions.

Implementation challenges in the intensive care unit: the why, who, and how of daily interruption of sedation.

PURPOSE: Despite strong medical evidence and policy initiatives supporting the use of daily interruption of sedation in mechanically ventilated patients, compliance remains suboptimal. We sought to identify new barriers to daily interruption of sedation. MATERIALS AND METHODS: We conducted 5 focus groups of intensive care unit physicians, nurses, and respiratory therapists during a 2-month period to identify attitudes, barriers, and motivations to perform a daily interruption of sedation. Each focus group was audiotaped, and the transcripts were analyzed using qualitative methods to identify recurrent themes. RESULTS: There was wide consensus on the importance of daily interruptions of sedation; however, practitioners usually performed sedation interruption for 1 of 5 distinct reasons: minimizing the dose of sedation, performing a neurologic examination, facilitating ventilator weaning, reducing intensive care unit length of stay, and assessing patient pain. Participants rarely espoused more than 1 main reason, and there was no shared understanding of why one might do a daily interruption of sedation. This lack of shared understanding led to different patients being selected and diverse approaches to carrying out the DIS. CONCLUSIONS: Despite apparent consensus, lack of shared understanding of the rationale for an intervention may lead to divergent practice patterns and failure to implement standardized, evidence-based practice.

Which patients and where: a qualitative study of patient transfers from community hospitals.

BACKGROUND: Interhospital transfer of patients is a routine part of the care at community hospitals, but the current process may lead to suboptimal patient outcomes. A microlevel analysis of the processes of patient transfer has not earlier been carried out. RESEARCH DESIGN: We conducted semistructured qualitative interviews with care providers at 3 purposively sampled community hospitals to describe patient transfer mechanisms, focusing on perceptions of transfers and transfer candidates, choice of transfer destination, and perceived process. We interviewed physicians, nurses, and care technicians from emergency departments and intensive care units at the hospitals, and analyzed the resultant transcripts by content analysis. RESULTS: Appropriate triage and the transfer of patients was a highly valued skill at the community hospitals. On the basis of participant accounts, the transfer process had 4 components: (1) Identifying transfer-eligible patients; (2) Identifying a destination hospital; (3) Negotiating the transfer; and (4) Accomplishing the transfer. There were common challenges at each component across hospitals. Protocolization of care was perceived to substantially facilitate transfers. Informal arrangements played a key role in the identification of the receiving hospital, but patient preferences and hospital quality were not discussed as important in decision making. The process of arranging a patient transfer placed a significant burden on the staff of community hospitals. CONCLUSIONS: The patient transfer process is often cumbersome, varies by condition, and may not be focused on optimizing patient outcomes. Development of a more fluid transfer infrastructure may aid in implementing policies such as selective referral and regionalization.