Implementing a Child Mental Health Intervention in Child Welfare Services: Stakeholder Perspectives on Feasibility.

This pilot study integrated quantitative and qualitative data to examine the feasibility of implementing a modified version of a multiple family group behavioral parent training intervention (The 4Rs and 2Ss for Strengthening Families Program [4Rs and 2Ss]) in child welfare (CW) placement prevention services, from the perspectives of participating caregivers (n = 12) and CW staff (n = 12; i.e., 6 caseworkers, 4 supervisors, and 2 administrators). Quantitative surveys were administered to caregivers and CW staff followed by semi-structured interviews to examine the feasibility of implementing the modified 4Rs and 2Ss program, as well as factors impacting feasibility. Results indicated that quantitative benchmarks for high feasibility were met in all assessed areas (e.g., family recruitment, caseworker fidelity ratings, CW staff feasibility ratings) except for family attendance, which was markedly lower than desired. Factors facilitating feasibility included agency and research support, intervention ease-of-use, perceived benefits to existing CW practice, as well as logistical support (e.g., food, transportation, childcare) promoting attendance. Factors hindering feasibility included conflicts between research-based eligibility criteria and existing client population demographics, research-related processes resulting in delays, CW staff role conflicts, added workload burden, complex family issues, and power differentials inherent to CW services which complicated families' voluntary participation.

An Examination of the 4 Rs 2 Ss for Problem Behaviors: A Preventive Approach.

Early treatment of behavioral problems can prevent their progression into intractable disorders. This study examined the impact of a multiple family group (MFG) intervention for children with behavior symptoms and their families. Fifty-four (n = 54) caregiver/child dyads with sub-clinical levels of oppositional defiant disorder (ODD) participated in a 16-week MFG. Child, caregiver, and family outcomes were assessed at baseline, post-treatment, and at 6 months follow-up. Significant decreases in impairment with parents, family members, and peers, and improvements in child self-esteem were found from baseline to follow-up. Caregiver stress increased; no significant changes in depression or perceived social support were found over time. The effectiveness of MFG as a preventive approach and areas of future research are discussed.

Partnering for Success: Factors Impacting Implementation of a Cross-Systems Collaborative model Between Behavioral Health and Child Welfare.

Cross-system implementation efforts can support needed mental health (MH) service utilization among children involved in the child welfare (CW) system. The Partnering for Success (PfS) initiative is one such effort that promotes greater collaboration between the CW and MH providers by building capacity within and across each system. Frontline CW providers learn to accurately identify child MH treatment targets, link families to locally-provided evidence-based treatments (EBTs), and monitor treatment progress. Concurrently, local MH providers are trained along with CW workers to utilize Cognitive Behavioral Therapy plus Trauma-Focused CBT (CBT +), a common elements training and consultation approach focusing on typical MH issues for CW-involved children: Anxiety, Depression, Behavioral Problems, and Traumatic Stress. Finally, agency leadership receive support around promoting implementation and sustainment. This paper examines factors identified by participating CW and MH staff which impacted PfS implementation. Twenty-nine frontline, supervisory, and executive CW and MH providers were interviewed via audio-recorded web-based calls in six focus groups and 10 individual interviews. Factors facilitating implementation success included training/consultation, support from supervisors and agency leadership, improved referral processes, high quality relationships and communication between CW and MH frontline staff, PfS tools and resources, opportunities to use PfS, as well as buy-in from providers and families. Implementation barriers included poor communication between CW and MH providers, conflicts over role expectations, workload and turnover challenges, lack of buy-in, as well as provider (e.g., not aligned with CBT +) and client characteristics (e.g., frequent crises).

Skills for Developing and Maintaining Community-Partnerships for Dissemination and Implementation Research in Children's Behavioral Health: Implications for Research Infrastructure and Training of Early Career Investigators.

By engaging with community partners, dissemination and implementation scholars can enhance research relevance and translation. We illustrate the skills needed for developing and maintaining community partnerships by presenting two case studies of partnerships between early-career investigators and child welfare systems to implement mental health interventions. The cases represent two models of partnership (investigator-led and agency-led), highlighting the value and difficulty of conducting community-engaged implementation research. The experiences described feature strategies for building and managing relationships, navigating rules and regulations, adaptation, and securing resources. We offer suggestions for improving training and research infrastructures to support community-engaged implementation scholars.

Perceptions Among Child Welfare Staff when Modifying A Child Mental Health Intervention to be Implemented in Child Welfare Services.

In order to increase access to child mental health evidence-based interventions (EBIs) for vulnerable and hard-to-engage families involved in the child welfare (CW) system, innovative approaches coupled with input from service providers are needed. One potential solution involves utilizing task-shifting strategies and implementation science theoretical frameworks to implement such EBIs in CW settings. This study examined perceptions among CW staff who were members of a collaborative advisory board involved in the implementation of the 4Rs and 2Ss Strengthening Families Program (4R2S) in CW placement prevention settings, utilizing task-shifting strategies and the Practical, Robust, Implementation, and Sustainability Model. Advisory board members reported difficulties in engaging families, heavy workloads, and conflicting implementation initiatives. While 4R2S was perceived as generally aligned with their organization's mission, modifications to the intervention and to agency procedures were recommended to promote implementation success. Suggested modifications to the existing 4R2S training and supervision are discussed. Findings underscore the importance of understanding the experiences of CW service providers, which can inform future efforts to implement child mental health EBIs in CW services.

Multiple family group service delivery model for children with disruptive behavior disorders: Impact on caregiver stress and depressive symptoms.

Disproportionately high rates of caregiver stress and depression are found among poverty-impacted communities, with high levels of caregiver stress and depression putting youth at heightened risk for the onset and perpetuation of disruptive behavior disorders. The purpose of this study was to examine the effects of a behavioral parent training program called the 4Rs and 2Ss for Strengthening Families Program (4R2S) on caregiver stress and depressive symptoms among 320 youth aged seven to 11 and their families assigned to either the 4R2S or services as usual (SAU) condition. Among caregivers with clinically significant scores at baseline, 4R2S participants manifested significantly reduced scores on the stress and depressive symptom scores to SAU participants at 6-month follow-up. Findings suggest that 4R2S may reduce caregiver stress and depressive symptoms among those caregivers initially manifesting clinically significant levels of stress or depressive symptoms.

Utilization of peers in services for youth with emotional and behavioral challenges: A scoping review.

This scoping review synthesizes published and unpublished information on Youth Peer Support Services (YPSS), where young adults with current or prior mental health challenges provide support services to other youth and young adults currently struggling with similar difficulties. Existing published and unpublished "grey" literature were reviewed, yielding 30 programs included for data extraction and qualitative syntheses using a descriptive analytic framework. Findings identify variations in service delivery structures, program goals, host service systems, peer roles, core competencies, training and supervision needs, outcomes for youth and young adult consumers, as well as organizational readiness needs to integrate YPSS. Recommendations for future research, practice, and policy include more studies evaluating the unique impact of YPSS using rigorous methodological study designs, identifying developmentally appropriate training/supervision strategies and overall service costs and financing options, as well as distinguishing YPSS from other peer models with regard to certification and billing.

Validation of the Parenting Stress Index-Short Form With Minority Caregivers.

OBJECTIVES: There has been little examination of the structural validity of the Parenting Stress Index-Short Form (PSI-SF) for minority populations in clinical contexts in the Unites States. This study aimed to test prespecified factor structures (one-factor, two-factor, and three-factor models) of the PSI-SF. METHODS: This study used confirmatory factor analysis in a sample of 240 predominantly Black and Latino caregivers of children with behavioral difficulties. RESULTS: The three-factor model fit was reasonable, and the criterion validity for the subscale and total scores was good supporting continued cautious use of the PSI-SF for clinical minority populations. CONCLUSIONS: The PSI-SF could be integrated as part of screening and intake assessment procedures, which could allow social work practitioners to make more informed decisions about treatment planning, as well as facilitate conversations with caregivers around identifying sources of stress and developing healthy coping strategies.

Multiple Family Group Service Model for Children With Disruptive Behavior Disorders: Child Outcomes at Post-Treatment.

The purpose of this study was to determine the benefits of a multiple family group (MFG) service delivery model compared with services as usual (SAU) in improving the functioning of youth with oppositional defiant/conduct disorder in families residing in socioeconomically disadvantaged communities. Participants included 320 youth aged 7 to 11 and their families who were referred to participating outpatient clinics. Participants were assigned to the MFG or the SAU condition, with parent report of child oppositional behavior, social competence, and level of youth impairment as primary outcomes at post-treatment. Family engagement to MFG was measured by attendance to each group session. Caregivers of youth in the MFG service delivery model condition reported significant improvement in youth oppositional behavior and social competence compared with youth in the SAU condition. Impairment improved over time for both groups with no difference between treatment conditions. The MFG led to greater percentage of youth with clinically significant improvements in oppositional behavior. Attendance to the MFG was high, given the high-risk nature of the study population. The MFG service delivery model offers an efficient and engaging format to implement evidence-based approaches to improving functioning of youth with oppositional defiant and/or conduct disorder in families from socioeconomically disadvantaged communities.

Multiple Family Groups for Child Behavior Difficulties Retention Among Child Welfare-Involved Caregivers.

Among children who remain at home with their permanent caregivers following a child welfare investigation, few who manifest emotional and behavioral difficulties actually engage in mental health treatment. The Multiple Family Group service delivery model to reduce childhood disruptive behavior disorders (MFG) has shown promise in engaging child welfare-involved families. This qualitative study examines caregiver perceptions of factors that influence retention in MFGs among child welfare-involved families. METHODS: Twenty-five predominantly Black and Hispanic adult (ages 26-57) female caregivers with child welfare services involvement participated in individual, in-depth interviews about their experience with MFGs. Transcribed interview data were thematically coded guided by grounded theory methodology. Emergent themes were subsequently organized into a conceptual framework. RESULTS: Within the overarching influence of child welfare services involvement, specific components of MFGs influencing retention included the quality of interaction among group members, group facilitators' attentive approach with caregivers, supports designed to overcome logistical barriers (i.e., child care, transportation expenses, meals), and perceptions of MFG content and activities as fun and helpful. Caregiver factors, including their mental health and personal characteristics, as well as children's behavior, (i.e., observed changes in behavioral difficulties) were also associated with retention. CONCLUSIONS: High acceptability suggest utility for implementing MFGs within settings serving child welfare involved families, with additional modifications to tailor to setting and client features.

Meeting the complex needs of urban youth and their families through the 4Rs 2Ss Family Strengthening Program: The "real world" meets evidence-informed care.

Youth living in poverty face compounding familial and environmental challenges in utilizing effective community mental health services. They have ongoing stressors that increase their dropout rate in mental health service use. Difficulties also exist in staying engaged in services when they are involved with the child welfare system. This study examines the 4Rs 2Ss Family Strengthening Program, developed across four broad conceptual categories related to parenting skills and family processes that form a multiple family group service delivery approach. A total of 321 families were enrolled in this randomized intervention study, assigned to either the 4Rs 2Ss Family Strengthening Program or standard care services. Caregivers and their children randomly assigned to the experimental condition received a 16 week multiple family group intervention through their respective outpatient community mental health clinic. Data was collected at baseline, midtest (8 weeks), posttest (16 weeks), and 6 month follow-up. Major findings include high engagement in the 4Rs 2Ss Family Strengthening Program, compared to standard services. Although child welfare status is not related to attendance, family stress and parental depression are also related to participant engagement in this multiple family group intervention. Involvement in the 4Rs 2Ss Family Strengthening Program resulted in improved effects for child behaviors. Lastly, no evidence of moderation effects on family stress, child welfare involvement, or parental needs were found. The 4Rs 2Ss Family Strengthening Program appeared able to engage families with more complex "real world" needs.

Screening and Assessment of Suicidal Behavior in Transition-Age Youth with Foster Care Involvement.

Transition-age youth with foster care involvement (TAY, ages 17-22) are at heightened risk for suicidal behavior. Despite this, mental health screenings are not standardized across child welfare (CW) systems and existing assessment tools are not designed for use with this specific population. As such, TAY are unlikely to be adequately screened for suicide risk and connected with needed services. In this paper, we sought to identify screening and assessment tools that could be effective for use with TAY in CW settings. Using PubMed and PsycINFO, we conducted a search of the current literature to identify some of the most commonly used screening and assessment tools for youth. We then narrowed our focus to those tools that met predefined inclusion criteria indicating appropriateness of use for TAY in CW settings. As a result of this process, we identified one brief screening tool (the ASQ) and four assessments (the SIQ-JR, the C-SSRS, the SHBQ, and the SPS) that demonstrated specific promise for use with TAY. The strengths and limitations of the tools are discussed in detail, as well as the ways that each could be used most effectively in CW settings. We highlight three key points intended to guide social work practice and policy: (1) systematic, routine assessment of mental health and suicide risk across CW settings is critical; (2) the protocol for assessing suicidal behavior in TAY must account for the wide variations in context and service provision; and (3) CW workers administering assessments must be thoughtfully trained on risk identification and the protocol implementation.

Engagement in Trauma-Specific CBT for Youth Post-9/11.

Treatment participation was examined among youth enrolled in an evaluation of cognitive behavioral therapy (CBT) for trauma following the 9/11 World Trade Center disaster. Staff at nine agencies serving a predominantly low-income ethnically diverse population were trained to deliver CBT and structured engagement strategies. Four hundred and forty-five youth ages 5-19 were eligible for CBT, and 417 (94%) received at least one treatment session. Pretreatment and treatment show rates and overall dose were examined. Treatment participation rates were higher than those typically reported in community studies of children's mental health services. Regression analyses indicated variability across sites in treatment show rates with the highest rates at where services were delivered in schools. However, sites, demographic factors and trauma symptoms accounted for a small amount of variance in treatment participation overall. The study suggests structured engagement strategies, linked to evidence-based treatments may improve treatment participation for youth.

Absorptive capacity in child welfare: A qualitative study with child welfare staff eliciting key factors for evidence-based practice adoption.

Child Welfare (CW) provides an array of services to meet the needs of families, requiring agencies to be malleable in their ability to absorb new practices. Absorptive capacity (ACAP) refers to the routines and processes in which an organization acquires, assimilates, and applies new knowledge. ACAP has yet to be the focus of implementation research in CW settings. This exploratory study elicited feedback from CW staff in determining factors to consider when absorbing a new practice. Themes of logistic support, agency culture, and feedback from families emerged. Findings offer insights for CW agencies to consider when adopting a new practice.

A Collaboratively Designed Child Mental Health Service Model: Multiple Family Groups for Urban Children with Conduct Difficulties.

This paper presents preliminary outcomes associated with an experimental, longitudinal study of a Multiple Family Group (MFG) service delivery approach set within thirteen urban outpatient clinics serving children and their families living in inner-city, primarily African American and Latino communities. Specifically, this paper focuses on parent reports of child oppositional behavior and parenting stress over time. MFG is a flexible, protocol-driven approach designed to address the most common reason for referral to outpatient child mental health clinics, childhood behavioral difficulties. The MFG also aims to enhance family-level engagement and retention in ongoing care. Further, the service delivery model was collaboratively developed with intensive input from parents rearing children with conduct difficulties, parent advocates, community-based child mental health providers and services research staff in order to ultimately expand the number of effective service models that can be situated within "real world," urban child mental health settings.

Multiple family groups: an engaging intervention for child welfare-involved families.

Differences between child welfare- and non-child welfare-involved families regarding barriers to child mental health care, attendance, program satisfaction, and relationship with facilitators are examined for a multiple family group service delivery model aimed at reducing childhood disruptive behaviors. Although child welfare-involved caregivers reported more treatment barriers and less program satisfaction than non-child-welfare-involved families, no significant differences exist between groups on average total sessions attended and attendance rates over time.

Scaling up evidence-based treatments in youth behavioral healthcare: Social work licensing influences on task-shifting opportunities.

Youth behavioral healthcare workforce shortages have inhibited the scale-up of evidence-based treatments to address longstanding unmet needs andinequitable service coverage. Task-shifting is a strategy that could bolster workforce shortages. Legal and regulatory barriers, such as scope of practice licensing regulations, have hampered the use of task-shifting. Social workers make up the majority of the behavioral healthcare workforce in the U.S. and most social workers provide services to children and families. As such, social workers would play a pivotal role in any scale-up effort. In this guest editorial, we discuss the importance of social work licensing and use a case example to illustrate the unintended consequences that certain licensing regulations have on scaling-up evidence-based treatments via task-shifting. We conclude with recommendations on how social workers could be involved in taskshifting efforts to scale-up evidence-based treatments.

Caregiver-relevant perspectives from a multi-stakeholder collaborative advisory board on adapting a child mental health intervention to be delivered in child-welfare settings.

Adapting evidence based mental health interventions (EBI) to be provided in child welfare (CW) settings by CW workers could reduce barriers to families receiving mental health care. In order to promote implementation success, the adaptation of EBIs should include the perspectives of those who deliver and those who receive the EBI. The following study uses qualitative methods to elicit and analyze caregiver-relevant perspectives and adaption recommendations from CW stakeholders about the 4Rs and 2Ss Strengthening Families Program, an EBI for youth disruptive behavior disorders, to be implemented in CW settings. Recommendations included adjusting curriculum to better fit the culture of recipients and conveying the importance of openness and respect to providers.

It Takes a Village to Deliver and Test Child and Family-Focused Services.

OBJECTIVES: The purpose of this article is to highlight the benefits of collaboration in child focused mental health services research. METHOD: Three unique research projects are described. These projects address the mental health needs of vulnerable, urban, minority children and their families. In each one, service delivery was codesigned, interventions were co-delivered and a team of stakeholders collaboratively tested the impact of each one. RESULTS: The results indicate that the three interventions designed, delivered, and tested are associated with reductions in youth mental health symptoms. CONCLUSION: These interventions are feasible alternatives to traditional individualized outpatient treatment.