Translating and Implementing Evidence-Based Mental Health Services in Child Welfare.

Children in the child welfare system with mental health difficulties seldom receive evidence-based treatment (EBT) despite the abundance of validated interventions that exist. This manuscript describes two projects aimed at increasing access to EBTs. The first is a completed field trial of an adapted parent-child interaction therapy intervention with foster-parent child dyads. New findings are presented from variable- and person-centered analyses of impact on diverse symptom profiles. The second is an ongoing statewide initiative that is increasing access to multiple EBTs while navigating implementation barriers. Lessons learned for bridging gaps between children's mental health research, services, and policy are discussed.

Those Who Disappear and Those Who Say Goodbye: Patterns of Attrition in Long-Term Home Visiting.

Most evidence-based home visiting models are designed to support families from pregnancy through a child's second birthday, though programs often struggle to retain families for this long. Previous research on client and program factors that predict attrition has produced mixed results, which may be partly because attrition is typically conceptualized as a homogeneous phenomenon. The current study sampled 991 women who received home visiting services from one of 26 agencies in a statewide network of evidence-based programs. Participants who remained in services were compared to three types of early leavers: those who communicated their intent to leave (active attrition), those whose cases closed due to non-participation (passive attrition), and those who moved from the service area. Within a year of enrollment, 42% of women exited services. Cox regression results suggested no differences in the timing of service exit among the three attrition types. Multinomial analyses revealed that, when compared to participants who remained in services, active leavers were more likely to be married or cohabitating, while passive leavers were more likely to be younger, African American, unemployed, and to have a home visitor with low job satisfaction. Participants who moved were less likely to be Latina and employed. An early pattern of inconsistent attendance was the strongest predictor of active and passive withdrawal. Rates of attrition varied by home visiting model, though inconsistent attendance was a robust predictor of passive attrition across models. This study underscores the need to scrutinize service duration as a metric of success in home visiting.

Adverse Childhood Experiences and Postpartum Depression in Home Visiting Programs: Prevalence, Association, and Mediating Mechanisms.

Objectives In this study, we examined the prevalence of postpartum depression (PPD) and its association with select demographic factors and antenatal conditions. We also investigated whether greater exposure to adverse childhood experiences (ACEs) is associated with PPD, and if antenatal conditions mediate the ACE-PPD relationship. Methods Data were collected from 735 low-income women receiving home visiting services. Descriptive and bivariate analyses provided estimates of PPD and its correlates, and nested path analyses were used to test for mediation. Results We found that rates of PPD were high compared to prevalence estimates in the general population. Sample rates of antenatal depression were even higher than the rates of PPD. Omnibus tests revealed that PPD did not vary significantly by maternal age or race/ethnicity, although Hispanic women consistently reported the lowest rates. American Indian women and non-Hispanic white women reported the highest rates. PPD was significantly associated with increased exposure to ACEs. Nested path models revealed that the effects of ACEs were partially mediated by three antenatal conditions: intimate partner violence (IPV), perceived stress, and antenatal depression. Conclusions for Practice Supporting prior research, rates of PPD appear to be high among low-income women. ACEs may increase the risk of antenatal IPV and psychological distress, both of which may contribute to PPD. The findings have implications for screening and assessment as well as the timing and tailoring of interventions through home visiting and other community-based services.

Intergenerational transmission of child protective services involvement: Exploring the role of ACEs and domestic violence among families who receive home visiting services.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with negative outcomes over the life course and across generations, including domestic violence (DV) and child maltreatment. However, no studies have examined the connection between parents' ACEs and their child's risk of child protective services (CPS) involvement or possible mechanisms of transmission. OBJECTIVE: In addition to describing the prevalence and correlates of CPS involvement, our primary aims are to test whether parental adversity in childhood is associated with CPS involvement and whether DV victimization mediates the ACE-CPS association. PARTICIPANTS AND SETTING: The sample included 3039 primary caregivers and 3343 children served by home visiting programs in Wisconsin between 2014 and 2019. METHODS: Using matched home visiting and CPS records, we generated prevalence estimates of screened-in CPS reports and assessed bivariate associations between CPS involvement and ACEs, DV, and household demographics. We then conducted a two-stage path analysis to test the association between ACEs and CPS involvement and whether DV mediated the ACE-CPS association. RESULTS: Overall, 22.8 % of caregivers had a screened-in report. Prevalence rates were higher among women who endured ACEs and DV, and they varied by demographic characteristics. ACEs were directly linked to DV and CPS involvement, and there was an indirect pathway linking ACEs to CPS involvement through DV exposure. CONCLUSIONS: Home visiting programs serve families that frequently interact with the child welfare system. By enhancing the trauma-responsive potential of these interventions, it may be possible to interrupt intergenerational mechanisms that contribute to child abuse and neglect and CPS involvement.

Adverse adult experiences and health outcomes: Racial and ethnic differences in a low-income sample.

Extending research on adverse childhood experiences (ACEs), this study aimed to investigate whether the prevalence of and outcomes associated with adverse adult experiences vary among racial and ethnic subgroups. Survey data were collected from 1566 low-income women in Wisconsin using the Adult Experiences Survey (AES). Ten major adult adversities were assessed, including items that reference an intimate partner or household member (e.g., physical or emotional abuse, substance use) along with other social and economic stressors such as homelessness and discrimination. Adverse adult experiences were highly prevalent overall, but even more so among non-Hispanic Whites than their Black and Hispanic counterparts. The results reinforce prior research on ACEs in low-income populations. Lending further credence to these findings, tests of measurement invariance indicated that the AES demonstrated acceptable configural and scalar invariance across racial and ethnic groups. As expected, greater exposure to adult adversity was significantly related to poorer physical and mental health. These associations manifested cross-sectionally and longitudinally for observed and latent measures of adult adversity-even after controlling for ACEs. Associations between adult adversity and health were not moderated by race/ethnicity. In sum, adverse adult experiences were unequally distributed across racial/ethnic groups, but the consequences associated with adversity appeared to be evenly dispersed.

Impact of a family treatment court on child permanency and safety.

BACKGROUND: Family Treatment Courts have been linked to promising effects on key child welfare outcomes, though few rigorous program evaluations have been conducted. OBJECTIVE: This study employs a robust quasi-experimental design to evaluate effects associated with Family Treatment Court participation on child permanency and safety. PARTICIPANTS AND SETTING: The sample included 648 eligible adults who were referred to a Family Treatment Court in a Midwest metropolitan area, including 266 program participants and 382 non-participants. METHODS: Propensity score weighting was applied to match program and comparison groups on demographic and case characteristics. Child welfare records yielded safety and permanency outcomes. Participants and non-participants were compared following an intent-to-treat principle, with logistic regressions used to test the odds of reunification and maltreatment recurrence, and Kaplan-Meier analyses used to explore time to reunification and permanency. Moderation tests were performed to analyze differences in program impact across racial/ethnic groups and substance use types. RESULTS: Compared to non-participants, program participants were 81 % more likely to reunify. Group differences in time to reunification and permanency were mixed, and there was no evidence of program impact on maltreatment recurrence. Substance use type and race/ethnicity did not moderate associations between program participation and study outcomes. CONCLUSIONS: Mounting evidence suggests that Family Treatment Courts are more effective than usual services in promoting family reunification, though it is unclear if these interventions hasten reunification or increase safety post-reunification. Rigorous evaluations are needed to explore moderating and mediating processes and identify implementation drivers and local conditions that contribute to heterogeneous results.

Secondary traumatic stress among home visiting professionals.

OBJECTIVE: This study examined the reliability and factor structure of the Secondary Traumatic Stress Scale (STSS) and the prevalence and correlates of secondary traumatic stress (STS) among home visitors. METHOD: Survey data were collected between 2015 and 2020 from 301 home visitors with caseloads. Participants completed the 17-item STSS, which assesses intrusion, avoidance, and arousal symptoms using the DSM-IV-TR diagnostic criteria. Internal reliabilities of the scale and subscales were measured and confirmatory factor analyses were performed to validate hypothesized model solutions. Symptom prevalence among the sample was calculated and linear regressions were conducted to examine whether personal and workplace factors were associated with STS. RESULTS: Analyses confirmed that the STSS had sound internal consistency and that both 3- and single-factor measurement models fit the data. Approximately 10% of home visitors met the clinical criteria for PTSD, though prevalence decreased to 8% after omitting an intrusion item that was endorsed by most respondents. Increased exposure to adverse childhood experiences and poorer work environment ratings were associated with increased STS. Non-Hispanic White race was associated with elevated arousal symptoms. No other personal or workplace factors were associated with scores on the STSS full scale or subscales. CONCLUSION: This study reaffirms that the STSS has sound psychometric properties, but it also raises questions about the prevalence and etiology of STS. Given the likely costs of PTSD to personal well-being and professional efficacy, further research is needed to advance the measurement and prediction of secondary traumatic stress. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effects of COVID-19 on home visiting services for vulnerable families: A cross-state analysis of enrollment, engagement, and attrition patterns.

INTRODUCTION: COVID-19 has resulted in massive health and economic consequences, with effects felt most acutely by populations that were disadvantaged prior to the pandemic. For families with young children, the effects have been compounded by service interruptions, though there is a lack of empirical evidence that demonstrates how COVID-19 has affected home visiting programs. This cross-state study is the first to examine the effects of the pandemic on home visiting enrollment, engagement, and retention patterns. METHOD: Program implementation records gathered from 2017-2020 in Arkansas and Wisconsin were analyzed. Both states operate a large network of home visiting programs that serve predominantly low-income families and that are supported by the federal Maternal, Infant, and Early Childhood Home Visiting program. Trends prior to COVID were compared to post-COVID trends (March 12 to December 31, 2020) in program enrollments, service capacity, visitation frequency, service modalities, attrition rates, and service duration. RESULTS: Compared to average pre-pandemic enrollments from 2017-2019, post-COVID enrollments decreased by 33-36%. Total visits fell by 15-24%; the percentage of completed visits relative to expected visits declined more modestly. However, the average duration of services increased post-COVID while rates of early program dropout decreased. DISCUSSION: The findings suggest that enrollment and engagement in home visiting decreased during the COVID-19 pandemic, which is unfortunate given the large number of vulnerable families served nationwide. Further research is needed to examine how COVID affected both consumer and program behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Disparities in adverse childhood experiences by race/ethnicity, gender, and economic status: Intersectional analysis of a nationally representative sample.

BACKGROUND: Adverse childhood experiences (ACEs) are disturbingly common and consequential. Priority should be given to identifying populations that bear a disproportionate share of the burden of ACEs, but such disparities have received limited attention to date. OBJECTIVE: This study analyzes data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative sample in the U.S., to explore variation in ACEs by race/ethnicity, economic status, and gender. METHODS: In addition to using conventional statistical methods to generate unadjusted and adjusted estimates, we conduct an intercategorical intersectional analysis of variation in ACEs using multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). RESULTS: Descriptively, we find that ACEs are more prevalent overall among the poor than the non-poor, among most racial/ethnic minority groups than non-Hispanic Whites, and among females than males. However, multivariate regression results indicate that gender is not a robust correlate of cumulative adversity and that economic status moderates racial/ethnic differences. MAIHDA models further expose heterogeneity in aggregate ACE scores between intersectional strata representing unique combinations of gender, race/ethnicity, and economic status. CONCLUSIONS: The MAIHDA results confirm that conclusions based on unadjusted group differences may be spurious. While most variance in ACE scores is explained by additive main effects, accounting for intersections among social categories generates a more complex portrait of inequality. We compare our work to prior studies and discuss potential explanations for and implications of these findings for research on disparities.

Toward the assessment of adverse adult experiences: An initial validation study of the adult experiences survey.

OBJECTIVE: The current investigation is a validation study of the Adult Experiences Survey, a seminal assessment of adverse adult experiences. METHOD: Data were collected between July 2015 and June 2019 from a sample of 1,747 low-income women as part of a longitudinal study in Wisconsin, United States. Analyses of 10 adversities were conducted to assess item prevalence and internal consistency in the full sample and test-retest reliability in a subsample of 90 participants. Exploratory and confirmatory factor analyses were performed to examine the factor structure of the measure, and multivariate regressions were conducted to estimate the effects of adult adversity on 3 health-related outcomes: poor physical health, depression, and posttraumatic stress disorder. RESULTS: Most participants (86%) endorsed at least 1 adversity. Each item demonstrated good test-retest reliability except crime victimization, and the full measure had sound internal consistency. Each adversity was associated with all health-related outcomes at the bivariate level, and most were linked to 1 or more outcomes in multivariate analyses. Exploratory and confirmatory factor analyses validated 1- and 2-factor solutions with good fit. A cumulative adult adversity score was associated with all study outcomes controlling for adverse childhood experiences, and effects associated with a latent adversity score were even larger in magnitude. CONCLUSIONS: Extending research on adverse childhood experiences, the findings indicate that adverse adult experiences can be measured reliably and validly using a brief assessment. Implications are discussed, including opportunities to advance the study of trauma and resilience over the life course. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Home Visiting Effects on Breastfeeding and Bedsharing in a Low-Income Sample.

BACKGROUND: Research suggests that home visiting interventions can promote breastfeeding initiation, though their effects on breastfeeding continuation are unclear. No known studies have assessed the impact of home visiting on bedsharing. AIMS: To test the effects of home visiting on breastfeeding and bedsharing in a low-income, urban sample in the United States. METHODS: During a field trial conducted in Milwaukee, Wisconsin, from April 2014 to March 2017, referrals to a public health department were randomized to a Healthy Families America (HFA) program or a prenatal care and coordination (PNCC) program. Of the 204 women who accepted services, 139 consented to the study and were allocated to the two treatment groups, which were compared with each other and a third quasi-experimental group of 100 women who did not accept services. Data were collected at four time points up to 12 months postpartum. RESULTS: Breastfeeding initiation was higher among 72 HFA participants (88.4%; odds ratio [OR] = 2.7) and 67 PNCC participants (88.5%; OR = 2.2) than 100 comparison participants (76.5%). Similar results emerged for breastfeeding duration, though group differences were not statistically significant. Unexpectedly, bedsharing prevalence was higher among HFA participants (56.5%) than PNCC participants (31.1%; OR = 2.9) and comparison group participants (38.8%; OR = 2.0). DISCUSSION: Home visiting was linked to increased breastfeeding, while effects on bedsharing varied by program. Progress toward precision home visiting will be advanced by identifying program components that promote breastfeeding and safe sleep. CONCLUSION: Further research is needed to examine whether home visiting reduces disparities in breastfeeding and safe sleep practices.

Crafting the Greenbook: framers reflect on the vision, process, and lessons learned.

Guided by research and the experiences of judges nationwide, the National Council of Juvenile and Family Court Judges made a commitment in 1998 to improve community response to families experiencing domestic violence and child maltreatment. A year later, the council's work culminated in a set of recommendations commonly called the Greenbook, which summoned child welfare agencies, domestic violence service providers, and dependency courts to implement internal changes and collaborate to address co-occurring domestic violence and child maltreatment. In 2000, the federal government funded six community-based demonstration programs to implement the Greenbook recommendations. As part of the evaluation of the Greenbook initiative, the evaluation team asked the national experts who helped frame the Greenbook to reflect on the processes used and the decisions that shaped the document. In addition, the experts were asked to describe their expectations for the systems and communities that implemented the recommendations, including anticipated challenges.

Coordinated community response to family violence: the role of domestic violence service organizations.

There is increasing awareness that domestic violence (DV) and child maltreatment often overlap and that there are significant negative consequences to women and children who are victims in the same families. The present study contains data from a participatory evaluation of a multisite national demonstration project on family violence (the Greenbook Initiative), funded jointly by the U.S. Departments of Health and Human Services and Justice. The goal of this initiative was to increase community capacity to assist dually victimized families. This article focuses on the DV service organizations in the demonstration with regard to collaborations with other agencies and work within the DV system to respond to dually victimized families. Findings suggest that DV agencies participated in leadership roles, cross-system collaborations, and cross-system trainings throughout the initiative. Within-agency practice changes were less apparent. Research and policy implications are discussed.

Domestic violence and dependency courts: the Greenbook demonstration experience.

This field study reports on a cross-site evaluation of dependency courts in communities receiving federal funding to implement the Greenbook initiative, a multisite demonstration for community improvement of coordinated responses to families victimized by domestic violence and child maltreatment. This article focuses on the dependency court, where child maltreatment cases are heard, specifically court participation in collaborative activities and court practice improvements. Findings indicate that perceptions of judicial leadership varied considerably by site. Cross-training appeared to increase over time, particularly with court staff. Collaborative efforts emerged across the Greenbook initiative with regard to the courts, and some innovative practices appeared within Greenbook sites, such as separate case plans for perpetrators and victims of violence in families, reducing the likelihood of controversial failure to protect charges. Results also highlight challenges inherent in changing court practices. Research and practice implications are discussed, focusing on relevance to other communities attempting to work collaboratively with the court system.

Racial and ethnic differences in the prevalence of adverse childhood experiences: Findings from a low-income sample of U.S. women.

Despite great interest in adverse childhood experiences (ACEs), there has been limited research on racial and ethnic differences in their prevalence. Prior research in the United States suggests that the prevalence of ACEs varies along socioeconomic lines, but it is uncertain whether there are racial/ethnic differences in ACE rates among low-income populations. This study examined the distribution of ACEs in a sample of 1523 low-income women in Wisconsin that received home visiting services. Participants ranging in age from 16 to 50 years were coded into five racial/ethnic groups, including Hispanics and four non-Hispanic groups: blacks, whites, American Indians, and other race. Following measurement conventions, ten dichotomous indicators of child maltreatment and household dysfunction were used to create a composite ACE score. Five other potential childhood adversities were also assessed: food insecurity, homelessness, prolonged parental absence, peer victimization, and violent crime victimization. Results from bivariate and multivariate analyses revealed that, while rates of adversity were high overall, there were significant racial/ethnic differences. Total ACE scores of American Indians were comparable to the ACE scores of non-Hispanic whites, which were significantly higher than the ACE scores of non-Hispanic blacks and Hispanics. Whites were more likely than blacks to report any abuse or neglect, and they were more likely than blacks and Hispanics to report any household dysfunction. The results underscore the need to account for socioeconomic differences when making racial/ethnic comparisons. Potential explanations for the observed differences are examined.

Poor mental health among low-income women in the U.S.: The roles of adverse childhood and adult experiences.

RATIONALE: It is well established that exposure to a greater number of adverse childhood experiences (ACEs) increases the risk of poor physical and mental health outcomes. Given the predictive validity of ACE scores and other cumulative risk metrics, a similar measurement approach may advance the study of risk in adulthood. OBJECTIVE: We examined the prevalence and interrelations of 10 adverse adult experiences, including household events such as intimate partner violence and extrafamilial events such as crime victimization. We also tested the relation between cumulative adult adversity and later mental health problems, and we examined whether adult adversity mediates the link between childhood adversity and mental health. METHODS: Data were collected from 501 women in the Families and Children Thriving Study, a longitudinal investigation of low-income families that received home visiting services in Wisconsin. We conducted correlation analyses to assess interrelations among study measures along with multivariate analyses to test the effects of childhood and adult adversity on three outcomes: depression, anxiety, and posttraumatic stress disorder (PTSD). We then fit a structural equation model to test whether the effects of childhood adversity on mental health are mediated by adult adversity. RESULTS: Over 80% of participants endorsed at least one adverse adult experience. Adult adversities correlated with each other and with the mental health outcomes. Controlling for ACEs and model covariates, adult adversity scores were positively associated with depression, anxiety, and PTSD scores. Path analyses revealed that the ACE-mental health connection was mediated by adult adversity. CONCLUSION: Our findings indicate that mental health problems may be better understood by accounting for processes through which early adversity leads to later adversity. Pending replication, this line of research has the potential to improve the identification of populations that are at risk of poor health outcomes.

Rethinking the Measurement of Adversity.

Research on adverse childhood experiences (ACEs) has unified the study of interrelated risks and generated insights into the origins of disorder and disease. Ten indicators of child maltreatment and household dysfunction are widely accepted as ACEs, but further progress requires a more systematic approach to conceptualizing and measuring ACEs. Using data from a diverse, low-income sample of women who received home visiting services in Wisconsin ( N = 1,241), this study assessed the prevalence of and interrelations among 10 conventional ACEs and 7 potential ACEs: family financial problems, food insecurity, homelessness, parental absence, parent/sibling death, bullying, and violent crime. Associations between ACEs and two outcomes, perceived stress and smoking, were examined. The factor structure and test-retest reliability of ACEs was also explored. As expected, prevalence rates were high compared to studies of more representative samples. Except for parent/sibling death, all ACEs were intercorrelated and associated at the bivariate level with perceived stress and smoking. Exploratory factor analysis confirmed that conventional ACEs loaded on two factors, child maltreatment and household dysfunction, though a more complex four-factor solution emerged once new ACEs were introduced. All ACEs demonstrated acceptable test-retest reliability. Implications and future directions toward a second generation of ACE research are discussed.

The influence of differential response on decision-making in child protective service agencies.

Differential response (DR) profoundly changes the decision pathways of public child welfare systems, yet little is known about how DR shapes the experiences of children whose reports receive an investigation rather than an alternate response. Using data from the National Child Abuse and Neglect Data System (NCANDS), this study examined the relationship between DR implementation and decision outcomes in neglect cases, as measured by investigation, substantiation, and removal rates in 297 U.S. counties. Multivariate regression models included county-level measures of child poverty and proportions of African American children. Path analyses were also conducted to identify mediating effects of prior decision points and moderating effects of DR on poverty and race's influence on decision outcomes. Results indicate that compared to non-DR counties, those implementing DR have significantly lower investigation and substantiation rates within county populations but higher substantiation rates among investigated cases. Regression models showed significant reductions in removal rates associated with DR implementation, but these effects became insignificant in path models that accounted for mediation effects of previous decision points. Findings also suggest that DR implementation may reduce the positive association between child poverty rates and investigation rates, but additional studies with larger samples are needed to confirm this moderation effect. Two methods of calculating decision outcomes, population- and decision-based enumeration, were used, and policy and research implications of each are discussed. This study demonstrates that despite their inherit complexity, large administrative datasets such as NCANDS can be used to assess the impact of wide-scale system change across jurisdictions.

Enhancing Foster Parent Training with Parent-Child Interaction Therapy: Evidence from a Randomized Field Experiment.

OBJECTIVE: Research indicates that foster parents often do not receive sufficient training and support to help them meet the demands of caring for foster children with emotional and behavioral disturbances. Parent-Child Interaction Therapy (PCIT) is a clinically efficacious intervention for child externalizing problems, and it also has been shown to mitigate parenting stress and enhance parenting attitudes and behaviors. However, PCIT is seldom available to foster families, and it rarely has been tested under intervention conditions that are generalizable to community-based child welfare service contexts. To address this gap, PCIT was adapted and implemented in a field experiment using 2 novel approaches-group-based training and telephone consultation-both of which have the potential to be integrated into usual care. METHOD: This study analyzes 129 foster-parent-child dyads who were randomly assigned to 1 of 3 conditions: (a) waitlist control, (b) brief PCIT, and (c) extended PCIT. Self-report and observational data were gathered at multiple time points up to 14 weeks post baseline. RESULTS: Findings from mixed-model, repeated measures analyses indicated that the brief and extended PCIT interventions were associated with a significant decrease in self-reported parenting stress. Results from mixed-effects generalized linear models showed that the interventions also led to significant improvements in observed indicators of positive and negative parenting. The brief course of PCIT was as efficacious as the extended PCIT intervention. CONCLUSIONS: The findings suggest that usual training and support services can be improved upon by introducing foster parents to experiential, interactive PCIT training.