Healthcare experiences of pregnant and postnatal women and healthcare professionals when facing child protection in the perinatal period: A systematic review and Critical Interpretative Synthesis.

BACKGROUND: The perinatal period is known as time of transition and anticipation. For women with social risk factors, child protection services may become involved during the perinatal period and this might complicate their interactions with healthcare providers. AIM: To systematically review and synthesise the existing qualitative evidence of healthcare experiences of women and healthcare professionals during the perinatal period while facing child protection involvement. METHODS: A systematic search of databases (Web of Science, MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, MIDIRS, Social Policy and Practice and Global Health) was carried out in January 2023, and updated in February 2024. Quality of studies was assessed using the Critical Appraisal Skills Programme. A Critical Interpretative Synthesis was used alongside the PRISMA reporting guideline. RESULTS: A total of 41 studies were included in this qualitative evidence synthesis. We identified three types of healthcare interactions: Relational care, Surveillance and Avoidance. Healthcare interactions can fluctuate between these types, and elements of different types can coexist simultaneously, indicating the complexity and reciprocal nature of healthcare interactions during the perinatal period when child protection processes are at play. CONCLUSIONS: Our findings provide a novel interpretation of the reciprocal interactions in healthcare encounters when child protection agencies are involved. Trust and transparency are key to facilitate relational care. Secure and appropriate information-sharing between agencies and professionals is required to strengthen healthcare systems. Healthcare professionals should have access to relevant training and supervision in order to confidently yet sensitively safeguard women and babies, while upholding principles of trauma-informed care. In addition, systemic racism in child protection processes exacerbate healthcare inequalities and has to be urgently addressed. Providing a clear framework of mutual expectations between families and healthcare professionals can increase engagement, trust and accountability and advance equity.

Predictive risk modeling for child maltreatment detection and enhanced decision-making: Evidence from Danish administrative data.

Child maltreatment is a widespread problem with significant costs for both victims and society. In this retrospective cohort study, we develop predictive risk models using Danish administrative data to predict removal decisions among referred children and assess the effectiveness of caseworkers in identifying children at risk of maltreatment. The study analyzes 195,639 referrals involving 102,309 children Danish Child Protection Services received from April 2016 to December 2017. We implement four machine learning models of increasing complexity, incorporating extensive background information on each child and their family. Our best-performing model exhibits robust predictive power, with an AUC-ROC score exceeding 87%, indicating its ability to consistently rank referred children based on their likelihood of being removed. Additionally, we find strong positive correlations between the model's predictions and various adverse child outcomes, such as crime, physical and mental health issues, and school absenteeism. Furthermore, we demonstrate that predictive risk models can enhance caseworkers' decision-making processes by reducing classification errors and identifying at-risk children at an earlier stage, enabling timely interventions and potentially improving outcomes for vulnerable children.

Mental health service use in children at risk of significant harm: A record linkage study of a child protection register.

Children with experience of maltreatment, abuse or neglect have higher prevalence of poor mental health. In the United Kingdom, child protection services identify children at risk of significant harm on the Child Protection Register (CPR) and intervene to reduce risk. Prevalence and incidence of mental health service use among this population of children are not well understood. We analysed records from one Scottish Local Authority's CPR, linked to electronic health records for all children in the broader health board region aged 0-17 years. We described mental health service use among children with a CPR registration using measures of mental health prescribing and referrals to child and adolescent mental health services (CAMHS). We calculated age- and sex-specific incidence rates for comparison with the general population. Between 2012 and 2022, we found 1498 children with a CPR registration, with 69% successfully linked to their health records. 20% were registered before birth and median age at registration was 3 years. Incidence rates in all measures of mental health service use were higher in children with a CPR record across all ages (at outcome) and genders compared to the general population. The largest absolute difference was for boys aged 5-9 with a CPR record, who had 31.8 additional mental health prescriptions per 1000 person-years compared to the general population (50.4 vs. 18.6 prescriptions per 1000 person-years, IRR: 2.7). Girls aged 0-4 years with a CPR registration had the largest relative difference, with a rate of CAMHS referral 5.4 times higher than the general population (12.3 vs. 2.3 per 1000 person-years). Our reproducible record linkage of the CPR to health records reveals an increased risk of mental health service use during childhood. Our findings have relevance to public mental health surveillance, service prioritisation and wider policy aiming to reduce childhood exposure to risk of harm.

Transformational Leadership, Secondary Traumatic Stress, and Burnout of Child Welfare Workers: Multilevel Moderation Effects.

This study examines the moderating effects of distant leader's practice of transformational leadership on the relationship between secondary traumatic stress (STS) and burnout among child welfare workers. Caseworkers and supervisors in a Midwest U.S. state (N = 210) rated their regional director's use of transformational leadership skills using a survey. Given the nature of the clustered data, multilevel modeling was employed to examine the main effects of transformational leadership on worker burnout and its cross-level interaction effect on the association between worker STS and burnout. Multilevel modeling demonstrated that worker burnout was positively associated with STS and negatively associated with organizational-level transformational leadership. The cross-level interaction between transformational leadership and STS was significant. Specifically, the positive association between workers' STS and burnout decreased as transformational leadership increased. These findings suggest that organizational approaches such as transformational leadership can influence workforce results. Further research will guide child welfare policymakers to develop more sophisticated training programs in leadership skills and strategies.

Mandatory Child Protective Services Reporting for Substance-Exposed Newborns and Peripartum Outcomes: A Difference-in-Differences Analysis.

This cross-sectional study examines data across 17 birthing hospitals before and after a policy change at Boston Medical Center in how reporting decisions are made in cases of prenatal substance exposure.

Emergency Department Triage Chief Complaints Among Children Evaluated for Physical Abuse Concerns.

OBJECTIVES: The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services. METHODS: This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ 2 , Fisher exact, Kruskal-Wallis). RESULTS: Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting. CONCLUSION: Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse.

Parent Peer Advocacy, Mentoring, and Support in Child Protection: A Scoping Review of Programs and Services.

Objective: Parent peer advocacy, mentoring, and support programs, delivered by parents with lived child protection (CP) experience to parents receiving CP intervention, are increasingly recognized internationally as inclusive practices that promote positive outcomes, but little is known about what shared characteristics exist across these types of programs and what variations may exist in service delivery or impact. This scoping review examines 25 years (1996-2021) of empirical literature on these programs to develop a systematic mapping of existing models and practices as context for program benefits and outcome achievement. Method: Studies were selected using a systematic search process. The final sample comprised 45 publications that addressed research on 24 CP-related parent peer advocacy and support programs. Data analysis explored how programs were studied and conceptualized and examined their impact on parents, professionals, and the CP system. Results: Substantial variation in program settings, target populations, aims, advocate roles, and underlying theoretical frameworks were identified. Across program settings, existing empirical evidence on impact and outcomes also varied, though positive impacts and outcomes were evident across most settings. Conclusions: Findings from this review highlight the need to account better for parent peer advocacy and support program variations in future practice development to ensure alignment with inclusive and participatory principles and goals. Future research is also needed to address current knowledge gaps and shed light on the impact of these differences on individual, case, and system outcomes.

Dental caries prevalence in children during temporary protective care according to type of abuse.

BACKGROUND: This study investigated the correlation between the prevalence of dental caries and the presence and type of abuse. METHODS: Participants were 534 children admitted for care at two child guidance centers (CGCs) in Niigata, Japan. Data pertaining to abuse, including the reason for temporary protective care and the type of abuse, and the oral examination results of the children, were collected. These results were then compared with those of a national survey and analyzed in relation to the presence and type of abuse. RESULTS: The odds ratio for decayed teeth was 4.1, indicating a higher risk in children admitted to the CGCs. However, no significant association was found between the presence of decayed, filled, or caries-experienced teeth and the presence of abuse. A significant positive association was observed between dental caries and one type of abuse, indicating a greater prevalence of dental caries in cases of neglect. The findings of this study suggest that the type of abuse, rather than its presence, is associated with dental caries. CONCLUSIONS: Our findings suggest that proactive support should be provided to children in problematic nurturing environments, regardless of whether they have been subjected to abuse.

"Instead of just taking my baby, they could've actually given me a chance": Experiences with plans of safe care among birth parents impacted by perinatal substance use.

BACKGROUND: Federal legislation mandates healthcare providers to notify child protective service (CPS) agencies and offer a voluntary care plan called a "plan of safe care" (POSC) for all infants born affected by prenatal substance use. While POSCs aim to provide supportive services for families impacted by substance use, little is known about birth parents' perceptions and experiences. OBJECTIVE: To examine birth parents' perceptions and experiences regarding POSC. PARTICIPANTS AND SETTING: Parents offered a POSC in Philadelphia in the prior year were included. METHODS: This is a qualitative interview study. Participants were recruited from birth hospitals and community-based programs with telephone consent and interview procedures. Transcripts were analyzed using an inductive, grounded theory approach to identify content themes. RESULTS: Twelve birth parents were interviewed (30.7 % of eligible, contacted individuals). Fear of CPS involvement and stigma were common. Some birth parents reported that the increased scrutiny related to POSCs negatively impacted their attitudes toward healthcare providers and medications for opioid use disorder (MOUD). While parents found the consolidated resource information helpful, many did not know how to access services. Finally, parents desired more individualized plans tailored to their unique family needs. CONCLUSIONS: Stigma, confusion, and fear of CPS involvement undermine the goal of POSCs to support substance-exposed infants and birth parents. Providers serving this population should be transparent regarding CPS notifications, provide compassionate, non-stigmatizing care, and offer coordination services to support engagement after discharge. Policymakers should consider separating POSCs from CPS to avoid exacerbating fear and mistrust.

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study.

BACKGROUND: Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions. METHODS: A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC). RESULTS: Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent. CONCLUSIONS: This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Untreated Psychiatric and Substance Use Disorders Among Caregivers With Children Reported to Child Protective Services.

Importance: Mental and substance use disorders can interfere with parents' ability to care for their children and are associated with a greater likelihood of child protective services involvement to address child maltreatment. Parent engagement in psychiatric and substance use disorder treatment can prevent child maltreatment and family separations. Objective: To determine whether caregivers with psychiatric or substance use disorders whose children were referred to child protective services received Medicaid-funded psychiatric or substance use disorder treatment. Design, Setting, and Participants: Caregivers listed on child welfare records were linked with their Medicaid records using 2017 to 2020 Medicaid and child welfare data from Florida and Kentucky. Medicaid claims were analyzed to determine if caregivers had a psychiatric or substance use disorder diagnosis and whether those caregivers received counseling or medications. The analysis was conducted in 2023. Exposure: Diagnosis of a psychiatric or substance use disorder in 2020. Main Outcome and Measure: Receipt of psychiatric or substance use disorder counseling or medications. Results: Of the 58 551 caregivers, 65% were aged between 26 and 40 years; 69% were female and 31% were male. Overall, 78% identified as White, 20% identified as Black/African American, and less than 1% identified as American Indian/Alaska Native, Asian, or Native Hawaiian/Other Pacific Islander. In 2020, 59% of caregivers with Medicaid and children referred to child protective services had a mental health or substance use disorder diagnosis, compared with 33% of age- and sex-matched Medicaid beneficiaries without children referred to child protective services (P < .001). Among caregivers with a psychiatric disorder, 38% received counseling and 67% received psychiatric medication. Among those with a substance use disorder, 40% received counseling and 38% received a substance use disorder medication. Conclusions and Relevance: In this case-control study, despite Medicaid coverage of an array of effective behavioral health treatments, large portions of caregivers with Medicaid coverage, who need treatment and whose children were referred to child protective services, were not receiving treatment. Medicaid and child welfare agencies should make a greater effort to connect caregivers to behavioral health services.

Evidence-based practice criteria's effect on the implementation of the Family First Prevention Services Act in Nebraska and Colorado.

Child abuse, particularly neglect, is often preventable because many causes of harm stem from poverty, lack of social connections, substance use disorders, mental illness, lack of childcare, and other family support shortages. Prevention of child abuse and neglect starts with family support in these areas. The federal government recognized this need for prevention, and through considerable bipartisan support, passed the Family First Prevention Services Act on February 9, 2018. The Family First Prevention Services Act was designed to divert investment away from long-term foster care and toward programs that prevent unnecessary placement and child protective services interventions. The Family First Prevention Services Act restricts the state's use of federal funds for institutional foster care placements and uses those savings to fund reimbursements for evidence-based family preservation. The requirement for evidence-based prevention is a first in child-welfare federal law, and compliance with this requirement requires public-private partnership with agencies implementing the models, infrastructure, and evaluation standards that most states must build to be eligible for the new funding. This evaluation research analyzed how the stringent guidelines for prevention funding and the requirement of federally approved evidence-based practice programming affect the implementation of the Family First Prevention Services Act in Nebraska and Colorado.

Providers' experiences collaborating with child welfare workers: The good, the bad, and the impacts.

BACKGROUND: Successful interprofessional collaborations have been identified as a potential solution to mitigate problems associated with negative outcomes for clients involved with the child welfare system. The barriers to collaborative relationships need to be better understood and effectively addressed. OBJECTIVE: To understand the characteristics, barriers, and facilitators of collaborations between different types of providers and child welfare workers, as well as their impacts. PARTICIPANTS AND SETTING: Mental health professionals, foster and kinship parents, legal professionals, and other providers responded to an online survey distributed in a Northeastern State of the United States of America. METHOD: Participants (n = 208) completed the Quality of Collaboration with Child Welfare survey. Qualitative responses were analyzed by three coders using three levels of axial coding with constant comparison. RESULTS: Participants identified different aspects of communication, relationships, and follow-through as key elements of successful collaborations, as well as the items most likely to interfere with their formation. Providers differed somewhat in how concerned they were with various aspects of collaborations in accordance with their professional roles. Barriers to successful collaborations included both individual and systemic factors which often resulted in negative outcomes. Overall, more negative experiences were offered than positive ones. CONCLUSIONS: Strategies are needed to improve communication, promote positive relationships, and address systemic barriers to enhance collaboration and, in turn, improve outcomes for child welfare-involved clients.

Primary Care Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement.

Importance: Child maltreatment, which includes child abuse and neglect, can have profound effects on health, development, survival, and well-being throughout childhood and adulthood. The prevalence of child maltreatment in the US is uncertain and likely underestimated. In 2021, an estimated 600 000 children were identified by Child Protective Services as experiencing abuse or neglect and an estimated 1820 children died of abuse and neglect. Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate benefits and harms of primary care-feasible or referable behavioral counseling interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of maltreatment. Population: Children and adolescents younger than 18 years who do not have signs or symptoms of or known exposure to maltreatment. Evidence Assessment: The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of or known exposure to maltreatment. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective: To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection: English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results: Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Presentation, Management, and Child Protective Service Reporting of Children Who Test Positive for Cannabis in an Emergency Room Setting.

OBJECTIVES: Rates of cannabis ingestion among young children are increasing. Small studies have evaluated symptomatology of these children. The literature lacks research regarding factors influencing medical management. Our goal was to 1) understand circumstances leading to exposure over time and 2) gain insight into factors that may influence emergency room management and Child Protective Services reporting over time. METHODS: Retrospective cross-sectional study on children younger than 10 years with cannabis-positive urine drug screens in the emergency room setting. Single-factor analysis of variance and Fisher exact tests were used to assess for trends. Two-tailed t tests and Fisher exact tests were used to compare management of children presenting to the emergency room with chief complaint (CC) "ingestion" versus those without. RESULTS: Of the 179 children, the mean age was 3.7 years and 48% were boys. We observed a significant increase over time in cannabis-positive children. The most common location of exposure was the primary residence (54%), with parents as the most frequent users (46%). In the emergency department, the most common CC was ingestion followed by altered mental status and fatigue. Children with an "ingestion" CC were managed with less testing than those with other CCs. They received fewer needle sticks (43% vs 91%), less imaging (5% vs 56% computed tomography heads), and fewer procedures (0% vs 8% lumbar punctures). Children with "ingestion" CC were less likely to be reported to Child Protective Services. CONCLUSIONS: Pediatric cannabis exposures are increasing and have a wide array of clinical presentations that complicate emergency room management. Parental report of cannabis ingestion seems to impact and reduce potentially unnecessary testing.

La violencia como problema de salud / Violence as a health problem

La violencia es un problema de salud pública. Esta, cuando afecta a la infancia, puede generar enfermedad a lo largo de toda la vida del individuo. Aparte de poder producir daños en la esfera física, psíquica y social, supone una vulneración de los derechos de los niños afectados y un elevado consumo de recursos tanto económicos como sociales.Multitud de investigaciones han mejorado la atención a esta violencia. Sin embargo, estos avances no son parejos con el manejo práctico que se realiza a las víctimas tanto en la atención primaria como en la hospitalaria. Existe una significativa área de mejora para la atención pediátrica.A través de este artículo, distintos profesionales de todas las áreas sanitarias pediátricas establecidas desarrollan líneas generales de conocimiento y actuación con respecto a la violencia contra la infancia. Se hace un recorrido a través de la legislación relacionada con la infancia, las distintas tipologías de maltrato que existen, sus efectos, manejo y prevención. Concluye con un epílogo, a través del cual pretendemos mover sensibilidades.En resumen, este es un trabajo que pretende fomentar la formación y sensibilización de todos los profesionales especializados en la salud infantil, para que persigan como objetivo el que sus pacientes alcancen su mayor potencial en la vida y, de esa manera, ayudar a crear una sociedad más sana, con menos enfermedad y más justa.(AU)

Violence is a public health problem, and when it affects childhood, it can cause illness throughout the individual's life. Apart from being able to cause damage in the physical, mental and social spheres, it represents a violation of the rights of the affected children, and a high consumption of resources, both economic and social.A multitude of investigations have improved attention to this violence. However, these advances are not consistent with the practical management of victims, both in Primary and Hospital Care. There is a significant area of improvement for paediatric care.Through this article, different professionals from all established paediatric health care facilities develop general lines of knowledge and action regarding violence against children. An overview is taken of the legislation related to childhood, the different types of abuse that exist, their effects, management and prevention. It concludes with an epilogue, through which we aim to move sensibilities.In summary, this work aims to promote the training and awareness of all professionals specialized in children's health, so that they pursue the goal of achieving their patients’ greatest potential in life, and in this way, to help create a healthier society, with less disease, and more justice.(AU)

Commentary: Early intervention for conduct problems as a child protection strategy - reflections on Nobakht et al. (2023).

Adverse childhood experiences (ACEs), including child maltreatment and interparental aggression, are known to have far-reaching consequences for mental health across the lifespan. Emerging evidence, such as that reported by Nobakht et al. (Journal of Child Psychology and Psychiatry, 2023), indicates that child conduct problems (e.g. oppositional defiant disorder, conduct disorder) may not only result from adversity but also contribute to it through transactional cascades that amplify risk for adversity over time. This commentary addresses some of the key implications of this evidence for translation into practice. It is argued that child conduct problems can be viewed as modifiable determinants of adversity and that the early identification and treatment of child conduct problems may allow for the early identification and reduction of risk for numerous ACEs.

Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations.

BACKGROUND: Cross-system interventions that integrate health, behavioral health, and social services can improve client outcomes and expand community impact. Successful implementation of these interventions depends on the extent to which service partners can align frontline services and organizational operations. However, collaboration strategies linking multiple implementation contexts have received limited empirical attention. This study identifies, describes, and specifies multi-level collaboration strategies used during the implementation of Ohio Sobriety Treatment and Reducing Trauma (Ohio START), a cross-system intervention that integrates services across two systems (child welfare and evidence-based behavioral health services) for families that are affected by co-occurring child maltreatment and parental substance use disorders. METHODS: In phase 1, we used a multi-site qualitative design with 17 counties that implemented Ohio START. Qualitative data were gathered from 104 staff from child welfare agencies, behavioral health treatment organizations, and regional behavioral health boards involved in implementation via 48 small group interviews about collaborative approaches to implementation. To examine cross-system collaboration strategies, qualitative data were analyzed using an iterative template approach and content analysis. In phase 2, a 16-member expert panel met to validate and specify the cross-system collaboration strategies identified in the interviews. The panel was comprised of key child welfare and behavioral health partners and scholars. RESULTS: In phase 1, we identified seven cross-system collaboration strategies used for implementation. Three strategies were used to staff the program: (1) contract for expertise, (2) provide joint supervision, and (3) co-locate staff. Two strategies were used to promote service access: (4) referral protocols and (5) expedited access agreements. Two strategies were used to align case plans: (6) shared decision-making meetings, and (7) sharing data. In phase 2, expert panelists specified operational details of the cross-system collaboration strategies, and explained the processes by which strategies were perceived to improve implementation and service system outcomes. CONCLUSIONS: We identified a range of cross-system collaboration strategies that show promise for improving staffing, service access, and case planning. Leaders, supervisors, and frontline staff used these strategies during all phases of implementation. These findings lay the foundation for future experimental and quasi-experimental studies that test the effectiveness of cross-system collaboration strategies.