Multiple Stakeholder Perspectives Regarding Implementing a Child Mental Health EBP into Child Welfare Services

Background and Purpose: Children with behavior difficulties reared in child welfare (CW) involved families often experience multiple barriers to accessing mental health treatment. Integrating mental health interventions into CW services (e.g., placement prevention services) may be an effective way to bridge this service gap. Unfortunately, few evidence-based practices (EBPs) have been successfully implemented in CW settings, especially those originally designed to be delivered by mental health providers. Given that CW caseworkers generally lack advanced mental health training, this is a significant implementation barrier. This study utilized World Health Organization-endorsed task-shifting strategies to modify an existing mental health EBP for delivery by CW caseworkers. Strategies included: (1) tailoring the EBP for provision by caseworkers; (2) training caseworkers in the modified EBP; and (3) establishing regular supervision by mental health specialists. This paper describes the perspectives of multiple stakeholders (e.g., parents, caseworkers, supervisors, administrators) who worked collaboratively to adapt an EBP to address child behavioral difficulties for CW involved families in placement prevention services.

Methods: N = 8 stakeholders were recruited from a local CW advocacy organization as well as a CW placement prevention agency. All stakeholders were female, consisting of n = 3 parents with prior CW service experience, n = 2 caseworkers, n = 2 supervisors, and n = 1 administrator. Trained observers took written field notes of 5 collaborative board meetings with stakeholders and research staff.  The Practical, Robust, Implementation, and Sustainability Model (PRISM) guided meeting discussions, focusing on the organization’s and clients’ perspective of the intervention, characteristics of the recipient agency and intended clients, external environmental factors, and infrastructure considerations. Stakeholders also provided written feedback about the acceptability, feasibility, and relevance of the EBP for the organization and intended clients. Meeting notes and feedback were organized into relevant PRISM categories by the first author, and subsequently reviewed by 2^nd and 3^rd authors. Any disagreements were resolved via discussion to reach final consensus on categorization.

Results: Although the EBP was viewed favorably by all board members as relevant to the organization and intended client population, organization staff expressed concerns about implementing a new intervention primarily due to its length and caseworkers feeling already overburdened with existing caseloads.  Parent board members emphasized the importance of integrating parent advocates as part of the implementation process, due to their lived experience of CW involvement and caring for children with mental health difficulties.  They also raised concerns about confidentiality and low literacy levels of intended clients.   Finally, licensing regulations prohibited unlicensed individuals from providing specific therapeutic activities. In response, modifications included reducing intervention length, providing workload relief for caseworkers though administrative support, including parent advocates when training caseworkers, modifying the intervention curriculum to address confidentiality and literacy concerns, as well as removing any restricted practices from the intervention to comply with licensing regulations.

Conclusions and Implications: Findings exemplify concerns and recommendations to overcome barriers specific to implementing mental health interventions into CW service contexts.  Next steps will involve pilot testing the modified intervention with CW placement prevention services for feasibility and acceptability.