Barriers to Treatment Fidelity: A Case Study Regarding Implementation of Integrated Child-Focused Adoption Recruitment Strategies

Background and Purpose:The value of treatment fidelity in the area of child welfare practice has gained traction. However, there is a limited body of research concerned with barriers to treatment fidelity and implementation of new practices, particularly in the area of adoption and permanency services.

This paper helps fill this gap by examining documented barriers to treatment fidelity in the complex, multi-site evaluation of the Nebraska Adoption Project. This federally funded research project is aimed at improving permanency outcomes for children in care. The project seeks to meet this objective by integrating intensive child-focused adoptive parent recruitment strategies into the adoption process. A randomized experimental research design is being utilized to assess the effectiveness of these intensive strategies as compared to “treatment as usual”. Treatment fidelity has been difficult to maintain with components of the experimental intervention. This paper examines the barriers to this work.

Methods: In-depth case reviews were conducted on all 17 cases (31 youth) served by the project over the course of one year.  Inclusion criteria for the project include youth who (at time of referral) were legally free for adoption or had a concurrent plan of adoption, were not in a prospective adoptive placement, were eight years of age or older, had been in out-of-home care for 24 months or longer, had experienced three or more placements while in care, and had one or more DSM-V diagnoses. Upon referral for adoption recruitment services, youth were randomly assigned to one of two treatment group agencies. Documentation related to implementation of the experimental approach was systematically reviewed and assessed for adherence to fidelity. Workers were asked to document barriers to treatment fidelity in their case notes and court reports. The evaluation team documented the barriers in field notes and thematically coded and analyzed the data using qualitative content analysis principles and an inductive approach to qualitative analysis.

Findings: Data analysis reveals that barriers to treatment fidelity were noted in every case. A small group of youth expressed a preference to age out of the system and were reluctant to engage in services. Several families struggled to engage in services and support youth in care. Some workers struggled to identify supportive family and other caring adults through searches. Issues related to youth placements (e.g. not being placed with siblings and distance from family) were present in a majority of cases. Some cases had professional team members who expressed hesitance and a reluctance to support the strategies of the experimental approach. Finally, systemic barriers, specifically the legal system, presented as a significant barrier to treatment fidelity in a majority of cases.

Conclusions and Implications: In addition to some of the implementation barriers noted in research concerning closely related areas of practice, the current findings highlight the existence of systemic barriers beyond the boundaries of service agencies – a finding that has been lacking in previous research on treatment fidelity. These barriers and their potential solutions are worth considering as child welfare agencies seek to adopt and implement new practices.