Staff Perceptions of Feasibility and Acceptability on Implementing an Evidence-Based Child Mental Health Intervention to Reduce Behavioral Difficulties in Child Welfare

Background and purpose:

Children remaining at home following a child welfare (CW) investigation manifest disproportionately high rates of behavioral difficulties, yet encounter many barriers to accessing needed treatment. Community-Based Organizations (CBOs) which provide support services to families at risk of out-of-home placement may provide an alternative service platform to provide evidence-based practices (EBPs) addressing children’s emotional/behavioral health needs.  Consequently, a multiple family group delivered EBP designed to reduce disruptive child behavioral difficulties (The 4Rs and 2Ss for Strengthening Families Program; 4R2S) was modified using task-shifting strategies and the Practice, Robust, Implementation, and Sustainability Model (PRISM) so that it could be delivered in CW settings by caseworkers without advanced mental health training.  This paper describes CW staff perceptions of feasibility and acceptability when pilot-testing the modified 4R2S in a CBO providing placement prevention services to families at risk of out-of-home placement.

Methods:

This qualitative study purposively selected caseworkers (n = 6), supervisors (n = 4), and administrators (n = 2) at one CBO providing placement prevention services, where 3 cohorts of families (n = 12) received the modified 4R2S. Staff participated in a 60-90 minute semi-structured, audio-recorded, individual, in-depth interview.  Interview questions focused on identifying the factors perceived as promoting and/or hindering feasibility and acceptability when implementing the modified 4R2S.  All interviews were transcribed verbatim, verified, and reviewed to develop the codebook using a priori and emergent themes. Codes related to facilitators and barriers were used to organize the text, and interpretation, and were guided by the Template Approach (Crabtree & Miller, 1992; 1999). 

Results:

Overall, the feasibility of modified 4R2S was made possible due to reductions in caseloads for caseworker-facilitators, utilizing in-house support staff to handle logistics (e.g., reminder calls, reserving rooms, setting up transportation), the accessible manualized intervention, and the ability to leverage research-funded resources for implementation (training, supervision, technical assistance, materials, funding for food, child care, transportation expenses). Organizational factors facilitating feasibility included an agency culture open to innovation, caseworkers’ motivation, 4R2S alignment with CBO and state child welfare values and mission, and agency flextime.  Barriers to feasibility included initial eligibility criteria for target families, the required time commitment for staff facilitating 4R2S sessions, staff turnover, and the high-risk nature of families hindering consistent attendance.  Overall, staff felt the modified 4R2S was acceptable, due to positive feedback from families, the opportunity for caseworkers to learn new skills and prioritize engagement over compliance, as well as the perceived benefits to the families related to the multiple family group modality (e.g., normalization of family difficulties, solidarity, social support, validation). Perceived barriers to acceptability were related to research supervision procedures, bureaucratic approval procedures resulting in delays, and inconsistent family attendance.  

 

Conclusion and Implications:

Overall, CW staff perceived the initial implementation of the modified 4R2S intervention as feasible and acceptable. Next steps include continued implementation while substantially reducing research supports, and building in-house infrastructure for long-term sustainability.  Findings may be useful when guiding implementation efforts for other child mental health EBPs in CW services.