Why Are They Leaving Them in the Waiting Room? A Systematic Scoping Review Examining Caregiver Engagement in Children's Therapy from the Provider's Perspective

Background and Purpose: Caregiver engagement (i.e., the extent to which biological parents, foster parents, or other attachment figures participate in children’s therapy) is an essential component of effective mental health treatment for young children and youth. Evidence-based mental health interventions for children support the integration of caregivers into treatment. But despite over 40 years of research championing engagement, limited studies have examined clinical provider characteristics, perceptions, abilities, and decision-making processes that determine the reasons some caregivers are “left in the waiting room.” Consequently, a scoping systematic review was conducted to fill a critical gap in the literature concerning provider-related dynamics and decision-making regarding caregiver engagement in treatment for children. The review’s aims were to determine: 1) What factors influence providers in determining when and how to engage caregivers in mental health treatment for children? 2) What are providers’ perspectives concerning facilitators and barriers to caregiver engagement? and 3) What are providers’ perspectives regarding how these barriers may be overcome?

Methods: Employing a PRISMA method, a systematic scoping review was completed through a comprehensive search of 9 electronic databases and citations for studies published in English. Inclusion criteria were providers of mental health services (clinical social workers, professional counselors, early intervention specialists, family therapists, and marriage and family therapists) for children (0-18 years). Excluded were case managers, clinical nurse practitioners, medical staff, and school counselors. Records were screened and data was extracted and collated using Covidence software and Excel spreadsheets.

Results: A total of 681 records were identified. Synthesized findings (n=14 studies) suggest that facilitators to engagement are clinical training and skills in working with caregivers, beliefs and attitudes about caregiver involvement, and case-specific factors. Barriers represent the richest set of data, but few articles (n=2) incorporated providers’ perspectives regarding how they may be overcome. Findings suggest that three variables (child in foster care, parental stress level, and working in a private practice setting) were reported in conflicting ways. Provider demographics (gender, age, and years of experience) may limit generalizability to older females with more than 9 years of post-graduate clinical experience.

Conclusions and Implications: This review advances caregiver engagement research from the perspective of the provider, and findings reflect the need for these voices to inform future research in the development of a systematic definition of this construct. The concept of caregiver engagement is defined and operationalized in multiple ways. The terms “engagement,” “involvement,” “involvement and participation,” “working with,” “working alliance,” “integration,” and “engagement and participation” were used interchangeably, further confusing a delineation in the research. Future social work studies should examine clinician decision-making related to the engagement of caregivers in trauma treatment for young children. Results also call for an investment in policies and social work education programs that support family-centered services, highlighting caregiver involvement as an essential component in children’s mental health treatment.