Informing child welfare caseworkers about effective therapies and practice seems like common sense. But while a US training programme successfully raised awareness of evidence-based practices, caseworkers did not make significantly more referrals to them than untrained colleagues. Does that mean it was a bad idea?
Children and young people in foster care are much more likely to have mental health problems than youth in the general population. So equipping child welfare caseworkers with better information about the use and availability of effective therapies and practice would seem like common sense.
But while a bespoke training and consultation programme for caseworkers in Washington State successfully increased their awareness of evidence-based practices (EBPs), it did not lead them to make significantly more referrals to them than other caseworkers. Does that mean it was bad idea?
Shannon Dorsey and colleagues at the University of Washington developed and evaluated the training programme – known as Project Focus – as a contribution towards improving foster children’s emotional and behavioural outcomes by better connecting them to EBPs. Their idea was to train child welfare caseworkers as “brokers” so that they could correctly identify children’s mental health needs, identify appropriate evidence-based treatments and help children gain access to them.
Writing in the journal Child Maltreatment, the researchers note that rates of clinically significant mental health problems among children in foster care are between double and four times greater than those for children generally. Mental health services are a common element of service plans for youth in out-of-home care, yet recommendations are often nonspecific or formulaic. Particular types of service are rarely identified or requested.
Caseworkers, who are expected to fulfil wide-ranging responsibilities, receive limited training in the identification of mental health needs and in EBPs. But even when aware of mental health needs and appropriate referral options they often face systemic barriers, including limited services, restricted access and waitlists.
Focusing on training
According to the Washington research team, a child welfare caseworker acting as a mental health services broker should:• be able to identify emotional or behavioural problems that require intervention• know about EBPs• understand which EBPs are available locally and how to access them• ask the right questions when assessing provider appropriateness• maintain contact during treatment to ensure progress towards agreed goals• identify supports and incentives, where needed, to encourage children and young people’s engagement and participation in treatment.
To develop these skills, Project Focus trained caseworkers in Washington State in understanding the mental health needs of foster children, screening strategies and the theory and practice of evidence-based treatment approaches. These included the use of cognitive behaviour therapy (CBT) for depression and other internalizing disorders, parenting programmes for disruptive behaviour and psycho-pharmological and behaviour therapy for attention deficit problems.
The training also covered specific “brands” of EBP that were available locally – includingParent Child Interaction Therapy (PCIT) and the “Triple P” parenting programme. Training took the form of lectures, small group activities, vignettes, short modelling and video demonstrations of EBPs.
For practical reinforcement, caseworkers were given access to four months of biweekly, one hour, case-specific consultations with experts. They were encouraged to review screening data on children, discuss appropriate treatment options and construct action plans.
As a way of increasing the local availability of EBPs, the research team also provided training and consultation for community clinicians in a manualised programme for youth aged 8 to 14 known as the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma or Conduct (MATCH-ADTC).
The evaluation of Project Focus was conducted as a small-scale trial where four child welfare offices in a mix of rural and urban areas were randomly allocated to either take part in the training programme (24 caseworkers) or a waitlist control group (27 caseworkers). Results showed that awareness of EBPs improved significantly among programme participants while remaining much the same among caseworkers in the control offices. Participants were also more knowledgeable than the control group about appropriate referrals.
However, though the number of referrals to EBPs by caseworkers who took part in Project Focus doubled, it also grew by 50 per cent among the control group – resulting in a difference that was not large enough to be statistically significant.
Dorsey and her colleagues describe their results as “disheartening”. Among possible explanations, they highlight the small sample size, which restricted the study’s power to detect significant differences. Another possible reason they advance for the lack of behaviour change amongst caseworkers is simply bad timing.
The trial took place in 2008 when Washington was confronting one of the worst state budget deficits in America. It was also implementing a new state-wide data programme that required child welfare staff to take part in training. Both of these factors placed additional demands on caseworkers to a point where less than half the participants in Project Focus attended all sessions. Those who missed training days were asked to watch a video - but it was not possible for the researchers to verify that this was done.
Accepting that this may help explain the disappointing findings, the researchers argue that behaviour change might have been achieved by increasing the intervention “dose” of training for caseworks, while simultaneously intervening to make supportive structural or organisational changes at systems level.
They also continue to insist that the role of welfare caseworkers and other brokers is worth pursuing among efforts to increase the spread and implementation of EBPs: “Given case workers’ broad responsibility and their central role in brokering services for youth, continued research and testing of models like Project Focus offer one avenue through which youth may have increased access to services that may alleviate mental health concerns.”
Dorsey, S., Kerns, S. E. U., Trupin, E. W., Conover, K. L. and Berliner. L. (2012) Child Welfare Caseworkers as Service Brokers for Youth in Foster Care: Findings from Project Focus, Child Maltreatment, 17, (1), 22-31.Return to Features