Evidence-Based Elements of Child Welfare In-Home Services

Children who are involved in the child welfare system manifest higher rates of behavioral difficulties in comparison to youth within the general population. According to the National Survey of Child and Adolescent Well-Being, 33-43% of youth whose families were investigated by child protective services (90% of whom remained at home following the investigation) manifested clinical/borderline externalizing behavioral difficulties, while comparable estimates for the general population range from 5-7% (Administration for Children & Families [ACF], 2005; Burns et al., 2004). At the same time, their families experience substantial barriers to accessing and engaging in mental health services, such as concrete and logistical barriers (e.g., lacking money for transportation and childcare, competing demands for families mandated to receive multiple services by child welfare authorities) (McKay & Bannon, 2004; Kemp, Marcenko, Hoagwood, & Vesneski, 2009). Additionally, negative perceptions about mental health and treatment, including stigma and prior negative experiences with other services providers and child welfare staff, reduces service use (Anderson, 2006; Kerkorian, McKay, & Bannon, 2006; McKay & Bannon, 2004; Kemp et al., 2009). As a result, most children with mental health problems who are involved in the child welfare system do not receive needed treatment (Burns et al., 2004), while those who are able to engage in treatment are likely to terminate before receiving therapeutic benefit (Lau & Weisz, 2003). Untreated mental health need among children is detrimental to the entire family, particularly among those involved in the child welfare system. Children with behavioral difficulties are at increased risk for future maltreatment (Black, Heyman, & Slep, 2001; Schumacher, Slep, & Heyman, 2001), and families often voluntarily place children with severe behavior problems into out-of-home placement (Barth, Wildfire, & Green, 2006). Longer-term consequences of untreated behavioral issues include increased risk for criminal involvement, substance abuse, and risky sexual behavior (Brown, Danovsky, Lourie, DiClemente, & Ponton, 1997; Gillmore, Morrison, Lowery, & Baker, 1994; Inciardi, Pottieger, Forney, Chitwood, & McBride, 1991; Lewis, 2010; Morris, Baker, & Huscroft, 1992; Schaeffer, Petras, Ialongo, Poduska, & Kellam, 2003; Weber, Elfenbein, Richards, Davis, & Thomas, 1989). The services required to address these compounded needs result in substantial expenditure increases (up to 10 times), making youth behavioral difficulties a costly public health concern (Scott, Knapp, Henderson, & Maughan, 2001). Thus, enhancing access to service use is a high priority, particularly amongst families who are involved in child welfare. Peer-delivered services offer promise for connecting vulnerable families to needed resources, including mental health care (Acri, Olin, Burton, Herman, & Hoagwood, 2013; Chinman, et al., 2006; Chinman, Young, Hassell, & Davidson 2008; Solomon, 2004). In the adult health and mental health fields, peers, who themselves have a health or mental health problem, provide outreach, education, and in some cases, therapeutic services to individuals who are at-risk or in treatment (Auslander, Haire-Joshu, Houston, Rhee, & Williams, 2002; Chinman et al., 2008). In the child mental health system, peers are typically caregivers of children with mental health challenges who are trained to provide family support, including instruction/skill development (e.g., parenting strategies, anger management and stress reduction techniques), emotional support, and instrumental services (e.g., transportation, respite, childcare). Including family support as part of child mental health treatments may optimize services by addressing many of the family-level issues (e.g., caregiver strain and mental health), which could derail treatment engagement and outcomes (Barnard & McKeganey, 2004; Leslie, Aarons, Haine, & Hough, 2007; Petterson & Albers, 2001; Reyno & McGrath, 2006). A newer model of family support service delivery in child mental health interventions consists of an interdisciplinary team composed of a mental health professional and a peer. Team-delivered interventions have been associated with important caregiver outcomes including: increased knowledge of mental health services, an enhanced sense self-efficacy, high satisfaction with services, and increased social support and reduced isolation (Hoagwood et al., 2010). A lesser-studied area of inquiry involves how caregivers perceive services co-led by a peer, and if there are any additive benefits to involving a peer in child mental health interventions. In the adult mental health literature, for example, peers have been shown to deliver services as effectively as other professionals (e.g., case managers; Chinman et al., 2008) as well as offer unique benefits (e.g., foster caregiver empowerment and self-care; Hoagwood et al., 2010). Whether this is true of co-led child mental health interventions, and particularly amongst families with complex needs such as those involved in the child welfare system, is not clear. The purpose of this study is to describe caregiver perceptions of a co-led model for children with behavioral problems among families with complex needs (i.e. child welfare involvement), and to explore whether there are any additive benefits associated with utilizing peers as part of a team service delivery model. The current undertaking derives from a larger effectiveness study that examined the impact of a Multiple Family Group (MFG) service delivery model for children with disruptive behavior disorders and their families--also known as the 4Rs and 2Ss Family Strengthening Program (Chacko et al., in press; Gopalan et al., in press; Gopalan et al., 2014; Gopalan, Fuss, & Wisdom, in press; Gopalan & Franco, 2009; McKay et al., 2011; Small, Jackson, Gopalan, & McKay, in press). Within this model, interdisciplinary peer-clinician teams provided treatment to low-income, inner-city families, which included a substantial proportion of families reporting child welfare involvement. Briefly, the MFG model integrates therapeutic principles from family therapy, behavioral parent training, and group therapy. Weekly group sessions involve six to eight families (including caregivers, identified child with behavioral difficulties, and siblings) over the course of four months. Additionally, MFG addresses barriers to treatment and promotes positive service experiences for youth and their families. The larger study, which began in October, 2006 and concluded in October, 2010, enrolled 320 children (n= 225 Experimental MFG group; n= 95 Services as Usual group) between seven and 11 years of age who met criteria for Oppositional Defiant Disorder or Conduct Disorder and their families. See Chacko et al. (in press) and McKay et al. (2011) for a more thorough description of the MFG service delivery model and the study from which the current project derives. To date, MFG has been shown effective in reducing child behavioral difficulties and improving youth social skills when compared to services as usual (Chacko et al., in press; Gopalan et al., in press). This model may be beneficial for child welfare involved families as an innovative mental health intervention focused on engaging and retaining low-income, urban minority families, reducing childhood behavioral difficulties, and addressing inner-city service capacity limitations. Consequently, before MFG can be tested exclusively with child welfare involved families, understanding how child welfare involved caregivers respond to the intervention will identify where modifications, if any, may be necessary.