Search

BackgroundThe majority of literature on evidence-based practice (EBP) adaptation focuses on changes to clinical practices without explicitly addressing how organizations must adapt to accommodate a new EBP. This study explores the process of organizational-rather than EBP-adaptation during implementation and sustainment. To the authors' knowledge, there are no previous implementation studies that focus on organizational adaptation in this way.MethodsThis analysis utilizes a case study approach to examine longitudinal qualitative data from 17 community-based organizations (CBOs) in one state and seven county-based child welfare systems. The CBOs had sustained a child-neglect intervention EBP (SafeCare®) for 2 to 10 years. The unit of analysis was the organization, and each CBO represented a case. Organizational-level profiles were created to describe the organizational adaptation process.ResultsThree organizational-level adaptation profiles were identified as follows: incorporators (n = 7), early investors (n = 6), and learners (n = 4). Incorporators adapted by integrating SafeCare into existing operations to meet contractual or EBP fidelity requirements. Early Investors made substantial organizational adaptations during the early implementation period, then operated relatively consistently as the EBP became embedded in the organization and service system. Learners were characterized by steady and continuous attention to new ways that the organization could adapt to support the EBP.ConclusionThe profiles demonstrated that there can be multiple effective paths to EBP sustainment. Organizational adaptation was calibrated to fit a CBO's operations (e.g., size of the program) and immediate environmental constraints (e.g., funding levels). Additionally, organizations fulfilled different functional roles in the network of entities involved in EBP implementation. Knowing organizational roles and adaptation profiles can guide implementation planning and help to structure contract designs that bridge the outer (system) and inner (organizational) contexts. Adaptation profiles can also inform the intensity of the implementation strategy tailoring process and the way that strategies are marketed to organizations.

ObjectiveWe examine how frontline workers and supervisors delivering a research supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients.MethodsWe conducted semi-structured interviews, small group discussions, and focus groups with frontline workers and supervisors in one large county over two time periods. We used iterative coding to analyze qualitative data.ResultsFrontline workers navigated several aspects of RSI implementation and sustainment: (1) contract requirements and information dissemination, (2) fidelity, (3) competing demands and crises, (4) structure versus creativity, and (5) relationships with clients.ConclusionsWorkers dynamically negotiated multiple system- and provider-level (or outer- and inner-contextual) demands influencing RSI provision for clients with complex service needs. Results affirm the need to attend to the unintended consequences of implementing new contract, reimbursement, and other system organizational processes and to address the "committed work" supporting RSI delivery.

The use of evidence-based practices (EBPs) is associated with favorable client outcomes, yet perceived burden of using EBPs may affect the adoption and implementation of such practices. Multilevel path analysis was used to examine the associations of transformational leadership with organizational climate, and their associations with perceived burden of using EBPs. Results indicated significant relationships between transformational leadership and empowering and demoralizing climates, and between demoralizing climate and perceived burden of EBPs. We found significant indirect associations of leadership and perceived burden through organizational climate. Findings suggest that further research is needed to examine the extent to which improving leadership and organizational climate may reduce perceived burden and use of EBPs with the ultimate goal of enhancing quality of care.

BackgroundLeadership is important in the implementation of innovation in business, health, and allied health care settings. Yet there is a need for empirically validated organizational interventions for coordinated leadership and organizational development strategies to facilitate effective evidence-based practice (EBP) implementation. This paper describes the initial feasibility, acceptability, and perceived utility of the Leadership and Organizational Change for Implementation (LOCI) intervention. A transdisciplinary team of investigators and community stakeholders worked together to develop and test a leadership and organizational strategy to promote effective leadership for implementing EBPs.MethodsParticipants were 12 mental health service team leaders and their staff (n = 100) from three different agencies that provide mental health services to children and families in California, USA. Supervisors were randomly assigned to the 6-month LOCI intervention or to a two-session leadership webinar control condition provided by a well-known leadership training organization. We utilized mixed methods with quantitative surveys and qualitative data collected via surveys and a focus group with LOCI trainees.ResultsQuantitative and qualitative analyses support the LOCI training and organizational strategy intervention in regard to feasibility, acceptability, and perceived utility, as well as impact on leader and supervisee-rated outcomes.ConclusionsThe LOCI leadership and organizational change for implementation intervention is a feasible and acceptable strategy that has utility to improve staff-rated leadership for EBP implementation. Further studies are needed to conduct rigorous tests of the proximal and distal impacts of LOCI on leader behaviors, implementation leadership, organizational context, and implementation outcomes. The results of this study suggest that LOCI may be a viable strategy to support organizations in preparing for the implementation and sustainment of EBP.

Implementation and scale-up of evidence-based practices (EBPs) is often portrayed as involving multiple stakeholders collaborating harmoniously in the service of a shared vision. In practice, however, collaboration is a more complex process that may involve shared and competing interests and agendas, and negotiation. The present study examined the scale-up of an EBP across an entire service system using the Interagency Collaborative Team approach. Participants were key stakeholders in a large-scale county-wide implementation of an EBP to reduce child neglect, SafeCare. Semistructured interviews and/or focus groups were conducted with 54 individuals representing diverse constituents in the service system, followed by an iterative approach to coding and analysis of transcripts. The study was conceptualized using the Exploration, Preparation, Implementation, and Sustainment framework. Although community stakeholders eventually coalesced around implementation of SafeCare, several challenges affected the implementation process. These challenges included differing organizational cultures, strategies, and approaches to collaboration; competing priorities across levels of leadership; power struggles; and role ambiguity. Each of the factors identified influenced how stakeholders approached the EBP implementation process. System-wide scale-up of EBPs involves multiple stakeholders operating in a nexus of differing agendas, priorities, leadership styles, and negotiation strategies. The term collaboration may oversimplify the multifaceted nature of the scale-up process. Implementation efforts should openly acknowledge and consider this nexus when individual stakeholders and organizations enter into EBP implementation through collaborative processes.

The objective of this study is to examine the characteristics of outpatient mental health services delivered in community-based outpatient clinics, comparing information obtained from two different sources, therapists serving children and families, and observational coders viewing tapes of the same treatment sessions. Videotaped therapy sessions were rated by therapists and independent coders regarding goals and strategies pursued during each session. Sixty-three sessions were taped of outpatient care provided to 18 children and their caregivers by 11 therapists. Children were 4–13 years old and families were receiving services at least in part due to reported child behavior problems, confirmed by ratings from the Child Behavior Checklist and Conners Parent Rating Scale—Revised. Analyses assessed the frequency, type, and intensity of goals and strategies pursued in therapy sessions from both therapist and observational coders’ perspectives. Reliability of observer ratings and correspondence between therapist and observer reports were also examined. The reliability of observational coding of goals and strategies was moderate to good, with 76% of 39 codes having ICCs of .5 or greater. Therapists reported pursuing 2.5 times more goals and strategies per session, on average, than identified by observational coders. Correspondence between therapists and coders about the occurrence of specific goals and strategies in treatment sessions was low, with 20.5% of codes having a Kappa of .4 or higher. Substantial differences exist in what therapists and independent coders report as occurring in outpatient treatment sessions. Both perspectives suggest major differences between the content of services provided in community-based outpatient clinics and the structure of evidence-based programs, which emphasize intense pursuit of a small number of goals and strategies in each treatment session. Implications of the findings for quality improvement efforts in community-based mental health care settings are discussed.

There is minimal existing research providing detailed, reliable data characterizing usual community-based psychotherapy practice, and, thus, limited established methods for such research. This article identifies methodological challenges of usual care descriptive research, including, (a) general design considerations, (b) measurement, (c) data analytic, and (d) ethical challenges. Case examples drawn from studies reported in this special issue are used to illustrate the implications, strengths, and weaknesses of different methodological decisions. Central themes include achieving an acceptable balance of scientific rigor, feasibility, and generalizable practice relevance, as well as working collaboratively with practice partners to select and implement study methods.

Objective: To examine the prevalence/predictors of mental health (MH) problems and services use in 12- to 36-month-old children who had been investigated for maltreatment. Method: Data came from the second National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal study of youth ages 0 to 17.5 years referred to U.S. child welfare agencies. These analyses involved 1117 children 12 to 36 months of age. Sociodemographic, social services, developmental and health data were collected on the children and caregivers. Outcomes were scores over the clinical cutoffs on the Brief Infant Toddler Social and Emotional Assessment (BITSEA) Scales for 12- to 18-month-olds and the Child Behavior Checklist (CBCL) for 19- to 36-month-olds. Results: In all, 34.6% of 12 to 18 month-olds scored high on the Problem Scale of the BITSEA, and 20.9% on the Competence Scale, whereas 10.0% of 19- to 36-month-olds scored over the CBCL clinical cut-off. Children of black ethnicity were less likely to have elevated scores on the BITSEA Problem Scale, whereas children who lived with a never-married caregiver were five times more likely to have elevated scores. Competence problems were associated with prior child welfare history. Elevated CBCL scores were associated with living with a depressed caregiver. Few children with identified MH problems, 2.2%, received an MH service. When we added parenting skills training that might be related to the treatment of child problems, 19.2% received a service. Conclusions: Identifiable MH problems are common, but few children receive services for those problems. The lack of services received by these young, multi-challenged children is a services systems and social policy failure. (Contains 4 tables.)

Objectives: To examine emergency department (ED) use among children involved with child protective services (CPS) in the US but who remain at home, and to determine if ED use is related to child, caregiver and family characteristics as well as receipt of CPS services. Method: We analyzed data on 4,001 children in the National Survey of Child and Adolescent Well-being. Multivariate models compared rates of ED use for whether the family "received" CPS services "or did not receive" CPS services as well as child characteristics, caregiver characteristics and caregiver/family psychological variables. Results: ED use among children who remained at home "receiving" CPS services was similar to that of children "who did not receive" CPS services (35.6% and 37.4%, respectively). In multivariate modeling, children with families who received CPS services, children 6 years or older, and children without a chronic health problem were less likely to use the ED. Children who remained at home in families identified with numerous stressors and, therefore, likely at high risk for future abuse and neglect were 1.73 times (95% CI, 1.14-2.63) more likely to have repeat ED use than children in low risk families. Conclusion: Children who remain at home after a CPS evaluation are at high risk for ED use. Future research should focus on the health problems that precipitate an ED visit as well as the relationship between primary care and ED use. (Contains 2 tables.)

Objective: To examine the frequency and predictors of out-of-home placement in a 30-month follow-up for a nationally representative sample of children investigated for a report of maltreatment who remained in their homes following the index child welfare report. Methods: Data came from the National Survey of Child and Adolescent Well-being (NSCAW), a 3-year longitudinal study of 5,501 youth 0-14 years old referred to child welfare agencies for potential maltreatment between 10/1999 and 12/2000. These analyses focused on the children who had not been placed out-of-home at the baseline interview and examined child, family and case characteristics as predictors of subsequent out-of-home placement. Weighted logistic regression models were used to determine which baseline characteristics were related to out-of-home placement in the follow-up. Results: For the total study sample, predictors of placement in the 30-month follow-up period included elevated Conflict Tactics Scale scores, prior history of child welfare involvement, high family risk scores and caseworkers' assessment of likelihood of re-report without receipt of services. Higher family income was protective. For children without any prior child welfare history (incident cases), younger children, low family income and a high family risk score were strongly related to subsequent placement but receipt of services and case workers' assessments were not. Conclusions/practice implications: Family risk variables are strongly related to out-of-home placement in a 30-month follow-up, but receipt of child welfare services is not related to further placements. Considering family risk factors and income, 25% of the children who lived in poor families, with high family risk scores, were subsequently placed out-of-home, even among children in families who received child welfare services. Given that relevant evidence-based interventions are available for these families, more widespread tests of their use should be explored to understand whether their use could make a substantial difference in the lives of vulnerable children.

Objective: Behavioral difficulties increase the risk that children will experience negative placement disruptions while in foster care. Chamberlain et al. (2006) found that the Parent Daily Report (PDR), a brief measure of parent-reported child behaviors, was a strong predictor of negative placement changes over 1 year among children receiving "usual case work" services. This paper sought to replicate and extend original findings regarding the PDR among 359 foster parents participating in a group parent-training intervention. Methods: Foster parents of children experiencing a recent foster placement, and taking part in the KEEP parenting program, were included in analyses. Foster parents completed 16 weekly PDR calls about the behavior of a foster child in their care during the KEEP intervention and about their stress related to the child's behaviors. Multiple strategies, including latent class analysis of weekly PDR counts and continuous moving averages of PDR counts over shorter time frames, were used to test improvements in prediction of negative placement changes. Results: Consistent with prior findings, children with elevated PDR ratings and children living with non-relative foster parents had significantly higher levels of negative placement disruptions. Prediction improved with decision rules relying upon increased amounts of weekly PDR information, although good prediction was achieved with 3-5 weeks of PDR information. Parent-reported stress associated with behavior did not improve prediction. Conclusions: This study confirmed the potential utility of the PDR as a predictor of negative placement changes and illustrates how longitudinal PDR information may aid in improving such prediction. Potential applications of the PDR for improving the timing, type, and quantity of services offered to help foster parents prevent placement disruptions are discussed. (Contains 4 tables and 1 figure.)

This study compared data from 34 research trials of five empirically supported treatments (ESTs) with one large usual care (UC) sample on child, parent, and family characteristics for children with Disruptive Behavior Disorders. Large variations were found within and across ESTs on sample characteristics during the past two decades. Most parent and family characteristics were not reported in EST studies. Statistical comparisons between UC and EST samples revealed that occurrences of child demographics and symptom severity levels were similar, but occurrences of most parent and family characteristics were different, with higher rates of problems for the UC sample. Results indicate that UC clients have complex needs, with multiple child, parent, and family issues. The findings are discussed in relation to the importance of acknowledging parent and family contextual variables in implementation efforts. (Contains 2 tables and 1 note.)

Using longitudinal data from the National Survey on Child and Adolescent Well-Being (NSCAW), this study investigates entry into intensive or restrictive settings during a 36-month study period. Specifically, this analysis examines entry into treatment foster care, group homes, residential treatment, and inpatient psychiatric care for youth placed into out-of-home care (n = 981). It aims to determine at what point in their first out-of-home episodes and for what reasons youth entered such settings. As NSCAW used a national probability sampling design, this analysis provides national estimates about entry into intensive or restrictive settings for youth in out-of-home care. Twenty-five percent of youth (n = 280) experienced an intensive or restrictive setting during their first out-of-home care episode; 70% were in either group homes (33.2%) or residential treatment settings (37.0%). About half of the youth with such placements (48.9%) were placed into intensive or restrictive settings as a first placement during their first out-of-home episode.

Objective: To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics. Method: A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review. Results: Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors. Conclusion: Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(2):130-144. Key Words: quality of care, child mental health attention-deficit/hyperactivity disorder, psychotropic medication, safety.

Objective: To determine factors influencing the use of outpatient mental health services provided by mental health professionals (OMHS) for children in foster care using a national probability sample in the United States. Method: As part of the National Survey of Child and Adolescent Well-being, detailed survey data were collected on 462 children, ages 2-15, who had been in out-of-home care for approximately 12 months at the time of sampling. A multivariate logistic regression model was used to determine how clinical need, as measured by a Total Problem, Externalizing, or Internalizing Scale T-score of 64 or greater on the Achenbach Child Behavior Checklist (CBCL), and non-clinical factors affected OSMHS use. Results: Over half of the children in the sample received at least one OMHS. Need, older age, and history of sexual abuse history all positively predicted OMHS. A history of physical neglect negatively predicted OSMHS. African-Americans used fewer services than children of Caucasian ancestry at all values on the CBCL. This finding was particularly salient at lower levels of CBCL scores; at higher levels, the discrepancy in the use of services diminished but the proportion of children receiving services remained lower for African-American children. Conclusions: This national study confirms previous findings regarding the use of mental health services based on regional data. Limitations in the use of services imposed by non-clinical factors, specifically, age, race/ethnicity and type of abuse, need to be examined in order to address implicit and explicit policies and practices that may result in inequitable distribution of services.

A study of service-representation patterns of four racial/ethnic groups across five public youth-service sectors in San Diego County found that race/ethnicity affects service-use patterns and that socioeconomic status should be taken into consideration when examining racial/ethnic representation. (Author/CR)

Copyright of Family Process is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Evidence is given about the most promising programs from other child service sectors with information about the current parent training approaches in child welfare. A range of proposals about next steps to enhance the capacity of parent training is generated and fulfills the high expectations set in law and practice.

ABBREVIATIONS. CWLA, Child Welfare League of America; AAP, American Academy of Pediatrics; PSU, primary sampling unit; CCCW, Caring for Children in Child Welfare; NSCAW, National Survey of Child and Adolescent [...], Objectives. To 1) investigate the status of policies for comprehensive health assessments of children entering out-of-home care, 2) develop a profile for each primary sampling unit (PSU) regarding the comprehensiveness of its assessment policies with respect to physical, mental, and developmental health, and 3) examine the relationship between inclusiveness and the estimated percentage of children assessed, primary assessment location, and principal assessment provider type. Method. In collaboration with the National Survey of Child and Adolescent Well-Being, a national probability sample of 92 PSUs was identified. Detailed telephone survey data, addressing policies for the assessment of physical, mental, and developmental needs of children on entry into out-of-home care, were collected from child welfare key informants. Descriptive statistics were used for analyses, and were weighted to account for the sampling strategy. Results. Over 94% of PSUs surveyed assessed all children for physical health problems. The percentage of PSUs with inclusive policies regarding mental health and developmental assessment was much lower (47.8% and 57.8%, respectively). Only 42.6% of PSUs provided comprehensive physical, mental health, and developmental examinations inclusive of all children entering out-of-home care. Community locations and primary care providers were most often used to conduct assessments for physical and developmental problems. Conclusions. Despite the publication of national guidelines regarding assessment, many PSUs do not have comprehensive policies or routine practices that address all children entering out-of-home care. Given the high use of primary care providers, these providers must be educated regarding the prevalence and types of problems experienced by children entering foster care.

Child abuse and neglect (CAN) is a complex issue that is subject to both under- and overreporting; yet, research into the underlying neighborhood-level drivers of these practices remains limited. The current study gathered perspectives from 30 child protective service (CPS) workers and agency leaders in Southern California neighborhoods to identify perceptions of social and contextual neighborhood factors that might influence over- and underreporting of CAN. The data were analyzed using a grounded theory approach, which revealed five themes: (a) neighborhood conflict, (b) neighborhood fear and mistrust, (c) neighborhood norms, (d) poor CAN reporting knowledge, and (e) mandated reporters' discretion. These themes highlight the potential impact of neighborhood contexts and social dynamics on CAN reporting practices, emphasizing the need for prevention and early intervention neighborhood-level initiatives that improve CPS relationships within their local community. [ABSTRACT FROM AUTHOR]