Abstract
Objective
To examine the extent to which child welfare agencies adopt new practices and to determine the barriers to and facilitators of adoption of new practices.
Methods
Data came from telephone interviews with the directors of the 92 public child welfare agencies that constituted the probability sample for the first National Survey of Child and Adolescent Well-being (NSCAWI). In a semi-structured 40 minute interview administered by a trained Research Associate, agency directors were asked about agency demographics, knowledge of evidence-based practices, use of technical assistance and actual use of evidence-based practices.. Of the 92 agencies, 83 or 90% agreed to be interviewed.
Results
Agencies reported that the majority of staff had a BA degree (53.45%) and that they either paid for (52.6%) or provided (80.7%) continuing education. Although agencies routinely collect standardized child outcomes (90%) they much less frequently collect measures of child functioning (30.9%). Almost all agencies (94%) had started a new program or practice but only 24.8% were evidence-based and strategies used to explore new programs or practices usually involved local or state contracts. Factors that were associated with program success included internal support for the innovation (27.3%), and an existing evidence base (23.5%).
Conclusions
Directors of child welfare agencies frequently institute new programs or practices but they are not often evidence-based. Because virtually all agencies provide some continuing education adding discussions of evidence-based programs/practices may spur adaption. Reliance on local and state colleagues to explore new programs and practices suggests that developing well informed social networks may be a way to increase the spread of evidence0based practices.
Keywords: Evidence-based practice, child welfare, community networks
1. Introduction
1.1 Literature Review
Child welfare agencies are responsible for multiple mandates. They must ensure optimal, stable placements for children who are investigated for maltreatment and who are placed in out-of-home care. They must also deliver or facilitate the delivery of services to assist parents of investigated children who are not placed in retaining their children safely at home, preventing further maltreatment and future out-of-home placements as well as promoting child wellbeing. There are numerous efficacious interventions that can change family environments, improve parenting skills and decrease difficult child behaviors that are appropriate for the families child welfare serves. However, research has documented that most of the interventions delivered in child welfare are not treatment strategies with solid empirical support (Hurlburt et al, 2005; Chadwick Center, 2004).
There are multiple reasons that these evidence based practices are not commonly used in child welfare. Social work educational curricula have not focused on evidence-based practices (EBPs) (Weissman et al, 2006) although some evidence-based practice focused programs do exist such as the USC School of Social Work and the associated Hamovitch Center for Science in the Human Services (www.sowkweb.usc.edu accessed 3/9/2012). Given that professionals practice using the content and techniques they learned while in their graduate or professional educational programs, the lack of EBPs training for social workers is a concern (Horwitz et al, 2010; Institute for Advancement of Social Work Research, 2007). Two additional barriers to the implementation of EBPs for child welfare agencies are the ability to access research-based information on evidence-based programs and the level of comfort with both exploring and considering adoption of EBPs (Chadwick Center, 2004; Chaffin and Friedrich, 2004; Glisson and Schoenwald, 2005). In contrast to the field of medicine, discussions of evidence based practices only began within the last decade in child welfare (Barth et al, 2005; Chaffin and Friedrich. 2004; NAPCWA, 2005; Chadwick Center, 2004; The California Evidence-Based Clearinghouse for Child Welfare, 2004), an important reason that there is this lack of comfort with the exploration, adoption and implementation of EBPs (Horwitz et al, 2010). What little we do know about the exploration and adoption of EBPs in child welfare agencies comes from the study of adoption of specific interventions (Aarons and Palinkas, 2007; Chamberlain et al, 2008; Wang et al, 2010) and suggests that organizational structure, climate, context, and culture influence both agency effectiveness (Yoo et al, 2007; Glisson and Himmelgarn, 1998; Glisson and Green, 2011) and implementation of specific EBPs (Aarons and Palinkas, 2007; Palinkas and Aarons, 2010; Chamberlain et al, 2008) with more recent work by Palinkas et al (2011) suggesting that interagency networks may be a driver of innovation adaption and Aarons et al (2011) identifying the importance of positive leadership. Importantly, Chamberlain et al (2011) have identified stages of implementation completion and have examined agencies' progression through these stages.
Unlike in mental health, there are no national or state data on the extent to which child welfare agencies implement EBPs, how far into the implementation process agencies progress or on the barriers and facilitators to adopting and subsequently implementing EBPs. Data from a statewide EBP implementation project in mental health suggest that risk-related assessments, resource availability and an organization's past propensity to take risks are related to adoption (Panzano and Roth, 2006) while data, from a national sample of directors of mental health agencies serving children show most agencies (83%) implemented at least one new clinical treatment or service within the last 5 years yet only 10% could be classified as evidence-based. Existing implementation practices, infrastructure support and organization mission and support were found to be most important for implementation of a new treatment/service (Schoenwald et al, 2008).
1.2 Study Purpose
Given the paucity of information about child welfare agencies' adoption of evidence-based practices, we examined the extent to which agencies explore and adopt new practices and the barriers to and facilitators of exploration and adoption in a national sample of county child welfare agencies.
2. Methods
2.1 Design
Data for these analyses came from the 92 primary sampling units (usually a county) that constituted the national probability sample for the first National Survey of Child and Adolescent Well-being (NSCAWI). Mandated by Congress, NSCAWI enrolled a cohort of 5,501 children birth to 14 years of age and followed them prospectively. The affiliated Caring for Children in Child Welfare (CCCWI) study examined services delivered, policies and agency characteristics of the public, usually county, child welfare agencies making up the 92 PSUs. Data was solicited from key informants at the agencies between September 2000 and June 2001 (Leslie et al, 2003).
Beginning in March 2010, the public agencies in the 92 PSUs in NSCAWI were again contacted to gather information on their experience with exploration and adoption of evidence-based practices as well as barriers and facilitators to the exploration, adoption, and implementation process. All interviews were conducted by telephone using semi-structured interviews by one Research Associate. This individual had interviewed the county welfare directors in the CCCWI study and had extensive interviewing experience. She was trained to administer the questionnaire through role playing, paying specific attention to questions with follow-up prompts and was supervised by one of the authors (JR). Interviews took, on average, about 40 minutes, and no child or case specific data were collected. Over a 15- month time period 184 key informants, usually agency directors and the individual responsible for parent training activities, were interviewed. Of the original 92 PSUs, 83 (90%) agreed to be interviewed. These 83 PSUs contained 88 agencies. All procedures were approved by the Rady Children's Hospital San Diego Institutional Review Board.
2.2 Measures
The Director's interview asked about size and staffing of the agency, continuing education, knowledge of evidence-based treatments and technical assistance using a semi-structured interview format with closed-ended questions and questions with opportunities for further elaboration. We asked specifically about 10 resources that potentially could provide technical assistance around the adoption of evidence-based care including:
Annie E. Casey Foundation—a private foundation to foster human service reforms to effectively meet the needs of vulnerable children through grants, technical assistance and demonstration projects. A specific focus is child welfare and the Foundation has a long track record of moving promising interventions into community settings (www.aecf.org, accessed 5/10/2012).
Casey Family Services—the direct service arm of the Annie E. Casey Foundation both supports a range of direct services and partners with local and state organizations on a number of initiatives.
Children's Bureau Technical Assistance—has a number of technical assistance activities designed to support and build the capacity of state and local child welfare agencies including three quality improvement centers dedicated to disseminating evidence-based and evidence-informed practices (www.acf.hhs.gov/programs/CB, accessed 5/10/2012).
State Technical Assistance—a number of states such as California and Ohio have established quality improvement initiatives and centers to facilitate the diffusion of evidence-based practices into community agencies.
Chapin Hall—located at the University of Chicago is dedicated to improving the well-being of children, youth, families and communities. Chapin Hall supports the Center for State Foster Care and Adoption data that supplies child welfare agencies with technical assistance to examine agency outcomes as well as data to assess service and policy innovations (www.chaplinhall.org, accessed 3/10/2012).
Walter R MacDonald—a firm supporting national, state and local human services agencies to improve outcomes for children and families. They developed the National Statewide Automated Child Welfare Information Systems Prototype and have conducted successful quality improvement projects with state and county child welfare agencies (www.wrma.com; accessed 5/12/2012).
NAPCWA—the National Association of Child Welfare Directors is a national organization representing child welfare agencies dedicated to implementing effective programs, practices and policies. It supports a number of initiatives including educational conferences and guidance for critical service areas (www.napcwa.org; accessed 05/12/2012).
American Humane Association—one of the earliest efforts to protect children the Humane Society supports a number of initiatives such as Family Group Decision Making as well as Quality Improvement Centers (www.americanhumaneassociation.org; accessed 05/12/2012).
CWLA—a network of public and private agencies to advance best practices to promote better outcomes for vulnerable children and families. They have developed standards of excellence for child welfare and have numerous consulting and training initiatives aimed at improving programs/practices in child welfare (www.cwla.org; accessed 05/12/2012).
California Evidence-based Clearing House for Child Welfare—provides child welfare professionals web-based access to research evidence on programs applicable to the children and families served by child welfare agencies. Initiated in 2004 and funded by the California Department of Social Services this is a free, easily accessible resource describing and rating innovative treatments and interventions relevant for this population (www.cebc4cw.org; accessed 5/12/2012).
Open-ended questions were followed up with a series of probes. To solicit information about the use of evidence based practices, we used the questions contained in the program change module from the MacArthur Research Network on Youth Mental Health Clinic Directors Survey described in Schoenwald et al (2008). Specifically, we used the questions that asked if the agency had instituted a new practice or procedure in the last 5 years, the name of the practice or procedure and how far along in the implementation process the agency had come – describing this progress using the stages outline in Aarons et al, 2011. Directors were next asked to describe the implementation process for the practice or procedure they felt was most successful and factors that served as facilitators or barriers.
2.3 Analyses
Descriptive analyses are provided for all variables, and all analyses were weighted for sampling and other design features making the descriptive statistics representative of child welfare agencies nationally at the time of NSCAW I. Responses to the questions with open-ended responses were coded by one of the authors (EF) by organizing specific responses into broad themes. Notably, a system reform was considered any structural change such as a billing system or a new service such as a crisis unit without a specifically named programmatic basis. A program was anything labeled as a new program or treatment usually tied to a specific need such as foster parent attachment training. A program was considered evidence-based when it was rated as 1, 2 or 3 by the California Evidence-based Clearing house for child welfare meaning that the evidence supporting the efficacy of the intervention was well supported by research evidence (1), supported by research evidence (2) or had promising research evidence (3) (The California Evidence-Based Clearing House for Child Welfare, 2004). The specific responses and themes were reviewed by two of the other authors (SMH, JRR) and the few minor discrepancies (<5%) were resolved through a consensus discussion.
3. Results
3.1 Sample Description
Characteristics collected on child welfare agencies are shown in Table 1. Agencies reported that the majority of their staff had a maximum of a BA degree (53.4%) with 46.9% of agencies reporting challenges filling case worker positions. They usually paid for (52.6%) or provided (80.7%) continuing education courses, and almost all agencies (94.8%) reported that staff could attend continuing education classes during working hours.
Table One. Characteristics of the Child Welfare Agencies Participating in CCWII.
| Characteristic | Weighted % |
|---|---|
| Professional disciplines of staff by agency | |
| MSW | 16.4% |
| BSW | 28.5% |
| BA or below | 53.4% |
| Other degrees | 1.7% |
| Had difficulty filling vacant case worker positions: Yes | 46.9% |
| Continuing education: Yes | |
| Pay for courses | 52.6% |
| Reimburse for courses | 34.8% |
| Provide for continuing education | 80.7% |
| Allowed to attend during work hours | 94.8% |
| Collect standardized child outcome measures | 90.0% |
| Why: Mandated by government | 88.7% |
| Required for reimbursement | 69.6% |
| Used for treatment planning | 61.0% |
| Used for clinical supervision | 47.9% |
| Used for agency management | 81.0% |
| Used for quality improvement | 99.8% |
| Collect child functioning measures | 30.9% |
| Agency involved in Child and Family Services Review (CFSR): Yes | 58.8% |
| Did CFSR recommend a specific program: Yes | 28.5% |
| Types of technical assistance | |
| Annie E. Casey Foundation | 36.3% |
| Casey Family Services | 41.1% |
| Regional Technical Assistance Sponsored by the Children's Bureau | 25.3% |
| State Technical Assistance | 21.4% |
| Chapin Hall | 17.7% |
| Walter R MacDonald | 0.6% |
| NAPCWA | 5.3% |
| American Humane Association | 23.9% |
| CWLA | 25.9% |
| Heard of California Evidence-based Clearing House for Child Welfare | 14.0% |
| Visited the website | 86.9% |
Agencies routinely collect standardized child outcome measures (90 %) largely because they are mandated to do so (88.7%) and, of these, 99.8% stated that they used them for quality improvement. When asked about collection of measures of child functioning only 30.9% reported collecting these. Just over one half the agencies (58.8%) had been involved in a Child and Family Services Review (CFSR) and of these, 28.5% reported that the CFSR recommended the addition of a specific program. Agencies used a range of technical assistance with assistance from the Annie E. Casey Foundation (36.3%) and Casey Family Services (41.1%) most frequently used. Few agencies knew of the California Evidence-Based Clearinghouse for Child Welfare (CEBC) (14.0%), but those that knew of this resource had visited the website (86.9%).
3.2 Innovations
Ninety four percent of agencies reported starting a new program or practice in the last five years with a range of 0-8 (average 2.04) new endeavors. System Reforms (e.g. a new crisis unit) were mentioned by 35.7% of the Directors while 47.1% mentioned a new program (Table 2). Few of the programs mentioned were evidence-based (24.8% had a program with an evidence based that would score a 1-3 by the CEBC). Agencies reported that for new programs 100% progressed to the planning stage, 94.6% progressed to budgeting, 94.3% were implemented, and 83.4% were sustained. Thus, multiplying across the percentages achieving each stage, about 76% of all planned programs were sustained. For system reforms, 100% completed the planning stage, 94.4% progressed to budgeting, 94.0% were implemented but only 65.6% were sustained. For systems reforms about 58% of those reforms that were planned were sustained.
Table 2. Experience with Exploring Adopting: Implementing New Programs or Practices.
| Weighted % | ||
|---|---|---|
| Characteristic | ||
| New program or practice in last 5 years (%yes) | 93.9% | |
| Number of new programs or practices: (see output below for each items) |
||
| Mean | 2.04 | |
| Range | 0-8 | |
| Total programs mentioned | 204 | |
| Type of program/practice: | ||
| Systems reform | 35.7% | |
| Program | 47.1% | |
| Program Evidence-Based | 24.8% | |
| Exploration Strategies | ||
| Outside of the state/county: | ||
| Collaborations with child welfare researchers/program developers | 6.5% | |
| Child welfare services conferences | 0.7% | |
| Interactions with National Child Welfare Services Organizations | 5.4% | |
| State: | ||
| State child welfare agency staff | 35.7% | |
| State RFP for programmatic change | 4.4% | |
| Country: | ||
| Interactions with other county child welfare directors | 36.8% | |
| Interactions with Directors of other community agencies, (mental health, developmental disabilities) | 37.3% | |
| Agency: | ||
| Research by Agency Staff (internet or literature searches) | 54.0% | |
| Discussions with local stakeholders | 5.1% | |
| Implementation stages | ||
| Adoption | Programs | System Reforms |
| Planning (sum ‘Yes’ from 8 programs, range 1=8) | 100 % | 100 % |
| Budgeting (sum ‘Yes’ from 8 programs, range 1=8) | 94.6 % | 94.4 % |
| Implementation (sum ‘Yes’ from 8 programs, range 0=8) | 94.3 % | 94.0 % |
| Sustained (sum ‘Yes’ from 8 programs, range 0=8) | 83.4 % | 65.6 % |
Directors mentioned a range of strategies used to explore new programs or practices. Approaches that did not involve state or local contacts were much less frequently mentioned than those that involved local contacts. For example, only 6.5% of Directors mentioned contacting a university researcher or program developer, less than 1% mentioned conference attendance and only 5.4% indicated that they had explored new programs or practices through discussions with National Child Welfare Service Organizations. Conversely, 35.7% of Directors mentioned interactions with state child welfare agency staff as a means for exploring new programs or practices. Likewise, these child welfare agency directors heavily depend on their interactions with their child welfare colleagues (36.8%) and directors of other community agencies (37.3%) as well as research by their own agency staff (54.0%) to explore new programs or practices. Discussions with local stakeholders do not often prompt such exploration (5.1%).
3.3 Most Successful Innovation
Table 3 shows the characteristics of the program the Director assessed as most successful. Programs were most often implemented in response to needs generated from agency level data, concerns about the high cost of existing services or recommendations from individuals within the agency. Approximately one third (34.6%) of Directors said they implemented a program because it was being promoted by another agency. Factors that lead to the success of the program were internal support for the program (27.3%) and an existing evidence base for the program or practice (23.5%). Factors that most often hindered successful adoption were problems in implementing the selected program or practice (37.3%) and resistance to change on the part of agency staff (32.2%).
Table 3. Characteristics of the Agencies' self assessed most successful program. CCCW data.
| Characteristics | Weighted % |
|---|---|
| Reason program implemented | |
| Agency became more safety focused | 7.7% |
| Analysis of data from current system | 41.2% |
| Availability of funds to implement | 5.8% |
| Funding concerns—High costs of existing services | 23.5% |
| Directive from above | 5.5% |
| External recommendation | 10.8% |
| Internal recommendation | 28.1% |
| Lawsuits/legal | 1.6% |
| Program promoted by another agency: Yes | 34.6% |
| Factors that supported successful implementation | |
| Clear need for the program | 4.4% |
| Cultural change/paradigm shift within agency | 9.3% |
| Existing evidence base for program | 23.5% |
| External support | 20.1% |
| Financial resources | 27.3% |
| Fit of program with agency | 17.1% |
| Internal support | 40.1% |
| Support from program staff | 18.6% |
| Factors that hindered success for implementation | |
| Cultural change/paradigm shift was needed, did not occur | 9.4% |
| Financial issues | 10.5% |
| Fit of program within agency | 2.4% |
| Lack of external support | 9.5% |
| Problems implementing the program itself | 37.3% |
| Problems sharing data between partners | 10.6% |
| Resistance to change | 32.2% |
4. Discussion
These unique data from a national probability sample of Directors of Child Welfare Agencies are in agreement with the data generated by Schoenwald et al, 2008, and suggest that agencies are almost universally (94%) experimenting with new programs or practices although these programs are not often evidence-based (24.8%). That the programs are unlikely to be evidence-based is not surprising given that the majority of case workers (53.4%) have college but not professional degrees and are therefore highly unlikely to have been exposed to EBPs, that the use of technical assistance is not universal and that there is little recognition of existing resources about EBPs—only 14% of Directors had heard of the California Evidence-based Clearing House for Child Welfare, a resource funded by the State of California to, promote the dissemination of information about EBPs appropriate for use in child welfare (www.cachildwelfareclearinghouse.org).
When we specifically examined the details about the new practices implemented, we found that Directors reported from 0-8 new programs or practices in the last five years (mean 2.04). Of these reported programs/practices, 35.7% were some form of a system reform (e.g., development of a new crisis unit) while 47.1% were programmatic interventions suggesting that on average new programs were somewhat infrequently adopted, a rate of approximately one new program in the five year period.
The strategies used to explore new practices or programs are extremely revealing. Directors infrequently mentioned using resources outside their counties or states. Unlike medicine with its emphasis on continuing education, licensure and recertification and, thus, its focus on research, Directors rarely collaborated with researchers (6.5%), garnered information from national conferences (0.7%) or used the interactions they reported that they had with organizations dedicated to improving programs and treatments for child welfare families and children (e.g., Child Welfare League of America) to investigate possible new programs or practices. Conversely, Directors often report using state child welfare agency staff (35.7%) and directors of other agencies in the same county (37.3%) as resources for exploring new programs and practices indicating that professional social networks are important sources of information about evidence based practices as noted by Palinkas et al, 2011 and Valente et al. 1996. Directors reported that new programs and practices are most often generated by research done by agency staff (54.0%) and that continuing education courses are commonly provided (80.7%), suggesting that using continuing education as a means to expose agency staff to evidence based practices and programs may be an opportunity for programmatic improvement. Directors more often reported that programs (76%) as compared to systems reforms (58%) were sustained.
When Directors reported on their most successful program, they indicated that the program was initiated in response to a need generated from agency level data, concerns about the high cost of a service or because someone in the agency perceived a need. These responses are consistent with adoption theories that stress the importance of perceiving a need before any exploration of an innovation is likely to occur (Wisdom et al, 2012). The importance of other agencies as a prompt for program adoption once again was expressed by 34.6% of these Directors when they confirmed that the reason a particular program was implemented was because another agency had promoted its use. Success was thought to be due to agency staff support for the program (40.1%), adequate financial resources (27.3%) and an existing evidence-base for the selected program (23.5%), factors consistent with theoretical models of adoption and implementation (Aarons et al, 2011; Wisdom et al, 2012). Factors that most often served as barriers were problems in implementing the program/practice (37.3%) and resistance on the part of agency staff (32.2%). Again, these factors are well described in the extant literature (Aarons et al, 2011).
4.1 Limitations
These data have certain limitations. They are all self report and no attempt was made to verify any information. Data on exploration and adoption of evidence-based practices were only gathered from one individual and may not reflect the totality of an agency's efforts. Detail about technical assistance was not collected so it may be that use of technical assistance was not around evidence-based practices. Additionally, it could be that agencies did not use technical assistance for exploring evidence based, practices because they did not perceive that the assistance could provide information about these practices. CCCW2 data have not been linked with NSCAWII agency data preventing an examination of the relationships of agency characteristics to exploration and adoption issues.
5. Conclusions
Like Directors of Mental Health Agencies in the same counties (Schoenwald et al, 2008), Directors of Child Welfare Agencies almost universally have instituted a new program or practice within the last 5 years, but new programs are not frequently adopted nor are they evidence based. Comments from Agency Directors suggest two possible strategies for increasing the exploration and hopefully adoption and implementation of evidence-based programs. First, because virtually all agencies provide some continuing education, adding discussions of evidence-based programs and practices to continuing education offerings may increase knowledge of and enthusiasm for such programs and practices. This may both increase exploration and adoption activities as well as prevent some staff resistance to change once a new program has been implemented. Second, the reliance on state and county colleagues as resources when exploring possible new programs and practices suggests that developing well informed social networks may be a way of spreading evidence based practices. Much like the activities of the Community Development Teams in supporting the uptake of Multidimensional Treatment Foster Care in the implementation experiment effort in California (Saldana and Chamberlain, 2012), employing naturally occurring or newly developed networks, for example networks developed through the use of learning collaboratives, to increase the spread of evidence-based practices may shorten the time it traditionally takes to move quality initiatives into community practice.
Highlights.
Child welfare agencies commonly initiate new programs or practices but these are not usually evidence-based.
Agencies rely on other community agencies or state contracts to explore possible new programs/practices.
Well informed social networks may be a way to spread evidence-based practices.
Acknowledgments
This study was supported by National Institute of Mental Health (NIMH) award P30-MH074678 (JL). The findings/conclusions are those of the authors and do not necessarily reflect the opinions of the NIMH.
Footnotes
Disclosures: The authors report no financial interests or potential conflicts of interest.
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