Barriers and facilitators to delivering effective mental health practice strategies for youth and families served by the child welfare system

Highlights

• Racial disparities in mental health service delivery among foster youth are well documented.

• Caseworkers identified why disparities in service delivery linger.

• Barriers identified at the macro level have a negative impact on organizational functioning.

• Organizational incapacity often imparts negative client-provider relationships.

• Supports at the macro, meso, and micro levels are needed to ameliorate mental health service disparities.

Abstract

While the gap between need for and access to mental health services is well documented among children of color in foster care, little is known about why they are sustained. To illuminate barriers of service delivery, thirty-six caseworkers participated in one of five focus group meetings in a large urban Mid-Atlantic City. Ground Theory Methods revealed that there are barriers and facilitators at the macro, meso, and micro practice orientations. At the macro-level, development of effective practice strategies and proximity to effective services are likely to influence dissemination of effective practices. Secondly, at the meso-level, job support is needed to facilitate awareness, but for case managers to feel supported, they need effective training and opportunities to facilitate interagency collaboration. Finally, at the micro-level, cultural competence largely impacts implementation of effective practices. However, increased awareness around the social ills of stigma and the salience of “insider work” are needed to increase cultural competence. A “downstream” effect in which there are numerous barriers identified at the macro level has a direct negative impact on organizational capacity and readiness to deliver and engage youth and families in mental health services served by the child welfare system. Findings underscore the need for child welfare agencies to build supports at the macro, meso, and micro practice levels to ameliorate mental health service disparities.

Introduction

Approximately 400,000 children in the U.S. who are placed in foster care (USDHHS, 2014) are more likely to be diagnosed with a host of externalizing and internalizing behaviors, including depression, anxiety, ADHD, conduct disorder, PTSD, substance use, and suicidal behavior than children in the general population (Del Vecchio et al., 2012, Jonson-Reid et al., 2012, McCrae, 2009, Silvern and Griese, 2012, Trickett et al., 2011). Scholars assert that child welfare caseworkers may act as “service brokers” in that if (1) they are trained to detect negative symptomatology and (2) are aware of services that are readily available, they will play an instrumental role in ensuring that children in foster care receive effective and timely mental health services (Dorsey et al., 2012, Stiffman et al., 2004). Previous research shows that children placed in foster care are ten times more likely to utilize mental health services than children in community samples (Garland, Landsverk, Hough, & Ellis-MacLeod, 1996). In spite of this relationship, Garcia, Palinkas, Snowden, and Landsverk (2013) highlight that a number of studies published over the past fifteen years show that children of color who are involved in the child welfare system (CWS) are significantly less likely to receive mental health services than their Caucasian counterparts, even after controlling for need and maltreatment exposure.

The question that remains unaddressed is how and under what conditions do these disparities linger. Garcia and colleagues recommend that “researchers need to analyze via multivariate pathways the direct and/or indirect individual, socio-environmental and organizational contextual factors, and the number of potential mediating factors…that may influence service-use experiences for at-risk youth and families of color in the CWS” (Garcia et al., 2013, p. 1731). Effective services will not be delivered unless we have a clear understanding of these pathways. To that end, this explorative study relied upon focus group data collected from child welfare case managers to understand, from their perspective, what factors facilitate and impede access to and use of effective services to promote positive developmental outcomes for youth of color served by the foster care system. The intent is to build an explanatory model of service delivery to later be tested in the context of relying upon quantitative methods.

The aforementioned public health concerns resonate for many of the children in a large urban city on the East Coast. As part of a new initiative to ensure safety, permanency, and well-being, the public child welfare institution initiated the implementation of a large-scale program that decentralizes the provision of direct case management services through a network of several different community-based child welfare agencies, all of which are, more or less, separated by police precinct districts. To that end, this study takes stock of case managers' knowledge, experience, and practices to understand patterns of services delivery in the context of early privatization efforts. Moreover, the public child welfare agency provides the perfect “laboratory” for this study, given than an overwhelming number of the 6000 children served by the local foster care system are African American (80%) and Latino (13%).