Child welfare caseworkers' perspectives on the challenges of addressing mental health problems in early childhood

https://doi.org/10.1016/j.childyouth.2016.04.003Get rights and content

Highlights

  • We examine challenges in addressing ECMH concerns in child welfare contexts.

  • Workers recognize the importance of early identification and intervention for ECMH.

  • Differing parent and worker views on child development create challenges.

  • Communities lack high-quality, developmentally appropriate ECMH services.

  • Workers disagree on the scope of their work related to ECMH.

Abstract

Although nearly half of child maltreatment victims are under the age of five and at high risk for developing serious emotional or behavioral problems, few young children involved in the child welfare system receive treatment. As the first point of service contact, child welfare caseworkers can play a key role in quickly identifying children with mental health problems and linking them to services. This study examines caseworkers' perspectives on the challenges of addressing mental health problems in early childhood. Based on five focus groups conducted with 50 caseworkers from an urban, public child welfare agency, results suggest that although workers acknowledge the importance of early intervention, difficulty identifying mental health needs in early childhood and workplace barriers impede linkage to services. Given the lasting impacts of early experiences on children's development, it is imperative that these challenges be addressed. Implications for systematic mental health screening and caseworker training are discussed.

Introduction

Almost half of child maltreatment victims in the United States (U.S.) are under the age of five (U.S. Department of Health and Human Services, 2016). Young children who have suffered maltreatment are more likely to experience mental health problems compared to those who have not. These problems include difficulties with self-regulation and attachment, as well as developmentally inappropriate levels of aggression or anxiety (Gleason & Zeanah, 2006). Identification of mental health concerns that warrant further treatment is often missed except when accompanied by significant delays in other developmental areas or when professionals make use of specialized screening and assessment tools. Mental health services for this population frequently include counseling focused on the parent and child relationship, but can also include participation in a therapeutic nursery or preschool, as well as placement in a therapeutic foster care setting. Estimates of the number of very young children in the U.S. child welfare system with a mental health need range from 10% to 35% (Horwitz et al., 2012a, Horwitz et al., 2012b); however, only between 2% and 13% receive services (Horwitz, Hurlburt, Goldhaber-Fiebert, et al., 2012). Child welfare caseworkers can close the gap between mental health service identification and receipt of services for very young children involved in child welfare systems.

When a child enters the child welfare system in the U.S., a caseworker conducts an initial investigation to determine child welfare need and occurrence of abuse or neglect. If an ongoing need is identified, a caseworker will develop a case plan, provide recommendations and referrals for needed services, as well as monitor the family's progress. Depending on the specific needs of the child and family, other specialized caseworkers may become involved in the case (e.g., a caseworker may specialize in adoption services). As the first point of service contact in the lives of very young children (Leslie et al., 2005), caseworkers can play a key role in linking children to needed services by quickly identifying their needs and referring them to appropriate services (Stiffman, Pescosolido, & Cabassa, 2004). In older children, service access is largely determined by caseworkers' general knowledge of children's mental health and their familiarity with service resources (Bunger et al., 2009, Stiffman et al., 2000). However, mental health problems can manifest differently in very young children and developmentally tailored services may be scarce. Without specialized early childhood training, child welfare caseworkers may have difficulties identifying potential early childhood mental health (ECMH) concerns as well as appropriate services for very young children.

Currently, little is known about the challenges child welfare caseworkers face when attempting to identify and connect very young children with mental health concerns to care. Nor do we understand the challenges that caseworkers face when understanding and responding to the unique developmental needs of very young children. To address this gap and inform future training and workforce interventions that promote improved mental health service access for very young children in the child welfare system, this study explores the challenges caseworkers face when addressing ECMH concerns in child welfare contexts. To provide background, we review the extant literature on mental health problems among very young children involved in child welfare, the role of child welfare caseworkers in service linkage, and caseworkers' training and knowledge of mental health issues. Afterwards, we present the methods and results of a qualitative study examining the challenges faced by caseworkers in addressing ECMH concerns in the context of a child welfare agency in the Mid-west U.S. We conclude with a discussion of our findings, and suggest implications for workforce training and development initiatives.

Compared to school-aged children and adolescents, knowledge of mental health problems experienced by very young children is limited. However, many early childhood scholars are working to reduce this gap in knowledge. The literature presented in the following section focuses on what is currently known about mental health problems in very young children. In early childhood, mental health concerns can manifest in a variety of ways, from difficulties with self-regulation and attachment, to delays in achieving developmental milestones, to more “classic” mental health symptoms such as extreme sadness or anxiety, social withdrawal, or inappropriate levels of aggression. Mental health concerns may also appear as feeding and sleep problems (e.g., food refusal or abnormal sleep patterns), sensory integration difficulties (e.g., being under responsive or hypersensitive to noise, light, or texture), or problems with emotional expression (Gleason & Zeanah, 2006).

ECMH problems interfere with children's abilities to express and regulate emotions, understand themselves and others, explore their environments, and form relationships with peers and adults (Brown & Conroy, 2011). These problems decrease overall child well-being and have the potential to negatively influence their relationships with peers and adults (Webster-Stratton & Reid, 2003). Children with ECMH problems are at a higher risk for being expelled from child care (Gilliam, 2005) and are at risk for future mental health problems as well as substance use, risky sexual behavior, and aggression (Schubert Center for Child Studies, 2009, Shonkoff and Phillips, 2000).

Compared to the general early childhood population, very young children who have been the victims of maltreatment are more likely to experience mental health problems. Maltreatment may include physical, sexual, or emotional abuse, as well as exposure to the direct or indirect effects of domestic violence, but most often is in the form of neglect (U.S. Department of Health and Human Services, 2016). Very young children are acutely susceptible to the impacts of adversity and chronic, or toxic stress. Toxic stress is defined as a “strong, frequent, and/or prolonged activation of the body's stress-response systems in the absence of the buffering protection of adult support” (Shonkoff, Boyce & McEwen, 2009, p. 2256). Over time, toxic stress can lead to poor developmental outcomes, including mental health problems (Shonkoff et al., 2009).

Early exposure to maltreatment has immediate impacts on important attachment relationships between caregivers and children that facilitate development during the early years of life. Additionally, early exposure to maltreatment negatively impacts the development of the brain through the release of stress hormones that can change the structure of neurons (McEwan, 2008). When a child experiences toxic stress, neural connections in the areas of the brain responsible for fear, impulsivity, and anxiety may en. In contrast, neural connections related to behavior control, reasoning, and planning, may weaken (Shonkoff et al., 2009). Once very young children are involved with the child welfare system, those with mental health problems stay in care for longer periods of time (Becker, Jordan, & Larsen, 2007), with frequent placement disruptions (Newton, Litrownik, & Landsverk, 2000) and a lower likelihood of achieving positive permanency outcomes including family reunification or adoption (Akin, 2011).

Despite the negative consequences of maltreatment, its effects can go unnoticed in early life due to wide variation in typical developmental trajectories of very young children. Given the broad range of developmentally appropriate behaviors and the transactional processes that occur between child and caregiver during early childhood (Sameroff, 2010) it can be difficult to distinguish between typical development and pathology without the assistance of appropriate screening and assessment tools (Carter, Briggs-Gowan, & Davis, 2004). In child welfare contexts, screening and assessment tools have been used to more easily identify very young children in need (Jee et al., 2010, McCrae et al., 2011). Furthermore, when screening and assessment tools are paired with collaborative efforts between child welfare and behavioral health systems children are more likely to be identified and linked to needed services (He, Lim, Lecklitner, Olson, & Traube, 2015).

Although mental health services exist, access for very young children involved in child welfare is severely limited. In a study using national child welfare data, Horwitz, Hurlburt, Goldhaber-Fiebert, et al. (2012) estimated that only 2% of children ages 1.5 to 2 and 13% of children ages 2 to 5 who need mental health services actually receive them. These findings illustrate large service gaps for very young children and highlight a need for supports within the child welfare system that promote identification and service linkages for very young children with mental health concerns.

In the U.S., child welfare caseworkers may be the first point of service contact for very young children in the child welfare system. These individuals act as “gateway providers” that facilitate children's access to mental health services (Stiffman et al., 2004). Drawing from the Gateway Provider Model, children's service access is largely determined by their provider's knowledge and perceptions of mental health and the mental health service delivery system. When providers are knowledgeable about children's mental health needs and mental health resources in the community youth are more likely to access services (Bunger et al., 2009, Stiffman et al., 2004). However, in the U.S., the child welfare and mental health systems have been criticized as being disconnected from one another (Stiffman et al., 2010). Caseworkers can play a key role in bridging this systemic barrier.

However, child welfare caseworkers often vary in their knowledge of mental health issues and services. This may be, in part, due to limited academic training in mental health or human development among caseworkers (Dorsey, Kerns, Trupin, Conover, & Berliner, 2012). Only about 40% of caseworkers have social work training, with the remainder trained in other fields that may be completely unrelated to human services (Barth, Lloyd, Christ, Chapman, & Dickinson, 2008). For caseworkers with academic training in human service relevant fields, early childhood specific content is often lacking in the curricula (Herman-Smith, 2013).

In addition to educational background, organizational factors also shape workers' abilities to address children's mental health needs. Research with early childhood specific gateway providers (e.g., child care teachers) suggests that professionals feel inexperienced and need more support in the area of ECMH (Gleason et al., 2012). Although training and consultation interventions show promise for child welfare caseworkers (Fitzgerald et al., 2015), the burden of high caseloads and extensive paperwork might mitigate any improvements in workers' knowledge of mental health issues and services (Stiffman et al., 2001). In work environments characterized by high stress, competing demands, and time pressures, caseworkers may deprioritize mental health concerns as they focus on more immediate safety issues (Smith & Donovan, 2003).

Given their role as gateway providers, caseworkers are uniquely positioned to improve service access for very young children. However, little is known about the challenges faced by caseworkers as they recognize and address mental health problems for very young children, which could provide insight into why very young children in child welfare have such low rates of service access. To address this gap, this study examines the following research question: what challenges do child welfare caseworkers face in relation to ECMH identification and treatment linkage?

Section snippets

Study context

Although the federal government in the U.S. supports child welfare systems through funding and child welfare legislation, the system is largely controlled by individual states. Each state decides how to operate its child welfare system. The state described in this particular study allows each county to develop and run its own child welfare system. Therefore, each county within this particular state has the ability to individualize the child welfare system based on the needs of its residents as

Results

Four major themes emerged from the qualitative analysis. The first two themes that emerged were related to the specific types of challenges that caseworkers face when addressing ECMH concerns in the children with whom they work. These challenges include (1) age group challenges and (2) workplace challenges. The third and fourth themes address (3) the importance of early identification and intervention for very young children and (4) what would happen in an ideal work environment. Each theme is

Discussion

Although mental health concerns are common among children involved in the child welfare system, few receive services. These service gaps are even more pronounced among very young children (Horwitz, Hurlburt, Goldhaber-Fiebert, et al., 2012), yet we know little about contributing factors and conditions. This exploratory study identified potential reasons for these large services gaps from the perspectives of child welfare caseworkers. Findings highlight how discrepancies between parents' and

Conclusion

Child welfare workers are uniquely positioned to identify very young children with mental health concerns early, and connect them with care. Yet, for the youngest children involved with the child welfare system, gaps in access to ECMH services persist. Our study suggests that child welfare workers recognize the importance of early identification of mental health problems in the very young children they serve, and the potential of early intervention services for preventing problem escalation as

Acknowledgements

The authors wish to thank their child welfare agency partners, and the caseworkers who shared their experiences and ideas. This research was supported by the Department of Health and Human Services, Administration for Children, Youth and Families, Children's Bureau [grant number 90CO1104]. The findings and discussion do not represent the official view of Children's Bureau. A version of this article was presented at the 2014 meeting of the Council on Social Work Education.

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