National Social Science Association

Is Child Welfare Ready to Jump on the
Evidence-Based Practice Bandwagon?

Catheleen Jordan
University of Texas at Arlington

David Cory
New Horizons

Child Protective Services (CPS), the public social service system designed to protect children at both a practice and policy level, has a long and complex history. The practice and policy levels have not traveled the same path developmentally. By briefly reviewing the early history of CPS to the present, this paper aims to show how practice has evolved to a level of having evidence-based techniques shown to be effective in guiding practice activities. Child protection policy, on the other hand, has lagged behind practice in becoming evidence-based, therefore hindering positive outcomes in CPS. After our brief historical review, we present some current evidence-based techniques to show the status of current practice, followed by barriers to implementation of evidence-based practice and finally our recommendations.
History
Two years after Texas became a State (1848) a law was enacted providing for “apprenticeship” as a form of guardianship. This law:

allowed impoverished orphaned children under the age of fourteen to be bound to be a “suitable person” who promised to support and educate the child until the age of twenty-one, or until marriage for females, making apprenticeship a forerunner of present day adoptions. Unfortunately, widespread abuse and lack of oversight led to these children being known as “little slaveys.” They did not enjoy the protection of court guardianship (adapted from the Texas Council of Child Welfare Boards 2007-2008 Resource Manual).

     US children were generally considered the property of their parents and received limited protection from maltreatment prior to the late 1800’s. In 1874 the Society for the Prevention of Cruelty to Children originated to protect maltreated children and states increased efforts toward legislating child protection policies (Wells, 1995). Child protection laws addressed issues of maltreatment and neglect, as well as parental behaviors defined as “immoral”. The 1909 White House Conference on Children focused on indicators of child maltreatment excluding poverty alone as a reason for out of home child placement, but it was not until the 1960’s that specific physical indicators of child abuse began to be identified by physicians (Wells, 1995).
     In the 1970’s the work of Goldstein, Freud, and Solnit (1973) focused increasing awareness on children’s rights versus the rights of their parents. These authors identified childrens’ basic needs that should be met by their families, including children’s moral and intellectual needs in addition to physical and environmental requirements. Historically, the focus areas of policy makers since the early years are child protection, family based services, out of home care, and adoption. Trends in recent decades have been toward keeping families together. For example the Children’s Justice and Assistance Act of 1986 gave states funds for improved response to child physical and sexual abuse (Wells, 1995). Programs supporting keeping families intact are referred to as family preservation.
     The major issues arising out of this system of care are: (1) legislating policies to protect children and to provide them effective services in a timely fashion; (2) defining agency practice including foster care standards; and (3) specifying techniques and guidelines for effective practice in children’s services.
     On the practice level, Mary Richmond published her book, “Social Diagnosis” in 1917 which moved the field toward a medical model approach using clinical diagnosis with clients to determine their categorical problems. The field has moved toward using both assessment and diagnosis to better serve clients. More recently, Jordan and Franklin’s book Clinical Assessment for Social Workers, (2003, 2nd edition) integrates the available technology and recommends approaches for assessment, including diagnosis as a tool.
     In the 1960’s at Mental Research Institute in Palo Alto, California, a group of researchers began to focus on treating family members all together rather than treating individual members separately, an approach which influences family-centered practice to this day. Many brief family therapy models evolved out of these approaches that are in use today. Family preservation and family psychoeducational models, for example, have been thoroughly researched on some populations; these were developed by social workers (Jansen, Harris, Jordan & Franklin, 2006).
     Other brief family therapy models which have importance for family-centered family practice in child welfare services include structural family therapy, solution-focused family therapy, behavioral and cognitive behavioral family therapy, and family strengthening models. These have been applied in the areas of child welfare practice identified over the years including child protection, family preservation, out of home care, and adoption (Janzen, et al., 2006).

Current Status of Practice

While the “practice” of social work during the early years was primarily focused on development of programs and policies, specific treatment techniques for children and families served by the child welfare system have only more recently been the focuses of child welfare researchers and practitioners. Superior tools, informed by evidence-based behavioral practice have been developed. These techniques have been shown effective with populations experiencing problems similar to those in child welfare settings.
Today’s practice environment is focused on evidence. Here we must differentiate between evidence-based and evidence-informed practice, language used in today’s practice environment. Sometimes these are used interchangeably. The Institute of Medicine (IOM) defines:

"evidence-based practice" as a combination of the following three factors: (1) best research evidence, (2) best clinical experience, and (3) consistent with patient values (CEBC, 2001).

These three factors are also relevant for child welfare. We propose adopting the Institute of Medicine's definition for evidence-based child welfare practice with a slight variation that incorporates child welfare language:

Best Research Evidence
Best Clinical Experience
Consistent with Family/Client Values (IOM from CEBC, 2007).

     Evidence-informed behavioral practice is not that different from evidence-based practice with one exception; the three factors (research evidence, clinical experience, and client values) are placed in an environmental/organizational context (see Figure 1). As social workers, we prefer this systemic view of practice and prefer using evidence-informed practice for this reason; though we consider evidence-informed and evidence-based to be essentially interchangeable terms and we will use them as such in this article.
     Evidence-informed behavioral interventions are non-pharmacological, non-surgical procedures that may be used in conjunction with medical treatments or substituted for them. They range from intensive treatments with techniques whose mastery requires considerable professional training (e.g., psychotherapy, behavior analysis) to less intensive interventions that use simpler procedures and require less professional training (psychosocial support, patient education, brief behavioral counseling/advice). Those who will be affected by the behavioral health care decision can include individuals, families, organizations, and communities. Collaborative decision-making incorporates the characteristics, values, and preferences, of care recipients in order to best serve them. Stakeholders include patients, consumers, providers, payers, insurers, and policy-makers.
(See Figure 1)
     Figure 1 is adapted from the Institute of Medicine (2001;http://www.ebbp.org/About_EB.html ). It depicts the factors that go into decision-making from the evidence-informed perspective. We share Gambrill’s (2006) view of EBP as “involving a philosophy of ethics of professional and policy-related enterprises including education, research and scholarly writing, a philosophy of science (epistemology), and a philosophy of technology”. Further, by evidence-informed we imply a broad epistemological perspective encompassing both quantitative and qualitative data.
     In a forthcoming publication, designed to further EBP in macro practice, Hoefer and Jordan (in press) extended the five step EBP problem-solving approach (see Table 1). Note that this approach is equally salient for use with micro or macro practice though the table is presented from a macro perspective. The process begins with converting information into a researchable question, involves use of the best literature in collaboration with social worker and client input, as in the diagram in Figure 1. The process is completed by assessing implementation fidelity as well as evaluating outcomes.
     Resources are available to help find the evidence mentioned in step 2 above, that is, the best evidence to answer the question of what to do in a micro/macro situation. Table 2 gives examples of some of these resources. Table 3 gives examples of resources for childhood disorders.
(See Table 1-3 and Figure 2)
Techniques
     Though EBP has been most often discussed by micro level social workers, a recent movement toward introducing EBP to macro social work is well under way. At a recent ACOSA Symposium Presentation at CSWE, (2006), Gambrill, Thyer, and Salcido discussed the importance of this approach to macro social workers and the trend toward use of evidence-based social work practice in these settings.
The importance of EBP to funders such as SAMHSA was stressed.
     In child protection practice, the trend has been toward risk assessment or development of indicators substantiated by research and agreed upon by child protection experts. Herring, for example, researched the literature to identify eleven empirically validated risk factors. (Brissett-Chapmand, 1995).
     Currently, research has provided superior tools to be used for assessment, treatment planning, treatment, and follow up of children and their families. These include: standardized measures, treatment planning formats, manualized treatment protocols, and evidence-based web sites (Jordan & Franklin, 2003).
     Designed to quantitatively measure couple’s attitudes about their ex-spouse as they go about trying to negotiate the tasks of co-parenting. Examples of qualitative techniques are: genograms, maps, sculpting
games, and logs and diaries. See figure 3 for an example of an eco-map, a qualitative technique.   Figure 4 is an example of a treatment planning format. These documents help one to move from assessment to intervention.
     The Division 12 Task Force on Promotion and Dissemination of Psychological Procedures discusses the minimum criteria needed for a treatment to be either “well established” or “probably efficacious” (p. 246-263).   The “well established” treatments are manualized and have met rigorous research requirements. The “probably efficacious” treatments are not manualized and the studies on these are not as rigorous. Some examples of child treatments which meet the Division 12 criteria are listed by Okamoto and LeCroy (2004) and include: Munson’s (2004) evidence-based treatment for traumatized and abused children; and Springer’s (2004) treatment for juvenile delinquents with conduct disorder, attention-deficit/hyperactivity disorder, and oppositional disorder.
     Jordan (forthcoming) recommends uses a blend of quantitative and qualitative techniques to inform client assessment. Quantitative techniques are methods which allow for operationally defining clients problems; an example is a scale which gives a numerical score of the client’s depression. Qualitative techniques describe the complexity of clients’ problems in more detail; an example is a mapping technique such as a genogram. Examples of quantitative methods are interviewing schedules, self-anchored scales, rating scales, logs and diaries, and standardized measures. See Figure 2 (Jordan and Cory, in preparation) to view the Post-Divorce Co-Parenting Collaboration Inventory. This scale is
(See Figure 4)

Barriers to Evidence-Based Practice

     If there are proven techniques to be used in Child Welfare, why are they not being used? Federal child & family services reviews (CFSR), conducted by HHS’s Children’s Bureau, measure states’ performance in meeting federal outcome goals. In its first round of CFSRs, completed in the 3 year period ending 3/04, the Children’s Bureau reported:
             No state had substantially conformed with all federal performance goals, half or more states did not meet performance indicators such as providing adequate services for children/families,
providing child welfare staff with the ongoing training needed to fulfill their duties, and ensuring the diligent recruitment of foster/adoptive homes (http://www.gao.gov/new.items/d07850t.pdf. p.3, GAO-07-850T, a testimony before the Subcommittee on Income Security and Family Support, Committee on Ways and Means, House of Representatives).
     Further, states reported “that their ability to improve child outcomes was challenged most by inadequate levels of mental health and substance abuse services available to children and families, too few caseworkers for too many child welfare cases, and a lack of homes that can meet the needs of certain children, such as those with developmental disabilities” (http://www.gao.gov/new.items/d07850t.pdf. p.6).
     Other barriers to implementation included: lack of training in manualized procedures, too large caseloads, no administrative support for integration of policy/practice, no legislative support, politically driven legislative management, no requirement for hiring social workers in CPS, and funding for family support services not keeping up with the need, resulting in children entering foster care and staying there longer. Some states did not have caseload standards to ensure that caseworkers had enough time to adequately serve each child and family, and caseworkers in some areas of most states often carried more than double the caseload standard established by the Child Welfare League of America (http://www.gao.gov/new.items/d07850t.pdf. p.9-10).
     One example of politically driven legislative management was the addition of significant numbers of CPS investigators following the 2005 Texas legislative session. This was driven by several child death cases which received statewide publicity. Unfortunately, there was no concomitant increase in the number of staff to work with increased numbers of children coming into care. Coupled with an aborted plan to entirely privatize the state’s foster care system by 2011, this led to a situation of children regularly sleeping in CPS offices or hotels under the supervision of CPS workers. A new system had to be created to track the numbers of children in this situation, which has ranged from 37 to 160 per month since January of 2007.

Recommendations

     We return to our original question, is child welfare ready to jump on the evidence-based band wagon? The answer is yes…and no. Yes, promising technology exists with demonstrated positive outcomes for children and families. But, no, the supports in practical terms of adequate staff and training are not there!   Thus, here are our recommendations for Child Welfare policy, practice, and research.
Recommendations: Policy
   Legislative advocacy is needed at the state and federal level to: hire more case workers; train them in evidence based models; retain caseworkers in the job (hire social workers); and increase the current $12 billion in state funds and $8 billion in federal funds that annually support child welfare services.
Recommendations: Practice
     At the practice level, the need is to increase the level of supervision to prevent line workers from leaving CPS. CPS must collaborate with fellow practitioners in mental health and education settings to leverage resources in support of services to child welfare families.
Recommendations: Research
     CPS practitioners must develop research methodologies to reflect the cost-savings achieved by evidenced–based practice and put a dollar figure on the cost benefits of practice improvements.

References

Brissett-Chapman, S. (1995). Child abuse and neglect: Direct practice. In Encyclopedia of social work. 19th edition.
       Washington, D.C.: NASW Press, pages 353-366. California Evidence-Based Clearinghouse for Child Welfare (CEBC),
       2007. http://www.cachildwelfareclearinghouse.org/importance-of-evidence-based-practice#explain on 9-5.
Collins, D., Jordan, C., & Coleman, H. (2007). An introduction to family work. Belmont, CA: Brooks/Cole.
Gambrill, E. 2006. Social work practice: A critical thinker’s guide. NY: Oxford.
Hoefer, R. & Jordan, C. (in press). Evaluating the implementation of evidence-based macro interventions. In a special issue
       called “The paradigm of evidence-based macro practice”. In The Journal of Evidence-based Social Work. Maria
       Roberts-DeGennaro, editor.
Jordan, C. (forthcoming). Assessment. In The Encyclopedia of Social Work. Oxford Press.
Jordan, C. & Cory, D. (in preparation). Post-Divorce Co-Parenting Collaboration Inventory.
Jordan, C. and Franklin, C. 2003. Clinical assessment for social workers: Quantitative and qualitative methods. 2nd edition.
       Chicago: Lyceum.
Munson, C. 2004. Evidence-based treatment for traumatized and abused children. In Roberts and Greene, eds. Social
       Workers’ Desk Reference. NY: Oxford. Pp. 252-263.
Okamoto. S. & LeCroy, C. (2004). Evidence-based practice and manualized treatment with children. Chapter 25. In Roberts
       & Greene, eds. Social Worker’s Desk Reference. NY: Oxford.
Sackett, D., Richardson, W., Rosenberg, W., & Haynes R. (1997). Evidence-based medicine: How to practice and teach
       EBM. New York: Churchill Livingstone.
Springer, D. 2004. Treating juvenile delinquents with conduct disorder, attention-deficit/hyperactivity disorder, and oppositional
       disorder. In Roberts and Greene, eds. Social Workers’ Desk Reference. NY: Oxford. Pp. 263-273.
Texas Council of Child Welfare Boards 2007-2008 Resource Manual, p. 8, retrieved from
       http://www.tccwb.org/documents/TCCWB2007_2008ResourceManual.pdf on 09-05-2007.

Figure 1.

Table 1. Evidence-Based Macro Practice Process

Step 1	Convert information needs into a relevant question for practice in a community and/or organizational context.
Step 2	Track down with maximum efficiency the best evidence to answer the question.
Step 3	Critically appraise the evidence for its validity and usefulness.
Step 4	Provide clients with appropriate information about the efficacy of different interventions and collaborate with them in making the final decision in selecting the best practice.
Step 5	Apply the results of this appraisal in making policy/practice decisions that affect organizational and/or community change.
Step 6	Assess the fidelity implementation of the macro practice intervention.
Step 7	Evaluate service outcomes from implementing the best practice.

Note. In Hoefer & Jordan (in press, adapted from Sackett, D., et al., 1997).

Table 2. Resources for Finding the Best Evidence.

The Campbell Collaboration, particularly what they call their C2-RIPE (Campbell Collaboration Reviews of Interventions and Policy Evaluations) Social Welfare database which had 41 listings as of October 13, 2006. Their website is www.campbellcollaboration.org.

The Centers for Disease Control Diffusion of Effective Behavioral Interventions (DEBI) project which can be found at www.effectiveinterventions.org

The Centers for Disease Control Replicating Effective Programs (REP) project, available at www.cdc.gov/hiv/projects/rep/default.htm

The Coalition for Evidence-based social Policy—social programs that work, can be found at www.evidencebasedprograms.org

The Cochrane Collaboration focuses on health care, which includes mental health, and is available at www.cochrane.org

Columbia University’s Evidence Based Practice and Policy Online Resource Training Center (http://www.columbia.edu/cu/musher/Website/Website/EBP_Resources_WebEBPP.htm)

The Swedish Institute’s compilation of effective practices in the areas of substance abuse, child and adolescent welfare, economic aid (social assistance), ethnicity, migration and social work and theory and practice of evaluation is on the web at http://www.sos.se/Sose/cuse.htm.

Table 3. Resources for Childhood Disorders

American Academy of Child and Adolescent Psychiatry
www.aacap.org

Parent Education and Advocacy Organization for ADHD
www.chadd.org

National Alliance for the Mentally Ill
www.nami.org/youth

Figure 2.

Post-Divorce Co-Parenting Collaboration Inventory

1. How likely are you to list your co-parent on your child/ren's school emergency contact list?