Helping parents with mental illnesses and their children: a call for family-focused mental health care

1. Large numbers of individuals with mental illnesses are parents to minor children. 2. Recommendations to improve services suggest that services provided by the adult mental health system and child service agencies be coordinated. 3. Nursing care intersects both the adult and child systems, and nurses have the expertise to offer a variety of services. 4. There is an urgent need to improve family-focused mental health nursing care to benefit parents with mental illnesses, their children and families, and the overall community and society.     

Services for maltreated children: variations by maltreatment characteristics

Mental health services were the most frequently recommended service for maltreated children known to a child protective service agency, but more than one-fourth of the children with serious behavioral problems did not receive referrals for such services. Children with long histories of maltreatment were more likely to be referred for some services, especially out-of-home care. Gaps in services remain, underscoring a need for research focused on the need for interventions targeted to maltreated children involved with child protective service agencies.     

A recent look at the factors influencing workforce retention in public child welfare

Consistency of services to children and their families continues to be an ongoing problem in public child welfare agencies. Worker turnover is high, thus affecting the availability of a well trained, experienced workforce. It is critical that we continue to explore the factors associated with worker turnover and retention in public child welfare agencies. Such knowledge will allow us to determine the needs of workers, administrators, and the agency in general, in an effort to create an environment that will result in worker retention, and a better quality of services. Children and their families will be major benefactors of such knowledge as the consistency and quality of services will be enhanced. Existing research has found that outcomes for families and children are affected by the workload and training of frontline workers, and organizational characteristics (GAO, 2003, NASW, 2004, and Milner, 2003). This study describes personal and organizational factors relative to worker retention for public child welfare workers in the northwest corridor of Georgia.     

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

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.     

Assessment of Intimate Partner Violence by Child Welfare Services

The purpose of this study was to describe policy and practice with respect to the assessment of intimate partner violence in a sample of child welfare agencies located throughout the United States and to examine the relationship of contextual characteristics and assessment practices. Telephone interviews were conducted with key informants from child welfare agencies. A snowball interviewing strategy was used to identify the best informant in each agency. Almost all of the participating agencies conducted some assessment of intimate partner violence, with most reporting that the majority of screening or assessment occurred during investigation of referrals. However, only 43.1% reported that all of the families referred to the child welfare system were assessed for intimate partner violence, and 52.8% indicated they had a written policy pertaining to screening and assessment of the problem. There was little relationship between county or agency characteristics and assessment practices. Additional research is needed to determine factors that influence assessment practices and to identify strategies to support and extend efforts to identify intimate partner violence and provide appropriate services for families in the child welfare system.     

Psychotherapeutic care for sexually-victimized children – Do service providers meet the need? Multilevel analysis

ObjectivesSurprisingly little is known on the decision to refer sexually-victimized children to psychotherapy. Previous research on service provisions for victims of child maltreatment has analyzed the impact of case characteristics, like child or caregiver functional levels, lack of social support, and socioeconomic status. Findings, however, show that the decision to provide services is not only needs-driven, but also affected by external factors like provincial legislation, institutional policies, and the availability and accessibility of services. By analyzing characteristics behind the decision to refer sexually-victimized children to psychotherapy at the case and institutional level, we aimed to disentangle the complex interplay of factors driving this decision.MethodsThe data for this analysis were drawn from the first nationally-representative agency survey on reported child sexual victimization (CSV) in Switzerland. Over a 6-month data-collection period, 165 child protective services, 87 penal authorities and 98 agencies in the health and social sector documented a total of 911 incidents of CSV. Multilevel logistic regression was applied to analyze factors at both the case and contextual level.ResultsThe main finding was that the severity of consequences was strongly associated with the probability of psychotherapeutic service referrals (OR = 10.4; p < 0.001). However, one bias was identified at the individual level: sexually-victimized children born in Switzerland were more likely to be referred to psychotherapy than immigrant children. Institutional disparities in the decision to refer a sexually-victimized child to psychotherapy were large (median OR = 3.83), with penal authorities referring significantly fewer cases to psychotherapy than specialized agencies in the health and social sector. What exactly was driving the difference between psychotherapy referral in different types of agency remains largely unexplained.ConclusionsFuture research should invest in scrutinizing contextual factors of child protective service decisions. As we operationalize the need for psychotherapy as proxy-rated consequences of victimization, routine screening for mental health needs using standardized measures for children in contact with child protection agencies should be implemented, to help frontline workers to identify the psychotherapeutic needs of victimized children.     

The mental health problems of mothers experiencing the child protection system: identifying needs and appropriate responses

This article presents the findings of a small pilot study which examined the needs of 13 mothers with severe mental health problems whose children were involved in the child protection system. The use of the diagnosis of ‘personality disorder’ in relation to this group of women is discussed and the finding that all these women had experience of domestic violence is considered in the context of other research findings. The extent to which child protection social workers and mental health professionals worked together on these cases was explored and only limited evidence of good communication and collaboration was found. The need for effective inter‐professional and inter‐agency coordination is argued, but differing conceptions of maternal mental health problems and their relationship to children's needs may make for difficulties in professional communication and decision‐making. The article seeks to identify the differing approaches to maternal mental health problems which appear to be developing out of different groups of research studies and argues that practitioners need to be explicit in identifying their perspectives on the associated issues of maternal mental health problems and child protection. Copyright © 1999 John Wiley & Sons, Ltd.     

Facilitating Mental Health Service Use for Caregivers: Referral Strategies among Child Welfare Caseworkers

Unmet needs for mental health care are common among caregivers involved in the child welfare system. Although child welfare caseworkers are well positioned to identify service needs and refer caregivers to treatment, little is known about the types of referral strategies used in practice, or their effectiveness for promoting mental health service use. The current study examined child welfare caseworkers' use of different referral strategies and the extent to which these strategies are associated with caregivers' receipt of mental health services within a national sample of child welfare cases. Analyses of the second cohort of families from the National Survey of Child and Adolescent Well-Being suggest that child welfare workers more often use informational strategies for referring caregivers, including suggesting treatment or providing information about treatment options. However, social referral strategies such as providing caregivers with direct assistance in completing applications and making and attending appointments were associated with a greater likelihood of caregivers receiving mental health services. Findings support evidence from other service contexts that service use is facilitated by caseworkers' direct support for arranging services. Implications for research and for child welfare managers and administrators are discussed.     

Mental health services for children and caregivers remaining at home after suspected maltreatment

ObjectiveBehavioral problems are common among children remaining at home after suspected maltreatment, but the effectiveness of current mental health services to improve these behavioral problems is unknown. The objective was to determine whether receipt of child and caregiver mental health services was associated with improvements in behavioral problems in maltreated children remaining at home.MethodsWe retrospectively analyzed Second National Survey of Child and Adolescent Well-being data. We included 1117 children ages 2–17 remaining at home after a maltreatment investigation, excluding children with missing outcome, covariate, or survey weight data. We compared mean Child Behavioral Checklist (CBCL) change scores from baseline to 18 months between children who did and did not receive mental health services, before and after adjusting for child, caregiver, and child welfare agency factors using survey-weighted linear regression.ResultsNearly one-quarter (22.6%) of children and 16.0% of caregivers received mental health services. Children receiving services had worse unadjusted baseline and 18-month CBCL scores than children not receiving services (all P < 0.001). Adjusted CBCL change scores revealed behavioral worsening among children receiving services but improvement among children not receiving services (all P < 0.001). However, children had improved behavior, regardless of their own service receipt, if their caregivers received services and reported an absence of depression at 18 months.ConclusionsChildren receiving mental health services had worse behavioral changes than children not receiving services. Caregiver receipt of services was associated with improved child behavior, suggesting that a family-centered approach may be most influential in improving behavioral outcomes among this population.     

Establishing a mental health service for young children in out-of-home care: The Gumnut Clinic for 0 to 5 year olds in Western Sydney

Objective

Children aged 0 to 5 years in out-of-home care represent a vulnerable population at high risk of social, emotional and developmental problems, yet there are few services specifically addressing their psychological needs. This paper is the first of two concerning the establishment of The Gumnut Clinic, a specialist mental health assessment clinic in Western Sydney for this population. The current paper provides the rationale for the development of the clinic and detail of the referral and assessment processes.

Method

The paper describes the establishment of The Gumnut Clinic at Redbank House in Sydney, Australia, the approach to assessment of these young children and their carers, and the challenges encountered.

Conclusions

Young children are overrepresented in child protection and out-of-home care services. Their social, emotional and developmental needs are under-recognized. Development of a specialist mental health service is a step towards improving health outcomes for these children.     

Parental mental health as a child protection issue: data from the NSPCC national child protection helpline

Analysis of a sample of 2084 child abuse referrals to the NSPCC Child Protection Helpline showed that in 10% a parent or carer was reported as having a mental health problem. Mothers were the parent affected in the majority of these cases. The mental health sample differed from the other referrals in an increased concern about emotional abuse and less about sexual abuse; greater levels of violence and discord between parents; and more agency involvement. Issues of potential labelling and therapeutic needs are discussed. Copyright © 1999 John Wiley & Sons, Ltd.     

Do working mothers have healthy children?

This paper examines the effects of maternal employment on children's physical and mental health. The data used are from the Health Interview Survey 1981, Child Health Supplement. A health production model is developed on the basis of Becker's household production theory. The results reveal that a mother's employment is a significant factor affecting her child's physical health. Use of physician services, prices (i.e., CPI used as a proxy variable), sex of the child, receipt of Medicaid, the number of relocations, the mother's education, the mother's health status, breast-feeding practices, and the birth weight of the child are other important variables explaining the health status of children. The role of each of these factors varies according to the marital status of the mother.The authors wish to thank anonymous reviewers for their helpful comments resulting in a much improved product.She received her Ph.D. from Cornell University in 1990. Her current research interests include health care of children and elderly, teen pregnancy and welfare use, children and divorce, and immigrant consumers.She received her Ph.D. from Northwestern University in 1983. Her research includes long-term health care for frail and ethnic elderly, health insurance purchases for the elderly, and health services utilization by the employed and working poor.     

Caregivers' Endorsement of Barriers to Mental Health Services for Children and Youth in Child Welfare

The purpose of this study was to examine the three most common types of caregivers in the child welfare system (birth parents, relative caregivers, and foster parents), an active child welfare case, caregivers' endorsement of barriers to mental health services and mental health service use by caregivers for the children under their care. The sample consisted of 430 dyads (caregivers and their children). Results indicate that an active child welfare case, provider characteristics, and accessibility of services predicted mental health service use for children. Implications for the child welfare and mental health systems are discussed.     

Inter‐professional working in child protection with families with long‐term and complex needs

Within the United Kingdom there is growing awareness of the need to identify and support the small number of children who are living in families experiencing multiple problems. Research indicates that adverse experiences in childhood can result in poor outcomes in adulthood in terms of lack of employment, poorer physical and mental health and increases in social problems experienced. It is acknowledged that most of these children are known to child welfare professionals and that some are referred to social services, subsequently entering the child protection system. This paper reports research conducted with 28 experienced child welfare professionals. It explores their views about families known to the child protection system with long‐term and complex needs in relation to the characteristics of children and their families; the process of intervention with families; and the effects of organisational arrangements on practice. The research indicates that these families are characterised by the range and depth of the problems experienced by the adults, such as domestic violence, mental health difficulties and substance misuse problems, and the need for professionals to have good inter‐personal skills and access to specialist therapeutic services if families are to be supported to address their problems. Copyright © 2008 John Wiley & Sons, Ltd.     

An integrative approach to threat assessment and management: security and mental health response to a threatening client

Workplace violence threat assessment and management practices represent an interdisciplinary approach to the diversion of potentially dangerous employees and clients. This case study illustrates such an intervention in a complex situation involving a social service agency and its client. Following a curtailment of services and an arrest, the client developed an escalating homicidal anger toward the agency administrator. Once a Tarasoff warning was received, the agency contacted a security company who organized a threat assessment and management plan involving interdisciplinary collaboration. Information developed in the course of the assessment was presented to prosecutors, who facilitated the client's arrest and involuntary psychiatric commitment until he was judged to be no longer dangerous. This case ultimately involved an integration of the services of security, law enforcement, mental health professionals, prosecutors, the courts and the state mental health system in leading to a successful diversion of the client from a path of intended violence.     

Out‐of‐Home Placement of Children Exposed to Violence

There is growing concern about the increasing number of children in the USA who are exposed to community violence and the need to remove some of them from their families. This study examines risk factors for out‐of‐home placement among a large pool of children and adolescents who were referred for general clinical assessment following exposure to violence and/or psychological trauma in their communities or homes. Children with greater familial and environmental support and children exposed to incidents involving a non‐parental personal threat were associated with a significantly lower risk of out‐of‐home placement. A greater likelihood of being placed out of home was associated with older age (adolescents), history of mental health service use, involvement with law enforcement agencies, higher clinical ratings of depression or impaired thought processes, lower clinical functioning and greater exposure to traumatic events. Evidence of maltreatment and a threat to life was associated with 13.6 times greater likelihood of being placed out of the home. This study raises an important issue in respect to the children's past use of mental health service and current symptoms. It is not just the risk of violence but also evidence of psychiatric problem that trigger out‐of‐home placement. Further studies are needed to assess the quality and effectiveness of mental health services provided to children exposed to violence. © 2007 The Author(s). Journal compilation © 2007 National Children's Bureau.     

Improving mental health assessments in child protection through audit

Existing agency records, together with questionnaires completed by social services referrers and mental health providers, were used to identify problems in current arrangements for obtaining specialist mental health assessments in child protection cases. Standards were set and implemented through a multi‐agency steering group. The practice of referrers and providers was then reaudited. Sixty‐nine social workers, six mental health specialists and 27 child protection initial case conferences (involving 31 children) were involved in the reaudit over a 4‐month period. Initially, main problems concerned communications, unclear referral and access arrangements, waiting times and disagreements over prioritization. Standards concerned consultation and decision‐making arrangements within the child mental health service, the format of referral and reply letters, the sharing of information and the attendance of mental health professionals at child protection case conferences. There appeared to be improvements in all these areas at reaudit. In conclusion, some shared views of problems, additional support funding and the audit process appear to have helped to improve inter‐agency collaboration and develop more efficient referral and care arrangements. There is a need to maintain and further develop this work, and audit would again be a useful means. Copyright © 1999 John Wiley & Sons, Ltd.     

Re-painting the golden gate bridge: Coordination of services for abducted children reunited with their families

This is a case study of a program implemented to serve abducted children who have been recovered and returned to their families. Development of working relationships between and coordination of mental health, law enforcement, child protective, judicial, mediation and victim assistance services is a process which produced effective readjustment services for children traumatized by abduction and has reduced systems trauma for the children and their families. Trials and triumphs of the continuing and tedious process of re-painting the bridge are reviewed as potential guidelines to be employed for other such coordinated efforts, a concept increasingly viewed as thesine qua non of service in complex and chronic problem situations.Credit for the application of the bridge painting metaphor to the Child Abduction Tast Force process goes to Michael Durfee, MD.The Reunification Project would not have been possible without the dedicated work of Rebecca Refuerzo, LCSW, in establishing the Center's Program, and the clinical expertise of Merilla McCurry-Scott, Ph.D., Jenenne Macklin, LCSW, Melissa Gleason, MSW, and Karina Walters, MSW.The Reunification Program is jointly funded by Find the Children and the U.S. Office of Juvenile Justice Programs.