Team decision-making service planning for children and adolescents at risk for placement instability: Fidelity and initial outcomes

Children and Youth Services Review 120 (2021) 105705

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Team decision-making service planning for children and adolescents at risk for placement instability: Fidelity and initial outcomes☆ Sonya J. Leathers a, 1, Roni Diamant-Wilson b, Jill E. Spielfogel c, Lee Annes d, Amy Thomas d, Shirlyn Garrett-Wilson d a

University of Illinois at Chicago, United States Case Western Reserve University, United States Mathematica, United States d Aunt Martha’s Health and Wellness, United States b c

A R T I C L E I N F O

A B S T R A C T

Keywords: Foster care Service planning Mental health Adolescents Placement disruption

Child welfare standards of care emphasize service planning that provides an opportunity for meaningful participation of youth, caregivers, and family members. For youth who are at high risk for multiple moves while in foster care, participatory service planning can be difficult to achieve. This research focused on a statewide program that uses team decision-making meetings to identify needs and plan services for youth who are at risk for instability while in foster care. Results from meetings held for 364 children and adolescents over a six-week period affirm that use of team decision-making for youth experiencing placement stability can result in a collaborative planning process. Immediately after the meeting, most participants endorsed meeting qualities such as believing that their participation was valued and that the entire team would support the plan. At follow-up four months after the meeting, significant improvements had occurred in emotional and behavioral symp­ toms, caregivers’ need for child care support, and satisfaction with mental health services, suggesting that the meeting process, subsequent services, and placement decisions supported changes in some key areas of concern. Additional research using controlled research designs is needed to identify the unique effects of team decisionmaking processes and subsequent services on short- and long-term outcomes.

1. Introduction

review processes do not typically include the full range of providers of children and adolescents with complex needs and are not scheduled flexibly when critical needs arise. Proactive, specialized service plan­ ning specifically focused on stabilizing placements is needed to identify unmet service needs, assure care settings have the capacity to meet special needs, and improve placement outcomes. Despite the importance of interrupting high risk placement trajec­ tories, there are no established models for effective service planning for children and adolescents at risk for placement instability. This study sought to provide initial data on outcomes from a collaborative planning model specifically designed to address placement instability using a team decision-making process. Although collaborative or participatory service planning that involves youth, family, service providers, and other stakeholders in developing goals and service plans is now the standard of care in child welfare practice (AECF, 2013; Child Welfare

Although the majority of children and adolescents placed in foster care have stable placements while in care, more than a third will experience three or more placements (Annie E. Casey Foundation [AECF], 2018). Those who experience multiple moves typically have complex service needs due to disruptive behavior problems, older age, and difficulty forming positive relationships with caregivers (Koh, Rolock, Cross, & Eblen-Manning, 2014; Leathers, 2006). Addressing these needs through effective services and appropriate placements is essential to lessen risk of the potential harms of multiple placement moves including increased behavior problems over time (Aarons et al., 2010; Barth et al., 2007). Administrative case reviews ideally identify unmet service needs, increase follow-through with service plans, and support permanency outcomes (Whitaker, 2011). However, these

This research was supported by the Illinois Department of Children and Family Services (DCFS). The views expressed in this paper solely reflect the views of the authors and do not necessarily reflect the views of DCFS. E-mail address: [email protected] (S.J. Leathers). 1 University of Illinois at Chicago, Jane Addams College of Social Work, 1040 W. Harrison St., Chicago, IL 60607, United States. ☆

https://doi.org/10.1016/j.childyouth.2020.105705 Received 22 June 2020; Received in revised form 5 November 2020; Accepted 6 November 2020 Available online 21 November 2020 0190-7409/© 2020 Elsevier Ltd. All rights reserved.

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League of America, 2014), collaborative planning has not been sys­ tematically implemented and studied specifically for placement stabili­ zation. The team decision-making model is particularly relevant to planning meetings that seek to incorporate the perspectives of a range of stakeholders, as the model provides clear specification of an ideal collaborative meeting process and the type of facilitation that should occur to support this process. However, research examining whether youth and other participants perceive of these meetings as truly collaborative is limited. It is also unclear whether outcomes targeted by the meetings, such as placement quality and adequacy of services, are improved after a meeting. This study explored these questions in a statewide program using a team decision-making model adapted to support placement stability.

opportunity to participate in decisions while in care experience a greater sense of control (Bell, 2002; Leeson, 2007; McLeod, 2007), while those who do not participate can experience negative feelings about their selfworth (Leeson, 2007). Youth appreciate and appear to benefit when their perspectives are shared with service providers, even if placement and service decisions do not ultimately match what they desire (Cash­ more, 2002). Participation is also associated with a higher level of youth investment in the service plan, suggesting that services may be more responsive to youth’s needs (Woolfson, Heffernan, Paul, & Brown, 2010). To obtain the potential benefits of collaborative planning, the meeting process specified in collaborative planning models will need to be actualized in the meeting process experienced by participants. Little research has examined the extent that inclusive, collaborative planning occurs in planning meetings held for the purpose of placement stabili­ zation. Placement instability is frequently characterized by conflicting views of situations and difficulty managing stressful behaviors and feelings, which could create obstacles to collaboration with youth and nonprofessionals. In these meetings, clinical views of how to best address behavioral health needs, which frequently contribute to place­ ment disruptions, might be prioritized over stakeholders’ views of the situation, and young people might disagree with adults’ perspectives about the difficulties they are having in their placements. Research suggests that professionals may be more likely to report feeling engaged in family-group meeting processes. Xu, Ahn, and Bright (2017) study examining participant engagement following collaborative planning meetings for a range of reasons, including placement change, provides some insight into the difficulties with supporting a fully collaborative planning meeting process (Xu et al., 2017). A positive finding from this study was that mean engagement scores were high across all participant types (family members, workers, and other pro­ fessionals) and reasons for the meeting, with no significant differences found for meetings held for different reasons. However, findings also included that levels of participation for nonprofessionals (youth, family members, and other meeting participants) were lower than for pro­ fessionals. In this study as well as a small observational study (Healy, Darlington, & Yellowlees, 2012), professionals had higher levels of engagement and participation than other participants (including family members and youth). In addition, nonprofessionals rated meeting facilitation (respectful, kept meeting focused, neutral at all times, making respondents comfortable) more negatively (Xu et al., 2017, p. 39). These findings appear to suggest that it may be more challenging to engage and fully include family members, youth, and other non­ professionals in a collaborative planning process. Because the study combined all nonprofessionals in one group, it is unclear whether engagement was lower for all nonprofessional participant types or if this finding was driven by lower levels for one or more of the participant types. Thus, research is needed to understand if team decision-making meetings can support a collaborative process across different types of participants involved in placement stabilization meetings. The extent that meeting process and facilitation adhere to the intended team decision-making model is an important aspect of fidelity (Bearman, Garland, & Schoenwald, 2014), as these aims are central goals of the model, and low fidelity could suggest difficulties with implementing the model in placement stabilization meetings. Additionally, given the lack of research focused on use of this model for placement stabilization, an exploratory question is whether young people experience more positive outcomes after a meeting. This study examined these questions in a study that examined youth outcomes after team decision-making meetings conducted in a program called Clinical Intervention for Placement Preservation (CIPP).

1.1. Participatory planning and team decision-making models A wide range of collaborative meeting models have been developed for use in child welfare services (see AECF, 2013, for a review), but the majority of previous evaluation studies have focused on the use of collaborative planning (termed family group conferencing) when fam­ ilies first come into contact with child protection services. Most results from this research are disappointing, with a meta-analysis of 14 studies of family conferencing models that included a comparison group finding that maltreatment, out-of-home placement, and length of child welfare involvement were not improved (Dijkstra, Creemers, Asscher, Dekovi´c, & Stams, 2016). Similarly, two more recent randomized controlled studies of family group conferencing after allegations of maltreatment did not find positive effects for family conferencing on child placement (Dijkstra, Asscher, Dekovi´c, Stams, & Creemers, 2019; Hollinshead et al., 2017) or re-referral for services (Hollinshead et al., 2017). In fact, negative effects for re-referral to services were found by Hollingshead and colleagues for African American families, potentially due to the greater contact with child welfare staff in the family conferencing condition. Despite these findings, several factors suggest that collaborative models convened to address placement instability could have more positive effects than those convened after allegations of maltreatment. The overarching goals of placement stabilization planning meetings are to better understand the child or adolescent’s needs and strengths, to identify services and placement settings to address needs, and to bring together perspectives regarding unmet needs, goals, and services to in­ crease follow through with the plan developed. Although research focused on team decision-making used specifically for placement sta­ bilization is scarce, findings from other relevant studies focused on youth in foster care support that bringing together key stakeholders as well as the young person could support attainment of these goals. Providing youth age 12 and older with tools to participate in planning meetings is consistent with their desire for more communication and collaboration with child welfare staff (Barnett et al., 2018). Inclusion of those who are most involved and invested in the youth’s future such as biological family members provides the opportunity to better under­ stand the youth’s needs and strengths and potentially create more effective plans to address the youth’s most pressing needs (Tilbury & Osmond, 2006). Additionally, foster parents are likely to benefit from the opportunity to participate in service planning as this would address their desire for greater involvement in decision-making and planning (Brown, 2008). Providing a structured process to hear their perspectives about the child or adolescent’s current needs and collaboratively plan has the potential to decrease their sense of isolation and address chil­ dren’s needs, particularly difficult behaviors, that can contribute to placement disruptions (Farmer, Lipscombe, & Moyers, 2005; Geiger, Hayes, & Lietz, 2013). Additionally, results across studies not specifically focused on placement stabilization meetings indicate that youth in foster care personally benefit from participating in decision-making in case re­ views. Findings suggest that young people who have had the 2

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1.2. Clinical intervention for placement preservation (CIPP): Team decision-making adapted for placement preservation

1.3. Research questions The aims of this study were to understand participants’ perceptions of the CIPP meeting process immediately after the meeting and to assess changes in youth wellbeing, placement quality, and services adequacy three to four months after the meeting. Data was collected from case­ workers, caregivers, youth age 12 and older, and other participants in the meeting. Research questions included the following:

The CIPP program uses team decision-making to plan services for children and adolescents at risk for placement disruption or an increase in level of care. Based on the Family to Family team decision-making model (see AECF, 2008, for a full description of Family to Family components), the primary goal of the CIPP program is to improve placement stability by strengthening social connections and relation­ ships, supporting shared understanding of a youth’s most pressing needs, and addressing risks for future changes in placement by formu­ lating a collaborative plan to address these needs. The program is family-centered, strength-based, and uses a trauma-informed lens to understand the difficulties youth in care experience. At the time of data collection for the evaluation, the program had 25 facilitators that served approximately 2,500 children and adolescents across the state each year. While the goal of the program is to preserve placements, referrals to the program are frequently made when an agency requests a higher level of care due to a youth’s needs or a recent disruption. Additionally, youth moving from a foster home to a transitional living program are also staffed by the program. Thus, the program serves youth who are expected to remain in the same placement with enhanced services, as well as youth who require placement and service planning to meet their needs in a new placement. The CIPP program includes a facilitator-guided team decisionmaking meeting focused on a youth’s unmet needs and the develop­ ment of a plan to address these needs. The meeting is typically two hours, with follow-up meetings scheduled when needed. Youth age 12 and older are invited except when participation is not possible (e.g., when youth are incapable of participating, or whereabouts are un­ known). Other participants are primarily identified by caseworkers who provide contact information to the CIPP scheduler. Although youth are also asked about participants, often youth are not directly contacted by the CIPP staff and so not all participants the youth would like to have present can be contacted prior to the meeting. To prepare participants, CIPP staff and caseworkers contact invited participants (other than guardians ad litem) to explain the focus of the meeting and how the meeting will be conducted. In the meeting, a specially trained facilitator from the CIPP program first establishes ground rules and then leads a discussion focused on the individual needs, motivation, and capabilities of the youth. Participants are encouraged to offer their assessment of the youth’s needs and strengths. A primary goal of the meeting is to build consensus on the key needs that need to be addressed to support the youth. The team then generates ideas to address these needs, ideally in the youth’s current placement, and formulates short-term goals and service recommendations. Facilitators play an active role in the meet­ ings by providing structure, ensuring that all participants are heard, and helping resolve differences in views. The program began using the team decision-making model eight years ago and implemented several strategies to increase fidelity to the model over time. As a part of this process, a team of psychologists who had participated in previous CIPP meetings observed and rated model fidelity for all facilitators using a standardized tool to provide an op­ portunity for additional supervision and coaching as needed. Ongoing facilitator training, coaching, and supervision continue to support fi­ delity to the practice model. Training of newly hired facilitators occurs over a period of two months and includes observation of experienced facilitators, co-conducing meetings with an experienced facilitator, and then independent facilitation with an observer who provides additional coaching as needed. Ongoing weekly group supervision that parallels a team decision-making process and quarterly trainings are provided to reduce drift from the model, and individual consultation is provided on an as-needed basis, typically twice monthly.

(1) Are participants’ perceptions of the service planning meeting consistent with team decision-making principles emphasizing youth and caregiver participation, joint planning, and consensus building and agreement on a plan to address the youth’s needs? (2) Do participants have similar perceptions of the meeting process, or do different types of participants, such as youth, other non­ professionals, and professionals, view the meeting process differently? (3) Do indicators of youth wellbeing (emotional and behavioral is­ sues, optimism about the future, stress, and supportive relation­ ships with adults) improve after the meeting? (4) To what extent do participants report improved placement quality and service adequacy after the meeting? 2. Methods 2.1. Study design A collaborative research group that included agency administrators and a university partner developed the evaluation study’s research questions, design, and measures. Following several months of planning, the research group decided on a pre- post design involving data collec­ tion from caregivers, caseworkers, and youth age 12 and older right before the CIPP meeting (“pre-meeting wellbeing survey”) and again four to five months after the meeting (“follow-up wellbeing survey”) to assess youth wellbeing and placement quality at both time points. All 364 children and adolescents staffed by the program in a six-week period were selected, with no exclusion criteria other than that chil­ dren younger than 12 and those with conditions such as severe devel­ opmental disorders were not engaged in completing measures. However, caregivers and caseworkers for younger children and those with disabilities were eligible to complete measures. Additionally, immediately after the meeting, data collection included a team decisionmaking fidelity survey that asked all participants about their perceptions of the extent that the meeting followed team decision-making principles. Again, there were no exclusion criteria other than that children under 12 and others who did not attend their meeting did not complete this survey. Prior to initiating the full study, a pilot study including meetings for just four facilitators was completed for 107 planning meetings. Pilot study data were used to test the properties of the measures (i.e., internal reliability, correlation with other measures as expected, correlations across time and between respondents), modify measures as needed, and refine data collection protocols. Measures performed well, with only minor changes made based on these analyses. In the full study, all facilitators across the state participated in data collection for meetings in the specified six-week period. A total of 2,450 participants attended 391 meetings that occurred in this period. Twentyseven meetings were follow-up meetings after an initial meeting that occurred in the period, so a total of 364 children and adolescents were served by these meetings. When two meetings occurred, data from the follow-up meetings were selected for analysis (i.e., any data collected for first meeting were dropped) so the total number of meetings included was 364.

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2.2. Data collection procedures

After developing the indicators of fidelity in each of these areas, the group then created 16 items rated on a 5-point anchored scale. In the final measure, items corresponded to two dimensions reflecting the goals of team decision-making and corresponding facilitator behaviors. Facilitation included “The CIPP decision-making process was fully explained when the meeting started”; “I understood the purpose of the meeting”; “The facilitator made sure the meeting guidelines (“ground rules”) were followed during the meeting”; and “The people necessary for the meeting to be successful were here.” Process included items such as “The meeting helped me to better understand the perspectives of the other members of the group,” “The entire group will support the plan,” ”My participation was valued” and “I will try my best to make the group’s plan work.” Internal consistency of the team decision-making process variable was moderate to high across types of participants (Cronbach’s alpha range, 0.78–0.89). For the facilitation dimension, the reliability was relatively low for facilitators (Cronbach’s alpha = 0.60), indicating that they had more variability in their ratings across different aspects of facilitation. This variability was found to be related to more negative ratings in specific areas such as “the people necessary to for the meeting to be successful were there” by some facilitators. To allow for comparisons across groups, we decided to keep the two-dimensional structure of the measure for facilitators and all scale items despite the lower internal consistency. In contrast, ratings were more highly correlated for other participant types (Cronbach’s alpha range, 0.73–0.86). The full measure is available from the first author.

Caregivers (foster parents and direct care agency staff), caseworkers, and youth 12 and older were invited to complete pre-meeting and follow-up wellbeing surveys using a structured protocol. Program staff sent pre-meeting wellbeing surveys created in SurveyMonkey to youth, caregivers, and caseworkers soon after the meeting was scheduled via email. However, the majority of the respondents chose to complete the pre-meeting survey immediately before the meeting in hardcopy form. In addition, all participants attending a meeting were given a team decision-making fidelity survey to complete immediately after the meeting ended. Although the fidelity survey was distributed by program staff, facilitators left the room before the surveys were completed and surveys were placed in a sealed envelope to preserve confidentiality of the responses. If participants attended the meeting by phone, they were sent a SurveyMonkey link by email to complete the fidelity survey. At the four to five month follow up, links to the wellbeing follow-up survey were sent via email to youth, caregivers, and case managers. Caregivers completing follow-up surveys may or may not have been the same caregiver that responded prior to the meeting due to moves or a different caregiver in the placement completing the survey. Because caregivers were not identified in the surveys, it was not possible to code whether they were the same caregiver. A dedicated staff member who was not involved in the youth’s meeting made follow-up phone calls to participants who had not completed the wellbeing surveys. Evaluation procedures and survey content were approved by the state child welfare research review board. No written consent or assent forms were required, but the structured script used by facilitators informed partic­ ipants that completion of measures was their choice, and any partici­ pants who indicated that they did not want to complete measures were not asked again to complete them. Procedures for data sharing with the university partner were also approved by the university’s Human Sub­ jects Review Board. The response rate for the fidelity surveys was 88.1% (N = 2,159). For the wellbeing baseline surveys, response rates were 91%, 84%, and 90% for youth, caregivers, and caseworkers, respectively. Post well-being rates were lower, with 42% of youth, 64% of caregivers, and 65% of caseworkers who completed pre-meeting surveys responding. Lower response rates for youth at follow up were attributed to difficulty con­ tacting youth by telephone after the meeting. Due to the low response rates at follow up, particularly for youth, findings from these data should be considered exploratory.

2.3.2. Youth wellbeing Adult Support (Youth). Youth responded to four items measuring adult support. Three items were adapted from the Belonging and Emotional Security Tool (BEST; e.g., “I have an adult in my life who will always be someone I can count on for help if I need it”; Frey, Cushing, Freundlich, & Brenner, 2008) and one item was drawn from the National Survey of Child and Adolescent Wellbeing (NSCAW) survey (e.g., “I have an adult I can trust to talk to about my personal and family problems”; See http://www.acf.hhs.gov/sites/default/files/opre/nscaw_child_i nstru.pdf for NSCAW measures description.) Future Perceptions (Youth). Two items assessed youth perceptions of whether they would graduate from high school and have a good job at age 30 (NSCAW items; also see Bearman, Jones, & Udry, 1997). Items were analyzed separately due to low correlation of these items at follow up. Youth Stress Level (Youth). Stress level was measured with a standardized question from the Ohio Scales of Behavior and Functioning (“How much stress or pressure is in your life right now?”; Ogles, Melendez, Davis, & Lunnen, 1999). This measure includes five anchored responses ranging from “Not much stress at all” to “Unbearable amounts of stress.” Youth Emotional and Behavior Problems (Caregiver and Case­ worker). The Ohio Youth Problems, Functioning, and Satisfaction Scales assessed emotional and behavioral problems. This validated scale has two dimensions for externalizing and internalizing symptoms and is strongly correlated with other measures such as the Child Behavior Checklist (see Ogles et al., 1999 for scale development and psychometric properties). Because this scale’s overall score (total of 20 items) had been used for a statewide evaluation of mental health services, the mean scores and changes over time could be compared to those of children beginning mental health services and after receiving 90 days of services in the same state. For the overall scale, reliability was 0.90 for care­ giver’s pre-test report, and 0.86 at post-test (Cronbach’s alpha). Reli­ ability for caseworkers was 0.90 at pre-test and 0.89 at post-test.

2.3. Measures 2.3.1. Indicators of team decision-making fidelity To develop a measure of fidelity to a team decision-making process, the research group (which included program administrators as well as previous and current meeting facilitators) held a series of meetings that focused on identifying the key aspects of the collaborative team decision-making framework used in the CIPP meetings. Conducting observations or coding recordings of meetings to understand the corre­ spondence between observational data and participant reports was not feasible. However, participants’ perceptions immediately after the meeting provides important indicators of fidelity by measuring the quality of facilitation, or facilitator behaviors supporting a team decision-making process, and process, reflecting the extent that partici­ pants felt the meeting provided the opportunity to participate in decision-making and brought together participant perspectives. Reli­ ance on participants’ reports after a meeting occurs is also consistent with Bearman and colleagues’ (2014) development of a fidelity measure for team-decision making. Thus, while the measure of fidelity is not as strong as a measure involving observations and coding of actual meet­ ings, the measure captures important indicators of fidelity and is consistent with previous work in this area (Bearman et al., 2014; Xu et al., 2017).

2.3.3. Placement and services adequacy Placement Quality (Youth). Seven items in the youth survey assessed placement experiences including safety, feeling like a part of a family where they lived, receiving emotional support and help, and ability to talk about personal problems with foster parent or the staff. 4

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Items included four questions adapted from the Multidimensional Scale of Perceived Social Support (Zimet, Dahlem, Zimet, & Farley, 1988), two from NSCAW, and one project-developed question. The Cronbach’s alpha for this measure was 0.89 at baseline and 0.90 at follow up. Placement Quality (Caseworker). This measure included seven project-developed questions asking caseworkers to rate the extent that the foster parent or placement staff (1) had the skills needed to address the youth’s needs, (2) were warm and caring, (3) had appropriate limit setting and discipline skills, (4) were accepting of developmentally normal behavior, (5) had rigid ideas about acceptable behavior, (6) had an understanding of the effects of trauma on the youth’s behavior, and (7) needed more training and support to improve care of the youth. Reliability was 0.81 (Cronbach’s alpha) before the meeting and 0.75 at follow up. This scale is available from the first author. Caseworker Support (Youth). Two averaged project-developed items measured youth’s perception of caseworker support. These items included “How often do you feel like your caseworker supports you” and “How often do you feel like your caseworker listens to you when de­ cisions are made about your life?” These items were highly correlated (r = .80, p < .001). Caseworker Support (Caregiver). Three NSCAW items assessed the extent the caregiver felt like a respected member of the team, felt the caseworker listens to their concerns, and treated them with respect. The reliability for this measure was 0.73 at pre-test and 0.82 at post-test (Cronbach’s alpha). Need for Child Care Support (Caregiver). Five items from the Support Functions Scale measured the caregiver’s perceived need for child care support (e.g, someone to talk to about problems with raising your foster child; Dunst, Jenkins, & Trivette, 1984). The reliability for this measure was 0.83 at pre-test and 0.72 at post-test (Cronbach’s alpha). Services Adequacy: Mental Health Services, Involvement in Decision-making, and Training and Support (Caregiver). Three questions asked foster parents or placement staff to rate their satisfac­ tion with the mental health services their youth had received, the extent their caseworker involved them in decision-making about services, and the training and support they had been provided. Items were drawn from NSCAW and project-developed. Because understanding any changes that occurred in each of these areas was of interest, each item was analyzed separately.

level of symptoms in the current sample relative to two community and clinical samples. Caregivers’ total scores for emotional and behavior problems at each time point were compared with a community-based sample of 329 (Ogles et al., 1999) and a clinical sample of 3,960 chil­ dren and adolescents who began mental health services in the state in 2010 (Starin et al., 2014).

2.4. Data analysis

Table 1 Youth characteristics and placements.

3. Results 3.1. Youth and meeting characteristics 3.1.1. Youth characteristics Children and adolescents served by the program had been in child welfare placements for an average of over two and a half years. Their placement histories suggest a high level of need. Prior to the meeting, they had an average of 3.45 (SD = 2.66) placements (Table 1). Those in foster care placements for more than 90 days had an average of 2.22 (SD = 2.18) placements per year, not counting hospitalizations or gaps in placements due to reunification or running way. A small proportion had experienced a high number of moves in care while others had been stable or relatively so. In fact, 10.6% had lived in only one placement, and 33.2% had lived in either two or three placements. In contrast, 31.1% had moved five or more times, and 13.3% experienced eight or more moves. Prior to the meeting, 23.1% had been previously placed or were currently placed in an institutional setting such as residential treatment, 16.7% had been in detention, 38.6% had hospitalizations, and 29.2% had one or more runaway episodes. At the time of the meeting, just over 20% were placed with a relative. Additionally, a proportion of those placed in specialized foster care may also have been with a relative; administrative codes do not distinguish between relative and nonrelative specialized care providers. 3.2. Meeting characteristics The 364 meetings that occurred in the six-week period had an average of 6.73 people other than the facilitator attend each meeting. A total of 3,572 people had been invited to attend meetings, and 69% of those invited participated (N = 2,450), either in person (78%) or by phone (22%). Ninety percent of youth 12 and older attended their

Mean scores for team decision-making facilitation and process were analyzed across participant types using one-way ANOVA tests. A post hoc Games-Howell test was used to identify differences for youth, par­ ents, foster parents, caseworkers and supervisors, clinical staff (thera­ pists, intensive placement stabilization staff and psychologist), guardians ad litem and court appointed advocates, youth supports (extended family members who were not caregivers and other supports), agency staff, and facilitators. The Games-Howell test was selected as it compares all possible combinations of group differences and does not require data to include groups of equal size with homogeneity of vari­ ances across the groups. Prior to examining changes in youth wellbeing over time, indepen­ dent sample t-tests examined differences between youth who completed surveys at follow up and those who did not. No significant differences in placement histories, demographic characteristics, baseline wellbeing, or perceptions of the planning meeting were found (ps > 0.4 for all vari­ ables), indicating that missing data were not related to any available youth characteristics. Changes in indicators of youth wellbeing and service adequacy were then analyzed using paired t-tests within each participant type. In these analyses, the n varied depending on the response rate at each time point, as tests were conducted for each var­ iable for respondents with complete data for the variables at both time points. For emotional and behavioral problems, we also compared the

Mean (SD) Male gender Age 12 or older Race African American White Native American Hispanic Years in foster care Prior placements Current placement Traditional foster care Specialized foster care Kinship foster care Residential treatment Detention Independent Living Department of corrections Hospital Othera

13.2 (5.1)

2.69 (3.09) 3.45 (2.66)

% 51.8 73.2 64.3 35.2 0.6 9.4

25.2 20.8 20.6 10.8 7.8 5.3 3.1 1.9 6.6

N = 363. Data could not be matched for one case. a Includes 9 youth on run, 3 in a shelter, 3 in an unauthorized placement (not with parent), 4 in unauthorized placement with parent, 3 with fictive kin, and 2 reunified with parent. 5

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followed during the meeting”) and process (e.g., “The entire group will support the plan”; “My participation was valued”). Fig. 1 shows mean scores across groups of participants on a scale from 0 to 4. All mean scores were above 3, indicating fidelity rated between “true” and “very true” for both team decision-making facilitation and process. Results from the analysis of variance analysis indicate that there were no significant differences in reports of fidelity to team decisionmaking facilitation across different groups. In contrast, perceptions of team decision-making process were significantly different across groups (F(9, 2094) = 3.34, p < .001). Post hoc analyses using the Games-Howell criterion for significance indicated that this finding is driven by two significant differences between groups, with clinical staff perceiving of more positive team decision-making processes (M = 3.64, SD = 0.51) as compared to both biological parents (M = 3.27, SD = 0.66, p = .04) and guardians ad litem and court-appointed special advocates (M = 3.42, SD = 0.72, p = .02). Although the parent, guardian ad litem and courtappointed advocates’ scores were still above an average of 3, indi­ cating a mean response of “true” for process fidelity (as shown in Fig. 1), these groups had the lowest scores for process.

meeting (N = 256), with 11% of those attending participating by phone. Sixty-six meetings were held for children under 12, who typically did not attend their meeting. Other participants primarily consisted of pro­ fessionals, with all meetings attended by either a caseworker or their supervisor (Table 2). Frequently, both attended, with 370 caseworkers and 348 supervisors attending the meetings in this period (29.3% of all participants). Half of the meetings were attended by guardians ad litem or court-appointed advocates (8.7% of all participants), and other pro­ fessionals who frequently attended included specialty consultants, other agency staff, and clinical staff (Table 2). One or more staff from the state’s in-home intensive placement services program (N = 134) also attended a quarter of meetings. Among nonprofessionals, foster parents most frequently attended meetings, with 53.6% of meetings occurring with a foster parent (kinship or unrelated) in attendance. Overall, 9.4% of all participants (N = 231) identified as a foster parent. A quarter of meetings included one or more biological parent, with a total of 108 parents attending (4.4% of all participants). Lower participation of biological parents is partly related to more difficulty in engaging biological parents, many of whom had not had custody of the youth for several years. The majority of foster parents (88.1% of foster mothers and 66.7% of foster fathers) who were invited to participate were able to attend, in comparison to 50.6% of mothers and 31% of fathers who were invited. Other nonprofessionals attended infrequently, with less than one in five meetings attended by one or more nonprofessional supports to the youth. These non­ professionals included 46 family members (other than parents or those providing kinship foster care) and 53 other youth supports (1.9% and 2.7% of all participants, respectively). Two thirds of the meetings (66.9%) were the first meeting held for the youth, while 29.1% were follow-up meetings. Information about the type of meeting was missing for 18.7% of the meetings. Meetings were scheduled most frequently due to a request for a higher level of care (42%) followed by concerns that a placement was unstable (33.4%). Meetings were also held due to a youth’s placement in juvenile deten­ tion or a department of corrections facility (9.8%) or a temporary shelter (11.2%). A small number of youth (2.6%) had a meeting to renew a placement authorization contract.

3.4. Changes in youth wellbeing Four months after the CIPP meeting, indicators of youth wellbeing were either improved or unchanged. Table 3 shows youth wellbeing scores at each time point. There was no statistical difference in youth’s perceptions of adult support. Youth did report more optimism about having a good job by age 30 and, at a marginal level of significance, lower levels of stress. Both caregivers and caseworkers reported significantly fewer emotional and behavior problems at follow up as compared to prior to the meeting. Similarly, caregivers’ reports of combined emotional and behavioral issues from the overall Ohio Scale score was significantly lower at follow up, decreasing from 20.56 (SD = 15.53) to 17.01 (SD = 13.27). Table 4 presents comparison of the scores over time in the cur­ rent study with two other samples, an older community-based sample (Ogles et al., 1999) and scores submitted by clinicians in a statewide sample of youth receiving Medicaid reimbursed mental health services in the same state in 2010 (Starin et al., 2014). The average level of behavior problems at the time of the meeting was about a standard deviation higher than in a community sample and the decrease in scores (3.55) was just slightly less than observed among youth receiving mental health services over a period of three months (4.04).

3.3. Participants’ perceptions of team decision-making fidelity and differences across groups Mean values for team decision-making process and facilitation indicate a high level of fidelity to team decision-making principles in the areas of facilitation (e.g., “I understood the purpose of the meeting”; “Facilitator made sure the meeting guidelines (‘ground rules’) were

3.5. Changes in placement quality and services Placement quality as reported by both youth and caseworkers was unchanged at follow up. At both time points, youth reported relatively high placement quality, rating items such as the extent that their care­ givers tried to help them and supported them and that they felt safe where they lived just below 2.5 on a scale ranging from 0 to 3. Average caseworker ratings were also relatively high, with ratings at about 3 on a scale ranging from 0 to 4 at both time points. Youth’s and caregivers’ perceptions of caseworker support were also similar before and after the meeting, as were caregivers’ ratings of the adequacy of the training they had received on how to meet the youth’s needs and the extent the caseworker involved them in the youth’s care (Table 5). In contrast, the caregivers’ need for child care support was improved at follow up, with a significant reduction in needs such as someone to talk with about problems raising the youth and to help get services for them. Additionally, caregivers reported greater satisfaction with the services that the youth was receiving to address emotional and behav­ ioral problems at follow up. This area was rated fairly low at baseline, with a rating of less than 2 on a 0–3 scale. While the level of satisfaction with mental health services reported four months after the meeting remained below 2.5, it was significantly improved relative to the level prior to the meeting.

Table 2 Meetings including one or more participant types. % Biological parent Foster parent Other caregivera Caseworker/ caseworker supervisor Youth support (nonprofessional)b Youth’s therapist Specialty consultantsc Other agency staff Intensive Placement Support GAL/ CASA

25 53.6 23.6 100 18.7 27.7 40.4 20.9 25.5 51.1

N = 364. a Other caregivers include individuals that identified as care­ givers other than current foster parents (e.g., direct care staff in shelter or residential setting). b Youth supports include family members other than parents, unrelated adults (nonprofessional relationship), and friends. c Specialties included areas such as juvenile justice, education, nursing, and developmental disabilities. 6

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Fig. 1. Team decision-making fidelity across participant types. Table 3 Youth wellbeing indicators at baseline and follow up. Baseline

Follow Up

M

SD

M

SD

n

95% CI for Mean Difference

Youth Stress level Optimism - graduate Optimism - good job Adult support

3.13 3.60 3.43 2.59

1.40 0.85 0.82 0.63

2.80 3.72 3.59 2.61

1.50 0.70 0.76 0.76

84 84 86 88

− − − −

Caregiver Behavioral problems Emotional problems

1.43 0.66

1.17 0.76

1.2 0.52

0.89 0.57

142 143

Caseworker Behavioral problems Emotional problems

1.28 0.52

1.07 0.68

0.93 0.32

0.85 0.42

190 190

a

Baseline CIPP program youth Community sample1 Youth in Medicaid-reimbursed mental health services2 2

t

0.36 0.22 0.61 0.20

− − − −

0.04, 0.42 0.02, 0.26

0.43 0.40

2.43* 2.26*

141 142

0.20, 0.50 0.10, 0.30

0.42 0.29

4.60** 4.07**

189 189

0.02, 0.69 0.34, 0.08 0.31, − 0.03 0.02, 0.69

df 1.86a 1.23 2.16* 0.20

83 83 85 87

p ≤ 0.10, *p ≤ 0.05*, **p ≤ 0.01.

clinical expertise to decide on appropriate treatment, leading to the tendency to disengage from nonprofessionals and youth in planning processes. Results from this study indicate that team decision-making might counter this tendency for disengagement and create a participa­ tory process, resulting in a plan that youth, caregivers, and other pro­ fessionals support and believe will be helpful. Additionally, several important youth outcomes (emotional and behavioral symptoms, opti­ mism about the future) and current caregiver perceptions of adequacy of child care support and mental health services were improved at followup four to five months after the meeting. In the current study, indicators of fidelity to team decision-making facilitation and process were examined in a large sample of partici­ pants with a variety of roles. The program integrated a range of mech­ anisms enhancing fidelity to team decision-making principles, including comprehensive facilitator training, fidelity observations, and supervi­ sion in adherence to team decision-making principles. This provided an opportunity to understand the extent that implementation of team decision-making could create a fully participatory process resulting in a plan that youth, caregivers, other nonprofessionals, and professionals supported. Despite the program’s efforts to involve nonprofessionals, meetings had relatively low representation of nonprofessionals relative to professionals, raising questions about the extent that this could be achieved in a context in which professionals could easily predominate the discussions. Yet findings indicate that most participants reported experiences indicative of a high level of fidelity to the model in terms of perceptions of both facilitation and process. Consistent with Xu and colleagues’ (2017) findings for meetings held for a range of different

Table 4 Ohio scales behavior scores: comparison between samples.

1

r

Follow Up

M

SD

M

SD

N

20.56 10.29 23.77

15.53 10.29 –

17.01 – 19.73

13.27 – –

142 329 3,960

Ogles et al., 1999. Starin et al., 2014.

4. Discussion In contrast to the professional-dominated service planning models traditionally used in child welfare services, team decision-making practices attempt to create a collaborative, inclusive planning process that provides the opportunity for meaningful participation of youth, caregivers, and family members. By incorporating the perspectives of youth and those closest to them, plans are expected to better address the concerns and needs of youth and their caregivers. However, full implementation of team decision-making meetings with young people who are at risk for placement instability could be difficult in actual practice, given their often complex needs. Disruptive behaviors and difficulties with forming positive relationships contribute to placement disruptions, and complex trauma may underlie these difficulties (Villo­ das et al., 2016). Professionals may view these issues as requiring 7

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Children and Youth Services Review 120 (2021) 105705

Table 5 Placement and Services at Baseline and Follow Up. Baseline

Follow Up

M

SD

M

SD

n

95% CI for Mean Difference

r

t

df

Youth Placement quality Caseworker support

2.42 2.37

0.73 0.91

2.42 2.37

0.73 0.79

89 86

− 0.18, 0.18 − 0.19, 0.19

0.31 0.45

0.01 0.00

88 85

Caregiver Need for child care Support Caseworker support Involved in care decisions Training/support adequate Mental health services adequate

2.06 3.34 2.30 2.18 1.91

1.02 0.99 0.78 0.74 0.83

1.68 3.24 2.27 2.19 2.11

0.87 0.97 0.69 0.72 0.72

121 114 139 142 128

0.17, 0.60 − 0.13, 0.33 − 0.12, 0.20 − 0.18, 0.15 − 0.37, − 0.02

0.21 0.20 0.15 0.11 0.21

3.5** 0.91 0.44 − 0.17 − 2.25*

120 113 138 141 127

Caseworker Placement quality

2.99

0.84

3.08

0.74

171

− 0.25, 0.08

0.04

− 1.01

170

*p ≤ 0.05, **p ≤ 0.01.

behavioral problems in this study to data from a statewide evaluation of outpatient mental health services using the same measure (Starin et al., 2014) indicates that the decrease in symptoms at follow up was similar to the decrease occurring for youth while in outpatient mental health services. Scores decreased 4 points among youth involved in mental health services over a period of three months as compared to the 3.5point decrease in this study. As noted, the reasons for the improvement in youth wellbeing cannot be determined from this study, but caregivers’ reports of significant improvements in adequacy of child care support and greater satisfaction with mental health services might point to factors that supported posi­ tive changes. The meeting might have resulted in provision of needed services that more adequately met the needs of the youth in their current placement, leading to improved wellbeing. Alternatively, placement in a higher level of care, such as specialized foster care, might have better met the needs of the youth. Whether these improvements occurred in the same placement or a new placement, reduction in behavior problems and a decrease in caregivers’ need for child care support is meaningful, given the correlations between these factors and placement instability (Aarons et al., 2010; Leathers, Spielfogel, Geiger, Barnett, & Vande Voort, 2019). Additional research is needed to better understand whether team decision-making meetings improve outcomes through provision of more adequate services and support that lessens both disruptive behavior and risk for moves over time. In contrast, measures of placement quality as assessed by both youth and caseworkers, caseworker support to youth and caregivers, other adult support to youth, and caregiver involvement in services were statistically the same over time. Considering that the majority of youth were referred to the team decision-making planning meeting due to a placement disruption or request for a different level of care, it seems surprising that perceptions of placement quality would not improve, as these referral categories suggest that caregivers were struggling to provide care prior to the meeting. However, reports from both youth and caseworkers suggest a different experience, with relatively high to moderate caseworker ratings of caregivers’ parenting skills both prior to the meeting and afterwards, with no significant change detected over time. Similarly, most youth rated their relationships and support in their placements positively overall at both time points. Given the consistency across reporters, these findings suggest that placement quality was un­ changed. However, it is possible that the questions asked did not capture the specific placement attributes likely to change during the course of service planning and the following months, or that more time might be needed to assess some of the placement attributes included in the measures, such as a feeling of belonging. Future studies using controlled designs will ideally include multi-dimensional measures of placement characteristics to better understand potential planning meeting effects.

reasons, most participants endorsed meeting qualities such as believing their participation was valued and that the entire team would support the plan. Results from two earlier studies point to lower levels of engagement of youth, parents, and other nonprofessionals in team decision-making meetings relative to professional staff (Healy et al., 2012; Xu et al., 2017). These discrepancies suggest challenges with implementing a fully participatory model. In contrast, this study’s results indicated no sig­ nificant differences in perceptions of team decision-making facilitation (e.g., understood purpose of meeting, facilitator made sure ground rules were followed) or process (e.g., my participation was valued, the entire group will support the plan) across most participant types. Participants across different roles (youth, caseworkers, foster parents, external meeting facilitators, clinical staff, other professionals, parents, and youth supports and advocates) all reported comparable levels of adherence to active team decision-making facilitation. However, two differences were found for perceptions of the team decision-making process, with clinical staff (e.g., therapists and psychologists) viewing the process as more consistent with team decision-making than either parents or guardians ad litem/ court advocates. The reasons for the contrast in parent and guardian ad litem per­ spectives with clinical staff are not clear, but as noted by Xu et al. (2017), the difficult emotions experienced by parents whose children are in foster care placements could affect parents’ ability to engage in planning meetings and trust that their perspectives will be heard in child welfare meetings. The extended length of time that youth had been in foster care could also create some challenges in engaging parents and creating a shared decision-making process given their history of previ­ ous potentially conflictual contacts with the child welfare system. In contrast, clinical staff are likely to feel comfortable sharing their per­ spectives and are unlikely to have had negative experiences in previous service planning meetings. The reasons for the lower ratings for guardians ad litem is unclear. Factors such as professional differences in expectations for meetings or alignment with parents’ perspectives could be relevant, but to better understand these differences in perceptions of the team decision-making process will require additional research focused on understanding their experiences. The young people served by the team decision-making program had significantly lower emotional and behavioral problems four to five months later as rated by both caseworkers and caregivers. While it is expected that caregivers frequently changed in this period, caseworkers are more likely to be the same, supporting that the consistently reported reduction in behavior problems reflected a real decrease. Youth who were 12 and older also reported more optimism about having a good job as an adult. Without a randomized control group, these changes cannot be attributed to the program or the services youth received as a result of planning in the meeting, as they might have naturally occurred without the meeting. However, comparison of the change in emotional and 8

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Children and Youth Services Review 120 (2021) 105705

4.1. Limitations

observations of practice followed feedback, and ongoing support to establish collaborative practices that emphasized hearing the perspec­ tives of nonprofessionals and incorporating these views in understand­ ing the youth’s needs. This level of training and support is likely to be required to create an equitable, participatory process. Future research is needed to build upon the promising results from this study with controlled research designs that can better assess the effects of collaboration and provide a longer-term view of the types of services and supports to increase positive placement outcomes and stability. Critical questions that remain unanswered in this study include whether the meeting process resulted in meaningful engagement in effective services and ongoing collaborative relationships that improved outcomes for youth. Randomization might be difficult in a state with statewide implementation of team decision-making, but opportunities for randomization should be optimized in states or localities that are initiating use of the model and seek to build an evidence-based service system. Finally, variation in composition of the meeting participants was not examined in this study, but other uncontrolled research has found that meeting composition is related to placement decisions (Crea, Wildfire, & Usher, 2009). Given these findings and the relatively low proportion of nonprofessional participants in our study, future studies might examine how efforts to include more nonprofessional participants might affect outcomes.

Although this study’s promising results support continued research of team decision-making with youth at risk for placement instability, its uncontrolled design restricts the extent that the positive changes in several important outcomes can be attributed specifically to use of team decision-making. Without a comparison group, it is not clear whether the positive changes that occurred would be gained through a different planning model or even just naturally over time with no intervention at all. Respondents might also report more positive wellbeing due to an expectation that improvements should have occurred after the meeting. Future research should build on these exploratory findings to assess effects using stronger research designs. Additionally, although the study used a validated measure of emotional and behavioral problems and drew upon established mea­ sures whenever possible, a limitation includes the use of many short measures to limit the time burden on youth and other meeting partici­ pants. Further validation of these measures would increase confidence in the results. A longer follow-up period with assessment of types of ser­ vices provided and perceptions of these services would also provide a better understanding of how team decision making with different levels of subsequent services and additional planning meetings supports pos­ itive outcomes including immediate effects on wellbeing and service as well as placement trajectories over time. Finally, although analyses across the responding and non-responding groups did not detect any differences in these groups, the low response rate of youth at follow-up is a concern as it is possible that youth who did not respond had more negative outcomes despite their similarities at baseline. For example, those who experienced arrest or hospitalization might not have been able to complete the measures. If so, the level of missing data at follow up with youth could have affected the results.

4.3. Conclusions The current standard of care in child welfare settings emphasizes service planning that provides an opportunity for meaningful partici­ pation of youth and those closest to them. Results from this study suggest that team decision-making can be used with fidelity for youth experi­ encing placement stability and support the continued development and study of this practice approach for this population. Findings indicate that significant improvements occurred in emotional and behavioral symptoms, caregivers’ need for support, and satisfaction with mental health services, suggesting that the meeting process might have facili­ tated service provision that addressed some key areas of concern. Additional research is needed to identify the unique effects of a team decision-making processes on short- and longer-term outcomes as well as perceptions of child welfare services over time.

4.2. Implications for practice and future research Service planning for young people at risk for placement instability ideally incorporates perspectives from caregivers, service providers, and young people themselves. Caregivers and youth, in particular, report a desire for more involvement in service planning (Barnett et al., 2018; Brown, 2008), and creating a process that supports collaboration and greater cohesion of perspectives about a youth’s needs is essential to meet standards calling for collaborative planning (AECF, 2013; Child Welfare League of America, 2014). This study’s findings support that statewide programs that adopt team decision-making can achieve an important aspect of fidelity to the model’s principles, including an in­ clusive process and facilitation consistent with the model’s specified goals. Skilled facilitation is likely to have been critical to this success, as active facilitation strategies support a participatory and collaborative process. Findings from previous research suggest that some of the factors that enhance effective participation in team decision-making meetings include good relationships between the youth/family and the facilitator; clear and open communication; opportunities for youth/family to voice their perceptions, opinions and needs; and encouragement of all stake­ holders’ participation (Gallagher, Smith, Hardy, & Wilkinson, 2012; Nixon, 2007). To create these conditions, external facilitators need strong engagement skills, as no pre-existing relationship or trust has been built with participating youth or other stakeholders. The specific skills required for successful facilitation may diverge significantly from typical child welfare practices and require considerable training and coaching to achieve. How facilitation was supported in this program is likely to be rele­ vant to its outcomes and has implications for practice as well as future research. The program had dedicated facilitators whose primary task was to facilitate team decision-making meetings. This provided the op­ portunity to provide neutral facilitators who received ongoing training in the model. Consistent with implementation research (Nadeem, Gleacher, & Beidas, 2013), initial training was followed by supervision,

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