Expanding Access, Centering Staff: Task-Shifting In Child Welfare Practice

Background: Children involved in child welfare (CW) services experience increased rates of behavioral challenges (e.g. disruptive, aggressive behavior). Limited availability of mental health (MH) providers poses a barrier to service utilization. Task-shifting strategies involve redistributing tasks from professionally trained MH specialists to providers with lesser qualifications, thereby expanding access and reach of evidence-based programs (EBP) and MH treatments. However, little is known about the experience of task-shifting MH treatments to CW staff. Perspectives across staff roles offer complementary insights: caseworkers provide frontline experiences; supervisors bridge frontline staff and organizational leadership, address workforce development and staff buy-in; and administrators highlight organizational factors that shape implementation. This study focuses on CW staff perceptions of task-shifting strategies for implementing a modified version of an evidence-based MH treatment addressing child behavioral difficulties the 4Rs and 2Ss Strengthening Families Program (4R2S). Method: Data for this study were drawn from a larger, NIMH-funded exploratory project that used task-shifting to adapt the 4R2S for delivery by CW caseworkers in placement-prevention settings rather than MH clinicians. After implementation of the modified 4R2S with multiple family cohorts, audio-recorded qualitative semi-structured interviews with administrators (n=2), supervisors (n=4), and caseworkers (n=6) were conducted. For the purposes of the current study, participants responded to questions about their experience with task-shifting. Participant responses were then coded by the authors using grounded theory strategies (e.g, open coding, axial coding) in which initial codes were applied to excerpts during a preliminary review, followed by more focused coding based on content. This study focuses on feedback from caseworkers and supervisors regarding task-shifting. Results: Participant feedback fell within four major categories: (1) staff capacity and role alignment (e.g., EBP alignment with staff responsibilities, overall capability to implement EBPs, and navigating both benefits and challenges of integrating EBPs into CW settings including managing time, and balancing workload demands), (2) buy-in from staff and families (e.g., importance of building relationships with families and alignment with needs of client population), (3) fidelity/accountability (e.g., challenges with adherence to model standards, and factors that impact fidelity including staff capacity, and organizational characteristics), and (4) supports for EBPs (e.g., program manuals and access to specialized experts supported implementation) Conclusion: While participants emphasized the shared commitment of learning new skills and strategies for their clients; participants also referred to tensions related to model fidelity, describing it as both essential and in conflict with flexibility required in practice. Similarly, interviewees discussed that model fit for both staff and clients depends on alignment between staff and organizational capacities (e.g., time, skillset, infrastructure), and family circumstances/needs (i.e., task-shifting a family-centered model to caseworkers already engaged in family-centered work). Overall, task-shifting was viewed as a strategy that supports MH for CW-involved families, yet barriers to implementation remain. Findings point to concrete considerations, including staff training history, family-staff relationships, and fidelity supports; each of which can guide CW organizations in expanding access to EBPs equitably and sustainably. As CW navigates shrinking resources and growing expectations, task-shifting provides a pathway to do more with what already exists.