'Mothers Have 100,000 Things on Their Minds': A Rapid Qualitative Study of What Drives Mental Health Referral Decisions Among Frontline Child Welfare Staff

Background and Purpose: Nine out of ten child welfare (CW)-involved mothers have experienced trauma, yet the majority do not receive mental health services (MHS). CW-involved mothers have high rates of PTSD (54.3%) and depression (61.7%) — conditions consistently linked to parenting limitations and increased risk of child maltreatment, a serious threat to children's well-being. In 2018, $500 million in federal funding was dedicated to prevention efforts, yet fewer than half of CW-involved mothers who need MHS are referred and less than a quarter initiate services, rendering this investment underleveraged. Further, mothers of color are overrepresented in the CW system across all 50 states, reflecting racial inequities in how the system engages with families. CW frontline staff play a primary role in facilitating access to MHS, yet little is known about the factors that influence their referral decisions and behaviors. This study uses rapid qualitative analysis (RQA) to investigate CW frontline-staff driven determinants of MHS referral for CW-involved mothers, with the goal of identifying actionable strategies to close the post-referral gap (the discontinuity between referral and initial use) and maximize the public health impact of federal investments in care.

Methods: Semi-structured interviews were conducted with 12 frontline CW staff recruited from six preventive agencies across New York City. Informed by the Gateway Provider Model (GPM) and the Behavioral Model for Health Services Utilization (BMHSU), interview guides focused on knowledge of available MHS, perceptions of maternal MH, and referral decision-making. Data were analyzed using RQA informed by the framework method: interviews were summarized into structured templates and transferred to a cross-case matrix. GPM and BMHSU concepts guided deductive coding; inductive coding allowed for emergent themes. Co-coding, peer debriefing, and analytic memos supported rigor.

Findings: Findings from semi-structured qualitative interviews with CW prevention supervisors, caseworkers, and case aides revealed four themes: (1) competing concrete needs: mothers' housing instability, food insecurity, and immigration status influenced staff perception of mothers' readiness for and timing of MH referral; (2) dual role conflict and structural constraints: staff described tension between meeting family needs and fulfilling CW system requirements; (3) rapport and stigma: staff described the quality of the working relationship and mothers' receptiveness to MH services as guiding referral conversations, and (4) training and supervision: newer staff described relying heavily on experiential learning in the absence of formal training, and noted that variability in supervision quality shaped how MH need was identified and addressed.

Implications and Conclusions: These findings provide insight into perspectives of CW prevention staff who link mothers to care and illuminate four possible mechanisms to explore to improve MHS access for CW-involved mothers. This study addresses a persistent challenge in CW service delivery, with implications for workforce training, agency policy, and the improvement of frontline CW practices. Ultimately, translating these findings into practice and policy has the potential to improve outcomes for one of the most multiply stressed populations in the United States and capitalize on available funds provided by the Family First Prevention Services Act.