Child Welfare Perceptions of Contingency Management

Background

Contingency management (CM) is a highly supported practice for people with stimulant use disorders. While adoption of the practice has increased in recent years, it remains underutilized, a concern given the increased prevalence of methamphetamine use in the U.S. In the context of the child welfare system, parental methamphetamine use is associated with higher rates of placements in state custody, longer stays in out-of-home care, and lower rates of reunification compared to parents who use other drugs. Widespread adoption of CM could improve outcomes for parents and families in the child welfare system due to methamphetamine use, though use of incentives may be controversial among child welfare workers. This study explored the perceived acceptability and effectiveness of CM among child welfare workers.

Methods

Participants included child welfare workers and supervisors in eight mostly rural counties in a southeastern state. Items from two existing measures of CM were adapted for this study. Perceived effectiveness and acceptability was assessed using 2 items on a 7-point Likert scale. Relative agreement about beliefs about incentives in treatment related to CM was assessed using an adapted 22-item measure on a 5-point Likert scale. The 22-item scale demonstrated excellent internal consistency (Cronbach’s α = .97). The sample consisted of 27 mostly white and female participants. Over 60% worked for child welfare for 3 years or longer. Because of the sample size and homogenous sample characteristics, findings are reported in aggregate.

Results

Overall, respondents demonstrated moderate support for CM as a treatment approach for substance use, with notable variability in perceived effectiveness, acceptability, and philosophical alignment. For perceived effectiveness and acceptability, participants generally viewed contingency management as somewhat effective, with a mean effectiveness rating of 5.19 out of 7 (SD = 1.44). Perceptions of acceptability were less favorable, with a mean acceptability rating of 4.19 out of 7 (SD = 1.82). Approximately 18% viewed CM as unacceptable or mostly unacceptable, indicating ambivalence about its appropriateness. Regarding beliefs about incentives in treatment, on average, respondents modestly agreed that incentives can have more positive than negative effects on clients (M=3.65, SD=1.04, range=1-5) and that incentives help the client achieve sobriety, allowing the counselor to focus on helping them make other life changes (M=3.47, SD=1.08, range=1-5). There was stronger agreement with incentive programs focusing on what is good in the client's behavior (e.g., being abstinence), not what went wrong in recovery (M=3.94, SD=.81, range=1-5). The 22-item total score suggested relative agreement with belief about incentives in treatment with a total scale score of M=69.76 (SD=13.73, range=43-97).

Implications

Findings underscore the need for further investigation into how child welfare professionals’ attitudes toward contingency management influence implementation processes and client outcomes. These results point to the importance of education, values-based discussion, and pre-implementation guidance when introducing CM approaches to individuals or programs. Research is needed to evaluate whether improving worker acceptability of CM translates into increased uptake, fidelity, and ultimately improved family reunification and permanency outcomes for parents with stimulant use disorders involved in child welfare.