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Journal of Evidence-Based Social Work, 7:481–487, 2010

ISSN: 1543-3714 print/1543-3722 online

DOI: 10.1080/15433714.2010.494977

Evaluating the Effectiveness of Infant Mental Health Enhanced Case Management for

Dependency Populations

DAVID CONGDON Central Florida Director of Mental Health Services and Corporate Director of Research,

The Children’s Home Society of Florida, Winter Park, Florida, USA

Children who are receiving services for abuse and neglect are

likely to have reduced developmental levels and are less prepared

for success in school as a result. The progress of 144 children

receiving services from The Children’s Home Society of Florida

was tracked with half being randomly assigned to a control group

and half to an experimental group receiving enhanced infant

mental health oriented case management services from two so-

cial work professionals in each of two locations in Tallahassee

and West Palm Beach Florida. Those receiving enhanced case

management showed significantly higher results in the following

areas: more visits with their parents (for those removed from the

family home), more service referrals, more completed assessments

for services, more services based on the assessments they received,

and more success in completing goals of treatment for which they

were referred. Their parents had more contact with professionals

to whom they were referred and had more success in completing

goals of the treatment for which they were referred. Children who

received intensive case management also showed improvement in

their developmental skills related to problem solving from inception

to completion of services. Implications for further research are

considered.

KEYWORDS Children, infant mental health, dependency, evalu-

ation, case management

Address correspondence to David Congdon, Director of Mental Health Services, Central Florida Division, The Children’s Home Society of Florida, 5766 S. Semoran Blvd., Orlando, FL 32882. E-mail: [email protected] or [email protected]

481

482 D. Congdon

NEED

Children who have come to the attention of the child welfare system related to allegations of abuse or neglect are certainly at risk of suffering develop- mental delays. This is related to several factors. Increased levels of cortisol, released by the body in response to abuse and other threats, negatively affect a child’s developmental process (Kendall, 2002, p. C1). Similarly, the National Scientific Council, in conjunction with the Center on the Developing Child at Harvard University (Shonkoff et al., January, 2007, Boston, MA) has shown that abuse and neglect have a negative impact on children’s development. This view is supported by the work of Allen et al. at the Center for the Study of social Policy in their April, 2004 work, ‘‘Strengthening Families Through Early Care & Education.’’

For children to do well in school, they should be performing at normal developmental levels for their age, when entering school, since educational programs depend on taking children from one predictable developmental and knowledge level to another. It follows then that efforts to improve the developmental levels of children who have been identified as being abused or neglected could benefit their school readiness. Such efforts allow these children to come closer to norms for their age and to perform on a more level playing field with other children.

Improving developmental levels for preschool children exposed to abuse or neglect has been the focus of the Ready by Five research project conducted at The Children’s Home Society of Florida (CHS). The project has been generously funded by The W. K. Kellogg Foundation and the Center for Prevention and Early Intervention Policy at Florida State University.

BACKGROUND

Both the National Scientific Council and the Center for the Study of Social Policy have suggested in the works referenced here that social service efforts to identify and address developmental needs in children can help them reach age appropriate developmental levels to prepare them to do as well as possible in school. These outcomes are addressed through early childhood development efforts focusing on the child, parent, and community support.

The design of the Ready by Five research project followed such an approach. CHS worked with staff from the Center for Prevention and Early Intervention Policy at Florida State University to develop an approach that could successfully address the developmental needs of a particular group of children aged 0 to 5. These children and their parents were clients of CHS to address problems of abuse or neglect under contracts with two community based care entities in Tallhassee, Florida (Big Bend Community Based Care) and West Palm Beach, Florida (Child and Family Connections).

Evaluating Infant Mental Health in Dependency 483

PROJECT DESIGN

The Ready by Five research project was a quasi experimental design with two parts. In the first part, the project compared referral levels, several steps of referral follow through and the results of referrals for control and experimental groups in the Tallahassee and West Palm Beach, Florida com- munities. In the second part, the project compared pretest to posttest scores on the Ages & Stages and Ages & Stages Social Emotional developmental screening instruments (Bricker, Squires, Mounts, Potter, Nickel, Twombly, et al., 1999; Paul H. Brooks, Baltimore, MD.) to determine if children in the experimental group made any improvement in their developmental skills, for their age, for the period prior to intervention of services to after services. This instrument measures skills in the following six areas: communication, gross motor skills, fine motor skills, problem solving, and personal-social skills. Social-emotional skills are measured on a separate instrument also used in this study.

Services were assessed for 144 children who were randomly assigned to the control and experimental groups in each location (72 in each). Exper- imental group clients received enhanced case management from a team of two professionals in each service site. The team was composed on one MSW Licensed Clinical Social Worker who had completed or was participating in a specialized course of training in Early Childhood Intervention services and one MSW trained clinician. The team identified candidates to be included in either the control or experimental group on a randomized basis, conducted Ages & Stages assessments with those in the experimental group, provided referral and intensive monitoring and support for referral follow up and success, or lack of it, for children and their parents in the experimental group, as possible, assisted parents in working with their children to promote developmental skills, and completed final Ages & Stages assessments for ex- perimental group clients at the end of the intervention. All candidate families received appropriate notifications related to the research process required by the State of Florida required Institutional Review Board process. The intervention began on July 15, 2007 and ended on September 30, 2008. Final Ages and Stages Assessments were completed in October and November of 2008. The project also trained all staff working with both experimental and control group clients in early childhood intervention approaches that may enhance work with clients.

The design of the project was to test the following 14 hypotheses.

1. Children who receive enhanced case management will go into perma- nent placement sooner than those who do not.

2. Children who receive enhanced case management will have more visits with parents during services than those who do not.

484 D. Congdon

3. Children who receive enhanced case management will have more visits with siblings during services than those who do not.

4. Children who receive enhanced case management will have more refer- rals for services than those who do not.

5. Children who receive enhanced case management will have more con- tact with referral resources, when referrals made than those who do not.

6. Children who receive enhanced case management will receive more completed assessments with referral resources, when referrals made and contact made than those who do not.

7. Children who receive enhanced case management will receive more services based on the assessments they received than those who do not.

8. Parents who receive enhanced case management will have more referrals for services than those who do not.

9. Parents who receive enhanced case management will have more contact with referral resources, when referrals made than those who do not.

10. Parents who receive enhanced case management will receive more com- pleted assessments with referral resources, when referrals made and contact made than those who do not.

11. Parents who receive enhanced case management will receive more ser- vices based on the assessments they received than those who do not.

12. Children who receive enhanced case management will have more results of successfully completing treatment than those who do not.

13. Parents who receive enhanced case management will have more results of successfully completing treatment than those who do not.

14. Children who receive enhanced case management will show progress on Ages & Stages and Ages & Stages Social Emotional developmental scores for their age from the beginning to the end of the project.

The first 13 hypotheses compared results for the experimental and control groups and the 14th hypothesis compared pretest and posttest results for the experimental group.

Data on each of these findings and other demographic data about the clients was maintained in an electronic file that could be sorted on each of the data elements and on which relevant statistical tests could be conducted for each variable of interest. Because of the nature of the tests being conducted, all results could be assessed through variations of simple one tailed t-tests comparing group means on the variables in question.

RESULTS

Children who received intensive case management had significantly more (better than chance) of the following: Visits with their parents (p < .001), more service referrals (p < .01), more completed assessments for services

Evaluating Infant Mental Health in Dependency 485

(p < .01), received more services based on the assessments they received (p < .05), and had more success in completing goals of treatment for which they were referred (p < .05). Their parents had more contact with profes- sionals to whom they were received (p < .05), and they had more success in completing goals of the treatment for which they were referred (p < .05).

Children who received intensive case management also showed signif- icant improvement in their developmental skills related to problem solving from inception to completion of services, according to the results of this research (p < .05).

Detail statistics on these analysis are included in the chart on pages Tables 1 and 2.

IMPLICATIONS

To the degree that participation in referred services and completing those services successfully indicates improvement, enhanced case management appears to have been a positive factor for children. It also appears to have been a positive factor for their parents. To the degree that problem solving skills are an important developmental skill for the success of children in school and other future activities, enhanced case management appears to have been a positive factor for the children who received it. Of course, the efficacy of these results is limited to the populations being studied in their particular communities.

Several factors are important for future consideration. As the project developed, it did not have adequate resources to do pre- and post-test Ages & Stages screenings on both control and experimental group clients. Doing so would have enriched the data greatly, and such a study should be considered for future efforts. It is very possible that though the control group scores for most of the developmental screening scores stayed stable for the experimental group, the scores for the control group may have gone down, since these children were in an at risk situation. Statistical tests to compare change scores for these groups would be very informative. It could be that the enhanced case management services worked to stabilize developmental skill levels for the experimental group where it they may have normally gone down, as a natural consequence of the risk experienced by the children studied. This study does not give us the answer to that question but it leaves it open.

Certainly, the time spent by the enhanced case managers in collecting data could have been used in providing services that appeared to be effective in some situations. If more separate resources were allocated simply to client recruitment, group assignment, and possibly to conducting screening assessments for the children in the study, it is possible that a higher level of direct service could have provided with even stronger results.

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486

Evaluating Infant Mental Health in Dependency 487

TABLE 2 Detail Statistical Results on Pre- and Post-Test Scores for Ages Stages Scores for Experimental Group on Ready by Five Project

Communication Gross motor

Fine motor

Problem solving

Personal social

Social emotional

1 2 3 4 5 SE

Mean initial 47.50 54.08 47.33 43.93 50.63 22.00 Mean final 45.58 54.67 47.67 48.58 51.17 17.97 sd initial 15.60910208 11.91394521 15.17766721 15.78871799 11.8535794 29.57610121 sd final 15.54358734 10.07878569 15.63532145 13.65717253 11.3632871 29.3794386 n 60 60 60 60 60 60 sig. 0.155513776 0.331185443 0.443945226 0.016912834 0.36392799 0.108521878

Generally, children who received more intensive infant mental health oriented case management, referral, and follow up showed improved out- comes on 9 of the 19 measured variables. Most of these were in the area of following up with referred services, but both the children and their parents in the experimental group showed greater improvement in accomplishing the goals of services to which they were referred than did those in the control group. Children in the experimental group also showed improvement on problem solving skills. Based on the research reported here, enhanced case management from an infant mental health perspective appears to be a promising approach to improving developmental skills and school readiness for children impacted by the child welfare dependency system. The results of this research showed progress on almost half of the variables studied. This success, plus the appropriateness of doing change score analysis on pre and post test scores on the Ages & Stages scales indicate strong potential for future studies in how dependent children can benefit from and specifically become more school ready from the implementation of infant mental health services.

REFERENCES

Allen, M. L., Blount-Clark, J. E., Crompton, D. A., Dunst, C., Hampton, D. J., Knitzer,

J., et al. (2004). Strengthening Families Through Early Care & Education. Wash- ington, DC: The Center for the Study of Social Policy.

Bricker, D., Squires, J., Mounts, L., Potter, L., Nickel, R., Twombly, E., et al. (1999).

Ages & Stages Questionnaires (ASQ) A Parent-Completed, Child-Monitoring System, Second Edition. Baltimore, MD: Paul H Brooks Publishing Co.

Kendall, J. (2002). How child abuse and neglect damage the brain. Boston Globe, p. C1. Boston, MA: Globe Newspaper Company.

Kendall, J. (2002, September 24). How child abuse and neglect damage the brain. The Boston Globe, C1. Retrieved from http://www.snapnetwork.org/psych_effects/ how_abuse_andneglect.htm

Shonkoff, J. P., Boyce, W. T., Cameron, J., Duncan, G., Fox, N. A., Greenough, W., et al. (2007). The Science of Early Childhood Development: Closing the Gap

between What We Know and What We Do. Boston, MA: National Scientific Council, Center on the Developing Child at Harvard University.

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