Among parents in home based child welfare services, depression symptoms were strongly correlated with problems and resources across a range of other common family preservation target areas, and changes in parental depression symptoms over the course of in-home family preservation services were found to parallel changes in these other areas. It is important to note that depression was the only mental health, internalizing or distress variable included in this intercorrelated nexus, and that the other variables spanned a range of domains—social, familial, parental, and socio-economic. A more parsimonious second-order model was ultimately accepted as best fitting the data. In effect, this model suggests that a general tide of improvement may lift (or lower) many boats including depression symptoms. The observation does not confirm that any one of these factors drives the others---it may simply be that all of these changes move in concert.
The quality of the home visitor-parent working alliance was associated with greater improvement, suggesting that attention to relationship factors may be important in family preservation services. A home visitor---client relationship characterized by goal clarity, shared goals, culturally sensitive attitudes and language, trust, and a sense of mutual liking was modestly but significantly associated with depression change. Although the hypothesis was supported, the size of the effect was small. Cultural competency and working alliance were correlated variables, with similar relationships to depression symptom change.
Contrary to prediction, linkage to adjunctive usual care mental health services was not associated with depression symptom change, controlling for baseline symptom level, and in fact the opposite finding was observed. There is a concerning precedent for this finding in the parenting and child welfare literature, including in randomized studies (Chaffin et al., 2004
), and in one meta-analysis of parenting programs (Kaminski, Valle, Filene, & Boyle, 2008
). There are several possible explanations for this phenomenon. The current study design cannot distinguish among these possibilities, and we believe that more definitive and focused studies are clearly needed. One possibility is that the adjunctive mental health treatment services received by the parents in this study were simply ineffective, of low quality, or had inadequate compliance. Because we measured only service utilization in the broadest terms, we do not have data on the quality of adjunctive usual care mental health services, their use of evidence-based models, or whether the service dose and client compliance were sufficient. True experimental design studies that tightly control the type and quality of depression treatment and accurately model the impact of compliance variations might help resolve this question. Another possibility is that adjunctive usual care mental health services, as currently delivered, may rely on elements that mesh poorly with the typical skill-focused and behavioral orientation of parent training and family preservation services. The other possible explanation is selection bias. There may have been any number of unobserved factors potentially biasing the selection process of who received adjunctive mental health services and who did not. For example, cases may have self-selected or been differentially encouraged into adjunctive services by home visitors if their depression was worsening and vice versa if they experienced spontaneous recovery. Any of these types of selection processes could have contributed to the findings that were observed. Studies using experimental designs to test family preservation with versus without adjunctive usual care services, and capturing finer grained data about depression symptom history and change might help address this possibility.
Consistent with the global change pattern that was observed, there also is the possibility that the current family preservation adjunctive linkage strategy is fundamentally flawed in some ways. The adjunctive service linkage strategy is founded on the assumption that services should be fully comprehensive, linking each identified problem to a corresponding and often separate service program. Given that families in child welfare commonly have a multitude of identifiable problems, this might result in service packages that are complex, that could work at cross purposes, that may create confusion, or that may add to rather than lift the burdens and demands on already thinly stretched parents. It is well known than some families in child welfare are underserved, but there also is sometimes the converse observation—that other cases are inundated by multi-component service plans that may overwhelm or prove more burdensome than helpful. Each of these potential explanations for the observed concerning findings are possible. More importantly, each would point to very different implications for child welfare service delivery. We would argue for more focused and definitive research on these possibilities before drawing conclusions about service implications.
Findings should be interpreted with some limitations in mind. Data for the study were limited to self-report. Although efforts were made to manage social desirability response bias, common method bias may still have operated. We also would note that the findings were obtained from a single statewide service network and may or may not generalize well to others. Study observations were captured on only three occasions (baseline, post-treatment, follow-up) which limited our ability to specify finer grained change trajectories. We attempted to assess the influences of missing data under certain assumptions, but these assumptions cannot be fully verified or refuted. Interpretation should respect the customary limits for any within-subjects correlational study, including caution about inferring causality.
In summary, the findings suggest that among parents in the child welfare system receiving home-based family preservation services, changes in overall wellbeing tend to involve a global improvement pattern, rather than separate or independent patterns for individual target areas, and this pattern includes parental depression symptoms. This may suggest some re-thinking of service plans based on a presumption that every identified problem requires a corresponding discrete service and that services must be fully comprehensive in order to deliver broad benefits.