The Sobriety Treatment and Recovery Teams program for families with parental substance use: Comparison of child welfare outcomes through 12 months post-intervention.

BACKGROUND: The 2018 Family First Prevention Services Act (FFPSA) shifted child welfare funding to interventions proven effective in preserving families with parental substance use and child welfare involvement. The Sobriety Treatment and Recovery Teams (START) program serves this population with FFPSA aligned goals. OBJECTIVE: This study was the first to test the sustained effects of START from the initial CPS report through 12-months post-intervention. PARTICIPANTS AND SETTING: Children (n = 784) receiving START services in four sites were compared to 784 children receiving child welfare treatment as usual (TAU). METHODS: Using child welfare administrative data, children in START were matched to children in TAU using propensity score matching. Outcomes were tested during the intervention period, and at six- and 12-months post-intervention using comparative statistics and multilevel logistic regression. RESULTS: The odds of START children being placed in out-of-home care (OOHC) during the intervention period were half those of children in TAU (20.3% vs. 35.2%, p < .001, OR = 0.47, 95% CI [0.37, 0.59]). When placed in OOHC, START children were more likely to be reunified with their parents (p = .042, OR = 1.44, 95% CI [0.99, 1.62]). At 12-months post-intervention, 68.5% of START and 56.0% of TAU-served children remained free from both OOHC placement and child abuse and neglect (after multilevel clustering adjustment: p < .001, OR = 1.85, 95% CI [1.41, 2.43]). CONCLUSION: The primary impact of START was significantly reduced rates of OOHC placement, with results sustained through 12-months post-intervention and after accounting for family clusters and site differences.

Comparative outcomes for Black children served by the Sobriety Treatment and Recovery Teams program for families with parental substance abuse and child maltreatment.

INTRODUCTION: An urgent need exists for child welfare and substance use disorder (SUD) interventions that safely preserve Black families, engage parents in treatment services, and improve child and parent outcomes. The Title IV-E Prevention Services Clearinghouse rated The Sobriety Treatment and Recovery Teams (START) as a promising practice for families with parental substance use and child maltreatment. This study is the first to test the effects of START on Black families. METHODS: This study compared child welfare and parent outcomes for 894 children and their 567 primary parents in three groups: Black children served by START, Black children served in treatment as usual (TAU), and White children served in START. This was a quasi-experimental study using a propensity score matched dataset of START-served children to TAU children. Comparisons included placement in state custody and repeat child abuse or neglect (CA/N) during the intervention period, and at 12 months post-intervention. Generalized linear models accounted for the effects of clustering and unbalanced covariates on outcomes. RESULTS: In this study, 51.8% of children were neonates or infants at the CPS report. At 12-months post-intervention, 80.6% of Black children served by START, but only 56.0% of Black children in TAU, remained free of both placement in state custody and CA/N (p < .001, OR = 3.27, 95% CI [2.14, 4.98]); these effects held after controlling for family clusters. Black and White families in START received equal SUD treatment and community-based services. For START-served families, parental use of opioids (p = .005, OR = 3.52, 95% CI [1.46, 8.48]) and mental health issues (p = .002, OR = 1.90, 95% CI [1.27, 2.86]), rather than race, predicted child placement in state custody. Parent mental health issues or opioid use doubled or quadrupled, respectively, the odds of failing to achieve early recovery by case closure. CONCLUSIONS: START is a potent intervention, co-implemented with SUD treatment providers, that kept Black children safely with their families through the intervention and 12-months post-intervention periods. Scaling up effective programs, like START, that align with the goals of the Family First Prevention Services Act might reduce racial disparities and improve child welfare and SUD treatment outcomes.

Sobriety Treatment and Recovery Teams for families with co-occurring substance use and child maltreatment: A randomized controlled trial.

BACKGROUND: Co-occurring parental substance use and child maltreatment has increased in recent years and is associated with poor child welfare outcomes. The Sobriety Treatment and Recovery Teams (START) program was developed to meet the needs of these families. OBJECTIVE: A randomized controlled trial was implemented to compare START to usual child welfare services on three outcomes: out-of-home care (OOHC) placements; reunification; and subsequent child maltreatment. PARTICIPANTS AND SETTING: Families reported to child welfare services in Jefferson County, Kentucky, were eligible if they had a current finding of child maltreatment or services needed, substance use as a primary risk factor, a child under six years of age, and no other open child welfare cases. METHODS: Biased coin randomization was used for a control: treatment randomization ratio of 1:2. Analyses were conducted using intent-to-treat (ITT), though a subsample of families receiving services was also analyzed. Differences were assessed using t-tests, chi-square, and risk ratios. RESULTS: A total of 348 families including 526 children were randomized to START (n = 346) and usual services (n = 180). There were no significant differences between groups on the three outcomes in the ITT sample or the subsample that received services, though the START OOHC rate was 7 percentage points lower (relative difference: 21.6 %) and the reunification rate was 13 percentage points higher (relative difference: 27.6 %) in the subsample. CONCLUSIONS: Although differences between groups were not significantly different, the relative differences were meaningful and this is the third study showing lower rates of OOHC among START relative to usual services. Additionally, the START reunification rate is higher than the overall U.S. average in spite of notable risk factors.

Identifying Homogeneous Outcome Groups in Adult Rehabilitation Using Cluster Analysis.

IMPORTANCE: Adults receiving occupational therapy in inpatient rehabilitation are a heterogeneous population with differing needs, outcomes, and rehabilitation processes. Outcome studies based on what works for all clients may obscure the needs of population subgroups who benefit unequally from rehabilitation services. OBJECTIVE: To identify subgroups on the basis of client satisfaction and progress in functional self-care among a diverse rehabilitation population and to understand subgroup differences in occupational therapy and rehabilitation processes and client discharge status. DESIGN: Using an existing dataset, we used K-means cluster analysis of demographics, status at admission, and the outcomes of satisfaction and change in self-care to identify five homogeneous outcome groups. Occupational therapy and rehabilitation processes and discharge status were compared across subgroups. SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: The dataset included 1,099 inpatients age 18 yr and older who received occupational therapy over a 27-mo period. MEASURES: Admission measures included the Inpatient Rehabilitation Facility-Patient Assessment Instrument and self-care items of the FIM™. The Satisfaction with Continuum of Care-Revised was administered after discharge. RESULTS: Five subgroups showed statistically different patterns of medical complications, functional self-care, rates of progress, satisfaction with intervention, and course of treatment. The profile of each group suggests differing therapeutic needs. Although all groups made significant gains in functional self-care, two groups continued to need physical assistance at discharge. CONCLUSION: and Relevance: Cluster analysis proved useful in segmenting a typical heterogeneous rehabilitation population into more homogeneous subgroups to enhance understanding of clinical needs and to potentially increase the potency of outcomes research. WHAT THIS ARTICLE ADDS: This research identified subgroups within a typical population of rehabilitation clients receiving occupational therapy and identified their unique needs and outcomes using cluster analysis techniques.

Medication-Assisted Treatment Improves Child Permanency Outcomes for Opioid-Using Families in the Child Welfare System.

Parents who use opioids and are involved in the child welfare system are less likely to retain custody of their children than parents who use other drugs. No previous studies have described medication-assisted treatment (MAT) utilization and child permanency outcomes for this population. The Sobriety Treatment and Recovery Team (START) model is a child welfare-based intervention focused on families with co-occurring substance use and child abuse / neglect issues. This study examined the prevalence and correlates of MAT utilization among parents in the START program with a history of opioid use, and compared child outcomes for families who received MAT services to those who did not. Of the 596 individuals with a history of opioid use in the START program, 55 (9.2%) received MAT. Receipt of MAT services did not differ by gender, age, county of residence, or drug use, though individuals who identified as White were more likely to participate in MAT. In a multiple logistic regression model, additional months of MAT increased the odds of parents retaining custody of their children. To address barriers to MAT, results-focused educational interventions may be needed for the child welfare workforce, as well as programs to improve collaboration and decision-making between the child welfare workforce, court personnel, and drug addiction treatment providers.

Sobriety Treatment and Recovery Teams: Implementation Fidelity and Related Outcomes.

BACKGROUND: Although integrated programs between child welfare and substance abuse treatment are recommended for families with co-occurring child maltreatment and substance use disorders, implementing integrated service delivery strategies with fidelity is a challenging process. OBJECTIVE: This study of the first five years of the Sobriety Treatment and Recovery Team (START) program examines implementation fidelity using a model proposed by Carroll et al. (2007). The study describes the process of strengthening moderators of implementation fidelity, trends in adherence to START service delivery standards, and trends in parent and child outcomes. METHODS: Qualitative and quantitative measures were used to prospectively study three START sites serving 341 families with 550 parents and 717 children. RESULTS: To achieve implementation fidelity to service delivery standards required a pre-service year and two full years of operation, persistent leadership, and facilitative actions that challenged the existing paradigm. Over four years of service delivery, the time from the child protective services report to completion of five drug treatment sessions was reduced by an average of 75 days. This trend was associated with an increase in parent retention, parental sobriety, and parent retention of child custody. Conclusions/Importance: Understanding the implementation processes necessary to establish complex integrated programs may support realistic allocation of resources. Although implementation fidelity is a moderator of program outcome, complex inter-agency interventions may benefit from innovative measures of fidelity that promote improvement without extensive cost and data collection burden. The implementation framework applied in this study was useful in examining implementation processes, fidelity, and related outcomes.

Factors predicting client satisfaction in occupational therapy and rehabilitation.

Client satisfaction, a widely used outcome indicator of quality in health care, is inherently client centered and important in occupational therapy. We developed an instrument called the Satisfaction With Continuum of Care Revised (SCC-R) and tested a logistic regression model of satisfaction for six predictive research questions. Data collected from 769 clients from a large rehabilitation hospital using the SCC-R were paired with data that included demographics, functional status, and measures of the rehabilitation including occupational therapy. Satisfaction was stratified into two groups, satisfied and dissatisfied. The most robust and consistent predictors of satisfaction were functional status and improvements in functional status, presence of a neurological disorder, total rehabilitation hours, and admission to rehabilitation within 15 days of condition onset. The finding that improvements in functional status, especially self-care, were predictive of satisfaction is particularly relevant for occupational therapy. Implications for practice and future research are discussed.

Sobriety Treatment and Recovery Teams in Rural Appalachia: Implementation and Outcomes.

The Sobriety Treatment and Recovery Teams (START) model is designed for families with co-occurring substance use and child maltreatment. This study describes the implementation and outcomes of START in a rural Appalachian county with high rates of poverty, non-medical prescription drug use, and child maltreatment. Despite a severely limited addiction treatment infrastructure at baseline, children served by START were less likely to experience recurrence of child abuse or neglect within 6 months or re-enter foster care at 12 months compared with a matched control group.

Client-chosen goals in occupational therapy: strategy and instrument pilot.

ABSTRACT Client-centered practice and outcomes research are missions of occupational therapy. Although strategies for client goal-setting have advanced the field, the process has limitations. This study tested a self-report strategy using brief, easy to score measures. The Goals for Occupational Therapy List was completed at mostly independent intake and paired with a follow-up measure of Goal Satisfaction Rating by 40 clients in an outpatient rehabilitation center. The strategy of pairing self-report measures of goal-setting and attainment was useful for clinicians and yielded important research findings. Application to occupational therapy and future research are suggested.

The impact of an application of telerehabilitation technology on caregiver burden.

The objective of this research was to assess the effects of an application of telerehabilitation reducing time and financial obligation on caregiver burden among eleven caregivers of elderly persons with Parkinson's disease. Clients (care receivers) participated in speech therapy delivered via videophones in their homes; the protocol required 16 treatments delivered four times a week for four weeks. At the conclusion of treatment, caregivers completed a structured interview about the impact of telerehabilitation on time and financial aspects of the burden of care. On average, this speech therapy protocol delivered by videophones saved 48 hours of time, more than 92 hours of work time, and $1024 for each caregiver. Savings were significant and previous research demonstrated nearly equal outcomes using the videophone delivery method. Implications for practice and research are discussed.

Recruiting and retaining child welfare workers: is preparing social work students enough for sustained commitment to the field?

Graduates of specialized BSW child welfare education programs are more likely to be retained after two years of service in the agency, but many leave at the four year mark. Two studies explored possible reasons for departure at this time. The first study found that graduates of specialized child welfare programs were significantly more likely to engage in best practices in nine areas than workers from other fields. Thus, frustration with practice skill was ruled out as a cause. The second qualitative study found that poor supervision, lack of coworker support, and organizational stress among other variables prompted these high-functioning workers to leave the agency. Suggestions for innovative interventions to enhance retention at this critical juncture are included.

Videophone-delivered voice therapy: a comparative analysis of outcomes to traditional delivery for adults with Parkinson's disease.

Individuals with idiopathic Parkinson's disease (IPD) usually develop a speech disorder characterized by reduced loudness, hoarse and breathy voice, monotony of pitch, short rushes of speech, and imprecise consonants. The inability to effectively communicate impairs their ability to function in society and quality of life. A successful program developed to improve speech in these individuals is the Lee Silverman Voice Treatment (LSVT). A critical component of this treatment is intense daily therapy for 4 weeks, a regimen that is difficult for many elderly patients to complete. Treatment delivered through videophones placed in the homes of individuals with IPD offers an alternative and could improve accessibility of treatment if the results were the same. This study compared the outcomes of LSVT delivered via videophones to the outcomes of traditional treatment delivered face-to-face.

Comprehensive Family Services and customer satisfaction outcomes.

Comprehensive Family Services (CFS) is a strengths-based and partnership-oriented approach to casework implemented through multiple initiatives. This study examines the relationship between the practice of CFS and satisfaction of clients, foster parents, and community partners. CFS indicators are paired with statewide customer satisfaction survey results. CFS practices are associated with significantly higher customer satisfaction that improved over time for all groups. Although causality cannot be determined, the relationship is consistent, robust, and meaningful.

The Occupational Therapy Practice Checklist for adult physical rehabilitation.

OBJECTIVE: Although the practice of occupational therapy is described in textbooks, research, and professional standards, a tool for outcomes research is needed. METHOD: The Occupational Therapy Practice Checklist (OTPC), based on the Model of Occupational Performance (Pedretti, 1996), includes domains of adjunctive, enabling, purposeful, and occupational performance. Practices are also identified by phase of therapy (early, middle, late). The OTPC was piloted with 40 adults in an outpatient physical rehabilitation center. RESULTS: The Kuder Richardson 20 coefficient of internal consistency was .91. Practices on the OTPC discriminated between clients with and without neurological disorders. CONCLUSION: The OTPC has potential for yielding knowledge about occupational therapy practice. Results of the pilot show that occupational therapy practice was not linear, as theorized, but rather a complex integration of techniques.

Community participation and quality of life outcomes after adult traumatic brain injury.

OBJECTIVE: This study examined outcomes after traumatic brain injury in adults salient to occupational therapy. METHOD: Demographic data and Functional Independence Measure (FIM) scores from the inpatient rehabilitation stay were first gathered from a retrospective chart review. At follow-up, 25 adults, on average 21 months post-injury, completed measures of disability, community participation, quality of life, and satisfaction with occupational therapy during a telephone interview. Analysis of covariance was used to test the differences between pretest and posttest scores on the FIM; regression analysis and correlations were used to analyze predictions and relationships. RESULTS: Statistically significant improvements in FIM scores during rehabilitation were predictive of the level of long-term disability and community participation among participants. At follow-up, participants were often unemployed, depressed and withdrawn, and experienced limitations in decision making, hand use, bladder control, and community integration. Less disability and more community participation were related to higher quality of life. Satisfaction with occupational therapy, although high, was unrelated to most outcomes. CONCLUSION: Results support the premise that participation is associated with a high quality of life, yet persons with brain injury have significant needs for long-term occupational therapy.

The adolescent role assessment: psychometric properties and theoretical usefulness.

OBJECTIVE: Fostering career adaptability may improve vocational outcomes for adolescents. This study examined the responses of adolescents on the Adolescent Role Assessment (ARA) to explore its usefulness as a measure of career adaptability. METHOD: The ARA was administered to 101 adolescents 12 to 17 years of age. Descriptive statistics, reliability analysis, and factor analysis were generated from the ARA scores. Dominant narrative themes were coded into the six domains of the ARA and into the domains identified in the factor analysis. RESULTS: The internal consistency of the ARA was low with few differences in findings across age. The identified factors--developing aspirations, self-efficacy, interpersonal competencies, and autonomy--are consistent with constructs of career adaptability found in the literature and differentiated low and high scorers. CONCLUSION: Major changes to the ARA content and scaling or development of a new assessment of career adaptability using the factor structure are recommended for clinical and research applications.