Cluster randomized controlled trial (RCT) to support parental contact for children in out-of-home care

Abstract

Background

There is an identified need to improve the evidence-base in relation to contact visits for children in the out-of-home-care (OOHC) system, to ensure optimal outcomes.

Objective

The aim of this cluster randomized controlled trial (RCT) was to test the effectiveness of a contact intervention for parents having supervised contact with children in long-term OOHC.

Participants

183 study children in 15 clusters (OOHC services) and their parent(s) were randomized to the intervention (8 clusters, 100 children) and control groups (7 clusters, 83 children) in three Australian jurisdictions.

Setting

The manualized intervention consisted of increasing the preparation and support provided by caseworkers to parents before and after their contact visits.

Method

Interviews were conducted with carers, parents and caseworkers of the study children at baseline and nine months post-randomization. Interviews included standardized assessment tools measuring child and adult wellbeing and relationships, carer and caseworker ability to support contact, and contact visit cancellations by the parent.

Results

Compared with controls, the intention-to-treat (ITT) analyses showed that fewer visits were cancelled by parents in the intervention group at follow-up (−10.27; 95 % CI: −17.04 to −3.50, p = .006). In addition, per-protocol (PP) analyses showed higher caseworker receptivity to contact (6.03; 95 % CI: 0.04–12.03, p = .04), and higher parent satisfaction with contact (7.41; 95 % CI: 0.70–14.11, p = .03) in the intervention group at follow-up.

Conclusions

While the intervention did not have an effect on child wellbeing, as measured by the SDQ, the trial reports significant positive findings and demonstrates the benefits of the kC kContact intervention in providing support to parents to attend contact visits. The findings of the current study provide an important contribution to knowledge in an area where few RCTs have been completed, notwithstanding the null findings.

Introduction

When children are removed from their parents by child protective services, contact visits between them and their parents are established in most cases to maintain the child’s relationships with their family of origin (Sen & Broadhurst, 2011; Taplin & Mattick, 2014) and to help them develop a positive personal and cultural identity (Haight, Kagle, & Black, 2003).

Good quality contact visits have been found to promote positive outcomes and are positively correlated with children’s current psychosocial wellbeing (Cantos, Gries, & Slis, 1997; McWey, Acock, & Porter, 2010; Sen & Broadhurst, 2011). Poorly managed contact visits and negative contact experiences can disrupt the relationship between the child and their new carers, destabilize care placements and exacerbate behavioral and emotional problems (Haight et al., 2003; Morrison, Mishna, Cook, & Aitken, 2011; Murray, Southerland, Farmer, & Ballentine, 2010; Murray, Tarren-Sweeney, & France, 2010; Sen & Broadhurst, 2011). However, the research evidence on contact provides little guidance as to what “good quality contact” entails (Taplin et al., 2015).

Research has found that caseworker engagement with parents can impact on the regularity of parent contact visits, that carer support for visits can impact on the relationships between the two sets of parents and their ability to support the child, and that parental supports can improve contact and relationships (Bullen, Taplin, McArthur, Humphreys, & Kertesz, 2017; Chateauneuf, Turcotte, & Drapeau, 2018; Nesmith, 2015).

The majority of children in foster and kinship care (56–94 %) have some direct contact with their parents, and about half of that direct contact is supervised, usually by caseworkers or foster/kinship carers (Farmer & Moyers, 2008; Hunt, Waterhouse, & Lutman, 2010; Sinclair, Baker, Gibbs, & Wilson, 2005; Taplin & Mattick, 2014). Supervision of direct contact visits has been reported in Australia at levels as high as 90 % (Paxman, Tully, Burke, & Watson, 2014).

At present, there is no common understanding of either the concept, definition, or purpose of supervised contact amongst service providers nor of what constitutes optimal supervision (Wattenberg, Troy, & Beuch, 2011). Supervised contact has been described as contact taking place with interactions and conversations between the parent and child being closely monitored by a nominated person, such as a carer, relative, agency or contact service (Perry & Rainey, 2007). Formal contact supervisors may either simply observe and take notes, or they may have a more engaged role that supports and enhances parent-child interactions (Triseliotis, 2010).

When contact supervision is overly intrusive it may become distressing for parents and act as a deterrent for contact; parents with limited parenting skills may find it difficult to engage with their children under supervised contact conditions, particularly when restrictions are placed on their behavior and conversation topics (Bullen et al., 2017; Höjer, 2009). Furthermore, parents may experience challenges in attending supervised contact visits, either resulting from logistical or transport issues and/or the distress of seeing their child in the care of others (Nesmith, 2015; Taplin & Mattick, 2013).

Given the prevalence and importance of supervised contact visits to outcomes for children in care, there are surprisingly few reported contact interventions, and none which use a robust methodology to test the effectiveness of such an intervention in an OOHC setting. The California Evidence-Based Clearinghouse for Child Welfare (https://www.cebc4cw.org/) lists 13 contact visitation programs, but none has yet been scientifically rated. Furthermore, most contact interventions tend to focus on contact for families for whom reunification is the goal, with little research and few interventions available for those remaining in long-term care, many of whom continue to have their contact supervised for reasons that are not clearly articulated. The opportunity to improve the management of and interactions in relation to supervised contact visits was the major impetus for the current study.

A systematic review was undertaken as an earlier component of the current study to identify promising practices in the management of contact (Bullen et al., 2017). It identified a need for additional supports for parents in relation to contact visits; programs providing emotional support for parents before and after visits were found to have positive effects on the contact experience and child wellbeing in families with a history of multiple separations and disadvantages (Fernandez, 2013; Höjer, 2009; Osmond & Tilbury, 2012). None, however, has been tested via a RCT.

The current study (named the kContact study) then developed and trialled a contact intervention for children in long-term care who were having supervised contact with their parents; it aimed to contribute to the research evidence by conducting one of the first randomized controlled trials of a contact intervention. A cluster randomized controlled design was used with agencies providing foster and kinship care and managing contact, forming the clusters.

It was hypothesised that the kContact intervention would, within the nine-month follow-up period in comparison to a control group:

• Decrease children’s externalising and internalising behaviours (primary outcome);

• Improve relationships between children and their parents;

• Improve the ability of carers and caseworkers to support birth family contact;

• Reduce the proportion of contact visits cancelled by parents.

This paper describes the main outcomes of the study which was conducted across three jurisdictions in Australia.