Do professionals ask about children when establishing a collaborative individual plan for clients? A cross-sectional study

Abstract

Aim: To examine the extent to which structured action plans, i.e. collaborative individual plans (CIPs), used by professionals within the psychiatric care, substance use treatment services and social services, evaluate if clients have children, and if professionals take actions if clients do have children. According to Swedish law, a CIP should be established when a client is in need of care from more than one branch of the care network. Professionals who meet adult clients have the opportunity to identify children at risk. Including a question in the CIP on whether a client has a child is a good approach to identify children in need of support.

Methods: Cross-sectional data from professionals were collected prior to attending a three-day CIP course. A total of 705 individuals (n = 797 invited) responded to the questionnaire.

Results: More than 90% reported that they meet clients for whom a CIP should be established, and 52.6% of these (n = 346) were aware of an existing CIP template within their organization. Approximately 30% (n = 203) reported that this template included an item on whether the client has one or more children. Of these, a majority reported ensuring that the children receive adequate care (83.3%, n = 169), and that they follow up on the receipt of such care (62.6%, n = 125).

Conclusions: The care network needs to implement CIPs to a higher degree, and CIP templates need to include items about the clients’ children to ensure that children at risk are identified and thereby can receive adequate support.

Keywords:

• Children of impaired parents
• integrated care
• social services
• psychiatric care
• substance use treatment services

Introduction

A substantial proportion of all children grow up in families with parental problems such as mental health and/or substance use problems. For instance, available international estimates suggest that 8–23% of all children have parents with mental health problems [1,2] while 8–30% grow up with at least one parent having alcohol drinking problems [3–5]. Estimates in Sweden are in line with these figures [6–8], which puts a large proportion of Swedish children at risk for many acute and long-lasting negative consequences such as poor mental health, substance use problems and poorer academic achievement [9–15]. For instance, parental mental health problems such as mood and anxiety disorder and depression appear to have a high and long-lasting risk for children to develop own depression, somatic morbidity and higher mortality [16,17], which may also be explained by genetic vulnerability [18]. Support is available to these children via, for instance, the municipal social services. However, estimates reveal that only 1–2% of these children receive such support [19], mainly due to difficulties in identifying and recruiting them.

Professionals who, in their work, have direct or indirect contact with children have the opportunity to identify this group of children and to initiate child-focused interventions [20,21]. In fact, according to Swedish law [22] professionals are compelled to report to the social services if they suspect that a child is exposed to any harm. Furthermore, collaboration between the various branches of health care and the social services has been established in Swedish law [23,24], which states that one component of inter-organizational collaboration involves establishing a collaborative individual plan (CIP), i.e. a written action plan dictating how collaboration should be carried out so as to benefit the client in the treatment and support process. A CIP should be established when a client is in need of care from more than one branch of the care network, such as the social services, psychiatric care or substance use treatment services. Within the Stockholm County Council Health Care Services, professionals have at their disposal a template for establishing a CIP which contains an established set of items covering, for instance, what the client’s needs are, what actions should be taken, overall responsibility for the action plan, and when to follow up the action plan. The CIP is then typically established at meetings where concerned professionals meet face-to-face together with the client. It is also possible to include other items to the template. Adding an item about whether or not clients have children would increase the likelihood to identify children in need of support due to parental mental health or substance use problems. A previous Swedish study has even demonstrated that almost thirty percent of adult inpatients admitted to acute psychiatric care had minor children [25], which is in line with international estimates [26].

To increase inter-organizational collaboration and use of CIPs, brief training courses have been developed and offered to professionals within the health care and social services. In Stockholm, a three-day course was developed and offered to professionals in the Stockholm County. We conducted a study aimed at exploring the current inter-organizational collaboration and use of CIPs among health care units and social services in Stockholm County. Results from this study have been reported elsewhere [27], but for instance respondents reported participating in one to two CIPs per month, and about 70% reported using a particular template for establishing this plan when meeting a client for whom a CIP should be established. We also included questions concerning the clients’ children and whether children were considered in the CIP templates. Here we report further findings from this study focusing on the clients’ children. Specific research questions are: Do the CIP templates contain an item on whether or not the client has children? Do the professionals ensure that children in need receive adequate care? Do the professionals follow up on the receipt of such care?

Methods

The Regional Ethical Review Board in Stockholm approved this study (registration no. 2015/483-31/5). In the invitation to participate, the respondents were informed that they consented to participate if they answered the questionnaire and that findings in the study were to be published on a group-level.

Design and procedure

Personnel in Stockholm County working in the municipal social services, psychiatric care and substance use treatment services were invited to participate in a three-day course on inter-organizational collaboration focusing on CIPs. The course was developed by Region Stockholm and Stockholm County Association of Local Authorities (KSL) and took place on ten different occasions, starting in November 2014 and ending in March 2015, at different locations in Stockholm. About two weeks before the course started, an invitation to participate in the study was sent out via e-mail to each course participant. The e-mail contained a link to a web-based questionnaire. Up to three reminders were sent and non-responders were also given the option of completing a paper version of the questionnaire before the course onset.

Measures

A self-constructed web-based questionnaire was developed containing 33 questions, which took approximately 10 min to complete. The questionnaire included background questions followed by questions about their current inter-organizational collaboration in relation to CIPs. The present paper focuses on the four items concerning the clients’ children: (i) Do your organization’s CIP template contain an item on whether the client has a child/children? (ii) Do you ensure that the child/children are offered adequate support/care if needed? (iii) Do you follow up that the child/children receive such support/care? (iv) Do you establish a CIP for the child/children if necessary? Those respondents who reported that there exists a CIP template within their organization could only answer these four items. However, given the fact that the law [22] states that a CIP should be established for every client fulfilling the criteria, in the analyses, these four items have been compared to all those respondents who meet clients in need of a CIP.

Participants

Operation managers and heads of units at the psychiatric care, substance use treatment services, and municipal social services in Stockholm County were informed about the course and asked to enroll front-line personnel in the course. In total, 797 employees participated in the course and were invited to respond to the questionnaire. A total of 705 individuals responded to the questionnaire corresponding to a response rate of 88.4%. Missing data on particular items within respondents never exceeded 1% (e.g. five participants did not report their age). The mean age was 44.7 years (SD = 11.5), the proportion of women was 80.1% (n = 563), and the current work area was the social services (51.7%, n = 363), psychiatric care (24.9%, n = 175), substance use treatment services (19.2%, n = 135), and other health care services (4.1%, n = 29). The mean working years at the current workplace was 6.1 years (SD = 6.8).

Statistical analysis

Descriptive statistics and between-group comparisons were conducted using Pearson χ² statistics run in SPSS 23.0. Results yielding a p < 0.05 (two-tailed) were considered statistically significant.

Results

As previously reported [21], 658 out of 705 respondents (93.6%) reported that they, in their current work, meet clients for whom a CIP should be established. Furthermore, 52.6% of the respondents (n = 346) reported that they were aware of the existence of a particular template to create a CIP within their current organization, while 11.4% of the respondents (n = 75) reported that there was no existing template available and 10.5% (n = 69) that they were not aware of a template. Of those who reported that they in their current work meet clients for whom a CIP should be established (n = 658), 30.9% (n = 203) reported that their currently available CIP template includes an item on whether the client has one or more children, while 9.9% (n = 65) reported that such item is not included, and 11.9% (n = 73) did not know whether such an item is included. There was a statistically significant difference in the distribution of professionals reporting that their respective templates include an item on the presence of children, as the proportion was 20.2% within the social services, 39.9% within the psychiatric care, and 41.4% within the substance use treatment services (χ²(4)=35.56, p<0.001).

As seen in Table 1, more than 80% of those who reported that their CIP includes an item on the presence of children also reported ensuring that the clients’ children receive adequate care. Furthermore, >60% reported following up on receipt of such care, and about 10% reported establishing a CIP if necessary. There were no statistically significant differences between the social services, psychiatric care and substance use treatment services with regard to these items.

Table 1. Actions taken by professionals if a client has one or more children^a.

	Yes % (n)	No % (n)
Do you ensure that the child receives adequate care? (n = 203)	83.3 (169)	16.7 (34)
Do you follow-up that the child receives adequate care? (n = 200)	62.5 (125)	37.5 (75)
If necessary, do you establish a CIP for the child? (n = 200)	12.5 (25)	87.5 (175)

^aOnly includes those respondents who reported that the CIP template included an item on whether the client has one or more children.

Discussion

Our results reveal that in the vast majority of cases, clients within the social services, psychiatric care and substance use treatment services are not evaluated if they have children or not. There are differences between the health care agencies and a higher proportion of professionals in psychiatric care and substance use treatment services, compared to professionals in the social services, report that their CIP template includes such an item.

According to Swedish law [23,24] a CIP should be established when a client is in need of care from more than one health care agency. A CIP provides an opportunity for professionals to work in a structured manner to identify children who may be in need of support. Our previously reported results revealed that about half of all professionals who met clients in need of a CIP knew that there existed a template within their organization [27]. The psychiatric care and substance use treatment services share a common CIP template. This template is not shared with the social services. Thus it appears as if many children who grow up in families with substance use or mental health problems, that potentially could have been identified and forwarded to adequate care, are left as an unobserved group. However, results reveal that when professionals become aware that there are children present, the majority ensure that these children receive adequate care and follow up on such care. If needed, a CIP should also be established for a client’s child, however, only a small proportion of the professionals report that they establish a CIP. This may partially be explained by the fact that a caregiver must consent to such a plan.

Current figures demonstrate that only a small proportion of all children who grow up in families with substance use problems receive existing care via for instance the social services [19]. Thus, there is a need to identify these children and recruit them to existing care and other child-focused interventions [20,21]. One excellent opportunity would then be to evaluate whether or not clients within the social services, psychiatric care and substance use treatment services have children. Given that professionals use CIP templates, including a mandatory item in the CIP template asking if a client has children would be one solution. As previously mentioned [27], facilitating factors for the use of CIP templates would be that all agencies within the care network use the same template, and that training in collaboration with regards to CIP is also incorporated at university-level health care and social work education. Furthermore, the use of CIPs could be facilitated via monetary incentives and by a management who encourage participation in CIP training courses and use with in their organizations.

The present results are limited by the representativeness of the study participants, as they were selected by their managers and restricted to Stockholm County. However, more than 90% reported that they, in their current work, see clients in need of a CIP, which indicates that our study population is relevant. Furthermore, almost 90% of the invited professionals responded to the questionnaire, and one may therefore argue that it is possible to extrapolate these findings to the whole population of eligible collaborators within psychiatric care, substance use treatment services, and social services in Stockholm. Yet another limitation is that the data collected is self-reported so the responses may not reflect what professionals actually do. The use of registry-based data, available via the social services and the health care agencies would resolve this problem.

Conclusions

To conclude, our findings suggest that CIPs should be established to a greater extent, which could be improved by the use of a common template, further training and policy work at an organizational level. Moreover, this template should include an item on whether clients have children. This is particularly important bearing in mind that professionals have an obligation to consider whether or not children are exposed to any harm. Furthermore, it would be desirable that professionals in a more structured manner, like for instance adding items to a CIP, should ensure that children receive adequate care and follow up on receipt of such care.

Acknowledgements

The authors would like to thank Emma Fredriksson and Anna Thurang for valuable comments on the questionnaire.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was funded by grants from Region Stockholm and the Stockholm County Association of Local Authorities (KSL). KSL was partly involved in data collection and read and commented on an earlier version of this paper. Apart from this the funding bodies had no role in the design of the study, analysis, and interpretation of data and in writing the manuscript.

Notes on contributors

Tobias H. Elgán

Tobias H. Elgán PhD, is a researcher at STAD, a unit at the Department of Clinical Neuroscience, Karolinska Institutet. His research focus is on digital interventions targeting at-risk groups such as children who have parents with substance use problems, and also substance prevention by applying community-based approaches at the local level.

Håkan Källmén

Håkan Källmén PhD, associate professor, is a senior researcher at STAD, a unit at the Department of Clinical Neuroscience, Karolinska Institutet. His research focus is on screening instruments for problematic substance use and following trends in alcohol consumption and habits among the population.