Season 1, Episode 14: Dr. Anne Atkinson, president and founder of PolicyWorks, Ltd. & Debbie Riley, LCMFT, CEO of the Center for Adoption Support and Education, discuss the importance of providing adoption competent mental health care to all members of the adoption triad. They begin by explaining what is meant by adoption competency and outline two post-graduate programs that have been developed, the Training in Adoption Competency curriculum and the web-based National Training Initiative. They describe the research that has been done to rigorously evaluate the trainings in terms of their impact on mental health practitioners knowledge and practice as well as outcomes for adoptive families. They end by summarizing important policy initiatives that can continue to grow an adoption competent mental health workforce.
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Routledge Handbook of Adoption
Transcript
Dr. Emily Helder: Welcome. I’m Dr. Emily Helder and I’m here with Debbie Riley and Anne Atkinson. Debbie is the CEO of the Center for Adoptive Support and Education or C.A.S.E., and the co-author with Ellen Singer of the chapter in the Routledge Handbook of Adoption “Training for Adoption Competency Curriculum.” Anne is the president and founder of Policyworks and the author of a chapter in the Handbook entitled “Adoption Competent Clinical Practice.” So thanks so much both for being here.
Debbie Riley, LCMFT: Thanks, Emily.
Dr. Emily Helder: So Debbie, will you begin and tell us a bit about C.A.S.E., give us a brief overview of your mission and the services that you offer.
Debbie Riley, LCMFT: Sure. Well, C.A.S.E. was a cofounded by myself and another individual, Kathleen Dugan, 24 years ago. Our mission is to strengthen the wellbeing of foster and adoptive families, promote adoption awareness and enhance adoption sensitivity, developing the skills for professionals and families to really the goal is to empower children to thrive.
We’ve developed an array of, I would say adoption competent, responsive services, including clinical services, educational trainings, and publishing materials to strengthen the field. You know, we really have dedicated our, our mission to ensuring positive outcomes for families and, you know, really proud that C.A.S.E. has never really strayed from our mission.
You know, we continue to provide specialized pre and post adoption mental health services and educational services, and broaden the reach to train professionals. It’s really interesting when I was preparing to have this dialogue with you today, I was just looking back on, you know, sort of the impact and over the past 24 years, we’ve served over 6,300 foster and adoptive families, both domestically and internationally. So our span is across the broad spectrum of adoption and, you know, really interesting we conduct about 7,000 counseling sessions annually. So we’re probably one of the largest, if not the largest entity that focuses exclusively on this population.
You know, when I think about the Handbook and the work that you’re trying to put forward, you know, I think about the, the wealth of information that we have, when you look at the breadth of the population that we’ve been supporting for so long. So that’s kind of interesting and, you know, I think that our goal is to combine, you know, best practice and innovative, you know, I guess, programming to meet the specialized needs of this population.
Certainly wanting to address some of the unique issues that are inherent in, you know, foster care and adoption and post-institutionalized children. We have a large footprint in that arena.
Dr. Emily Helder: Yes. Yes. Your reputation proceeded you when we were putting together the Handbook. So we were so excited that you were open to writing this chapter
Debbie Riley, LCMFT: It was an honor.
Dr. Emily Helder: Good. So, Anne, why don’t you tell us a bit about Policyworks and how your organization intersects with C.A.S.E.
Dr. Anne Atkinson: Well, Policyworks as a program evaluation and policy research firm founded about 25 years ago and based in Virginia. And it was in my, and the work that we’ve done has been in education, prevention and juvenile justice, criminal justice, as well as child welfare.
And I first became acquainted with C.A.S.E. when I was evaluating for Virginia’s statewide post adoption services network, and C.A.S.E. was a key partner in that collaboration. Debbie subsequently invited me to consult on some of their evaluation needs, and that was the avenue by which I became acquainted and involved with TAC from the very beginning and fortunately was able to design the comprehensive evaluation of TAC that actually continues today.
Dr. Emily Helder: That’s great. Great. Well, and we’ll talk a little bit more about TAC in just a little bit, but before we do I’d love to start with you Anne, your chapter gives a really detailed definition of what really is meant by adoption competent mental health providers, and also give some history on how consensus was developed around that definition.
And I don’t know that it’s a term that, you know, everybody’s familiar with. So I wondered if you could give a brief overview.
Dr. Anne Atkinson: Adoption competency means that the professionals involved with adoptive families have a real specialized knowledge, skills, and values that equip them to more effectively serve and treat adoptive families.
They have a very deep understanding of adoption as a method of family formation. Of the normative challenges of adoption and the core clinical issues that really need to be recognized and addressed within the context of treatment. Their approach is family based, strength based and evidence based and when I talk about family based it means that the therapist believes that a family based approach is really necessary if you’re going to address the critical issues of trauma and attachment. The therapist really demonstrates a commitment to work with the family as a whole, as the core client, rather than the child, simply in isolation.
Therapists also recognize that the challenging behaviors are typically really manifestations of a variety of biological and experiential factors that predate the adoptive placement and they avoid blaming the, the adoptive family for simply bad parenting, creating these challenges. When you view parents, as agents, primary agents of healing, the therapists really engaged in a very genuine collaboration with the parents and they provide a good bit more psychoeducation and guidance related to therapeutic parenting than you often see in typical standard mental health practice. When I’m talking about strength based, the therapist are really careful to avoid pathologizing the normal developmental processes and they work to focus on empowering the parents to truly understand, have a deep understanding of their child’s history and the implications of the history to reframe behaviors and to really begin to master the art of therapeutic parenting.
And then the evidence based approach, everything done is based on, you know, it has, a basis in the research and is supported by research best practice and what is the, the family needs and values. But there’s also a recognition that there are some real limitations in current practice with adoptive families because many of the models of intervention that have recently in recent years been recognized as evidence-based haven’t necessarily been validated specifically with adoptive populations. So TAC does not really teach one particular model, but exposes the trainees to all the current models that they might choose from and use strategically in their treatment of families.
Dr. Emily Helder: Thanks, that’s so helpful. And, and Debbie, I’m assuming that at CASE you really can see firsthand the way that adoption competency impacts adoptees, their adoptive family, maybe their birth or first family. Can you say a bit more about why having an adoption competent mental health provider would be so important?
Debbie Riley, LCMFT: You know, Emily, just to sort of set the tone on this. I mean, yes, we do see it. And I think that’s how we came to this place of wanting to create these products and really move a workforce that would have these competencies. You know, I’m, I’m a marriage and family therapist now of probably close to 37, 38 years.
And you know, when I first moved into this specialized work. I didn’t know what I know now. And, you know, that’s how I came to thinking about the impact that we were having and that it really was a specialization. I mean, we know that there are elevated health, mental health risks that impact, you know, adopted children, youth, birth families, first families, you know, those adopted from foster care or institutions.
And, you know, in general, you see in the research that adopted children overrepresented in higher levels of mental health care. And in my earlier work, I was always concerned about why was that and why weren’t we seeming to in the field align treatment protocols that you know, really helped to support this population.
And in fact, the research has showed that there were poor clinical outcomes. And when you interviewed members of the adoption network, they reported not having access to qualified clinicians or the clinicians that they were working with really didn’t have the skillset and the knowledge to address the issues that were being presented.
So, in fact, some families reported more harm than good. I mean, you know, it kind of pains my, my heart to, you know, when families come and you see sort of the negative impact. And so I, you know, kind of believe in my core now as a therapist, I’ll take my administrator hat off for a minute, that the issues in foster care and adoption does really require a subspecialty of training and knowledge that doesn’t come by just graduate level training.
And I think adoption competency, you know training is critical to the wellbeing of those we serve in this network.
Dr. Emily Helder: Right. Yeah, I would think it’s so even well connected with issues of adoption disruption, adoption dissolution, and, mental health outcomes. There’s such a broad range of outcomes that could be connected with.
Debbie Riley, LCMFT: Yeah.
I mean, totally. I mean, I think that’s what motivated my work in this, this area that we’re talking about now, because we began to see that we were preventing disruptions and dissolutions. I’m really seeing positive outcomes because we were, we had a focused treatment, I’ll use the word model loosely because we still haven’t been able to fully test that.
But, the efficacy, I think, really spoke to why we needed to take the tenants, then we did and how we vetted those to formulate this conceptualization of adoption competency training.
Dr. Emily Helder: Yeah. Anne I wanted to ask you one thing you mentioned as you were talking about your definition is that adoption competency is marked by certain principles and foundational requirements.
And then these competencies that you outlined, and we had this conversation back when you were writing your chapter about the relationship between those things and really your, your answer to me at that time really clarified it for me. And so, yeah, I wondered if we could kind of recreate that discussion a bit.
Could you tell me a bit about how you see the principles, the foundational requirements, the competencies kind of relating to each other, fitting together.
Dr. Anne Atkinson: Good. Well, actually the specifications of the competencies and the development of an expert consensus definition of an adoption competent mental health professional actually came first. With expert advisors, CASE, more than a decade ago now specified some 336 knowledge, skills, and belief competencies that were organized into 18 domains. And that really formed the foundation for TAC. TAC was actually designed, its curriculum was designed to develop those specific 336 competencies. Subsequently, and, and it was designed to actually be offered as training to clinicians who already met the foundational requirements of graduate training and clinical licensure.
So we’re, you know, we’re not seeking in this training to substitute for basic clinical competence. But to build on top of that, and make more of a specialty, and we’ve recently begun to ask the enrollees about their motivation for training, for enrolling and interestingly the most prevalent is just professional interest in this population, but the second most frequent reason is the desire to develop a specialty practice.
There’s a recognition in the field of a need for this additional, you know, we feel that it very much validated our reasons for creating this and the same reasons that they have for, for enrolling. The practice principles have been developed more recently. They’re consistent with the original definition, but now they’re informed by huge body of data on clinical practice from the TAC evaluation. And therefore they’re not only theoretically sound, but they really have a very strong empirical base now.
Dr. Emily Helder: That’s so helpful. Thanks for clarifying that. Yeah. So Debbie, I’m going to ask you to add a bit to some of the thread of ideas that Anne is bringing up about this adoption competency, being an advanced area of clinical practice.
You alluded to it earlier but I wondered if you could say more about that, you know, why, why are you seeing adoption competency as this distinct subspecialty maybe, or area of advanced practice. And how is it different than, just being trauma informed? I think, you know, a lot of therapists or counselors, seek out that, that sort of approach.
And I I’d like to hear from your perspective, how adoption competency builds on that a bit.
Debbie Riley, LCMFT: Sure. We’ve now learned from, as Anne said, that the rigorous evaluation of TAC and also the National Training Initiative that we have funded through the Children’s Bureau. That, you know, mental health providers, you know, and we also look at child welfare when we’re looking at NTI really lack the depth of knowledge that Anne is speaking to and the skills to treat the confounding complexities of these issues that are connected to these domains that, that Anne is referencing.
And the adoption competent therapist training is, is really embedded now in a, as she’s saying a theoretical and philosophical framework, that establishes a foundation. And I want to use the word foundation of clinical knowledge, the practice and the skills woven in, you know, your ethics and then the cultural competence on which I think the specialization can be developed.
You know, when we think about the validating, the need for these competencies and going beyond sort of the, where we were as the field is, is that focus on trauma training in the NTI pilot, for example, we reached over 5,100 child welfare workers and supervisors. And in one of the modules, this is really interesting, focused on the concepts of loss and grief, which are one of the core, domains in our training for TAC and NTI.
These are social workers that had at least seven years of experience, supervisors, 15 years of experience. Out of the 10 questions that they were to answer on a pretest for the areas of issues of loss and grief. This body of individuals scored, could only answer four questions out of 10. So this was really alarming to us.
It was alarming to the Children’s Bureau to think that, you know, all of this work is predicated on loss, and yet we have a workforce that did not understand the underpinnings and the connection to unresolved loss and grief and the impact on children’s mental health. After the intervention of NTI, we were seeing scores at a level of about 94.4%.
So, you know, I think this just speaks to when we have this narrow focus, that everything, we see the trauma as part of this larger foundational body of knowledge that we want to impart. It was also interesting in mental health, in the pilot, this is really fascinating. The area that mental health providers scored the lowest, which is also, it makes me feel sad, was the area of attachment. Now you would think that most of us in our basic training, right, would have pretty strong foundational knowledge in the area of attachment when working with children, adolescents, and in that pilot, they only could answer three out of 10 questions. And these were providers that had about 10 years of clinical experience.
So I hope that that gave you some, you know, validation of why this, this should exist. And why we need to open the lens beyond the trauma informed, you know, sort of focus.
Dr. Emily Helder: Yeah, those are some big gaps in knowledge to address.
Yeah. Yeah. Well, and let me follow up because we’ve been talking about, we’ve been throwing around these acronyms, let me ask you a little bit more about them. So, CASE has been involved in developing and delivering the Training in Adoption Competency or TAC that we’ve been talking about and then the National Training Initiative or NTI. And I wondered if you could just compare, contrast them a little bit and describe the intended role of both and audience, you know, who, who would be best for both of those approaches.
Debbie Riley, LCMFT: So for the TAC program, Training in Adoption Competency, it was a designed to really be a post-masters. Focusing on clinically licensed mental health professionals. Who were seeking a more advanced training beyond foundational and it really is focused on, you know, the clinical practice of therapists working with this population in public private arenas. It is really meant to be an, you know, sort of this advanced focus, really delving into these critical issues in adoption to, as Anne said, we, then what we see as best practice that aligns with meeting the needs of the population. And we’re really also focused on opportunities for transfer and application of learning through clinical case consultation. So woven throughout the TAC curriculum, which is 72 hours. And initially classroom-based right now, you know, we’ve been able to move it to a virtual platform, but we hope to get back for a lot of reasons to classroom based. We’re weaving in at least five of the 11 modules, the opportunity for the students to present cases that are aligned with those topical areas, those competencies, so that we can help further embed those skills into practice. Then what we’ve learned from clinicians that have been, you know, in the TAC protocol is that the work has been very isolating and to keep them engaged, and it’s very hard work. They have found the clinical consultation as to be invaluable and some of these groups have actually continued past, past TAC. The other difference about TAC and Anne and I are really proud of this because we set forth the evaluation very early in the protocol. We have moved TAC to an evidence based rating by the California Evidence-based Clearing House. NTI on the other hand is a wonderful opportunity to, I think, make a great impact in the field, in, moving this knowledge forward, where we’re reaching mental health professionals that are licensed or not licensed interfacing in public and private agencies for the mental health curriculum, and then for child welfare to infuse NTI again, which is web based into all child welfare agencies, tribes and territories across the country. So I would say our focus in NTIs is really moving those foundational content forward, basing in on current research and practice to elevate the knowledge base of those individuals that are interfacing with this population again the mental health curriculum in NTI is 25 hours of standardized interactive web based training, organized into 10 modules and has a plethora of downloadable resources. And, I think tools that the field the providers can access. And then for child welfare, it’s 20 hours of standardized again, interactive web based training with eight modules with wonderful resources.
And then we also added foundational modules to help supervisors. Again, focusing on transfer of learning how to embed some of this in their clinical supervision with their staff. So it’s just so exciting that, you know, we have this range of products, that can take it from foundational to really intensive work with this population.
Dr. Emily Helder: Thanks so much. Yeah. It’s really exciting to see the TAC sites spread across the nation. Just that there’s remote sites where people can access that.
Debbie Riley, LCMFT: Yeah, we’re 18 partners for TAC across the country. And for NTI, now we have over 20 state systems that have embedded it into their learning management systems or their, you know, community based mental health.
So it’s really exciting that we’re moving this footprint across the country.
Dr. Emily Helder: Yes. Yes. And Anne you’ve been really involved through, with Policyworks in partnership with CASE in the evaluation of TAC. And I wondered if you could say a bit about, what’s your latest update on some of the research that you’ve been doing about its effectiveness?
Dr. Anne Atkinson: Okay. Well, the evaluation of TAC is designed to evaluate the delivery of the training, effectiveness of the training, and the outcomes in terms of changes in clinical practice and certain defined areas. The findings have consistently demonstrated TAC to be a very effective, very high quality, high relevance curriculum and to be developed or delivered effectively by the TAC trainers, something we do that few training programs do, but really is best practice is that we do fidelity observations.
We did pretty intensive observations of the new trainers. And then we cut back just a little bit, but we do continue observations even of our most experienced, trainers. And we make sure that they’re delivering 100% of the content that they’re doing the learning activities and that essentially that the curriculum is delivered in a way it’s designed and intended to be delivered.
So that’s been a rather labor intensive initiative because someone has to sit there all day long and do a very detailed observation and report. And then the other part of this that I have to commend CASE for is that there are debriefing calls following the delivery of each module for the new trainers and then the delivery of every two or three modules for our more experienced trainers.
So we share with them the feedback from the participants and what the trainers observed at the time. And we debrief that and they think about, well, maybe how I can deliver this better next time, or if there are issues, or sometimes we learn about new resources that we incorporate back into the curriculum as soon as possible.
So it, it’s a very, it’s not just a scholarly exercise or an academic exercise to collect data. The data get used and the data get used immediately in the debriefing calls and it’s used systematically as, the modules are, are looked at and updated and refined. So probably the richest data we get is from our participants in their descriptions of how their practices have been influenced by the training.
And at this point we have some 20,000 narrative descriptions of clinical practices. And it is actually those that have helped inform development of the practice principles. And we anticipate a continuation of this robust evaluation, which is really an important element in the accreditation of the training program.
Now, what I’ve described thus far has really focused just on the evaluation of TAC as a training model, but we have always wanted to take, take the next step and to examine whether or not TAC, whether or not we’re able to see any effects of the training in the quality and the effectiveness of that, of the treatment in a community based mental health setting. And fortunately the Annie E Casey foundation they did fund us to do such a study. We have just completed that study. And more specifically the study assessed whether or not TAC trained clinicians are perceived by adoptive parents as being more effective than comparably, comparably qualified clinicians who are not TAC trained.
And whether or not the outcomes for adoptive families are better when they see a TAC trained clinician. And we looked specifically at the adoptive parents’ satisfaction with treatment, which is a really basic kind of measure, but it’s a real good barometer for how long they’re going to actually engage.
If they’re dissatisfied, they often discontinue. So we look at satisfaction. We look at the quality of the alliance with the clinician, adoption sensitivity, or relevance of the treatment and the family wellbeing and basic functioning of the children, post intervention compared to pre intervention.
What brought them to the treatment? We collected data from 159 adopted parents. 89 of the families had been treated by TAC trained clinicians, 70 families treated by comparably qualified clinicians and across all four areas of inquiry. We have statistically significant differences were found.
Those treated were more satisfied with the by TAC trained clinicians were more satisfied. They achieved a more positive alliance with the clinician. They experienced a treatment that they felt was far more relevant to their issues and they reported higher levels of wellbeing and basic function of the children.
So we’re preparing manuscripts now and we’re really eager to share this with the field. And so thankful that we were able to take the evaluation a next step to look at outcomes.
Dr. Emily Helder: Yes. Yes. I was so excited to hear you were doing that work because that just seems like such a important part of demonstrating its effectiveness.
And so it’s exciting!
Dr. Anne Atkinson: We’ve been wanting to do it several years earlier, but we didn’t have the funding and then we got it and we were able to move forward and we’re delighted to have done it.
Dr. Emily Helder: Great. And Debbie, maybe add a bit to what Anne was talking about in terms of NTI evaluations, if there’s anything you wanted to add about that.
And then also, what are some of CASE’s future plans about implementation and that sort of thing?
Debbie Riley, LCMFT: I, you know, where for NTI the evaluation, I mean, it was, I think amazing that we were able to reach over 10,000, through eight state pilot, 10,000 users, both child welfare and mental health. And, you know, for a child welfare, we had almost a 74% completion rate.
When you think about the impact of, of how many child welfare workers, you know, we hear that they’re overwhelmed, they’re burnt out, they have so much training, hung in there with a synchronistic web training protocol and had such high completion rates with sort of astounding feedback about the relevance to practice.
Again, we were hoping that we could have similar outcomes with change in practice is really exciting. I mean, you know, this is a product where you just can’t put it on and, you know, go throw some laundry in, I mean, you really have to engage and, you know, just what I shared before what we were seeing in pre and post, just the tremendous sort of acquisition of knowledge.
In these critical domain areas. So, so, we’re really excited about that. And we’re excited that the federal, the Children’s Bureau has added more funding to the grants so that we could move it even further into other systems. I think what lies ahead, Anne kind of alluded a little bit to this, but from 2009, when we started TAC, we began researching the underpinnings of a accreditation or certification.
I, you know, I felt, I do feel really strongly that this is a subspecialty and should be recognized in that way. And recognized also by third party reimbursement and, you know, just really move this forward, but it needed something more behind it, certainly to get the evidence based rating that’s important.
So we’ve just finished a very rigorous process to submit TAC to the Institute of Credentialing Excellence, where we’re in our second round of responses back to them but beieve that this should get approved, that it will be the first adoption competency training program to be accredited in the country, and it will be assessment based.
So moving forward, all of the practitioners that take the 72 hour training will have to complete 135 question based exam. And I think that this for me, the importance is really protecting families, you know, I want a family to know that when they’re picking up the phone and calling someone for help, that they’re going to get a clinician that has had this rigorous training and had to perform in some way to show that they have acquired the knowledge.
Dr. Emily Helder: Yeah. And I’m sure it would even serve as an incentive for clinicians as well, you know, to be able to build their practice if they have this demonstrated sub-specialty.
Debbie Riley, LCMFT: Yeah. I mean, I’m hoping that those who are listening to the podcast or however they’re getting this information and reading what’s fabulous in the Handbook, that they’ll come on board that they’ll want to take the trainings that we have to offer and really become part of this I think movement that you know is really critical. So, those listening check us out, come to our website.
Dr. Emily Helder: Definitely. As we conclude both of your chapters and with really helpful policy implications, practice implications, and we’ve been, you know, this, our whole conversation, talking a bit about them, certifying these programs, changes to graduate training, maybe incentive structures to get clinicians into this training. And I wondered if you could both speak to where you see progress happening. And if individuals want to advocate on behalf of this, these kinds of policies, do you have suggestions for them about how to do that? And, and Debbie, maybe I’ll, I’ll let you begin.
Debbie Riley, LCMFT: Well, I think just the mere fact of the penetration that we’ve had really says that we’ve moved the needle in the field. And I think the kind of funding, when you begin to see, you know, the federal government getting behind this, it really speaks to that.
I think we’ve educated the field to the relevance and efficacy of, of this type of training. I’m hoping that there’ll be continued funding to, to continue offering these initiatives. We’re beginning to see some language and policy, state and federal level around adoption competency. And, you know, I think that, I’m hoping that those listening will advocate for the training within their own systems of care, whether they’re large systems or whether you’re, you know, in smaller organizations, community based that you help your administration see the value of bringing these trends into your systems.
Dr. Emily Helder: Great, great. Anne, anything you would add?
Dr. Anne Atkinson: I just hope that the policy makers and organizational decision makers really look at the body of evidence supporting the need for adoption competency and begin to really ensure that those that are treating adoptive parents are equipped well equipped to do so.
As a researcher, I would love to see our outcomes study replicated elsewhere, and perhaps even dig a bit deeper into some of the aspects of, of that study. And finally, in, in addition, I’d really like to see more treatment models that are validated for adoptive population so that we would have greater certainty of these, the effectiveness of these models with this particular population.
Dr. Emily Helder: Great. Well, thank you so much, both for your time and for writing the chapters to begin with. Again, we were so thankful that both of you were willing to contribute.
Dr. Anne Atkinson: It was an honor to have been asked and a wonderful opportunity to advance and inform the field further about this area.
Debbie Riley, LCMFT: Yeah.
Dr. Anne Atkinson: Thank you.
Debbie Riley, LCMFT: Emily, we really appreciate the opportunity and it was wonderful experience. Thank you.