The Benefits and Risks of Evidence-Based Practice in Child Welfare

Bookmark and Share

The move toward evidence-based practice has important legal and ethical implications for child welfare agencies and professionals. Evidence-based practice (EBP) has been growing in popularity in child welfare and other human service fields since the 1990s, but its merits are still the subject of many debates. When agencies and practitioners do not follow research on best practices, they may be leaving themselves open to claims of malpractice by clients, family members, and other interested parties. More importantly, many managers are unclear on how to "do" EBP. In an era of increasing litigation and insurance premiums, as well as growing public pressure around accountability, child welfare leaders have to know how to implement best practices at their agencies. Strategic use of best practices research cannot only ensure more effective services for children and youth, but also shield agencies and practitioners against claims related to malpractice.

In one of the most commonly cited definitions of EBP for social services, Leonard Gibbs defines EBP as an approach to providing professional care based on conscientious, explicit, objective, and judicious use of the best information relative to each question pertaining to the client's needs, concerns, and well-being. EBP assists clinicians in providing effective interventions and assists agencies in developing sounder policies. If a certain type of intervention works, and practitioners can quantitatively and qualitatively demonstrate that it works, keep on doing it; however, if the intervention does not prove to be effective, then why continue to use it? The use of EBP helps preserve the integrity of the field by protecting those served from risky or unproven interventions.

When using the principles of EBP to make policy and practice decisions, child welfare agencies and practitioners should evaluate the potential benefits and risks of their options, including the risk of legal liability. A theory or treatment that diverges from mainstream treatment or modalities is not necessarily bad or negligent on its face; however, to avoid legal liability--and more importantly, to avoid harm to the client--agencies and practitioners should make sure they draw on the best evidence available. Agencies or practitioners who use practices without a thorough evidence base put themselves at risk in two ways: legally for malpractice or child abuse resulting in harm, and ethically as a violation of ethical standards of competence, integrity, promoting safety, and acting in the best interest of clients.

"Child welfare agencies must exercise caution when developing internal policies that affect the welfare, safety, and health of the clients they serve," says Joy Stewart, a social worker at the Chrysalis Center in Fort Lauderdale, Florida. "To mitigate risk to agencies and harm to clients, it is important to provide treatments and therapies that have a degree of scientific basis and avoid fringe treatments that are untested."

A Nuanced Approach

In a perfect world, child welfare agencies and practitioners would be able to remove all subjectivity and reach conclusions about the best treatment or intervention with 100% certainty. Even when there is strong research support for a particular intervention, however, one size does not fit all. Agencies and practitioners need to take into account cultural and individual differences. Further, in many instances, research does not support a singularly best form or intervention.

To illustrate, consider the 2009 scientific study conducted by Michael Saini, "A Meta-Analysis of Psychological Treatment of Anger: Developing Guidelines for Evidence-Based Practice." Saini reviewed research focusing on psychological approaches to treat anger and concluded that a definitive approach that yields the best results for treating or reducing anger and aggression does not exist. Instead, there appear to be many methods that have shown some level of success. In a recent interview, Saini noted, "Anger is such a complex concept... it's very complicated and deserves a complex approach." Saini's study suggests that although many individual psychological treatments are successful, a nuanced approach that incorporates multitheoretical, multimodal methods is desirable. Further, Saini notes significant variability of outcome depending on sample, setting, gender, and qualifications of the therapist. Saini also cautions practitioners to consider the context of the research, explaining, "If you look at the research, although it's been looked at across the board, the majority of the work has been done on undergraduate students." Thus, research findings may not be directly transferable to the contexts and client populations in which child welfare practitioners are working.

So, what are the implications of such findings for child welfare agencies and practitioners? Empirical, quantitative evidence should be an important component of how agencies determine what forms of treatment are most effective and least risky; however, agencies and practitioners cannot rely solely on large-scale clinical trials and quantitative program evaluations. They need to consider multiple forms of research and ways of knowing, including clinical impressions based on professional experience, and take the individuality of clients into account. Any agency that sets a "one-size-fits-all" policy for intervention risks is not only ignoring the uniqueness of each client, but also the need for nuanced decision-making.

Reducing Risk

Clinical specialists, researchers, ethicists, and lawyers can be consulted for guidance about how to turn best practice research into agency policy.

Although the ongoing development of best practices research should lead to better child welfare policies and practices, it may also lead to greater risk of legal liability, as Arnold Rosoff notes in a 2001 article, "Evidence-Based Medicine and the Law: The Courts Confront Clinical Practice Guidelines." In cases without solid research about prudent practice, courts cannot determine what constitutes an appropriate standard of care or impose liability for malpractice. As research draws clearer lines about what constitutes a dereliction of the standards of prudent practice, courts may eventually be able to hold practitioners and agencies more strictly accountable.

Child welfare professionals have an ethical obligation to take reasonable steps to protect clients from harm. Malpractice suits have involved a broad range of nontraditional therapies: use of shamanic journeying and soul retrievals for a client with depression; animal-assisted therapy for children dealing with loss issues; New Age spiritual guidance for a client with panic disorder; and use of an unproven method of interpreting reports of child abuse with anatomically correct dolls. Managers at agencies or associations may be wise to develop protocols for whether and how to offer nontraditional services, particularly in areas where the consequences of malpractice can be particularly tragic.

Dawn Hobdy, manager of the National Association of Social Workers' Office of Ethics and Professional Review, has received a number of requests for consultation from practitioners planning to use nonconventional interventions. She suggests that they consider ethical responsibilities in terms of competence. She asks, "Do you have the training, skills, experience, and supervision from someone who is competent in those interventions and techniques to carry out the intervention in an ethical manner?" Hobdy notes that touch therapies are particularly risky. Even if the practitioner has competence in the touch therapy, clients may not understand what is being offered and may feel their boundaries have been violated. When offering novel or risky interventions, it is particularly important to ensure that clients have an ample opportunity to discuss the intervention with the practitioner, ensuring that consent is fully informed and voluntary.

In addition to the risks of services that child welfare workers provide directly, they should also take precautions when referring clients to programs that offer novel or risky treatments. "Although therapies such as biofeedback, acupuncture, and other alternative modalities of treatment may be effective with appropriate child populations, [obtaining] written informed consent of the guardian or parent and the child is essential to reduce the risk of lawsuit," suggests Danielle Leporino, a social worker at All 'Bout Children in West Palm Beach, Florida. "It is our obligation as social workers to present our clients with the opportunity to participate in treatments that may not be 'mainstream,' but rather, treatments that have been shown scientifically to help clients when administered by trained professionals who have thoroughly informed and explained the benefits and risks to their clients."

While new research can be used to substantiate malpractice claims, there are also ways that agencies and practitioners can use research to reduce the risk of malpractice:

  1. When child welfare agencies develop new programs and services, they should make use of a strategic development process that includes:
    1. identifying a specific problem or concern that needs to be addressed;
    2. reviewing existing practice theory and best practices research;
    3. conceptualizing services based on the current state of the knowledge;
    4. ensuring proper policies, training, and supervision are in place prior to implementation of services; and
    5. using a quality assurance plan that includes mechanisms for risk management, monitoring, evaluation, feedback, and service improvement.
  2. Practitioners and supervisors should consult with other experts whenever they have questions about best practices research that they cannot answer on their own. Depending on the nature of the issue, potential consultants include clinicians with special training and expertise, researchers, ethicists, and lawyers.
  3. Agencies should periodically conduct an ethics audit of their policies and practices to ensure they are consistent with best practices research, including emerging knowledge.
  4. Where best practices research conflicts with agency policy or practice, agencies must bring these into line with best practices, or document why they are out of sync (e.g., explain that the agency is testing a new model of practice).
  5. Agencies and practitioners should participate in continuing education--which may include attending conferences, sponsoring in-house training, reading journals, and consulting with other agencies to ensure their practices reflect current theory and research.
  6. All staff (professional, student, paraprofessional, and others) must be properly supervised, with supervisors taking responsibility for ensuring that the agency's interventions reflect research evidence regarding effectiveness and
  7. When an agency or practitioner decides to use a novel or radical form of intervention with a particular client, it should:
    1. Document the rationale for using the nontraditional intervention rather than a more traditional one, citing theory or research in support of the decision, as well as client factors that make this client a good candidate for the nontraditional intervention.
    2. Ensure the client is offered full information (in language the client can understand, including an explanation of risks and benefits of the nontraditional intervention, as well as traditional therapies that the client could select as alternatives) and ensure the client has an opportunity to provide voluntary, informed consent (ideally having the client sign a carefully drafted consent form, reviewed by a lawyer, explaining all these details).
    3. Determine whether the intervention is covered by liability insurance.
    4. Become a member of a reputable professional organization that champions the nontraditional therapy or provides training and support, obtaining licensure or accreditation where possible.
    5. Educate the child welfare community about this nontraditional intervention so that it may become more acceptable as a prudent practice.
    6. Consider potential risks of the intervention and take steps to reduce these risks (e.g., if using aroma therapy, find out if the client may be allergic; if using dance therapy, have the client go for a physical examination to see if this poses any medical risks for the client).
  8. Agencies and practitioners should ensure they have proper coverage for malpractice insurance; if existing insurance does not cover certain types of services, the agency should see if it can obtain alternate insurance or use other safeguards to protect clients and staff.

In many instances, research does not support a single best practice or intervention - different children may need different services.

When defending against a malpractice allegation, agencies and practitioners may draw upon best practices research to support their practices. As outlined in Clinicians in Court (in press), they may also use independent researchers as expert witnesses to help the court understand why particular practices may have been beneficial, reasonable, or prudent given the specific facts of the case. Child welfare researchers can educate the courts about methods of applying best practices research, including how to sort through the growing body of research, particularly with respect to ambiguous or conflicting research findings.

Executive directors, managers, supervisors, and other agency leaders must establish and promote clear agency policies. When a court is determining what constitutes a reasonable standard of care, the court may consider these policies. When workers stray beyond agency policy, they incur greater risk of being held liable for malpractice, as outlined in T. O'Brien's 2004 book Child Welfare in the Legal Setting.

Consider, for instance, the controversy over reparative therapy, recently sparked by media reports that presidential candidate Michele Bachmann's husband, Marcus Bachmann, has used reparative therapy to try to change the sexual orientation of gay clients (including minors). If a former client sued Bachmann for malpractice, he or she would need to prove that Bachmann breached his duty of care to the client by using reparative therapy.

In determining whether reparative therapy constitutes a breach, a court would consider agency policy, standards of professional practice, and research on the risks and effectiveness of such therapy. In this case, Bachmann could use agency policy in his defense, arguing that his practice is consistent with agency policies and procedures. He might also identify research in support of his methods of intervention. The former client's case may rest on discrediting Bachmann's research and providing evidence that reparative therapy is not only ineffective, but harmful. In support of his or her case, the client could make use of policy statements issued by various mental health associations that have reviewed the research and concluded that reparative therapy is not a valid intervention.

Balancing Research with Clients' Needs

The existence of best practices research does not mean there is just one way to practice in order to properly exercise one's duty of care to clients. Leaders should not only help their agencies create policies or standards of practice, but also encourage their employees to respect the diverse needs of their client base. Although the research might point toward one model of intervention, for instance, the client may prefer another model due to cultural considerations. Practitioners should respect client self-determination, but be clear in explaining what the research says about the intervention options. Practitioners and supervisors may also require discretion when the preferred services are not readily available. Clients may not have access to the preferred services due to lack of resources or other pragmatic constraints. Thus, practitioners, supervisors, and clients may need to develop creative alternatives. Agency policies and professional standards of practice should permit practitioners and supervisors to use their discretion, including the ability to develop and use new and innovative interventions.

In child welfare, there are obviously some situations and issues that are riskier than others. In particular, concerns related to child abuse, neglect, suicidal ideation, homicidal ideation, and substance abuse require special precautions. Where there are gaps in best practices research about how to assess and respond to these types of situations, agencies have legal and ethical incentives to sponsor research or collaborate with researchers to help fill the gaps. Where agencies are testing new models of assessment and intervention, or older models that have not been adequately researched, agencies should ensure these models are being properly evaluated. In addition, it may be useful to make data available to researchers who want to compare the effectiveness, risks, and benefits of various interventions.

All child welfare practitioners, administrators, and researchers should remember that the laws and ethical rules regarding malpractice are meant to promote competent, effective practice, while also protecting clients from harm. In the end, both child welfare service providers and clients will benefit from the further development of broad, best practices research. Moreover, a broad definition of EBP will include the ability of the clinician and agency to use both quantitative and qualitative studies to lead the clinician and client towards the right course of intervention; however, clinical judgment, aided by agency supervision and policy, will be the final determiner, as opposed to a scientific formula. It is incumbent upon agency leaders to keep abreast of research as it evolves, and stay connected to colleagues in the field to maintain an understanding of how they are using the latest evidence to further their practice and, ultimately, improve outcomes for children and families.

Allan Barsky PhD is a professor of social work at Florida Atlantic University and author of Ethics and Values in Social Work (Oxford University Press) and Clinicians in Court (Guilford Press). David Kolker is a graduate social work student at FAU with a background in law. The authors may be contacted via abarsky@fau.edu. This article is adapted from an article in Child Welfare, Vol. 88, No. 2.

To comment on this article, e-mail voice@cwla.org.

Bookmark and Share

Have something to say?

Let us know!

Send a letter to the editor at voice@cwla.org.