Implementing an RCT in Childrens Social Services challenges

Implementing an RCT in Children’s Social Services challenges & complexities Dr Nina Biehal & Jo Dixon Social Work Research & Development Unit 1

Evaluating Multi-Dimensional Treatment Foster Care (MTFCE) Specialist, intensive foster care (from USA) Df. ES pilot: 15+ local authorities in England For adolescents with challenging/complex needs (11– 16 yrs) Intervention delivered by foster carer + MTFCE team Time-limited placement Costly (as are some alternatives) Social Work Research & Development Unit 2

Design Pragmatic trial Comparing outcomes for young people placed in MTFCE and those in usual care placements Data collection - outcome measures+qualitative Randomise to offer of MTFCE placement or TAU Parallel Case Control Study Social Work Research & Development Unit 3

Challenges RCTs - well established in Health research and increasingly in Education research Different to other English Foster Care RCTs v children to placements v carers to training packages A number of challenges arise in implementing an RCT in social care: v v Practical – implementation of the programme Contextual - social care arena Cultural – professional concerns Gatekeeping – recruiting to the trial Social Work Research & Development Unit 4

Practical Challenges Multi-site – each site very small v v v Few places available (2 – 9) Few & slow referrals, may be one at a time MTFCE recruitment problems IMPACT upon trial recruitment Implications for sample size/power Heterogeneity of TAU Analysis of how/why MTFCE ‘works’ is complex v v Many components/professionals/outcomes Variations in treatment fidelity across sites Social Work Research & Development Unit 5

Contextual Issues RCT requires some control over intervention & practitioner support but: v v 15 autonomous local authorities Multiple stakeholders in each LA: conflict /changing decisions Financial concerns – resistance to RCT: v v v Referrals to MTFCE can be driven by strategic/budgetary concerns (most costly yps earmarked) Anxiety that costly places left empty Concerns over selection bias Blinding difficult - strategies to overcome this Social Work Research & Development Unit 6

Cultural Issues & Professional Concerns Cultural issues: v v RCT unfamiliar in social care (medical model) Distrust, reluctance, resistance to RCT Professional concerns: v v v RCT undermines decision-making Raises issue of accountability Issue of placement ‘choice’ Concerns about professional autonomy v Bureaucratisation of SW Social Work Research & Development Unit 7

Gatekeeping Need agreement from all concerned v v v Parallel consent processes (intervention & trial) Information overload for child Fears that will put child off intervention Timing - Trial recruitment at point of transition Fear that randomising out = more rejection Lengthy negotiation to engage child in intervention v v v Can’t then reject child So randomise to an offer, not to intervention ITT analysis Social Work Research & Development Unit 8

Meeting these Challenges Real practical, contextual and wider difficulties Need to adapt design to context and intervention Get in early to influence referral procedures Flexibility and adaptation to professional concerns without compromising trial e. g. v Allow for matching pre-randomisation v Randomisation to offer, not intervention Encourage cultural shift v Protecting children from research/untested interventions v Convince of need for rigour Need for ongoing, sensitive negotiation v At all levels, on all sites v Staffing implications (funding) Find opportunities for ‘natural’ experiments? Social Work Research & Development Unit 9