Implementing an RCT in Children’s Social Services challenges & complexities

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

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

3. 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

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

5. Practical Challenges • Multi-site – each site very small • 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 • Many components/professionals/outcomes • Variations in treatment fidelity across sites Social Work Research & Development Unit

6. Contextual Issues • RCT requires some control over intervention & practitioner support but: • 15 autonomous local authorities • Multiple stakeholders in each LA: conflict /changing decisions • Financial concerns – resistance to RCT: • 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

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

8. Gatekeeping • Need agreement from all concerned • 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 • Can’t then reject child • So randomise to an offer, not to intervention • ITT analysis Social Work Research & Development Unit

9. 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. • Allow for matching pre-randomisation • Randomisation to offer, not intervention • Encourage cultural shift • Protecting children from research/untested interventions • Convince of need for rigour • Need for ongoing, sensitive negotiation • At all levels, on all sites • Staffing implications (funding) • Find opportunities for ‘natural’ experiments? Social Work Research & Development Unit