The main aim of this study is to evaluate the feasibility, preliminary effects and experiences of the Collaboration-Screening-Referral approach (in Swedish: Samverkan-Screening-Hänvisning - SSH) when used with parents referred to the Swedish child welfare services. The SSH is an approach to screen parents for symptoms of mental illness using structured questionnaires, establish intra-agency collaboration, and refer to mental health services. Additionally, to increase social workers' competence in assessing and handling mental illness through receiving training in the SSH and administering the screening to parents.

The main questions the project aims to answer are:

• Are parents engaged with child welfare services willing to undergo screening for symptoms of depression and anxiety?
• How have the implementation of the SSH proceeded and to what degree is it sustained?
• How do parents and social workers experience the SSH?
• Do social workers' behaviors, knowledge and competence relevant to supporting parents with mental illness increase when implementing the SSH?

Social workers answer questions before and after their training and after 6 and 12 months. Additionally, social workers and parents will be interviewed. Qualitative and quantitative within-group analyses will be conducted to examine experiences and preliminary effects of the SSH.

BACKGROUND:

Parental mental illness is prevalent and associated with several family-related risks. Parental mental illness is more common during circumstances characterized by family-related risk factors and for parents in contact with the child welfare system. Further, children to parents with mental health problems are at increased risk of developing own psychiatric problems in childhood and later adulthood. Additionally, parental mental illness influences parenting ability and is a strong risk factor for child maltreatment (CM). CM strongly increases the risk of children developing a range of psychiatric problems.

Identifying mental illness among parents within the child welfare services (CWS) and referring them to evidence-based treatment in healthcare could be essential for improving children's well-being and reducing the risk of CM. For that, intra-agency collaboration is considered crucial. Collaboration between the CWS and healthcare is however a known issue.

One way to address the lack of knowledge in assessing mental illness and support intra-agency collaboration can be routines for screening and referrals. Screening everyone in a setting can be a non-stigmatizing approach to assess symptoms and risk behaviors. Screening parents for mental health symptoms is widely implemented within pediatric healthcare, e.g., screening for post-natal depression, but is to our knowledge not a common approach within the CWS. Additionally, the lack of evidence-based methods has often been cited as a shortcoming within the CWS. Furthermore, social workers could lack the competence to identify mental illness, as it is not included in their basic education. It is therefore assumed that social workers do not always assess parents' mental health with validated procedures and do not always refer parents in need.

PURPOSE AND RESEARCH QUESTIONS:

The main aim of this project is to improve early identification of mental illness in parents reported for CM and to make treatment accessible for families with additional needs. The feasibility of the Collaboration-Screening-Referral model (in Swedish: Samverkan-Screening-Hänvisning - SSH) will be evaluated - an approach for screening parents for symptoms of mental illness and referring to support. The research questions are:

1. Are parents engaged with CWS willing to undergo screening for symptoms of depression and anxiety?
2. What barriers and facilitators to implementing the SSH have there been?
3. In what ways do parents and social workers experience that the children are influenced by the SSH, and what support the children in these families might need?
4. Do social workers' behaviors relating to assessing and handling mental illness and intra-agency collaboration procedures increase when implementing the SSH?
5. Do social workers' knowledge and perceived competence in assessing and managing mental illness increase after employing the SSH?
6. What strategies have been employed by the CWS agencies in the implementation of the SSH?
7. To what degree is usage of the SSH sustained 12 months after initiation?

METHODS:

SSH is a structured approach for screening and referring parents who need mental health support, designed for use by social workers within CWS. Municipalities will be recruited to take part in the research project and implement the SSH. First, staff will be trained in mental health screening, and a referral routine will be established. Units will also be encouraged to arrange meetings with local mental health clinics. Social workers will then administer the screening to parents. Questionnaires are followed by a discussion about well-being and support needs. The social worker can provide information on available mental health resources and offer support in establishing a contact.

The data collection will include surveys and interviews/focus groups. In connection with the training, staff will respond to a survey (baseline measurement) regarding their work methods and perceived competence in addressing mental health issues. Prior to participation, staff will be given information about the study and provide informed consent via an online platform before they access the survey. The data collection will then be divided into two phases.

Phase 1. After the first municipalities have used the SSH for approximately 3 months, social workers will participate in interviews or focus groups. If necessary, the SSH will be modified before further evaluation.

Phase 2. In the next phase, these and additional municipalities will continue to use the SSH as part of routine work. Approximately 6 months from baseline, staff will answer a follow-up survey and interviews and/or focus groups will be conducted. Further, social workers will be asked to recruit parents who have completed the screening for interviews. They will give oral information and provide a link to where parents can read written information and give informed consent. For parents who consent to participate, a person from the research team will call and inform the parent about the study, give the possibility to ask questions, and book a time for the interview. Interviews/focus groups will be conducted by phone calls or video meetings.

SAMPLE SIZE CALCULATION AND ANALYSES:

Quantitative data in surveys to staff will be presented descriptively and statistically analyzed (e.g., t-tests/non-parametric alternative). Psychometric statistics will be calculated. For a power of 80% to detect a medium sized effect (d = 0.50), the total sample size of participating staff has to be N = 34 (alpha = 0.05). To account for a drop-out rate of approximately 10%, the aim is to recruit 40 participants. Qualitative data will be analyzed employing qualitative methods, e.g., thematic analysis. For interviews, 20-40 social workers and 10-25 parents will be recruited. The specific number will be dependent upon achieving a sufficiently rich dataset according to qualitative methodological standards, e.g., data saturation or information power.

The data from the questionnaire administered to parents to assess symptoms of depression and anxiety is presented in a separate study: "Identifying Parents in Child Welfare Services Who Need Mental Health Support: Depression and Anxiety Symptoms". Based on the power calculation for that study, the aim is that 290 parents respond to the questionnaire. In this study, only the questions from parents' questionnaire assessing acceptability of the screening process are included.

SOCIAL WORKERS:

Inclusion Criteria:

• Working at the participating units.

Exclusion Criteria:

• None.

PARENTS:

Inclusion Criteria:

• A parental role in relation to a child 0-17 years old (the participant does need not be a guardian or biological parent, can also be, for example, a partner to a parent).
• A child welfare report has been filed for the child or the parent has reached out to the CWS themselves.

Exclusion Criteria:

• None.