Child Mental Health Systems Research Articles

The Emergency Department as a Gateway to Child Mental Health Services in Florida

Recent research suggests that the emergency department (ED) is increasingly becoming an entry point to the child mental health system of care. Some caregivers may present to the ED with their children because of an urgent psychiatric crisis or for routine mental health care since they lack a medical home. However, this practice setting is often disconnected from community-based mental health services and it may be unclear to ED providers what role they may play in the identification of mental health issues.

Vectoring for true north: building a research base on family support.

When a parent seeks mental health services for their child, particularly if they are uninsured and poor, they are faced with systemic impediments that are often debilitating and always daunting. In addition to the scarcity of mental health specialists, parents face stigma (Hinshaw 2007), stereotypic threats (Heflinger & Hinshaw 2010), long wait lists (sometimes six months or more), and lack of experienced and competent providers (U.S. Department of Health and Human Services, The Substance Abuse and Mental Health Services Administration (USDHHS SAMHSA) 2013). In short, they have to deal with a fragmented, discontinuous, and non-responsive “system.” Even using the word “system” to describe what families face is generous. In 2001, The Institute of Medicine (IOM) released its report entitled, Crossing the Quality Chasm (IOM, 2001). The report outlined six principles for quality care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Patient-centered care was called “true north” by Donald Berwick (2002) because it conceptualized that compass point as the ultimate destination for quality care. The Quality Chasm report endorsed the overarching purpose proposed by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998): “The purpose of the health care system is to reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States”(p. 83). True North retains its significance as an organizing principle in healthcare and in mental health care. In the child mental health system, ensuring quality services for families with children with mental health needs is the endpoint, and the sine qua non. (We will use the term “families” to refer to parents/caregivers, and their children). Systematizing services that will improve the quality of mental health outcomes for families, however, requires a shift away from a unilateral focus on children's needs to a focus that encompasses the perspectives, needs, values, and experiences of parents, caregivers, and other significant adults. This is not a small change. It requires a different knowledge base and a new set of tools. The research base on effective treatments and services for children has grown exponentially over the past three decades (U.S. Public Health Service 2000; U.S. Department of Health and Human Services 1999), but research on the supportive services that enable and empower families to sustain their child's treatment gains has been remarkably lacking (Hoagwood et al 2010; Cavaleri et al 2011). The papers in this special issue begin to fill this hole. They are targeted at the supportive services for families that, when added to effective treatments for children, can create a package of care that is likely to improve outcomes on a broad scale. We as editors see the papers in this volume as advancing research, and consequently – we hope practice and policy about children's services – by adding important new knowledge to the research base. The papers describe in detail a set of services delivered by parents and for parents of children with mental health needs. These supportive services are more than a worthy goal or lofty ideal. They are specific targeted supports that include knowledge, skills, and practical assistance provided by trained professionals who are also parents or caregivers. The goal of these supportive services – often called family support services – is to assist other parents or caregivers to advocate for and actively participate in treatment planning for their children. The studies described in these papers were deliberately positioned to align with the major shifts in healthcare delivery that are shaping mental health services in the future. Specifically, the studies address issues about three of the large changes to the healthcare system that are occurring, namely: (a) new workforce training competencies; (b) development and testing of quality indicators in the workplace; and (c) organizational supports in agencies to sustain changes and improve outcomes. In short, these three changes provide the impetus for the creation of a new system of family support services. We will first provide a brief background to the three system problems that are being addressed through the healthcare changes: workforce shortages; fragmentation and poor quality; and disorganized organizations. Second, we outline some of the problems that healthcare reform is trying to address, changes that are redefining the contours of the mental health system. Third, we describe the contributions that the five papers in this volume are making to align with these healthcare changes.

Obtaining Stakeholder Consensus on the Core Components of a Parent Support and Training Model for Parents of Children with Serious Emotional Disturbances

Parent-to-parent peer interventions are nationally recognized as an important service within children's community-based mental health systems of care. Despite rapid growth, clearly defined models of professional parent services for statewide application do not exist. In this study, concept mapping was used to achieve stakeholder consensus on the core components of the Parent Support and Training (PST) peer intervention model developed within the Kansas community mental health system. Participants rated the importance and observed frequency of 49 distinct statements related to the service and sorted them into conceptual groups. Analyses reflected a high level of agreement across stakeholders on statements identified as most important and most frequently demonstrated in PST services statewide.

Development and Validation of a Wraparound Parent Partner Fidelity Tool

Parent partners are parents or caregivers such as foster parents who have had success in dealing with a difficult child in a child welfare, mental health, or probation system and who become key players on Wraparound teams for families with youths with emotional or behavioral disabilities who are in out-of-home care. Although many studies have been conducted on the Wraparound model, none of them have described the parent partner's role and fidelity to the model. The Parent Partner Fidelity Tool (PPFT) was developed to address this gap in Wraparound research; it is the first tool designed to measure parent partner adherence to the Wraparound model and identify parent partner training and support needs. The 28-item PPFT captures parent partner activities related to the four Wraparound phases designated by the National Wraparound Initiative: engagement, planning, implementation, and transition. Similar PPFT versions are completed by Wraparound facilitators, parent partners, and parents/caregivers to provide multiple perspectives on the parent partner's work. The PPFT pilot testing project was conducted with 14 California Wraparound programs. Analyses of the 585 responses showed good reliability and validity for the PPFT, indicating that it is a psychometrically sound tool.

Evaluation eines Projektes zur Sensibilisierung der Jugendhilfe für Traumafolgestörungen bei Pflegekindern

Foster children are exposed to multiple psychosocial and biological risk factors and have an elevated risk for developmental delays and the development of mental disorders. Many children experienced compromising situations such as neglect, physical abuse, or sexual abuse before out-of-home placement. Consequently, they show a higher need for mental health services than other children. However, out-of-home placement is often considered as the sufficient measure to help these children. Hence this project had the aim to sensitize child welfare agencies and foster parent organisations for the special needs and history of foster children, to provide them with instruments for the assessment of emotional and behaviour problems and to promote the cooperation at the interface between child welfare system and mental health system. Twenty-four child welfare agencies and four foster parent organisations participated. The control group consisted of 16 non-participating child welfare agencies. After one year, participants recorded more often children's social history (p = .023), conducted more often standardized psychosocial assessments (p = .001), assessed more often the medical needs of foster children (p = .029), and informed foster parents more often about behaviour problems of their foster child (p = .034). In summary, child welfare agencies were very interested, could be sensitized for mental disorders following traumata and implemented the offered instruments in their work. Limits of resources could be observed due to the case workers' high case load.

The elementary-school functioning of children with maltreatment histories and mild cognitive or behavioral disabilities: A mixed methods inquiry

This mixed methods inquiry examined the school functioning of elementary school-aged children with maltreatment histories and mild cognitive or behavioral disabilities. Quantitative analyses of linked social service and education administrative data bases of 10,394 children in Minnesota with maltreatment histories indicated that 32% were eligible for special education services. Of those children with maltreatment histories and identified disabilities, 73% had mild cognitive or behavioral disabilities. The most frequent primary disabilities categories were specific learning disabilities (33%) and emotional/behavioral disabilities (27%). Children with maltreatment histories and mild cognitive or behavioral disabilities scored significantly below children with maltreatment histories and no identified disabilities on standardized assessments of math and reading, and this gap increased with grade level for math. Qualitative interviews with 22 child welfare professionals and 15 educators suggested why some children with maltreatment histories, especially those with mild cognitive or behavioral disabilities, struggle in school. Risks to school functioning included children's and families' multiple unmet basic and mental health needs which can mask or overshadow children's mild disabilities; poor cross systems collaboration between child welfare, education and mental health systems; and inadequate funding, especially for mental health services. Protective factors included child engagement in school, parent engagement with child welfare services and a professional culture of cross-systems collaboration. Implications are discussed for holistic child, family and system-level interventions.

Ecosystemic Structural Family Therapy: Theoretical and Clinical Foundations

Ecosystemic structural family therapy (ESFT) is a systemic, strength-based, and trauma-informed family therapy model that has evolved from structural family therapy (SFT; Minuchin in Families and family therapy, Harvard University Press, Cambridge, 1974). ESFT is an evidenced-based family therapy approach designed to intervene with families of children who are experiencing behavioral health problems and are at the risk of out-of-home placement. In this article we review the theoretical, applied, and empirical evolution of ESFT relative to extant SFT models. ESFT is based on the fundamental assumption that child, parental, and marital functioning are inextricably linked to their relational environment. Five interrelated constructs guide ESFT therapists in their understanding of clinical problems: family structure; family and individual emotional regulation; individual differences (e.g., historical, biological, cultural, developmental); affective proximity; and family development (Gehart 2010). ESFT has an extensive evaluation history dating back to the 1980s involving over 4,000 families in 39 different sites. While ESFT is considered evidence-based, it might be more consistent with “Practice-Based Evidence” given its long, extensive, and successful, history in the child mental health system in Pennsylvania.

A Comparison of Child Mental Health Systems in France and the United States

Background and objectives: Economic conditions, policies, family environment and cultural models of parenting all impact a child’s well- being and development. Differing theoretical orientations in mental health between countries govern the respective under standing, assessment, and treatment of children and their families. Method: This paper provides an overview and critical examination of child mental health care systems in North America and Europe using the United States (US) and France as comparisons. Results: France has a national policy of universal access to health care; in the US access is determined largely by insurance companies and varies from state to state. Conclusions: By examining the similarities and differences between health care systems, mental health providers, training, diagnosis and treatment approaches in this cross-national comparison, much can be learned about developing effective practices to improve health care delivery worldwide. Keywords: Cross-cultural comparisons, France, USA, children, adolescents, mental health

Introduction to the Special Issue

n advancing a metasystems approach to evidence-based practice in mental health care for children, Kazak and her colleagues recently characterized the child mental health system in the United States as fragmented. They described it as being composed of at least six different sectors, broadly found to be administratively and fiscally segregated, of which child welfare and juvenile justice are but two (Kazak et al., 2010). Similar fragmentation and a host of associated problems have been described in the Canadian context (Manion, 2010). Among the many concerns arising from this state are the resulting challenges of providing needs-driven, evidence-based continuity of services for youth who populate multiple sectors and multiple levels within sectors, from secure residential placements down. Compounding this is the lack of consensus--both within and across disciplines--as to what criteria should be used to identify beneficial interventions and what interventions meet the standards (Weisz, Sandler, Durlak, & Anton, 2005, p. 642). Notwithstanding the identification of children and adolescents in both juvenile justice and child welfare systems as populations in pressing need of stronger foundations of evidence-based practices, Kazak et al. (2010) point out that evidence-based assessment methods and interventions do exist within these systems. But they suggest that for many personnel working within these systems, limited awareness of the evidence bases as well as limited opportunities for training mean many children and adolescents in need of mental health services go without (see also Wasserman et al., 2003). This is despite the well-documented high levels of mental health needs among children and adolescents in these systems. For example, estimates of adolescents with mental health problems in the child welfare system are as high as 50% (Burns et al., 2004; Garland et al., 2001), and up to 70% of adolescents in the U.S. juvenile justice system (across a range … Language: en

Becoming an Evidence-Based Service Provider: Staff Perceptions and Experiences of Organizational Change

In 2006, Ontario’s Policy Framework for Child and Youth Mental Health identified a need to improve the dissemination of what works in mental health practice and put it into practice. While an encouraging policy direction, the operationalization of evidence-based practice (EBP) implementation in child and youth mental health systems requires further consideration and the provision of support at the organizational and workforce levels. Thus far, the field of implementation science has identified that the implementation of effective and efficient behavioral health treatment programs involves a number of factors beyond that of consulting the research evidence and committing to the adoption of a particular practice. The range of factors identified as important in EBP implementation is captured in several frameworks and has been synthesized in a Consolidated Framework for Implementation Research (CFIR). This framework provides an overarching typology or meta-theory of relevant implementation constructs: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. The CFIR identifies constructs for which evidence supports their influence (positively or negatively, as specified) on implementation but does not specify the interactions between these constructs. We know little of how the process of implementation unfolds in real-world settings, and thus stand to learn a great deal through practice-based implementation studies done in partnership with community-based providers. Here, we have selected to explore the process through an exploratory case study. Given the paucity of literature examining implementation processes within the pediatric behavioral healthcare field, the present study used an exploratory framework to follow a change initiative involving the implementation of multiple EBPs over a four-year period in a large pediatric behavioral health service provider organization. In this paper, we report on staff

Building a Consumer Base for Trauma-Focused Cognitive Behavioral Therapy in a State System of Care

This paper documents the scope and limitations of an outreach effort to build a consumer base for Trauma-focused cognitive behavioral therapy in a state public mental health system for children. Three key aspects are discussed: the fostering of an informed referral network, the development of screening and identification services, and the engagement of families. Referral, screening and engagement are each examined against the backdrop of existing literature on implementation and dissemination. Each aspect of the implementation plan is described in detail-as are the barriers encountered and lessons learned during the course of execution. We provide several recommendations to assist other efforts to implement Evidence-Based Treatments into state systems of care.

The critical role for psychology in the children's mental health system: Being a catalyst to implement and build better interventions.

Abstract The increasing demands for accountability, effectiveness, and use of research in the children's mental health system places psychology in a unique and important position. Psychology practitioners are highly trained in scientific and clinical methods and possess the skills needed to implement evidence-based practices in community organisations. Moreover, psychology's central role in the increasing demand to evaluate services can help to foster the development of reflective learning organisations. The current article describes current directions in evidence-based practice in the children's mental health system and the critical role psychology can play in building more effective services. Key priorities and directions for psychology's role in children's mental health are provided. Keywords: children, implementation, evidence-based, treatment, organizations The children's mental health field, like most sectors of our society, is in the midst of dramatic transformation. There are increasing demands for accountability, effectiveness, and integration of available empirical research into everyday service delivery. While this represents a positive shift in clinical it also leaves many frontline clinicians, organisations, and policymakers in a state of uncertainty about how to achieve such ideals. What does it mean to be evidence-based? Am I using the research information possible? What constitutes a sound or adequate program evaluation? These questions, and many others like them, receive a wide range of answers by current psychology practitioners. This variability, in part, represents the nascent status of the field and the paucity of research in children's mental health. Notwithstanding these challenges, it is an exciting and important time of transition where practitioners, organisations, and policymakers are all striving toward the realisation of improved child and adolescent mental health interventions. However, much is to be learned as frontline practitioners face the challenge of incorporating new knowledge into daily clinical practice. This journey is a process which will require collaboration across multiple sectors and disciplines, and will inevitably result in some failures and mistakes along the way. Like Dr. Seuss, who was rejected by publishers 27 times before his first book, And to Think That I Saw it on Mulberry Street, was published, persistence in our efforts to implement and build more effective interventions is critical to the success of our work. The current article will attempt to describe my perspective and thoughts as a frontline practitioner on how psychology's unique skill set can be used to build more effective interventions in the children's mental health system. This will include psychology's ability to use the various approaches to evidence-based practice that currently exist in the children's mental health field. In addition to promoting the use of effective approaches, psychology can and should play an increasingly critical role in facilitating the careful implementation of evidence-based practices. Finally, in light of the current state of the field, recommendations for moving forward are provided both from the perspective of a frontline practitioner and from the personal lessons learned through implementing evidencebased programs in a community-based children's mental health centre (Schmidt & Taylor, 2002). Effectiveness of Usual Children's Mental Health Treatment Kutcher (2011) argues that the children's mental health field must move toward best evidence, not best practice, and must use interventions which are right rather than using what feels right. These strong statements by Kutcher arise from the disappointing results found in past reviews of Treatment as Usual (TAU) in the children's mental healm system. As described in past studies, TAU refers to the usual provision of eclectic treatment services, by community-based clinicians, under the confines of existing available resources. …

Critical Issues for Psychiatric Medication Shared Decision Making with Youth and Families

The primary aims of this article are to describe the current context for youth shared decision making (SDM) within the U.S. children's mental health system and to identify important considerations for the development of this approach as a research and service domain. The notion is substantiated in the literature that participation in treatment decisions can prepare youth for making their own decisions as adults, can be therapeutic, and can have positive effects on their self-confidence and self-esteem. Still, the complex youth–family–provider dynamic raises important issues that need to be addressed before SDM can be successfully implemented.

Three Collaborative Models for Scaling Up Evidence-Based Practices

The current paper describes three models of research-practice collaboration to scale-up evidence-based practices (EBP): (1) the Rolling Cohort model in England, (2) the Cascading Dissemination model in San Diego County, and (3) the Community Development Team model in 53 California and Ohio counties. Multidimensional Treatment Foster Care (MTFC) and KEEP are the focal evidence-based practices that are designed to improve outcomes for children and families in the child welfare, juvenile justice, and mental health systems. The three scale-up models each originated from collaboration between community partners and researchers with the shared goal of wide-spread implementation and sustainability of MTFC/KEEP. The three models were implemented in a variety of contexts; Rolling Cohort was implemented nationally, Cascading Dissemination was implemented within one county, and Community Development Team was targeted at the state level. The current paper presents an overview of the development of each model, the policy frameworks in which they are embedded, system challenges encountered during scale-up, and lessons learned. Common elements of successful scale-up efforts, barriers to success, factors relating to enduring practice relationships, and future research directions are discussed.

Exploring the Feasibility and Benefits of Arts-Based Mindfulness-Based Practices with Young People in Need: Aiming to Improve Aspects of Self-Awareness and Resilience

Research in mindfulness-based methods with young people is just emerging in the practice/research literature. While much of this literature describes promising approaches that combine mindfulness with cognitive-behavioral therapy, this paper describes an innovative research-based group program that teaches young people in need mindfulness-based methods using arts-based methods. The paper presents qualitative research findings that illustrate how young people in need (children and youth involved with child protection and/or mental health systems) can benefit from a creative approach to mindfulness that can teach them emotional regulation, social and coping skills, and that can improve aspects of their self-awareness, self-esteem, and resilience.

Methodological Issues in Child Welfare and Children’s Mental Health Implementation Research

Methodological Issues in Child Welfare and Children’s Mental Health Implementation Research

Early Intervention for Substance Abuse Among Youth and Young Adults with Mental Health Conditions: An Exploration of Community Mental Health Practices

This mixed method study examined current practices and barriers for screening and assessing substance use among youth/young adults in community mental health systems. Substance use rates remain high among youth/young adults in the general population and substance use disorders are prevalent among young people involved in public service systems such as mental health. In an effort to understand the dynamics for early intervention, 64 case managers and/or clinical directors from children's mental health systems in two states participated in an online survey or focus group in fall 2008. Quantitative survey questions and qualitative focus group questions explored attitudes and perspectives about screening and early intervention for substance use among youth/young adults involved in the mental health system and current agency practices. Mixed method results suggest a number of barriers to substance use screening and early intervention and point to innovations that could be more effectively supported.

Putting the “Community” Back into “Mental Health”: The Challenge of a Great Crisis in the Health and Well-being of Children and Families

For more than a generation, the levels of anxiety, depression, and misconduct among young people in the United States have been steadily increasing. So too have isolation, alienation, mistrust, and boredom, with the result that ongoing social support has been diminishing, particularly for young people. These trends constitute a national public health crisis affecting young people in general, those already defined as having mental health problems, and their families. To respond adequately, the child mental health system must change dramatically--away from the provision of units of service defined by protocols, time, and professionals' presence and toward the engagement of primary community institutions in the creation and maintenance of new norms of giving and receiving help. Initial evidence suggests that such a shift requires massive effort but that it is feasible and potentially effective.

Organizational Adaptation: Bridging the Research to Practice Gap

Currently, the children's mental health system appears dysfunctional and in need of serious attention. A possible remedy for this disarray would be for researchers and providers to establish integrated management systems which include mutual, cross organizational learning, and reciprocal feedback mechanisms. This type of adaptive co-management to organizational governance would fully integrate research and practice at the community level. Using a public health service model, this organizational management approach to research and practice would harvest diverse scientific knowledge and disseminate that knowledge through the natural occurring culture and practice of each community. Organizational and clinical knowledge acquisition, as well as practice improvements would necessarily occur over time and across institutions.

Multisystemic Therapy as an Alternative Community-Based Treatment for Youth With Severe Emotional Disturbance: Empirical Literature Review

According to the New Freedom Commission report (2003), the mental health system for children is very fragmented. Gaps of knowledge exist of effective, culturally competent, community-based services for children and adolescents with a serious emotional disturbance. Multisystemic therapy (MST) stands out as a culturally competent home-based service with strong empirical evidence for treating youth in the juvenile justice system and may have promise for treating youth with a serious emotional disturbance in the community mental health system. This article will present the theoretical basis of MST, program design, and service provision. A review and critique of the empirical literature on MST will be presented. Finally, implications for social work practice and research with children and adolescents in the community mental health system are discussed.