IT TAKES A VILLAGE (of youth, family members, parent advocates, peers, clinicians and services researchers) to create, deliver and test youth and family-focused.

IT TAKES A VILLAGE IT TAKES A VILLAGE (of youth, family members, parent (of youth, family members, parent advocates, peers, clinicians and advocates, peers, clinicians and services researchers) to create, services researchers) to create,

deliver and test youth and family-deliver and test youth and family-focused engagement interventions focused engagement interventions and engaging child mental health and engaging child mental health

servicesservices

Mary McKay, PhDMary McKay, PhDProfessor of Psychiatry & Preventative MedicineProfessor of Psychiatry & Preventative MedicineAssistant Director of Social Work in PsychiatryAssistant Director of Social Work in Psychiatry

Head, Division of Mental Health Services Head, Division of Mental Health Services Research DivisionResearch Division

Mount Sinai School of MedicineMount Sinai School of Medicine

Acknowledgements HOPE Health team (Rita Lawrence, Greg Mudd, Natalie Parker,

Indy Castro, Neal Chambers, Mary Savva) HOPE Family team (Ervin Torres, Nisha Behare, Angela Paulino,

Kosta Kologerogiannis, Anita Rivera, Ana Miranda, Aida Ortiz) Step-Up team (Gisselle Parado, Kelly Conover, Ervin Torres, Greg

Dunne, Tiffany Nesbit, Kerby Jean, Geetha Gopalan, Stacey Alicea) Multiple Family Group team (Kara Dean, Lydia Franco, Kassia

Rangel, Vivian Escrogima, Rebecca Gomez, Clair Blake) Social work interns from Hunter College, Fordham University,

New York University and Columbia University

National Institute of Mental HealthNational Institute on Drug AbuseNew York State Office of Mental HealthRobinhood Foundation

Acknowledgements (Continued)Acknowledgements (Continued)

Bronx Community Collaborative BoardBronx Community Collaborative Board

Welcome and Introductions

Identify 1 obstacle that you have encountered as you tried to involve children and their families in services.

Responding to an Child Mental Health Crisis

• Two thirds of children in need of mental health care do not receive services

• Rates of service use are at their lowest in low income, urban communities

• No show rates can be as high as 50%

• Drop outs occurring after two or three sessions are common

Responding to Serious Urban Service Delivery Challenges

Obstacles to initial and ongoing engagement in care are significant

Multi-level needs of youth and families not easily met by available resources or existing evidence-based interventions

Service capacity is severely limited relative to need

Stigma related to mental health care and specific life circumstances interferes with engagement

Range of service options and trained, supported service providers limited

The Research: Barriers to Engagement The Research: Barriers to Engagement (Urban Settings)(Urban Settings)

Triple threat: poverty, single parent status Triple threat: poverty, single parent status and stressand stress

Concrete obstacles: time, transportation, Concrete obstacles: time, transportation, child care, competing prioritieschild care, competing priorities

Attitudes about mental health, treatment, Attitudes about mental health, treatment, stigmastigma

Previous negative experiences with Previous negative experiences with mental health or institutionsmental health or institutions

Collaboration is a Necessary Collaboration is a Necessary Foundation Foundation

Program of services research based on core assumptionsProgram of services research based on core assumptions ::

Collaboration with consumers (youth, parents, Collaboration with consumers (youth, parents, providers, and communities) lead to services and providers, and communities) lead to services and prevention programs that potentially are:prevention programs that potentially are:

• acceptableacceptable to consumers to consumers• relevantrelevant to consumer’s context, specific needs and to consumer’s context, specific needs and

core valuescore values• potentially potentially effectiveeffective when… when…• implemented in implemented in “real world” settings“real world” settings by naturally by naturally

existing providers and resources (sustainable)existing providers and resources (sustainable)

Empirically supported Empirically supported Engagement InterventionsEngagement Interventions

Focused telephone procedures associated Focused telephone procedures associated with increased initial show rates with increased initial show rates

Structural family therapy telephone Structural family therapy telephone engagement intervention associated with engagement intervention associated with 50% decrease in initial no show rates and 50% decrease in initial no show rates and a 24% decrease in premature a 24% decrease in premature terminations (Szapocznik, 1988; 1997; terminations (Szapocznik, 1988; 1997; 2004)2004)

Summary:Summary: Initial Initial Engagement Strategies Engagement Strategies

to Address Barriersto Address Barriers

““First Contact”First Contact”

Initial Engagement Initial Engagement InterventionIntervention

Grounded in an ecological Grounded in an ecological perspective of child, family, perspective of child, family, community and system level barriers community and system level barriers to child mental health careto child mental health care

Goals: Goals:

1) clarify the need 1) clarify the need

2) increase youth and caregiver 2) increase youth and caregiver investment and efficacyinvestment and efficacy

Telephone Engagement Telephone Engagement Intervention (cont.)Intervention (cont.)

Goals: Goals:

3) Identify attitudes about previous 3) Identify attitudes about previous experiences with care and experiences with care and institutions institutions

4) PROBLEM SOLVE! PROBLEM SOLVE! 4) PROBLEM SOLVE! PROBLEM SOLVE! PROBLEM SOLVE! around concrete PROBLEM SOLVE! around concrete obstacles to careobstacles to care

Engagement Study MethodsEngagement Study Methods

Outcome of interest: # of families Outcome of interest: # of families that brought their child to an initial that brought their child to an initial appointmentappointment

Setting: outpatient clinicSetting: outpatient clinic Sample: Sample: nn=54=54 Design: Matched comparison of Design: Matched comparison of

consecutive referrals in one monthconsecutive referrals in one month

Telephone Engagement Study Telephone Engagement Study ResultsResults

21

6

1314

0

5

10

15

20

25

Engage Compare

# of children broughtto first session (n=27per condition)no show

Engagement Study #2 Engagement Study #2 MethodsMethods

Outcome of interest:Outcome of interest: # of families # of families that brought their child to an initial that brought their child to an initial appointmentappointment

Setting:Setting: Outpatient clinic Outpatient clinic Sample:Sample: nn=108=108 Design:Design: random assignment to random assignment to

conditioncondition

Engagement Study #2 Engagement Study #2 ResultsResults

40

15

24

29

0

5

10

15

20

25

30

35

40

Engage Compare

# of families that cameto 1st appt.No show

Exercise 1: Barriers to child/family engaging in the

helping process

Instructions for participants:

•List 5 – 10 obstacles that would interfere at the parent/family level in getting to an appointment.

•What new strategies can you develop to help families address obstacles?

Exercise 2: What would make a families’ experience perfect at your

site?

Instructions for participants:

Consider your first contact with a parent and their child. Describe what would make the experience perfect for that parent and child.

First Interview Engagement First Interview Engagement StrategyStrategy

Summary: Engagement Summary: Engagement Approach to Involving Approach to Involving

Youth and their Families Youth and their Families

First InterviewFirst Interview

Purpose of first interview Purpose of first interview engagement strategy engagement strategy

Two primary Two primary purposes:purposes:– To understand why To understand why

a youth and family a youth and family want help from want help from provider.provider.

– To engage the To engage the youth and family in youth and family in a helping process, if a helping process, if appropriate.appropriate.

Four Critical Elements of the

Engagement Process

Element – 1 Element – 1 Clarify the helping process…Clarify the helping process…

Carefully introduce self, agency intake process, and Carefully introduce self, agency intake process, and possible service options.possible service options.

Do not assume that client has been given accurate Do not assume that client has been given accurate information about services.information about services.

Do not assume clients know what is expected of them and Do not assume clients know what is expected of them and what they should expect from intake process/workerwhat they should expect from intake process/worker

Element – 2 Element – 2

Set the foundation for a Set the foundation for a collaborativecollaborative working relationship.working relationship.

Explicate roles and responsibilities of all going Explicate roles and responsibilities of all going forward towards shared goalsforward towards shared goals

““We” begun to be createdWe” begun to be created

Element – 3 Element – 3 Focus on immediate, practical concerns…Focus on immediate, practical concerns…

Be ready to schedule a second appointment sooner than the Be ready to schedule a second appointment sooner than the following week.following week.

Parents often need help negotiating with other “systems” (i.e. Parents often need help negotiating with other “systems” (i.e. school).school).

Responding to parents concerns provide an opportunity for Responding to parents concerns provide an opportunity for worker to demonstrate their commitment and potential worker to demonstrate their commitment and potential capacity for help.capacity for help.

Element – 4 Element – 4 Identify and problem-solve around barriers to help Identify and problem-solve around barriers to help

seekingseeking Every first interview must explore potential barriers to Every first interview must explore potential barriers to

obtaining ongoing servicesobtaining ongoing services Specific obstacles, such as time and transportation must be Specific obstacles, such as time and transportation must be

addressed.addressed. Other types of barriers include previous negative experiences Other types of barriers include previous negative experiences

with helping professionals; discouragement by others to seek with helping professionals; discouragement by others to seek professional help; differences in race or ethnicity between the professional help; differences in race or ethnicity between the interviewer and the client; families experiences with racism interviewer and the client; families experiences with racism and its impact on their willingness to receive services from a and its impact on their willingness to receive services from a “system” need to be carefully explored.“system” need to be carefully explored.

First Interview Study First Interview Study MethodsMethods

Outcome of interest: # of families Outcome of interest: # of families that came to initial and ongoing that came to initial and ongoing appointmentsappointments

Setting: Outpatient clinicSetting: Outpatient clinic Sample: Sample: nn=107=107 Design: Random assignment to Design: Random assignment to

conditioncondition

First Interview ResultsFirst Interview Results

100

88 8576

100

64

52

40

0

20

40

60

80

100

120

Accepted 1st Appt. 2nd Appt. 3rd Appt.

% for first interview(n=33)% for comparison(n=74)

MFG (Multiple family groups for MFG (Multiple family groups for youth with disruptive behavioral youth with disruptive behavioral

difficulties)difficulties)

New York Board Members (Ervin Torres and Francis Lewis) and Co-New York Board Members (Ervin Torres and Francis Lewis) and Co-Coordinator (Rita Lawrence)Coordinator (Rita Lawrence)

Multiple family groupsMultiple family groups

• Target family factors that have been Target family factors that have been empirically linked to youth conduct empirically linked to youth conduct difficultiesdifficulties

• Focus on practical parenting strategies that Focus on practical parenting strategies that can be immediately incorporated in order to can be immediately incorporated in order to reduce stress and increase optimismreduce stress and increase optimism

• Build upon family strengths and reduce Build upon family strengths and reduce stigmastigma

• Address barriers to service use via active Address barriers to service use via active problem solvingproblem solving

In the words of families…In the words of families…

Multiple family groups should focus on:Multiple family groups should focus on:• RRulesules• RRoles and Responsibilitiesoles and Responsibilities• RRespectful communicationespectful communication• RRelationshipselationships• SStresstress• SSocial supportocial support

Multiple family group intervention Multiple family group intervention outlineoutline

Session 1Session 1 What are multiple family What are multiple family groups?groups?

Session 2Session 2 Building on family strengthsBuilding on family strengths

Session 3Session 3 Rules for home and schoolRules for home and school

Session 4Session 4 Responsibility at home and at Responsibility at home and at schoolschool

Session 5Session 5 RelationshipsRelationships

Session 6Session 6 Respectful communicationRespectful communication

Session 7Session 7 Dealing with stress at homeDealing with stress at home

Session 8Session 8 Who can we turn to (building Who can we turn to (building supports)?supports)?

Multiple family group intervention Multiple family group intervention outlineoutline

Session 9Session 9 Fixing broken rulesFixing broken rulesSession 10Session 10 Everyone does their share in Everyone does their share in

solving problemssolving problemsSession 11Session 11 Building kids upBuilding kids upSession 12Session 12 Everybody gets a chance to be Everybody gets a chance to be

heardheardSession 13Session 13 Dealing with stress/Finding Dealing with stress/Finding

resourcesresourcesSession 14Session 14 Stress & resources - Part IIStress & resources - Part IISession 15Session 15 How did group go?How did group go?Session 16Session 16 Ending partyEnding party

MFG Research StudyMFG Research Study

Multiple family group (MFG) is clinical service Multiple family group (MFG) is clinical service meant to enhance child mental health service use meant to enhance child mental health service use and mental health outcomes for urban, low-and mental health outcomes for urban, low-income children of color.income children of color.

Randomized effectiveness trial of MFG vs. services Randomized effectiveness trial of MFG vs. services as usual in 13 outpatient clinics across NYCas usual in 13 outpatient clinics across NYC

ODD or CDODD or CD Low-income African American and Latino familiesLow-income African American and Latino families Up to 8 families meet in MFG for at least 4 monthsUp to 8 families meet in MFG for at least 4 months

MFG content and process was designed in MFG content and process was designed in collaboration with parents & clinicianscollaboration with parents & clinicians

MFG Clinical ModelMFG Clinical Model

Clinician and parent advocate co-facilitateClinician and parent advocate co-facilitate Clinicians provide professional expertiseClinicians provide professional expertise Parent advocates provide support and practical Parent advocates provide support and practical

informationinformation Sessions guided by a manual characterized by Sessions guided by a manual characterized by

flexibility, choice of activities, discussion questionsflexibility, choice of activities, discussion questions Parent consumers made substantive contributions to Parent consumers made substantive contributions to

the development of the intervention guide based on the development of the intervention guide based on their experience and existing literature (e.g., their experience and existing literature (e.g., brought stress to the forefront)brought stress to the forefront)

To date….To date…. completed our fourth year of fundingcompleted our fourth year of funding

– Preliminary data from first 376 youth Preliminary data from first 376 youth and their families involved in the and their families involved in the project is availableproject is available

MFG Attendance MFG Attendance (in comparison to rates on retention (in comparison to rates on retention in outpatient urban individualized in outpatient urban individualized

mental health services)mental health services)

The continuous quality improvement The continuous quality improvement cyclecycle

Plan

Check

Inpu

t

CQI cycleCQI cycle

Plan – define organizational plan for Plan – define organizational plan for quality tied to customer needs.quality tied to customer needs.

Do – improve organizational Do – improve organizational performance on key indicators.performance on key indicators.

Check – assess how well the services Check – assess how well the services delivered in “DO” phase accomplished delivered in “DO” phase accomplished the objectives in “PLAN” phase.the objectives in “PLAN” phase.

Act – evaluate and refine quality plan.Act – evaluate and refine quality plan.

Summary & Wrap-upSummary & Wrap-up

Final questions and answersFinal questions and answers