Engaging and Retaining Multi-Stressed Children and Families

1. Engagement and Retention:Serving the Diverse Needs of Multi-Stressed Children and their Families in LA CountyElizabeth Park, Psy.D., Natalie Carlos, Psy.D., Vasni Briones, LCSW, and Karen Rogers, Ph.D.15th Annual Conference on Parent-Child Interaction Therapy for Traumatized ChildrenSeptember 9, 2015

2. Background and Significance • 1 out of 5 children has a diagnosable mental, emotional, or behavioral disorder and approximately 70% of these children do not receive mental health services (National Research Counsel and Institute of Medicine, 2009). • As many as 40-60% of families stop treatment prematurely (Gopalan et al., 2010). • Gap for minorities and families with low SES is larger in terms of receiving mental health services (Smith et al., 2013). • Greater risk factors exist for mental health problems among urban minority youth, such as the negative effects of poverty, violence, and racial discrimination. Urban minority families are less likely to utilize mental health services, even when controlling for financial and structural barriers and parental level of education (Hobberman, 1992; Yeh et al., 2004, Larson et al., 2013).

3. Attrition • Characteristics that help predict attrition include socioeconomic status, parental stress, ethnicity, child symptom severity, and single parent status (Garcia and Weisz, 2002). • Parent engagement problems that impact treatment attendance, treatment adherence/compliance, and active participation in treatment are frequently cited as reasons for ineffectiveness of care (Brannan, 2003; Staudt, 2007; Baker-Ericzen et al., 2013). • Family and parent characteristics often contribute more to dropping out than do child characteristics.

4. Barriers • Research suggests increasing children’s access to mental health services should consider strategies that address (Bussing et al., 1998, 2007; Larson et al., 2013; Lavigne et al, 1998; Owens et al., 2002; Yet et al., 2005; Larson et al., 2013): • Structural barriers • Perceptions regarding mental health problems • Perceptions regarding mental health services • Caregivers feel overwhelmed by their child’s symptoms, do not feel supported by formal service systems, and report a lack of service system coordination and ineffective treatment strategies. Caregivers feel blamed, judged, and not listened to by therapists (Baker-Ericzen et al., 2013). • Therapists feel overwhelmed by families’ complex needs, children and parents’ mental health issues, parents’ lack of involvement and perceived unwillingness to participate (Baker-Ericzen et al., 2013).

5. Engagement • Approaches that have demonstrated improvement in engaging families in treatment (Ingoldsby, 2010): • Brief early treatment engagement discussions • Family systems approaches • Enhancing family support and coping • Motivational interviewing

6. Engagement and Retention Strategies • Providers who effectively engage families (Miller & Rollnick, 2002) • Identify potential benefit of services • Discuss family expectations for treatment process and outcomes • Develop a plan with family to address practical issues (e.g., scheduling, transportation) • Address psychological engagement challenges (e.g., other stressors, family member’ resistance to treatment) • Successful engagement methods (Miller & Rollnick, 2002) • Individualized • Personalized, collaborate approach • Convey understanding and respect (Miller & Rollnick, 2002) • Intensive and address engagement in multiple ways throughout • Integrated into the underlying treatment

7. PCIT-ER Chart: Engagement and Retention • Identifying intrapersonal, interpersonal, environmental, and systemic treatment factors that may influence attrition and treatment outcomes • Areas of concern or potential treatment barriers: Child and caregiver factors, attachment/relational, family function, socioeconomic status, culture and diversity, and life stressors/events • Strategies: Practical, psychological, and/or resource based

8. Case Application: Ana I • “Ana” is an 8 year-old girl who has a history of severe neglect, physical abuse, & sexual abuse • She presents with sexualized behaviors, noncompliance, tantrums, and withdrawing behaviors • PCIT is provided to Ana and her adoptive mother who feels overwhelmed and is doubtful about her parenting abilities

9. Case Application: Ana II

10. Case Application: Job I • “Job” is an 6 year-old boy who’s father was deported to Mexico six months ago • He presents with separation anxiety, nightmares, tantrums, depression, and trauma history • PCIT is provided to Job and his mother who feels “unable to parent” her child by herself

11. Case Application: Job II

12. Summary • Challenges for PCIT clinicians: identifying potential barriers and utilizing engagement and retention strategies seamlessly throughout treatment while maintaining fidelity to the PCIT model • Addressing treatment barriers needs to occur throughout treatment to effectively engage multi-stressed families • PCIT-ER chart: Assist clinicians in facilitating treatment for multi-stressed families to reduce treatment barriers and mental health problems while enhancing support, coping, and resilience