Scaling up evidence-based practices for children and families in New York State: toward evidence-based policies on implementation for state mental health systems.

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the children's mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

Enhancing the resilience of nurses and midwives: pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress.

Health workers in general, and midwives and nurses in particular, experience high levels of stress/distress due to the nature of their work and workplaces; and, their socialization into ways of working that minimizes the likelihood of self-care. Increasing interest in the development of resilient workers has meant an enormous growth in interest in the role of holistic practices such as mindfulness meditation. Kabat-Zinn's mindfulness-based stress reduction (MBSR) is one of the most commonly used by those seeking to practise, theorize or research mindfulness across multiple contexts. The primary aim of this study was to pilot the effectiveness of an adapted mindfulness-based stress reduction intervention on the psychological wellbeing of nurses and midwives. More specifically, we sought to test the acceptability and feasibility of a modified MBSR intervention to inform a future randomized controlled trial (RCT). The pilot study used a pre and post intervention design. Twenty midwives and 20 nurses participated in a one-day workshop, undertook to meditate daily for 8 weeks and completed pre and post intervention measures: general health questionnaire (GHQ-12); sense of coherence (SOC) - orientation to life and the depression, anxiety and stress scale (DASS). A subgroup took part in interviews or focus group discussions of their experiences of the program and their ongoing mindfulness practice. The quantitative findings included significant improvements on the GHQ-12, SOC and the stress subscale of the DASS. Qualitative findings support the acceptability of the intervention, and highlighted a number of issues related to feasibility of any future RCT. In conclusion, mindfulness practice holds promise for increasing individual and workplace resilience, however, meaningful research evidence from carefully constructed studies will be required to engage and motivate participation and organizational support.

Developing the Support, Teambuilding, and Referral (STAR) Intervention: A Research/Community Partnership.

This paper describes the process by which child mental health researchers partnered with paraprofessionals called peer family advisors to create a stress-reducing intervention for caregivers of children and adolescents with mental health challenges. The issues that arose as the team strove to develop an intervention that was both relevant to the issues that these caregivers grapple with, as well as palatable and feasible for peers to deliver, are discussed.

Impact of Empowerment Training on the Professional Work of Family Peer Advocates.

A pilot study using a prospective design examined the impact of a collaboratively developed training model, called the Parent Empowerment Program (PEP), for professionally-employed family peer advocates who work with caregivers of children with mental health needs. This training used a combination of didactic, practice exercises, and group discussion. It targeted specific mental health knowledge content and collaborative skills to facilitate the work of family peer advocates in empowering caregivers. Co-delivered by a family peer advocate and clinician, the training consisted of a 40-hour face-to-face training, followed by six monthly face-to-face booster sessions. A total of 15 advocates participated in assessments conducted at baseline and post-training. This group of experienced family peer advocates showed no significant increase in knowledge about mental health content, but post-training assessments indicated increased collaborative skills and mental health services self-efficacy. This initial evaluation has implications for expanding training and support for the emergent workforce of professionally-employed family peer advocates in children's mental health.

A Response to Proposed Budget Cuts Affecting Children's Mental Health: Protecting Policies and Programs That Promote Collective Efficacy.

Children stand to lose if the federal government follows through on threats to cut funding for critical safety-net programs that have long supported families and communities. Although cuts directly targeting children's mental health are a great concern, cuts to policies that support health, housing, education, and family income are equally disturbing. These less publicized proposed cuts affect children indirectly, but they have direct effects on their families and communities. The importance of these services is supported by an extensive body of social learning research that promotes collective efficacy-neighbors positively influencing each other-shown to have positive long-term effects on children's development and adult outcomes. In this article, the authors describe two federal programs that by virtue of their impact on families and communities are likely to promote collective efficacy and positively affect children's mental health; both programs are facing severe cutbacks. They suggest that states adopt a cross-system approach to promote policies and programs in general medical health, mental health, housing, education, welfare and social services, and juvenile justice systems as a viable strategy to strengthen families and communities and promote collective efficacy. The overall goal is to advance a comprehensive national mental health policy for children that enhances collaboration across systems and strengthens families and communities, which is especially critical for children living in marginalized communities.

Parent Depression and Anger in Peer-Delivered Parent Support Services.

Knowledge about parents who seek peer-delivered parent support services in children's mental health is limited. In this prospective study, characteristics of 124 parents who sought peer parent advocate services related to their children's behavioral difficulties are described. This urban sample consisted primarily of low-income mothers of color, 80% of whom were caring for children with clinically significant behavioral problems. Of these parents, 64% endorsed clinically significant levels of depressive symptoms at baseline. Linear mixed effects models were used to examine associations between parent depression and anger expression with working alliances with peer advocates. No independent or combined effects of parent depression or anger expression on working alliance were found. However, adjusting for family demographic factors, caregiver strain and child symptoms, parent depression interacted with anger expression to influence working alliances, primarily around agreement and mutual engagement on goals. Among parents who endorsed clinically significant depressive symptoms, anger expression did not influence working alliance but among non-depressed parents, anger expression was negatively associated with working alliance. Implications for training peer parent advocates to more effectively engage low income parents are discussed.

Innovations in the Identification and Referral of Mothers at Risk for Depression: Development of a Peer-to-Peer Model.

This paper describes a feasibility study of a peer-delivered prevention intervention to identify mothers at high risk for depression and facilitate engagement in mental health services for their emotional health. Sixteen family peer advocates and their supervisors partnered with academic researchers over a period of six months to develop a four-session intervention that focused on identifying symptoms of depression, providing education about depression and treatment, actively linking caregivers to treatment for their own emotional health, and assisting caregivers in becoming active participants in their mental health care. Collaborating with peers to develop the model enhanced its perceived relevance and utility, and resulted in an intervention that was complimentary to their roles and the mission of peer-delivered support services. Peer/professional partnerships may be beneficial for enhancing the feasibility and acceptability of research efforts; the impact of peers' participation in the current project and the need for future research to develop and study peer-delivered models is discussed.

Family Peer Advocates: A Pilot Study of the Content and Process of Service Provision.

Professional family peer advocates are increasingly employed by public mental health systems to deliver family-to-family support that reduces barriers families face in accessing children's mental health care. These services, however, are neither uniformly available nor standardized. This pilot study describes the process, content and context of family-to-family support services. Simulating a parent seeking services, a trained standardized parent participated as a client in meetings with advocates in four programs and collected data through structured observations, a structured survey, and session audiotapes. The "walk-through" process was determined to be feasible and acceptable to family peer advocates as a way of evaluating services. Four family peer advocates provided an average of 25 services during each 2-session simulation with the standardized parent, including the following: information and educational support, instruction and skills development, emotional and affirmational support, instrumental support, and advocacy. Findings also revealed variability in the range of services provided and identified challenges in aspects of service provision, such as boundaries of advocate roles, availability of confidential service environments, and addressing crises and parent concerns about child safety. This paper provides the first in-depth look at services provided by this emerging workforce.

The Development and Evaluation of a Parent Empowerment Program for Family Peer Advocates.

Family-to-family services are emerging as an important adjunctive service to traditional mental health care and a vehicle for improving parent engagement and service use in children's mental health services. In New York State, a growing workforce of Family Peer Advocates (FPA) is delivering family-to-family services. We describe the development and evaluation of a professional program to enhance Family Peer Advocate professional skills, called the Parent Engagement and Empowerment Program (PEP). We detail the history and content of PEP and provide data from a pre/post and 6-month follow up evaluation of 58 FPA who participated in the first Statewide regional training effort. Self-efficacy, empowerment, and skills development were assessed at 3 time points: baseline, post-training, and 6-month follow-up. The largest changes were in self-efficacy and empowerment. Regional differences suggest differences in Family Peer Advocate workforce across areas of the state. This evaluation also provides the first systematic documentation of Family Peer Advocate activities over a six-month period. Consistent with peer specialists within the adult health care field, FPA in the children's mental health field primarily focused on providing emotional support and service access issues. Implications for expanding family-to-family services and integrating it more broadly into provider organizations are described.

The Application of Behavior Change Theory to Family-Based Services: Improving Parent Empowerment in Children's Mental Health.

We describe the development of a parent empowerment program (PEP) using a community-based participatory research approach. In collaboration with a group of dedicated family advocates working with the Mental Health Association of New York City and state policy makers, academic researchers took an iterative approach to crafting and refining PEP to better prepare family advocates to help bridge the gaps in service access among children with emotional and behavioral problems. Despite the growth of family-led, family support programs nationally, research that demonstrates the positive benefits of such programs is scarce in the children's mental health literature. The PEP model is based on research data about barriers families face in mental health service utilization (e.g., stigma, perceptions of providers, attitudes towards mental illness, service availability, etc.). PEP is premised on (a) the concept of empowerment as a process, (b) the need to engage parents in becoming active agents of change, and (c) the application of an integrated framework to empower parents, called the Parents as Agents of Change model. Our paper focuses on describing the application of a Unified Theory of Behavior Change as a theoretical framework to help activate parents as change agents in meeting their children's mental health needs. Based on an integrated model of grassroots driven Principles of Parent Support and research-based Unified Theory of Behavior Change, PEP's Parents as Agents of Change model provides a conceptual framework for testing the effectiveness of family support services in children's mental health, a much-needed area for future research.