PERSPECTIVE: Economic and Policy Research Interests Highlighted in the 25th NIMH-Sponsored Mental Health Services Research Conference.

BACKGROUND: The National Institute of Mental Health (NIMH) remains committed to addressing real-world challenges with delivering high quality mental health care to people in need by advancing a services research agenda to improve access, continuity, quality, equity, and value of mental healthcare nationwide, and to improve outcomes for people with serious mental illnesses (SMI). The NIMH-Sponsored Mental Health Services Research Conference (MHSR) is a highly productive venue for discussing topics of interest to NIMH audiences and disseminating NIMH's latest research findings directly to mental health clinicians, policy makers, administrators, advocates, consumers, and scientists who attend. AIMS: This Perspective summarizes and provides highlights from the 25th MHSR. It also reviews three papers presented at the 25th MSHR and subsequently published in the June 2023 special issue of The Journal of Mental Health Policy and Economics (JMHPE). METHODS: The authors review three papers published in the June 2023 special issue of JMHPE, identifying common themes across the papers and illustrating how the papers' findings promote key areas of NIMH research interests. RESULTS: Three important areas are highlighted in this review: (i) service user engagement in the research enterprise, (ii) financing the implementation of the 988 Suicide and Crisis Lifeline, and (iii) methods to predict mental health workforce turnover. DISCUSSION: These three papers illustrate key areas in which policy research can help to promote quality mental health care. One notable common theme across the papers is that of the role that end users play in the research enterprise. The papers focus on (i) service users and the value they bring to informing the practice of research, (ii) policy makers and the information they need to make evidence-informed decisions, and (iii) provider organization leadership, by using an innovative machine learning process to help organizations predict and address staff turnover. IMPLICATIONS FOR HEALTH CARE: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. The three papers reviewed in this perspective are exemplars of how necessary stakeholder partnerships are to improve care for those with mental illness. IMPLICATIONS FOR HEALTH POLICIES: The highlighted papers (i) provide recommendations for structural changes to research institutions to increase service user engagement in all aspects of the research enterprise, (ii) identify policy solutions to improve fiscal readiness to address increased demand of 988, and (iii) pilot a novel data-driven approach to predict mental health workforce turnover, a significant problem in community mental health clinics, offering health system leaders and policy makers an opportunity to proactively intervene to help maintain continuity of staffing. IMPLICATIONS FOR FURTHER RESEARCH: Consistent with NIMH's Strategic Plan for Research and current funding announcements, there remains an urgent need to (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services, particularly in historically underserved communities, and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.ing and clinical outcomes remains uncertain.

Implementing a Child Mental Health Intervention in Child Welfare Services: Stakeholder Perspectives on Feasibility.

This pilot study integrated quantitative and qualitative data to examine the feasibility of implementing a modified version of a multiple family group behavioral parent training intervention (The 4Rs and 2Ss for Strengthening Families Program [4Rs and 2Ss]) in child welfare (CW) placement prevention services, from the perspectives of participating caregivers (n = 12) and CW staff (n = 12; i.e., 6 caseworkers, 4 supervisors, and 2 administrators). Quantitative surveys were administered to caregivers and CW staff followed by semi-structured interviews to examine the feasibility of implementing the modified 4Rs and 2Ss program, as well as factors impacting feasibility. Results indicated that quantitative benchmarks for high feasibility were met in all assessed areas (e.g., family recruitment, caseworker fidelity ratings, CW staff feasibility ratings) except for family attendance, which was markedly lower than desired. Factors facilitating feasibility included agency and research support, intervention ease-of-use, perceived benefits to existing CW practice, as well as logistical support (e.g., food, transportation, childcare) promoting attendance. Factors hindering feasibility included conflicts between research-based eligibility criteria and existing client population demographics, research-related processes resulting in delays, CW staff role conflicts, added workload burden, complex family issues, and power differentials inherent to CW services which complicated families' voluntary participation.

An Examination of the 4 Rs 2 Ss for Problem Behaviors: A Preventive Approach.

Early treatment of behavioral problems can prevent their progression into intractable disorders. This study examined the impact of a multiple family group (MFG) intervention for children with behavior symptoms and their families. Fifty-four (n = 54) caregiver/child dyads with sub-clinical levels of oppositional defiant disorder (ODD) participated in a 16-week MFG. Child, caregiver, and family outcomes were assessed at baseline, post-treatment, and at 6 months follow-up. Significant decreases in impairment with parents, family members, and peers, and improvements in child self-esteem were found from baseline to follow-up. Caregiver stress increased; no significant changes in depression or perceived social support were found over time. The effectiveness of MFG as a preventive approach and areas of future research are discussed.

Male Caregivers and Engagement in a Family Strengthening Program for Child Disruptive Behavior Disorders.

Awareness and interest in involving male caregivers in child mental health treatment has grown, especially for youth with disruptive behavior disorders like oppositional defiant disorder (ODD). The purpose of this study was to examine the relationship between male caregiver involvement and treatment engagement for child ODD. Children (n = 122) ages 7-11 and their caregivers participated in the 4 Rs 2 Ss Strengthening Families Program for child-onset ODD. Families were compared based on male caregiver presence. Families with a male caregiver were significantly more resourced with respect to income, educational status, and food security. Additionally, they were over three times less likely to drop out of the program than those without a male caregiver. The presence of a male caregiver was associated with increased resources and higher rates of engagement in services than single, female-headed families. Future research is needed to discern the underlying mechanisms of this association.

Examining Organizational Factors Supporting the Adoption and Use of Evidence-Based Interventions.

The purpose of this study was to develop a greater understanding of the factors influencing the adoption of evidence-based interventions in outpatient mental health clinics serving youth. An improved understanding of these factors can potentially improve efforts to ensure effective adoption, implementation, and sustainment of evidence-based interventions, and thus improve treatment for youth in mental health settings. This explanatory cross-sectional study involves secondary data analysis of a longitudinal randomized control intervention trial. The SEM- based model that was tested supported the primary hypothesis that a more supportive organizational climate with greater readiness for change is more likely to improve the chances for the adoption of evidence-based interventions in outpatient mental health clinics serving youths.

Pilot Study of an Online Parent-Training Course for Disruptive Behavior with Live Remote Coaching for Practitioners.

OBJECTIVE: Many clinicians find it challenging to obtain training in evidence-based interventions, including behavioral parent training, which is considered the front-line treatment for children with disruptive behaviors (Chacko et al., 2017). Workshops, ongoing consultation, and feedback provided in person are effective, yet are rarely feasible for clinicians in the field (Fixsen, Blase, Duda, Naoom, & Van Dyke, 2010). The purpose of the present study was to conduct a preliminary assessment of an online tutorial combined with live remote coaching for training mental health professionals in behavioral parent training. METHOD: Participants in this pretest-posttest open trial were 22 clinicians and graduate students (73% female) from around the United States. RESULTS: The web platform operated successfully, and clinicians found the training to be highly satisfactory. Compared to pre-training, participants demonstrated large improvements in knowledge about disruptive behavior and behavioral parent training and performed significantly better on demonstrations of skill in administering behavioral parent-training components. CONCLUSIONS: An online course combined with live remote coaching is a promising methodology for significantly increasing the number of clinicians trained in evidence-based interventions for disruptive behavior in children. Next steps for evaluation and expansion of this training model are discussed.

Outcomes Associated With Adapting a Research-Supported Treatment for Children With Behavior Disorders.

PURPOSE: The aims of this study are to describe an adaptation process of a research-supported treatment (RST) for children with oppositional defiant disorder and to examine provider attitudes toward RSTs prior to and following this process. METHOD: Providers from 14 agencies in New York State delivered the adapted RST, following training. Attitudes toward RSTs were measured by the Evidence-Based Practice Attitude Scale at baseline and posttest. RESULTS: Openness toward RSTs decreased from baseline to posttest. The majority of providers reported modifications to the structure and process of the intervention. DISCUSSION: To improve the uptake and usability of RSTs in practice, future research must further address adaptation processes and their relationships to attitudes toward RSTs.

Getting to the table: Agency characteristics and evidence-based intervention adoption in children's mental health care.

Scaling evidence-based interventions (EBI) for children and families across healthcare systems can expand public health impact. Research has identified EBI adoption determinants. However, less understood are characteristics of agencies that opt in across the stages of adoption. This study examined the relationship between agency (N=69) characteristics (e.g., revenue) and four adoption stages during a large-scale trial of an EBI for children with significant behavioral difficulties and their families. 48 (70%) of agencies demonstrated interest, 28 (41%) scheduled an informational meeting, 20 (29%) received training, and 16 (22%) demonstrated EBI uptake. Analyses indicated no differences in characteristics and initial interest. However, agencies with small-sized revenue had significantly reduced odds at other adoption stages. Implications for strategies to bring EBI access to scale are discussed.

An Assessment of The New York State Behavioral Health System's Readiness to Transition to Medicaid Managed Care.

New York State has one of the most richly funded Medicaid programs in the United States. In an effort to achieve the triple aim New York State is undergoing a significant redesign of its Medicaid program including transitioning nearly all Medicaid funded behavioral health services into Medicaid managed care. In preparation for this transition, a state funded technical assistance center assessed the behavioral health care system's readiness to undergo this reform across 11 domains. Between September and November, 2014, the TA center electronically distributed a readiness survey to 897 mental health and substance abuse agencies: 313 (n = 269, 33%) organizations completed the assessment. As a whole, the sample felt partially ready to transition; analysis by domain revealed agencies were most ready to interface with managed care providers, and least ready to collect and evaluate outcome data. Significant differences in readiness were found depending by organizational characteristics (number of programs, licensure, and region). In anticipation of large-scale reforms, states would benefit from an initial needs assessment to identify gaps in knowledge and skills, which in turn, can then guide preparatory efforts and provide needed supports to facilitate major changes in service delivery and billing.

Disseminating clinical and fiscal practices across the New York State behavioral healthcare system.

In order to facilitate the adoption of innovative practices in the mental health service system, providers require access to both new information and methodologies, and ongoing training, supervision and consultation. Technical Assistance centers have been proposed as a way to disseminate effective interventions through the provision of resources including information, ongoing training and consultation. The purpose of this study is to describe the New York State Technical Assistance Center's reach across the child public mental health service system and variations in characteristics of training activities, including dosage, content and method of format. Between 2011 and 2015, 460 (92.6%) of all New York State mental health clinics attended a training. The most highly attended events focused on business practices, followed by evidence-based treatments and clinic practices, and trauma-informed care. All were delivered via a webinar format, and were less than one day in duration. The behavioral health service system must be equipped to adapt to changing clinical and business practices in order to provide quality care and remain fiscally viable. New York State's TA center reached the majority of child mental health service providers across the state. Next steps are to closely examine the impact of TA supports upon adoption and sustained use of practices. Implications of these findings and additional future directions are presented.

Provider Attitudes, Organizational Readiness for Change, and Uptake of Research Supported Treatment.

PURPOSE: As implementation and evaluation of research supported treatment (RST) expands across diverse mental health settings, it is essential to understand the facilitators and inhibitors of uptake. The current study examined the relationships between organizational readiness for change, attitudes toward RST, and use of RST among a sample primarily of social workers. METHODS: Participants included 158 providers from public child mental health outpatient clinics in the New York metropolitan area. Data were analyzed using structural equation modeling. RESULTS: Use of RST was greater among providers who were younger and had fewer years of professional experience. Both organizational need for change and climate directly and indirectly related to use of RST through attitudes toward RST (partial mediator). DISCUSSION: The organizational context is an important factor that relates to attitudes toward and use of RST in practice. Future research is needed to continue examining factors of RST uptake and sustainability.

Prepared to Care: An Exploration of Continuing Education Trends of Nurses Caring for Injured Children.

The significance of nursing competence in the care of pediatric trauma patients has been well documented. Continuing education for trauma nurses is a critical component of maintaining competence in pediatric trauma care; yet, there is significant variability in the programs and resources used to support this goal. The purpose of this current study was to describe the educational activities that practicing registered nurses engage in to inform their care of injured children. A quantitative, descriptive nonexperimental research design was utilized to describe the educational programs that members of the Society of Trauma Nurses (STN) must complete to work in verified and designated trauma centers. Participants completed a survey instrument that included demographic questions, pediatric trauma educational programs required/offered by their employer, and feedback about pediatric trauma nursing education. A total of 266 STN members completed the electronic survey, reflecting a 9% response rate. Most of the participants reported that the verifying body required trauma nursing education hours (n = 187, 70.3%). The number of required courses ranged from 1 to 6, with 33 (12.4%) reporting this 3-course combination-emergency nursing pediatric course (ENPC), pediatric advanced life support (PALS), and trauma nursing core course (TNCC). The second most common combination of courses (n = 30; 11.3%) was required to take both PALS and TNCC. No significant relationship was found between verifying agency type and continuing education program required (p> .05). Trauma nursing core course was the most popular course (n = 208; 79%), followed by PALS (n = 194; 73%) and ENPC (n = 103; 38%). Participants also shared barriers to continuing education activities. It has been 10 years since pediatric trauma nursing course utilization was first explored in the literature. There continue to be significant opportunities to support nurses in continuing education activities related to the care of injured children. While barriers to accessing these types of activities sometimes exist, it is the responsibility of the pediatric trauma community to explore these challenges even further and collaborate with others interested in improving the care of injured children.

The Cost of Caring: An Exploration of Compassion Fatigue, Compassion Satisfaction, and Job Satisfaction in Pediatric Nurses.

PURPOSE: The purpose of this study was to describe levels of compassion satisfaction, compassion fatigue, and job satisfaction among pediatric nurses in the United States and determine if there was a relationship among these constructs. DESIGN AND METHODS: All members Society of Pediatric Nurses were sent an electronic invitation to participate, and those who consented received three measures; a demographic questionnaire, the Job Satisfaction Survey (JSS) and the Professional Quality of Life (ProQOL) measure. RESULTS: Three hundred eighteen (10.6%) of members of the Society of Pediatric Nurses participated in the study: Over three quarters (245, 76%) of the sample had another career before nursing. The sample's mean job satisfaction level was 149.8 (SD=29.74), which was significantly higher than published reported means for nurses. Bivariate analyses revealed a significant relationship between gender and the compassion satisfaction, in that women were more likely to evidence compassion satisfaction than men (t=1.967, p=.05, df=298). No other significant relationships were found. CONCLUSIONS: The majority of nurses had high levels of compassion satisfaction and job satisfaction; further, female gender was associated with higher levels of compassion satisfaction. PRACTICE IMPLICATIONS: This current study had a very high response from second-career nurses (n=245, 76.8%) and overall, the sample had higher levels of compassion satisfaction. It is possible that second career nurses are better equipped in some way that helps them mediate negative responses of caring as a pediatric nurse and future research should explore this. Due to the significant financial costs to institutions of having nurses who have low levels of job satisfaction and high levels on compassion fatigue, it is imperative for hospital administrators to develop infrastructures to support employees.

An Examination of Peer-Delivered Parenting Skills Programs Across New York State.

Peers are an important adjunct to the public mental health service system, and are being increasingly utilized across the country as a cost-effective solution to workforce shortages. Despite the tremendous growth of peer-delivered support over the past two decades, it has only been within the past few years that peer programs have been the subject of empirical inquiry. The purpose of this study was to examine the prevalence and characteristics of peer-delivered parenting programs across the New York State public mental health service system. We surveyed 46 family peer organizations across New York State regarding their delivery of structured peer-delivered parenting programs. Thirty-four (76%) completed the questionnaire, and of them, 18 (53%) delivered a parenting program. Subsequent interviews with seven of the 18 organizations revealed peer organizations had been delivering eight unique parenting programs for upwards of two decades. Additionally, organizations offered multiple supports to families to participate. Training, supervision, and issues around fidelity are discussed, as well as the implications of this study for states utilizing a peer workforce.

Multiple family group service delivery model for children with disruptive behavior disorders: Impact on caregiver stress and depressive symptoms.

Disproportionately high rates of caregiver stress and depression are found among poverty-impacted communities, with high levels of caregiver stress and depression putting youth at heightened risk for the onset and perpetuation of disruptive behavior disorders. The purpose of this study was to examine the effects of a behavioral parent training program called the 4Rs and 2Ss for Strengthening Families Program (4R2S) on caregiver stress and depressive symptoms among 320 youth aged seven to 11 and their families assigned to either the 4R2S or services as usual (SAU) condition. Among caregivers with clinically significant scores at baseline, 4R2S participants manifested significantly reduced scores on the stress and depressive symptom scores to SAU participants at 6-month follow-up. Findings suggest that 4R2S may reduce caregiver stress and depressive symptoms among those caregivers initially manifesting clinically significant levels of stress or depressive symptoms.

Who is accessing family mental health programs? Demographic differences before and after system reform.

Childhood mental health disorders are on the rise in the United States. To ensure equitable access to care, it is important to examine the characteristics of children and families who access services. This study compares the demographic characteristics of two samples of families who participated in National Institute of Mental Health-funded studies of a Multiple Family Group model, entitled the 4Rs and 2Ss Multiple Family Group (4Rs and 2Ss) in New York City. One sample is currently receiving services, and the other received services a decade ago. Significant differences in demographic characteristics were found between the two samples pertaining to child race, child nativity, caregiver age, primary caregiver, caregiver marital status, caregiver race, caregiver education, caregiver employment, and family income. Families currently engaging in the public mental health service system are primarily White, and are less disadvantaged than families a decade ago. These differences are examined in light of changing policy and epidemiological trends, and potential unintended consequences are discussed.

An Examination of the Relationship between Maternal Depression and Barriers to Child Mental Health Services.

OBJECTIVE: Maternal depression is a common, chronic set of disorders associated with significant burden to caregivers, children and families. Some evidence suggests that depression is associated with perceptions of barriers to child mental health treatment and premature termination from services. However, this relationship has not yet been examined among a predominantly low-income sample, which is at disproportionately high risk of depression, child mental health problems, and treatment drop out. Accordingly, the purpose of this study is to examine the relationships between caregiver depression and perceived barriers to treatment. METHODS: Three hundred twenty (n=320) children between the ages of 7 to 11 and their caregivers were assigned to either the 4 Rs and 2Ss for Strengthening Families, which is a multiple family group intervention, or services as usual (SAU) consisting of typical outpatient mental health services. Caregiver depression was measured by the Center for Epidemiologic Depression Scale; perceived barriers to treatment were assessed via the Kazdin Barriers to Treatment Scale. RESULTS: Clinically significant levels of depressive symptoms at baseline were significantly associated with greater scores in all four barriers to treatment subscales (stressors and obstacles competing with treatment, treatment demands and issues, perceived relevance, relationship with therapist) at post-test. CONCLUSIONS: Addressing maternal mental health, and attending to stressors that impede poverty-impacted families from child services is critical for the health and functioning of caregivers, and to ensure that children with mental health problems receive treatment.

Utilization of peers in services for youth with emotional and behavioral challenges: A scoping review.

This scoping review synthesizes published and unpublished information on Youth Peer Support Services (YPSS), where young adults with current or prior mental health challenges provide support services to other youth and young adults currently struggling with similar difficulties. Existing published and unpublished "grey" literature were reviewed, yielding 30 programs included for data extraction and qualitative syntheses using a descriptive analytic framework. Findings identify variations in service delivery structures, program goals, host service systems, peer roles, core competencies, training and supervision needs, outcomes for youth and young adult consumers, as well as organizational readiness needs to integrate YPSS. Recommendations for future research, practice, and policy include more studies evaluating the unique impact of YPSS using rigorous methodological study designs, identifying developmentally appropriate training/supervision strategies and overall service costs and financing options, as well as distinguishing YPSS from other peer models with regard to certification and billing.

Peer Models in Mental Health for Caregivers and Families.

Peer-delivered mental health models may hold important benefits for family members, yet their prevalence, components, and outcomes are unknown. We conducted a review of peer-delivered services for families of children and adults with mental health problems. Randomized studies of interventions published between 1990 and 2014 were included if the intervention contained a component for family members and examined familial outcomes. Of 77 studies that were assessed for their eligibility, six met criteria. Familial components included coping and parenting skills, knowledge about mental health, and emotional support. Outcomes were uneven, although significant improvements in family functioning, knowledge about mental illness, parental concerns about their child, and parenting skills were associated with the intervention. Peer-delivered services for family members may have important benefits to family members and individuals with mental health problems; however, the research base remains thin. A research agenda to develop and examine these models is discussed.

Technology Use and Technological Self-Efficacy Among Undergraduate Nursing Faculty.

AIM: This study explored faculty responses to a survey about using technology to teach undergraduate nursing students. BACKGROUND: Little is known regarding faculty confidence, technology use, or supports for integrating technology into nursing education. METHOD: A descriptive correlational design was utilized to explore the relationship between technology use and technological self-efficacy in faculty (N = 272) who teach at Commission on Collegiate Nursing Education-accredited nursing programs. Instruments used were a sociodemographic questionnaire, the Roney Technology Use Scale, and the Technology Self-Efficacy Scale. RESULTS: Participants who taught didactic content had moderate technology use as compared to those teaching didactic and clinical/laboratory who reported high levels of technology use. A weak relationship between age and technological self-efficacy (ρ = .127, p < .05) was also found. CONLUSION: This research was an initial step in understanding levels of technology use and responses to this challenge by undergraduate nursing faculty.