Implementing an early childhood development intervention with routine immunization visits in India: a feasibility trial.

Integrating an early childhood development (ECD) intervention within routine healthcare visits offers an important opportunity for a population-level approach to support ECD in low- and middle-income countries (LMICs) where 250 million children under the age of 5 years fail to reach their full developmental potential. This paper reports on the feasibility of integrating an adapted healthcare-based ECD intervention (Sit Down and Play) in primary health centers (PHCs) serving low-income rural communities in Karnataka, India, and its potential to support research-informed components needed to improve ECD (e.g., opportunities for learning). Using a prospective cluster nonrandomized pilot and feasibility trial, caregivers with infants 6-10 weeks of age were recruited from 2 PHCs: one which delivered the intervention at two subsequent immunization visits (n = 25) and the other as care as usual (n = 28). Feasibility was assessed using the following indicators: implementation, practicality, acceptability, demand, and limited efficacy. Quality of home stimulation and opportunities for learning were explored with key items from the UNICEF Multiple Cluster Index Surveys with generalized estimating equation models. While outcome measures were to be obtained from all participants 3-month post-enrollment, due to COVID19 restrictions, there was variability in timing of follow-up interviews; however, outcome data from all participants were obtained and no significant group differences existed in contact time. Results suggest the feasibility of delivery of SDP during routine immunization visits, high satisfaction with adapted content, and utility of developed training and fidelity measures. Though not powered for hypothesis testing, our exploratory analyses reveal the intervention group demonstrated greater improvements on quality of home stimulation over time than the control group. CONCLUSION: Our findings suggest integrating an ECD intervention with routine healthcare visits is a feasible and promising strategy for supporting ECD in India. Further studies are needed to determine the effectiveness of SDP on children's development. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04167254. WHAT IS KNOWN: • Interventions are increasingly being developed to target responsive caregiving and opportunities for learning because of their potential to support early childhood development (ECD) in low- and middle-income countries where 250 million children under the age of 5 years fail to reach their full developmental potential. • A critical issue in ECD intervention research is the gap between what is known to be effective treatment to protect healthy brain development and what is provided to millions of caregivers during routine care who live in low-income communities. WHAT IS NEW: • We adapted a brief, ECD intervention for use with routine healthcare visits in India as a population-level strategy to support ECD in LMICs. • Our results demonstrate feasibility, acceptability, and improvements in key parenting behaviors that promote ECD.

Healthcare-Based Interventions to Improve Parenting Outcomes in LMICs: A Systematic Review and Meta-Analysis.

OBJECTIVES: Although a number of early childhood development (ECD) interventions in healthcare settings in low- and middle-income countries (LMICs) have been developed to improve parent-directed outcomes and support ECD, their impact have yet to be established. This review assesses the effectiveness of healthcare-based ECD interventions in LMICs on the following key evidence-informed parenting outcomes affecting ECD: (1) responsive caregiving (2) cognitive stimulation and (3) parental mental health. Impacts on parental knowledge regarding ECD and parenting stress were also assessed. METHODS: PubMed, PsycINFO, Scopus, CINAHL and Embase were searched. We included randomized controlled trials reporting effects of healthcare-based ECD interventions in LMICs on parent-directed outcomes in the first five years of life. Data extraction included study characteristics, design, sample size, participant characteristics, settings, intervention descriptions, and outcomes. Meta-analyses were conducted using random effects models. RESULTS: 8 articles were included. Summary standardized mean differences demonstrated significant benefits of healthcare-based interventions in LMICs for improving: (1) cognitive stimulation (n = 4; SMD = 0.32; 95% CI: 0.08 to 0.56) and (2) ECD knowledge (n = 4; SMD = 0.44; 95% CI: 0.27 to 0.60). No significant effects were seen on maternal depression and parenting stress; only one study assessed parent-child interactions in the context of responsiveness. Limitations included small number of studies for moderation analysis, high heterogeneity, variability in measures used for outcomes and timing of assessments. CONCLUSIONS FOR PRACTICE: Our results demonstrate statistically significant effects of healthcare-based interventions in LMICs on improving key evidence-based parenting outcomes and offers one promising strategy to support children reach their full developmental potential.

Trajectories of Parent Participation in Early Intervention/Prevention Services: The Case for Flexible Paraprofessional-led Services.

Objective: This study examined parents' participation in a school-and home-based prevention and early intervention service model designed to promote positive parenting and parent involvement in schooling. Method: Paraprofessionals (n = 32) employed by four social service agencies provided parenting support and education through parent groups, home/community visits, case management, and individual contacts to African American and Latino/a families in urban high-poverty communities (n = 375). In this open trial, we identified longitudinal trajectories of parents' participation across all service formats over the course of a full school year using latent class growth models, then examined group differences in baseline child and family characteristics, participation in specific service formats, and parenting skills practice across the year. Results: Four distinct trajectories were identified: parents with consistently low participation; parents whose participation declined and subsequently rebounded; parents with increasing participation; and parents with consistently high participation. Significant differences between trajectory groups were identified on baseline child and family characteristics, and the number and types of service formats in which parents participated participation. Parents across trajectories consistently practiced parenting skills over the school year, with parents who demonstrated increasing participation over time showing the most growth in the number of skills practiced each month. Conclusions: Unique patterns of parent participation across a school year in paraprofessional-delivered services indicates the promise of capitalizing on multiple opportunities to engage parents and suggests the potential for paraprofessional staff to overcome longstanding disparities in parent involvement in children's mental health services.

After-School Programs and Children's Mental Health: Organizational Social Context, Program Quality, and Children's Social Behavior.

OBJECTIVE: The current study examined associations among organizational social context, after-school program (ASP) quality, and children's social behavior in a large urban park district. METHOD: Thirty-two park-based ASPs are included in the final sample, including 141 staff and 593 children. Staff reported on organizational culture (rigidity, proficiency, resistance) and climate (engagement, functionality, stress), and children's social skills and problem behaviors. Children and their parents reported on program quality indicators (e.g., activities, routines, relationships). Parents also completed a children's mental health screener. RESULTS: A series of Hierarchical Linear Models revealed that proficiency and stress were the only organizational predictors of program quality; associations between stress and program quality were moderated by program enrollment and aggregated children's mental health need. Higher child- and parent-perceived program quality related to fewer staff-reported problem behaviors, while overall higher enrollment and higher aggregated mental health need were associated with fewer staff-reported social skills. CONCLUSIONS: Data are informing ongoing efforts to improve organizational capacity of urban after-school programs to support children's positive social and behavior trajectories.

Engaging Parents in Mental Health Services: A Qualitative Study of Community Health Workers' Strategies in High Poverty Urban Communities.

Empirical engagement-promoting strategies in child and family mental health services have been identified largely within the context of clinic-based services delivered by mental health professionals. However, the magnitude of unmet youth mental health need necessitates expanding the scope of mental health services, and the associated engagement strategies, beyond traditional models and service providers. The present study aimed to extend our understanding of engagement strategies to a school-based mental health service model, using a community health worker (CHW) workforce implementing an early intervention program with parents and school-aged children (K-4) in high poverty urban communities. Qualitative semi-structured individual interviews were conducted with 16 CHWs to capture their descriptions of the engagement strategies they utilized with parents throughout program implementation. Transcripts were coded and themes were identified following procedures for thematic analysis. Thematic analyses revealed ten themes describing a range of engagement strategies falling into two overarching categories: (1) rapport building, and (2) responsive delivery. Themes within the rapport building category included non-judgmental supportive listening, increasing social proximity, praise, privacy and confidentiality, and leveraging relationships. Themes within the responsive delivery category included flexibility, consistency, advocacy, incentives, and meeting needs. Findings provide preliminary evidence regarding the ability of CHWs to identify and implement a range of engagement strategies with parents and families that parallel empirically-based engagement strategies in traditional services. These findings speak to the potential of this workforce to engage underserved families in mental health services, underscoring the important role for CHWs in reducing mental health disparities.

Festschrift for Leonard Bickman: Introduction to The Future of Children's Mental Health Services Special Issue.

This introductory article describes the genesis of the Festschrift for Leonard Bickman and of this Festschrift special issue entitled, The Future of Children's Mental Health Services. The special issue includes a collection of 11 original children's mental health services research articles, broadly organized in accordance with three themes (i.e., Improving Precision and Use of Service Data to Guide Policy and Practice, Implementation and Dissemination, and Preparing for Innovation), followed by an interview-style article with Bickman. Then follows a featured manuscript by Bickman himself, three invited commentaries, and a compilation of letters and notes in which colleagues reflect on his career and on their experiences of him. The introduction concludes with a few thoughts about the future of children's mental health services portended by the extraordinary scholarly contributions of Bickman and those who have been inspired by him.

Encouraging Parenting Behaviors That Promote Early Childhood Development Among Caregivers From Low-Income Urban Communities: A Randomized Static Group Comparison Trial of a Primary Care-Based Parenting Program.

Objectives Encouraging key parenting behaviors in early infancy may help decrease income-related developmental disparities. In this study we assessed whether a brief, primary care-based program (Sit Down and Play; SDP) could be successful in impacting key parenting behaviors that promote early childhood development. Methods An ethnically diverse group of predominantly low-income caregivers of children 2-6 months of age were enrolled, interviewed, and randomized to intervention (n = 20) or control (n = 20) groups. Intervention families received SDP at recruitment and the subsequent well-child visit. Control families were provided handouts regarding developmental milestones. One month after the second well-child visit, all families were reinterviewed (n = 34; 85% retention rate). Using open-ended questions and standardized measures (i.e., StimQ), parents were asked about parenting behaviors central to children's development: (1) participation in cognitively stimulating activities, (2) provision of learning materials, and (3) the quality of parent-child verbal interactions. Potential impact on perceived parenting confidence was also explored utilizing The Parenting Sense of Competence Scale. Analyses were conducted using chi square tests and analysis of variance. Results A significant main effect of time, and as hypothesized, an interaction between time and condition emerged that favored SDP on play behaviors (p = 0.03). Post-intervention, SDP families had significantly higher levels of interactional activities between a parent and child that promote cognitive development (p = 0.02). Conclusions for Practice Results appear promising for an accessible, low-intensity program delivered in the primary care setting. Further studies to determine the effectiveness of SDP on parenting behaviors and subsequent developmental outcomes are warranted.

Collaboration with Urban Community Stakeholders: Refining Paraprofessional-led Services to Promote Positive Parenting.

This paper describes the process of a community-academic partnership to navigate implementation challenges for a school-based service model led by paraprofessionals to promote positive parenting in high poverty urban communities. We describe the process by which we (a) identified implementation challenges, (b) sustained a university-community collaboration to redesign the paraprofessional service model, and (c) assessed the feasibility of the new model involving four social service agencies in 16 schools with over 600 families. The structure and process of the collaboration and refinement are described with attention to who was best positioned to engage in the collaboration and how the partnership worked to balance scientific rigor with responsiveness to paraprofessional workforce strengths. Feasibility data indicated that the revised model was successfully implemented by paraprofessional staff; 92.2% of possible staff monthly reports were completed and discussion of key goals was incorporated into 94.2% of interactions. Continual monitoring provided critical feedback from stakeholders as we drew on and interpreted these various sources of information to build and refine the service model. We suggest that these processes are critical steps to bridge the research-to-practice gap, by promoting practices that are aligned with the needs of children and families, and the staff who serve them.

A qualitative study to explore paraprofessionals' role in school-based prevention and early intervention mental health services.

This study explored the role of paraprofessionals within a school-based prevention and early intervention program to promote children's engagement in learning and positive parenting practices. Study aims were designed to understand how paraprofessionals perceive their role in high-need communities and how they define their work within schools. Two focus groups were conducted with school family liaisons (SFLs) during the 2015-2016 school year. Transcribed audio recordings were coded using thematic analysis wherein 2 authors coded independently, followed by audited discussion and final consensus codes. SFLs acknowledged the importance of serving high-need communities and relationship building was central to their role. They leveraged contextual knowledge (culture, language, and neighborhood) to engage parents, allowing them to serve as effective advocates for parents/families in the school setting. Findings support the importance of paraprofessionals in prevention-focused services and highlight how leveraging shared experiences and prioritizing relationship building facilitates their work as advocates within schools.

Community Health Workers and Social Proximity: Implementation of a Parenting Program in Urban Poverty.

Community health workers (CHWs) offer a potential means through which to mitigate many of the barriers to mental health services faced by minority youth and their families. The primary aim of the present study was to better understand a core feature of CHWs: their shared community membership with the population served, or social proximity. We conducted qualitative semi-structured interviews with 16 CHWs implementing a school-based early intervention program in Latino and African American communities of urban poverty. The program promoted child and parent/caregiver engagement in schooling as a protective factor for children's mental health. Thematic analyses revealed three main themes defining social proximity: (a) experiences of parenthood or caring for children, (b) familiarity with and understanding of culture, and (c) experiences of life hardships and struggles. Additionally, the process of relating with parents/caregivers through shared experiences was the main theme to describe how CHWs leveraged their social proximity. CHWs' accounts illustrated how their experience of social proximity to the population served was central to how they engaged parents/caregivers in services, highlighting the importance of supporting and promoting CHWs' natural traits and lived experiences.

Correction to: The Effect of a Change Agent on Use of Evidence-Based Mental Health Practices.

The original version of this article unfortunately contained a mistake.

Schooling and Children's Mental Health: Realigning Resources to Reduce Disparities and Advance Public Health.

Schools have long been the primary setting for children's mental health services but have neither the resources nor the expertise to manage these services independently. The critical importance of school success for children's adjustment provides a strong rationale for schooling as an essential component of children's mental health services. In this article, we review evidence for how schooling and mental health coalesce, suggesting an alignment of school and community mental health resources that prioritizes successful schooling as a key mental health outcome. We describe collaborative principles and ecological practices that advance a public health focus on children's mental health while also reducing the burden on schools to maintain mental health services. We close with a model of mental health services illustrating these principles and practices in high-poverty urban schools and propose future directions for research and practice to promote positive mental health for all children and youth.

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap.

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.

The Effect of a Change Agent on Use of Evidence-Based Mental Health Practices.

Children's service systems are faced with a critical need to disseminate evidence-based mental health interventions. Despite the proliferation of comprehensive implementation models, little is known about the key active processes in effective implementation strategies. This proof of concept study focused on the effect of change agent interactions as conceptualized by Rogers' diffusion of innovation theory on providers' (N = 57) use of a behavioral intervention in a child welfare agency. An experimental design compared use for providers randomized to training as usual or training as usual supplemented by change agent interactions after the training. Results indicate that the enhanced condition increased use of the intervention, supporting the positive effect of change agent interactions on use of new practices. Change agent types of interaction may be a key active process in implementation strategies following training.

Use of evidence-based interventions in child welfare: Do attitudes matter?

Implementation of evidence-based programs in progressed slowly, with the majority of services in child welfare settings lacking empirical evidence for effectiveness. In other settings, research has identified providers' attitudes about evidence-based practices (EBPs) as a potential barrier to adoption of EBPs. As little research has focused on the role of attitudes in influencing use after training in an EBP in child welfare, the potential for attitudes to impede implementation efforts in child welfare is unclear. This study addressed this question in a sample of 55 caseworkers and therapists randomly assigned to enhanced support to use an EBP following training or a training-only condition. Information on providers' use of the intervention after training and their attitudes about EBPs were measured for up to five time points. Results indicate that attitudes did not predict providers' use of the EBP, and attitudes did not change overall or in the enhanced condition that provided greater exposure to the intervention. Providers perceived of requirements to use a practice as more influential in their use than their openness to EBPs. However, those who were more open to EBPs were more likely to participate in implementation support after the training, suggesting that openness facilitates participation in activities that support use of a new intervention.

Psychological Science and Innovative Strategies for Informing Health Care Redesign: A Policy Brief.

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models.

Youth Mentoring Relationships in Context: Mentor Perceptions of Youth, Environment, and the Mentor Role.

Youth mentoring is primarily understood as a relationship between mentor and mentee, yet mentors often enter into home, school, and other community settings associated with youth they serve, and interact regularly with other people in mentees' lives. Understanding how and why mentors negotiate their role as they do remains underexplored, especially in relation to these environmental elements. This qualitative study drew on structured interviews conducted with professional mentors (N = 9) serving youth at risk for adjustment problems to examine how mentors' perceptions of their mentees and mentee environments informed their sense of how they fulfilled the mentoring role. Mentors commonly characterized problems youth displayed as byproducts of adverse environments, and individual-level strengths as existing "in spite of" environmental inputs. Perceptions of mentees and their environments informed mentors' role conceptualizations, with some mentors seeing themselves as antidotes to environmental adversity. Mentors described putting significant time and effort into working closely with other key individuals as well as one-on-one with mentees because they identified considerable environmental need; however, extra-dyadic facets of their roles were far less clearly defined or supported. They described challenges associated with role overload and opaque role boundaries, feeling unsupported by other adults in mentees' lives, and frustrated by the prevalence of risks. Community-based mentoring represents a unique opportunity to connect with families, but mentors must be supported around the elements of their roles that extend beyond mentor-mentee relationships in order to capitalize more fully on the promise of the intervention.

Moving science into state child and adolescent mental health systems: Illinois' evidence-informed practice initiative.

In 2005, the Illinois State Mental Health Authority embarked on an initiative to close the gap between research and practice in the children's mental health system. A stakeholder advisory council developed a plan to advance evidence informed practice through policy and program initiatives. A multilevel approach was developed to achieve this objective, which included policy change, stakeholder education, and clinician training. This article focuses on the evidence-informed training process designed following review of implementation research. The training involved in-person didactic sessions and twice-monthly telephone supervision across 6 cohorts of community based clinicians, each receiving 12 months of training. Training content initially included cognitive behavioral therapy and behavioral parent training and was adapted over the years to a practice model based on common element concepts. Evaluation based on provider and parent report indicated children treated by training clinicians generally showed superior outcomes versus both a treatment-as-usual comparison group for Cohorts 1 to 4 and the statewide child population as a whole after 90 days of care for Cohorts 5 to 6. The results indicated primarily moderate to strong effects for the evidence-based training groups. Moving a large public statewide child mental health system toward more effective services is a complex and lengthy process. These results indicate training of community mental health providers in Illinois in evidence-informed practice was moderately successful in positively impacting child-level functional outcomes. These findings also influenced state policy in committing resources to continuing the initiative, even in difficult economic times.

Implementation Preparation Costs of Virtual Interview Training in Pre-Employment Transition Services: A Budget Impact Analysis.

Virtual Reality Job Interview Training (VR-JIT) and Virtual Interview Training for Transition Age Youth (VIT-TAY) demonstrated initial effectiveness at increasing employment among transition-age youth with disabilities engaged in pre-employment transition services. We characterized activities and estimated the labor and non-labor costs required to prepare schools to implement VR-JIT or VIT-TAY. Implementation preparation and support teams reported labor hours throughout the implementation preparation process. Implementation preparation labor hours at 43 schools cost approximately $1,427 per school, while non-labor costs were $100 per trainee (student). We estimated the replication of implementation preparation labor activities would cost $1,024 per school (range: $841-$1,208). Most costs were spent in delivery planning and teacher training. Given that implementation preparation costs can be barriers to intervention adoption, our results provide critical information for contemplating future implementation of VR-JIT or VIT-TAY.

Not just a walk in the park: efficacy to effectiveness for after school programs in communities of concentrated urban poverty.

This study examined a model for mental health consultation, training and support designed to enhance the benefits of publicly-funded recreational after-school programs in communities of concentrated urban poverty for children's academic, social, and behavioral functioning. We assessed children's mental health needs and examined the feasibility and impact of intervention on program quality and children's psychosocial outcomes in three after-school sites (n = 15 staff, 89 children), compared to three demographically-matched sites that received no intervention (n = 12 staff, 38 children). Findings revealed high staff satisfaction and feasibility of intervention, and modest improvements in observed program quality and staff-reported children's outcomes. Data are considered with a public health lens of mental health promotion for children in urban poverty.