Observational Assessment of Engagement Strategies to Promote Parent Homework Planning in Community-Based Child Mental Health Treatment: A Pilot Study

Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service

The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.

Quantifying parent engagement in the randomized Fuel for Fun impact study identified design considerations and BMI relationships

BACKGROUND

Parent participation in children's health interventions is insufficiently defined and measured. This project quantified parent participation to enable future examination with outcomes in an intervention focused on 4th graders, aged 9-11 years, and their families living in northern Colorado.

METHODS

Indices were developed to measure type (Parent Participation Profile; PPP) and intensity (Parent Engagement Intensity; PEI) of engagement in Fuel for Fun (FFF), an asymmetric school-and family-based intervention for 4th graders. Study arm-specific participation opportunities were catalogued and summed to calculate the PPP. An algorithm considered frequency, effort, convenience, and invasiveness of each activity to calculate PEI. Indices were standardized (0-100%) using study arm-specific divisors to address asymmetric engagement opportunities. Parents who completed ≥75% of the PPP were defined as Positive Deviants. Youth height and weight were measured. Youth BMI percentile change was compared with parent Positive Deviant status using general linear modeling with repeated measures that included the participation indices.

RESULTS

Of 1435 youth, 777 (54%) had parent participation in at least one activity. Standardized means were 41.5 ± 25.4% for PPP and 27.6 ± 20.9% for PEI. Demographics, behaviors or baseline FFF outcomes did not differ between the Positive Deviant parent (n = 105) and non-Positive Deviant parents (n = 672); but more Positive Deviant parents followed an indulgent feeding style (p = 0.015). Standardized intensity was greater for Positive Deviant parents; 66.9 ± 20.6% vs 21.5 ± 12.7% (p < 0.001) and differences with non-Positive Deviant parents were related to activity type (p ≤0.01 for six of eight activities). Standardized participation intensity was associated with engagement in a greater number of standardized activity types. Among participating parents, standardized intensity and breadth of activity were inversely related to the youth BMI percentile (n = 739; PEI r = -0.39, p < 0.001; PPP r = -0.34, p < 0.001). Parent engagement was not associated with parent BMI change.

CONCLUSIONS

An activity-specific intensity schema operationalized measurement of parent engagement in a complex, unbalanced research design and can serve as a template for more sensitive assessment of parent engagement. Positive deviance in parent engagement was not a function of personal, but rather activity characteristics. PPP and PEI increased with fewer requirements and convenient, novel, and personalized activities. Parent engagement indices affirmed lower engagement by parents of overweight/obese youth and concerns about target reach.

What got in the way? Caregiver-reported challenges to home practice of assigned intervention skills

Background

Evidence-based intervention (EBI) effectiveness is hindered by low rates of caregiver home practice, or caregiver rehearsal of intervention skills at home. Although home practice is essential to intervention success, we know little about what makes home practice difficult to complete. We sought to identify the challenges caregivers face when attempting home practice assignments within the context of community implementation of a family-based preventative EBI. We also aimed to identify barriers, perceived need, and implementation-related factors that may contribute to frequency of home practice challenges.

Methods

The family-based preventative intervention Bridges was delivered to caregivers and adolescents in three public middle schools in North America within a randomized efficacy-effectiveness hybrid trial. Caregivers (N = 233) completed worksheets in which they reported challenges to home practice of intervention skills. Caregiver-endorsed challenges were coded for emergent themes and categorized into higher-order home practice challenge domains. Additional data was gathered through multiple methods. In addition to descriptive analyses, multilevel linear regressions were conducted to identify factors associated with frequency of home practice challenge domains.

Results

Over 85% of caregivers reported one or more home practice challenges. Challenges fell into six domains: daily stresses, cognitions/beliefs about the intervention/practice, caregiver wellness/regulation, adolescent responsiveness, relevance/acceptability of intervention or assignment, and external barriers to practice. Adolescent externalizing symptoms, academic performance, and caregiver participation in the English-language intervention group (compared to Spanish-language delivery) were associated with greater frequency of reported challenges.

Conclusions

Among caregivers already attending intervention sessions, specific support to overcome challenges in daily stresses and beliefs about the intervention/practice can support greater home practice compliance, which in turn may impact overall intervention effectiveness. Findings suggest that providing services in caregivers' preferred language may avert potential challenges. Further research into home practice challenges is necessary to identify appropriate home practice implementation supports.

Plain Language Summary

Low rates and poor quality of caregiver home practice of intervention skills hampers intervention effectiveness, but no prior studies have identified the difficulties caregivers face when attempting home practice of intervention skills and their rates of occurrence. Within a community implementation of a family-based preventative intervention, we found that difficulties were common and largely fell in the domains theorized to impact engagement, such as daily stresses and beliefs about the intervention/practice. Findings also suggest that providing services and materials in caregivers' preferred language may avert potential home practice challenges. By identifying common home practice challenges and correlates of different challenges, our findings point to a need to develop appropriate and effective home practice implementation support.

Parent And Caregiver Active Participation Toolkit (PACT): Adaptation for a Home Visitation Program

OBJECTIVES

Parent engagement poses a persistent challenge to home visitation (HV) programs. Previous work on parent engagement in HV has focused primarily on enrollment, attendance, and retention, with less attention on participation. The purpose of this study was to adapt an engagement toolkit originally developed for child mental health treatment settings, the Parent And Caregiver Active Participation Toolkit (PACT), and test the adapted toolkit in a HV program, SafeCare® (SC), with a focus on parent participation.

METHODS

Toolkit adaptation was informed by interviews/focus groups with parents and home visitors. Next, home visitors (n = 6) were trained to use adapted PACT for SC as part of SC delivery to 18 parents. A comparison group included 24 parents who received SC one year prior to this study. Analyses compared PACT for SC participants to the comparison group on parent participation and home visitor fidelity to assignment of homework. Qualitative and quantitative data from parents, home visitors, and supervisors (n = 4) assessed the acceptability, utility, appropriateness, and feasibility of PACT for SC.

RESULTS

Parents receiving PACT for SC had higher participation and reported greater home visitor fidelity to homework assignment than comparison parents. Parents found PACT for SC acceptable and useful as part of SC. Home visitors and supervisors identified some limitations in PACT for SC's utility but generally found it to be a positive, feasible addition to HV services.

CONCLUSIONS

Results suggest that enhancing HV programs with an engagement toolkit may improve parents' participation in services and providers' assignment of homework between sessions.