Involving urban children and their families in child mental health services research: Reaching those often missed

1. Involving urban children and their families in child mental health services research: Reaching those often missed Mary M. McKay, Ph.D. Professor of Social Work in Psychiatry & Community Medicine Mount Sinai School of Medicine

2. Engagement of youth and families in the �real world� Two thirds of children in need of mental health care do not receive services Rates of service use are at their lowest in low income, urban communities No show rates can be as high as 50% Drop outs occurring after two or three sessions are common

3. Evidence-based engagement interventions Reminders reduced missed appointments by as much as 32% (Kourany et al., 1990; McLean et al., 1989; Shivack et al., 1989; & Sullivan) Intensive family-focused telephone engagement intervention associated with 50% decrease in initial show rates and a 24% decrease in premature terminations (Szapocznik, 1988; 1997)

4. Empirically supported telephone engagement strategy Intervention during the initial telephone intake or appointment call Relies on an understanding of child, family, community and system level barriers to mental health care Goals: 1) clarify the need for mental health care; 2) increase caregiver investment and efficacy

5. Telephone engagement strategy (cont.) Goals: 3) Identify attitudes about previous experiences with mental health care and institutions; 4) PROBLEM SOLVE! PROBLEM SOLVE! PROBLEM SOLVE! around concrete obstacles to care

6. Telephone Engagement Study #1 Methods Outcome of interest: # of families that came to an initial appointment Setting: urban outpatient child mental health clinic Sample: n=54 Design: Matched comparison of consecutive referrals in one month

7. Telephone Engagement Study Results

8. Telephone Engagement Study #2 Methods Outcome of interest: # of families that came to an initial appointment Setting: Urban outpatient child mental health clinic Sample: n=108 Design: random assignment to condition

9. Telephone Engagement Study #2 Results

10. Getting a child to a first appointment is not enough! The most vulnerable child populations, in terms of seriousness of presenting problems or complexity of social situations, are less likely to be retained beyond the 1st mental health session Premature terminations occur regularly after two or three visits

11. First interviews are critical It is critical for providers to apply targeted engagement strategies during the first interview to address the range of barriers that can exist within families, urban environments, and agencies. A protocol for first/engagement interviews was developed and tested (a. sensitivity to concerns about intake; b. seeking practical assistance; c. development of collaborative foundation and; d. active problem solving of ongoing barriers).

12. First interview study methods Outcome of interest: # of families that came to initial and ongoing appointments Setting: Urban outpatient child mental health clinic Sample: n=107 Design: Random assignment to condition

13. First Interview Results

14. CATS Combined telephone and first interview engagement interventions (McKay et al., 1998). Intensive training where providers learn ways to discuss �difficult to talk about� barriers with adult caregivers (e.g. stigma, mistrust of professionals, fear of being blamed) and enhance proactive problem solving around concrete obstacles to care. Video � �I went for an intake and never came back� Training is divided into two parts: 1) first contact engagement skills and; 2) initial interview engagement skills.

15. Site Show Rates for Assessment