Clinician's Toolkit for Children’s Behavioral Health

Clinician's Toolkit for Children’s Behavioral Health provides a wealth of clinical tools, best practices, and research-based recommendations on the behavioral health of children. Based on the current perspectives on behaviorism, social-cognitive theory and attachment theory, the book reviews the evidence-base on developmentally appropriate methods to promote and reinforce positive, prosocial behaviors in children. Each chapter covers the most recent evidence base on normal and atypical development treatment parameters, best practices, and how to most effectively address issues with families, providing guidance on verbal or physical aggression, punishment spirals, and other ineffective or potentially harmful methods.

Evidence-based best practices are outlined for addressing bedtime problems, toilet training, bullying behavior and victimization, the relationship between somatic complaints, anxiety, and school refusal, problematic use of screen media, and more.

• Provides a wealth of clinical guidance on treating behavioral problems in children
• Addresses toilet training, bullying, aggressive behavior, sexual behavior, and more
• Outlines how to deliver parent-focused education and interventions
• Reviews best practices in interviewing about, and reporting on, child maltreatment
• Looks at teaching methods, learning settings and children’s academic/social outcomes

• Language: English
• Publisher: Academic Press
• Release date: Jan 6, 2020
• ISBN: 9780128162910

Book preview

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Preface

Michele Knox

Research suggests that just over 20% of youth experience a serious mental health problem at some point in their lives (National Alliance on Mental Illness, 2019). In fact, roughly half of all mental disorders begin early, by the age of 14 years (Kessler et al., 2007). Such mental health problems may be preventable or minimized with early intervention efforts. The evidence clearly has demonstrated that parents and caregivers are key players in much of the groundwork in the prevention and early intervention. When parents and caregivers are provided support and guidance in effective, nurturing parenting and discipline, the likelihood of child and adolescent behavioral and emotional problems, child maltreatment and youth violence significantly diminish. However, the current health system places little emphasis on the prevention and early intervention. Such efforts have been impeded by the fact that historically, there has been virtually no system of reimbursement for professionals providing preventive health care. Furthermore, despite the demonstrated need for education, support, and guidance for parents, there is no accessible system in place for parents to receive such help and information.

When opportunities for prevention are missed, mental health intervention by qualified providers is imperative to prevent long-term suffering and related costs. However, findings from large, population-based studies indicate that only 20% of the youths who need mental health treatment actually get it (American Academy of Child and Adolescent Psychiatry, 2013). Young people of color, those who live in families with limited financial resources, and those with disabilities have particularly limited access to services that would identify, prevent or treat mental health problems. Poor access is linked to the scarcity of qualified child and adolescent mental healthcare professionals in the US. The Annapolis Coalition on the Behavioral Health Workforce described a workforce crisis in behavioral health, citing the lack of such providers to deliver care, especially in rural America (Hoge et al., 2007, p. 2). Child and adolescent psychiatry, for example, has long been recognized as a shortage subspecialty field. Even in large metropolitan areas, many youths will never be able to access psychiatry services. Nonetheless, the demand for services in child and adolescent psychiatry was expected to increase by 100% between the years 1995 and 2020 (Kim, 2003). Although efforts to bring healthcare providers, psychiatrists, and psychologists together into integrated work settings are underway, the workforce shortages will make this plan impossible in many areas of the United States.

In part due to these shortages, primary care clinicians are principal sources of prevention and care for children and adolescents who are at risk or who are already suffering from mental health issues. For example, research suggests that behavioral, emotional, or educational issues are brought up by families in one-fourth to one-half of pediatric visits (Cooper, Valleley, Polaha, Begeny, & Evans, 2006). Unfortunately, many healthcare clinicians often do not have the resources to address these needs and frequently report that they lack the time and training to effectively address them and are not reimbursed for these services. Consequently, families often are left without needed support. For example, in one study, 75% of the parents reported not receiving any guidance from healthcare professionals on discipline, 66% did not receive guidance on toilet training, and 59% on sleep (Schuster, Duan, Regalado, & Klein, 2000). Further, research has suggested that more than 94% of the parents have significant unmet needs for guidance or screening by pediatric service providers (Bethell, Reuland, Halfon, & Schor, 2004).

Although reimbursement for behavioral health prevention and intervention historically has been almost nonexistent for healthcare clinicians, methods of healthcare coding, billing, and reimbursement are changing to address these needs. The American Academy of Pediatrics has responded to this situation and is now training its members in how to code and bill for prevention, counseling, risk reduction, and behavior change interventions. The American Psychological Association has recommended the development of a primary mental healthcare system to rectify the inadequate access to child and adolescent mental health services, emphasizing the need for reimbursement of clinicians for prevention and early intervention services. Moreover, there is now greater recognition on the policy level of the high societal costs of untreated behavioral health conditions. Public and private systems are recognizing that consumers with behavioral health conditions are often the costliest enrollees to cover. In keeping, treatment of behavioral health conditions has become a greater priority for clinicians and policymakers, and Medicaid and insurance organizations increasingly are basing reimbursement on the combination of health and mental health outcomes. State-based systems are being redesigned in order to improve health outcomes and decrease costs. In these new systems, innovative approaches to health care, such as evidence-based methods to promote healthy lifestyles, are incentivized. Healthcare providers are now expected to move well beyond the biomedical model to address behavioral, emotional, and developmental needs.

Such changes in systems of care and reimbursement are finally removing obstacles to the effective provision of preventive care. At long last, third-party payors are newly willing to cover prevention and intervention provided by healthcare clinicians (see Chapter 9: Physical punishment and child maltreatment, for details). Promotion of healthy lifestyles and prevention of mental health disorders are being prioritized. Thus the time is right for mental health and related professionals to find innovative ways to share their expertise on behavioral, emotional, and educational issues with other professionals who treat children. One critical objective should be to help such providers to identify and use efficient methods of prevention and intervention that work within the context of the standard office visit. This book has the goal of preventing suffering, adverse emotional and behavioral outcomes, as well as their associated costs, by providing needed support, education and guidance to clinicians as well as the parents and caregivers of the children and adolescents they treat.

This book provides an update on the evidence base on issues commonly brought up by families to physicians, nurses, physician assistants, child psychologists, psychiatrists, counselors, social workers, and other professionals. It also provides evidence-based advice about how to effectively and efficiently address these topics in the context of a brief office visit. Graduate students and professionals in a wide variety of fields will find the content useful and relevant to their practice. Each chapter summarizes the most recent evidence base on normal and atypical development, mental health and health outcomes, treatment parameters, best practices, and how to most effectively address issues with families. Handouts for clinicians and families are provided to promote the dissemination and use of the information.

A few notes on the vocabulary used in the book are worth noting. Throughout the book, the term parents is used instead of parents and caregivers for simplification, but readers are advised to understand this to mean any primary caregiver of a youth. Furthermore, the term clinicians is used throughout to indicate any professional in the role of advising families with children on behavioral health issues. Some chapters, such as Chapter 6, Helping children succeed in school: a guide to special education services, may be useful to parents, so clinicians may want to recommend the entire book to parents. Lastly, if more information is needed on the topics addressed, readers are advised to visit websites such as Pediatrics for Parents (https://pedsforparents.com/), National Institute of Child Health and Human Development (https://www.nichd.nih.gov/health/topics), and Zero to Three (https://www.zerotothree.org/) that provide a wealth of information on a variety of children’s behavioral health topics.

References

1. American Academy of Child and Adolescent Psychiatry. (2013). Child and adolescent psychiatry workforce crisis: Solutions to improve early intervention and access to care. Retrieved March 6, 2019 from <https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap_workforce_crisis_201305.pdf>.

2. Bethell C, Reuland CHP, Halfon N, Schor EL. Measuring the quality of preventive and developmental services for young children: National estimates and patterns of clinicians’ performance. Pediatrics. 2004;113(Supplement 5):1973–1983.

3. Cooper S, Valleley RJ, Polaha J, Begeny J, Evans JH. Running out of time: Physician management of behavioral health concerns in rural pediatric primary care. Pediatrics. 2006;118(1):e132–e138.

4. Hoge MA, Morris JA, Daniels AS, Stuart GW, Huey LY, Adams N. An action plan for behavioral health workforce development Cincinnati, OH: Annapolis Coalition on the Behavioral Health Workforce; 2007.

5. Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustun TB. Age of onset of mental disorders: A review of recent literature. Current Opinion in Psychiatry. 2007;20(4):359.

6. Kim WJ. Child and adolescent psychiatry workforce: A critical shortage and national challenge. Academic Psychiatry. 2003;27(4):277–282.

7. National Alliance on Mental Illness. (2019). Mental health by the numbers. Retrieved March 6, 2019 from <https://www.nami.org/learn-more/mental-health-by-the-numbers>.

8. Schuster MA, Duan N, Regalado M, Klein DJ. Anticipatory guidance: What information do parents receive? What information do they want?. Archives of Pediatrics & Adolescent Medicine. 2000;154(12):1191–1198.

Chapter 1

Parents and caregivers: creating a strong foundation for engagement

Morgan Dynes,    Departments of Psychiatry and Pediatrics, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States

Abstract

This chapter provides a framework for the importance of parent engagement when working with youth in medical and therapeutic settings, and how to best navigate the parent engagement process. It explains how to build strong alliances with the parents of youth seeking treatment services, assess caregivers’ readiness for change, manage resistance and ruptures in the provider/patient alliance, and how to deliver parent-focused education and interventions with effective caregiver engagement. The chapter is based on social learning and motivational interviewing theories and best practices and provides easy-to-use advice about how to foster a positive engagement with caregivers and prevent and manage lack of follow-through.

Keywords

Engagement; parent engagement; treatment engagement; treatment resistance; noncompliance

Why is engagement important?

Parenthood is talked about as one of the most rewarding journeys one can embark on in life and is regarded as a highly important role across cultures. However, parenting youth of all ages can be stressful, and challenges can present at any turn. Many families experience emotional problems, behavioral challenges, and disruptions in development while raising their children and adolescents. An estimated 20%–40% of youth have a psychiatric disorder (Costello, Copeland, & Angold, 2011) and may need mental health services. Other findings suggest that between 24% and 50% of pediatric office visits involve a behavioral, emotional, or educational concern (Cassidy & Jellinek, 1998; Cooper, Valleley, Polaha, Begeny, & Evans, 2006), making pediatricians increasingly responsible for identifying and addressing these issues (NIHCM Foundation, 2009). However, the majority of pediatric providers do not receive specialized training in identifying or treating behavioral health disorders (Leaf et al., 2004; Williams, Klinepeter, Palmes, Pulley, & Foy, 2004). Untreated childhood behavior problems have been shown to predict the development of unfavorable adolescent outcomes, such as early rejection by prosocial peers, academic difficulties, school dropout, out-of-home placement, criminal involvement, substance use, and teen pregnancy (Broidy et al., 2003; Webster-Stratton & Reid, 2003). Similarly, internalizing problems in childhood, such as depression or anxiety disorders, can contribute to long-term impairments or even suicide (Copeland, Angold, Shanahan, & Costello, 2014; Copeland, Goldston, & Costello, 2017; Fergusson, Horwood, Ridder, & Beautrais, 2005).

While childhood mental health disorders exert a cost at the individual, family, and societal levels, several promising evidence-based treatments exist. For example, parent-management training is a theoretically sound, empirically well-founded, and efficacious method for the treatment and prevention of externalizing behavior problems (e.g., oppositionality, defiance, and disruptive behavior) in children (Dretzke et al., 2009; Eyberg, Nelson, & Boggs, 2008; Webster-Stratton, Reid, & Beauchaine, 2011). Cognitive-behavioral therapies (CBT) are efficacious treatments for childhood internalizing disorders. In addition to individual treatment of the child directly, CBT for youths often includes education and engagement of parents in order to facilitate positive treatment outcomes for the child (O’Neil, Brodman, Cohen, Edmunds, & Kendall, 2012; Wood, Piacentini, Southam-Gerow, Chu, & Sigman, 2006).

While the efficacy of parent-focused interventions across treatment modalities has been well documented, obstacles to treatment delivery and engagement may reduce the effective dissemination of these interventions in real-world practice settings. For example, Merikangas et al. (2010) demonstrated with national survey data that half of youth in need of treatment do not even start services. Further, half of the youth who initially engage in mental health services discontinue treatment prematurely (Nock & Ferriter, 2005; Pellerin, Costa, Weems, & Dalton, 2010; Becker, Boustani, Gellatly, & Chorpita, 2017). McKay, Pennington, Lynn, and McCadam (2001) found a third of families did not attend their requested appointments for mental health treatment, and families that were enrolled in services missed almost half of their scheduled appointments.

How does the engagement process work?

Who notices a child is suffering and decides to get her help? Who enrolls the child in treatment? Who gets the child to appointments? Who helps him to use the skills he learns in treatment? Who…? The answer is almost always parents. For these reasons, effective service delivery of any treatment for youths depends on successful parent engagement and retention (National Institute for Health and Clinical Excellence, 2006, 2009; Nock & Ferriter, 2005; U.S. Department of Health and Human Services, 2001, 2003). There are various ways in which researchers have gone about defining the parent engagement process. Becker et al. (2017) summarized 40 years of engagement research and propose that engagement represents an individual’s multidimensional commitment to services and includes cognitive, social, and behavioral dimensions. Cognitive dimensions include a parent’s attitudes, beliefs, and expectations about themselves, their children, and the services or treatment they are seeking. Some examples of these cognitive dimensions include a parent’s overall attitudes toward mental health services and possible preconceived ideas about treatment providers; past experiences with providers; their understanding of their role in treatment and how it would address their child’s needs; a parent’s confidence in their efficacy as a parent; a parent’s beliefs about their child and their child’s problems, a parent’s locus of control, and the parent’s readiness for change (Lindsey et al., 2014; Lindsey, Chambers, Pohle, Beall, & Lucksted, 2013). Behavioral dimensions of engagement include treatment enrollment, appointment attendance, participation in session, and completion of homework or assigned intervention activities outside of session (Lindsey et al., 2014; Nock & Ferriter, 2005). A parent’s transportation, financial resources and insurance status, and availability of childcare should also be considered when thinking about behavioral dimensions of engagement. Social dimensions (e.g., quality of the therapeutic alliance) also are included by some researchers in their understanding of the engagement process (Staudt, 2007). A strong therapeutic alliance could be seen as a result of a successfully navigated engagement process, during which cognitive and behavioral dimensions are assessed and addressed with respect.

It should be noted that these aforementioned dimensions of engagement can operate as barriers or promoters of the engagement process. For example, if a parent has positive attitudes toward treatment, believes in their own and their child’s abilities to participate in treatment, has a strong therapeutic alliance with child’s provider, and makes efforts to try the suggestions of the provider inside and outside of session, the parent is likely to be positively engaged in their child’s services. For example, Joe brings his 8-year-old son into your pediatric practice for diarrhea that seems to relate to stress. Joe’s son has been your patient since birth. He had the same problem as a child and it was successfully treated. Joe recalls his mother being patient as they helped him manage his stress better, and you notice Joe take a few quick notes on his phone to remember your suggestions.

However, if the parent does not feel comfortable with the provider, is unsure if the child will benefit from treatment, is not sure of his or her role in the child’s care, and has unreliable transportation, then this parent will struggle to be meaningfully engaged in services. For example, Kendra is a 55-year-old African-American woman who has custody of her 6-year-old granddaughter. Kendra brings her granddaughter to a licensed mental health counselor, Allison, at their local community mental health center to get help for her granddaughter’s behavior problems at school and sleep issues at home. Allison is White, in her early 20s, and makes very little eye contact. Kendra is nervous and uncertain when first meeting Allison, because she is reflecting on how she tried to take her granddaughter to another young White counselor in a neighboring town. Kendra was never asked to participate in any of her granddaughter’s appointments and was only given a 2-minute summary of the session activities by her previous counselor in the waiting room at the end of the appointment. Her granddaughter’s behavior and sleep issues were not improving, and Kendra was growing more concerned that something has happened to her granddaughter when not in her care. Despite her negative experiences with mental health services, Kendra feels at a loss of how to help her granddaughter on her own, so she decides to try another community mental health center, in hopes of a better experience.

Becker and Chorpita (2016, as cited in Becker et al., 2017) created an organizing framework where they propose five domains of engagement, using the relationship, expectancy, attendance, clarity, and homework (REACH) acronym. These domains can be seen as engagement outcomes that practitioners are hoping to positively influence by effectively addressing and navigating the aforementioned cognitive and behavioral dimensions of engagement.

• Relationship—Therapeutic alliance between clinician and parent or patient (Shirk, Karver, & Brown, 2011)

• Expectancy—Parents’ attitudes and beliefs about their children, themselves, and treatment services (Nock & Kazdin, 2001)

• Attendance—Presence at treatment sessions (Nock & Ferriter, 2005)

• Clarity—Understanding the treatment approach or parent’s role in treatment (Shuman & Shapiro, 2002)

• Homework—Multiple adherence and participation dimensions such as completion of homework or in-session participation (Nock & Ferriter, 2005).

Engagement is also a dynamic process that occurs across time in services and is transactional in which service providers play a primary role. Across studies (Becker et al., 2017; Eames et al., 2010; Ingoldsby, 2010; Koerting et al., 2013; Lindsey et al., 2014), researchers have identified multiple behaviors of service providers that may enhance the parent engagement process:

• Using effective assessment skills

• Assessing parents’ practical (e.g., transportation and childcare) and perceptual (e.g., stigma about disorders and services, negative experiences with prior treatment, and beliefs about illness and acceptable treatments) barriers to treatment

• Psychoeducation about treatment, presenting problems, or service delivery

• Addressing parents’ perceptions about services

• Discussing with parents their beliefs about their children and themselves as parents

• Building positive parent–therapist alliances based on trust and mutual respect

• Evaluating parents’ stages of change and motivation

Best practices for navigating the engagement process

Researchers across disciplines have been working to clarify how providers can facilitate and navigate the parent engagement process, in order to provide parent-focused, evidence-based interventions that will positively impact children in need. For example, Becker et al. (2017) identified 30 practice elements in their comprehensive review of the engagement literature. The five practice elements most frequently included in effective engagement interventions were Assessment, Psychoeducation, Accessibility promotion, Barriers to treatment, and Goal setting. Table 1.1 connects the practice elements with the respective REACH domain outcomes that they facilitate and provides examples of how these practice elements could be used in a usual care setting. An additional factor to consider when trying to navigate the engagement process is a family’s cultural background. Researchers suggest that ethnic minorities underutilize mental health services due to differential beliefs about the causes of mental health problems (Hoberman, 1992; Ruiz, 1995; U.S. Department of Health and Human Services, 2001). Further, differences between the way the parent and the service provider view the source of the child’s problems may impede treatment progress and compliance (Foulks, Persons, & Merkel, 1986). Therefore it is important to adapt program content or delivery to address specific characteristics of the culture of families being served (McDonald, Coover, Sandler, Thao, & Shalhoub, 2012; McDonald, FitzRoy, Fuchs, Fooken, & Klasen, 2012). Please find examples across the five practice elements in Table 1.1 of how to assess components of a family’s cultural, ethnic, and religious background in order to facilitate a collaborative relationship with parents that fosters engagement, while honoring important aspects of their culture (Ecklund & Johnson, 2007).

Table 1.1