Building Partnerships:Building Partnerships:Bringing Research to ChildrenBringing Research to Children’’s Mental Health in Ontario s Mental Health in Ontario

Presented at the CMHO Annual Conference, November 21Presented at the CMHO Annual Conference, November 21stst, 2008, 2008

Yvonne Bohr & Leigh ArmourYvonne Bohr & Leigh ArmourInfant Child Treatment Team, Aisling Discoveries Child and FamilInfant Child Treatment Team, Aisling Discoveries Child and Family Centrey Centre

&&Department of Psychology, York University Department of Psychology, York University

AgendaAgenda

►►ContextContext►►Goals of our partnershipGoals of our partnership►►SettingSetting►►The projects: four examplesThe projects: four examples►►The challengesThe challenges►►Lessons learnedLessons learned►►Next stepsNext steps

Building Partnerships Building Partnerships ––Why Conduct Research in a Why Conduct Research in a

ChildrenChildren’’s Mental Health Centre?s Mental Health Centre?►

Community clinical settings have always strived

to provide the most effective, helpful and beneficial programs to their clients, but often use outdated methods. Recently these settings are increasingly being called upon to

evaluate the

effectiveness of their programs and even to conduct research (Ollendick & King, 2004).(Ollendick & King, 2004).

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Research and evidence-based practice models often reach community clinical settings circuitously and slowly (Barwick et al., 2005). (Barwick et al., 2005).

K nowledge

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Research knowledge may frequently be distorted or lost in translation. Research populations often do not reflect clinical populations. As a result, transferred models are routinely modified by clinicians and lose empirical validity ((FixsenFixsen, 2004)., 2004).

Building Partnerships Building Partnerships ––Why Conduct Research in a Why Conduct Research in a

ChildrenChildren’’s Mental Health Centre?s Mental Health Centre?

K

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There is a need for more ecologically valid treatment research

(Jensen et al., 2005 ).(Jensen et al., 2005 ).

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Research and program development should not remain the prerogative of academia and teaching hospitals. Community settings can learn to apply and replicate empirical findings and develop

novel

interventions based on an extensive familiarity with their

client populations and their highly

developed clinical knowledge.

Building Partnerships Building Partnerships ––Why Conduct Research in a Why Conduct Research in a

ChildrenChildren’’s Mental Health Centre?s Mental Health Centre?

►Practice based evidence VS evidence-based practice

Building Partnerships Building Partnerships ––Why Conduct Research in a Why Conduct Research in a

ChildrenChildren’’s Mental Health Centre?s Mental Health Centre?

Goals of our PartnershipGoals of our PartnershipBeyond pre and postBeyond pre and post

►To facilitate bilateral knowledge exchange.

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To train scientist practitioners: making clinicians research savvy and producing researchers that are grounded in practice.

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To design ecologically valid investigations by integrating research and practice.

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To go beyond pre-

and post-assessments and develop innovative intervention protocols and research designs that meet client & clinician needs.

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The SettingThe Setting

THE CENTRE - Aisling Discoveries Child & Family Centreserves children (0-12) and their families for over 30 years in East Toronto / Scarborough.

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38% of this community’s residents report a mother tongue other than English and 58% are first-generation Canadians.

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50% belong to a visible minority group.•

24% of all families in this area are headed by a single-

parent.•

More than 40% of adults report having less than a high school education.

•

24% of families are subsisting below the poverty line; over 40% declare incomes of less than 40,000.

The SettingThe Setting

►►THE INFANT CHILD TREATMENT PROGRAMTHE INFANT CHILD TREATMENT PROGRAM (0(0--6)6)

►►THE COMMUNITY INTERVENTION & TREATMENT THE COMMUNITY INTERVENTION & TREATMENT PROGRAMPROGRAM (6(6--12)12)

THE CLINICAL TEAM

►Multidisciplinary: social work, child and youth work, early childhood education, psychology, with consultation from speech and language and psychiatry.

►Clinicians that are highly motivated to consider the integration of research into their practice.

►Practicum students in psychology, social work and child and youth work.

►A team leader who is simultaneously positioned in both settings.

The PartnershipThe PartnershipTHE RESEARCH TEAM

►One faculty member from clinical developmental psychology at York University.

►Five graduate and four undergraduate students in psychology.

►Students who demonstrate commitment to integrated community practice and knowledge exchange

The Projects The Projects –– Four ExamplesFour Examples

1. Design of an intervention to alter parents’ negative cognitions in the context of attachment behaviors.

2. Adaptation of an established parenting skills program for a diverse group of parents.

3. Study of a culture- specific parenting practice and evaluation of a tailored intervention.

4. Evaluation of the effectiveness of a group CBT program for children with anxiety

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Approach was designed collaboratively from ground up Approach was designed collaboratively from ground up with clinicians as an early intervention treatment with clinicians as an early intervention treatment program for highprogram for high--risk, sometimes transient families risk, sometimes transient families

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Has been shown to be useful in addressing a variety of Has been shown to be useful in addressing a variety of carecare--giving challengesgiving challenges

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Designed as assessment, but doubles as treatmentDesigned as assessment, but doubles as treatment►►

Brief, flexible videoBrief, flexible video--feedback intervention that might feedback intervention that might initiate a shift in maladaptive caregiver behaviours, but initiate a shift in maladaptive caregiver behaviours, but also support parenting competencies and improve dyadic also support parenting competencies and improve dyadic functioning in few meetingsfunctioning in few meetings

Project 1 Project 1

““Mapping Attributions of ParentsMapping Attributions of Parents”” Using assessment as brief intervention in the Using assessment as brief intervention in the

prevention of maltreatmentprevention of maltreatment

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Intervention addresses risk with a focus on careIntervention addresses risk with a focus on care--giving giving sensitivity, interpretation of child behaviour (i.e. sensitivity, interpretation of child behaviour (i.e. cognitions: parental attributions), developmental cognitions: parental attributions), developmental knowledge, and selfknowledge, and self--perceived efficacy perceived efficacy –– context is context is AttachmentAttachment

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Evaluation builtEvaluation built--inin►►

A shift in cultureA shift in culture►►

Very promising results: lower maternal depressive Very promising results: lower maternal depressive feelings, stress, better confidence, more benign feelings, stress, better confidence, more benign assessment of child, more cognitive flexibility after few assessment of child, more cognitive flexibility after few sessions. Lowered CAP very likely.sessions. Lowered CAP very likely.

Project 1 Project 1

““Mapping Attributions of ParentsMapping Attributions of Parents”” Using assessment as brief intervention in the Using assessment as brief intervention in the

prevention of maltreatmentprevention of maltreatment

Project 2Project 2

““Songs, Songs, RhymesRhymes’’nn

MoreMore

““ Evaluating the effectiveness of adapted EB Evaluating the effectiveness of adapted EB

programs with a diverse population of clientsprograms with a diverse population of clients

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Parenting education programs offered in community Parenting education programs offered in community settings are very popular, but little information is available settings are very popular, but little information is available on the specific effects they have on parenton the specific effects they have on parent--child interactionchild interaction

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This is true especially when programs have been This is true especially when programs have been customized and thus diverge from their original empirically customized and thus diverge from their original empirically validated bluevalidated blue--prints. prints.

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This exploratory study examined the effectiveness of an This exploratory study examined the effectiveness of an attachmentattachment--focused, group parenting intervention that was focused, group parenting intervention that was delivered in a childrendelivered in a children’’s mental health center and adapted s mental health center and adapted to meet the needs of a diverse group of caregiversto meet the needs of a diverse group of caregivers

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Results indicate that despite substantial modifications to Results indicate that despite substantial modifications to the programthe program’’s evidence based model, benefits were s evidence based model, benefits were obtained across several domains of parenting, for example obtained across several domains of parenting, for example cognitive growth fostering and caregiver distress. cognitive growth fostering and caregiver distress.

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The expected increase in sensitivity however was observedThe expected increase in sensitivity however was observed►►

Program was thus modified based on these findings Program was thus modified based on these findings resulting in a more effective delivery of intervention resulting in a more effective delivery of intervention services to a diverse group of clientsservices to a diverse group of clients

Project 2Project 2

““Songs, Songs, RhymesRhymes’’nn

MoreMore

““ Evaluating the effectiveness of adapted EB Evaluating the effectiveness of adapted EB

programs with a diverse population of clientsprograms with a diverse population of clients

Project 3 Project 3

““Satellite babiesSatellite babies”” Understanding culture specific practicesUnderstanding culture specific practices

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Infant clinicians in multiInfant clinicians in multi--cultural communities are cultural communities are challenged daily by culturechallenged daily by culture--specific practicesspecific practices

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Our mental health models and Our mental health models and EBPsEBPs are still primarily are still primarily based on Western research and philosophybased on Western research and philosophy

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Some new immigrant parents engage in the practice of Some new immigrant parents engage in the practice of sending infants back to their country of origin, to be raised sending infants back to their country of origin, to be raised by members of their extended family.by members of their extended family.

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The children return to their parents in time to begin The children return to their parents in time to begin schooling, having endured multiple separationsschooling, having endured multiple separations

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Does this have serious repercussions for socialDoes this have serious repercussions for social--emotional emotional development?development?

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Our research program examined: 1) the decisionOur research program examined: 1) the decision--making making process of parents in the Chinese Canadian communityprocess of parents in the Chinese Canadian community2) child, parent and family characteristics of returning 2) child, parent and family characteristics of returning children VS children who did not leavechildren VS children who did not leave

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Findings: culture interacts with other considerations such Findings: culture interacts with other considerations such as attachment, and often overrides thoseas attachment, and often overrides those

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There are likely no linear relationships between customs There are likely no linear relationships between customs considered problematic according to mainstream models, considered problematic according to mainstream models, and outcomeand outcome

Project 3 Project 3

““Satellite babiesSatellite babies”” Understanding culture specific practicesUnderstanding culture specific practices

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Project addressed a need to know whether an Project addressed a need to know whether an established evidenceestablished evidence--based approach is as effective based approach is as effective when delivered in a community setting, as in more when delivered in a community setting, as in more controlled, researchcontrolled, research--oriented settings (where efficacy oriented settings (where efficacy was established)was established)

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Attempt to better understand the role of heterogeneous Attempt to better understand the role of heterogeneous client groupsclient groups

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Goal included an examination of the way in which we Goal included an examination of the way in which we measure outcome: use of standard quantitative but also measure outcome: use of standard quantitative but also qualitative assessmentsqualitative assessments

Project 4 Project 4

““Effectiveness of CBT group Effectiveness of CBT group treatment for anxious childrentreatment for anxious children””

Comparing established efficacy with Comparing established efficacy with communitycommunity--based effectivenessbased effectiveness

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Findings suggest that outcomes approximate, but are Findings suggest that outcomes approximate, but are not quite as positive as in efficacy studiesnot quite as positive as in efficacy studies

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Findings also suggest that measuring outcome is a Findings also suggest that measuring outcome is a complex process: contradictory narrative complex process: contradictory narrative vsvs questionnaire data for both children and their parentsquestionnaire data for both children and their parents

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Need to investigate further which children benefit and Need to investigate further which children benefit and which donwhich don’’t and how to optimize outcomes for allt and how to optimize outcomes for all

Project 4 Project 4

““Effectiveness of CBT group Effectiveness of CBT group treatment for anxious childrentreatment for anxious children””

Comparing established efficacy with Comparing established efficacy with communitycommunity--based effectivenessbased effectiveness

The Challenges The Challenges –– The OrganizationThe OrganizationFROM THE CLINICIANSFROM THE CLINICIANS’’ POINT OF VIEWPOINT OF VIEW

►►Increased time commitment and Increased time commitment and workload created by research design and workload created by research design and the implementation of standardized the implementation of standardized procedures; logistics of data collection.procedures; logistics of data collection.

►►Research as addResearch as add--on to clinical on to clinical caseload.caseload.

►►Lack of compensatory resources (e.g., Lack of compensatory resources (e.g., additional staff, technical help, research additional staff, technical help, research incentives for participants). incentives for participants).

FROM THE RESEARCH TEAMFROM THE RESEARCH TEAM’’S POINT OF VIEWS POINT OF VIEW

►►Effort and time necessary to shift Effort and time necessary to shift organizational culture.organizational culture.

►►Continued work involved in securing Continued work involved in securing accommodations and fundingaccommodations and funding

, even when , even when administrative and Board support has been administrative and Board support has been obtained.obtained.

►►Introduction and management of a Introduction and management of a constant student/research assistant constant student/research assistant presence.presence.

►►Restrictions of a unionized environment.Restrictions of a unionized environment.

►►Managing the need for training and Managing the need for training and certification on evidencecertification on evidence--based tools for based tools for researchresearch

The Challenges The Challenges –– The Clients / ParticipantsThe Clients / ParticipantsFROM THE RESEARCH TEAMFROM THE RESEARCH TEAM’’S POINT OF VIEWS POINT OF VIEW

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Small sample sizes that are Small sample sizes that are dependent on client participation.dependent on client participation.

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Inconsistent attendance rate and Inconsistent attendance rate and participant drop out.participant drop out.

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High rate of crisis issues that High rate of crisis issues that interfere with research protocol.interfere with research protocol.

FROM THE CLINICIANSFROM THE CLINICIANS’’ POINT OF VIEWPOINT OF VIEW

►►Concerns about burdening families Concerns about burdening families in crisis with research procedures.in crisis with research procedures.

►►Effects of standardized research Effects of standardized research protocols on the therapeutic alliance.protocols on the therapeutic alliance.

►►Challenges of including clients from Challenges of including clients from high risk populations and diverse high risk populations and diverse backgrounds.backgrounds.

►►To continue to provide services To continue to provide services based on a clientbased on a client--centered philosophy centered philosophy while implementing a research while implementing a research agenda.agenda.

The Challenges The Challenges –– The PartnershipThe PartnershipFROM THE CLINICIANSFROM THE CLINICIANS’’ POINT OF VIEWPOINT OF VIEW

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Demands of marrying divergent Demands of marrying divergent perspectives and clinical versus perspectives and clinical versus research needs.research needs.

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Disruption of the intimacy of the Disruption of the intimacy of the clinical team created by the clinical team created by the involvement of multiple new team involvement of multiple new team members, roles and increased members, roles and increased traffic.traffic.

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Lack of clarity relating to the roles Lack of clarity relating to the roles and functions of all involved in the and functions of all involved in the partnership; acclimatizing to the partnership; acclimatizing to the demands of multiple roles. demands of multiple roles.

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Ambiguity and need for Ambiguity and need for coordination of complex coordination of complex organization and decisionorganization and decision--making.making.

FROM THE RESEARCH TEAMFROM THE RESEARCH TEAM’’S POINT OF VIEWS POINT OF VIEW

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Managing of cliniciansManaging of clinicians’’

concerns that concerns that client service will suffer if they are client service will suffer if they are asked to participate in research.asked to participate in research.

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CliniciansClinicians’’

worry about burdening worry about burdening clients with research protocols.clients with research protocols.

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CliniciansClinicians’’

skepticism about skepticism about standardized methods.standardized methods.

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Frequent exclusion of clients from Frequent exclusion of clients from participation based on cliniciansparticipation based on clinicians’’

concerns.concerns.

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Restrictions and limitations of funding Restrictions and limitations of funding opportunities that are directed to more opportunities that are directed to more traditional academic research.traditional academic research.

DiscussionDiscussion

►►Your project goals, past present or futureYour project goals, past present or future►►Your experienced or anticipated challengesYour experienced or anticipated challenges

Lessons LearnedLessons Learned

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Integration of research and practice is Integration of research and practice is invaluableinvaluable and there is much to be gained by and there is much to be gained by conducting conducting ecologically validecologically valid treatment research in treatment research in community settings. community settings.

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Bilateral knowledge exchangeBilateral knowledge exchange is more potent is more potent than traditional knowledge translation in promoting than traditional knowledge translation in promoting evidenceevidence--based practice. based practice.

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Partnership and teamPartnership and team--buildingbuilding are key. The are key. The integration of research and practiceintegration of research and practice must be must be bilateral in reality, not just in theory. Feelings of bilateral in reality, not just in theory. Feelings of shared ownershipshared ownership and involvement must be and involvement must be engendered for research to flourish. engendered for research to flourish.

Lessons LearnedLessons Learned

►►Clinical issues and the therapeutic alliance Clinical issues and the therapeutic alliance must remain at the forefrontmust remain at the forefront in providing the in providing the intervention and determining when client need intervention and determining when client need must override research integrity. must override research integrity.

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Clinical advantages must be Clinical advantages must be tied very explicitly tied very explicitly and clearly to research activitiesand clearly to research activities to better to better engage cliniciansengage clinicians. Moreover, the research team . Moreover, the research team must balance its commitment to a standardized must balance its commitment to a standardized protocol, while remaining flexible and open to protocol, while remaining flexible and open to constant evaluation.constant evaluation.

Lessons LearnedLessons Learned

►►Collaborative leadershipCollaborative leadership and ongoing support and ongoing support are required to adopt and maintain this type of are required to adopt and maintain this type of research model. A research model. A wellwell--designed organizational designed organizational structurestructure is essential and should include regular is essential and should include regular communicationcommunication (e.g., monthly research meetings) (e.g., monthly research meetings) as well as a dedicated role to coordinate as well as a dedicated role to coordinate partnership activities.partnership activities.

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The host agency must not only support research The host agency must not only support research in principle but also in principle but also back up itsback up its commitment with commitment with support and support and resourcesresources. Clinician . Clinician workloadsworkloads must be amended to reflect increased demands.must be amended to reflect increased demands.

Lessons LearnedLessons Learned

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A A paradigm shiftparadigm shift is essentialis essential to view to view research and practice as research and practice as mutually supportivemutually supportive rather than as separate silos. Research should rather than as separate silos. Research should not to be seen as an addnot to be seen as an add--on, taking away from on, taking away from direct clinical services.direct clinical services.

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CommunityCommunity--based research will never be based research will never be flawless, and flawless, and the process is imperfectthe process is imperfect. . Researchers and clinicians must Researchers and clinicians must tolerate tolerate ambiguityambiguity, anxiety and differences due to their , anxiety and differences due to their divergent perspectives to advance the research divergent perspectives to advance the research agenda.agenda.

Lessons LearnedLessons Learned

From Implementation to Outcome: From Implementation to Outcome: Making it HappenMaking it Happen

►► Implementation in diverse organizationsImplementation in diverse organizations►► From lessons learned to next stepsFrom lessons learned to next steps

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Securing the Securing the resourcesresources to firmly establish the research to firmly establish the research projects, to maintain the partnershipprojects, to maintain the partnership’’s momentum and to s momentum and to ensure itensure it’’s growths growth..

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Conveying research resultsConveying research results to clinicians and exchanging to clinicians and exchanging knowledge both inside the partnership organizations as well knowledge both inside the partnership organizations as well as externally with similar organizations and research as externally with similar organizations and research partnerships.partnerships.

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Educating all sectors of the organizationEducating all sectors of the organization,, including including administrative staff, regarding the importance of research administrative staff, regarding the importance of research efforts and promoting further awareness of the resources efforts and promoting further awareness of the resources needed to equip clinicians with the tools necessary for needed to equip clinicians with the tools necessary for evidenceevidence--based practice and research.based practice and research.

Next StepsNext Steps

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Promoting Promoting clinician reliability and protocol clinician reliability and protocol adherenceadherence and increasing client protocol completion.and increasing client protocol completion.

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Lobbying funding agencies and governmentsLobbying funding agencies and governments to to increase their support by raising awareness of increase their support by raising awareness of communitycommunity--based research partnerships and the based research partnerships and the important types of research being conducted.important types of research being conducted.

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Promoting acceptance in, andPromoting acceptance in, and educating academia educating academia to the benefitsto the benefits of communityof community--based research which is based research which is often seen as inferior to more traditional largeoften seen as inferior to more traditional large--sample sample size, controlsize, control--group trials.group trials.

Next StepsNext Steps

AcknowledgmentsAcknowledgments

@ Aisling Discoveries Child & Family Centre

Linda Brightling, Lisa Milligan, Norma Sockett-DiMarco, Joan Williams, Carrie McLlwain, Carrie McLlwain (Infant Child Treatment Team); Zel Fellegi, Betty Kashima, Caron Gabbidon,

Connie Tse, Val Dunham and Barb McKinnon

Special thanks to: Our client participants, and

@ York University Lab

Brooke Halpert, Jenn Summers, Natasha Mullen-Whitfield, Jessica Chan, Bramilee Dhayanandhan, Baila

Ellenbogen, Vicky Lishak

& Meg McLeod

Thank you!Thank you!