Defining the scope of systems of care: an ecological perspective

The association between anxiety and internet addiction among left-behind secondary school students: the moderating effect of social support and family types

BACKGROUND

The left-behind children (LBC), children and adolescents aged 0-18 whose parents have migrated for economic purposes for extended periods exceeding three months, present a unique social concern. These children remain in their place of household registration, often under the guardianship of relatives, while receiving compulsory education. LBC with growing Internet addiction (IA) have made it urgent to take a close look at the mechanisms and effective interventions for them. Anxiety has been proven to be correlated with IA in adolescents; however, the mechanisms of addiction in this population are less well-fully grasped. Based on the current theories and empirical results, the study examined whether and how social support (SS) and family types moderated the associations between anxiety and IA among left-behind secondary students.

METHODS

Stratified cluster sampling survey. A questionnaire was administered to 5290 secondary school children (2553 classified as left-behind) to explore the relationships between anxiety, IA, left-behind types, family types, and social support. This cross-sectional study employed a stratified cluster sampling survey of students in the ethnic areas of southeast Chongqing. The study sought to appraise the relationships between anxiety and IA in different types of left-behind children and to assess the potential moderating effect of SS on the relationship among the population and its family types differences.

RESULTS

The relationship between anxiety and IA was moderated significantly by social support and family types. Notably, the impact of social support on the moderating effect between IA and anxiety varied among students from both family types. For students from families where both parents had migrated, social support weakened the association between IA and anxiety. Conversely, for students from single-parent families where the parent had migrated, social support seemed to strengthen the relationships between these two issues.

CONCLUSIONS

The moderating effects of SS on the relationship between anxiety and IA differs based on family type among various groups of left-behind secondary students. Gaining insights into the IA mechanisms can guide the development of targeted intervention strategies aimed at minimizing IA among diverse groups of left-behind students.

Factors Associated with Child Removal Among American Indian and Alaska Native People in an Alcohol Intervention Study

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.

Implementing Integrated Early Childhood Mental Health Services in Primary Care: Relationships, Vision, and Sustainability

The Massachusetts Multi-City Young Children's System of Care Project was a federally funded program to provide integrated early childhood mental health (ECMH) services in primary care for families of very young children (birth-six years old) with Serious Emotional Disturbances across three cities in Massachusetts, U.S.A. This study describes lessons learned from the implementation of this program and makes recommendations for best practices to improve the delivery and efficacy of ECMH services in primary care settings. Staff and leadership (n = 35) from 11 agencies (primary care practices, community service agencies, and local health departments) that co-implemented this program participated in focus groups and semi-structured key informant interviews. Thematic analysis was used to characterize specific facilitators and barriers to successfully implementing system-wide programming for ECMH. Four main themes were identified: (1) Strong multilevel working relationships are critical for integration, (2) Capacity-building activities can be leveraged to improve implementation, (3) Financial challenges are a primary barrier to building efficacious systems of care, and (4) Flexibility and resourcefulness can help overcome logistical challenges in integration. Implementation lessons learned may serve as guidance for other states and institutions in the U.S. seeking to improve the integration of ECMH services into primary care. They may also provide strategies to adapt and scale these interventions to improve the mental health and well-being of young children and their families.

Perceptions of professionals about factors affecting the implementation of early childhood support systems: A case study evaluation from an ecological perspective

This evaluation research looked at factors affecting collaboration across the various levels of implementation of early childhood support systems. An ecological conceptual framework was used to examine barriers and facilitators to implementing social and health care services from the perspective of the professionals involved at the national, state, and local level of government. A single case study following a qualitative research strategy was conducted with a total of 29 professionals from social development and health ministries, one municipality and a family health center responsible for implementing the Chile Grows with You system. The results show that at the national level, the main factors include socio-political aspects, funding, and the empathy that professional employees hold for peers who are at lower rungs in the hierarchy. At the state level workplace conditions play a key role. For the local level those factors include information system management and the political support of the local government. The discussion section emphasizes the relevance of considering the interdependence of such factors that influence implementation outcomes and the need to move away from a single program evaluation to a multilevel implementation analysis of public policy.

Examining Integrated Youth Services Using the Bioecological Model: Alignments and Opportunities

Integrated youth service (IYS) is a collaborative approach that brings practitioners together from across disciplines to provide comprehensive services including mental health care for youth and their families. IYS models serve as an advancement in practice as they go beyond the capacity of individual programs and services to reduce the fragmentation of care. Yet, there continue to be opportunities to expand on this perspective and promote health beyond the scope of formalized services. The bioecological model is a theoretical model that examines individual development within multiple systems of influence as well as through interactional processes between the individual and their environment. This paper provides an overview of the bioecological model and the major components of the IYS model, describing alignment and complementarity. The bioecological model provides some explanations for why IYS models may be effective and helps to provide direction to expand applied practice toward a more holistic perspective.

Children exposed to the arrest of a family member: Associations with mental health

The arrest of a parent or other family member can be detrimental to children's health. To study the impact of exposure to the arrest of a family member on children's mental health and how said association may change across developmental periods, we examined baseline data for children (birth through 11 years) entering family-based systems of care (SOC). Children exposed to the arrest of a family member had experienced significantly more 5.38 (SD = 2.59) different types of potentially traumatic events (PTE) than children not exposed to arrest 2.84 (SD = 2.56). Multiple regression model results showed that arrest exposure was significantly associated with greater behavioral and emotional challenges after controlling for children's age, gender, race/ethnicity, household income, caregiver's education, parenting factors, and other PTE exposure. Further analyses revealed differences in internalizing and externalizing behaviors associated with arrest exposure across developmental levels. This study highlights some of the mental health challenges for children exposed to the arrest of a family member, while adding to our knowledge of how such an event affects children across different developmental periods. More trauma-informed, developmentally appropriate systems need to be in place at all levels to assist children and families experiencing arrest.

A mental health needs assessment of urban American Indian youth and families

American Indian (AI) youth experience significant mental health disparities. The majority of AI youth live in urban areas, yet urban AI youth are underserved and unstudied. This manuscript describes a qualitative study of community mental health needs in an urban population of AI youth, conducted as part of the planning process for a system of care (SOC). Participants included 107 urban AI youth and families that participated in one of 16 focus groups assessing mental health needs and services. Forty-one percent of participants were youth or young adults. Data were coded and analyzed using qualitative software and then further analyzed and interpreted in partnership with a community research workgroup. Results indicated various community characteristics, mental health and wellness needs, and service system needs relevant to developing a system of care in this community. Key community, cultural, and social processes also emerged, reinforcing the importance of broader system changes to promote a sustainable SOC. These systems/policy changes are reviewed in the context of previous literature proposing necessary systems change to support behavioral health care in AI communities as well as to ensure that SOC implementation is consistent with core values and philosophy across all communities.

Sustaining and expanding systems of care to provide mental health services for children, youth and families across America

The Substance Abuse and Mental Health Services Administration has been instrumental in supporting the development and implementation of systems of care to provide services to children and youth with serious mental health conditions and their families. Since 1993, 173 grants have been awarded to communities in all 50 states, Puerto Rico, Guam, the District of Columbia, and 21 American Indian/Alaska Native communities. The system of care principles of creating comprehensive, individualized services, family-driven and youth-guided care and cultural and linguistic competence, supported by a well-trained and competent workforce, have been successful in transforming the field of children's mental health and facilitating the integration of child-serving systems. This approach has achieved positive outcomes at the child and family, practice and system levels, and numerous articles have been published using data collected from system of care communities, demonstrating the effectiveness of this framework. This article will describe lessons learned from implementing the system of care approach, and will discuss the importance of expanding and sustaining systems of care across the country.

"If we're going to change things, it has to be systemic:" systems change in children's mental health

Communities that undertake systems change in accordance with the system of care philosophy commit to creating new systems entities for children and adolescents with serious emotional disturbance. These new entities are values-based, voluntary, and cross-agency alliances that include formal child-serving entities, youth, and families. Describing the scope and intent of one such implementation of systems of care, a mental health administrator commented, "If we're going to change things, it has to be systemic" (B. Baxter, personal communication, December 2, 2005). This paper explores the concept of "systemic" in the context of systems of care. Systems theory is used to understand strategies of purposeful systems change undertaken by stakeholders in established system of care communities. The paper presents a conceptual model of systems change for systems of care that is grounded in data from a national study of system of care implementation (Research and Training Center for Children's Mental Health in Case Studies of system implementation: Holistic approaches to studying community-based systems of care: Study 2, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, Tampa, FL, 2004). The model is based on Soft Systems Methodology, an application of systems theory developed to facilitate practical action around systems change in human systems (Checkland in Systems thinking, systems practice, Wiley, Chichester, 1999). The implications of these findings to real world actions associated with systems change in systems of care are discussed.

Systems of care: new partnerships for community psychology

For almost two decades, the federal government has supported the development of integrated models of mental health service delivery for children and families, known as systems of care (SOCs), that strive to be child-centered, family-focused, community-based, and culturally competent. These efforts align well with the values and principles (e.g., empowerment, collaboration, strengths emphasis, focus on macro-level social/system change) central to community psychology (CP; Kloos et al. in Community psychology, Cengage Learning, Belmont, 2012). Despite the convergence of many core values, CPs have historically been underrepresented in key roles in SOC initiatives. However, this has changed in recent years, with increasing examples of community psychology skills and principles applied to the development, implementation, and evaluation of SOCs. Because successful and sustainable implementation of SOCs requires community and system-level change, and SOCs are increasingly being urged to adopt a stronger "public health" orientation (Miles et al. in A public health approach to children's mental health: a conceptual framework, Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children's Mental Health, Washington, DC, 2010), there is great potential for CPs to play important roles in SOCs. This paper discusses opportunities and roles for CPs in SOCs in applied research and evaluation, community practice, and training.

Moving forward with systems of care: needs and new directions

The articles in this Special Issue on system change within systems of care (SOCs) provide guidance regarding strategies for modifying SOCs to address the needs of different populations, and ways for changing systems to support more positive child and family outcomes. This paper frames central needs, unanswered questions, and issues that remain for those working to implement SOCs. Specific needs and new directions considered include: (1) rigorous implementation-focused research to identify the necessary and sufficient elements of SOCs and the primary practice approach currently used in SOCs, wraparound; (2) applied research to assess SOCs and document their effectiveness in non-standard or non-traditional settings (i.e., non-mental health settings, including child welfare, juvenile justice, local housing authorities); (3) controlled outcome studies for school-based wraparound initiatives; (4) research to document the effectiveness of the family support efforts that are part of most SOCs; and (5) attention to context, for families, service providers, and collaborative implementation efforts, by researchers and providers alike. Progress in these areas can inform well-targeted system change efforts in the context of SOCs, a critical need given changes in federal funding for these initiatives.

The ABLe change framework: a conceptual and methodological tool for promoting systems change

This paper presents a new approach to the design and implementation of community change efforts like a System of Care. Called the ABLe Change Framework, the model provides simultaneous attention to the content and process of the work, ensuring effective implementation and the pursuit of systems change. Three key strategies are employed in this model to ensure the integration of content and process efforts and effective mobilization of broad scale systems change: Systemic Action Learning Teams, Simple Rules, and Small Wins. In this paper we describe the ABLe Change Framework and present a case study in which we successfully applied this approach to one system of care effort in Michigan.

The effects of caregiver social connections on caregiver, child, and family well-being

This study examines the degree to which caregiver social connectedness influences the effects of strain associated with caring for a child with severe emotional disturbance (SED) on caregiver well-being. We propose a model describing the relationships among the variables of interest and investigate elements of this model. Caregiver strain and social connections were significantly associated with caregiver well-being. Although, no significant interaction effects of caregiver strain and social connections were detected, study findings suggest that caregiver well-being can affect child progress and adjustment. Implications for child- and family-serving systems are considered.

Using latent growth curve modeling to examine changes in mental health outcomes for children enrolled in a system of care

MeckCARES, a system of care (SOC) in Mecklenburg County, North Carolina, is designed to serve youth with severe emotional disturbances and their families. This study employed latent growth curve (LGC) modeling to examine (a) the degree to which youth improved on indicators of adjustment over the course of the first year of enrollment in MeckCARES, and (b) the services or demographic variables associated with individual differences in the rate of change over time. Participant caregivers (N = 121) reported on 3 major indicators of youth adjustment at baseline, 6-month follow-up, and 12-month follow-up. Primary analyses indicated that there was a modest yet significant improvement in all 3 outcome measures over the first year of enrollment in MeckCARES. Additional analyses revealed that caregiver reports of receiving case management at any point in the first year were associated with improvement in behavioral and emotional strengths as well as a reduction in psychological and behavioral symptoms. No significant differences in rate of change were observed based on caregiver-reported receipt of individual or family therapy nor any demographic variables. These findings suggest that MeckCARES may be particularly effective when youth are receiving case management services. Additional implications for practice are discussed.

Profiles of Systems Involvement in a Sample of High-Risk Urban Adolescents with Unmet Treatment Needs

This study examined profiles of involvement in four systems (education, child welfare, legal, and treatment) in a sample of 253 high-risk urban adolescents with unmet behavioral health needs. Self-report data were collected on multiple dimensions of involvement within each system, demographics, and DSM-IV diagnoses. Latent class analysis revealed four profiles: Education System: Academic and Disciplinary, Education System: Academic Only, Legal/Juvenile Justice Involved, and Multiple Systems/Child Welfare. Profiles differed based on gender and psychiatric diagnoses. Boys were overrepresented in Education System: Academic and Disciplinary and Legal/Juvenile Justice Involved, and girls were overrepresented in Multiple Systems/Child Welfare. The two education system focused classes were characterized by depressive disorders and ADHD. Youth in Legal/Juvenile Justice Involved and Multiple Systems/Child Welfare were characterized by conduct disorder and substance abuse. Implications for assessment and treatment planning for high-risk youth and for the organization of community-based behavioral health services are discussed.

Moving from principles to practice: recommended policy changes to promote family-centered care

This paper emphasizes the value of family-centered care. Discussion highlights family-centered philosophies (e.g., Systems of Care [SOCs]) and practice models (i.e., wraparound) and identifies discrepancies between conceptualizations and actual practice. Data from multiple sources detail issues in fidelity to family-centered values and needs and risks experienced by siblings of children with severe emotional disturbance and their caregivers. This discussion provides a springboard for policy recommendations to strengthen family support programming and enhance family-centered care, from modifying funding streams such that systems extend their reach beyond children with full-blown, diagnosable problems (those meeting standards of "medical necessity), to supporting prevention and early intervention initiatives that address families as targets for intervention. Recommendations include ensuring that communities with SOC funding address the needs of families; broadening Medicaid rules and definitions; expanding the range of reimbursable activities and services; and increasing funding for evaluating family-centered care models and family support programming.

Organizational capacity to deliver effective treatments for children and adolescents

Treatment and services research in the general medical sector has emphasized the importance of addressing organizational capacity to improve interventions for patients with chronic conditions. Efficacious interventions for child and adolescent mental disorders without substantial enhancements in mental health organizational capacity will not result in improvements for children. This paper (a) lists some organizational enhancements that have resulted in improved medical care, (b) briefly underscores recent market trends such as state healthcare reform efforts, increased use of electronic records and contracting initiatives that push consolidation of agencies, and (c) describes one example of the organizational development of child behavioral services that will enhance treatment delivery.

Factors associated with positive adjustment in siblings of children with severe emotional disturbance: the role of family resources and community life

This study builds on the scant research involving siblings of children with severe emotional disturbances (SED) and examines: associations between adversity experiences and adjustment among 5- to 10-year-old siblings, and relations among family resources, community life, and sibling adjustment. Caregivers from 100 families completed standardized indicators of sibling adjustment and scales reflecting multiple contextual variables. Results document negative associations between stress exposure and sibling adjustment. Regression models also indicate positive associations between the caregiver-child relationship and broader family resources on sibling behavioral and emotional strengths, even after accounting for adversity experiences; adversity exposure was the prime correlate in regression models involving sibling oppositional behavior. Analyses also suggest that strain related to parenting a child with SED is associated with sibling adjustment. This work documents the needs of these siblings and their family systems and highlights the relevance of not only core proximal influences (e.g., child-caregiver relationship) but also elements of their broader contexts. Implications and recommendations are described, including the need to support plans of care that involve services, supports, or preventive strategies for these siblings.

The importance of context in fostering responsive community systems: supports for families in systems of care

The importance of helping families of children with severe emotional disturbances (SED) connect with informal or natural supports-that is, individuals who are part of their ongoing communities and daily lives-has been widely recognized. Utilization of informal supports has thus become a core element within systems of care (SOCs) designed to improve services for children with SED and their families. However, research demonstrates that implementation of wraparound, the key practice approach within SOCs, often does not include involvement of informal supports. Using a measure of social connectedness (SC), developed to augment the instruments used for the SOC national evaluation, this study assessed parents' and caregivers' views of their connections to and support from their community within a SOC. Overall, parents and caregivers reported low levels of support across multiple sources as well as a desire for more support. Greater levels of perceived support related positively to caregiver strain, types of and satisfaction with services received, and views of their communities as supportive and safe. Greater attention to families' contexts and the identification of effective ways to connect families to their communities are recommended.