A benchmarking study of father involvement in Australian child mental health services

The Ws of Parental Help-Seeking: When, Where, and for What Do Parents Seek Help for Child Mental Health

Parental help-seeking preferences may help explain the treatment gap in child mental health. This study examined mothers' and fathers' help-seeking behaviors for child mental health to further understand their individual preferences for treatment. A total of 394 mothers and fathers completed questionnaires assessing the types of help sought for mental health concerns for a target child (age 3-7 years), as well as measures representing illness profile, predisposing characteristics, and barriers/facilitators proposed to influence help-seeking. Parents often sought informal rather than professional help. Regression modelling indicated mothers' different help-seeking behaviors were significantly associated with illness profile (marital quality, child mental health, parental education), predisposing factors (parental attributions, child age), and family income, while fathers' different help-seeking behaviors were significantly associated with child demographics (age, gender). The results support expanding treatments into nonclinical settings and improving child mental health literacy to improve appropriate parental help-seeking for child mental health concerns.

Barriers and Facilitators to Engaging Mothers and Fathers in Family-Based Interventions: A Qualitative Systematic Review

The current systematic review examined the similarities and differences between mothers' and fathers' reported barriers and facilitators to engaging in family-based interventions for child and adolescent behavioural problems (aged 2-17 years). Systematic searches of six electronic databases and grey literature alongside a two-way screening process identified twenty eligible qualitative studies from 2004 to 2019. A thematic meta-synthesis identified similarities in major themes of psychological, situational, knowledge/awareness, programme/intervention, co-parenting, practitioner, and beliefs/attitudes factors, alongside group experiences and stages of engagement. However, differences emerged in subthemes related to parental, treatment, and service delivery factors that included individual ideologies of parenting, parental roles, and treatment participation; the role of mothers in facilitating engagement; and individual preferences for treatment content and delivery. Overall, findings suggest that while mothers and fathers experience similar challenges to engagement, they can also experience distinct challenges which need to be addressed at the treatment outset to maximise engagement.

Toward evidence-informed child rearing: Measurement of time-out implementation in a community sample

BACKGROUND

Time-out (TO) is a widely used parental discipline strategy with strong research support in programmes that promote positive child development. Concerns have been raised, however, regarding adverse impact on child mental health (CMH) in part driven by evidence of widespread variability in appropriate implementation. There are no existing measures of TO. We present the first measure of procedural implementation of TO in a community sample of parents of children aged 6-8 years.

METHODS

A nationally representative sample (N = 474) of parents completed a survey on the implementation of TO, parent-child relationships, and emotional and behavioural difficulties. The scale of TO use was used to test the convergent validity between TO implementation and parenting practices/family adjustment and CMH.

RESULTS

Consistent with international research, >70% of parents have used TO with their children. There was high variability in the levels of appropriate implementation of TO. Scale reliability (Cronbach's alpha) was acceptable and tests of convergent validity indicated that as expected, less appropriate implementation of TO was associated with worse CMH and poorer parenting and family adjustment.

CONCLUSIONS

The current findings suggest that the scale is a psychometrically sound instrument for measuring the appropriate procedural implementation of TO with young children.

Intervention and Implementation Characteristics to Enhance Father Engagement: A Systematic Review of Parenting Interventions

In recent years, the prevalence rates of children's mental health disorders have increased with current estimates identifying that as many as 15-20% of children meet criteria for a mental health disorder. Unfortunately, the same robust parenting interventions which have long targeted some of the most common and the most treatable child concerns (e.g., externalizing, disruptive behavior, and aggression) have also shown consistently low rates of father engagement. This persistent issue of engagement comes in the wake of an increasingly large body of literature which highlights the unique positive contributions fathers make to children and families when they are engaged in parenting interventions. As the role fathers play in families shifts to become more inclusive of childcare responsibilities and less narrowly defined by financial contributions, it becomes increasingly important to understand how best to engage fathers in interventions that aim to enhance parenting efficacy and family outcomes such as coparenting. The current review examined intervention (e.g., format and setting) and implementation characteristics (e.g., training and agency-level changes) associated with father engagement. Particular attention is paid to studies which described father-specific engagement strategies (e.g., inviting fathers directly, father-only groups, and adapting intervention to incorporate father preferences). A total of 26 articles met inclusion criteria after screening and full-text review. Results indicate that father engagement (i.e., initiating treatment) remains low with 58% of studies either not reporting father engagement or having engagement rates below 50%. More than two-thirds of studies did not include specific father engagement strategies. Those that did focused on changes to treatment format (e.g., including recreational activities), physical treatment setting (e.g., in-home and school), and reducing the number of sessions required for father participation as the most common father-specific engagement strategies. Some studies reported efforts to target racially and ethnically diverse fathers, but review results indicated most participants identified as Non-Hispanic White. Interventions were largely standard behavioral parent training programs (e.g., PCIT and PMT) with few exceptions (e.g., COACHES and cultural adaptations), and very few agencies or programs are systematically making adjustments (e.g., extended clinic hours and changes to treatment format) to engage fathers. Recommendations for future directions of research are discussed including the impact of differential motivation on initial father engagement in treatment, the importance of continuing to support diverse groups of fathers, and the potential for telehealth to address barriers to father engagement.

Strategic Priorities for Implementation of Father-Inclusive Practice in Mental Health Services for Children and Families: A Delphi Expert Consensus Study

The aim of this study was to investigate expert consensus on barriers and facilitators to the organizational implementation of Father-Inclusive Practice (FIP) in child and family services to establish strategic priorities for implementation. An international panel of 56 experts in child and family service provision and father inclusion were surveyed using the Delphi technique. Three online questionnaires were used to gather opinions and measure experts’ levels of agreement in regard to factors that enable or hinder the organizational implementation of FIP. Survey design, analysis and interpretation was guided by the Consolidated Framework for Implementation Research (CFIR). Consensus was achieved for 46.4% (n = 13) statements. Eight barriers and five facilitators were identified as strategic priorities to organizational implementation of FIP. The key factors were related to the following CFIR themes: leadership engagement, access to information and knowledge, implementation climate, structural characteristics, networks and communication, client needs and resources, external policies and incentives, and reflecting and evaluating. The study findings suggest that issues related to central prioritization, top-down organizational processes and external policy context should represent priority areas for implementation. Our results prioritise methods for improving FIP by highlighting the key areas of organizational practice to be addressed by tailored implementation strategies.

Assessing the extent of shared decision making in Pediatrics: Preliminary psychometric evaluation of the German CollaboRATEpediatric scales for patients aged 7-18 years, parents and parent-proxy reports

OBJECTIVE

To conduct a preliminary evaluation of psychometric properties of CollaboRATE^pediatric, a set of three scales to assess shared decision making (SDM) with pediatric patients, parents and parents on behalf of their children (parent-proxy reports). As secondary objectives we examined the scales' distributional characteristics, acceptability, and agreement between scales.

METHODS

Patients aged ≥ 7 years and parents were recruited in two outpatient facilities providing healthcare services for children with neurological and behavioral health conditions. We collected 46, 169 and 227 pediatric patient, parent-proxy and parent reports, respectively. Convergent, divergent and discriminative validity were investigated. Acceptability of the scales and agreement between patient and parent-proxy reports were explored by assessing item nonresponse and Bland-Altman plots.

RESULTS

While convergent and divergent validity were established for the parent scale, discriminative validity was not demonstrated for any of the scales. The scales showed good to excellent acceptability. Parent-proxy reports agreed to a moderate extent with patients' self-reports of SDM.

CONCLUSION

CollaboRATE^pediatric offers a starting point for parsimoniously assessing SDM in Pediatrics, however further psychometric testing is warranted.

PRACTICE IMPLICATIONS

Given limited psychometric support for the pediatric patient scale, we recommend using both the pediatric patient and parent-proxy report scales to assess SDM in pediatric patients until further psychometric testing is concluded.

Bridging the gap between child mental health need and professional service utilisation: Examining the influence of mothers' parental attributions on professional help-seeking intentions

There is a significant gap between the need for child mental health services and use of these services by families. Parental attributions may play a role in this. This study examined whether mothers' attributions about their child's problems influence professional help-seeking intentions in a general sample of community mothers. Secondary analysis re-examined this hypothesis in a subgroup of mothers of children with clinically elevated mental health symptoms. Cross-sectional survey data were collected from mothers (N = 184) of children aged between 2 and 12 years recruited from the community. Mothers completed self-report questionnaires measuring parental attributions: child-responsible attributions and parental self-efficacy; professional help-seeking intentions; and psychosocial covariates: child mental health, mothers' anxiety and depression, child age, gender, marital status, education, and professional help-seeking experience. Hierarchical regression modelling indicated that parental attributions explained professional help-seeking intentions after controlling for covariates in both the general sample (ΔF = 6.07; p = .003) and subgroup analysis (ΔF = 10.22, p = .000). Professional help-seeking intentions were positively associated with child-responsible attributions (β = .19, p = .002) but not parental self-efficacy (β =  - .01, p = .865) in the general sample, while positively associated with child-responsible attributions (β = .20, p = .009) and negatively associated with parental self-efficacy (β =  - .16, p = .034) in the subgroup analysis. Findings were independent of the presence of clinically elevated symptoms, problem type, and severity. Overall, the findings support models suggesting that parental attributions have a role in professional help-seeking for child mental health problems.

Global Workforce Development in Father Engagement Competencies for Family-Based Interventions Using an Online Training Program: A Mixed-Method Feasibility Study

Global access to practitioner training in the clinical engagement of fathers in family-based interventions is limited. The current study evaluated the feasibility of training practitioners in Canada and UK using online training developed in Australia by examining improvements in practitioner confidence and competence in father engagement, training satisfaction, qualitative feedback, and benchmarking results to those from an Australian sample. Practitioners were recruited to participate in a 2-h online training program through health services and charity organisations. The online program required practitioners to watch a video and complete self-reflection exercises in a digital workbook. Pre- and post-training measures were collected immediately before and after the online training program. The results indicated significantly large improvements in self-reported confidence and competence in engaging fathers following training, with levels of improvement similar to those found in Australia. Training satisfaction was high and qualitative feedback suggested providing local resources and increasing representation of social diversity could improve training relevance in local contexts. The findings suggest online training in father engagement can contribute to global workforce development in improving practitioners' skills in engaging fathers in family-based interventions.

Patients', carers' and clinicians' attitudes towards alternative terms to describe the at-risk for psychosis state

OBJECTIVE

Language used in psychiatry is important because it provides an understandable and accurate way of describing clinical and theoretical concepts. The use of labels in psychiatry has often been associated with stigma and reduced engagement with clinical services. This studys aims were to generate new terms for the 'at-risk mental state' (ARMS) concept and to investigate what young people, their caregivers and clinicians thought about them as well as terms commonly used in early intervention clinics. Another aim was to understand participants preference related to the best timing to introduce the at-risk concept and the extent and context of the information presented.

METHODS

New terms illustrating the at-risk concept have been generated by a youth reference group with lived experience of mental illness: 'pre-diagnosis stage' (PDS), potential of developing a mental illness (PDMI) and disposition for developing a mental illness (DDMI). A specifically designed questionnaire was administered to 46 patients with ARMS, 24 caregivers and 52 clinicians to obtain their feedback on newly proposed terms and on the terms already used in clinical practice and research.

RESULTS

The preferred terms were PDS, PDMI and ARMS. The least favoured terms were Ultra High Risk and Attenuated Psychosis Syndrome, which were thought to be associated with the most stigma. Most participants agreed that disclosure about diagnosis should be delivered early by the key clinician.

CONCLUSIONS

Patients generated terms such as PDS, PDMI, alongside ARMS should be considered to be used in clinical practice. They present with low stigma and are illustrative of young peoples difficulties.

Practitioner Review: Parenting interventions for child conduct problems: reconceptualising resistance to change

Parenting interventions based on social learning theory have received extensive empirical support in the treatment of child conduct problems; yet, they fail to produce lasting gains in as many as a third of cases. Perspectives on these poor outcomes have been informed by numerous lines of research, and practitioner recommendations for improving such outcomes have often emphasized processes related to clinical engagement. In this Practitioner Review, we examine recent theory and evidence pertaining to these processes, including emerging research into the therapeutic relationship across face-to-face and eHealth treatment modalities, and the clinical engagement of both mothers and fathers. The concept of resistance to change is examined in light of these developments, and it is argued that the process of overcoming such resistance can be characterized as one of reflective practice. A novel process model based on this perspective is presented, comprising practical clinical strategies that are designed to be initiated from the earliest contacts with a family and build on one another across treatment.

Midwives' experiences of father participation in maternity care at a large metropolitan health service in Australia

OBJECTIVE

Engagement of fathers to participate in pregnancy, birth and early postnatal care has significant advantages for women and infants as well as fathers. In Australia, guidelines for midwifery practice do not include specific recommendations about father-inclusive care, and models for publicly funded maternity care do not extend to the provision of care tailored specifically towards the needs of fathers. This study investigated the perceptions of midwives regarding their role in fathers' wellbeing, the extent of fathers' attendance at and participation in their services, advantages and disadvantages of father participation and barriers and enablers to father engagement.

DESIGN

Convergent mixed methods, cross-sectional.

SETTING

A large metropolitan public maternity hospital that provides care to some of the most socio-economically disadvantaged suburbs and multi-cultural communities in Melbourne, Australia.

PARTICIPANTS

All midwives employed at the hospital (n=196) were invited to participate.

METHODS

Anonymous online survey and semi-structured interviews. Descriptive statistics were calculated for quantitative survey responses. Interview data and qualitative survey responses were analysed thematically.

FINDINGS

Forty midwives working in all areas of maternity services across the hospital completed surveys, and six participated in interviews. The data illustrate the dilemma faced by midwives in their specific role of supporting women and babies. On the one hand, participants indicated that fathers' wellbeing should be part of their role and named many advantages of father participation in maternity services, including support and advocacy for mothers and bonding with infants. Participants estimated that most fathers attend births and visit their partner and infant on the postnatal ward, 52% attend antenatal appointments and 76% are present at postnatal home visits. Participants reported several midwife strategies and health service factors which facilitate father attendance and active engagement. On the other hand, participants reported several barriers to father engagement, including antenatal appointment schedules which are at odds with fathers' work commitments and the lack of on-site group antenatal education. Some of the barriers they reported are specific to the vulnerable communities for which they provide maternity care. Extraordinary circumstances were reported, including fathers working overseas, fathers in prison, new immigrant status that is often accompanied by a lack of family support to care for other children even during labour and birth, and poor socio-economic status. In addition, in many cultures, pregnancy and birth are seen as "women's work"; fathers would not traditionally be involved. Participants also reported that midwives lack training and confidence in engaging fathers, particularly in responding to fathers with mental health concerns. When providing care for families at risk of family violence, father attendance was perceived a significant disadvantage.

KEY CONCLUSIONS

Midwife-provided health services represent a significant opportunity to include and address fathers, and midwives recognise the significant advantages of engaging fathers, unless there is a risk of family violence. However, midwives currently report lack of training and confidence in addressing fathers' needs, and several individual, social, cultural, and health service factors can present barriers to engaging fathers.

IMPLICATIONS FOR PRACTICE

Given the substantial benefits of engaging fathers for women and infants, we argue that maternity services should promote father engagement, for example by offering after hours appointment schedules, free antenatal and parenting education, and workshops to upskill midwifery staff. Education regarding the importance of father participation and skills for working with fathers should be included in the undergraduate preparation of midwives and other key maternity care professionals. Addressing the challenges of providing care to a multicultural community requires sensitive discussion with families from each of those cultures.

Evaluating Practitioner Training to Improve Competencies and Organizational Practices for Engaging Fathers in Parenting Interventions

Fathers are consistently underrepresented in parenting interventions and practitioners are an important target for change in interventions to enhance father engagement. This research examined the effects of two practitioner training programs in improving practitioner rated competencies and organizational father-inclusive practices. Two studies were conducted, each with a single group, repeated measures (pre, post and 2-month follow-up) design. Study 1 (N = 233) examined the outcomes of face-to-face training in improving practitioner ratings of competencies in engaging fathers, perceived effectiveness and use of father engagement strategies, organizational practices and rates of father engagement. Study 2 (N = 356) examined online training using the same outcome measures. Practitioners in both training formats improved in their competencies, organizational practices and rates of father engagement over time, yet those in the online format deteriorated in three competencies from post-training to follow-up. The implications for delivering practitioner training programs to enhance competencies and rates of father engagement are discussed.