Building Partnerships:

1
Building Partnerships Bringing Research to
Childrens Mental Health in Ontario Presented
at the CMHO Annual Conference, November 21st,
2008 Yvonne Bohr Leigh Armour Infant Child
Treatment Team, Aisling Discoveries Child and
Family Centre Department of Psychology, York
University
2
Agenda

• Context
• Goals of our partnership
• Setting
• The projects four examples
• The challenges
• Lessons learned
• Next steps

3
Building Partnerships Why Conduct Research in
a Childrens 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  use outdated methods.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).
• Research and evidence-based practice models often
  reach community clinical settings circuitously
  and slowly (Barwick et al., 2005).

4
K
K
Knowledge
l
5
Building Partnerships Why Conduct Research in
a Childrens Mental Health Centre?

• 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
  (Fixsen, 2004).

6
K
7
Building Partnerships Why Conduct Research in
a Childrens Mental Health Centre?

• There is a need for more ecologically valid
  treatment research (Jensen et al., 2005 ).
• 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.

8
Building Partnerships Why Conduct Research in
a Childrens Mental Health Centre?

• Practice based evidence VS evidence-based
  practice

9
Goals of our Partnership Beyond pre and post

• To facilitate bilateral knowledge exchange.
• To train scientist practitioners making
  clinicians research savvy and producing
  researchers that are grounded in practice.
• To design ecologically valid investigations by
  integrating research and practice.
• To go beyond pre- and post-assessments and
  develop innovative intervention protocols and
  research designs that meet client clinician
  needs.

10
K ?
K ?
K?
K ?
11
The Setting

• THE CENTRE - Aisling Discoveries Child Family
  Centre
• serves children (0-12) and their families for
  over 30 years in East Toronto / Scarborough.
• 38 of this communitys residents report a mother
  tongue other than English and 58 are
  first-generation Canadians.
• 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.

12
The Setting

• THE INFANT CHILD TREATMENT PROGRAM (0-6)
• THE COMMUNITY INTERVENTION TREATMENT PROGRAM
  (6-12)

13
The Partnership

• 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 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

14
The Projects Four Examples

• Design of an intervention to alter parents
  negative cognitions in the context of attachment
  behaviors.
• Adaptation of an established parenting skills
  program for a diverse group of parents.

• Study of a culture-specific parenting practice
  and evaluation of a tailored intervention.
• Evaluation of the effectiveness of a group CBT
  program for children with anxiety

15
Project 1 Mapping Attributions of
ParentsUsing assessment as brief intervention
in the prevention of maltreatment

• Approach was designed collaboratively from ground
  up with clinicians as an early intervention
  treatment program for high-risk, sometimes
  transient families
• Has been shown to be useful in addressing a
  variety of care-giving challenges
• Designed as assessment, but doubles as treatment
• Brief, flexible video-feedback intervention that
  might initiate a shift in maladaptive caregiver
  behaviours, but also support parenting
  competencies and improve dyadic functioning in
  few meetings

16
Project 1 Mapping Attributions of
ParentsUsing assessment as brief intervention
in the prevention of maltreatment

• Intervention addresses risk with a focus on
  care-giving sensitivity, interpretation of child
  behaviour (i.e. cognitions parental
  attributions), developmental knowledge, and
  self-perceived efficacy context is Attachment
• Evaluation built-in
• A shift in culture
• Very promising results lower maternal depressive
  feelings, stress, better confidence, more benign
  assessment of child, more cognitive flexibility
  after few sessions. Lowered CAP very likely.

17
Project 2Songs, Rhymesn More Evaluating the
effectiveness of adapted EB programs with a
diverse population of clients

• Parenting education programs offered in community
  settings are very popular, but little information
  is available on the specific effects they have on
  parent-child interaction
• This is true especially when programs have been
  customized and thus diverge from their original
  empirically validated blue-prints.
• This exploratory study examined the effectiveness
  of an attachment-focused, group parenting
  intervention that was delivered in a childrens
  mental health center and adapted to meet the
  needs of a diverse group of caregivers

18
Project 2Songs, Rhymesn More Evaluating the
effectiveness of adapted EB programs with a
diverse population of clients

• Results indicate that despite substantial
  modifications to the programs evidence based
  model, benefits were obtained across several
  domains of parenting, for example cognitive
  growth fostering and caregiver distress.
• The expected increase in sensitivity however was
  observed
• Program was thus modified based on these
  findings resulting in a more effective delivery
  of intervention services to a diverse group of
  clients

19
Project 3 Satellite babiesUnderstanding
culture specific practices

• Infant clinicians in multi-cultural communities
  are challenged daily by culture-specific
  practices
• Our mental health models and EBPs are still
  primarily based on Western research and
  philosophy
• Some new immigrant parents engage in the
  practice of sending infants back to their country
  of origin, to be raised by members of their
  extended family.
• The children return to their parents in time to
  begin schooling, having endured multiple
  separations

20
Project 3 Satellite babiesUnderstanding
culture specific practices

• Does this have serious repercussions for
  social-emotional development?
• Our research program examined 1) the
  decision-making process of parents in the Chinese
  Canadian community
• 2) child, parent and family characteristics
  of returning children VS children who did not
  leave
• Findings culture interacts with other
  considerations such as attachment, and often
  overrides those
• There are likely no linear relationships between
  customs considered problematic according to
  mainstream models, and outcome

21
Project 4 Effectiveness of CBT group
treatment for anxious childrenComparing
established efficacy with community-based
effectiveness

• Project addressed a need to know whether an
  established evidence-based approach is as
  effective when delivered in a community setting,
  as in more controlled, research-oriented settings
  (where efficacy was established)
• Attempt to better understand the role of
  heterogeneous client groups
• Goal included an examination of the way in which
  we measure outcome use of standard quantitative
  but also qualitative assessments

22
Project 4 Effectiveness of CBT group
treatment for anxious childrenComparing
established efficacy with community-based
effectiveness

• Findings suggest that outcomes approximate, but
  are not quite as positive as in efficacy studies
• Findings also suggest that measuring outcome is a
  complex process contradictory narrative vs
  questionnaire data for both children and their
  parents
• Need to investigate further which children
  benefit and which dont and how to optimize
  outcomes for all

23
The Challenges The Organization

• FROM THE CLINICIANS POINT OF VIEW
• Increased time commitment and workload created by
  research design and the implementation of
  standardized procedures logistics of data
  collection.
• Research as add-on to clinical caseload.
• Lack of compensatory resources (e.g., additional
  staff, technical help, research incentives for
  participants).

• FROM THE RESEARCH TEAMS POINT OF VIEW
• Effort and time necessary to shift organizational
  culture.
• Continued work involved in securing
  accommodations and funding , even when
  administrative and Board support has been
  obtained.
• Introduction and management of a constant
  student/research assistant presence.
• Restrictions of a unionized environment.
• Managing the need for training and certification
  on evidence-based tools for research

24
The Challenges The Clients / Participants

• FROM THE RESEARCH TEAMS POINT OF VIEW
• Small sample sizes that are dependent on client
  participation.
• Inconsistent attendance rate and participant drop
  out.
• High rate of crisis issues that interfere with
  research protocol.

• FROM THE CLINICIANS POINT OF VIEW
• Concerns about burdening families in crisis with
  research procedures.
• Effects of standardized research protocols on the
  therapeutic alliance.
• Challenges of including clients from high risk
  populations and diverse backgrounds.
• To continue to provide services based on a
  client-centered philosophy while implementing a
  research agenda.

25
The Challenges The Partnership

• FROM THE CLINICIANS POINT OF VIEW
• Demands of marrying divergent perspectives and
  clinical versus research needs.
• Disruption of the intimacy of the clinical team
  created by the involvement of multiple new team
  members, roles and increased traffic.
• Lack of clarity relating to the roles and
  functions of all involved in the partnership
  acclimatizing to the demands of multiple roles.
• Ambiguity and need for coordination of complex
  organization and decision-making.

• FROM THE RESEARCH TEAMS POINT OF VIEW
• Managing of clinicians concerns that client
  service will suffer if they are asked to
  participate in research.
• Clinicians worry about burdening clients with
  research protocols.
• Clinicians skepticism about standardized
  methods.
• Frequent exclusion of clients from participation
  based on clinicians concerns.
• Restrictions and limitations of funding
  opportunities that are directed to more
  traditional academic research.

26
Discussion

• Your project goals, past present or future
• Your experienced or anticipated challenges

27
Lessons Learned

• Integration of research and practice is
  invaluable and there is much to be gained by
  conducting ecologically valid treatment research
  in community settings.
• Bilateral knowledge exchange is more potent than
  traditional knowledge translation in promoting
  evidence-based practice.

28
Lessons Learned

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

29
Lessons Learned

• Clinical issues and the therapeutic alliance must
  remain at the forefront in providing the
  intervention and determining when client need
  must override research integrity.
• Clinical advantages must be tied very explicitly
  and clearly to research activities to better
  engage clinicians. Moreover, the research team
  must balance its commitment to a standardized
  protocol, while remaining flexible and open to
  constant evaluation.

30
Lessons Learned

• Collaborative leadership and ongoing support are
  required to adopt and maintain this type of
  research model. A well-designed organizational
  structure is essential and should include regular
  communication (e.g., monthly research meetings)
  as well as a dedicated role to coordinate
  partnership activities.
• The host agency must not only support research
  in principle but also back up its commitment with
  support and resources. Clinician workloads must
  be amended to reflect increased demands.

31
Lessons Learned

• A paradigm shift is essential to view research
  and practice as mutually supportive rather than
  as separate silos. Research should not to be seen
  as an add-on, taking away from direct clinical
  services.
• Community-based research will never be flawless,
  and the process is imperfect. Researchers and
  clinicians must tolerate ambiguity, anxiety and
  differences due to their divergent perspectives
  to advance the research agenda.

32
From Implementation to Outcome Making it Happen

• Implementation in diverse organizations
• From lessons learned to next steps

33
Next Steps

• Securing the resources to firmly establish the
  research projects, to maintain the partnerships
  momentum and to ensure its growth.
• Conveying research results to clinicians and
  exchanging knowledge both inside the partnership
  organizations as well as externally with similar
  organizations and research partnerships.
• Educating all sectors of the organization,
  including administrative staff, regarding the
  importance of research efforts and promoting
  further awareness of the resources needed to
  equip clinicians with the tools necessary for
  evidence-based practice and research.

34
Next Steps

• Promoting clinician reliability and protocol
  adherence and increasing client protocol
  completion.
• Lobbying funding agencies and governments to
  increase their support by raising awareness of
  community-based research partnerships and the
  important types of research being conducted.
• Promoting acceptance in, and educating academia
  to the benefits of community-based research which
  is often seen as inferior to more traditional
  large-sample size, control-group trials.

35
Acknowledgments
Special thanks to Our client participants, and
_at_ 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
_at_ York University Lab Brooke Halpert, Jenn
Summers, Natasha Mullen-Whitfield, Jessica Chan,
Bramilee Dhayanandhan, Baila Ellenbogen, Vicky
Lishak Meg McLeod
36

• Thank you!