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7/30/2019 Dr. Pottie Strongest Families Institute
http://slidepdf.com/reader/full/dr-pottie-strongest-families-institute 1/33
Singapore 2013
Strongest Families InstituteProviding Faster Access to Skill-based Care
for Children, Youth and Families
Dr. Patricia Lingley-Pottie
President & COO, Strongest Families Institute
Assistant Professor, Dalhousie University
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Objectives
• Background: Pediatric Mental Health
• Current Issues
• Introduce Strongest Families Institute
o
Brief review program curriculumo Case examples
• Outcome
• Conclusion
• Future Plans• Questions
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Pediatric Mental Health
What do we know?
Pediatric mental health issues are very common• Ontario, Canada- 20% have a diagnosable disorder (Offord et al.,1987 )
• United States of America - 1 in 5 children (Centre for Disease Control, 2013)
• World Health Report- 10 to 20% (WHO, 2001)
o
1-16 year olds: India 13%; Ethiopia 18%; Switzerland 22%o 12-15 year olds: Japan 15%; Germany 21%
Environmental influences negatively impact child• Parenting quality (low warmth, resentment & rejection)
o linked to behavior and anxiety (Elgar et al., 2007; Wood et al., 2002)
• Parenting style (punitive; parental aggression)o linked to aggression, oppositional defiance, hyperactivity(Stormshak et al., 2002)
• Marital conflict linked to conduct issues (Waschbush et al., 2011)
• Maternal depression linked to behavior/emotional issues (Elgar et al, 2004)
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We also know…
Untreated conditions become worse overtime
• More difficult to manage
• Can lead to behavior problems at school affecting
o Antisocial behaviours cause negative reactions from others
o Child-peer and child-teacher/caregiver relationships
o School attendance
o Academic performance/progress
• Inflict a heavy burden on the child, family and society
• Lead to co-morbid conditions, tracking into adulthood
(Costello et al., 2005; Kessler et al., 2005)
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June 8, 2009
The Great Smoky Mountain Study Age of Onset (Costello et al, 1996)
Source: Institute of Medicine. Preventing mental, emotional, and behavioral disorders among young people: Progress and
possibilities. Washington, DC: National Academies Press, 2009.
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Current Issue…
Many families do not gain timely access
Barriers that families face:• Day-time appointments can be inconvenient
• Travel burden inconvenient for 12 weekly sessions• Financial burden with travel or time off work, especially rural
• Time from school; child resistance
• Stigma associated with receiving mental health services
System Access issues: • Limited # specialists available
• Long wait lists for Mild-Moderate cases
• Limited primary care services with a mental health focus
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June 8, 2009
The Great Smoky Mountain Study Age of Onset (Costello et al, 1996)
Source: Institute of Medicine. Preventing mental, emotional, and behavioral disorders among young
people: Progress and possibilities. Washington, DC: National Academies Press, 2009.
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…Access solution
Strongest Families Institute: Not-for-Profit Organization
Psychologically informed, Distance Education Model
Evidence-based, designed by team of experts
Delivered to families in home at convenient times
Early intervention focus (Mild- Moderate severity) Fills access gap: Targets the children typically waiting for service
Designed to overcome traditional access barriers
No need to travel; more convenient
Family-Centred Telephone appointments at convenient times to fit families’ schedule
No need to miss work or school
No financial burden (no travel, missed time from work)
Visual anonymity minimizes or eliminates stigma(Lingley-Pottie & McGrath, 2007)
Provides outreach to remote/rural communities
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…Access solution (cont’d)
Cost-effective intervention delivered conveniently to families at home:
Using highly trained, non-professional coaches from a call-centre base
Coaches schedule flexible for families (days, evenings, weekends)
Offered free of charge to families, no wait
Parent preference studies support this delivery model (Cunningham et al., 2008)
Outcomes consistently measured
Weekly parental ratings (change since baseline)
Brief Child and Family Phone Interview (BCFPI) (Cunningham et al., 2009)
Primary outcome measure
Includes customer satisfaction measure
Results communicated to referring agent and family mid & end(Lingley-Pottie et al., 2011)
Goal: Intervene early before problems get worse
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How does it work?
Targets specific problem areas
Behavior (Parent only): 3-12 years old
Anxiety (Parent and Child sessions): 6-12 years old
Self-help design with coach facilitation One skill-based session per week (11-12 skills)
Parent and/or child reviews material, completes exercises
Practices implementation of skill daily
Learn a variety of positive skills to overcome problems
Work with other providers (school/professionals)
Telephone “Coaches” Perform protocolized telephone skill sessions
Weekly caseload review by coach supervisor
Staff supervised by health care professional 24/7
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June 8, 2009
Nova Scotia Call Centre: Coach Call
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Coaches
Coaches (Family Centered care): Bright, capable, personable; excellent communication skills
Flexible schedule to accommodate needs of families (e.g., 0200 local)
Calls digitally recorded for quality assurance
Toll-free access 1-866-470-7111
Follow risk management protocols
Coach’s role is to: Reinforce information learned
Problem-solve with parent/child
Encourage and support family
Highly productive; highly monitored
30 cases (1:1); 90-100 per annum
180+ per annum with group-based coachingJune 8, 2009
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Evidence-based Programs
Behavior (3-12 yrs): Parent training Oppositional defiance, ADHD, conduct
One-to-one coaching or group-based
Anxiety (6-12 yrs): Relaxation skills & exposure Performance, social, specific phobia, generalized, separation
One-to-one coaching
Tested in randomized clinical trials
Proven to be effective with lasting effects up to one year (McGrath et al., 2011)
Strong therapeutic alliance
Parent-coach & Child-coach (Lingley-Pottie & McGrath, 2006, 2007, 2008)
Post-research, Service results:
o 85% success resolving child presenting issues
o Positive impact on bullying & informant depression scores
o < 10% attrition rate and high client satisfaction
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Behaviour: Parenting the Active Child
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Based on COPE : Positive Parenting (Cunningham et al., 1995)
Noticing the Good
Spreading Attention Around
Ignoring Whining and Complaining Change Warnings (Plan for transitions)
Planning Ahead (inside &outside home)
Using SOLVER, include child in the plan
Using Charts and Stickers Working with the School/Daycare
Time Out/Chill out
Advanced Problem-Solving using SOLVER
Putting it all together June 8, 2009
Behaviour: Parenting Program
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Build on parents’ strengths Learn problem-solving skills & learn to self-regulate own emotions
Indirectly child learns self-regulation and problem-solving
Strengthen parent-child relationship
Special time, relationship building rewards, include child in planning
Increase pro-social behavior
Reinforce positive behaviors- reward using praise, involving child in plan
Decrease antisocial behavior
Ignore minor whining; deal with aggressive behavior; plan with child
Strengthen parent-teacher/child-teacher relationship
Working with school or caregiver using communication strategies
Set child up for success
Break down tasks, frequent rewards
Objectives: Parenting Curriculum
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Example: Notice the Good skill
Challenge:
Children will act-up to get attention
Parents react quickly to negative behaviour
Miss opportunities to notice good behaviour when child is behaved
Children learn acting up is a good way to get attention
Video: Ineffective communication
Objective:
Pay attention to positive behaviour often everyday Children learn that positive behaviour is noticed
Children feel good when others Notice the Good
Children will act-up less to show more good behaviour
Avoid reacting to disruptive behaviour June 8, 2009
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Ways to Notice the Good often, everyday
Attend to positive behaviour often by: Warm body language:
be at child’s level, pay attention when talking
see the world through the child’s view
Communicating: Praise at first sign of good behaviour
Name what child is doing
Show interest by asking questions
Repeat what the child says
Limit reminders and controls
Give child a chance to follow-through with good behaviour
Wait & watch…Notice even small efforts/successes
VIDEO: Notice the Good Skill Demonstration
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Coaching Strategies
• Follow evidence-based protocolized scripts every session
• Conversational control strategies to stay on track
• Customize intervention to meet family/child needs
• Embedded strategies
Role-playing (Ignore Whining & Complaining)
June 8, 2009
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Case Example: Behavior
10 year old male
Presenting issues:
• Inattention - unable to focus & complete tasks, especially homework • Noncompliance – argues, doesn’t listen (home & school), blames
others
• Conduct – aggressive at home and school, destructive
• Parental separation issues• Threatens harm when angry
• Unhappy (lack of friends)
• Significant child and family impairment
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10-year-old male Behaviour: Outcome
Significant improvement:Attentive - able to focus & complete tasks, especially homework
Compliant – less argumentative, improved listening, blames less
Conduct – less aggressive; less destructive
Positive effect on internalizing issues
Informant Mood: t-score 86.6 (pre); 51.2 (post)
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June 8, 2009
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Anxiety: Chase Worries Away (6-12 year olds)
Coach-parent & Coach-child sessions
Types of Anxiety:
Social Phobia, Specific Phobia, Separation, Generalized, Performance
Cirriculum
• Understanding Anxiety
• Learn the skill, practice the skill, use the skill to face worries!
• Muscle Tension Relaxation
• Belly Breathing
• Mini-Relaxation• Imagery
• Positive self-talk
• Gradual Exposure using a worry diary
June 8, 2009
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7 year old Bailey“I liked the belly breathing the best,” Bailey reports. “It would make the nervous
feeling go away.”
June 8, 2009
Bailey’s mom: “We have our daughter back!”
VIDEO- Belly Breathing
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Case Example: Anxiety
9 year old female
Presenting issues:
• Panic Attacks• Separation Issues
• Co-sleeping with parents
• Generalized Worry
• Doing the wrong thing/making mistakes
• Things in the future (ie. Death)
• Pleasing others
• Specific Fear (Death, disease, the dark)
• Significant child and family functioning
June 8, 2009
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June 8, 2009
9-year-old Anxiety: Outcome
Significant Improvement
Panic attacks resolved
No longer co-sleeps
More confident and will try new things
Sleeps in own room in the dark with door closed
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June 8, 2009
Outcome Reporting
Effect Size Table (n=1025)
• BCFPI treatment effect size results (t-score ≥ 65 at baseline with an exit BCFPI)• Strong intervention effect across all mental health indicators
Mental Health Indicator Effect Size
Attention 2.7
Cooperativeness 3.1Conduct 3.0
Externalizing 3.1
Separation 3.0
Anxiety 3.1
Mood 3.0
Internalizing 3.4
Child Functioning 3.2
Family Situation 2.2
Informant Mood 2.0
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June 8, 2009
SFI Program Customer Satisfaction (n=1025)
76%
65%
76%
88%
72%70%
62%
74%
77%
16%
19%
16%
10%
18%
21%23%
18% 17%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Location Time on Waitlist Service time of
day
Staff courtesy Information re
problem
Useful
techniques
Participation in
planning
Helpfulness of
service
Overall quality
Excellent
Very Good
Good
Fair
Poor
• Satisfaction is high for all aspects of the program
• 94% rate overall quality of service as Excellent or Very Good
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Participant Experiences
“Always convenient for us; around our schedule; we didn’t feel judged”
“She <the child> was more likely to tell her coach than us about some things.”
“Right off the bat I felt she was easy to talk to… I just love her.
I prolonged my meetings in the end ‘cause I was scared of not talking to her
again… She has given me confidence to make the decisions on my own. Even
though I never got to meet her I feel like I know her.”
(Lingley-Pottie & McGrath, 2007)
June 8, 2009
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Awards Received
Mental Health Commission of Canada: Social Innovation Award, 2012
MHCC VIDEO
Progress Magazine: Health Innovation Award, 2012
Ernest C. Manning Innovation Award
Atlantic Nominee
June 8, 2009
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Conclusion
Strongest Families: A cost-effective access solution
Highly effective, highly accepted with low attrition
Teach children and families skills, building on strengths
Strengthens relationships, learn problem-solving & coping strategies
Positive impact on child functioning (home & school)
Convenient and accessible
Visual anonymity eliminates stigma
Providing outreach to parents who:
• Live in rural areas, work shift-work or have busy lives
• Struggle with a child who resists going to a clinic
• Are disadvantaged (e.g., physically/financially/psychologically)
Removing Barriers to CareJune 8, 2009
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Expanding services to those in need
Canada
Nova Scotia:
• Recent provincial expansion through Department of Health & Wellness
Ontario:
• Peel Children’s Centre, Thunder Bay Alberta:
• Alberta Health Services- Calgary Zone
British Columbia:
• CMHA-BC, Provincial funding acquired
Other Interest:
• Finland (RCT underway)
• Dubai
• United States June 8, 2009
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Thank You!
June 8 2009