1. Engagement and Retention: Serving the Diverse Needs of Multi-Stressed Children and their Families in LA County Elizabeth Park, Psy.D., Natalie Carlos, Psy.D., Vasni Briones, LCSW, and Karen Rogers, Ph.D. 15 th Annual Conference on Parent-Child Interaction Therapy for Traumatized Children September 9, 2015

2. Background and Significance 1 out of 5 children has a diagnosable mental, emotional, or behavioral disorder and approximately 70% of these children do not receive mental health services (National Research Counsel and Institute of Medicine, 2009). As many as 40-60% of families stop treatment prematurely (Gopalan et al., 2010). Gap for minorities and families with low SES is larger in terms of receiving mental health services (Smith et al., 2013). Greater risk factors exist for mental health problems among urban minority youth, such as the negative effects of poverty, violence, and racial discrimination. Urban minority families are less likely to utilize mental health services, even when controlling for financial and structural barriers and parental level of education (Hobberman, 1992; Yeh et al., 2004, Larson et al., 2013). 2

3. Attrition Characteristics that help predict attrition include socioeconomic status, parental stress, ethnicity, child symptom severity, and single parent status (Garcia and Weisz, 2002). Parent engagement problems that impact treatment attendance, treatment adherence/compliance, and active participation in treatment are frequently cited as reasons for ineffectiveness of care (Brannan, 2003; Staudt, 2007; Baker-Ericzen et al., 2013). Family and parent characteristics often contribute more to dropping out than do child characteristics. 3

4. Barriers Research suggests increasing children’s access to mental health services should consider strategies that address (Bussing et al., 1998, 2007; Larson et al., 2013; Lavigne et al, 1998; Owens et al., 2002; Yet et al., 2005; Larson et al., 2013): – Structural barriers – Perceptions regarding mental health problems – Perceptions regarding mental health services Caregivers feel overwhelmed by their child’s symptoms, do not feel supported by formal service systems, and report a lack of service system coordination and ineffective treatment strategies. Caregivers feel blamed, judged, and not listened to by therapists (Baker-Ericzen et al., 2013). Therapists feel overwhelmed by families’ complex needs, children and parents’ mental health issues, parents’ lack of involvement and perceived unwillingness to participate (Baker-Ericzen et al., 2013). 4

5. Engagement Approaches that have demonstrated improvement in engaging families in treatment (Ingoldsby, 2010): – Brief early treatment engagement discussions – Family systems approaches – Enhancing family support and coping – Motivational interviewing 5

6. Engagement and Retention Strategies Providers who effectively engage families (Miller & Rollnick, 2002) – Identify potential benefit of services – Discuss family expectations for treatment process and outcomes – Develop a plan with family to address practical issues (e.g., scheduling, transportation) – Address psychological engagement challenges (e.g., other stressors, family member’ resistance to treatment) Successful engagement methods (Miller & Rollnick, 2002) – Individualized Personalized, collaborate approach Convey understanding and respect (Miller & Rollnick, 2002) – Intensive and address engagement in multiple ways throughout – Integrated into the underlying treatment 6

7. PCIT-ER Chart: Engagement and Retention Identifying intrapersonal, interpersonal, environmental, and systemic treatment factors that may influence attrition and treatment outcomes Areas of concern or potential treatment barriers: Child and caregiver factors, attachment/relational, family function, socioeconomic status, culture and diversity, and life stressors/events Strategies: Practical, psychological, and/or resource based

8. Case Application: Ana I “Ana” is an 8 year-old girl who has a history of severe neglect, physical abuse, & sexual abuse She presents with sexualized behaviors, noncompliance, tantrums, and withdrawing behaviors PCIT is provided to Ana and her adoptive mother who feels overwhelmed and is doubtful about her parenting abilities 8

9. Case Application: Ana II ConcernPositive Outcome Strategies PracticalPsychologicalResources Family Function Rigid home schedule or structure (e.g., no Home Fun) Organized home environment with a predictable and stable routine -Conduct a home visit to establish daily routine/schedule and practice Home Fun -Address underlying resistance to establishing a routine that incorporates Home Fun -Provide a calendar or schedule that incorporates Home Fun Other siblings competing for attention Cooperation from siblings during Home Fun -Use PCIT skills with sibling -Schedule a separate special time with sibling -Normalize typical sibling rivalry and address issues impacting client’s treatment and mental health -Provide psychoeducation and handouts related to this issue Parenting DifferencesCollaborative parenting -Establish routine collateral sessions with both parents -Discuss and review appropriate communication and problem-solving strategies -If needed, provide referrals for separate co- parenting or couples therapy 9

10. Case Application: Job I “Job” is an 6 year-old boy who’s father was deported to Mexico six months ago He presents with separation anxiety, nightmares, tantrums, depression, and trauma history PCIT is provided to Job and his mother who feels “unable to parent” her child by herself 10

11. Case Application: Job II 11 ConcernPositive Outcome Strategies PracticalPsychologicalResources Caregivers’ Factors Lack of self-confidence Caregiver can confidently use the PCIT skills and see the positive results. -Frequent praise to caregiver -highlight child’s progress as directly linked to caregiver’s strengths and acquisition of skills -select a video clip that demonstrates caregiver’s effective use of skills and watch together. -Explore origins of apparent lack of confidence. -Validate how challenging it is to learn new skills & model therapist’s own self- correction at times. -Reading Material on self- confidence building. -Refer caregiver for own therapy if necessary. -Refer mother with an immigration lawyer. Trauma History Caregiver shows understanding/awareness of their own emotions and can manage them effectively when triggered in interactions with their child. -Provide psychoeducation regarding trauma (trauma symptoms in adults and children, impact of trauma on regulation, intergenerational transmission of trauma) -Assess for trauma triggers that may occur in session -Provide collateral sessions to caregiver to explore impact of caregiver’s own trauma on parenting -Assess for any ongoing trauma/safety risks and provide appropriate support and linkage as needed -Refer caregiver for his/her own therapy -Consider appropriateness of a TFCBT/CPP treatment following PCIT if child continues to exhibit trauma symptoms

12. Summary Challenges for PCIT clinicians: identifying potential barriers and utilizing engagement and retention strategies seamlessly throughout treatment while maintaining fidelity to the PCIT model Addressing treatment barriers needs to occur throughout treatment to effectively engage multi-stressed families PCIT-ER chart: Assist clinicians in facilitating treatment for multi-stressed families to reduce treatment barriers and mental health problems while enhancing support, coping, and resilience 12