Dr. Pottie Strongest Families Institute

7/30/2019 Dr. Pottie Strongest Families Institute

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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



Objectives

• Background: Pediatric Mental Health

• Current Issues

• Introduce Strongest Families Institute

o

Brief review program curriculumo Case examples

• Outcome

• Conclusion

• Future Plans• Questions



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)



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)



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.



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



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.



…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



…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



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



June 8, 2009

Nova Scotia Call Centre: Coach Call



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



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



Behaviour: Parenting the Active Child



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



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



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

http://localhost/var/www/apps/Videos/Strongest%20Families/Session%201%20Scene%203-Cropped%20H264%20Powerpoint.mov




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






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



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)



June 8, 2009



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



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

http://e/Session%204_Scene%201_Belly%20Breathing.mov







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



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



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



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



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



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



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



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



Thank You!

[email protected]

June 8 2009

Dr. Pottie Strongest Families Institute

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