Engaging Mental Health Services for Preschoolers at Risk
Trial Snapshot
- Phase
- Not Applicable
- Status
- Recruiting
- Enrollment
- 106
- Locations
- 2
- Primary Endpoint
- Navigate-Train-Referral-Intervention-Mental-Health (NTRI-MH) Satisfaction Questionnaire
Study Overview
Brief Summary
Most mental health (MH) disorders develop in early childhood but are not clinically identified or treated until later-delaying treatment services that could prevent the enduring effects of long-term MH problems. Moreover, low income, ethno-racial minoritized children who exhibit higher rates of persistent MH disorders, are at greater risk for lags in identification and treatment. Head Start (HStart) has shown early school success for low-income children, aged 3-5 years, who are disproportionately Black or Latinx. HStart monitors early childhood MH symptoms, yet studies have found that when detected, only those most impaired are referred for treatment. In our research, the investigators learned that system and individual level barriers preclude early treatment among HStart preschoolers with developmental concern. The investigators showed that caregivers encountered system barriers of HStart teachers and primary care providers (PCPs) falling behind in referrals for intervention, and caregiver beliefs about stigma, their limited knowledge and distrust of healthcare hindered early engagement in services. Studies on MH treatment obstacles for low-income, ethno-racial minoritized people illustrate similar barriers to those found among HStart preschoolers with developmental concern. We developed and tested an ethno-racially matched, peer-based family navigator program for HStart preschoolers with developmental concern. Navigators used trust and empowerment to increase caregiver advocacy thereby leading to improved professional alliances and treatment. A navigator program for those with primary MH concerns has not been trialed. For Aim 1, the investigators aim to tailor and trial in a case series the Navigate-Train-Referral-Intervention Mental Health (NTRI-MH) intervention to promote access, engagement, coordination, and optimization of services for preschoolers with MH symptoms. The investigators have used focus group feedback from caregiver, navigator, HStart teacher, and PCP stakeholders to adapt NTRI-MH and created a web-based dashboard to monitor outcomes (Phase 1). Then, for phase 2, the investigators will conduct a feasibility study for caregivers of HStart preschoolers with MH symptoms, guided by ethno-racially matched family navigators and referrals by HStart teachers and PCPs (n=20). Further, for Aim 2, the investigators will pilot test NTRI-MH for caregivers of preschoolers with MH symptoms compared to an active control group of caregivers who receive child behavior training (n=86). The investigators will trial the effectiveness of the NTRI-MH mechanisms of caregiver beliefs on MH, empowerment, and professional alliances on family functioning and child emotion regulation. If the aims of the project are achieved, this study would have a large impact on early MH service use for ethno-racial minoritized young children with the potential to improve child MH outcomes.
Detailed Description
The proposed project involves three phases:
Aim 1 (Phase 1): Focus groups. Six focus groups will be held to elucidate barriers and facilitators to access and engagement of HStart children in MH services. Separate focus groups will be conducted for each stakeholder and ethno-racial caregiver group (3 Black, Latinx, and White caregiver groups, 1 navigator, 1 teacher, and 1 PCP focus group). Latinx caregivers and navigators will have the option to attend an English or Spanish focus group session. The focus groups will be conducted via a web-based platform (e.g., MS Teams) at a variety of times to facilitate participation of caregivers, navigators, and professionals who provide childcare and/or work at different times or lack transportation or childcare to attend in-person sessions. Demographic data will be collected. Groups will employ an open format with guided questions to gain perspective and to help participants focus on 1) barriers and facilitators to access and engagement in MH services, 2) enriching a navigation program to address MH barriers and enhance facilitators, and 3) conceptualize the ideal dashboard to track and monitor the trajectory of MH clinical, functional, and behavioral outcomes. To ensure research integrity, focus group facilitation will be led by the co-PIs and research team experienced with focus groups. All sessions will be recorded, field notes composed, and sessions transcribed verbatim.
Web-based dashboard. The investigators will develop a web-based dashboard on a secure website to assist the navigators, and us, the research team, in monitoring and tracking child and caregiver progress over time with clinical, functional, and behavioral outcomes. This user-friendly system will track and monitor alignment of caregiver goals to service use on the primary outcomes of access, engagement, coordination, and optimization of MH services. Also, it will track the child's MH symptoms in the case series and pilot study. The goals and tasks will be set by the caregiver and navigator after visits with professionals, maximizing the benefits of goal-setting that include motivation, commitment, and self-regulation and working professional alliances. The research team will rate the progress toward the caregiver-determined goals and the child's MH symptoms from the data will allow us to measure care coordination. Access data on detection of risk for MH disorder and appropriateness of referrals will be inputted from the HStart data base (ChildPlus©), medical record, and navigator tracking of visits and referrals by teachers and PCPs and recommendations made. Engagement will be monitored by caregiver/navigator meeting content and goals, caregiver goal alignment with professional recommendations, and resources/tasks needed to reach the goals. Coordination will be tracked with caregiver initiation, completion and frequency of the child's MH services, and navigator-provided resources on advocacy, emotional support, basic needs, and MH disorders to support services use. Optimization will be monitored by agreement between caregivers and PCPs on the MH treatment goals and tasks including services type and frequency. The dashboard will be a core component of the NTRI-MH treatment manual. It will be built with the capacity to eventually scale up to involve caregivers, teachers, and PCPs in monitoring and tracking the trajectory of progress over time.
NTRI-MH adaptation. The stakeholder focus group findings and views on dashboard creation will inform the modifications to the 1st iteration of the NTRI-MH treatment manual. Adaptations to the treatment manual will focus on the barriers and facilitators to engagement in MH services, navigation enhancements to address these barriers, usefulness of the dashboard to track and monitor progress in MH outcomes. Implementation fidelity questionnaires will be modified for NTRI-MH. Once the NTRI-MH treatment manual is revised, the full research team and consultants will review it for a 2nd iteration. The NTRI-MH treatment manual adaptations will be completed prior to being implemented in the case series trial.
The primary deliverable is modification of the NTRI-MH intervention design and the content of a web-based dashboard to adapt the treatment manual for addressing the primary outcomes of access, engagement, coordination, and optimization of MH services.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Health Services Research
- Masking
- Single (Participant)
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Family Navigators: Having experience working as family navigator and/or community health worker; Latinx, Black or White; > 18 years old.
- •Caregivers: current caregiver of a HStart preschooler at-risk for MH disorders (ASQ-SE above threshold score)
- •Teachers: Current Head Start (HStart) teacher from one of the 2 HStart site;> 18 years old; Any race/ethnicity.
- •PCPs: Currently providing primary care for HStart preschool age children at risk for MH disorders; > 18 years old; Any race/ethnicity.
Exclusion Criteria
- •Unable to read/speak either English or Spanish.
Arms & Interventions
Intervention (NTRI-MH)
For the intervention group, the navigators will implement the NTRI-MH for 6 months with the caregivers, including 15 hours of navigation services with a 2-hour face-to-face meeting, at least 3 monthly in-person meetings, attending assessments and treatments with the caregivers at HStart, PCP offices, and MH services locations. After these visits, the navigator will follow up by phone, text, or email with the caregiver. Navigators will meet weekly with research staff for supervision and case review. Teachers will share a copy of screenings and recommend a visit with PCP, and PCPs will review the Just-In-Time packet and make referrals.
Intervention: NTRI-MH (Other)
Control
The caregivers in the active control group will receive a 2-hour training seminar and educational materials including handouts/videos from a developmental activities' toolkit pertinent to the emotional, behavioral, and developmental age of their child. The training seminar will include topics of common MH concerns of young children, steps to addressing challenging behavior, strategies for decreasing problems behaviors, and crisis management.
Outcomes
Primary Outcomes
Navigate-Train-Referral-Intervention-Mental-Health (NTRI-MH) Satisfaction Questionnaire
Time Frame: Immediately after intervention and 3 months after intervention
This is a 7-item Likert scale questionnaire that elicits caregivers' and family navigators' opinions regarding the format, content, length, and convenience of the intervention. Score Range: 7-28 (the higher the score, better satisfaction)
System Usability Scale
Time Frame: Immediately after intervention and 3-months after intervention
The SUS is a 10-item Likert scale questionnaire that elicits family navigators', teachers', and PCPs' global views of the NTRI-MH treatment manual's usability. Score range: 0-100 (the higher the score, better usability)
Family Navigator Activities Checklist
Time Frame: 3-months after intervention
This 29-item checklist will document family navigator-caregiver activities, including emotional support, action planning, information provision, advocacy, and skill development. Range 0-29 (the higher the score, more activities completed)
Implementation Questionnaire
Time Frame: 3-months after intervention
The implementation questionnaire will include 12-Likert score items recording information about acceptability, intervention appropriateness and feasibility of the intervention. Score range: 12-60 (the higher the score, better acceptability, feasibility, and appropriateness)
Referrals to Primary Care Providers (PCPs) and mental health services
Time Frame: Baseline
We will obtain data regarding referrals made to PCPs and/or mental health services by Head Start teachers though reviewing the ChildPlus Head Start Database.
Referrals to mental health services
Time Frame: Immediately after intervention and 3-months after intervention
We will obtain data regarding referrals to mental health services by Primary Care Providers (PCPs) through medical chart review.
Access to mental health services
Time Frame: Baseline, immediately after intervention, and 3-months after intervention
Using a web-based electronic dashboard, user-friendly system, we will record the number of referrals to mental health services.
Parental Stress Scale
Time Frame: Baseline, immediately after intervention, and 3-months after intervention
This is an 18-item self-report measure in which parents respond to statements about their typical relationship with their child. This measure will assess parents' feelings about positive aspects (e.g., emotional benefits, personal development) and negative views of parenting (e.g., demands on resources, feelings of stress). The possible range of PSS is 18 (low stress) to 90 (high stress).
Engagement and coordination to mental health services
Time Frame: Baseline, after intervention, 3-months after intervention
Using a web-based electronic dashboard, we will record the alignment with mental health recommendations.
Optimization of mental health services
Time Frame: Baseline, immediately after intervention, 3-months after intervention
Using a web-based, electronic dashboard, we will record the caregiver agreement with goals and tasks.
Secondary Outcomes
No secondary outcomes reported
Investigators
Kelly Kamimura-Nishimura
Associate Professor
Children's Hospital Medical Center, Cincinnati