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. Author manuscript; available in PMC: 2011 Dec 20.
Published in final edited form as: Res Soc Work Pract. 2011 Nov 1;21(6):664–674. doi: 10.1177/1049731511406740

A Collaboratively Designed Child Mental Health Service Model: Multiple Family Groups for Urban Children with Conduct Difficulties

Mary McKernan McKay 1, Geetha Gopalan 1, Lydia Franco 1, Kara Dean Assael 1, Anil Chacko 1, Jerrold Jackson 1, Ashley Fuss 1
PMCID: PMC3243310  NIHMSID: NIHMS287779  PMID: 22194642

Abstract

This paper presents preliminary outcomes associated with an experimental, longitudinal study of a Multiple Family Group (MFG) service delivery approach set within thirteen urban outpatient clinics serving children and their families living in inner-city, primarily African American and Latino communities. Specifically, this paper focuses on parent reports of child oppositional behavior and parenting stress over time. MFG is a flexible, protocol-driven approach designed to address the most common reason for referral to outpatient child mental health clinics, childhood behavioral difficulties. The MFG also aims to enhance family-level engagement and retention in ongoing care. Further, the service delivery model was collaboratively developed with intensive input from parents rearing children with conduct difficulties, parent advocates, community-based child mental health providers and services research staff in order to ultimately expand the number of effective service models that can be situated within “real world,” urban child mental health settings.

Each year, billions of dollars are spent responding to the legal, correctional, educational and psychological needs of disruptive youth (Burke, Loeber, & Birmaher, 2002; Foster & Jones, 2005). Nationwide, oppositional or aggressive behaviors are found among 5 to 10% of 8 to 16 year olds and account for one-third to one-half of all youth mental health referrals (Angold & Costello, 2001; Frick, 1998; Frick & Muñoz, 2006; Rowe, Maughan, Pickles, Costello, & Angold, 2002). However, within urban, low-income communities, significantly higher prevalence rates of childhood conduct related difficulties, ranging from 24 to 40%, have been found (Gorman–Smith, Tolan, Henry & Florsheim, 2000). Thus, addressing urban child conduct difficulties is a serious public health need. Further, emerging evidence suggests that despite recent advancements in the development of effective child mental health service models, there continues to be serious barriers in connecting the most vulnerable of children and their families with care. Therefore, the development of effective interventions associated with high engagement and retention of youth and families residing in urban, low income communities is greatly needed.

A disproportionate number of children with mental health problems do not receive adequate mental health care (National Institute of Mental Health, 2001; Ringel & Sturm, 2001; US Department of Health and Human Services, 2010; US Public Health Service, 2000, 2001). Specific to minority youth, addressing the serious disparities regarding receipt of appropriate, quality mental health service has also been urgently emphasized (Garland, Lau, Yeh, McCabe, Hough, & Landsverk, 2005; Kataoka, Zhang, Wells,2002; Padgett et al., 1994a,b). This is particularly important since urban minority youth are most deeply affected by the stressors that exist within inner-city communities, notably poverty, community violence, inadequate child-serving resources, under supported schools and substance abuse (Attar, Guerra, & Tolan 1994; Gorman-Smith, Tolan, & Henry, 1999; Grant et al., 2005; Hess & Atkins, 1999; Weist, Acosta, Youngstrom, 2001). Further, the number of children in need of care within urban communities far outstrips the availability of services and the number of service providers. Waiting lists for care within inner-city communities can extend up to six months (Brown, 2002). Accordingly, there appears to be a need for a comprehensive mental health service model capable of addressing the most common reason for referrals, barriers to services for urban children and serious service capacity issues.

Thus, the current paper presents preliminary outcomes of a study involving a Multiple Family Group (MFG) service delivery strategy tested in collaboration with thirteen urban outpatient clinics set within primarily African American and Latino communities. MFG is a protocol-driven approach designed to address oppositional defiant and conduct difficulties (Franco, Dean-Assael, & McKay, 2008; Gopalan & Franco, 2009). In addition, the MFG was specifically designed to enhance engagement and retention in outpatient child mental health care, as well as to contribute to the number of effective services that can be situated within “real world,” urban child mental health settings.

Multiple Family Groups (MFG) for Children with Behavioral Difficulties

The multiple family group service delivery strategy targets school-age, inner-city children (7 to 11 years of age) meeting diagnostic criteria for Oppositional Defiant (ODD) or Conduct Disorders (CD) and their families (including adult caregivers and siblings between the ages of 6 to 18 years). MFG consists of a 16-week series of group meetings with 6 to 8 families present in each group, and the intervention protocol which guides each group meeting was designed in collaboration with urban parents in previous studies to strengthen specific aspects of parenting skills and family relationship processes (e.g., child management skills, parental discipline practices, family communication, within family support and positive parent/child interaction) (McKay, Gonzales, Quintana, Kim, & Abdul-Alil, 1999; McKay, Gonzales, Stone, Ryland, & Kohner,1995; McKay, Harrison, Gonzales, Kim, & Quintana, 2002; see Franco, Dean-Assael, & McKay, 2008 for an earlier published version of the intervention protocol). In addition, intervention sessions were designed to target factors (e.g., parental stress, use of emotional and parenting support resources, and stigma associated with mental health care) which potentially impact inner-city child mental health service use and outcomes. See Tables 1 and 2 for a summary of empirically supported intervention targets and session goals.

Table 1.

Summary of empirically supported family-level influences on ODD and CD

MFG target Family process or parenting skill linked with youth conduct
problems or associated with positive youth behavioral outcomes
Rules 1) family organization; 2) consistent non harsh discipline practices,
including clear behavioral limits, appropriate consequences and
reinforcement; 3) parental monitoring and supervision skills
Responsibility 1) family interconnectedness; 2) positive behavioral expectancies for
youth
Relationships 1) family warmth and attachment; 2) within family support and; 3) time
spent together
Respectful
Communication		 1) family communication; 2) family conflict; 3) parent/child interaction
Stress 1) parenting hassles;2) parenting stress; 3) life stressors,
4) socio-economic disadvantage
Social support Social isolation
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Table 2.

Summary of MFG intervention targets

MFG target MFG
session		 MFG goals
Rules 3 & 9 1) Families clarify the set of rules that are operate in the family
2) Rules are more clearly identified for children
3) Parents examine their own behavior in relation to rules
4) Consequences for not following the rules are clarified
5) Rewards and giving praise for following the rules is increased
6) Parents come to understand link between behavioral success at home
and in school or community
Responsibility 4 & 10 1) Roles of parents and children are clarified
2) Each family member is given credit for the contribution that they
already make to the family
3) Expectations for children are clarified
4) Parents identify areas where they need additional support
and problem solve about ways to obtain necessary resources
Relationships 5 & 11 1) Families develop a consistent time to spend together
2) Families schedule fun activities, promoting positive relations
Respectful
communication		 6 & 12 1) Parents develop enhanced abilities to communicate
with children so that they will attend and understand
2) Parents develop enhanced ability to listen to their children
and be more available to them
3) Children become able to discuss concerns with their parents;
4) Children are able to more carefully attend to parent
communication
Stress 7 & 13 1) Families can identify the stressors that hinder the 4 R’s
2) Families will feel support from the group and have the
opportunity to share experiences that have been stressful in their
lives
3) Parents and kids will become more aware of the stressors
each one faces
4) Families will have the opportunity to practice supporting and
communicating with each other in hopes of alleviating stress
Social support 8 & 14 1) Parents see themselves as supports for each other
2) Kids see their parents as supports for them
3) Families identify the need for building supports in their lives
4) To be able to identify times when support is needed
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Involving the entire family in a series of group meetings was based upon strong existing evidence for a set of family-level risk factors related to the occurrence and persistence of serious conduct problems during childhood (see Table 1). More specifically, poor levels of parental discipline, monitoring, family communication, within family support, family interactions and bonding, and family disorganization, stressors, and conflict have been associated with conduct problems (Burke et al., 2002; Grant et al., 2005; Gutman, McLoyd, & Tokoyawa, 2005; Keiley, 2002; Kimonis & Frick, 2010; Kumpfer & Alvarado, 2003; Shaw, Vondra, Hommerding, Keenan, & Dunn, 1994; Alexander, Robbins, & Sexton, 2000; Dishion, French & Patterson, 1995; Kilgore, Snyder, & Lentz, 2000). For families living in more disadvantaged environments, specific factors affect parenting and influence the development of behavioral difficulties, such as poverty, social isolation, high stress and lack of social support (Kazdin & Whitley, 2003; Kazdin, 1995; Kotchick, Dorsey, & Heller, 2005; Wahler & Dumas, 1989).

Furthermore, the stressors that parents experience in their role as parents may impact parenting practices, and in turn, child mental health. A number of internal (e.g., parent’s mental health) and external factors (e.g., neighborhood context, child temperament) contribute to parental stress (Copeland & Harbaugh, 2005; McPherson, Lewis, Lynn, Haskett, & Behrend, 2009; Misri, Reebye, Milis, & Shah, 2006; Ostberg & Hagekull, 2000; Sheinkopf et al., 2006). Through its’ effect on parenting practices, parenting stress has been associated with poor parent-child interaction, and child disruptive behaviors (Crnic & Low, 2002; Deater-Deckard, 2004; Grant et al., 2003; Kazdin & Whitley, 2003; Morgan, Robinson, & Aldridge, 2002). Thus, supporting families and reducing the effect of each of these family factors is the basis for MFG.

Multiple Family Groups with Other Populations

Over the last three decades, evidence has emerged that supports the use of MFG with a range of populations. More specifically, the MFG modality has been developed and most frequently used within inpatient psychiatric settings with adults with serious mental illness (Anderson et al., 1986; McFarlane, 2002). In fact, strong empirical evidence suggests that family involvement in multiple family groups is significantly associated with improved adult outcomes, rehabilitative and vocational success, medication compliance, and reduced psychiatric hospitalizations (Dyck, Hendryx, Short, Voss, & McFarlane, 2002; Dyck et al., 2000; Lukens & Thorning, 1998). These particular multiple family groups rely upon psychoeducational models that provide both the adult and their families with information about mental illness within a group context that decreases stigma while offering support, suggestions for coping and opportunities to problem solve (Goldstein & Mikloitz, 1995; Hogarty et al., 1991; McFarlane, 2002).

In addition, the use of MFG has been described with battered women and their children (Rhodes & Zelman, 1986), urban families (Aponte, Zarski, Bixentine, & Cibik, 1991; McDonald et al., 2006), clients of family service agencies (Gritzer & Okun, 1983), families with difficulties in parent-child relationships (Cassanno, 1989), African American families (Boyd-Franklin, 1993), juvenile offenders and their families (Caldwell, Horne, Davidson, & Quinn, 2007) and with adopted adolescents and their families (Lang, 1993). Further, MFG has been described as being potentially effective with families experiencing a range of difficulties, including depression (Lemmens et al., 2009; Robinson, Berman, Neimeyer, 1990); drug abuse (Wermuth & Scheidt, 1986); chronic or life threatening illness (Steinglass, 1998); and children at risk of placement (Meezan & O’Keefe, 1998). In relation to use with children experiencing mental health disorders, there is evidence of their impact on youth mood disorders (Fristad, Gavazzi, & Mackinaw-Koons, 2003; Fristad, Goldberg-Arnold, & Gavazzi, 2002). Thus, pursuing a MFG service delivery model as a potentially effective option within the field of child mental health appears promising based on this growing body of knowledge.

Methods

The current study examined the preliminary impact of the MFG service delivery approach on two outcomes: 1) youth oppositional behavior and 2) parent stress over time.

Outcomes associated with the MFG are currently being examined via a 2 group (random assignment of youth and their family members to either the MFG or comparison condition consisting of standard outpatient child mental health care) by 5 assessments (baseline, 8 weeks (midway through the MFG) posttest (16 weeks), 6 and 18 month follow-up) research design as part of a R01-level study funded by the National Institute of Mental Health granted to the first author. Only data from the first four assessment periods are included here as the longitudinal study is still ongoing.

Data from thirteen participating outpatient community-based clinics are included. Data from the first 321 participating youth and their families were available for analyses at the time that this paper was prepared. All adult caregivers provided active informed consent and all youth participants provided assent. IRB approval was secured for this study.

Participants were randomly assigned within clinics to study one of two study conditions, MFG or standard care. Randomization procedures were as follows. The first 6–8 families whose children were screened and met eligibility criteria were enrolled in the experimental condition. The next 3–4 families who were successfully screened and met eligibility criteria were then assigned to the comparison condition (see details regarding eligibility and procedures in next sections of this paper).

Sample

To date, the study has involved 321 youth (ages 7 to 11 years) and their families (including adult caregivers and siblings between the age of 6 and 18 years) nested within child outpatient mental health clinics (n=13) that serve low income, African American and Latino children. See Table 3 for description of participating youth and their families.

Table 3.

Demographic Characteristics of Participants

Total
(n = 321)
 Experimental
(n = 224)
 Control
(n = 97)
Characteristic n %a n %a n %a
Caregiver Ethnicity:
  White/Caucasian 30 9.35 21 6.54 9 2.80
  Black/African American 96 29.91 62 19.31 34 10.59
  Hispanic/Latino 169 52.65 119 37.07 50 15.58
  Native American 3 0.93 2 0.62 1 0.31
  Asian/Pacific Islander 2 0.62 1 0.31 1 0.31
  Other 13 4.05 12 3.74 1 0.31
Child Ethnicity:
  White/Caucasian 25 7.79 16 4.98 9 2.80
  Black/African American 95 29.60 65 20.25 30 9.35
  Hispanic/Latino 157 48.91 112 34.89 45 14.02
  Native American 8 2.49 3 0.93 5 1.56
  Asian/Pacific   Islander 1 0.31 0 0.00 1 0.31
  Other 21 6.54 15 4.67 6 1.87
Primary Caregiver:
  Mother 253 78.82 175 54.52 78 24.30
  Father 6 1.87 5 1.56 1 0.31
  Mother and Father 24 7.48 21 6.54 3 0.93
  Grandparent 14 4.36 6 1.87 8 2.49
  Other 14 4.36 9 2.80 5 1.56
Caregiver Marital Status:
  Single 137 42.68 86 26.79 51 15.89
  Married or Cohabiting 106 33.02 80 24.92 26 8.10
  Divorced 14 4.36 7 2.18 7 2.18
  Separated 44 13.71 34 10.59 10 3.12
  Widowed 7 2.18 4 1.25 3 0.93
  Other 4 1.25 4 1.25 0 0.00
Family Income:
  Less than $9,999 125 38.94 91 28.35 34 10.59
  $10,000 to $19,999 81 25.53 55 17.13 26 8.10
  $20,000 to $29,999 47 14.64 32 9.97 15 4.67
  $30,000 to $39,999 23 7.17 14 4.36 9 2.80
  $40,000 to $49,999 5 1.56 3 0.93 2 0.62
  Over $50,000 17 5.30 13 4.05 4 1.25
Caregiver Education Status:
  8th Grade or Less 32 9.97 27 8.41 5 1.56
  Some High School 91 28.35 60 18.69 31 9.66
  Completed H.S./G.E.D. 77 23.99 51 15.89 26 8.10
  Some College 71 22.12 48 14.95 23 7.17
  Completed College 21 6.54 16 4.98 5 1.56
  Some Grad/Prof. School 6 1.87 5 1.56 1 0.31
  Competed Grad/Prof. School 14 4.36 9 2.80 5 1.56
Caregiver Employment Status:
  Employed Full-Time 75 23.36 54 16.82 21 6.54
  Employed Part-Time 54 16.82 40 12.46 14 4.36
  Student 18 5.61 13 4.05 5 1.56
  Retired 8 2.49 3 0.93 5 1.56
  Disabled 37 11.53 26 8.10 11 3.43
  Unemployed 104 32.40 71 22.12 33 10.28
  Other 16 4.98 10 3.12 6 1.87
Caregiver age (mean ± SD) 310 36.43 ± 8.74 215 35.74 ± 8.41 95 37.99 ± 9.30
Child age (mean ± SD) 299 8.87 ± 1.41 208 8.88 ± 1.45 91 8.85 ± 1.33
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Note: Numbers may not add up to n=321 due to missing data

a

% is out of Total sample size (n = 321)

Description of Participating Outpatient Child Mental Health Clinic Research Sites

The 13 outpatient child mental health clinics involved share common characteristics. All the sites included in the study provide a range of mental health services to youth and their families living in the New York City metropolitan area. Further, the vast majority of youth served at each site are low income. Generally, youth and families at each of the sites are members of minority groups with the largest proportion of youth being Latino (with ties to Puerto Rico, Dominican Republic or Mexico) or African American.

Recruitment and Informed Consent Procedures

Providers at each site received information about the study and were given printed materials to provide to their clients about participation. Recruitment strategies included: 1) a strong on-site presence at each of the clinics; 2) on-going reminder telephone contact with clinic supervisor to encourage planning to introduce the study to families scheduled for intake appointments; 3) presentation at staff meetings to problem solve any obstacles to recruitment; 4) meetings with families took place during after school and evening hours and concerted efforts to follow-up immediately with the family immediately upon their expression of interest were made.

Potentially eligible youth and their families (based on an intake diagnosis of ODD and CD made by clinical service providers) were informed of the study by their providers. Then, if the family was interested in learning more about the study, they were contacted by a member of the research staff. Informed consent materials were provided to the family by the research staff. If the adult caregiver provided consent and the youth provides assented, then the research staff administered two screening instruments to confirm the presence of clinically significant disruptive behavior difficulties to determine study eligibility. Over ninety percent of youth screened eligible for the study. If the youth and family were screened as eligible, then the family was immediately assigned to one of the two study conditions.

Description of Multiple Family Group Intervention Protocol

The MFG service delivery strategy is a 16-week series of meetings guided by a protocol (McKay, Gonzales et al., 1995). Groups are held weekly and are facilitated by mental health providers and parent advocates. Groups consist of six to eight families involving adult caregivers and all children over six years of age in the family. Each session follows the same procedures and proceeds through five stages: 1) creating social networks; 2) information exchange; 3) group discussions; 4) individual family practice and; 5) homework assignment. Each group begins with an opportunity for families to interact. Snacks are provided. The informational portion of the group lasts approximately 30 minutes. Next, the remainder of the time is divided equally between group discussions, family practice exercises and explanation of the homework assignment (Tolan & McKay, 1996).

Content of the MFG focuses on helping families to strengthen four aspects of family life that have been empirically linked to childhood behavioral disorders. Specifically, the intervention focuses on the 4 “Rs” of family life: 1) Rules; 2) Responsibilities; 3) Relationships and; 4) Respectful communication. In addition, four specific weeks are devoted to expanding support for parenting and reducing stressors (see Tables 1 and 2).

Multiple Family Group Delivery

At each of the clinics involved in the study, agency administrators and clinical supervisors were enlisted to identify potential MFG facilitators. A group meeting with providers was organized by agency leadership. Training of MFG service providers consisted of group learning and individual teaching modalities at the agency sites. Training consisted of information related to childhood conduct difficulties, family level factors that have been linked to child mental health outcomes, strategies to enhance engagement and motivation, group facilitation skills and processes specific to MFGs. In addition, participating providers reviewed training videotapes and engaged in practice activities and role plays. Providers also received at least two hours per week of ongoing supervision which included on-site supervision and group supervisory conferences across research sites. Approximately 75 providers have been trained thus far.

Fidelity assessments were conducted by independent raters fifteen of the thirty-five MFGs completed thus far. Across sessions, raters indicated 94% fidelity to core intervention content, discussion questions and practice activities.

Description of the Comparison Condition

Standard outpatient care served as the comparison condition of the study. In each of the agencies included in this study, a range of individualized youth treatment, family involved services or family therapy, medication and evaluation services are available. There are some groups being offered, however, they were exclusively child only groups or parent support groups at the clinics. No multiple family groups were offered at any of the research sites other than those offered as part of this study.

Data Collection Procedures and Instruments

Data was collected at baseline, 8 weeks (midway through MFG) posttest (16 weeks), 6, and 18 months following the program. For the current study, we examine preliminary results from the first four waves of assessment (baseline, mid-test, post-test, and 6 month follow-up). We used self-administered questionnaires with read-aloud procedures to address issues of literacy. The study instruments for parents were translated into Spanish using well-accepted procedures for adapting assessment instruments into non-English equivalents (Oquendo et al., 2000).

Instruments

Outcomes

MFG Attendance

Group facilitators indicated whether families attended each session (i.e., “Yes” or “No”). While most participants attended groups lasting 16 sessions, a subset (n = 45) received only 12 sessions due to requests to shorten the intervention by clinic providers. Consequently, the percentage of sessions attended was computed based upon scheduled sessions.

Connors Rating Scale (IA Crs)

The IA Crs measure is a 10 item parent self-report measure of childhood disruptive behavior problems, with subscales assessing for inattentiveness and oppositional behavior (Waschbusch & Willoughby, 2008). For this study, only data from the five item oppositional behavior subscale was be used. Respondents were asked to rate on a 0 to 3 scale (ranging from Not at All to Very Much) how often their child displays these various oppositional behaviors, such as “Defiant” and “Quarrelsome.” Possible scores range from 0 to 15, with higher scores indicating greater levels of child disruptive behavior. Cronbach alphas for baseline, mid-test, post-test and six month follow-up are, respectively, .80, .83, .86 and .88.

Parent Outcomes

Parent Stress Index (PSI)

The PSI is a 36 item, parent self-report measure of parenting stress and social isolation. Five subscales exist within this measure, including: parental distress, parent-child dysfunctional interaction, difficult child, Haskett childrearing stress and defensive responding (Abidin, 1995). Respondents are asked to rate on a 1 to 5 scale (ranging from Strongly Disagree to Strongly Agree) about how they feel such as, “I don’t enjoy things as I used to” or “My child rarely does things for me that make me feel good.” Possible scores range from 36 to 180 and higher scores indicate higher levels of parenting stress. Cronbach alphas for baseline, mid-test, post-test and six month follow-up are, respectively, .91, .92, .94, and .94.

Data Analysis

Random coefficient modeling was performed on data related to child oppositional behavior and parenting stress over time using the SuperMix program for mixed effects regression models (Hedeker, Gibbons, du Toit, & Cheng, 2008). Time was modeled as months from baseline using measurements from 4 time points: baseline, mid-test (mid-way through intervention), post-test (following intervention), and 6 month follow-up. Maximum Likelihood Estimation was utilized to compute model measurements over time within cases. For the current study, participants were nested by the hierarchies of their individual ID, with time treated as a random effect. Also known as hierarchical linear modeling or multilevel linear modeling, this form of analysis: (1) allows parameters (intercepts and slopes) for measurements over time within cases to vary between cases, (2) accounts for correlation between measurements within cases, (3) allows for different times and numbers of measurements within people, which is appropriate for modeling longitudinal change involving data where there is attrition over time, and (4) assumes the missing data is ignorable (i.e., at least missing at random), which is a reasonable assumption with this data.

In order to test differences in child oppositional behavior and parenting stress index between control and experimental group participants, a dichotomous variable for group (experimental vs. control) was included in the full model predicting each outcome. In addition, product terms for group were multiplied by time (i.e. months from baseline) to test whether there was a significant difference (interaction effect) between the groups regarding outcomes. Intercepts were allowed to vary randomly within each model, further enabling calculation of the intra-class correlation coefficient (ICC), a measure of the percentage of variance between people compared to the total variance.

Results

Preliminary results are summarized in Figures 1, 2 and 3 and Tables 4 and 5 presented next. First, Figure 1 already published in McKay et al., 2010 summarizes rates of attendance for MFG participants relative to families enrolled in standard care comparison group. Notably, 80% of families brought their children to the last MFG session (at 4 months following the beginning of the MFG service).

Figure 1.

Figure 1

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Figure 2.

Figure 2

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Multivariate analyses comparing Child Oppositional Behavior over time by treatment group

Figure 3.

Figure 3

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Multivariate analyses comparing Parenting Stress over time by treatment group

Table 4.

Multivariate analyses comparing Child Oppositional Behavior over time by treatment group

Variable β SE Z p-value
intercept 8.77 0.22 39.87 0.00 **
Treatmenta 0.03 0.40 0.07 0.95
Time -0.13 0.03 -4.82 0.00 **
Treatment X Time 0.11 0.05 1.97 0.049 *
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**

p < .01

*

p < .05

a

Treatment Group indicator: 0 = Experimental, 1 = Services as Usual

Table 5.

Multivariate analyses comparing Parenting Stress over time by treatment group

Variable β SE Z p-value
intercept 98.20 1.49 65.96 0.00 **
Treatment −2.69 2.68 −1.00 0.31
Time −1.03 0.15 −6.79 0.00 **
Treatment X Time 0.80 0.29 2.76 0.006 **
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**

p < .01

*

p < .05

a

Treatment Group indicator: 0 = Experimental, 1 = Services as Usual

Next, Table 4 and Figure 2 summarize preliminary multivariate results comparing child oppositional defiant symptoms over time by treatment condition.

The coefficient for Treatment (0 = Experimental, 1 = Services as usual), is not significant, indicating at time = 0 (i.e. baseline) there are no statistically significant differences between treatment groups (β = 0.03, SE = .40, p = .95). Moreover, as seen in Table 4, there is a significant interaction between treatment and time for child oppositional behavior. This suggests that participants in the experimental condition improved in terms of child oppositional behavior at a significantly different rate than those in the comparison condition (β = 0.11, SE = 0.05, p = .049). At the 6 month follow-up (approximately 10 months from baseline), the corresponding effect size is d = .29. As seen in Figure 1, there is little if any change in ODD symptoms for participants in the comparison condition while substantial decrease for experimental group participants. Post-hoc analyses of overall means confirms that there is little change in ODD symptoms from baseline (Mean = 8.99, SD = 3.71) to follow-up (Mean = 8.30, SD = 4.15) for control group participants, while there is substantial drop in ODD symptoms from baseline (Mean = 9.32, SD = 3.35) to follow-up (Mean = 7.45, SD = 3.91).

Similarly, Table 5 (see Figure 3 for graphic display) also indicates that the coefficient for Treatment is not significant (β = −2.69, SE = 2.68, p = .32), indicating that at baseline, the amount of caregiver-reported parenting stress is not significantly different between the treatment groups. There is a significant difference in the rate at which parenting stress decreases between treatment groups over time (β = 0.80, SE = 0.29, p = .006). At the 6 month follow-up (approximately 10 months from baseline), the corresponding effect size is d = .22. Figure 2 indicates that participants in the experimental group manifest a greater decrease in parenting stress over time than comparison group participants. Post-hoc analyses of overall means further indicates that a greater decrease in parenting stress from baseline (Mean = 100.17, SD = 22.98) to follow-up (Mean = 86.53, SD = 25.83) for experimental group participants, than the decrease from baseline (Mean = 95.33, SD = 21.38) to follow-up (Mean = 89.05, SD = 24.58) for comparison group participants.

Discussion and Implications

The multiple family group is a family-centered, group delivered, evidence-informed service delivery approach that has been designed based upon research related to factors that impact the engagement and retention of children and families, specifically: 1) seeking services is often associated with stigma (Alvidrez, 1999; McKay et al., 2001); 2) parents of children with mental health difficulties have reported fears of being blamed for their child’s problems and these fears may in turn influence decisions to continue in services over time (McKay et al., 1996), and; 3) mutual support and normalization of family struggles with child mental health needs could create more receptivity to treatment and potentially offer encouragement for family-level change needed to reduce child disruptive behavioral difficulties (Brannan et al., 2003; Koren et al., 1997).

Further, the MFG capitalizes on: 1) empirically supported, family-focused approaches consistently associated with reductions in child disruptive behavior (Bank et al., 1991; Kumpfer & Alvarado, 2003; Webster-Stratton, 1985; 1990; Sexton & Alexander, 2002); 2) a protocol driven approach that has been developed with maximum input from youth, adult caregivers and providers and successfully implemented by “real world” service providers across a diverse array of outpatient clinic settings (McKay et al., in press; McKay et al., 1998; McKay, Harrison et al., 2001) and; 3) accumulated data supporting an association between MFG service involvement and improvements in engagement and child/family-level outcomes (McKay et al., in press; Fristad et al., 2003; 2002; McKay, Harrison et al., 2001; McKay, Quintana et al., 1998; Stone & McKay, 1996).

Finally, the MFG service delivery model has been specifically designed to target a set of weakness, namely insufficient capacity and high inefficiency within the current delivery system (Atkins et al., in press; Atkins et al., 2004; McKay et al., 2004). Even the current number of children and their families approaching the public mental health service system far outstrips the availability of services and the number of service providers. It is not unusual for waiting lists for care within communities across the US to extend for months (Brown et al., 2002). Thus, MFGs are meant to specifically expand opportunities to receive care within provider organizations that struggle with service capacity and adequate levels of funding and which also have no reasonable expectation for additional resources to expand service slots in the near term.

Acknowledgments

Funding from R01 MH072649 (PI: McKay) and F32 MH090614 (PI: Gopalan) is gratefully acknowledged. In addition, the significant contributions of the members of the multiple family group collaborative working group, including parents, parent advocates, child mental health providers and research staff are also recognized.

Footnotes

This study was previously presented at the Stockholm Conference on Outcome Studies of Social, Behavioral, and Educational Interventions, on February 8th, 2011. It was invited and accepted at the discretion of the Editor.

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