Imagine a mental health service that builds stronger families

Imagine a mental health service for children with which thousands of families reported high satisfaction (95%), had <10% attrition and showed significant improvement in child outcome for behaviour (n=1062; Externalizing problems, F 6, 1049 = 2851.4; P<0.001; d= 2.4) or anxiety problems (n=235; Internalizing problems, F 6, 228 = 1090.7; P<0.001; d=2.8). Imagine that it had a no-waiting list policy, that it would arrange appointment times around families’ schedules (day, evening or night), and that removed barriers to care (no travel, no time off work or school and no stigma). Imagine that this program was based on the best evidence from dozens of studies and systematic reviews of interventions. Imagine that the service was shown to be effective in randomized trials and collected outcome data independently on each family and analyzed these data to improve the program. Imagine that the program customized the care for each family and constantly monitored quality. And imagine that it was cost effective for the health system, with the ability to quickly eliminate waitlists. Strongest Families Institute (SFI) is such a service!

In 2011, SFI (www.strongestfamilies.com) became a federally registered not-for-profit organization delivering distance services to families in the comfort and privacy of their homes. Strongest Families (1) was developed and clinical trials conducted from 2000 to 2007 at the IWK Health Centre, Halifax, Nova Scotia. The Strongest Families distance system of care was designed as a cost-effective access solution designed to remove the barriers to care, especially those in remote regions (2). With the capacity to ramp-up quickly to reduce waitlists and the efficiency afforded by the innovative ehealth system known as IRIS (Intelligent Research and Intervention Software <www.irisplatform.com>) (3,4), time nor distance are barriers to families when accessing SFI services. In 2012, under the Nova Scotia Department of Wellness five-year mental health strategy (5), SFI acquired approximately 400 children from waitlists within a 3.5-month period.

Strongest Families programs were developed to provide evidence-based care to families with children experiencing the two most common mental health problems: anxiety and disruptive behaviour disorders (eg, oppositional defiance, attention deficit-hyperactivity and conduct). Strongest Families is not designed for families with children with the most severe problems who are at immediate risk for harm to themselves or others: it helps families with moderate problems before they become more severe.

Strongest Families programs are cognitive-behavioural interventions that focus on building a strong relationship between parent and child. Families learn skills to overcome mental health problems of disruptive behaviour (three- to 12-year-olds; Parent-Coach only) and anxiety (six- to 17-year olds; Parent-Coach and Child/Youth-Coach). A pain and a bedwetting module are available. The programs include written material (handbooks or online- written at a grade five level), skill demonstration media (video and audio clips) and weekly telephone support from a SFI certified, paraprofessional coach. Services are available in English and French. Outcomes are measured and reported consistently. Validated tools are used pre- and postintervention, and weekly improvement ratings are recorded. Families and referring sources receive outcome progress updates at mid and end of intervention (6). Funders receive aggregate reports on referral numbers and outcomes quarterly. Coaches are highly trained on SFI protocols and follow SFI protocolized scripts to help the family learn skill application using role-playing and problem-solving strategies throughout each telephone call. Families learn one skill per week.

Coaches prepare the family for success. As a team, the client and coach will determine whether the family needs additional time to successfully implement the skill before moving on to the next one. Care is customized to meet the needs and challenges of the family; self-care is embedded as weekly goals for parents to take time for themselves.

Coach caseloads are reviewed weekly with a certified paraprofessional coach supervisor. Coach competency is evaluated by having a percentage of their coaching calls audited and scored; additional training is completed as needed. Coaches complete full intervention on approximately 100 families per year.

Approximately 15% of the clients served by SFI may not respond fully to intervention and are referred back to the referring agent for additional services. Because SFI targets mild to moderate conditions, there are few cases that become worse during the course of the program. SFI staff follow risk-management protocols and consult as needed with an SFI clinician. For cases that are not responding as expected by mid-intervention, or if a situation escalates, SFI will communicate with the referring source to help facilitate additional services.

We developed Strongest Families through a careful analysis of the existing literature, and conducted several studies to enhance our understanding of parents and children and outcome studies (Table 1).

TABLE 1.

Studies conducted to inform Strongest Families

Issue	Citations	Results	Comment
What predicts success in parent training	Reyno SM, McGrath PJ. Predictors of parent training efficacy for child externalizing behavior problems – a meta-analytic review. J Child Psychol Psychiatry 2006;47(1):99–111	Low family income most powerful predictor of failure	Need to design program accessible by all. Incidental costs areimportant
Does mother depression cause child problems or vice versa	Elgar FJ, McGrath PJ, Waschbusch DA, Stewart SH, Curtis LJ. Mutual influences on maternal depression and child adjustment problems. Clin Psychol Rev 2004;24(4):441–59	There is mutual interaction. Both contribute to the other	Teaching parenting skills may alleviate mother’s depression
What is the link between parents’ depression and children’s outcomes?	Elgar FJ, Mills RS, McGrath PJ, et al. Maternal and paternal depressive symptoms and child maladjustment: the mediating role of parental behavior. J Abnorm Child Psychol 2007;35(6):943–55	Specific parenting behavior seems to be critical link between parental depression and child maladjustment	Changing parenting behavior maychange child outcome even if parents are depressed
Can parents and children develop a therapeutic relationship if they never see their coach?	Lingley-Pottie P, McGrath PJ. A paediatric therapeutic alliance occurs with distance intervention. J Telemed Telecare 2008;14(5):236–40. Lingley-Pottie P, McGrath PJ. Distance therapeutic alliance: The participant’s experience. ANS Adv Nurs Sci 2007;30(4):353–66	Both children and parents develop a very strong therapeutic alliance with their coach when seen in Strongest Families	No need for other than telephone contact to develop strong relationships
What type of letters do doctors and parents prefer about children receiving mental health care	Lingley-Pottie P, Janz T, McGrath PJ, et al. Outcome progress letter types: parent and physician preferences for letters from pediatric mental health services. Can Fam Physician 2011;57(12):e473–81	Graphical representation of results preferred over text	Letters from Strongest Families use figures and tables to show outcomes
Does Strongest Families result in lower diagnosis of mental health problems after treatment?	McGrath PJ, Lingley-Pottie P, Thurston C, et al. Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: randomized trials and overall analysis. J Am Acad Child Adolesc Psychiatry 2011;50(11):1162–72	Strongest Families works for both anxiety and disruptive behavior. May be a lessening of effectafter a year	Need to develop long term interventions that are effective and inexpensive
Are there differences in perceived barriers and therapeutic processes between distance vs face-to-face treatment?	Lingley-Pottie P, McGrath P, Andreou P. Barriers to mental health care: Perceived delivery system differences. Adv Nurs Sci 2013;36(1):51–61	There are fewer barriers with distance treatment. Therapeutic alliance and self-disclosure scores are enhanced with distance treatment	Distance services remove barriers to care for families. The care experience can be enhanced and stigma is eliminated
Does Strongest Families work when it is routine care	Lingley-Pottie P, McGrath PJ, Cunningham C, et al. A clinical series of a large cohort of families using a distance model of parent training, Strongest Families. In submission	Both group and individual results were excellent for over a thousand families	Efficacy is maintained in usual care
Does Strongest Families work in other cultures if appropriate modifications are done?	McGrath PJ, Sourander A, Lingley-Pottie P, et al. Remote population-based intervention for disruptive behavior at age four: Study protocol for a randomized trial of Internet-assisted parent training (Strongest Families Finland-Canada). BMC Public Health 2013;13:985	The study is now completed and Strongest Families worked well. Paper is under review	We are now examining several other versions of Strongest Families eg, in Vietnam and for Aboriginal Canadians

The SFI service delivery team maintains a close relationship with our research group, the Centre for Family Research <www.crfh.ca> at the IWK Health Centre. Generally, research studies are conducted under the leadership of the research group and service dissemination is under the leadership of SFI.

Several other studies focusing on aspects of Strongest Families are underway or published. We have developed Strongest Families for children who have fetal alcohol spectrum disorder and a randomized controlled trial is underway. A trial for postpartum depression is being analyzed. We are planning versions for children with other developmental challenges and Strongest Families for Aboriginal families is in development. Strongest Families is now available in Finland and a randomized trial in Vietnam is about to begin.

SFI research has been generously supported by the Canadian Institutes of Health Research, the Canada Research Chairs program, NeuroDevNet and others. Strongest Families has received the Mental Health Commission of Canada Award for Social Innovation in 2012 and the Ernest C Manning Encana Principal Award for the best Innovation in Canada in 2013.

In summary, Strongest Families is a program of care that uses the best science to deliver care remotely to families, when and where they need it. The program is designed to remove many of the barriers to care that exist with the current system and to be a cost-effective access solution at approximately one-third of the cost of traditional services. SFI is a compliment to existing mental health services by bridging a serious access gap and providing equitable services to Canadian families.