A qualitative study to explore paraprofessionals’ role in school-based prevention and early intervention mental health services

Abstract

This study explored the role of paraprofessionals within a school-based prevention and early intervention program to promote children's engagement in learning and positive parenting practices. Study aims were designed to understand how paraprofessionals perceive their role in high-need communities and how they define their work within schools. Two focus groups were conducted with school family liaisons (SFLs) during the 2015–2016 school year. Transcribed audio recordings were coded using thematic analysis wherein 2 authors coded independently, followed by audited discussion and final consensus codes. SFLs acknowledged the importance of serving high-need communities and relationship building was central to their role. They leveraged contextual knowledge (culture, language, and neighborhood) to engage parents, allowing them to serve as effective advocates for parents/families in the school setting. Findings support the importance of paraprofessionals in prevention-focused services and highlight how leveraging shared experiences and prioritizing relationship building facilitates their work as advocates within schools.

1 ∣. INTRODUCTION

The community mental health service system continues to face significant challenges serving ethnic minority youth in urban poverty (Bringewatt & Gershoff, 2010; Huang et al., 2005), reflecting a lack of attention to issues of culture, context, and diversity (Alegría, Atkins, Farmer, Slaton, & Stelk, 2010). Long-standing mental health disparities persist despite decades of research focused on the dissemination and implementation of evidence-based practices, which highlight challenges in serving high need communities. Further, the persistent focus on services delivered through traditional clinic-based models limits the reach and impact for youth and families most in need (Atkins & Frazier, 2011; Atkins & Lakind, 2013).

While children in need of mental health services from all communities face significant barriers to seeking and receiving services in usual care settings (Kataoka, Zhang, & Wells, 2002), disparities are more complicated and entrenched for those living in poverty (Harrison, McKay, & Bannon, 2004; Yoshikawa, Aber, & Beardslee, 2012). Ethnic or racial minority status (Alegría, Vallas, & Pumariega, 2010) and immigrant status (Huang, Yu, & Ledsky, 2006; Yoshikawa, Kholoptseva, & Suárez-Orozco, 2013) compound these challenges. Ethnic minorities have historically been underrepresented in mental health services research, prompting concentrated efforts over the last two decades to promote equitable and ethical representation in research (Fisher et al., 2002; Vega & Lopez, 2001). Nonetheless, service use disparities continue for ethnic minority youth and families living in poverty (Alegría, Grief-Green, McLaughlin, & Loder, 2015). The lack of services to meet the needs of children in high-need communities calls for a public health approach that embeds services in natural settings like schools, expands targets for services to include prevention, and incorporates an expanded workforce of paraprofessionals (Atkins, Rusch, Mehta, & Lakind, 2016). This study aimed to gain a deeper understanding of the role of paraprofessionals working in schools to address the mental health needs of children and families in high-need urban communities.

1.1 ∣. The paraprofessional workforce in children's mental health

Paraprofessional workforces offer a promising means through which to address the many barriers and disparities in mental health service use for ethnic minority youth and families in poverty. The paraprofessional role can refer to a variety of titles (e.g., community health workers, family advocates, family resource developers, school liaisons) that all share the characteristics of workforce members who generally do not have formal professional or advanced educational training in health and/or human services but have some degree of specific training, such as promoting access to health information and resources and/or helping clients navigate a service system (Lewin et al., 2010; Perry, Zulliger, & Rogers, 2014). Paraprofessionals are often, but not always, members of the same community of the population they serve, enabling them to better engage clients in services. Indeed, paraprofessionals’ positionality as a near peer to the population they serve has been shown to be a prominent feature of how paraprofessionals engage clients in services (Gustafson, Atkins, & Rusch, in press). Given that paraprofessionals require less specialized professional training, they can also expand access to services by increasing service workforce capacity.

Paraprofessionals are well positioned to address access and usage disparities in underserved ethnic minority populations, with demonstrated utility across numerous child-and family-serving programs in the United States, including family medicine practice (Findley, Matos, Hicks, Chang, & Reich, 2014), maternal and infant health home visiting models (Olds et al., 2002), and pediatric medical care (Margellos-Anast, Gutierrez, & Whitman, 2012). A recent review of mental health interventions (both child or family and adult) delivered by paraprofessionals found that 72% of all studies examining these models were published after 2010, suggesting this is a relatively new area of inquiry (Barnett, Gonzalez, Miranda, Chavira, & Lau, 2017). However, most studies were conducted in low- and middle-income communities outside of the United States, and the authors point to the need to mobilize this workforce more effectively within high-need U.S. communities (e.g., to free up mental health providers to increase capacity for intensive level care services).

Researchers have advocated for restructuring the children's mental health workforce with recognition of the untapped potential of many frontline paraprofessional providers (Huang, MacBeth, Dodge, & Jacobson, 2004). Indeed, paraprofessional providers are particularly effective for engaging parents and families in specialty child mental health services (Hoagwood et al., 2010) and have been trained to provide family support activities within the specialty mental health sector (emotional support, action planning, information provision, skills development, and advocacy; see Olin et al., 2010; Rodriguez et al., 2011). The experiences of paraprofessionals have also been described in youth mentoring programs (Lakind, Atkins, & Eddy, 2015), which demonstrates how they utilize mental health promotion strategies in their work.

1.2 ∣. The role of paraprofessionals in school-based services

Expanded mental health services in schools relies upon collaboration between community mental health and school staff, and this can be challenging given the existing demands on both systems (Weist, Ambrose, & Lewis, 2006). This calls for resources, like paraprofessionals, that can serve as liaisons in the school setting. Researchers emphasize the importance of aligning mental health with the central mission of schools (i.e., student engagement in learning), which requires intentional efforts by community mental health providers to leverage the role of paraprofessionals and other indigenous school resources (Cappella, Frazier, Atkins, Schoenwald, & Glisson, 2008). Paraprofessionals have been used to provide direct social-emotional support to students (e.g., Wyman et al., 2010), as well as to support teachers in the implementation of classroom-based interventions and parents in the implementation of home-based learning supports (e.g., Atkins et al., 2015). Thus, there is evidence that paraprofessionals are critical in community mental health-school partnerships.

Expanded service models that leverage the role of paraprofessionals are increasingly critical in communities of concentrated poverty where mental health resources are scarce and community-level stressors are high. Community paraprofessionals play a salient role in enhancing parent involvement and engagement in their children's educational experiences and addressing barriers to accessing mental health services and supports (Atkins, Frazier, Abdul-Adil,& Talcott, 2003). The reach of more traditional parenting interventions is limited, especially in high-poverty communities, which further argues for expanding service delivery formats (e.g., informal contacts, in vivo messaging) via the use of paraprofessional workforces to help promote positive parenting (Lakind & Atkins, 2018).

1.3 ∣. Study aims

This study builds upon the existing literature focused on the role of paraprofessionals in schools by delving deeper into the meaning they ascribe to their role in order to better understand how they approach working within urban, low-resourced communities. We focused our inquiry on paraprofessionals (school family liaisons or SFLs) from the Partners Achieving Student Success (PASS) program, a school-based (pre-K to third grade) prevention and early intervention serving low-income families in communities of concentrated poverty. Aim 1 examined SFLs’ perceptions of their role in serving high-need communities through PASS. Aim 2, supplemental to the first aim, explored how SFLs leveraged contextual knowledge in their work with families. Finally, Aim 3 examined how SFLs defined their work to generate a greater understanding of the contextual meaning of family support provided by a school-based paraprofessional workforce.

1.4 ∣. Description of the PASS program

PASS was collaboratively developed through a community partnership with four social service agencies and providers (SFL training, program development, and services are described in Mehta et al., manuscript submitted for review 2018). SFLs were full-time employees of the agencies and supervised by master's level clinicians. SFLs ranged in level of education (high school/GED to master's level), with many indicating some college coursework. Sixty percent worked in social services, youth services, or community organizations for 2 years or less (Jacobs et al., 2017). This study was conducted during the 2015–2016 school year; services were implemented in 16 public elementary schools in a large Midwestern city, serving approximately 600 children.

PASS was developed to leverage the strengths and capacities of SFLs who were drawn from the local community to engage parents through formal groups and informal contacts (e.g., drop-in times at the school). SFLs’ primary focus was to engage parents in services in order to promote school engagement and positive parenting. Their work included meeting critical family needs through case management services while effectively communicating core messages related to six skill areas that supported the overall program goals: supporting reading, homework routines and home routines, positive parenting, positive discipline, family-school connections, and reducing stress. They did this through parenting groups, home visits, informal drop-in meetings with parents, and electronic communications (e.g., phone calls, texts, emails), in which they provided information, feedback, and case management support to address parents’ goals and challenges. SFLs also worked with children via in-class support, pull-out groups, and individual support, and they engaged in consultation with teachers to monitor academic and behavioral progress at school.

2 ∣. METHOD

2.1 ∣. Focus group recruitment

We recruited SFLs from all four social service agencies that delivered PASS Program services during the 2015–2016 school year. We conducted two focus groups to purposefully group agencies based on the population primarily served by their organization. The first group included two agencies that served primarily Latino and immigrant families (72.8%–78.3%; referred to as cohort 1 or C1) and the second group included two agencies that served primarily African American families (96.0%–98.3%; referred to as cohort 2 or C2). All agencies served predominantly poor school communities (91.9%–99.3% students eligible for free lunch).

SFLs were recruited via in-person, phone, or email contact. Eight C1 SFLS (of 12 eligible) and 10 C2 SFLs (of 19 eligible) provided consent to participate in the focus groups; C2 was recruited 3 months after C1. The size of each focus group approximated the recommended norm of 6–12 participants (Stewart & Shamdasani, 1990). Focus group participants were primarily female (83% C1, 100% C2) and between age 23 and 58 years (mean [M] = 36.8, standard deviation [SD] = 12.14). All C1 SFLs self-identified as Latino/a and all C2 SFLs self-identified as African American. Most SFLs were parents (67% C1,100% C2), had previous work experience in social services (67% C1,80%C2), and attended at least some college or university (83% C1, 100% C2).

2.2 ∣. Focus group protocol

To frame our inquiry, we relied on family support domains shown to be relevant for other paraprofessional-led mental health services in low-resourced communities (Wisdom, Olin, Shorter, Burton, & Hoagwood, 2011) that focus on engagement, reducing barriers, and parent empowerment (Olin et al., 2010; Rodriguez et al., 2011). The intention of this study was not to validate family support domains, but rather to use them as empirical anchors to explore the role of school-based paraprofessionals. Focus group questions broadly queried SFLs to describe their experiences and define their work in PASS. The C1 focus group questions also queried bilingual SFLs about serving the needs of Latino and immigrant-origin families. Each 2-hour focus group followed a series of guided questions (C1 only is noted in brackets).

First, we explored how SFLs described their role, experiences, and contextual knowledge (How would you describe your experience working with [immigrant] parents in the PASS program? [What expectations did you have about your role as a bilingual SFL?]). Second, we probed for deeper contextual meaning about how they define their work using family support domains (Hoagwood et al., 2010) as anchors: (In your role as an SFL, how do you provide emotional support to parents? What are some of the issues or concerns raised by [immigrant] parents that require dedicated time for action planning or setting goals, more generally? In what ways does PASS involve providing information that is specifically relevant to engaging [immigrant] parents? How can SFLs help direct or provide skills building opportunities for [immigrant] parents? What does advocacy mean to you?).

2.3 ∣. Theoretical approach and data analysis

The design of this study emerged from intentional decisions to document the role of the PASS paraprofessional workforce within a unique service model, given the paucity of research on the perspective of this workforce. Our research questions arose from ongoing observations and feedback our research team received from SFLs regarding perceptions of their role, the purpose of their work, and their experiences as providers working within high-need communities. Given the aforementioned gaps in the literature, we designed a study using qualitative methodology to systematically examine SFLs’ role and document their experiences, following guidelines for rigor and authenticity for naturalistic paradigms (see Guba & Lincoln, 1986).

This methodology focuses on gaining a deeper understanding of context. While the focus on a unique workforce and service model limits “sample to population” generalizability (Miles & Huberman, 1994), it could have instructive implications for other paraprofessional-led services. We relied upon our knowledge of these communities and contexts (schools, agencies) when interpreting these data in order to attend to multiple realities/perspectives and the credibility and consistency of findings (Guba & Lincoln, 1986). Researchers were not completely neutral or objective given their range of experience (2–4 years) in collaborating with SFLs or agencies, but, as noted below, steps were taken to minimize groupthink and individual biases (e.g., two primary coders, code auditors, reflective processes that resulted in additions or changes to code structure).

Transcribed focus group documents were analyzed using a secure web-based qualitative data analysis program (Dedoose.com). Transcripts were checked against audio recordings of the focus groups to ensure accuracy and each transcript was divided into segments for coding purposes. The coding team consisted of the first four authors of the current study. Consistent with a thematic analysis process (Braun & Clarke, 2006), the first author, who facilitated all focus groups, generated an initial coding framework based on the family support domains that informed the focus group protocol. This codebook was refined through discussions between the first and second author. Using the coding framework, the first and second author coded the transcripts independently.

Following the initial coding, all members of the coding team met and reviewed the codes. All coded segments were discussed until the team reached consensus; discussions focused on the application of codes and ongoing reflections on emerging themes within and across focus groups. To minimize subjective bias, the third and fourth authors served as auditors during this process (Hill et al., 2005). We were unable to perform a member check of our results; this confirmability audit was performed to ensure that themes accurately represented SFLs responses. Finally, the team reviewed the data by code category to further identify and finalize themes and interpretations of themes within the context of the PASS program and the communities served.

3 ∣. RESULTS

Aim 1 intended to capture SFLs’ broad perceptions of their paraprofessional role. We found evidence of two themes within this category. First, there was a shared understanding of context; SFLs reported their perceptions of the importance of serving high-need communities and strong dedication and commitment to their role (see the Why and for whom: The importance of PASS services section). Second, SFLs identified relationship building as the key to engaging both parents and teachers/school staff in order to maximize their impact in the high-need communities they served (see the How SFLs approach their role section).

Aims 2 and 3 represent a pointed focus on particular facets of SFLs’ experiences in their work with families and schools (contextual knowledge and their role as a liaison between families and schools, respectively). With regard to Aim 2, SFLs were asked to discuss their knowledge of contextual factors and how these were evident in their work (see the following sections: Leveraging contextual knowledge and experiences to support relationship building, C1 culture, and C2 community). We explicitly questioned C1 SFLs about cultural context, but consensus related to community context emerged more spontaneously in C2. For this reason, we present excerpts separately for each cohort, yet this theme represents cross-cohort consensus on the importance of contextual knowledge for engagement and building trust with parents and families. With regard to Aim 3, SFLs were asked to discuss their role as a service provider working in the school and community. According to SFLs, PASS agency–school partnerships positioned them as resources within schools, and they reported that they understood and labeled their tasks and responsibilities in schools as advocacy (see the Serving as advocates within schools section).

Participants’ own words are presented throughout this section and identifying information (e.g., participant name, agency, neighborhood) has been removed to maintain confidentiality.

3.1 ∣. SFLs’broad perceptions of their role (Aim 1)

3.1.1 ∣. Why and for whom: The importance of PASS services

SFLs’ responses indicated general consensus on the overall importance of PASS within high-need communities and the value that SFLs placed on their role. Specifically, SFLs reported the importance of situating PASS services within schools, which they saw as a valuable contribution to students and families in their community (“You’re talking about a service to [families] that is not going to cost [parent] anything … for [them] to know that someone is going to give [their] child extra support in school, in academics”). SFLs also reflected a seriousness and dedication they bring to their work, with a recognition of the high needs within their respective communities.

SFLs indicated their (often firsthand) knowledge of widespread stressors and struggles affecting families in their communities. This sometimes contributed to challenges in their work, for example, when discerning how to best support parents and families.

[S]ome of them hide it so well that they're not doing well and others are up front with it. But the ones that are not doing well, you wouldn't know. So it's, like, their masking skills, it's amazing … it's like you just never know what you're gonna walk in to.

Other challenges stemming from family and community needs included communicating with parents about children's behavioral or academic challenges (“Because if they're in denial about what they need—I mean, how am I gonna help you if you don't even admit to it?”) and maintaining parent engagement while also promoting accountability for child progress.

I got parents that sign their kids up and that's all they do is sign them up. I talk to them on the phone … but when it comes to coming to the school … nope. They can say they're coming to the school and they don't come to the school. You can go to their house and they don't come to the door. [all laugh] Yeah, right. I had a parent come to the door and say, “I'll be right there” and never did come out.

Notably, for some SFLs, their resolve to address the multitude needs of families resulted in challenges related to setting boundaries or acknowledging their limits (“And I do over analyze things. And, you know, it's good to know that.… There's some things you can't fix”; “It's hard to hear there's nothing that we can do, especially if we see this family every day or we see the child every day”). Despite these challenges, SFLs described how they persisted in their attempts to reach families and encouraged parents to take an active role in PASS activities. This was perhaps due to SFLs’ perceptions of the families’ and communities’ high level of need and recognition that few other available workforce resources were earmarked for providing necessary services and supports (“But for some parents, we are the only ones that are even trying to help them”). SFLs’ sense of responsibility was reflected in not “giving up” on parents (“A lot of these families don't have somebody to support them … I think a lot of us go above what we're supposed to do”), thus highlighting their perception of PASS services and their work as important for families.

3.1.2 ∣. How SFLs approached their role

SFLs shared information about how they approached their work with families. In particular, these responses identified the critical nature of relationship building and leveraging shared experiences to engage parents and families. SFLs described qualities that make relationship building successful, including the importance of respecting privacy while being trustworthy, dependable, and genuine. As demonstrated by the quote below, a few general strategies mentioned included: (a) using personal experiences to enhance connections, (b) taking time to get to know parents to develop a sense of consistency and genuineness, and (c) tailoring their approach to match parents’ styles and experiences.

I'm a mother too. So whatever situation I might have been through may be the same situation. I might have a different outcome because I did a, b, or c. So the fact that you can relate to them, that's very helpful. Not the fact that I'm here and you're there. We're at the same level trying to get these kids to go to a goal, to a certain goal. But I like the fact that she [another SFL in the focus group] said we're relatable.

SFLs’ ability to acknowledge and normalize family needs, sometimes stemming from their firsthand experience, allowed them to keep parents engaged. Their comments suggested a normalizing or equalizing quality to the SFL role.

You don't gotta go deep into your personal life but you can tell them well, my son, he was acting that way, you know, it's not just your child. You don't have a bad child. You know, you're not going through all of this alone. Somebody had bill problems before. You know? I think everybody had bill problems before.

SFLs also spoke about the importance of creating positive relationships with teachers as critical for fostering school–family partnerships. SFLs recognized the stress and difficulties experienced by teachers, which helped to build effective working relationships with them. By prioritizing relationship-building strategies with teachers, SFLs were able to help stabilize interactions between parent and teacher or school, as illustrated below.

I had an incident where the parent was constantly writing letters to the teacher seeming, you know, upset because the child wasn't coming home with his mittens or his hat. [The teacher] was getting upset saying, “I'm here to teach, I can't pay attention to one student when I have thirty. She needs to do her part at home.” So, I kind of explained that to the parent in a nice way.… I think most of the time it's the parent, advocating for the parent. But in some incidents, it's hard for the teacher too because it's a lot.

3.2 ∣. SFLs’ Use of contextual knowledge (Aim 2)

3.2.1 ∣. Leveraging contextual knowledge and experiences to support relationship building

Given the structure of our focus group protocols, each cohort described their experiences that were unique to the communities they served. The following section provides cohort-specific descriptions, which are not intended as a “true” comparison of group differences. Rather, these quotes are provided to elucidate the factors that SFLs described as salient to understanding the families they served and how they leveraged their knowledge and experiences to engage families in services. These descriptions provide a rich understanding of the extent to which SFLs attended to context and how this enabled them to leverage their role.

3.2.2 ∣. C1 culture

C1 was prompted to elaborate on their bilingual role and serving Latino immigrant families, and their responses reflected the cultural context. Specifically, three subthemes described the ways that culture manifested in C1 SFLs’ work with families: (a) the immigrant experience, (b) cultural norms, and (c) language. First, C1 perceived the immigrant experience as an important factor that shaped how their parents participated in the PASS program. Immigrant status and immigration-related struggles manifested in parents’ willingness to engage in both the program and the parents’ expectations of SFLs. SFLs reflected on the process of acculturative stress (e.g., “learning a new language, learning a new culture, coming here from a different country”) and generally identified with the immigrant experience.

It's the community I grew up in and I'm used to immigrant families from church where you learn their happiness or their sadness or their struggles because that's a place where they open up. So … when you've been in a place like that for many years, you learn what's going on really.

Their emotional identification with the immigrant context (all C1 SFLs were immigrants or children of immigrants) provided them unique insight, but sometimes created discomfort when setting boundaries or meeting a family's needs. Even when SFLs recognized the limits of their role, the significance of parents’ needs lingered on their minds, as did the manifestation of immigration stress in child functioning at school.

I had a parent ask me if I could sponsor her husband. They were in the process of legalizing his status here in the States. Of course, it's really hard to say, it's not really what I'm here to do.… I said, “I understand you. I'm an immigrant myself.” But I kind of left it like that until I asked her how's it going. And she said, “Oh we found someone.” But, of course, I do not know her husband. It's not why I'm there.… But she seemed, I don't want to use the word desperate … but she was needing someone. And this is what she said, “This means that he's going to get a better job sooner, we are going to have more money.” She's really stressed out because she works two jobs, you know?

[T]his child … would cry every morning coming to school and she would explain that they would walk at night and it was her and her mom. So that's how I knew. Mom needed a lot of help with her immigration status and I felt so bad ‘cause there was not much that I could help her with. But I would try my best.

C1 also discussed how immigrant status influenced parents’ help-seeking behaviors. For some parents, this manifested in a sense of fear or distrust of resources provided by PASS (“She's scared to sign anything … whatever resources we give her she gets scared because she is an immigrant”), whereas for other parents, their shared cultural identity manifested in an almost blind trust in the SFL (“I'm explaining the consents for HIPAA or anything they just nod their head and then yeah they are ready to sign … I'm like, ‘Wait, I'm not done explaining it to you’”). SFLs’ familiarity with the immigrant experience often served as an important reference point in their approach to service delivery. That is, they acknowledged that immigrant parents might have a lack of familiarity with the U.S. school system, which informed their approach to help parents support children's learning at home.

Maybe if the child is not doing so well academically, how can the parents help at home with that, whether its flash cards or … just sitting down with them, right. Um … because I know that most of them that come through an immigrant background they are all pretty low academically and that's because they don't have much support. And so then by trying to teach the parents, how they can work with them a little bit might work. Maybe songs or something … that will make it easy.… Maybe getting them easier Spanish books if parents can read.

Relatedly, immigrant parents had expectations about the role of schools and parent involvement (e.g., deference to schools) that also shaped their expectations of the PASS program.

And, ah … for an immigrant family, I think they are used to it because culturally too, you know? The school is like a second home and the teacher is like a second parent or any school official.… So that's why it's sort of like they go and leave their kids and they're not expecting any feedback, you know, or questions to be asked of them.

Latino cultural norms were another culture subtheme that C1 described as important to their work. C1 often drew upon a shared Latino identity to align with, and ultimately engage, immigrant parents. Their own lived experiences afforded them unique insight into parents’ experiences and they relied on knowledge of cultural customs. For example, this SFL referenced culture-based communication norms that directed interactions with parents.

And like I said … my caseload is completely Latino so it's nothing new to me because it's I guess how I was raised. You just approach it the same way. You talk to them. They're older so you're like okay well I'm going to be more respectful. You respect me, I respect you, that's all.

This SFL subsequently described a shared cultural reference point (Mexican cuisine) as a way of making intervention content more accessible.

That jalapeño, tell him that it's green … that lime, it's green. This is something he is going to see every day. And that's how you can incorporate that. Just giving them little suggestions this is how you can teach him his colors.… You have to make it so that it's not a burden on them. I guess I know it sounds bad but so they don't have to—they just worked 12 hours, you know.

Language was the third subtheme illustrating culture at play in the SFL role. They commented on the subtle ways they used language to perceive and respond to parents’ needs. For example, the nuances of a parent's language (e.g., use of slang, colloquialism, vocabulary, dialect/accents) gave SFLs a “sense” of the family's background (“I think even in the first meeting … the way they are talking to you, their accent, even the words they use, I would know right away”), and modified their recommendations accordingly (e.g., for parents who speak very little or no English, encourage older English-speaking siblings to assist with homework, or use Spanish-language books). Many PASS students were in bilingual education and SFLs found it important to convey knowledge to immigrant parents about the U.S. school system.

Another thing would be informing parents of what, just relaying information from what the school is looking for. Because we find–especially you [to the other SFL]–with [the school district] it's like for third graders…you relay how important it is that in fourth grade you will no longer be able to rely on Spanish. So that just emphasizes, just giving that information to a parent because parents, well, a lot of the parents aren't knowledgeable on how [the school district] works. How you have bilingual benchmark and how important is reading comprehension.

Being bilingual uniquely allowed C1 to build relationships and demonstrate a shared cultural understanding with Latino parents and students. Bilingual SFLs were accustomed to language brokering in their personal lives (“I don't mind it. I'm comfortable with it”; “Yeah, I've never thought about it”; “I've been translating all my life”), and this personal experience cued them to serve as translators for non-English-speaking parents. C1 carried an awareness of how the familiarity of shared language fosters trust and connection.

Then the Spanish, it's just a natural thing. I know a lot of the uh … slang, if you want to put it that way or colloquial, you know, way of conversating with them and talking to them. It's just kind of I find that to be just one of my strengths in order to engage them. Plus, you know, I always go back to the mother land and talk a little bit about what was going on over there and I find that they, that's a way for them to kind of like initiate a conversation with me. And then we, we connect right away.

While some SFLs mentioned fumbling at times with their fluency (“Then when you go around that word that you're trying to explain to them … they laugh a little and then we just keep it moving”), they did not cast this as an additional burden to their role. In fact, serving as interpreter was a unique way to help parents connect with resources.

“Well, we don't have any interpreters at the moment.…” So I said, “Well, I have her next to me and I don't mind translating for her. If you don't mind, I can do it for her.” They just needed her consent. As long as they feel comfortable, then I feel comfortable.

3.2.3 ∣. C2 Community

C2 responses reflected factors related to understanding the needs of two predominantly African American communities that are characterized by extremely high rates of poverty and community violence. Specifically, three subthemes described the ways knowledge of the community affected service delivery: (a) neighborhood affiliation, (b) school-community relationships, and (c) school district policies. C2 relied on their shared experiences as community members and knowledge of historical neighborhood-level struggles. C2 did not specifically mention their ethnic or racial similarity to parents; however, prior knowledge of the two neighborhoods inferred that neighborhood might serve as a proxy for racial affiliation.

Knowledge of and experience with the community/neighborhood were key factors that allowed SFLs to identify with parents and establish trust and nonjudgment in order to build relationships. Their comments pointed to the importance of understanding community needs, hardships, and stressors in order to connect with parents. This was often made clear via disclosure of personal experiences and/or ties to the neighborhood.

I grew up in [neighborhood] so I have family members that did half of the stuff that your family members do. Maybe more! … I'm not better than you. I'm telling you, I struggled. We struggled. We're gonna struggle together. Let's figure it out.

Within the subtheme of neighborhood affiliation, SFLs also reflected on the insights they gained through their experiences as SFLs via home visits, getting to know families, and observing family-school relationships. For example, despite growing up in the neighborhood, this SFL felt overwhelmed by how neighborhood risk manifested in her daily work.

[T]he first school it was so depressing going to work.… I wanted to quit because it was so … um … so much stuff going on inside the school with the parents, with the students. Stuff I only saw on TV … like even though I grew up in [neighborhood] as well. And, but I didn't know exactly, it was like we was just thrown in there. And I was like I didn't know I had to deal with all of this stuff.

C2 SFLs talked explicitly about shared experiences such as parenting struggles and stress and hardships, often tying these experiences back to parenting within the neighborhood context. For example, they described the dangers of street gangs and violence, which heightened a sense of urgency of connecting families to necessary supports and resources. They grappled with how to maintain positive and supportive relationships with parents while recognizing the negative, and potentially dire, consequences if parents did not intervene early enough.

I think it's hard to have some of those conversations with parents because growing up in [neighborhood], the reality is that if the kids, especially with the behavior problems, don't get it together … they either gonna end up dead or end up in jail.… So it's not easy to tell a parent, I see your child in the future.… What you gonna do when he gets in high school?

C2 regarded neighborhood not only as indicative of the level of family needs but also as a way to understand the dynamics between families and schools, as illustrated in the subtheme of school-community relationships (“[S]ome of our parents don't want to come in to that school because of maybe things that went on in the past … and now their kid has to go there, so it's like, ‘I don't want to go in there’”). They voiced significant concerns about how the city's school district policy (e.g., turnaround schools and closings) negatively affected family–school connections, as well as their own frustrations.

I worked there for a while even before joining PASS. So I knew the dynamics, and I knew the people, the staff, and everybody. We were a turnaround school so [school B] was kicked out, comes in [school A]. Now [school A]’s building was literally four or five blocks up the same street and across one block … but everything is so different … and for the worse.… So, you took away the teachers and the teaching method of a school thatȇs progressing well. You bring in a school that is underperforming and you expect miracles!

Longstanding complicated social histories within neighborhoods created problematic mergers of school populations. SFLs observed increased student behavior problems (“All those kids in the same building is chaotic”), safety issues (“We come from a neighborhood where, you know, certain blocks you can't cross”), and ongoing tensions because of parents not getting along with school personnel or with each other (“You integrated families that probably were not getting along”).

Some excerpts reflected that C2 was attuned to the barriers to relationship building with families within the context of stressed neighborhoods and strained community–school relationships. They regarded some parents as slow to trust and found it important to emphasize their near peer status and their position as fellow community members so that parents would not consider them to be affiliated with institutions perceived to be antagonistic (“We don't say, ‘I'm the SFL here at this school. I have this number.’ No. You know, they just know us as … some of them know as our own first name basis”). Toward this same end, SFLs also clarified their role as a social service agency employee (i.e., not affiliated with school district or child protective services) to emphasize their neutrality to parents.

3.3 ∣. Defining the work of SFLs (Aim 3)

3.3.1 ∣. Serving as advocates within schools

Given the centrality of SFLs’ roles as liaisons between schools and families, we asked both cohorts of SFLs to reflect on the nature and meaning of their work in their school contexts. Overall, SFLs framed their role as filling an important service delivery gap with regard to schools’ capacity to address students’ academic and behavioral needs. Their descriptions reflected how the school setting was central to understanding and defining the activities they engaged in to support and connect families to their child's school. Given their unique purpose in the school setting, SFLs devoted attention to supporting students, particularly those whose needs exhausted the efforts of existing school staff.

I am a whole other set of eyes on your child. You know, when they are at school and it seems like the teacher cannot—I know it sounds bad but–put up with the child anymore. The security guards are done with the child, like … nothing else works. It's like, the child will always have someone on their side, you know?

There was also a sense that schools had limited access to support and resources to meet the needs of parents and families; SFLs described their work as attempting to fill this void (“We see that their child needs help but the school is so under, um, how do you put it? They don't have the [resources]”). The exchange below illustrates the language SFLs used to describe their tasks and functions (e.g., mediator, navigator, go-between) in high-need communities, which aligned with their perception of the centrality of advocacy in their work.

“We do it all.”

“Mediators, translators, everything.”

“Middle men, middle women.”

“Case managers.”

“Yes. Yes, we are the middle person. We are the go-to.”

“They need them [SFLs]. They need them in the school.”

SFLs’ descriptions of what their work entailed was based on their perceptions of being an advocate within the school. SFLs’ actions within the school served the goal of fostering positive relationships between families and schools, and they viewed their work as valuable to all parties involved. Relationship building effectively served as a precursor to advocacy within schools, which highlights the relevance of the emotional support domain of family support services. Yet SFLs descriptions of emotional support did not necessarily reflect what SFLs provided, but rather how they generally approached their role, as discussed previously.

We are advocates. For everybody. For the family. Even for the teachers. For the administration at the school. We are, in essence, advocates because our role says that we're gonna support in absolutely whatever way we can. Whether it's resources, emotional, socially. Whatever it is, that's our role. To give the information, distribute it, and help you.… It's about advocacy.

Serving as advocates required SFLs to build trust, understand the perspectives of both sides, and serve as the connector or nexus (“I think on both sides, for some reason, they trust us–both ways, the teacher and the parent. Sometimes, I don't know, they don't communicate so well, a parent and a teacher … in most of my cases”). SFLs reported a strong sense of responsibility to protect a family's needs and interests when communicating with teachers and school staff (e.g., cutting the family some slack, easing up on discipline at school). Additionally, their role as the “go-between” assisted parents and teachers to communicate with one another to generate solutions.

Yeah cause the teacher is trying to do her own thing, the parent is trying to do her own thing and trying to get through all these obstacles and hurdles that life is throwing at her. And then you have a child who is in first grade and does not know a single letter, you know? Then just trying to get all of that together into one ‘cause mother doesn't know what's going on with teacher, teacher doesn't know what's going on with mother and then you have the child right there. I'm like ya'll need to get in the same room and think of something.

3.3.2 ∣. Relevance of family support services in school-based services

Again, we used the family support services framework to organize our focus group protocol, and SFLs described how they connect these activities (e.g., goal setting and problem identification, providing information, and skills development). This lends credibility to the relevance of these activities to the work of paraprofessionals within schools in high-need communities. We provide a series of excerpts to demonstrate how the descriptions of SFLs’ work reflected these activities while emphasizing their central task of advocacy within the school setting.

Goal setting often began with problem solving urgent needs, and case management emerged as an integral part of identifying student and family needs. Case management needs were categorized along four main areas: (a) basic needs (food, shelter, transportation); (b) education needs (student Individualized Education Plan [IEP] or support navigation, bilingual education, and/or English fluency support); (c) social services (domestic violence, jobs/employment, public benefits); and (d) other (immigration specific needs, legal aid, and parent's mental health). SFLs acknowledged the importance of finding relevant information and resources in the community as part of their role. This reflected an expectation of resource linkage (e.g., finding information and calling with or for the family, translating for parent, or showing how to find the resource via Internet search).

SFLs described their approach to problem identification with parents and working together toward action planning and setting goals. At times, SFLs’ efforts to involve parents in the program proved challenging, yet they capitalized on the time they had with parents.

Yeah, you can tell that some of them didn't expect that. Plus some other families are busy working. They really … I mean, when I have a chance to talk to a parent, I do ask them about short-term goals, long-term goals with the family or with their routine. This is something we talk about in the team too … what the child wants to get at home, what are they trying to achieve academically. You know?

SFLs emphasized that responsibility for progress had to be shared between SFL, parent, teacher, and student, and challenges arose when parties could not come to an agreement on the problem to be addressed. This echoes the challenges to engaging parents described earlier, with an additional layer of holding parents accountable for the child's progress.

It's not our responsibility to make sure … we're here to support you, we're not here to take care of him. I think that's where they get lost. “Well, he in your program and he should”-No. Because it's gonna take me, you, and that teacher to get this done.

SFLs were also responsible for monitoring parents’ progress across the PASS key skills areas. SFLs connected these skills to the everyday life context of families and described how to make the information relevant by taking into account busy work schedules, daily stressors, and limited literacy levels or English-language proficiency. SFLs attempted to build on what families were already doing at home or to provide realistic suggestions for each parent or family member.

Be like, “Reading is important. How can you help them read? Or, “How can you help them like books?”.… Giving them little hints and then asking them, “What do you think you can see yourself doing? Oh, well, I guess I can't sit there with them, but I can get so and so to sit there.”

Thus, SFLs were careful in their approach in order to keep parents engaged in discussing new strategies or skills (“You're not gonna say ‘positive parenting’ because if somebody tells a parent how to parent, you already lost them”). The ways that SFLs approached skills building with parents highlighted the importance of maintaining positive relationships and establishing themselves as a resource rather than as an expert or authority.

So, we pick our battles and we kind of tailor it, you know, to be a little gentler, a little softer. Make suggestions instead of telling you that, you know, you've been wrong all these years. So, we kind of tailor it sometimes. I'll make suggestions and I'll … drop a little hint here and there. And it's, “Do it this weekend and see how it works. Maybe it will, maybe it won't, but.…” So, we pick our battles and, you know, know where to change a little bit with how to make it flexible.

Moreover, SFLs tried to incorporate discussion of parenting strategies as an extension of skills the SFLs were working on with the students at school, again emphasizing the importance of relational aspects (e.g., encouragement, support).

So, you could also use it as a way to encourage parents, or to give them like a thumbs up like they are doing some of the things. Because a lot of times, like the reading and the homework part, a lot of the parents say, “Well, I'm already doing that.” You could use that as a way to say, “Well, great job! You're doing such an awesome job.…” Then you can incorporate, “Well, you know, may I make a suggestion? I’m working on this with Johnny in school … when he does something wrong that there are consequences.”

Advocacy activities within the school also included identifying and implementing support and finding resources for students. SFLs reported that many parents needed information about how to navigate IEP meetings (and school meetings more generally) and understand information presented to them, particularly when meetings focus only on a child's struggles. As the following excerpt illustrates, these advocacy efforts were intertwined with the provision of emotional support.

That's a lot of the emotional support, too, that we give to the parents because in IEP meetings, when I first started going, I was like, “Ohhhh.” Like, I would probably start crying if it was about my child. Because sometimes they just be talking and all I hear is “underdeveloped” … “below average.” That's all I hear.… Such and such and such “below average.” Such and such and such “under something.” Always under and below. It's never nothing positive. It's always below expectations or something like that.

4 ∣. DISCUSSION

This study examined the role of paraprofessionals in a prevention and early intervention program serving families in low-resource, high-poverty communities. Results provided lessons about the value of a flexible service model that centers on the unique attributes and skills of a paraprofessional workforce. SFLs perceptions of “why and for whom” PASS services were needed were rooted in knowledge of both cultural and community factors that were important to meeting family needs. Although SFLs in each cohort highlighted different contextual factors across high-need communities (i.e., cultural and community context), there was convergence on how SFLs approached working with families (building relationships to engage families) and what this work entailed (serving as advocates between schools and families). We found that relationship building was central to engaging parents in PASS services, which is consistent with the literature on the importance of common factors (Assay & Lambert, 1999) and relationship-based processes (Messer & Wampold, 2002) in clinical services.

The engagement process described by SFLs was marked by acknowledgment of shared experiences and “insider” knowledge of community context. Similarly, earlier community-based prevention programs (Fast Track) have found that program coordinator–parent engagement predicted session attendance, but that racial and experiential similarities were particularly impactful (Orell-Valente, Pinderhughes, Valente, Laird, & Conduct Problems Prevention Group, 2009). Shared cultural (C1) and community (C2) knowledge and experiences were key leverage points that allowed SFLs to engage parents, understand multiple perspectives, and identify goals.

4.1 ∣. Context matters

Our results demonstrate the importance of the knowledge and experiences of paraprofessionals who are embedded in the social contexts within which services are delivered. SFLs were aware of community and cultural factors that potentially affected the ways in which parents participated in PASS and applied this knowledge to engage parents and deliver key program components. Relationship building was central to the SFL role, with SFLs using context-specific knowledge and shared experiences to maximize the effect of their work.

Burrus, Mowery, Callejas, Nesman, and Hernandez (2010) provided engagement strategies for culturally and racially diverse families seeking mental health services that attend to community-level characteristics in the identification of strategies targeting services at the individual level (e.g., flexible service provision, outreach and education) and the organizational level (e.g., addressing language capacity, creating linkages, promoting family-driven decisions). These principles applied to this prevention model can help to address limited attention to engagement in preventative interventions (Spoth & Redmund, 2000). This also speaks to key issues addressed by community advocacy research, namely, the equal importance of where an intervention occurs, who the identified helpers are (with emphasis on community members as helpers), and how the helping occurs (Hess, Barr, & Hunt, 2009).

Findings from this study that were specific to C1 responses demonstrate that attention must be given to mobilizing workforces to serve the growing cultural and linguistic diversity of our nation. C1 SFLs spoke about their bicultural identity as a formative base for their role as service provider, and they recognized the unique value of these skills in understanding and meeting the needs of Latino and immigrant families. Other paraprofessionals have similarly reflected this process, for example, immigrant women in their process of becoming promotoras (Squires & O'Brien, 2012). Community paraprofessionals are poised to understand the immigrant social context and implement interventions accordingly (DeJesus, 2009). Also, paraprofessionals have been used in home-visiting programs focused on parenting skills for immigrant mothers (Williamson, Knox, Guerra, & Williams, 2013), reflecting the relevance of providers who understand the cultural context of these families. Relaying information about the U.S. education system and bilingual education was part of the SFL advocate role, consistent with a previously identified need for paraprofessionals in schools (Osterling & Garza, 2004).

C2 paraprofessionals believed that they served a particularly crucial role in creating positive home-school connections in communities that were disproportionately affected by violence and city school district policies. C2 did not specifically distinguish racial identity as a primary shared characteristic; however, neighborhood affiliation and familiarity may have served as a partial proxy for racial affiliation (neighborhoods were over 90% African American). Beyond that, it could also reflect distinct community factors extending beyond race (e.g., persistent inequity of resources). SFLs described how the proliferation of turnaround policies and procedural school closings disrupted positive connections, created tensions in family-school connections, and undermined families’ sense of safety and trust.

This relationship between local or neighborhood context and family-school engagement is supported by the literature. For example, neighborhood stress has been shown to negatively affect parental school involvement (Waanders, Mendez, & Downers, 2007) and the extent to which schools leverage relationships with social services agencies to encourage parent engagement seems particularly salient in schools located with “high liability zones” (Cohen-Vogel, Goldring, & Smreker, 2010). SFL experiences reflected the problems of working within low-resourced schools and how depletion of resources affects student and parent engagement and school climate; this yielded a more salient role for paraprofessionals in facilitating positive family-school connections.

4.2 ∣. Paraprofessionals as advocates in the school setting

Consistent with the purpose of PASS, SFLs viewed advocacy within the school setting as a primary function of their role. SFLs’ advocacy work required the integration of multiple points of view in order to identify shared goals and facilitate productive communication. This aligns with descriptions of how staff members from community organizations help to build collaborative family–school relationships and bridge the distance between schools and the communities they serve (Warren, Hong, Ruben, & Uy, 2009). SFLs deemed their efforts to be most effective when they could serve as mediators, liaisons, and connectors in the interest of families. SFLs also saw relationship building with teachers as critical to their advocate role, mainly as it facilitated shared understanding of the needs of students and families.

4.3 ∣. Promoting models that maximize paraprofessional workforce strengths

Findings from this study strengthen the assertion that paraprofessionals are poised to engage families in services through their relevant and shared knowledge and life experiences (e.g., culture, language, community membership), which may maximize the relevance of services. These connections proved critical as SFLs regarded culture and neighborhood as necessary touch points in order to impart skills, provide information, and link families to resources, both within and outside the school. Further, in addition to connecting families to services and needed resources, paraprofessionals may be well positioned to serve as agents for social change in their community (see Perez & Martinez, 2008). Additional focus on this workforce is warranted and should include investigations of outcomes and mechanisms of change associated with paraprofessional-led service models at the community, individual, and family levels.

SFLs described themselves as connectors between parents and communities and teachers and schools, and the PASS service model was designed to leverage this role and maximize impact. PASS key skills and messages focused on how to support children's learning (supporting reading, homework and home routines, positive parenting) and create positive school–family connections. SFLs found ways to make messages “acceptable” that also required a sense of knowing how and when to share PASS messages. In sum, SFLs’ status as near peers (Rogers, 2003) meant they were well positioned to convey relevant messages and model positive parenting practices, thereby reducing the stigma often associated with mental health services (Frazier, Abdul-Adil, Atkins, Gathright, & Jackson, 2007; Harrison et al., 2004).

Our findings suggest that the unique qualities of the PASS service model (free cost, school-based, flexible mode of service delivery) allowed SFLs to serve families that are often left out of traditional models, which heightened the sense of importance attributed to their paraprofessional role. We further argue that this flexible service model strategically leveraged how SFLs approach relationship building. This model drew upon the strengths of the SFL workforce by creating more service delivery opportunities within naturally occurring interactions (i.e., nongroup-based, individual contacts); this also heightened the sense of equality or parallel stance between SFLs and the parents/families. Rather than fidelity to a prescribed format and curriculum that underestimated their reach, this flexible model capitalized on SFLs’ engagement skills and focused on a set of key skills.

Discussion of the ways that SFLs made the key skills relevant to families is a direct reflection of the intentional flexibility of the PASS program service model. SFLs were encouraged to capitalize on their ability to infuse skills into informal and unstructured interactions with parents (i.e., structured groups were not the predominant service mode). Honing in on key messages that could be embedded within day-to-day interactions with parents also encouraged individualized goal setting and progress monitoring.

4.4 ∣. Limitations

We sought to understand SFLs perspectives in order to illuminate factors that may be important to consider in future research and practice and to provide extensive information to fully contextualize our findings. However, given the unique attributes of the service model as well as the small sample of focus groups (n = 2), study findings may not generalize to other paraprofessional workforces and contexts. Additional research is needed to elucidate the mechanisms of paraprofessionals’ roles in other school-based interventions. Given that not all SFLs in the PASS program participated in this study, the perspectives of more ineffectual or dissatisfied paraprofessionals may not be well represented in these findings. These SFLs may have shed light on struggles (e.g., role demands, engagement challenges, managing their caseloads) that would further enrich our understanding of the SFL role.

4.5 ∣. Future directions

This study lends support to expanding the mental health workforce in prevention and early intervention models for children in urban poverty. Our findings build on the literature demonstrating the importance of community paraprofessionals in children's mental health, with a unique focus on what makes them effective at engaging parents in school settings. This workforce is uniquely positioned to engage parents, embed innovative practices within existing and formative settings that children access, and inform program development to ensure relevance to community context. More disadvantaged community contexts have been found to be associated with more mental health concerns among youth, whereas factors such as collective efficacy mediate this effect (Xue, Levanthal, Brooks-Gun, & Earl, 2005). The use of paraprofessionals in schools within disadvantaged communities might serve to build parents’ sense of social capital or social cohesion, thereby mitigating neighborhood risk. It may be useful for future research to focus on parents’ experiences in programs like PASS to increase understanding of the perceived impact of support provided by paraprofessionals.

4.6 ∣. Conclusion

Given persistent shortages of providers in communities of concentrated poverty, the expansion of this mental health workforce is critical. The aforementioned shortcomings of efforts to scale-up evidence-based practice within high-need, low-resourced settings also suggest the need to redesign our service models. Focusing on adaptation of setting and function responds to recommendations for intervention adaptation (National Institute of Mental Health, 2010), which requires a more intentional emphasis on mental health promotion goals across broad functioning domains and naturalistic settings (Atkins, Hoagwood, Kutash, & Seidman, 2010; Frazier, Cappella, & Atkins, 2007; Kuo & Faber Taylor, 2004). This also reflects a strategic shift in focus toward effective and sustainable implementation of comprehensive mental health services (Stiffman et al., 2010), including reallocation of resources (Kelleher, 2010) and workforce development (Substance Abuse and Mental Health Services Administration, 2013; Schoenwald, Hoagwood, Akins, Evans, & Ringstein, 2010). Future work will require intentional efforts to better integrate paraprofessionals in community mental health practice, as well as aligning core competencies for paraprofessionals (e.g., Ruiz et al., 2012) to reflect the needs of settings that serve children and families.