Bringing prevention services home to the family

The backdrop to Bennett Lecturer Tom Dishion's current work is the poverty of services and shortage of funding for both the prevention and treatment of childhood mental health problems in the US. State services are patchy; they lack an evidence base and in some cases they are potentially harmful. About eight million US children have no health insurance and most of those who do are only covered for major disorders.

The response, Dishion will say, has to be affordable and effective assessments and interventions in schools and in agencies regularly in contact with children and families.

Dishion's expertise makes him a perfect fit for the Bennett Lectureship. Like those of Prevention Research Center [1] founder Mark Greenberg, his interests include ecological approaches to self regulation in children. "If we can influence the ways the home, schools and neighborhood change children's behavior and health,” he will argue, “then we can begin to have significant impacts on well-being"

At the heart of Dishion's new work is ecoFIT, an ecological approach to child and family interventions developed with his University of Oregon Child and Family Center [2] colleague Elizabeth Stormshak. Their analysis has persuaded them to back assessments and interventions that are empirically based, family centered and that work on children's motivation to improve their own situation.

Consistent with over three decades of his research, the interaction between family members and friendship groups is also seen as a good target for intervention. Bringing mental health support to the places where children and families ordinarily go is another dimension of ecoFIT.

If rapid assessments and brief interventions, involving all the people in a child's life, with the goal of sustained change in children's mental health add up to being the name of the game, is it achievable and will it work?

In his lecture this evening, Dishion outlines some early findings. For example, the Family Check-up, a rapid inclusive assessment of children and families (described in yesterday's edition) has been subject to a major experimental evaluation of 999 6th Grade Students, followed up into 11th Grade.

Each Family Check-up leads to a brief intervention calibrated to the needs of the child. For low risk cases contact time averaged little over an hour; for high risk cases it was nearer seven hours.

Despite the brevity of the intervention, the results are promising. Parental monitoring of children is much improved by Family Check-up and the subsequent brief intervention. Paradoxically, as parental anxiety increases during their children’s adolescence, supervision declines, mostly because parents take their cues from their teenagers resistance to parent involvement. The Oregon work arrests this decline, and in most cases reverses it.

The experimental evaluation also finds a reduction in family conflict among children in the intervention group. The benefits to the children are apparent in reduced rates of reported substance misuse and by a lower probability of arrest.

The work with adolescents has encouraged the Oregon team to develop the same ideas in approaches for young children, and the resulting 'Early Steps' program, which uses a similar mix of assessment and brief interventions with pre-schoolers, will also be discussed this evening.

'Early Steps' has been introduced in the US cities of Eugene, Pittsburgh and Charlottesville among 731 mothers looking for extra help with their toddlers. Once screened, the families are randomly assigned to intervention and control groups. The project appears significantly to improve parent's rating of children's behavior for high risk groups, and reduces decline in problems for low risk groups. Videotaped ratings of pro-active parenting are significantly better for the families getting Early Steps support.

In conclusion, Dishion will make some cautious claims for this new and emerging body of work. Embedding family interventions within agencies such as public schools and early years projects is feasible and cost effective. The results seem to reflect some classic public health principles, with the families most at risk being the most likely to engage.

"What is encouraging" Dishion will say, "is that single parents, teen mothers, low education and low income families will all engage with these interventions, and mostly to the benefit of their children".

Following so slight an intervention, usually measured in hours not days, effect sizes are understandably small. But as Dishion's studies show, the impact is long-lasting. Future work on the ecoFIT model will focus on improving engagement in skill-building interventions that not only address deficits but also promote positive parenting.

Reference
Stormshak, E A and Dishion, T J (2002). An ecological approach to child and family clinical and counseling psychology. Clinical Child and Family Psychology Review, 5, 197–215.