Family Groups for Urban Youth With Disruptive Behavior

This study aims to generate knowledge needed to address seemingly intractable urban service delivery challenges: 1) lack of engagement of low-income youth with serious disruptive behavioral disorders and their families; 2) too few clinics offering family-based, evidence-informed services; 3) lack of scalable, empirically supported interventions designed for resource-strapped child settings and; 4) few empirically supported options for public policy makers to support the uptake and integration of service innovations in their systems.

A multiple family group (MFG) is a family-centered, group delivered, evidence-informed, manualized intervention that targets the most common reason for referral to publicly funded clinics: youth oppositional defiant and conduct disorders.5,6 MFGs target family factors which have been consistently implicated in the onset and maintenance of childhood behavioral disorders.7-9 and integrate components of existing evidence-based practices (EBPs). The MFG service delivery model was developed in collaboration with urban parents and service providers to address the serious challenges associated with EBP roll-outs: low rates of family involvement; poor uptake by providers; clinic and provider impediments to maintaining fidelity; and attenuated child outcome effects. These obstacles are pervasively associated with living and providing care within poverty-impacted communities and resource scarce, urban child behavioral health systems.

Findings from a recently completed NIMH-funded R01 trial, "Family Groups for Urban Youth with Disruptive Behavior" reveal that MFGs are associated with significant improvements relative to standard care (SC) in: 1) rates of family engagement and retention (80% completed); 2) short- (16 weeks) and long-term (10 months) improvements in child conduct problems and impairment; and 3) improvements in parenting and family processes. Although promising, this earlier study did not systematically examine specific mechanisms of family-level change hypothesized to influence child behavior.

Further, although the clinic directors (n=13) and MFG providers (n= 62) expressed strong endorsement of MFGs for their urban, resource constrained sites, significant implementation challenges emerged, potentially compromising future fidelity and sustainability. Thus, clinic and provider-level moderators of MFG implementation and integration will be examined in the current study. The proposed study will also examine a specific implementation strategy based on social-organizational theory (PRISM). Specifically, the investigators will experimentally test the impact of local child mental health clinic implementation teams (CITs), consisting of supervisors, service providers and family partners, on the implementation and integration of MFG. CITs will create site-specific plans to enhance multi-level implementation processes (e.g. clinic readiness to adopt an innovation, leadership support, provider preparedness, motivation and fidelity) in order to increase the likelihood of integrating MFGs into urban child behavioral health clinics.

The proposed study, in response to RFA 15-320, Clinical Trials to Test the Effectiveness of Treatment, Preventative, and Services Interventions, will employ a mixed methods Type II effectiveness-implementation hybrid research design. In collaboration with the NYS Office of Mental Health (OMH), this longitudinal study will be conducted across the NYC OMH licensed child behavioral health clinic system (n=134). The investigators will use mixed methods, and involve 268 providers and 2,688 adult caregivers of youth (7 to 11 years).

This study will examine:

1. short-term and longitudinal impact of MFGs on urban youth with ODD and CD (replication);
2. family-level mediators (e.g. parenting, family process) of child outcomes;
3. clinic (readiness to adopt an innovation, leadership support and climate) and provider level moderators (preparedness, motivation and fidelity) of MFG implementation (Phase I) and integration (Phase II);
4. the impact of CITs on clinic and provider level moderators of MFG implementation (Phase I) and integration (Phase II).

In this RCT, clinics will be stratified by borough (Manhattan, Queens, Bronx, Brooklyn, Staten Island) and randomly assigned within borough to 3 study conditions: 1) MFG+CITs; 2) MFG (with standard research training and consultation) or; 3) Standard Care. Data will be collected baseline, 8 and 16 weeks and 6 mo. follow-up) in Phase 1 (focus on implementation) and Phase II (integration).

The investigators team includes the highest level of NYSOMH research and policy leadership. McKay and Hoagwood are the co-Directors of the NYS Clinic Technical Assistance Center, the NIMH-funded Advanced Center on Implementation of Evidence-based Practice for Children in State Systems (IDEAS; P30 MH09032) and the Center for Collaborative Urban Child Mental Health Services Research (CCCR; P20 MH085983). Advanced methodological expertise (Jaccard, Palinkas), policy (Hogan, Bradbury, Goldman), family (Kuppinger) and provider (Cleek, Perri) consultation from IDEAS/CCCR Center advisors positions the study for maximum public health impact. This team is uniquely prepared to build on an existing research and service infrastructure within a state public mental health system to conduct this study. Because of the nationally-focused centers and the partnerships with NYSOMH, the findings from this study are immediately actionable.