From Start to Finish: Parents' Help-Seeking Experience and Engagement Decisions in an Evidence-Based Child Mental Health Program

Background and Purpose: Engaging and retaining families is an ongoing challenge for the dissemination and public health impact of evidence-based programs. Despite the availability of such programs, a gap exists between service needs and use with attrition rates ranging between 40-60%, and even higher for the most vulnerable families. While research has shown that specific strategies can boost engagement, we know little about the nuances of parents’ decision-making and what contributes to families sticking with services, despite adversity in their ecological life context. Noting that (ironically) the voices of parents often are missing from parent engagement investigations, the objective was to explore both initial and ongoing help-seeking experiences and decision-making of parents pursuing mental health services for a child with conduct problems in a large multicultural city.

Methods:  This research was part of a clinical trial of an engagement phone intake for SNAP®, a gender-specific, evidence-based treatment program for conduct problems. Guided by grounded theory, a theoretical sampling of diverse parents (N=22) with significant life difficulties and high-risk children of both genders age 6-12 years were recruited to participate in semi-structured interviews, based on attendance of at least some of the SNAP parent-training sessions. Interviewers sought to elicit parents’ help-seeking stories with probes for decision-making at five time points, from initial call to groups end. Interviews continued until data saturation was reached. Analysis consisted of in-depth and line-by-line exploration of all potential themes, followed by the integration of themes to develop an interrelated and temporal set of schemas emerging from the participants’ experiences over time. Transcripts were coded by two coders using the qualitative analysis software MAXQDA.  Strategies for ensuring rigor included constant comparative analysis, reflective memos, peer debriefing and member checking.

Results:  Despite experiencing the range of adversity related to attrition, these parents actively pursued help, overcame barriers that often included navigating a maze to find the door to services, and persisted in treatment. A central theme of motivation emerged based on different time points. At initial help seeking, motivation elements included a “no matter what it takes” attitude and social influence variables before parents even walk through the door. Motivation to remain in treatment included the installation of hope, the child’s enjoyment of the children’s group, connection to the agency and group leaders, support from other parents and changes in parent isolation, and seeing change in their child. An interrelated theme of connection emerged that was also temporal, suggesting an expanded view of therapeutic alliance.

Conclusions and Implications:  The findings suggest that strategies to improve engagement could be better targeted, from innovative ways to increase initial access, such as how services are marketed in the broader community, to ecologically-responsive strengths-based motivational approaches once parents initiate agency contact that better utilize parents’ motivational fabric.  This study provides rich data to inform a theoretical model of engagement and social work practice, first by focusing on parents who experience adversity but do access and engage in treatment, and second, by providing a more complete picture over the course of help seeking.