Engaging parents in evidence-based treatments in schools: Community perspectives from implementing CBITS

Method

Participants

The data for this study is drawn from 11 schools (51 participants) across three distinct geographic regions: West Coast (4 schools), Midwest (4 schools), and Southern (3 schools). Following a community-partnered participatory research framework (e.g., Wells & Jones, 2009), school and community partners identified participating schools and assisted in recruiting this convenience sample. Of the 71 potential participants that were identified by community partners, 51 (72%) completed interviews, 15 declined participation, and 5 were unable to be contacted. Participants (including teachers, school and community clinicians, parents, administrators and regional administrators) were selected from schools where CBITS had been delivered for at least one year. Each participant provided verbal consent and received a $20 merchandise gift card for participating in the interview. This study was conducted in compliance with the university IRB.

The purpose of the present study focused on parents’ engagement in CBITS. Across the 11 schools, we interviewed 11 parents, 15 clinicians, 11 teachers, 9 school administrators, and 5 regional administrators (e.g., funding administrators, regional mental health coordinators). Parents of students who had participated in CBITS were recruited from 6/11 schools (Schools A-F). At the remaining 5 schools (Schools G-K), parents were either unable to be contacted (e.g., non-working telephone number) or declined participation in the research study. The clinicians included two psychologists, three counselors, and ten social workers. Two clinicians came from an outside agency to co-facilitate CBITS sessions. The remaining clinicians were school-based, though some partnered with outside agencies to implement CBITS in their schools. Clinicians had an average of 8.50 (SD=4.07) years of experience working in schools, ranging from 3 to 15 years. See Table 1 for a demographic summary of the participants.

Procedures

Participants took part in semi-structured phone interviews, from July 2010 to January 2011. The interviews sought to gather information about the adoption, implementation and dissemination of CBITS through questions from an interview guide that focused on a range of areas such as norms and attitudes about the role/relevance of mental health services in schools and about the perceived benefits of the CBITS program. Interview questions were developed drawing from a conceptual framework that considers the characteristics of the implementation process, contextual factors, sustainability, and financing of evidence-based interventions within community settings (Mendel, Meredith, Shoebaum, Sherbourne, & Wells, 2008). Relevant to the current study, clinicians were asked specific questions about overall parent engagement in the school and engaging parents in CBITS, such as: (1) How would you describe the parent-school connections at your school? (2) As you delivered CBITS, what are some strategies you have used for engaging and supporting parents? Parents were asked specific questions about their level of engagement in CBITS and overall parent participation at the school, including: (1) Sometimes there are also CBITS parent sessions - were you aware of any being offered? (2) How important do you think it is for parents to be involved in these services? (3) From your perspective is there a lot of parent involvement at your school? Can you think of ways to improve or increase parent involvement? Complete interview guides are available on request.

Data Analysis

All interviews were audio recorded and later transcribed by members of the research team. Atlas 6.2 was used for qualitative analysis of major themes across interviews. These themes were developed by the research team through a series of meetings where team members identified, discussed and agreed upon common themes using a grounded theoretical framework (Corbin & Strauss, 1990). After locating the major themes throughout the interviews, simple codes were created that represented each theme; each code was given a definition list for clarity. Some adjustments were made to the codes through team discussion and two members of the research team reviewed each interview for inter-rater reliability. Following the preliminary coding of the interviews, the research team identified codes that could be distilled further, codes that could be eliminated, and codes that could be collapsed. During this phase, the research team met weekly to ensure interrater reliability and resolve any coding differences through consensus.

For the qualitative analysis of this study, codes were identified from the larger study that pertained to parent engagement in CBITS, such as Parent Engagement, CBITS Implementation, and Improvement. Using the larger study’s coded data, the researchers of this study refined the analysis in order to identify recurring subthemes related to parent engagement within schools and across participants (Braun & Clarke, 2006). For the purposes of this analysis, two of the authors also reviewed full transcripts using open coding to identify additional themes relevant to this study and to ensure that all valuable information in regards to parent engagement was included within the more detailed codes and subthemes. We examined the themes from schools with parent interviews and those without parent interviews and found no clear differences in clinician and other participant responses. We also examined schools across regions to ensure results were not specific to region and found no clear patterns.

Results

General Impressions of Parent Engagement in CBITS

Descriptions of parent engagement in CBITS varied across schools, with some noting strong engagement and others describing challenges to engaging parents as part of CBITS. In addition, there was variation in what was attempted and offered to parents. Four schools described strong outreach and in-person parent sessions consistently offered, with generally good response from parents (School B, F, G, H). Other schools appeared to work with parents in multiple ways—phone, in-person, and letters, with formal parent sessions only occasionally offered and variable response from parents (School A, C, J, K). Finally three schools described not offering formal parent sessions in any consistent way, though some contact with parents was reported by all schools (School D, E, I). See Table 2 for a summary of results by school.

Schools B, F, G, and H described overall good engagement with parents. At these schools, parents, clinician, and school personnel agreed that relationships were strong due to outreach and trust, with a lot of communication initiated by the clinicians and many parents engaged in the school more generally. One School B clinician described good overall success in engaging parents in CBITS: “I think the beauty of CBITS is having the parents involved. So even from the start, I meet with the parent and the student to go through [the trauma] that has been bothering their child, and then all of this homework is getting shared with the families. So I feel like [the parent meeting] is bringing families together and teaching them that this is just a memory, but it does not have to be an unspoken topic and doesn’t have to be scary.”

In contrast, parent sessions were not typically offered at Schools D, E, and I. Parent engagement in CBITS was described as the “weakest link” and identified as an area of needed improvement (School E), or not a focus of the program despite good parent engagement at the school generally (School D).

At other schools the picture was more mixed. Clinicians at Schools A and C noted that there is some engagement in the school generally from parents, and parents seem receptive to CBITS, but good attendance at parent CBITS sessions was still challenging. At school J and K, clinicians noted that they were often able to connect with parents by phone individually, and only sometimes held in-person meetings, noting “Just because of time and other barriers it would have been next to impossible to get everybody in at the same time.” Describing parent-school connections, one clinician (School A) noted: “Unfortunately, it’s the ones who we need to reach out to [who] are the ones who are not [as available]. So I think the parent component is strong here but not always with the parents that we need.” Other clinicians (School C, E) noted that parent engagement in the school overall is fairly weak, which makes it even more challenging to engage parent in CBITS.

Parent Reactions and Preferences Regarding CBITS

Though parent engagement varied across schools, all parents (11/11) in this study reported being supportive of having mental health services, specifically CBITS, in their children’s schools. Parents described the need for CBITS in their schools due to various stressors common in the community, such as drugs (7 parents), exposure to violence (4 parents), peer pressure or bullying (4 parents), gangs (2 parents), and sex (2 parents). For example, a parent from School A reported a general sense of insecurity among both parents and children: “…when someone is walking around in the city, they are not sure when there will be a gun shot.” Clinicians reported similar concerns including violence exposure (5), poverty (5), peer pressure or bullying (7), and family problems (4). All parents reported feeling that it was appropriate and beneficial to have such services in the school. One parent (School D) noted that teachers might notice the need for treatment before parents: “parents are sometimes with the kids less than the teachers are on a given day…the teachers may see a change in the children quicker than the parents do.” Another parent (School D) noted that children might not have access to services outside of the school: “Unfortunately, there’s not enough because our mental health services are limited. There’s not much money at all, you know, for our kids or adults.” Due to these concerns, parents reported viewing CBITS as both needed and a positive program for their children.

In addition to supporting CBITS in their children’s schools, parents also discussed the importance of their own engagement in such services (10/11 parents). This theme is highlighted by a School A parent: “It is very important because this way we can help [our kids] too.” Numerous other parents (6/11 parents; School A, B, C, D, E, F) discussed the importance of knowing what their child was learning in groups so that they could support those skills and reinforce them at home: “It’s really important for us to be involved because it gives us a sense of knowing how to deal [with] the issues that our kids are going through and also gives us a sense of how to work through our own issues by being in on what they are learning,” (School C) and “It is very important for parents to be involved. It kind of goes back to what I was saying before, to be able to reinforce what the [child] learned and what you can do in certain situations,” (School D), and “[There] has to be a bridge between the school and the home. Teachers cannot do it alone, parents cannot do it alone” (School F).“ However, one parent also noted that some parents, including her, cannot always attend sessions due to other responsibilities.

Though competing responsibilities pose a barrier, parents consistently reported wanting more parent/family sessions or more contact with their child’s clinician. Ten (of 11) parents specifically mentioned wanting more sessions or more contact with the CBITS clinician. Parents thought parent sessions could benefit them directly by giving them a space to talk about their own experiences and allowing them to motivate each other, “…because we [parents], at times, are facing difficult situations.” (School A). Some parents suggested opening sessions up to additional family members, while others suggested a “parent package” at the beginning of the program describing CBITS sessions and offering advice to parents, as well as a “synopsis” at the end of the program describing the changes seen in the child and how to support change. In addition, some parents suggested offering sessions on family conflicts, managing parental stress, coping skills, loss and grief, and discussing sex and drugs with their children.

Barriers to Parent Engagement in CBITS

Various participants noted difficulties engaging parents in CBITS. The majority of these school clinicians (8/15) noted that lack of time limited their ability to work with parents. Many clinicians have competing responsibilities at their school, making it difficult to meet with parents. At three schools (School C, E, H), it was the first year that the clinician had been involved in implementing CBITS, although CBITS has been delivered at the schools by previous clinicians. Because the program was new to the clinicians and they were learning it as they implemented, they reported that they did not consistently offer parent sessions. The co-facilitator at School E partnered from an outside agency and reported that she had no parent contact, “I think that the weakest link of CBITS was the parent piece…I didn’t see it happen. I don’t think group facilitators did it…I think there were phone calls made, but there were no group meetings that I was involved in.”

Across schools, clinicians and teachers noted difficulties such as non-working telephone numbers for parents, parents having multiple jobs, limited transportation, and homelessness (7/15 clinicians; 8/20 teachers/administrators; School A, B, E, F, H, J, K). For example, when asked about parent sessions, a clinician noted “I think it’s challenging because our school is probably about sixty percent low-income and transportation is a barrier. We’re far away from the three main neighborhoods that feed in” (School J). Parents also noted that childcare, transportation, and work or scheduling conflicts as barriers (5/11 parents; School A, B, C, F). Others noted instability in clinician presence due to budget cuts and lack of trust as barriers: “…not sure that school will have a counselor next year” (School A). In describing lack of trust a teacher states: “…the community is a big factor. They don’t have a lot of trust” (School B). Parents also noted lack of awareness of services and parent sessions as a barrier: “I think the only thing is that a lot of parents are not informed” (School A).

How to Overcome Barriers

Despite barriers, respondents reported a number of strategies that helped them overcome barriers as well as ideas for how to overcome barriers in the future. At 9 of the 11 schools, clinicians described the need to make extra efforts to engage parents (12/15 clinicians; School A, B, C, E, F, G, H, J, K)—some had already done so with varying degrees of success, while others were discussing strategies to try in the future to engage parents in CBITS. For example, at Schools B, F, and H, clinicians reported making home visits when necessary to work with parents, while at school G and K, clinicians also described extra efforts to make personal connections: “I go out of my way to build relationships with parents and to help them with whatever situation they are in. So I would meet the parents whenever…if they work five different jobs, I meet them at that job site” (School K) and “You think parents are going to show up if I don’t call them personally? They’re not. A flyer is not going to do it. My success in the parent meeting a month ago was because I made phone contact to every single one of those parents. It’s a connection that makes a big difference in terms of parent involvement” (School G). Others described the need to make more consistent efforts: “Well I think one [solution] is trying to reach out to the parents…. get the parents more involved. Try to do more parent groups” (School A) and “There are mandatory parent meetings once a month, [this] could be a way to talk to parents either through a series of workshops or lectures …” (School C).

Clinicians also noted the need for more staff trained in CBITS to help implement all of the components (8/15; School A, B, C, E, F, H). One clinician noted that bringing in social work interns for practicum training could help, “…ideally if I could have one social worker from the district come in and work with two interns and take a group…I just think having more trained professionals that can do the service” (School B). Clinicians also noted that more awareness of CBITS from other school personnel supports their work (12/15; School A, B, C, E, F, G, H, I, J, K). From School F, the clinician noted, “Support staff here in this building know a lot about trauma because a lot of us were trained [in CBITS], it wasn’t just me. The psychologist and the nurse were trained…in general as a team we have more awareness.” The clinician from School B noted, “My principal has been an amazing supporter of everything related to school mental health on this campus.” A teacher at School B described a good working relationship with the clinician, “I would say I’m hands on in the sense that I’m always interested in what she’s doing and she’s a part of the leadership team, she meets regularly with us to develop our school plan…So I would say I count on her as a partner.” Supportive relationships with other school personnel seemed to reduce stress and burden, fostering more community outreach.

Parents (11/11) also offered suggestions to improve parent attendance and engagement in CBITS. Multiple parents suggested providing transportation, providing childcare, and offering sessions after work hours to increase attendance (School B, C, F). Parents also requested more sessions, more follow-up from clinicians, and more information (School C, E), “Just stick with follow-up. If we can’t make it to the actual sessions in person, there should always be contact information available to us” (School C). Another parent noted that fostering positive relationships before there are problems can help parents be more receptive to teachers and clinicians, “…if they show some type of want or desire for parents to be more involved then I feel that parents maybe want to more involved without having to just sit back and wait for things to pretty much get out of control before we are notified of anything” (School C).

Promoting Parent Engagement in CBITS

In some of the schools sampled, particularly noteworthy descriptions of factors that promoted parent engagement came up. Five schools reported having generally good parent engagement across the school (School A, B, D, F, H). A clinician from School A reported that “60-70 parents sign up every year as volunteers in the school,” while a teacher from School B said “I’ve been fortunate that I’m really blessed with the parents, they are really giving to me and maybe because I am very active with them along the year…They’re very giving and they’re very willing [to be involved].” A parent (School D) noted, “Parents are very involved, it is one of the best things about this school.” At most schools where general parent engagement at the school was high, clinicians noted that parents were more receptive to CBITS and to parent sessions. The exception was School D, where both clinicians and parents agreed that parents were very engaged at the school, but parent sessions were not offered as part of CBITS.

Another noteworthy factor that was discussed centered on trust, personal connections, and empathy (5/11 parents discussed this). Clinicians and school staff also noted the importance of trust at School B, F, and G, three schools that were very successful in engaging parents. At School F, a parent stated, “I like the atmosphere because when you go into the school you don’t feel like you are an outcast and always feel welcome.” A clinician (School F) noted the importance of positive interactions with parents generally: “I would say we try to have as much communication or contact with parents as possible. We encourage teachers to call parents with good news. We just got done with parent-teacher conferences, pretty good turnout there.” A clinician at School G described the importance of personal connections with parents: “That connection is powerful and meaningful and I think that affects the outcome that you can get with parent involvement.” A clinician at School B noted that she was able to meet with all parents, but puts in extra efforts to ensure that happens, “All of the parents whose children we screened and they came up high for CBITS, they came to meet with me and have that discussion with their child and me…because I feel that it is not enough to just meet with the kid. So I would rather expend the energy into tracking [parents] down.” A parent at the same school (School B) noted the trust she felt with this clinician, “her door is never closed” and “you don’t trust everybody with certain issues in your life and to come to one like that [name of clinician] it was real good, it was real helpful.” Another parent (School F), when asked why she allowed her child to participate in CBITS, responded with “Well I really trusted [the clinician]. I trust her, I trust the school.” An administrator (School B) described fostering empathy and trust between his staff and community through recognition accomplishments, talking with the community to build trust towards the school (4 or 5 times a year, teachers walk around the community to talk with families about the school), and offering classes for parents through the school clinician. This administrator felt that these efforts communicate hope and understanding to the entire school community: for the parents, “And they look at it and say—I can change, I do have some control, I do have the power to make things happen. That’s inspirational” and, for the staff, “So one of my routine strategies when a teacher comes to complain about a child or constantly sends a child to the office because of some problem. I say let’s go visit the home. And believe me, all you have to do is sit in somebody’s shoes for a little while and all of a sudden the perception of what you need to do changes” (School B). A teacher (School B) noted that because of her strong relationship with parents that some of them asked for her opinion before signing the CBITS consent form.

Discussion

This study explored parent engagement in CBITS, an evidence-based program developed to treat trauma-related symptoms in schools. Overall, parent engagement varied across the eleven schools included in this study. Although a recommended part of CBITS, parent sessions were not always offered to parents due to barriers faced by clinicians or difficulty with outreach. When parent sessions were offered, schools had variable responses; with School B, F, G, and H generally have good parent engagement through consistent and extensive outreach. Clinicians also varied in how much they prioritized reaching out to parents, with some clinicians believing parent engagement was essential (School B, G) and other clinicians prioritizing work with the children due to time constraints and unfamiliarity with the protocol.

Although actual engagement varied, a notable finding of this study was how open parents were to having the program offered in their children’s schools. In fact, the majority of parents discussed wanting more parent sessions in CBITS, with many offering suggestions for additional topics such as managing parental and family stressors and how to communicate better with their children. Parents also discussed wanting more tangible materials from CBITS—flyers, brochures, or a package for parents that includes descriptions of the program and well as tools for parents to support their children. Parents who identified barriers to attending CBITS parent sessions, such as long work hours, transportation, and childcare, recommended that sessions be held in the evening or that childcare and transportation be provided if possible. Much of the literature has described these common logistical barriers (e.g., Davis et al., 2009), along with underutilization of care resulting from stigma-related concerns, fear, or distrust of traditional systems of care especially among ethnic minority and/or immigrant populations (Copeland & Snyder, 2011; Nadeem et al., 2007). However, the findings from this study highlight the importance of not assuming that parents are disinterested in care or will not prioritize participation in services.

The logistical barriers that parents face raised in this study are consistent with prior research, identifying time, transportation, and childcare as common barriers that low-income parents report with regard to engagement in mental health services (e.g., Davis et al., 2009; Stevens et al., 2006). In addition, a number of additional logistical barriers that clinicians face were identified. Clinicians reported that lack of time was a major barrier to implementing the parent component of CBITS. Consistently calling and reaching out to parents can take a significant amount of time and when clinicians have a number of responsibilities in addition to CBITS, parent outreach may become a lower priority. Perhaps clinician efforts could be more strategic if parental preferences are assessed. For example, recent work suggests that some parents prefer active strategies and coaching, while others prefer information only (Cunningham et al., 2008). In some schools, budget unpredictability also contributed to lack of a consistent presence of clinicians in schools and lack of trust that clinicians would remain a source of support for parents.

To overcome barriers, some clinicians suggested that more staff be trained in CBITS so that there could be more support in initial organizational tasks and ongoing outreach to parents. Prior research has found that when clinicians have a network of support from others implementing the program along with administrative support, they are more likely to implement new evidence-based programs (Langley, Nadeem, Kataoka, Stein, & Jaycox, 2010). One clinician reported that social work interns have supported her work at the school, allowing her to run more CBITS groups than she would be able to on her own. Another clinician noted that training support staff in CBITS led to more awareness of trauma and support of CBITS on the team. Other schools described partnering with outside agencies to decrease staff burden. However, in one school the clinician from the outside agency had no contact with parents because the school was unfamiliar to her and parent connections were harder to establish. Thus, although partnerships between schools and agencies can reduce burden and stress, conscious efforts must be made to ensure that parent outreach remains a priority. Though time and staff support are constraining factors, clinicians with the most success engaging parents reported personally taking extra efforts to reach parents, such as meeting in person with both the parent and child to discuss the program, staying in consistent communication, and offering home visits to overcome logistical barriers.

In addition to logistical factors, a number of positive characteristics related to school-community relationships and climate emerged as important for fostering parent engagement. For example, respondents across School B described a climate where community outreach was a priority, home visits were common, and a strong and trusting relationship had been built between parents and the clinician. The clinician at School B strongly believed that parent engagement in CBITS was essential. Likewise, trust and positive interactions with parents were described at School F and G. School B, F, and G had relatively good parent engagement. Though it often requires additional effort and time, consistent outreach along with respect and empathy for the real barriers families may be facing is key for engaging low-income parents in mental health services (McKay, Nudelman, McCadam, & Gonzales, 1996; Santiago, Kaltman, & Miranda, in press).

The results from this study have a number of important implications for promoting parent engagement in evidence-based treatments that are implemented in schools. Clinician views of how important the parent sessions were to CBITS and their approach to working with parents varied despite being a recommended component of the intervention. Thus, training in evidence-based treatments may require additional time emphasizing parent sessions and describing strategies for engaging and working with parents. For example, when clinician and support staff training is specifically targeted towards improving parent engagement and retention in services, parent participation improves (McKay et al., 1996). In addition to this study, other research has identified door-to-door outreach, persistence, responsiveness, and resource linkages as key for parent engagement (Alameda-Lawson, Lawson, & Lawson, 2010).

In order to ensure that such extensive outreach is feasible, clinicians must be supported in reaching this goal, with recognition of the time involved in parent outreach and an overall school climate that prioritizes this same goal. Services in schools are often limited by budget and staff constraints, making it important not to view parent engagement as an all or none component. Research suggests that school-based services reach many more children and even with partial or little parent engagement, children demonstrate symptom reduction (Jaycox et al., 2010). Thus we want to emphasize services in schools with limited parent engagement are still better than not offering school-based programs or referring to clinics exclusively. Still, increasing parent engagement in school-based services may enhance effectiveness. Unfortunately outcomes were not directly assessed in this study, though some parents and clinicians indicated they believed parent engagement was key to child improvement. In this study, the majority of parents described wanting more opportunities to participate in CBITS suggesting many parents will likely be responsive to school outreach efforts. University-school-community partnerships can also work together to support this goal through shared training, outreach, and resources.

Although this study had a number of strengths, such as including both parent and clinician perspectives and sampling across different regions of the Unites States, it also has some limitations that are important to note. Community partners assisted with recruitment of both clinicians and parents, which could have introduced bias by nominating particularly successful or involved clinicians and parents. Further, parents were not able to be recruited from 5 of the 11 schools, limiting our conclusions with regard to those schools. The sample size was also relatively small and the current study examines experiences related to implementing CBITS only. Thus, this study should be interpreted as an exploratory one given the limited sample size and focus. The results of this study may generalize to implementation and parent engagement in other programs, though additional research will be needed to examine how these findings may translate to other programs or populations. Of note, barriers related to culture or race/ethnicity were not typically raised by clinicians or parents, though this was not directly assessed in the interviews limiting our interpretation of this finding. In addition, parents did not raise stigma-related concerns, though it is possible that parents who may have not participated in CBITS due to these concerns, may not have been identified for participation in this study.

Schools have become a focal source of mental health services for low-income students and further understanding of how schools can effectively engage and integrate parents into evidence-based mental health programs is an important next step for implementation research. The findings of this study illustrate that parents are invested in school-based mental health services and perceive them to be valuable and integral to their children’s well being and academic success, in contrast to a common assumption that that low-income parents are less interested in mental health services. Thus, in addition to the need for replicating and extending these findings, future research should also begin to evaluate the use of various engagement strategies and the training and support needed for ongoing implementation of such strategies.

Acknowledgements