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What was the research about?

Many children have mental illnesses such as depression. These illnesses can affect a child’s physical health and overall well-being. Children with mental illnesses may also struggle to do well in school. Latino children with mental illnesses are half as likely to get mental health care as white non-Latino children. Latino families often report that they have a hard time getting care. When they do get care, they may be unhappy with it. The research team created an education program to teach Latino parents and caregivers skills to help their children get the mental health care they need. Researchers call these skills parent activation skills.

Parent activation skills include:

• Having confidence in one’s ability to help one’s child get the mental health care that he or she needs
• Knowing when and where to get help
• Getting one’s child’s needs met at each healthcare visit

The research team wanted to know if the educational program improved parent activation skills in Latino parents. The team also wanted to know if the educational program improved children’s mental healthcare visit attendance, parents’ ability to work with school systems on children’s mental health-related needs, and parents’ mental health. The research team compared parents in the educational program and parents in a support group.

What were the results?

Compared with parents in the support group, parents in the educational program had more improvement in parent activation skills after three months. Parents in the educational program also improved their skills for working with their children’s school systems and became more involved in their children’s school lives. There were no differences between the two groups in how parents’ mental health or children’s mental health visit attendance changed during the study.

Who was in the study?

The study included 181 Latino parents who had children with mental health needs. Families lived in a medium-sized city in North Carolina. The average age of parents was 36.

What did the research team do?

To design the program, the research team used input from two groups: Latino parents who had children with mental health needs and Latino teens with mental health needs. The study took place in one mental health clinic run by Spanish-speaking staff. Parents joined the study when setting up a visit for their child.

The research team assigned patients to one of two groups by chance. Both groups had a similar number of patients insured by Medicaid. Parents in the first group went to four one-hour educational sessions over four weeks. A member of the research team led each session. Each session included teaching, discussion, and role play. The sessions focused on taking care of children’s mental health needs, working with doctors, and working with school systems.

Parents in the second group went to four one-hour support group sessions over four weeks. Parents shared experiences and advice. A member of the research team helped lead the discussion, but parents chose the direction of the conversation.

All study activities took place in Spanish. The research team interviewed both groups of parents before the study and then one month and three months after the sessions ended.

What were the limits of the study?

The study took place in one mental health clinic in North Carolina; results may be different in other clinics. Also, the study was relatively small. The results may be different with a larger group of parents. Parents who took part in the study may have been more open to learn new skills than those who didn’t join the study. The educational program might not work the same for parents who didn’t choose to join the study.

Future studies could see if the program works as well in different places or with larger groups of parents. Future studies could also see if parents who go through the educational program keep their activation skills beyond three months.

How can people use the results?

Mental health clinics that serve Latino parents could offer an educational program like the one in this study to help parents of children with mental health needs improve their parent activation skills.

Objectives

(1) To compare the effectiveness of a psychoeducational intervention against a nondirected social-support group on the activation skills of Latino parents or caregivers of children with mental health needs; (2) To explore the association between parent activation and child Patient-Reported Outcomes Measurement Information System (cPROMIS) measures.

Study Design

The research team conducted a randomized controlled trial to test the comparative effectiveness of a psychoeducational activation intervention called MePrEPA versus a nondirected social-support group. In Spanish, MePrEPA stands for “metas, preguntar, escuchar, preguntar para aclarar,” which, in English, means “goals, questioning, listening, questioning to clarify.” MePrEPA aims to teach activation skills to Latino parents of children with mental health needs. Activation skills include having self-efficacy, knowing when and where to get help, and getting needs met during a healthcare visit. Previous studies have linked activation skills with improved health management practices and outcomes. The research team received input from Latino teens with mental health needs and parents throughout the study to inform its development and implementation.

The study’s primary outcome was parent activation, as assessed by the Patient Activation Measure (PAM). The study’s secondary outcomes were:

• Education activation (adapted PAM to capture activation skills that support the child’s education)
• School involvement (quality subscale of the Parent-Teacher Involvement Questionnaire)
• Parent stress (Parental Stress Scale)
• Parent depression (eight-item Patient Health Questionnaire)
• Observed parent activation (qualitative coding of parent-provider communication)
• Child attendance (number of mental health visits attended, rescheduled, and missed)

The study included 181 Latino parents who had children with mental health needs. The children were patients at a mental health clinic run by Spanish-speaking healthcare providers and staff in a medium-sized city in North Carolina. Parents enrolled in the study when scheduling their children’s appointments at the clinic. The average parent age was 36; 94 percent of the parents were biological mothers.

The research team randomized parents into two study groups and matched patients in the groups by Medicaid coverage status. Parents in the MePrEPA group attended four weekly 60-minute facilitated sessions. Sessions included instruction, discussion, and role play about mental health needs and working with schools and healthcare providers. Parents in the comparison group attended four weekly 60-minute nondirected social-support group sessions. All activities took place in Spanish.

The research team collected data from both groups before the first session and then at one- and three-month follow-ups. Before making group comparisons, the research team adjusted outcome measures for baseline differences in the outcomes of interest, Medicaid status, and children who were new to therapy. Ninety-five percent of participants in the study completed baseline interviews; 83 percent completed one-month follow-up interviews; and 82 percent completed three-month follow-up interviews.

The research team also collected child-reported mental, physical, and social functioning cPROMIS measures from 97 children and assessed the measures’ association with increases in parent activation. Researchers used validity testing to examine cPROMIS measures in relation to parent proxy measures (concurrent validity) and school suspensions or expulsions (discriminant validity). Researchers collected cPROMIS data and comparative measures at each child mental health visit during the parents’ time in the study.

Results

Intervention effectiveness. Parent activation, educational activation, and school involvement increased for both groups. In a difference-in-difference model adjusting for variation between the two groups in Medicaid status and whether children were new to therapy, parents in the MePrEPA intervention group experienced significantly greater improvement in parent activation, educational activation, and school involvement at the one-month and three-month follow-up interviews compared with those receiving nondirected social support (p < 0.05). The study did not find differences between the two groups in change in parent stress or depression. In addition, there were no differences between the groups in child attendance at mental health visits or observed parent activation.

Parent activation and cPROMIS scores. The cPROMIS measures showed good concurrent and discriminant validity in Latino children receiving mental health services. cPROMIS scores were significantly associated with the corresponding parent proxy scores (p < 0.05). Children with school suspensions or expulsions had significantly higher anger, anxiety, and depression cPROMIS scores (p < 0.05). Examining changes in parent activation scores relative to changes in cPROMIS measures, after adjusting for multiple comparisons, showed that increases in both parent and education activation were associated with increases in the cPROMIS anxiety measure.

Limitations

The study had a relatively small sample size, took place in a single mental health clinic, and relied on self-reported parent activation data. There may have been self-selection bias in the sample because parents who agreed to participate in the study may have been more motivated to learn new skills than those who did not participate.

Conclusions and Relevance

Psychoeducational interventions like the MePrEPA program are promising for improving activation for Latino parents of children with mental health needs. Given the good concurrent and discriminant validity of the cPROMIS measures to parent proxy measures, cPROMIS may be an efficient way for mental health professionals to gather child-reported outcomes.

Future Research Needs

Future research could explore the effectiveness of the MePrEPA program in other settings or with larger populations. Future research could also examine whether parents who participate in the intervention maintain activation skills beyond the three-month follow-up. Future research could also develop behavioral measures of activation because communication-based observations were difficult to code.