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An evidence based model of care


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An overview of an innovative family model of care for parents and children where a parent has a dual diagnosis. Feedback about the model will be presented from children and parents, as well as from workers regarding implementation issues by PhD Andrea Reupert.
The conference Developing Strength and Resilience in Children, 1-2 Nov. 2010 in Oslo.

Published in: Health & Medicine
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An evidence based model of care

  1. 1. A model of care for families where parents have drug/alcohol and mental health issues Dr. Andrea Reupert A/Professor Darryl Maybery Ms. Mel Goodyear Ms. Ingrid Vet The program and research was funded by FaHCSIA, The Ian Potter Foundation, Rotary Australia and NSW Health
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  3. 3. Objectives • Describe the model of care developed by Northern Kids Care – On Track Community Organisation (NGO) • Present some preliminary evaluation data about the model • Discuss some of the implications when working with families with complex needs
  4. 4. Why focus on family? • Parental mental illness and substance abuse is highly prevalent and can adversely impact on children • Family interventions have empirical support – Benefits the parent with the problem – Benefits to children • Financially it makes sense • Australian government policy
  5. 5. It all started with...... Reupert, A., Green, K., & Maybery, D. (2008). Family care plans for families affected by parental mental illness. Families in Society: The Journal of Contemporary Social Sciences, 89(1), 39-43.
  6. 6. Vision for Northern Kids Care: On Track Community Programs Increased health and wellbeing of children, young people and parents living in families affected by parental mental illness or dual diagnosis through the development of a best practice outreach service delivery model
  7. 7. Theoretical framework of model 1. Family centred practice (Allen & Petr, 1998; Dempsey & Keen, 2008; Law, et al., 2003) 2. Strength based case management (Brun & Rapp, 2001; De Jong & Miller 1995; Rapp, 1997; 1998) “not all families are strong, but all have strengths” (Dorothy Scott) 3. Family care planning (Reupert, Green & Maybery, 2008)
  8. 8. Components of the model Family fun days Peer support groups Home visiting service Least intensive Most intensive The different levels of intensity allow: – Families to become familiar with services & workers – Opportunities to meet with other parents and children – For workers to get to know families
  9. 9. Family fun days • An opportunity to have fun and interact socially with similar families. • To learn more about the service and workers before committing to the more intensive aspects of the program • Over the three sites there were 189 participants attending family fun days from 2008-2010.
  10. 10. Peer support groups for young people and parents Aimed to: • Increase social connections • Provided with information • Develop and practice new skills Various groups for children of different ages, such as SMILES, Koping (n=414) Various groups for parents (n= 81)
  11. 11. Home visiting service Case manager works with individuals and family in the home using a strength based case management model A focus on planning rather than crisis using family care plans with 11 pre-determined goals in areas such as parenting, education, connectedness (within family and community) Each family “reviewed” every four months over a 12 month period (extended for some families)
  12. 12. Home visiting service Inclusion criteria •Parent has a diagnosed mental illness OR •Parent has a diagnosed dual diagnosis (co-existing mental health disorder and substance/abuse problem) •Cares for dependent children (0-18 years) •Young person are included with informed parental consent Exclusion criteria •Parents whose children are less than 20% at the parent’s residence are not included •If drug and alcohol is the primary problem families are referred to drug and alcohol centres •Current issues of violence, sexual assault and/or abuse excluded •Young people in acute stages of psychosis ineligible
  13. 13. Community approaches • SKIPS (Supporting Kids in Primary Schools) • Professional development days • MOUs with other agencies re referral, case management, coordination • Partnerships with others when running peer support programs and in case coordination
  14. 14. Evaluation consisted of a participatory, action research design • Individual interviews with children, parents and workers • Family care plans analyzed • Every six months data presented to workers and management: – What does this mean for our service? For management? • Refinements to model made accordingly
  15. 15. Demographic Parents with mental illness Parents with dual diagnosis # Parent - clients 10 10 # with partner 8 (2 with a mental illness, 1 alcohol abuse) 3 (1 also with a dual diagnosis and one with “unspecified drug use”) Mean age parent 41.4 yrs 36.3 yrs Gender parent 9 Females: 1 Male 8 Females: 2 Males Ethnicity All white Australian 8 white Australian, 2 Indigenous Parent diagnosis 2 Schizophrenia; 2 Bipolar; 1 Depression; 1 PTSD; 1 Anxiety; 3 depression & anxiety 3 Schizophrenia; 2 Depression; 4 Bipolar; 1 OCD & Depression Substance abuse of parent-client 5 marijuana, 2 alcohol, 2 alcohol & marijuana, 1 heroin. Family violence in last 3 years 5 families 3 families # Children 24 30
  16. 16. Children • Peer support programs reduced isolation • Acquired effective coping strategies • Enhanced knowledge about mental wellbeing and illness • Strengthen family relationships but wanted more support for their parent, especially around drug use: We need to change what mum does.... Mum needs to stop taking drugs (11 year old girl). [I need] someone who could come and talk regularly about how to help my mum more and not just to keep it going (12 year old girl).
  17. 17. Parents • Developed adaptive coping strategies for managing mental illness • Family fun days and peer support groups reduced isolation • Strengthened family relationships • Requested more support in terms of specific behavioural parenting strategies
  18. 18. Case managers Seven different case managers plus manager • Predominately young and open to new ideas and ways of doing things • Background in social work, welfare • Worked previously in mental health, child protection, rehabilitation Data includes • Interviews conducted every four months • Feedback sessions
  19. 19. Case managers • Engagement, change and improvement can be very slow • Some parents with a substance abuse have less insight into impact of disorder on children, are more difficult to work with b/c of multiple issues (exception are those parents with borderline pdo) • Skills required in varied areas • Important to establish and maintain relationships with multiple agencies • Need to screen for substance abuse for all parents • Not taking sides, boundaries and “seeing double” is an ongoing issue that requires supervision
  20. 20. 20 family care plans were analysed In two ways: 1. What do children and parents see as the most important things to work towards? 2. What areas do children and parents progress in? In what areas is little or no progress recorded? 3. (Differences in types of families?)
  21. 21. Family care plans Pre-determined goal areas for children and parents: 1. Family connectedness 2. Mental health knowledge 3. Child development 4. Education 5. Interpersonal skills 6. Substance abuse 7. Lifestyle, diet and exercise 8. Community and social connectedness 9. Finances 10.Family health and wellbeing 11.Accommodation 12.Other
  22. 22. What do children want to work towards? • Enhance interpersonal skills, e.g. Learn to express frustration in an appropriate way • Learn more about mental illness and wellbeing, e.g. Learn the difference between mum’s physical and mental health symptoms • Education, e.g. Attend school on a regular basis Get help with homework
  23. 23. Most progress Mental health knowledge Accommodation (e.g. child to have her own room) Substance abuse (e.g. better understanding of mum’s methadone program) Least progress Finances (e.g. child to receive pocket money) Interpersonal skills Family health and wellbeing
  24. 24. Child goals and progress Goal Area Goal No (Prop) Change score MI DD MI DD Family Connectedness 25 (15) 23 (13) 1.40 2.42 Mental health knowledge 24 (14) 24 (14) 2.25 2.21 Child development 16 (10) 14 (8) 1.88 2.43 Education 26 (15) 34(20) 1.81 2.29 Interpersonal Skills 26 (15) 24 (14) 1.85 1.67 Substance Abuse 2 (1) 5 (3) 2.00 2.40 Lifestyle, diet and exercise 16 (10) 22 (12) 1.88 2.09 Community and Social Connectedness 13 (8) 16 (9) 2.15 2.13 Finances 7 (4) 2 (1) 2.14 1.00 Family Health and Wellbeing 9 (5) 6 (4) 1.44 1.33 Accommodation 4 (2) 1 (1) 2.75 3.00 Total 168 (100) 171 (100) 1.88 2.14
  25. 25. What do parents want to work on? • How to manage their mental illness, e.g. Recognise early warning signs Practice effective coping strategies, such as regular exercise • Enhance interpersonal skills, e.g. Anger management skills Learn how to stand up for myself with partner • Enhance family connectedness, e.g. Mum to develop shared interest with youngest child
  26. 26. Most progress Mental health knowledge (e.g. identify early warning signs) Substance abuse (e.g. parent to ensure children are not exposed to drug use) Community and social connectedness (e.g. attend community choir) Least progress Family connectedness (e.g. mum to develop shared interest with youngest child) Interpersonal skills (e.g. manage anger) Lifestyle, diet and exercise
  27. 27. Parent goals and progress Goal Area Goal No (Prop) Change score MI DD MI DD Family Connectedness 22 (15) 14 (9) 1.36 1.71 Mental health knowledge 32 (21) 26 (17) 1.84 2.12 Child development 8 (5) 9 (6) 2.12 1.78 Education 13 (9) 16 (10) 2.08 1.81 Interpersonal Skills 25 (17) 17 (11) 1.44 1.35 Substance Abuse 3 (2) 17 (11) 2.33 2.18 Lifestyle, diet and exercise 11 (7) 15 (10) 1.73 1.27 Community and Social Connectedness 17 (11) 12 (8) 2.06 1.92 Finances 10 (7) 12 (8) 1.70 1.67 Family Health and Wellbeing 7 (5) 5 (5) 1.71 1.88 Accommodation 2 (1) 7 (5) 2.00 1.71 Total 150 (100) 153 (100) 1.75 1.78
  28. 28. Implications for practice • Incorporate behavioural parenting strategies for all parents in an ongoing manner • Specifically ask about substance abuse upfront and address addiction issues in the individual • “Not all families are strong, but all have strengths” • Recognise individual child and parent issues while acknowledging the interrelationship between the two • Recognise and use community supports • Family care plans can assist in identifying, monitoring and evaluating goals
  29. 29. Families with multiple needs require multiple strategies Data indicate that there is no one single strategy or program that can meet the needs of all family members
  30. 30. Implications for policy and funding • Protocols and procedures required between different services • Consideration required in regard to workers case loads • Provide staff training for working with individuals and groups, and on specific issues (addictions; borderline) • Provide supervision around “seeing double” • Provide flexible time arrangements for families • Ensure ongoing funding to ensure stability of staff and process • Recognise alternative but rigorous evaluation methodologies, especially those sensitive to the voices of consumers and carers
  31. 31. Implications for research • Accurate prevalence estimates that includes sub- groups • Can workers see double? How do they do this? • Measure the long term impact of interventions on children’s functioning, parenting capacity and family functioning/cohesiveness – Also need to consider the relative impact of various services provided (e.g. peer support vs home visiting service) and different subgroups (e.g. Parental diagnoses and substances) – Cost analyses of interventions
  32. 32. Future directions for us in this data set • Quantitative data analysis • Heterogeneous nature of groups, possible service differences and child, parent and family outcomes? • Consider drop out rates References available on request. Happy to be contacted