Show me the Evidence
Telephone-Based Mental Health Care Gets Help Quickly to Troubled Kids and Families
Home-centred program proves more effective than usual care
At a Glance
Who: Dr. Patrick J. McGrath, IWK Health Centre, Dalhousie University.
Issue: An estimated 18% of children have mental health problems but only 15–30% of them receive timely treatment due to limited health care resources. Among families who do get care, dropout rates during the process are high.
Project: As an alternative delivery model, Dr. McGrath developed the Strongest Families program to provide an intervention service to families with children diagnosed with disruptive behaviour disorders, attention-deficit/hyperactivity disorder and anxiety. The 11- to 12-week intervention involves the use of video materials, workbooks and weekly telephone sessions with trained coaches.
Research Evidence: Three CIHR-funded clinical trials conducted from 2003 to 2007 concluded that the Strongest Families program is effective in treating mild to moderate pediatric mental health disorders. Strongest Families was found to be more effective than usual care and produce sustained benefits.
Evidence in Action: Strongest Families operates in four of Nova Scotia's nine district health authorities. Almost 300 children were treated in 2010, with 1,000 children and families helped so far. The program is also offered in Calgary through Alberta Health Services and has been operational in Thunder Bay, Ontario for several years. Through a partnership with the Canadian Mental Health Association, Strongest Families is becoming available to 100 children across British Columbia.
Sources: Telephone-Based Mental Health Interventions for Child Disruptive Behaviour and Anxiety Disorders: Randomized Trials and Overall Analysis. Journal of the American Academy of Child & Adolescent Psychiatry 50, 11 (November 2011): 1162–1172.
Nine-year-old Calvin is having difficulty sitting still during class, affecting his ability to focus. Gathered together on the carpet for a group lesson, he thinks it's time for wrestling with his classmates. He's impulsive, often interrupting his teacher or simply acting silly to get attention. His daycare provider describes his energy level as equal to two boys in the body of one. With his unpredictable behaviour, he has trouble making and maintaining friends. At home, he argues and throws tantrums when he doesn't get his way. Calvin's teachers and parents struggle to manage his behaviour. They are worried, frustrated and concerned about what to do next.
Calvin is fictional, but many real children share his difficulties. At any given time, about one in five Canadian children and adolescents are experiencing some form of mental disorder.1 But the supply of professionals who can provide pediatric mental health care is limited, while the demand is overwhelming. As a result, many troubled children languish on waiting lists. In Ontario, for example, 90% of children and youth with an identified mental disorder wait an average of six months for treatment.2
Dr. Patrick J. McGrath has seen this problem first hand. "It bothered me back when I was a clinician in Ottawa at the Children's Hospital of Eastern Ontario. Too many parents were being told, 'When your kid gets worse we can give them treatment.' I've heard that so many times that it's discouraging."
When he saw the system wasn't working for families with children like Calvin, Dr. McGrath, now a clinician/researcher and Canada Research Chair at Dalhousie University and the IWK Health Centre in Halifax, began devising an entirely different program. Called Strongest Families, the telephone-based intervention helps families deal with their child's mild to moderate mental health problems before they morph into major ones.
"In almost every health region we work with, they give us kids from their waiting lists who meet the criteria of having either disruptive behaviour or anxiety but are not an immediate danger to themselves or anybody else," says Dr. McGrath. "We get the kid who will likely sit on a waiting list for a long time because they don't have a knife to their own throat or a knife to someone else's throat."
Typically running 11-12 weeks, the program incorporates cognitive behavior therapies such as "belly breathing" to allay anxiety and teaches problem-solving techniques. Families receive handbooks and instructional videos and take part in weekly telephone sessions with trained coaches. They can also email their coaches to seek advice or share concerns between the weekly meetings.
Begun in 2006, Strongest Families operates in four of Nova Scotia's nine district health authorities. Almost 300 children were treated in 2010, with 1,000 children and families helped so far, says Dr. Patricia Lingley-Pottie, co-investigator with Dr. McGrath and President/COO of the non-profit Strongest Families Institute. The goal is to eventually have the program available across Nova Scotia.
A review of three randomized clinical trials found that compared with usual care, the Strongest Families intervention "resulted in significant diagnosis decreases among children with disruptive behaviour or anxiety."3 The results indicate Strongest Families is generally more effective than usual care, with benefits sustained one year after treatment.
In Cape Breton, 146 children received Strongest Families treatment in 2010, with an 87% "problem resolved" rate, says Dr. Julie MacDonald, the health authority's Manager of Child and Adolescent Mental Health Services. She says that Strongest Families can significantly cut the time families spend on waiting lists – an impact that other health authorities also cite. "If you are a candidate for Strongest Families, you start treatment within about two weeks, as opposed to a four-month wait for face-to-face counselling."
Evidence in Action: Faster Access to Care
The program provides treatment to those with more moderate behaviour problems who may have remained on wait lists for months or much longer before they see a counsellor. Access to services from the Strongest Families team can begin in weeks.
As well, the dropout rate for Strongest Families hovers below 10% compared to an attrition rate for standard pediatric mental health counselling that Dr. McGrath estimates to be at least 40%.4
Dr. Lingley-Pottie credits "non-stigmatization" as a key reason why parents and children stay with the program. Children and parents don't have to arrange to excuse themselves from school and work to get counselling at an office or a clinic.5 "If a child can sit in his or her own home and talk with a coach, they are able to be open without worrying about being judged. They feel comfortable. They are not in a strange environment."
The program is also offered in Calgary through Alberta Health Services and has been operational in Thunder Bay, Ontario for several years. "We saw it as a good supplement to maximize the use of our professionals," says Tom Walters, Executive Director of the Children's Centre of Thunder Bay. "The primary focus has been in the rural parts of the district, because it doesn't really matter if the coach is in Nova Scotia talking to someone in Northern Ontario – it still works."
Through a partnership with the Canadian Mental Health Association (CMHA), Strongest Families is becoming available to 100 children across British Columbia, says Lynn Spence, Provincial Programs Director for CMHA's BC Division.
"A lot of kids and families who need support for relatively minor mental health concerns don't get that help," says Ms. Spence. "The result is much greater difficulties later in life. This allows us to address things early enough that there can be changes made so that these families and children will not have to enter the mental health system. Or, if they do, they will be identified early and get referrals for appropriate care."
Program Makes 'Huge Difference' to Families
Brenda Williams (not her real name) and her husband enrolled in Strongest Families after their eight-year-old daughter's anxiety and trouble focusing and paying attention created behavioural difficulties. At one point, their daughter refused to eat for almost a week. After contacting a mental health agency, the family was told they would have to wait six months to a year to see a counsellor, and appointments would require travel. After 11 weeks in the program, the Williams' daughter has no sign of her original anxiety problems. "The program changes the parents, who in turn change the child," says Williams. "It's made a huge difference."
For More Information:
- Telephone-Based Mental Health Interventions for Child Disruptive Behaviour and Anxiety Disorders: Randomized Trials and Overall Analysis. Journal of the American Academy of Child & Adolescent Psychiatry.
- Integrated Knowledge Translation in Mental Health: Family Help as an Example. Journal of the Canadian Academy of Child and Adolescent Psychiatry.
- Strongest Families Website.
- Mental Health Commission of Canada Annual Report 2010–2011.
- Children's Mental Health Ontario Pre-Budget Submission 2011.
- Telephone-Based Mental Health Interventions for Child Disruptive Behaviour and Anxiety Disorders: Randomized Trials and Overall Analysis. Journal of the American Academy of Child & Adolescent Psychiatry 50, 11 (November 2011): 1162–1172.
- Attrition in the treatment of childhood anxiety disorders. Journal of Consulting and Clinical Psychology 65, 5 (October 1997): 883–888.
- Distance therapeutic alliance: the participant's experience. Advances in Nursing Science 30, 3 (October/December 2007): 353–366.