Cover Two

Moderate Pediatric Behavioral Health Issues

A new program to assist parents

BY Christopher J. Mehus, PhD, LMFT and Sonja Colianni, MD 

Providing support to parents is often the best way to address behavioral health challenges in young children. Unfortunately, parent-focused programs for moderate behavior challenges are not widely available or accessible. We are filling this gap by providing a network of therapists who offer brief services to parents via online sessions. Therapists in our network have specialized training to effectively provide support to parents, who can then address child behavior challenges at home. 

Primary care clinicians who see patients from the ages of 3 to 8 have access to our network of therapists and can refer parents of children with moderate behavior concerns.

In this article, we provide background information about parent-focused interventions, explain how we are expanding access and share how primary care clinicians can access our network of therapists and help us expand services across Minnesota and beyond.

The benefits of parent-focused interventions grow over time.

Effective Support for Parents

Our core intervention is called Empowered Generations (eGen), a brief parent-focused intervention. Parent-focused interventions are designed to improve children’s behavioral health outcomes by providing direct support to parents, rather than to children.

Parent-focused interventions are an evidence-based, first-line treatment strategy for addressing behavioral health challenges in young children, such as tantrums, attention-deficit/ hyperactivity disorder, early conduct disorders, emotional dysregulation and other common concerns. All children deserve the best opportunity for healthy development. When it comes to children’s behavioral health, parents are in the best position to address many challenges but may need additional skills and tools to do so. 

Parent-focused interventions teach parents how to effectively help their children learn and practice healthy, prosocial behaviors. For example, in eGen, therapists help parents identify positively framed goals and new behaviors to work toward (rather than focusing solely on disruptive behaviors). Parents then learn and practice tools for supporting and coaching children in new behaviors. Examples range from giving effective directions, to using encouragement to teach new skills, to employing healthy, age-appropriate limit setting. 

Reflecting on the tools learned from a therapist in our network, one parent said, “The minute that we slowed down and got to [the child’s] level and did the things that [the therapist] told us to do, our cooperation with our child at that point literally skyrocketed to like, we’d say probably 80% of the time they listened the first time we said it. And we were just mind-blown... It really helped us remove a lot of stress from our lives.” Another parent commented, “I just felt very empowered that such a small change could make such a big difference in my relationship with my son and how I feel as a parent... I can see, still, months and months after I’ve completed this program, that I get a much better response and reaction.”

Extensive research across diverse communities and settings have shown that evidence-based, parent-focused interventions have a positive impact on children’s behavioral health outcomes. The children of parents who complete these programs grow up to have better mental health outcomes, have more prosocial peer groups, are less likely to abuse substances and are less likely to be involved with the justice system. 

Furthermore, the benefits of parent-focused interventions grow over time. The difference between children with parents who completed a parent-focused intervention and those with parents who did not becomes larger as time passes. Research even shows positive effects of these programs in the next generation of children with no further intervention.

As one therapist in our network said, “I see the difference in the families who do this [program]. If you help these parents with their little ones, there’s a ripple effect, it keeps on going. I feel like we’re really making a difference.”

Improving Access  

We make support for parents widely available by providing primary care clinicians with a simple referral resource. Engaging parents through primary care can solve the two main barriers to wide-spread implementation of parent-focused child behavior interventions.

The first challenge is stigma around seeking behavioral health support and parenting support. Parents most commonly share that the reason they did not attend an available parenting program is that it would suggest they are a bad parent or do not know how to raise their children. Of course, the opposite is true; parents who seek or receive support in raising healthy children are proactively pursuing their children’s best futures. Primary care clinicians are ideal for delivering this message to parents. Primary care is often the first place that parents ask questions about behavioral concerns, and primary care clinicians are a trusted source of information. When primary care clinicians connect parents to resources and encourage them to seek additional tools to support their children’s health, parents are more likely to attend parent-focused programs. 

The second challenge that prevents parent-focused interventions from being widely available is that they are not ‘housed’ in any one service setting. In other words, if a parent were interested in seeking this type of support, they likely would not know where to look. Because nearly all families with young children interact with primary care, it is the ideal setting for the initial engagement of parents in this care. Although parent-focused interventions are available in some mental health organizations, this is far from universal. Furthermore, parents do not often seek out mental health services until problems progress to more significant levels. Primary care clinicians can identify challenges early, when they are mild or moderate, and provide a widely available point of entry.

How the Program Works

Therapists in our network provide behavioral resources to parents with children from the ages of 3 to 8. Parents are offered practical tools to respond to common behavioral concerns calmly and confidently, and in a way that strengthens trust and their bond with their children.

The therapists meet online with parents and conduct one-on-one sessions, have immediate availability in most cases, and can provide services in a wide range of languages, including Spanish, Somali, Hmong and others. By providing services online, resources are accessible to parents all over the state. As one parent reflected, “I just want to say, basically, thank you for breaking down the barriers so that folks, moms, single moms, all the moms can be involved. I haven’t found a lot of things accessible, being that single parent.”

On a continuum of care, our program sits between universal parent and family education and intensive services for higher levels of need. Minnesota is fortunate to have broad access to Early Childhood Family Education (ECFE) through the public school system. Some families, however, need more support than general education can provide. At the other end of the continuum are services for families with significant behavioral health needs. Our program fills the gap in the middle. Families who are referred to therapists in our network are those who would benefit from more support than general education, but do not have safety concerns or significant needs related to mental health or substance use.

As one referring primary care clinician described, “It is a gift to be able to offer behavioral health resources before parents have lost confidence in their parenting.” 

In making referrals, we rely on primary care clinicians to use their clinical judgment as to whether a family might benefit from behavioral parenting tools and brief intervention. Some common reasons for referrals include: tantrums, difficulty with recent family transitions, hyperactivity, behavior challenges at school or daycare, observed coercive parenting behaviors, or a positive screening for social-emotional difficulties. 

When parents are referred to therapists in our network, they are offered our core program, called Empowered Generations (eGen), a six-session, parent-focused, behavioral intervention. Rather than being rigidly scripted, eGen is tailored to the family’s needs and values. It is strengths-based, includes active learning and practice, and equips parents with a core set of tools that help them set their children up for success. 

eGen is tailored to the family’s needs and values.

The eGen program is offered to parents on one of two timelines: (1) Some parents meet with a therapist for one initial session, in which the therapist guides the parent to various resources and tools that may address their challenges. Resources in the initial session range from videos to worksheets to online tools. The therapist encourages the parent to utilize the resources and then follows up with the parent in about six weeks to offer eGen if additional support is needed. While some parents find that their needs are met after the initial session, others elect to continue to eGen. The initial session is always free to parents. (2) Other parents are offered eGen immediately. In this case, therapists usually schedule an intake session and then provide the six-sessions of eGen. When appropriate, therapists bill insurance for the sessions like any other mental health service. Some therapists also offer sliding scale fees or other payment options.  

All therapists in our network are licensed mental health professionals, and nearly all are credentialed with all major insurance companies. The therapists receive extensive training through our project to equip them to work effectively with parents of young children. Their training covers the tools they teach parents as well as the clinical process skills needed to empower parents to try new skills without feeling shamed or criticized. When therapists agree to participate in our network, they hold appointment slots for these referrals, which allows for immediate appointment availability.

Initial data have shown noticeable benefits for families who participated, including a significant reduction in children’s externalizing behaviors and strengthened parenting behaviors. Parents’ experiences are illustrative of what we see in our data. Some parents who have participated report concrete behavior changes, such as, “We’ve had almost all good bedtimes for the past two weeks!” In other cases, parents have offered reflections on important second-order changes: for example, “It helped me better understand what my child thought in situations. It made me get less angry and helpless when he didn’t listen and put things in a new perspective.”

Three Levels of Impact

Our hope for this project is to have an impact on three levels, which is possible only with primary care clinician participation. At the most proximal level, the immediate goal is to offer resources to thousands of parents. Parents have access to this network of therapists only if their primary care clinician refers them. Primary care clinicians who enroll can refer as many eligible families as they wish for at least the duration of the project (approximately through 2029). 

At the state level, our hope is to grow this referral network of primary care clinicians and therapists to a large enough scale that it can continue after completion of the currently funded project. When primary care clinicians participate now, they help grow the network and provide feedback that helps to improve the referral process.

At the national level, we seek to generate data that will inform broader dissemination and implementation of parent-focused interventions across the country. Our project is funded by the National Institutes of Health. Referred parents have the option to participate in our research study, which will fill critical gaps in the literature related to the cost-benefit of parent-focused programs with primary care referred families. Research participation is completely optional, and parents get the exact same services whether they participate or not..

How to Access the Referral Network

There are currently over 200 primary care clinicians from 12 health care systems and clinics able to refer. Primary care clinicians who are interested in gaining access to this referral resource should enter their contact information at knowledgeforparents.umn.edu/referralstudy. 

Once system-level approvals are in place, primary care clinicians receive a brief introduction to the program, and two brief surveys ( less than 5 minutes) to complete. After completing the first brief survey, primary care clinicians can immediately begin to refer eligible parents. 

We are proud that this resource can support the great work of primary care clinicians, who are the front line of care for children. One referring physician said, “I’m just so grateful that you and the team of therapists are available to serve my patients and families. There is so much mental health need at this time and I am thankful for [this program]! Your team is meeting part of a need that used to bring me moral distress. When I see families and kids struggling with mental and emotional needs, I spend extra time with them, and give a list of options for them to get connected to services, but more than half of them never see a therapist because of various barriers. So it was a huge relief to find out about your project and a team of therapists that would actually reach out and connect to my patients.”

Another primary care clinician said, “I feel so lucky to have access to this resource.” And we feel lucky each time we partner with a new clinic or clinician! 

Please contact the Knowledge for Parents team kfp@umn.edu or the principal investigator, Dr. Christopher Mehusc jmehus@umn.edu, to learn how you can offer this resource to families you serve.

Christopher J. Mehus, PhD, LMFT is a research associate professor at the Family Social Science department at the University of Minnesota. He is the principal investigator for the e-Gen study.

Sonja Colianni, MD is a pediatrician at Hennepin Healthcare and has served as the director of Pediatric medical education at HCMC since 2011.