The proposed project involves three phases:
Aim 1 (Phase 1): Focus groups. Six focus groups will be held to elucidate barriers and facilitators to access and engagement of HStart children in MH services. Separate focus groups will be conducted for each stakeholder and ethno-racial caregiver group (3 Black, Latinx, and White caregiver groups, 1 navigator, 1 teacher, and 1 PCP focus group). Latinx caregivers and navigators will have the option to attend an English or Spanish focus group session. The focus groups will be conducted via a web-based platform (e.g., MS Teams) at a variety of times to facilitate participation of caregivers, navigators, and professionals who provide childcare and/or work at different times or lack transportation or childcare to attend in-person sessions. Demographic data will be collected. Groups will employ an open format with guided questions to gain perspective and to help participants focus on 1) barriers and facilitators to access and engagement in MH services, 2) enriching a navigation program to address MH barriers and enhance facilitators, and 3) conceptualize the ideal dashboard to track and monitor the trajectory of MH clinical, functional, and behavioral outcomes. To ensure research integrity, focus group facilitation will be led by the co-PIs and research team experienced with focus groups. All sessions will be recorded, field notes composed, and sessions transcribed verbatim.
Web-based dashboard. The investigators will develop a web-based dashboard on a secure website to assist the navigators, and us, the research team, in monitoring and tracking child and caregiver progress over time with clinical, functional, and behavioral outcomes. This user-friendly system will track and monitor alignment of caregiver goals to service use on the primary outcomes of access, engagement, coordination, and optimization of MH services. Also, it will track the child's MH symptoms in the case series and pilot study. The goals and tasks will be set by the caregiver and navigator after visits with professionals, maximizing the benefits of goal-setting that include motivation, commitment, and self-regulation and working professional alliances. The research team will rate the progress toward the caregiver-determined goals and the child's MH symptoms from the data will allow us to measure care coordination. Access data on detection of risk for MH disorder and appropriateness of referrals will be inputted from the HStart data base (ChildPlus©), medical record, and navigator tracking of visits and referrals by teachers and PCPs and recommendations made. Engagement will be monitored by caregiver/navigator meeting content and goals, caregiver goal alignment with professional recommendations, and resources/tasks needed to reach the goals. Coordination will be tracked with caregiver initiation, completion and frequency of the child's MH services, and navigator-provided resources on advocacy, emotional support, basic needs, and MH disorders to support services use. Optimization will be monitored by agreement between caregivers and PCPs on the MH treatment goals and tasks including services type and frequency. The dashboard will be a core component of the NTRI-MH treatment manual. It will be built with the capacity to eventually scale up to involve caregivers, teachers, and PCPs in monitoring and tracking the trajectory of progress over time.
NTRI-MH adaptation. The stakeholder focus group findings and views on dashboard creation will inform the modifications to the 1st iteration of the NTRI-MH treatment manual. Adaptations to the treatment manual will focus on the barriers and facilitators to engagement in MH services, navigation enhancements to address these barriers, usefulness of the dashboard to track and monitor progress in MH outcomes. Implementation fidelity questionnaires will be modified for NTRI-MH. Once the NTRI-MH treatment manual is revised, the full research team and consultants will review it for a 2nd iteration. The NTRI-MH treatment manual adaptations will be completed prior to being implemented in the case series trial.
The primary deliverable is modification of the NTRI-MH intervention design and the content of a web-based dashboard to adapt the treatment manual for addressing the primary outcomes of access, engagement, coordination, and optimization of MH services.
Aim 1 (Phase 2): NTRI-MH training and implementation. Training for the navigators and teachers will use evidence-based instructional strategies for adult professional development (i.e., lecture, discussion, case studies, role-playing).92 PCPs will receive training when their patient enters the study. The research team will provide training for the navigators and teachers, whereas the PCPs will receive training by e-Learning. Since the navigators were previously trained in NTRI-DD, navigators training will be adjusted to include adaptations to the NTRI-MH implementation and treatment manual, and use of the dashboard to assist navigation. This comprises 20 hours of didactic and interactive sessions (5 sessions of 4 hours each). The navigators' NTRI-MH training will include these areas specific to MH needs in young children at-risk: 1) benefits and barriers (professional and family) to early intervention for children with MH concerns, 2) approaches for empowering caregivers, 3) supporting strategies to assist families through early MH access and service engagement , 4) use of the dashboard to track and monitor the course of clinical, functional, and behavioral outcomes, 5) evidence-based working alliances with PCPs and teachers (including a 2 hour session with the child's teacher), and 6) MH resources, treatments and services, and strategies to support parental management of young child behaviors (See Appendix A). Teacher training will encompass 5 hours of didactic and interactive sessions with continuing education credits and focus on: 1) delivering difficult news to families of children at-risk for MH and use of letter for explaining screenings and next steps, 2) strategies to recommend the child visit their PCP for MH concerns, 3) evidence-based working alliances with caregivers, PCPs, and navigators (including a 2-hour session with the caregiver's navigators). PCP training will be formatted as 1-hour e-Learning with continuing education credit and focus on: 1) acting early to manage and mitigate MH disorders and use of the Just-In-Time decision aid, 2) talking to caregivers about evidence-based and appropriate treatments and services for MH, and 4) evidence-based working alliances with caregivers, teachers, and navigators. All training will be evaluated at the final training sessions. Following training, NTRI-MH implementation will comprise navigators executing the 3-month NTRI-MH intervention with the caregivers, including 10 hours of navigation services with a 1-to-2-hour face-to-face meeting, at least 3 monthly in-person meetings, and attending all meetings, visits, and/or services with the caregivers at HStart, primary care offices, and MH centers. After each visit, the navigator will follow up by phone, text, or e-mail with the caregiver and review goals and tasks and enter the dashboard data. Navigators will meet weekly with research staff for supervision and case review. Teachers will share a copy of the screenings with caregivers, a letter explaining the screening results, and recommend a visit with the child's PCP. PCPs will complete the e-Learning session, review the Just-In-Time decision aid (i.e., child's screening results and evidence-based treatment recommendations), and make referrals. Navigators, caregivers, teachers, and PCPs will complete questionnaires at baseline (Time 1), immediately post-intervention (Time 2), and 3-months post-intervention (Time 3). The study team will assess the child's MH symptoms and family function at baseline, post-intervention, and 3-months following. Findings from the assessments obtained at times 1, 2, and 3 will inform ongoing modifications to the NTRI-MH dashboard and treatment manual, and the dashboard evaluated by the navigators at a final weekly supervision meeting. In addition, at the end of the case series feasibility study the co-PIs will interview the navigators and caregivers to gain a more detailed understanding of their NTRI-MH experiences and the descriptive data compiled for treatment manual revisions.
Aim 1 (Phase 2) study measures include primary outcomes (NTRI-MH's feasibility and implementation by navigators; NTRI-MH satisfaction as per caregivers, navigators, teachers, and PCPs) and potential mechanisms of action (beliefs/perceptions about MH and its treatment, feelings of empowerment, working alliance with professionals) effects on access, engagement, coordination, and optimization of MH services and the child's MH symptoms and family function. The primary deliverable is a modified dashboard and NTRI-MH treatment manual with high feasibility, acceptability, and implementation ratings, and a preliminary description of a trend showing the potential mechanisms of action affect access, engagement, coordination, and optimization of MH services for at-risk preschoolers and the downstream outcomes of family function and the child's MH symptoms.
Aim 2: Ten navigators will implement the NTRI-MH. Caregivers will be randomly assigned by schools to the intervention group (n=30) or control group (n=30). Navigators', teachers', and PCPs' training will follow procedures outlined in Aim 1 (Phase 2), except for 10 additional training hours for all navigators to allow for changes needed since the treatment manual revisions. Following training, for the intervention group, the navigators will implement the NTRI-MH for 6 months with the caregivers, including 15 hours of navigation services with a 2-hour face-to-face meeting, at least 6 monthly in-person meetings, attending assessments and treatments with the caregivers at HStart, PCP offices, and MH services locations. After these visits, the navigator will follow up by phone, text, or email with the caregiver. Navigators will meet weekly with research staff for supervision and case review. Teachers will share a copy of screenings and recommend a visit with PCP, and PCPs will review the Just-In-Time packet and make referrals. The caregivers in the active control group will receive a 2-hour training seminar and educational materials including handouts and videos from a developmental activities' toolkit pertinent to the emotional, behavioral, and developmental age of their child. Navigators, caregivers, teachers, and PCPs from both the intervention and control groups will complete questionnaires at baseline (Time 1), immediately post-intervention (Time 2), and 3 months post-intervention (Time 3). The NTRI-MH treatment manual will be modified from analysis of the assessments and expert feedback solicited to create the final NTRI-MH treatment manual and R01 application revised accordingly.
NTRI-MH measures will be identical for both the intervention and control groups, except for intervention feasibility, acceptability, and implementation. Table 3 describes Aim 2 study measures, including primary outcomes (access, engagement, coordination, and optimization of MH services) and secondary outcomes (child's MH symptoms, family functioning, NTRI-MH acceptability, feasibility, and implementation). We will also measure potential mechanisms of action (beliefs/perceptions about MH and its treatment, feelings of empowerment, working alliance with professionals) to determine if these improve access, engagement, coordination, and optimization of MH services for at-risk preschoolers. The primary deliverable is revisions to NRTI-MH and dashboard in a treatment manual that attends to potential mechanisms impacting access, engagement, coordination, and optimization of MH services in at-risk preschoolers, child/caregiver outcomes and preliminary data to inform larger efficacy studies.
