The DECIDE Parent-Provider Intervention

Study Overview
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Brief Summary
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The DECIDE Parent-Provider Intervention is designed to support parents caring for adolescents who are receiving treatment for Disruptive, Impulse-Control, and Conduct disorders. Participating in DECIDE study may help you effectively ask questions and participate in decisions about your adolescent's care.

Detailed Description
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Interventions to optimize parent-provider interactions are urgently needed to ensure adolescents aged 3 to 17 years with Disruptive, Impulse-Control, and Conduct disorders (DIC) receive the behavioral health care they need. For these adolescents, behavioral health care is complex, long-term, and requires parental participation. Research shows providers have biases and limited skills and confidence to communicate with these parents to encourage them to voice their concerns and care preferences. Low income and minority parents are at greatest risk of not being involved in their adolescents' behavioral health care, having poor interactions with providers, and are more likely to perceive poor quality of their adolescents' behavioral health care, and low treatment engagement. If unaddressed, poor parent-provider interactions interfere with adolescents' retention in behavioral health care. No evidence-based interventions have targeted both parents and providers to optimize their interactions and improve behavioral health care for adolescents with DIC. To address these problems, the investigators propose modifying the evidence-based DECIDE intervention to target parents and providers of adolescents with DIC. DECIDE stands for Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution. DECIDE was developed for ethnically/racially diverse adult patients with serious mental illness and the latest evidence-based iterations include intervention components targeted to and shown to increase patient activation, provider communication, and patient-provider interactions. DECIDE has two primary components: 1) three patient training sessions designed to help patients effectively ask questions and participate in decisions about their care: and 2) a 4-hour workshop for providers to improve perspective-taking, reduce attributional errors, and increase receptivity to parent participation and collaboration. The purposes of this two-phase study are: Phase I, Aim 1. Modify the DECIDE intervention for parents and providers of adolescents with DIC. Phase II, Aim 2. Evaluate the feasibility and acceptability of modified DECIDE. Aim 3. Estimate preliminary effects of modified DECIDE to improve parent, provider, and adolescent outcomes. Innovative features of this study are the proposed focus on both parents and providers; and inclusion of parent activation and provider communication, which are new in field of child and adolescent behavioral health care, and focus on low income and minority parents. The investigators expect to find that compared to usual care: Hypothesis 3.1. Modified DECIDE parents will show greater improvements in: 1) activation; 2) parent-provider interactions; 3) perceived management of adolescents' behavioral health care, 4) perceived quality of adolescents' behavioral health care, and 5) engagement in adolescents' behavioral healthcare. Hypothesis 3.2. Modified DECIDE providers will show greater improvements in: 1) communication skills; and 2) parent-provider interactions. Hypothesis 3.3. Adolescents of modified DECIDE parents and providers will show higher rates of retention in behavioral health care. Sample will include 16 providers and their parents (   5 parents per provider, n= 80) recruited from the Child and Adolescents Program of a large safety net health system setting that serves predominately low income and minority persons. Feasibility will be assessed using tracking logs and field notes, and acceptability through parent and provider satisfaction scores and in depth, semi structured interviews. Outcomes will be assessed at baseline and within 4 weeks post- intervention using standardized questionnaires or surveys from parents, providers, and independent observers reports. Effects sizes will be estimated using linear mixed models. If study findings are positive, we will be poised to test the modified DECIDE intervention in a fully powered R01 level randomized, controlled, multi-site clinical trial.

Official Title
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Modification and Evaluation of the DECIDE Intervention to Improve Parent-provider Interactions in Low-income Parents of Adolescents With Disruptive Impulse Control, and Conduct Disorder

Conditions
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Modified DECIDE Intervention, Treatment as Usual Care Group

Intervention / Treatment
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* Behavioral: Modified DECIDE Parent and Provider Intervention


Participation Criteria
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Eligibility Criteria
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Phase 1, Aim 1. Inclusion Criteria (for Parent Advisory Board; to assist with intervention development): 1. Parents of adolescents with DIC, who are receiving services at Midtown Child and Adolescent Program or CAP. (We will invite parents 1) from our previous study advisory board (n=3), and two who participated in preliminary study 2 that agreed to be contacted for future studies.) Inclusion Criteria (for Provider Advisory Board; to assist with intervention development): 1. CAP staffs who do not meet the inclusion criteria in phase 2 (i.e. manager and clinical coordinators or supervisors, clinic nurse, advanced practice registered nurses, or psychiatrists). (We will invite two other direct care providers who work in the healthcare system but not at recruitment site. No providers or parents will be excluded on basis of race/ethnicity, gender, or sexual orientation.) Phase II, Aims 2 and 3. Inclusion Criteria: Inclusion Criteria for providers and interns: Providers will be regular paid staff members who are: Associate's or bachelor's or PhD prepared providers who work with parents OR Masters-prepared clinical social workers or mental health counselors and Provide behavioral health services to adolescents and their parents. OR Doctoral level interns (e.g. in psychology) and Provide behavioral health services to adolescents and their parents OR Providers who are bachelor's prepared interns must: (1) be currently working with a center or private practice to complete requirements for their Master's degree and (2) be providing behavioral health services to adolescents and their parents. Inclusion Criteria for Guardians: Guardians will have a child or adolescent with DIC receiving services from a participating mental health provider. Parents/guardians meeting all the following criteria are eligible: are aged 21 or older speak English are the guardian (biological parent, adoptive parent, step parent, foster parent, or legal guardian) of the child or adolescent or a parent surrogate serving in a primary caregiver role (referred to as parents; if foster parent or legal guardian, ). must have a child or adolescent aged 3 to 17 years with a diagnosis of Disruptive Impulse Control and Conduct Disorder (DIC) by a mental health professional. (This includes children with behavior problems, such as Oppositional Defiant disorder, Conduct disorders, or Intermittent Explosive disorders). Attends regular appointments with a provider Foster parents will be included if they have a child with DIC now or in the past, and regardless of whether that child is receiving services from a participating mental health provider or not. Exclusion Criteria for parents: Show significant cognitive impairment or acute emotional distress on screening Have an incarcerated adolescent No providers or parents will be excluded on basis of race/ethnicity, gender, or sexual orientation. Specifically for semi-structured interview post intervention. Include: All intervention providers (n = 8) and two of each of their parents (n = 16). To explore different levels of acceptability by parents, for each provider, one parent will be chosen who has a high score (> 3) on the CSQ and one parent who has a low score (< 3). Both parents and providers will be asked about their experience with the intervention, what was helpful or not, and how they would change the intervention.

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Interventional Model Description: For clarity, each intervention group was separate and not comparable to other intervention groups.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Modified DECIDE-Provider Arm<br>2-4 hour workshop for providers to improve perspective-taking, reduce attributional errors, and increase receptivity to parent participation. | Behavioral: Modified DECIDE Parent and Provider Intervention<br>* The parent component will include up to three 60 minutes sessions. Session 1 (Decisions and Agency) is designed to increase awareness of their role in clinical interactions and encourage participation and decision making in care. Session 2 (the Who, How, and Why of Decisions) teach skills for understanding treatment decisions in terms of roles, processes, and reasons involved. Session 3 (Self-efficacy and Consolidation) encourages parents to ask questions about their adolescents' behavioral health and health care and treatment options. The provider component is designed to improve provider communication in three key areas: 1) perspective taking to understand circumstances and perceptions; 2) attributional errors or attributing negative parent behaviors to character traits; and 3) receptivity to parent participation and collaboration.<br>|
| Experimental: Modified DECIDE-Parent Arm<br>Up to three parent training sessions designed to help patients effectively ask questions and participate in decisions about care. | Behavioral: Modified DECIDE Parent and Provider Intervention<br>* The parent component will include up to three 60 minutes sessions. Session 1 (Decisions and Agency) is designed to increase awareness of their role in clinical interactions and encourage participation and decision making in care. Session 2 (the Who, How, and Why of Decisions) teach skills for understanding treatment decisions in terms of roles, processes, and reasons involved. Session 3 (Self-efficacy and Consolidation) encourages parents to ask questions about their adolescents' behavioral health and health care and treatment options. The provider component is designed to improve provider communication in three key areas: 1) perspective taking to understand circumstances and perceptions; 2) attributional errors or attributing negative parent behaviors to character traits; and 3) receptivity to parent participation and collaboration.<br>|
| Other: Provider Subgroup Study<br>To boost provider recruitment, we sought recommendations from a subgroup of providers. We gave each provider access to the DECIDE online training and the pre- and post-survey. | Behavioral: Modified DECIDE Parent and Provider Intervention<br>* The parent component will include up to three 60 minutes sessions. Session 1 (Decisions and Agency) is designed to increase awareness of their role in clinical interactions and encourage participation and decision making in care. Session 2 (the Who, How, and Why of Decisions) teach skills for understanding treatment decisions in terms of roles, processes, and reasons involved. Session 3 (Self-efficacy and Consolidation) encourages parents to ask questions about their adolescents' behavioral health and health care and treatment options. The provider component is designed to improve provider communication in three key areas: 1) perspective taking to understand circumstances and perceptions; 2) attributional errors or attributing negative parent behaviors to character traits; and 3) receptivity to parent participation and collaboration.<br>|
| No Intervention: Treatment as Usual<br>Control arm | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Parent Activation Measure Mental Health (P-PAM-MH): baseline | 13-item scale measures parent activation for use with parents of youth with emotional and behavioral disorders [126]. It was adapted from the original PAM. Items are scored using a 4-point Likert-type scale (1 = disagree strongly to 4 = agree strongly). Raw scores are summed and scaled from 0-100. Higher scores indicate greater activation. Cronbach alpha is 0.89. To be completed by Parents. | Baseline (TI) | 
| Parent Activation Measure Mental Health (P-PAM-MH): post-intervention | 13-item scale measures parent activation for use with parents of youth with emotional and behavioral disorders [126]. It was adapted from the original PAM. Items are scored using a 4-point Likert-type scale (1 = disagree strongly to 4 = agree strongly). Raw scores are summed and scaled from 0-100. Higher scores indicate greater activation. Cronbach alpha is 0.89. To be completed by Parents. | Immediately post intervention (T2) | 
| Communication Scale of the Kim Alliance Scale Refined (KAS-R): baseline | 4-item scale measures provider perception of parent-provider communication. Response categories include 1-never to 4 = always. Items are summed with higher scores indicating higher quality of communication. Cronbach alpha is 0.94. | Baseline (T1) | 
| Communication Scale of the Kim Alliance Scale Refined (KAS-R): post-intervention | 4-item scale measures provider perception of parent-provider communication. Response categories include 1-never to 4 = always. Items are summed with higher scores indicating higher quality of communication. Cronbach alpha is 0.94. | Immediately post intervention (T2) | 
| Perceived Efficacy in Parent-Physician Interactions (PEPPI)-Short Form: baseline | Parent assessment is 5-item scale, measures patient's confidence in ability to elicit and understand information from and communicate information to providers. Response categories are 1 = low to 10 = high. A total score is obtained by summing all individual scores. Cronbach's alpha = 0.83. To be completed by parents. | Baseline (T1) | 
| Perceived Efficacy in Parent-Physician Interactions (PEPPI)-Short Form: post-intervention | Parent assessment is 5-item scale, measures patient's confidence in ability to elicit and understand information from and communicate information to providers. Response categories are 1 = low to 10 = high. A total score is obtained by summing all individual scores. Cronbach's alpha = 0.83. To be completed by parents. | Immediately post intervention (T2) | 
| Perception of Care Quality Survey: baseline | 18-item scale measures parent's perception of care quality. Higher scores indicate perceptions of higher quality of care [125].To be completed by parents. | Baseline (T1) | 
| Perception of Care Quality Survey: post-intervention | 18-item scale measures parent's perception of care quality. Higher scores indicate perceptions of higher quality of care [125].To be completed by parents. | Immediately post intervention (T2) | 
| Parent Participation Engagement Measure (PPEM): baseline | The 5-item scale measures the frequency with which the parent engaged during clinical encounter or parent-provider interaction. Behaviors assessed include asking questions, making suggestions or sharing one's opinion or point of view, and participating in therapeutic activities. Response options are on a 5-point scale ranging from 1 = not at all to 5 = very much. Higher scores indicate greater frequency of parent engagement. Cronbach alpha = 0.88 [122]. To be completed by providers and parents. | Baseline (T1) | 
| Parent Participation Engagement Measure (PPEM): post-intervention | The 5-item scale measures the frequency with which the parent engaged during clinical encounter or parent-provider interaction. Behaviors assessed include asking questions, making suggestions or sharing one's opinion or point of view, and participating in therapeutic activities. Response options are on a 5-point scale ranging from 1 = not at all to 5 = very much. Higher scores indicate greater frequency of parent engagement. Cronbach alpha = 0.88 [122]. To be completed by providers and parents. | Immediately post intervention (T2) | 
| Parent Needs & Resources Domain of CANS | Three items from the Parent Needs & Resources Domain of the CANS were given (Involvement with Care, Knowledge, and Organization). Each question is scored 0, 1, 2, or 3. A domain score can be created by averaging the items. High scores mean more need/less strength. To be completed by Providers. | Baseline (T1) | 
| Parent Needs & Resources Domain of CANS | Three items from the Parent Needs & Resources Domain of the CANS were given (Involvement with Care, Knowledge, and Organization). Each question is scored 0, 1, 2, or 3. A domain score can be created by averaging the items. High scores mean more need/less strength. To be completed by Providers. | Immediately post intervention (T2) |