Introduction to Special Issue

Challenge and Opportunity in Children’s Mental Health Research Sharon Hodges, PhD, MBA

Children’s mental health services research is both challenged and enriched by the complex environment of services and supports that exist for children and their families. It is a context in which the structures and processes that define children’s mental health are diffused across multiple sectors and the pathways to care are unclear, unavailable, and often inappropriate for the children and families most in need of services and support.1,2 This context presents a challenging research environment because it requires the development of knowledge and understanding within diffused service settings, across multiple and often multifaceted funding and service structures, and in collaboration with multiple stakeholders and an array of public and private agencies. The complexity of the research environment in which children’s mental health research is conducted creates methodological challenges that make it difficult for researchers to study phenomena objectively and independently of the natural service delivery settings. How do we understand the functioning of children’s service systems when they are composed of so many individual and dynamic parts? How do we understand the individual components of systems when we cannot isolate them from their multiple influences and interconnections? Either way, this makes for a research environment in which there are no clear starting points, it is difficult to isolate an intervention or create a control group, and researchers cannot assume that any variables are truly independent. Yet, these issues are faced daily in children’s mental health services research. This complex research environment also offers advantages. It is rich in opportunities to build knowledge that is based on experience and context, to build evidence of what works, and provide understanding of how successful service delivery models can be adapted to meet local needs. This special issue of the Journal of Behavioral Health Services & Research (JBHS&R) on qualitative methods explores that opportunity. The goal of this special issue is to examine the process of conducting research in the real-world settings of children’s mental health and to learn more about those settings from the people who are part of them. The use of qualitative methods to build the knowledge base in children’s mental health services research is growing. Qualitative research methods are valued in developing knowledge through experience and context, in understanding multiple perspectives on an issue or topic, and in understanding the complexity in which phenomena exist.3–5 Because child-serving environments

Address correspondence to Sharon Hodges, PhD, MBA, Division of Training, Research, Education, and Training, Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612, USA. Telephone: +1-813-9744651; Fax: +1-813-9747563; Email: [email protected].

) 2007 National Council for Community Behavioral

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are inherently complex and dynamic and because they often provide multifaceted and highly specialized interventions, qualitative research methods offer opportunities for knowledge development that do not require large random samples, comparison to a control group, or interventions that can be clearly isolated. The purpose of this special issue is to offer journal readers an introduction to the range and depth of qualitative methods in the field of children’s mental health. This special issue explores the process of building an evidence base in children’s mental health using qualitative methods, addresses issues of rigor in qualitative research, and considers the contributions of specific methods to the development of knowledge, representation of multiple perspectives, and development of participatory approaches to research. Contributors to this special issue were given a difficult task. Rather than write a paper focused on either the findings of their research or on the advantages and challenges of a specific qualitative approach, the authors were asked to do both. The papers in this issue present research findings of significant interest or concern in children’s mental health and pair this with a particular methodological focus. The result of this effort is seven papers that strike a balance between topical and methodological content and explore why qualitative methods were critical to the particular research endeavor. In addition to the seven regular papers, a brief paper by Hodges et al. opens the special issue with a review of 100 presentations published in the proceedings of the Annual Research Conference sponsored by the Research and Training Center for Children’s Mental Health from 1988 to 2003.6 This review is an effort to understand the impact of qualitative methods on the field of children’s mental health. Recommendations are also provided regarding future contributions of qualitative research to the advancement of knowledge of children’s systems of care. Among the full-length papers, the issue opens with a piece that uses qualitative methods to examine how the national mandate for family participation in children’s system of care evaluations is carried out in local contexts. Family involvement is a relatively new idea in children’s mental health, and system implementers and families are challenged to find strategies that support family involvement. Jivanjee and Robinson use the constant comparative approach of grounded theory in their paper titled “Studying Family Participation in System-of-Care Evaluations: Using Qualitative Methods to Examine a National Mandate in Local Contexts”.7 The authors build a theoretical understanding of how family members and evaluators work together, the challenges they encounter, and effective strategies for meeting those challenges. This paper illustrates the iterative nature of qualitative research and how the team adapted and expanded their study in response to what they were learning. Gyamfi et al. also investigate a mandated and emerging practice in the development of children’s systems of care.8 In their paper titled “Youth and Youth Coordinators’ Perspectives on Youth Involvement in Systems of Care”, the authors use focus groups with youth and youth coordinators to explore youth involvement in system-of-care communities that are funded through the Substance Abuse and Mental Health Administration. The authors chose the focus group method to gather data because of its capacity to incorporate a diverse range of responses. In addition, the authors found the experience of sharing with others who were consumers of mental health services helped the youth feel more at ease with the research process. Findings suggest that beyond participation in youth groups, youth participation in system development is minimal. Such findings are important as efforts to engage youth in system development shift from symbolic to active involvement. “A Qualitative Study of Programs for Parents with Serious Mental Illness: Building PracticeBased Evidence” describes beginning steps that can be taken in developing an evidence base for existing programs. Nicholson et al. present findings of a consumer-informed study on the needs of parents with mental illness and their children.9 This study of seven programs that developed in diverse community contexts and service settings uses a grounded theory approach to identify shared characteristics and diversity among these programs.

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In her paper titled “A Participatory Study of School Dropout and Behavioral Health of Latino Adolescents”, Nesman maintains that because dropout of Latino adolescents has been linked to behavioral issues such as delinquency and family conflict, it is important that we develop a better understanding of cultural, social, and developmental factors that impact Latino dropout rates.10 Nesman took a participatory approach to research design with all aspects of the research development shared by a Latino advocacy organization and the research team. Data were collected using an interactive group interview format. This paper illustrates a systematic process of data collection and analysis and the usefulness of qualitative methods in developing comprehensive programs to meet the needs of Latino adolescents at risk within a particular community context. “Issues Encountered in a Qualitative Secondary Analysis of Help-Seeking in the Prodrome to Psychosis” explores an infrequent practice in health and social science research: the reuse of existing qualitative data to answer new research questions. Using transcripts of interview data initially collected for the purpose of understanding young people’s experience of a first episode of psychosis, Gladstone et al. focused this study on an entirely different set of research questions related to the help-seeking behaviors of parents in the prodrome to their children’s psychosis.11 The authors offer considerable insight on secondary analysis of qualitative data as they discuss the methodological issues and challenges they encountered, which will be instructive to researchers considering this approach. Walker and Koroloff illustrate the usefulness of qualitative methods in studying the implementation context of wraparound, a team-based planning process used frequently in children’s mental health settings.12 Their paper, titled “Grounded Theory and Backward Mapping: Exploring the Implementation Context for Wraparound”, advances a conceptual and theoretical understanding of wraparound implementation context and provides practical information to guide decision-making and policy development where wraparound is being implemented. Walker and Koroloff capture the complexity of implementation by moving their analysis beyond the program level and addressing implementation at the organizational and system levels where conditions are likely to vary considerably from one community to another.12 They are also forthright in their discussion of the perceived lack of legitimacy of qualitative methods in peer-reviewed children’s mental health journals and offer valuable suggestions for improving the fit of qualitative methods with epistemological and practical expectations in children’s mental health research. “Linking Data to Decision-Making: Applying Qualitative Data Analysis Methods and Software to Identify Mechanisms for Using Outcomes Data” is the final paper in this special issue. Patel and Riley use a case study design to examine how staff members in children’s out-of-home care programs use outcome data to inform decision-making.13 In addition, they provide an excellent discussion of how qualitative data analysis software was applied at each step of their analytic framework and use their findings to illustrate their analytic process. Overall, the papers contained in this special issue of the JBHS&R provide great examples of how to conduct research in the absence of the kind of structure that is provided by well-defined linear relationships. This has significant implications because the approaches taken in these papers suggest different ways of knowing and understanding in the field of children’s mental health.14,15 As a field, we need to explore and advance methods that integrate scientific rigor with real-world experience because these will be better suited for understanding the dynamics and complex environments of our mental heath service systems. We have developed a comprehensive and sophisticated understanding of quantitative methods. We understand how to create a logical and convincing argument from a quantitative base. We have confidence in what we’re learning. We lack a similar sophistication when it comes to qualitative methods. We often devalue and disregard qualitative contributions to our knowledge base because we have not developed a clear understanding of what constitutes evidence in qualitative work. As a field, we have to better understand the nature of qualitative evidence to use these methods to expand our knowledge base.

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We also need to develop strategies for mixed method research. Many are quick to voice support of mixed methods design but often call methods “mixed” when they are nothing more than parallel processes. There is a lack of clarity around what should be mixed, why, and how to do this systematically. How do the multiple approaches inform one another? How did you use what you learned from each of the methods to build understanding? What are the challenges of the mixed method design? As a field, we have to develop partnerships that will help us understand and intervene in the diffused and multilayered children’s mental health systems. To do that, we have to rethink our existing paradigms of expert knowledge so that we can expand our concepts of the expert knowledge and expertise. This means working toward bringing multiple perspectives into our knowledge base, including culture and gender representation, consumer, youth, and family voice. This will help us think less in terms of seeking truth as a constant that is fixed in time and more in terms of understanding that truth may change over time as it is informed by the context in which it develops. The challenges of these research issues are significant, but the strategies are processes we have already begun to implement. The field of children’s mental health needs to become more planful and strategic, more committed in our efforts to tackle these research challenges. As a field, we are in a unique position to provide leadership in meeting these challenges across the applied social sciences.

Acknowledgements I would like to thank Mario Hernandez for supporting this special issue and the application of qualitative methods in the Department of Child and Family Studies at the University of South Florida, and also Bruce Lubotsky Levin for the myriad of adjustments he made as Editor-in-Chief, from the identification of reviewers with specific qualitative expertise to the accommodation of the qualitative convention of first person narrative in the published papers, to accommodate publishing a special issue of peer-reviewed qualitative work.

References 1. U.S. Department of Health and Human Services. Mental health: a report of the surgeon general. Chapter 3: children and mental health. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. 2. The President’s New Freedom Commission on Mental Health. Achieving the promise: transforming mental healthcare in America. Final report. Rockville, MD: U.S. Department of Health and Human Services, The President’s New Freedom Commission on Mental Health; 2003. 3. Patton MQ. Qualitative research and evaluation, 3rd ed. Thousand Oaks, CA: Sage; 1998. 4. Creswell JW. Qualitative inquiry and research design: choosing among five traditions. Thousand Oaks, CA: Sage; 1998. 5. Miles M, Huberman M. Qualitative data analysis: an expanded sourcebook, 2nd ed. Thousand Oaks, CA: Sage; 1994. 6. Hodges S, Hernandez M, Pinto A, Uzzell C. The use of qualitative methods in systems of care research. Journal of Behavioral Health Services & Research. 2007;34(4):361–368. DOI 10.1007/s11414-007-9087-x. 7. Jivanjee P, Robinson A. Studying family participation in system-of-care evaluations: using qualitative methods to examine a national mandate in local contexts. Journal of Behavioral Health Services & Research. 2007;34(4):369–381. DOI 10.1007/s11414-007-9051-9. 8. Gyamfi P, Kenns-Douglas A, Medin A. Youth and youth coordinators’ perspectives on youth involvement in systems of care. Journal of Behavioral Health Services & Research. 2007;34(4):382–394. DOI 10.1007/s11414-007-9068-0. 9. Nicholson J, Hinden BR, Biebel K, Henry AD, Katz-Leavy J. A qualitative study of programs for parents with serious mental illness and their children: building practice-based evidence. Journal of Behavioral Health Services & Research. 2007;34(4):395–413. DOI 10.1007/s11414007-9063-5. 10. Nesman TM. A participatory study of school dropout and behavioral health of Latino adolescents. Journal of Behavioral Health Services & Research. 2007;34(4):414–430. DOI 10.1007/s11414-007-9082-2. 11. Gladstone BM, Volpe T, Boydell KM. Issues encountered in a qualitative secondary analysis of help-seeking in the prodrome to psychosis. Journal of Behavioral Health Services & Research. 2007;34(4):431–442. DOI 10.1007/s11414-007-9079-x. 12. Walker JS, Koroloff N. Grounded theory and backward mapping: exploring the implementation context for wraparound. Journal of Behavioral Health Services & Research. 2007;34(4):443–458. DOI 10.1007/s11414-007-9054-6. 13. Patel VN, Riley AW. Linking data to decision-making: applying qualitative data analysis methods and software to identify mechanisms for using outcome data. Journal of Behavioral Health Services & Research. 2007;34(4):459–474. DOI 10.1007/s11414-007-9064-4. 14. Upshur REG. The status of qualitative research as evidence. In: Morse J, Swanson J, Kuzel A, eds. The Nature of Qualitative Evidence. Thousand Oaks, CA: Sage; 2001:5–26. 15. Office of Behavioral and Social Sciences Research. Qualitative methods in health research: opportunities and considerations in application and review. NIH Publication No. 02-5046. Bethesda, MD: National Institutes of Health; 2001.

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