Our goal with this review was to identify effective methods of improving families’ engagement and retention in parent and child mental health programs. Despite the critical importance of this area of research, the empirical literature is relatively sparse. Over the last three decades seventeen randomized-controlled trials of engagement interventions have been reported in the context of child and family mental health programs. Seven general engagement approaches were tested: appointment reminders; brief initial engagement discussions; family systems engagement methods; structural or other adaptations to program delivery; financial incentives; enhanced family support; and motivational interviewing. Studies varied in terms of populations (e.g. depressed mothers, families with youth with conduct problems) and treatment settings (e.g. clinics, neighborhood centers). However, most of these studies tested engagement interventions in a particular context (outpatient mental health clinics serving families with children with conduct problems), with few trials involving families seeking treatment for other problems or seeking preventive intervention services. The majority of the trials were small efficacy studies, with only a few investigations approaching effectiveness trials. Very few of these engagement interventions have been replicated. Despite these limitations, some consistent patterns emerged in this literature. Given the limited populations, contexts, and mental health programs in which these engagement interventions were tested, however, it is difficult to say whether any of the interventions have generalizability. While it is worthwhile to synthesize the findings to date, there is significant need to further develop, test, and replicate tests of engagement interventions.
Four of the seven general approaches demonstrated success in improving families’ engagement in treatment programs: brief early treatment engagement discussions, family systems approaches, enhancing family support and coping, and motivational interviewing. The four approaches all shared components that are likely to be “active ingredients” leading to improved engagement and retention. In each of these approaches, the provider directly elicited and addressed engagement issues with the family during the intervention process. Providers who effectively engaged families typically identified the potential benefits of services, discussed family expectations for treatment process and outcomes, and worked with the family to develop a plan to address practical (e.g. scheduling, transportation) and psychological engagement challenges (e.g. other stressors, family member’ resistance to treatment). Although the format varied across these different studies, in general, successful engagement methods were (a) individualized and addressed families’ particular needs, concerns, and barriers; (b) intensive, addressing engagement at multiple time-points, with multiple family members, and in multiple ways as families progressed in treatment; (c) developed from a strong theoretical framework, and (d) integrated seamlessly into the underlying treatment or prevention program structure.
Taking a personalized and collaborative approach to address families’ engagement challenges may reduce families’ ambivalence about treatment (Miller and Rollnick 2002
) and convey understanding and respect for families’ struggles to remain in treatment, which strengthens provider-family alliance. Miller and Prinz’s (2003)
finding that mismatches in families’ pre-treatment expectations about the type and structure of treatment they need and what they received led families to drop out at greater rates, highlights the potential benefit of assessing the full scope of family concerns about treatment at the outset and then adapting and matching to programs that address these concerns. This type of assessment and tailoring of program delivery to specifically fit individual families’ needs has not been explicitly tested in a randomized-controlled trial. Korfmacher et al.’s (1999)
finding that mothers participated in a home visiting preventive intervention at a greater rate when the program was delivered by nurses compared to paraprofessionals also supports the benefit of matching family expectations and goals to the way programs are delivered; mothers’ needs in pregnancy and infancy were better served by providers with greater legitimacy in addressing issues of physical health, a major concern of pregnant women and parents of infants. The findings from the trials reviewed here suggest that adapting program delivery has considerable promise for improving family participation in services.
Overall, only a few of the engagement interventions were shown to improve families’ rates of completing programs, even among programs with an expected short duration (i.e. 5–8 sessions). Improving families’ completion rates is important for maximizing the impact of interventions; if families do not receive adequate doses of treatment, the positive benefits are likely to be reduced. The three most promising clinical approaches that were successful in keeping families actively participating through the recommended course of treatment were Szapocznik’s et al. SSSE intervention (1988), Miller and Prinz’s (2003)
adjunctive family support intervention, and interventions utilizing motivational interviewing adapted to address engagement issues (Nock and Kazdin 2005
; Grote et al. 2009
). These interventions are particularly promising to test in future research with other settings and populations, as they are structured, have been manualized, and could easily be adapted for a variety of programs.
In contrast to the intensive and integrated methods described above, simple approaches (e.g. phone reminders) or where engagement was addressed indirectly showed modest short-term and no long-term benefits. For example, changes to the way in which families are invited to engage in intervention (i.e. through offering assessments prior to enrollment, group versus individual family treatment, or by being paid to attend sessions) did not affect on-going engagement or retention.
There are some populations for which engagement interventions have not been developed and tested, or are underdeveloped. Eleven of the seventeen studies tested engagement interventions that were specifically developed for or tested in clinics serving families with children with conduct problems; they face particular types of adversities and challenges that may not be relevant for families seeking other types of treatment (Kazdin 1996
). It will be important to extend engagement intervention research and to replicate these intervention approaches for a wider range of parent and child mental health concerns. In addition, engagement strategies have been tested primarily in treatment (clinic) settings. Only three of the seventeen studies tested engagement interventions in the context of prevention programs; two of these trials tested relatively simple methods (i.e. payment, group sessions, offering assessments prior to program) that were ineffective. Prevention programs face different challenges when trying to engage and retain families in programs given that families are less likely to perceive a need for service, the duration of programs tends to be longer (e.g. lasting several years), and clear benefits may only emerge much later (Becker et al. 2002
; Spoth and Redmond 2000
). Different engagement strategies across these two settings may be needed; it is currently unclear whether effective methods for clinic-based interventions will work for families in long-term prevention programs. The more intensive, personalized approaches found to be effective with families seeking outpatient treatment have yet to be tested in prevention settings. In many prevention programs, particularly those that are offered widely or universally, intensive approaches may not be feasible given the cost and needed resources. However, some personalized assessment of expectations and needs with tailoring of the prevention program may lead to greater engagement and participation and improve the public health benefit of these programs.
One neglected avenue is in developing and testing interventions that address engagement factors at multiple levels of service systems (McCurdy and Daro 2001
). Studies examining predictors of family engagement have found that provider attributes (e.g. cultural competence, communication style) and program characteristics (e.g. program inflexibility, staff turnover, service locations) may contribute to families’ decisions to seek out and engage in mental health services. Interventions reviewed here were largely focused on altering provider-family interactions or providing additional supportive services to families in conjunction with treatment. The exception was the trial testing the impact of varied provider background in delivering a home visiting preventive intervention, which showed that nurses were more effective than paraprofessionals in engaging and retaining pregnant women and parents of young children (Korfmacher et al. 1999
). Interventions in which all program support staff (not just clinicians) are trained on engagement barriers and strategies, or interventions to address systems or program barriers (e.g. duration between initial contact and first appointment, crowded waiting rooms, lengthy intake procedures, complex payment structures) may also facilitate family engagement (Korfmacher et al. 2008
; McKay et al. 2004
; Staudt 2003
). These approaches show promise in quasi-experimental studies but have not yet been tested in RCTs (McKay et al. 2004
; Rotheram-Borus et al. 1996
The seventeen studies reviewed here tested engagement interventions using rigorous research designs (RCT). Strengths across these studies include: developing engagement interventions based in theoretical frameworks; clearly operationalizing the intervention; and assessing fidelity. In particular, Szapocznik et al.’s (1988)
and Nock and Kazdin’s (2001
) programs of research are notable for having a strong theoretical model and pilot data to develop their engagement interventions, designing their studies to isolate the impact of the intervention approach, and for testing and reporting their results following CONSORT and APA evidentiary guidelines. Three engagement interventions were replicated in separate trials [Prinz and Miller’s family support intervention (1994; Miller and Prinz 2003
); McKay’s engagement interview (McKay et al. 1996a
), Szapocznik’s SSSE intervention (Szapocznik et al. 1988
; Santisteban et al. 1996
; Coatsworth et al. 2001
)], and the latter two were tested in small community effectiveness trials. This type of programmatic research provides strong evidentiary foundations and confidence that the approach will be effective if applied outside of research settings.
Several methodological limitations impede our ability to apply these findings to practice. We set our eligibility criteria in order to evaluate interventions tested with rigorous designs; however, the relatively small number of studies meeting these criteria, and the range in populations and settings across these few studies, make it difficult to draw broad conclusions. In addition, the bulk of these studies were efficacy trials, with small sample sizes (i.e. most averaged 30–75 families per condition). Efficacy trials, typically conducted in controlled contexts with a great deal of investigator involvement, identify promising engagement strategies that have a clear impact for specific populations and settings. However, these interventions need to be replicated and tested in larger effectiveness trials, in order to understand the impact under “real-world” conditions with a greater range in providers, populations, and settings. The relatively small number of eligible studies, and small samples in these efficacy trials, limit statistical power and generalizability of findings.
As this area of research moves forward, it is crucial that engagement methods be evaluated with longer follow-up periods. Most studies assessed early engagement in short-term treatment programs (i.e. 5–8 sessions); only the SSSE intervention, motivational interviewing intervention, and utilizing providers with experience matched to specific population needs (i.e. nurses in prenatal home visitation) demonstrated evidence for long-term retention. We know very little about how to facilitate family involvement across long periods of intervention. We may need different engagement strategies to keep families actively involved in lengthy mental health interventions and prevention programs (Kazdin 1996
There was wide variation in the extent to which these studies met evidentiary standards for reporting on RCTs. Operational definitions of engagement and retention measures are sometimes unclear. Two studies utilizing RCT designs were not included in this review, for example, because they assessed “attendance” without defining the term, making it impossible to determine the impact on ongoing engagement in services (Costantino et al. 2001
; Tait et al. 2004
). In addition, some studies provided insufficient information about sample characteristics, which limits our ability to specify the population that benefits and to assess generalizability. Finally, investigators frequently did not include adequate information about the timing of recruitment and randomization procedures. These elements are important for several reasons: families who are consented prior to randomization may be more likely to drop out because they are unhappy with their assignment, potentially resulting in differences across conditions; and when randomization is not masked or providers are involved in randomization, they may subtly affect group assignments and be influenced by knowledge of characteristics used in the randomization procedure (Olds et al. 2007
). These sources of bias may lead to differential drop out across conditions before the intervention is introduced, making it difficult to assess the true impact of the intervention. Moreover, wide variation in both characteristics and quality of these studies, and the relatively small database, limits ability to assess overall impact of engagement interventions quantitatively (i.e. with meta-analysis) with any degree of confidence.
In this review, we identified promising strategies to improve family engagement and retention in mental health intervention and prevention programs. Engaging and retaining families in interventions is a critical translational issue for evidence-based programs, and an important issue to address for programs already in community practice. Systematic research focused on theoretically-based, well-defined and operationalized engagement interventions is needed to strengthen the impact of mental health interventions for vulnerable children and families.