Family Involvement in Child Mental Health: Exploring Policies and Practices from Community-Based Mental Health Centers
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| Title: | Family Involvement in Child Mental Health: Exploring Policies and Practices from Community-Based Mental Health Centers |
|---|---|
| Language: | English |
| Authors: | Sheila Sjolseth (ORCID |
| Source: | Child & Youth Care Forum. 2026 55(1):177-204. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 28 |
| Publication Date: | 2026 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | Family Involvement, Children, Mental Health, Client Characteristics (Human Services), Mental Health Programs, Community Centers, Policy, Resilience (Psychology), Barriers, Program Implementation, Well Being, Interdisciplinary Approach, Cooperation, Labor Force Development |
| Geographic Terms: | Alabama |
| DOI: | 10.1007/s10566-025-09872-6 |
| ISSN: | 1053-1890 1573-3319 |
| Abstract: | Background: Outlined by the social organizational theory of action and change, community organizations such as community-based mental health (CBMH) centers play a crucial role in improving child mental health outcomes. However, the effectiveness of CBMH center policies in supporting families and bolstering family resilience during treatment remains underexplored. Objective: This dual-site, multi-informant qualitative study examined CBMH centers' policies and related practices around family support and involvement during child mental health treatment in Alabama Methods: A content analysis was conducted using two data sources: (a) CBMH center policies, and (b) interviews with CBMH policy administrators Results: The theory-driven analysis revealed that 6% of the policy textual data aligned with the family resilience framework. Thematic analysis of transcribed interviews identified barriers to family-centered care, complexities in managing policy dynamics, and recommendations for improvement. Key barriers included workforce challenges, privacy regulations, and insurance restrictions. Administrators emphasized the need for comprehensive family-centered models, streamlined consent processes, and improved staff training Conclusions: The analysis revealed notable gaps in addressing family resilience within CBMH policies and practices. By addressing identified barriers and implementing recommendations, CBMH centers can create a more family-centered approach that promotes family well-being and optimizes child mental health outcomes. This study highlights the importance of prioritizing family resilience through interdisciplinary collaboration, addressing local context, enhancing workforce development, and leveraging external opportunities to facilitate family-inclusive treatment. |
| Abstractor: | As Provided |
| Entry Date: | 2026 |
| Accession Number: | EJ1505872 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwFjprh3eeBzrJVvUqPZQAoUAAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDKNdA62NIAbf6tQEHgIBEICBmz7ALmcN2ANtH3rGuUfTBvONbXY8m3tOXzVyE22wEi4xhpvt4u6GylggPk5aYFrEheAk-U-wmlMoCjSKoJvkWTjKj_Go4UtjKIhWqOZA3kAiAeCMlHWbaeQ-k2M2ZrygVjTB5uq_45X6v0LLmD0pBY4xjeRA5142AtNp3XNz7LBAm4TIQgz4cCv-_UhnLaQ0BcLCQf5s_ZVA4HjZ Text: Availability: 1 Value: <anid>AN0191453681;5jr01feb.26;2026Feb11.04:54;v2.2.500</anid> <title id="AN0191453681-1">Family Involvement in Child Mental Health: Exploring Policies and Practices from Community-Based Mental Health Centers </title> <p>Background: Outlined by the social organizational theory of action and change, community organizations such as community-based mental health (CBMH) centers play a crucial role in improving child mental health outcomes. However, the effectiveness of CBMH center policies in supporting families and bolstering family resilience during treatment remains underexplored. Objective: This dual-site, multi-informant qualitative study examined CBMH centers' policies and related practices around family support and involvement during child mental health treatment in Alabama Methods: A content analysis was conducted using two data sources: (a) CBMH center policies, and (b) interviews with CBMH policy administrators Results: The theory-driven analysis revealed that 6% of the policy textual data aligned with the family resilience framework. Thematic analysis of transcribed interviews identified barriers to family-centered care, complexities in managing policy dynamics, and recommendations for improvement. Key barriers included workforce challenges, privacy regulations, and insurance restrictions. Administrators emphasized the need for comprehensive family-centered models, streamlined consent processes, and improved staff training Conclusions: The analysis revealed notable gaps in addressing family resilience within CBMH policies and practices. By addressing identified barriers and implementing recommendations, CBMH centers can create a more family-centered approach that promotes family well-being and optimizes child mental health outcomes. This study highlights the importance of prioritizing family resilience through interdisciplinary collaboration, addressing local context, enhancing workforce development, and leveraging external opportunities to facilitate family-inclusive treatment.</p> <p>Keywords: Child mental health; Policy; Family resilience; Qualitative content analysis; Community-based mental health centers; Medical and Health Sciences Public Health and Health Services Studies in Human Society Policy and Administration</p> <p>Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10566-025-09872-6.</p> <p>Child mental health challenges continue to rise, with increasing risks for negative outcomes across the United States (Chavira et al., [<reflink idref="bib9" id="ref1">9</reflink>]; Oblath et al., [<reflink idref="bib39" id="ref2">39</reflink>]). Although exact prevalence rates of child mental health illnesses are difficult to determine, an increase in the rate of child externalizing problems was documented between 2018 and 2020, rising from approximately 32% to 56% of children under the age of 18 (Rosen et al., [<reflink idref="bib45" id="ref3">45</reflink>]). As children continue to be at risk for negative mental health outcomes (e.g., anxiety, depression), identifying protective family processes and developing or maintaining family resilience are critically important given their links to positive child development and mental health outcomes (Masten, [<reflink idref="bib31" id="ref4">31</reflink>]). Furthermore, healthy, prepared families are positioned to provide ongoing support after treatment has concluded. Supportive family processes and family resilience can be strengthened through systematic investments by family members, supportive others, and community resources, a process Walsh ([<reflink idref="bib58" id="ref5">58</reflink>]) refers to as a multilevel system of resilience promotion. In line with this resilience promotion framework, community-based mental health (CBMH) centers are positioned to bolster family resilience and facilitate positive child outcomes during critical windows of need (Puma et al., [<reflink idref="bib43" id="ref6">43</reflink>]).</p> <p>Within their communities, CBMH centers are responsible for providing accessible and culturally sensitive mental health care to individuals. They often rely on federal and state government funding, grants, and private donations to provide vital services to community members in need. Specifically, CBMH centers have an opportunity to improve child mental health outcomes by (a) building child resilience (i.e., a child's capacity to navigate problems or challenges successfully) and (b) bolstering family resilience (i.e., the ability of the family system to maintain effective functioning or recalibrate to resume family functioning during times of stress) (Masten &amp; Motti-Stefanidi, [<reflink idref="bib32" id="ref7">32</reflink>]; Walsh, [<reflink idref="bib58" id="ref8">58</reflink>]). In other words, a local CBMH center can be a key contributor to a community's multilevel system of resilience promotion.</p> <p>Despite the recognized importance of family involvement in child mental health treatment, a significant knowledge gap exists regarding whether, and how, CBMH centers systematically engage families in care. While previous research has established the value of family-centered approaches in improving child outcomes (Foster et al., [<reflink idref="bib19" id="ref9">19</reflink>]), limited attention has been given to how organizational policies either facilitate or hinder family engagement in community-based settings. This gap is particularly concerning given the critical role these centers play in community mental health provision. The dearth of research on the ways in which CBMH policies and practices facilitate (or fail to facilitate) family engagement among youth in their care impedes the ability to understand how such family engagement may relate to youth outcomes.</p> <p>By examining both written policies and administrator perspectives, this study makes a unique contribution to the field by (<reflink idref="bib1" id="ref10">1</reflink>) documenting the degree to which family resilience principles are incorporated into CBMH center policies, (<reflink idref="bib2" id="ref11">2</reflink>) identifying barriers to family-centered care from the administrative perspective, and (<reflink idref="bib3" id="ref12">3</reflink>) illuminating potential pathways for policy improvement that could strengthen family systems during child mental health treatment. This dual-source approach provides a comprehensive understanding of both the current status of family-centered policies and the practical challenges that administrators face during implementation. Guided by the family resilience framework (Walsh, [<reflink idref="bib57" id="ref13">57</reflink>]) and the social organization theory of action and change (Mancini et al., [<reflink idref="bib30" id="ref14">30</reflink>]), this study fills this gap by examining how CBMH center policies explicitly and implicitly support families when a child is seeking mental health treatment.</p> <p>Table 1 Family resilience framework (Walsh, [<reflink idref="bib57" id="ref15">57</reflink>])</p> <p> <ephtml> &lt;table rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Framework areas&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Belief systems&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Making meaning of adversity&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Relational view of resilience&lt;/p&gt;&lt;p&gt; Normalize, contextualize distress&lt;/p&gt;&lt;p&gt; Sense of coherence: view crisis as meaningful, comprehensive, manageable challenge&lt;/p&gt;&lt;p&gt; Facilitative appraisal: explanatory attributions; future expectations&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Positive outlook&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Hope, optimistic bias; confidence in overcoming challenges&lt;/p&gt;&lt;p&gt; Encouragement; affirm strengths, focus on potential&lt;/p&gt;&lt;p&gt; Active initiative and perseverance&lt;/p&gt;&lt;p&gt; Master the impossible; accept what can't be changed; tolerate uncertainty&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Transcendence and spirituality&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Larger values, purpose&lt;/p&gt;&lt;p&gt; Spirituality: faith, contemplative practices, community; connection with nature&lt;/p&gt;&lt;p&gt; Inspiration: envision possibilities, aspirations; creative expression; social action&lt;/p&gt;&lt;p&gt; Transformation: learning, change, and positive growth from adversity&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Organizational processes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Flexibility&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Rebound, adaptive change to meet new challenges&lt;/p&gt;&lt;p&gt; Reorganize, reestablish continuity, dependability, predictability&lt;/p&gt;&lt;p&gt; Strong authoritative leadership: nurture, guide, protect&lt;/p&gt;&lt;p&gt; Varied family forms: cooperative parenting/caregiving teams&lt;/p&gt;&lt;p&gt; Couple/coparent relationship: mutual respect; equal partners&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Connectedness&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mutual support, teamwork, and commitment&lt;/p&gt;&lt;p&gt; Respect individual needs, differences&lt;/p&gt;&lt;p&gt; Seek reconnection and repair grievances&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mobilize Social and Economic Resources&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Recruit extended kin, social, and community supports; models and mentors&lt;/p&gt;&lt;p&gt; Build financial security; navigate stressful work/family challenges&lt;/p&gt;&lt;p&gt; Transactions with larger systems: access institutional, structural supports&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Communication&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Clarity&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Clear, consistent messages, information&lt;/p&gt;&lt;p&gt; Clarify ambiguous situation; truth seeking&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Open emotional sharing&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Painful feelings (sadness, suffering, anger, fear, disappointment, remorse)&lt;/p&gt;&lt;p&gt; Positive interactions (love, appreciation, gratitude, humor, fun, respite)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Collaborative problem solving&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Creative brainstorming; resourcefulness&lt;/p&gt;&lt;p&gt; Share decision-making; repair conflicts; negotiation, fairness&lt;/p&gt;&lt;p&gt; Focusing on goals; concrete steps; build on success; learn from setbacks&lt;/p&gt;&lt;p&gt; Proactive stance; preparedness, planning, prevention&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <hd id="AN0191453681-2">Importance of Family Resilience for Children</hd> <p>Families have the potential to be a critical source of assistance and intervention for children experiencing mental health difficulties (Foster et al., [<reflink idref="bib19" id="ref16">19</reflink>]). Families serve as the most proximal sphere of support during child development and contribute to multiple aspects of a child's well-being (Okwori, [<reflink idref="bib40" id="ref17">40</reflink>]; Walsh, [<reflink idref="bib57" id="ref18">57</reflink>]). Positive outcomes are more likely to occur when the family has the skills and knowledge to support their children during times of stress or challenge. Family resilience includes reciprocal, synergetic action, including resources families can call upon within their family and community (Walsh, [<reflink idref="bib57" id="ref19">57</reflink>]). The family resilience framework (Walsh, [<reflink idref="bib57" id="ref20">57</reflink>]), a clinical care framework for supporting families undergoing crisis or chronic stress, identifies key family processes associated with building and maintaining family resilience, organized under three primary domains: belief systems, organizational processes, and communication (see Table 1). These key processes are modifiable, that is, they can be learned and implemented by the family at any point, although many families need external support to establish and develop their skills when implementing these processes.</p> <p>The family resilience framework's three core domains (Walsh, [<reflink idref="bib57" id="ref21">57</reflink>])—belief systems, organizational processes, and communication—provide a structured lens for examining how CBMH center policies may support or hinder family functioning during child mental health treatment. Belief systems encompass meaning-making processes that help families contextualize challenges, maintain hope, and connect to larger values or spiritual resources that sustain them during difficult times. Organizational processes include the family's capacity for flexibility in response to challenges, maintaining connectedness despite stress, and mobilizing resources both within and outside the family system. Communication processes involve clarity in information sharing, open emotional expression, and collaborative problem-solving approaches. By examining CBMH policies through these three domains, the extent to which formal systems and support these aspects of family resilience can be identified. This approach is particularly relevant for this study as it allows for systematic analysis of how policies may enhance or constrain families' ability to develop these resilience-promoting processes when navigating the often complex and stressful experience of supporting a child with mental health needs (Foster et al., [<reflink idref="bib19" id="ref22">19</reflink>]; Walsh, [<reflink idref="bib57" id="ref23">57</reflink>]).</p> <hd id="AN0191453681-3">The Role of CBMHs in Community Capacity and Resilience Building</hd> <p>The community is considered by some as holding the "ultimate responsibility and authority for an individual's care" (Bentley, [<reflink idref="bib4" id="ref24">4</reflink>], p. 2). Community resilience regards how communities strengthen individuals and families, including how communities address widespread challenges through coordination and capacity building (Kirmayer et al., [<reflink idref="bib25" id="ref25">25</reflink>]). With this understanding, Ungar ([<reflink idref="bib53" id="ref26">53</reflink>]) firmly placed responsibility on the community and posited that community resilience occurs when individuals can "access the resources they need to sustain well-being... in ways that are meaningful" (p. 1743). Community organizations, such as CBMHs, are vital to this effort.</p> <p>The social organization theory of action and change provides a critical theoretical lens for examining CBMH center policies in relation to family resilience. This theory positions formal systems as key contributors to community capacity building through their organizational structures and policies (Mancini et al., [<reflink idref="bib30" id="ref27">30</reflink>]). Crucially, these formal systems do not operate in isolation but interact with informal networks to create a comprehensive support infrastructure for families (Mancini &amp; Bowen, [<reflink idref="bib29" id="ref28">29</reflink>]). Ruiz-Casares et al. ([<reflink idref="bib46" id="ref29">46</reflink>]) noted that community resilience is grounded in its physical and social systems or, as stated by Mancini and Bowen ([<reflink idref="bib29" id="ref30">29</reflink>]), in informal networks and formal supports.</p> <p>Formal systems, such as CBMH centers, can contribute to community resilience and, in turn, family resilience by providing diverse resources and supports and creating partnerships with other formal systems to promote service provision and community care (Ruiz-Casares et al., [<reflink idref="bib46" id="ref31">46</reflink>]). Underlying formal systems are the policies and procedures that guide the organization's mission and work (Mancini et al., [<reflink idref="bib30" id="ref32">30</reflink>]; Murray &amp; Zautra, [<reflink idref="bib36" id="ref33">36</reflink>]).</p> <p>Policies serve as the operational blueprint for how CBMH centers translate priorities into practice—they define goals and values, allocate resources, establish procedures, and shape interactions with consumers and their families (Kilonzo &amp; Ojebode, [<reflink idref="bib24" id="ref34">24</reflink>]; Murray &amp; Zautra, [<reflink idref="bib36" id="ref35">36</reflink>]). An analysis of CBMH center policies through this theoretical lens provides insight into how these organizations systematically structure their support for families in ways that either enhance or inhibit family resilience.</p> <p>The importance of formal systems is illustrated in a qualitative study on families during childhood cancer treatment, where 88% of parents identified assistance from the treatment team as critical for a family-resilient response, while 48% cited community support and 32% mentioned workplace support as essential (McCubbin et al., [<reflink idref="bib34" id="ref36">34</reflink>]). Parents reported that informal and formal supports were necessary to help them overcome logistical concerns (i.e., lack of care for siblings and transportation) in accessing treatment as well as providing emotional support and encouragement.</p> <p>The theory suggests that effective policies would explicitly recognize the interconnected nature of formal and informal support, create mechanisms for family engagement, and allocate resources toward strengthening family systems (Mancini et al., [<reflink idref="bib30" id="ref37">30</reflink>]). This theoretical foundation provides a clear rationale for studying CBMH policies: If these organizations are to fulfill their potential as essential contributors to community resilience and, by extension, family resilience, their policies must be structured to recognize and support family systems rather than focusing exclusively on individual treatment.</p> <hd id="AN0191453681-4">Child Mental Health and the Need for a Multilevel System of Resilience Promotion</hd> <p>Prior to the pandemic, prevalence rates for children diagnosed with depression or other mental health concerns ranged from 8 to 12 million (Centers for Disease Control &amp; Prevention, [<reflink idref="bib8" id="ref38">8</reflink>]), and mental health concerns for children and adolescents were increasing (Tall &amp; Biel, [<reflink idref="bib51" id="ref39">51</reflink>]). Furthermore, Cole et al. ([<reflink idref="bib11" id="ref40">11</reflink>]) noted that 75%–80% of children requiring mental health treatment do not access help. Structural and personal barriers that prevent families from accessing care for their children include a shortage of providers, restricted access to mental health services in their area, insurance restrictions, and/or limited financial resources (Bartlett &amp; Stratford, [<reflink idref="bib3" id="ref41">3</reflink>]; Prokosch et al., [<reflink idref="bib42" id="ref42">42</reflink>]).</p> <p>These disparities and challenges were likely exacerbated by the COVID-19 pandemic. In 2021, the American Academy of Pediatrics declared a national state of emergency for children's mental health (American Academy of Pediatrics, [<reflink idref="bib2" id="ref43">2</reflink>]). Moreover, research on previous pandemics has found that children living through periods of isolation struggled for more than nine years after the pandemic had ended (Loades et al., [<reflink idref="bib28" id="ref44">28</reflink>]). With enforced quarantining, a child was five times more likely to warrant mental health treatment (Loades et al., [<reflink idref="bib28" id="ref45">28</reflink>]). To provide solutions to these problems, Masten and Motti-Stefandidi ([<reflink idref="bib32" id="ref46">32</reflink>]) and Walsh ([<reflink idref="bib58" id="ref47">58</reflink>]) indicated that building family resilience was both necessary and a multilevel responsibility. In other words, to support child mental health, formal systems serving children and adolescents need to support families systematically.</p> <hd id="AN0191453681-5">Connection of CBMH Centers to Family Resilience Promotion</hd> <p>In the United States, CBMH centers receive state and federal funding to provide community mental health services and are recognized as organizations with the potential capacity to improve child outcomes (e.g., improved mental health) and family resilience through advocacy and service provision (e.g., providing family therapy, psychoeducation, and multifamily support groups) (Dixon &amp; Goldman, [<reflink idref="bib13" id="ref48">13</reflink>]). Nevertheless, little is known about such centers' efforts to engage families in care. Garland et al. ([<reflink idref="bib21" id="ref49">21</reflink>]) acknowledged the difficulty in studying CBMH center effectiveness and expressed the importance of expanding federal and state policies to guide care systems in meeting child mental health needs. Given the various challenges in improving child mental health treatment, Garland et al. recommended that, moving forward, organizations should consider evidence-based principles with respect to providing quality family services supported by strong policy.</p> <hd id="AN0191453681-6">Role of Social Policy</hd> <p>Although addressing societal problems via policy present steep challenges, multiple experts agree that policies define mental health services and are critical in structuring mental health treatment options for children and families (Callaghan et al., [<reflink idref="bib6" id="ref50">6</reflink>]). Historically, policies have been levers to improve mental health services. For example, previous policy reforms deinstitutionalized mental health services by forming CBMH centers (Dixon &amp; Goldman, [<reflink idref="bib13" id="ref51">13</reflink>]). To account for the cultural, social, and economic factors contributing to increasing barriers to care, it is important first to define the current focus and boundaries of policies in this area.</p> <p>Globally, only a few countries have adopted national mental health policies. The United States does not have a federal child mental health policy. Nevertheless, empirical research has informed and propelled national conversations about child mental health policies. For example, an analysis of child mental health policies across Canada found that only four of the 10 provinces had a child mental health policy or plan (Kutcher et al., [<reflink idref="bib27" id="ref52">27</reflink>]). Additionally, the variability of content and guidance in the policies were inconsistent, and an overall guiding approach to child mental health treatment was missing. Informed by those findings, Canadian government representatives began continued conversations on developing a national child mental health policy, with Ontario officials revising their comprehensive child mental health plan to address the analysis. As shown by this example, research-informed conversations on current policies can inform national policy development and continued improvement. Considering the importance of a multilevel system of resilience, this policy analysis can inform the conversation on the inclusion of families and resources to support family processes in child mental health policy, which, in turn, could bolster family resilience.</p> <hd id="AN0191453681-7">Analysis of CBMH Center Policies with Administrator Insight</hd> <p>Generally, policy analysis reviews current policies for achieving intended outcomes (e.g., economic well-being, quality healthcare; Kilonzo &amp; Ojebode, [<reflink idref="bib24" id="ref53">24</reflink>]). It identifies resources, supports, and systemic barriers, and then findings are used to formulate conclusions about effectiveness or requirements for policy development. While many researchers and practitioners have called for a change in existing policies and the establishment of a national child mental health policy, the current literature has not ascertained what CBMH center policies are currently in place and how they might already be inclusive of family engagement and, ultimately, family resilience promotion. A logical first step toward capturing the current status is a content analysis of local CBMH center policies for general trends and a specific understanding of the involvement and integration of families in care.</p> <p>Integrating stakeholder perspectives, such as those of policy administrators, can provide depth and nuance to the policy analysis and help identify areas for policy improvement (Clemons &amp; McBeth, [<reflink idref="bib10" id="ref54">10</reflink>]). Policy development scholar Deborah Stone has called for including stakeholder perspectives (e.g., those administering policies) in the assessment of policy development via focus groups, interviews, and participatory research to more clearly understand areas for improvement (van Ostaijen &amp; Jhagroe, [<reflink idref="bib54" id="ref55">54</reflink>]). As an example, when considering policy-focused studies, Kolko et al. ([<reflink idref="bib26" id="ref56">26</reflink>]) examined the usage and quality of outpatient mental health services for children in the child welfare system and found a lack of consistency across service agencies. In this multimethod study, ratings and interviews informed by administrator perspectives contributed to research findings that identified policy improvement areas (e.g., improvements to existing services). The inclusion of the administrator perspective also supported the design of recommendations to create a more collaborative treatment process and increase the range and accessibility of services. Thus, this current analysis also included the perspectives of the CBMH center policy administrators.</p> <hd id="AN0191453681-8">The Present Study</hd> <p>This study is positioned to advance the field of child mental health by examining CBMH center policies through a family resilience lens. In accordance with best practices, both written <emph>policies and guidance documents</emph> and <emph>administrator experiences</emph> were accounted for in this content analysis. Data were collected in Alabama, a state with demonstrated child mental health care needs and the infrastructure and potential capacity to serve (e.g., all counties are assigned a child-focused CBMH center). Alabama is ranked 45th in U.S. child well-being (The Annie E. Casey Foundation, [<reflink idref="bib52" id="ref57">52</reflink>]), with 1 in 5 children, from 6 to 17 years old, experiencing a mental health disorder each year (National Alliance on Mental Illness, [<reflink idref="bib37" id="ref58">37</reflink>]). While it is difficult to ascertain exactly how many children warrant mental health services, as many children go undiagnosed, Alabama provided an opportunity to look across CBMH centers, specifically their policies in place to serve children, as a first step. This exploratory qualitative study aimed to understand the degree to which CBMH center policies in Alabama explicitly involve families when their child undergoes mental health treatment by conducting a content analysis of (a) extant CBMH policies around family involvement and family resilience and (b) administrator interviews focused on CBMH center policies, especially with respect to family involvement, implementation barriers, and policy needs.</p> <p>The results will inform future policy development and research by capturing viewpoints and evidence through document and interview analysis. Two main questions guided the content analysis of policy documents and interviews.</p> <hd id="AN0191453681-9">Research Questions</hd> <p></p> <ulist> <item> As evidenced through the review of CBMH center policy and guidance documents, how do policies engage families (e.g., caregivers, siblings) in the child's treatment plan, whether through standard treatment-related actions (e.g., assessment, in-take, billing, discharge) or family-specific services (e.g., parent education, nutritional assistance)?</item> <p></p> <item> When considering how to leverage policies to support family resilience for families while their child is undergoing mental health treatment, how do CBMH administrators view (a) the effectiveness of current policies, (b) whether and how extant policies need revision, and (c) barriers to developing and implementing effective policies?</item> </ulist> <p>While qualitative analyses do not preclude proposing hypotheses, this study deliberately employed an exploratory approach given the substantial knowledge gap in how CBMH centers systematically engage families. This methodological choice allowed patterns to emerge organically from the data without the constraints of predetermined hypotheses, while still being informed by the theoretical frameworks.</p> <hd id="AN0191453681-10">Method</hd> <p></p> <hd id="AN0191453681-11">Overview of the Present Study</hd> <p>Qualitative content analysis, henceforth referred to as content analysis, is an analytical process used with visual, spoken, or written materials to capture phenomena (Downe-Wamboldt, [<reflink idref="bib14" id="ref59">14</reflink>]; Sandelowski, [<reflink idref="bib47" id="ref60">47</reflink>]). This method allows researchers to distill large amounts of textual data, in this case, documents and interviews, into content-related categories and identify patterns. For the current study, the research questions were addressed in two phases using different variations of content analysis. Phase 1 addressed research question 1 (policy and guidance documents) through a <emph>theory-informed content analysis</emph> approach, using the family resilience framework (Walsh, [<reflink idref="bib57" id="ref61">57</reflink>]) as a lens through which to identify (a) manifest content and (b) latent content through deductive coding (see Supplemental Information). Phase 2 addressed research question 2 (CBMH administrator interviews) via a <emph>thematic content analysis</emph> focused on latent content and employing inductive coding, an iterative coding process without a preselected theory or preestablished coding system.</p> <p>This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of Auburn University (Date/No: 9/19/2023; #23-464). The authors declare that they have no conflict of interest. The authors have no relevant financial or nonfinancial interests to disclose. Informed consent was obtained from all individual participants included in the study. Contact the corresponding author regarding datasets generated and analyzed during the study.</p> <hd id="AN0191453681-12">Inclusion Criteria and Recruitment</hd> <p>Recruitment criteria for CBMH centers were as follows: (a) identified as a CBMH center in Alabama, (b) treated children (birth to 19 years old), and (c) provided services through outpatient and inpatient centers; CBMH centers without a short-term inpatient unit were excluded. In Alabama, every two to four counties are served by a CBMH center (Alabama Department of Mental Health, n.d.). Purposeful sampling was used to identify CBMH centers serving pediatric clients, and their administrators were recruited to participate. The sampling framework aimed for data saturation and included triangulation of multiple data sources, administrator member checks, analytical memos from the research team, and field notes. The CBMH centers meeting the inclusion and exclusion criteria were invited to participate via their policy administrators. After providing consent, administrators emailed policies to the primary researcher and scheduled interviews.</p> <p>In total, 21 CBMH centers met the inclusion criteria. Over a period of five months, CBMH center leaders for all 21 centers were contacted via email, phone calls, and/or networking events. Despite multiple contact attempts, 19 either declined participation or did not respond. The final sample consisted of two CBMH centers. The final sample size was influenced by a significant contextual factor: an ongoing lawsuit against community-based mental health providers in the state at the time of data collection. This legal situation created an environment where centers were understandably hesitant to share internal policies or participate in research examining their practices. The participation of the two centers is particularly valuable given the challenging legal landscape. Both participating centers are key providers of publicly funded behavioral health services for the state's youth and adults, serving diverse communities across multiple counties.</p> <p>Table 2 provides client and regional demographics for clients served by these two CBMH centers. Comprehensive data (i.e., policy documents and administrator interviews) from two CBMH centers is a strong starting point for a qualitative content analysis study as it provides a manageable opportunity to identify trends and gaps in the phenomenon under investigation (Patton, [<reflink idref="bib41" id="ref62">41</reflink>]; Yin, [<reflink idref="bib60" id="ref63">60</reflink>]). These data are positioned to provide rationale and merit for the application of a family resilience promotion lens in child mental health policy and treatment.</p> <p>Table 2 Client demographic information for participating CBMH centers</p> <p> <ephtml> &lt;table rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Demographic&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Site 1&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Site 2&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Client ethnicity&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Caucasian&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;64%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;57%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; African American&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;28%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;34.8%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; American Indian&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.5%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.7%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Asian&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.5%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.5%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; More than one race&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Other&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Percentage of clients 0&amp;#8211;17 years old&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;32.9%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27.4%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Treatment type&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mental illness only&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;93%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;87%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Co-occurring mental illness and substance abuse disorder&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Insurance type&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Medicaid&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;50.2%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;48.4%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Commercial&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;28.4%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;40%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Self-pay&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;15.6%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7.8%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Medicare&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5.9%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.8%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Regional demographics&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Population living under the poverty level&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;50.2%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;48.4%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mean household income&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;$28,000&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;$40,000&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>The mean household income is the average across all counties served by the CBMH center</p> <hd id="AN0191453681-13">Study Design Phase 1: Theory-Informed Content Analysis of Policy Documents</hd> <p></p> <hd id="AN0191453681-14">Procedures and Sample</hd> <p>Policy documents contain rules, procedures, and guidance for the organization's operation and services. For this study, policy documents were eligible for inclusion if they were related to or contained information about policies, procedures, and communication with families about intake, assessment, treatment, discharge, training, billing, and client progress. These inclusion and exclusion criteria were developed in collaboration with a CBMH administrator through a series of emails and in-person conversations focused on helping the primary researcher understand the structure of CBMH centers and the scope of CBMH center policies. Purposeful sampling was used to identify CBMH centers, and administrators were approached via email initially, followed by phone calls when necessary.</p> <hd id="AN0191453681-15">Data Analysis</hd> <p>Using a theory-informed coding scheme, this study approached the content analysis in Phase 1 through (a) a deductive process coding for categories and keywords followed by (b) an inductive coding process on latent content. Two coders—a doctoral student with master's degrees in education and in human development and family science and an undergraduate student in human development and family science—manually coded all documents (for details on coder training and coding process, see Supplemental Information). Additionally, the coders wrote analytical memos before and after each independent coding session and conference. Coders used these memos to (a) capture insights and connections occurring throughout the coding process and (b) aid them in synthesizing data and addressing the inherently emotional nature of responses to textual data (Finfgeld-Connett, [<reflink idref="bib18" id="ref64">18</reflink>]).</p> <p>More than 750 pages of policies and guidance documents from the two CBMH centers were coded. In addition, more than 20 pages of analytical memos, written during the coding process, were reviewed. To ensure coder consistency and reliability, meetings between coders were held weekly to establish coding reliability, control coder drift (i.e., when coders unintentionally deviate from the protocol; Cooper et al., [<reflink idref="bib12" id="ref65">12</reflink>]), and clarify the codebook when discrepancies or questions occurred. Dedoose<emph>,</emph> a qualitative data management software application<emph>,</emph> was used to organize data and facilitate coordination between coders for reliability checks and data visualization. The primary coder coded 100% of the documents, while the secondary coder coded 90% of the documents. An interrater reliability check was conducted at the midpoint of the coding process and upon coding completion, revealing minimal demand for clarification. When clarification was needed, the codebook was adjusted with the secondary coder to maintain consistency. As measured by Cohen's kappa, the intercoder reliability exceeded 0.92 across all coded documents, indicating a high level of agreement (Mayring, [<reflink idref="bib33" id="ref66">33</reflink>]).</p> <hd id="AN0191453681-16">Study Design Phase 2: Themed Content Analysis of Administrator Interviews</hd> <p></p> <hd id="AN0191453681-17">Procedures and Sample</hd> <p>A semistructured interview guide was developed based on the research questions and theoretical framework. The guide was reviewed by an expert in qualitative methods but was not formally pilot tested. Interviews lasted between 60 and 75 min. Field notes capturing contextual details and nonverbal cues were recorded during and immediately after each interview. Participants did not review their interview transcripts but were involved in member checks of the preliminary findings.</p> <p>The primary researcher conducted all interviews privately with CBMH administrators. Interviews were conducted in private offices at the respective CBMH centers. No relationship was established with participants prior to study commencement. Participants were informed that the research aimed to understand family involvement in child mental health policy and that the interviewer was conducting this research as part of her doctoral studies. The researcher maintained a reflective journal throughout the process to document potential biases related to her background in special education and experience with families navigating mental health services.</p> <p>The interview process included a member check of the results for Phase 1 (see Supplemental Information for more detail). Then, the interviewer inquired about the administrator's lived experience with the policies at their organization and their view of policy effectiveness and barriers to care. A $25 gift card was offered to administrators as appreciation for participation. Interviews were recorded via laptop by Zoom along with a digital recording device, and the software Otter.ai was used to generate interview transcriptions. Interview transcriptions were based on a smooth verbatim transcript protocol without transcribing utterances or filler words. More than 60 pages of transcribed text were generated. After preliminary analysis, the researchers conducted member checks with participating administrators to verify the accuracy of interview interpretations and thematic groupings. This process allowed administrators to provide feedback on the findings.</p> <hd id="AN0191453681-18">Data Analysis</hd> <p>The second research question was addressed through a thematic content analysis centering on latent content—in other words, the meaning of what is communicated through the interviews. An inductive analysis approach was used to discover patterns, categories, and themes across interviews through an iterative coding process (Vears &amp; Gillam, [<reflink idref="bib55" id="ref67">55</reflink>]) that required coders to find patterns within the data itself rather than relying on codes developed a priori. The iterative nature of this process, which required coding the same document several times, was important to ensure that key patterns were not missed in the initial coding of the text.</p> <p>The same coders who completed the policy content analysis manually coded the interviews. Throughout the study, the primary researcher recorded field notes, impressions, and events by interview. Additionally, as in Phase 1, the qualitative analysis was aided by researcher reflection, including self-reflection (i.e., the process of thinking back to the researcher's own values, biases, and role in the coding), which was completed at the end of each interview via analytical memos (Elo et al., [<reflink idref="bib17" id="ref68">17</reflink>]). Meetings between coders were held to establish coding reliability, control coder drift, and clarify the codebook. Both coders coded 100% of the documents. The coding process took 1 week to complete, with a follow-up conference held 3 weeks later. An interrater reliability check was conducted between coding sessions and upon coding completion. Field notes, analytical memos, and member checking were also included in the analysis.</p> <hd id="AN0191453681-19">Validity and Trustworthiness</hd> <p>To address validity and trustworthiness, multiple strategies were used, including the use of theory, strategies for triangulation, and researcher reflexivity (e.g., analytical memos; Elo et al., [<reflink idref="bib17" id="ref69">17</reflink>]). Utilizing (a) manifest and latent content and (b) deductive and inductive coding schemes allowed for cross-validation and triangulation. Member reflections and triangulation were incorporated by (a) conducting member checks via administrator feedback at two time points (Elo et al., [<reflink idref="bib17" id="ref70">17</reflink>]) and (b) writing analytical memos throughout the data collection, coding, and reviewing process. In Phase 1, coders coded all policies submitted to the greatest extent possible to avoid coding the incorrect texts. In Phase 2, coding was performed across multiple interviews from different organizations, which served as a form of cross-checking.</p> <p>To ensure the reliability of qualitative coding across both phases, intercoder reliability was calculated using Cohen's kappa and percentage of agreement. Both coding phases demonstrated high reliability, with values exceeding the conventional threshold of 0.80, indicating excellent agreement (Mayring, [<reflink idref="bib33" id="ref71">33</reflink>]). When coding disagreements occurred, coders met to discuss divergent interpretations, referring to the theoretical framework, codebook definitions, or interview content to reach consensus. These discussions occasionally led to refinement of coding categories to better capture nuances in the data. Reliability was slightly lower for latent content (0.88) compared to manifest content (0.94) in policy documents, reflecting the greater interpretive judgment required for coding implied meanings. Similarly, coding reliability for themes related to policy creation and redesign (0.90) was slightly lower than for recommendations (0.94) in interview data due to the complexity in categorizing organizational policy dynamics. Complete reliability details for specific coding categories are available in the Supplemental Information.</p> <hd id="AN0191453681-20">Researcher Reflexivity</hd> <p>As many health organization policies are developed and based upon insurance requirements, the research team found areas of disconnect between the theory and what was written in the policy. Additionally, due to the research team members' backgrounds, they entered this study with a strong sense of the purpose and value of policy. In addressing this viewpoint, the research team purposefully participated in reflexivity as they acknowledged bias around policy, particularly around power, influence, and how families should be treated in mental health centers. The research team ascribed validity to others' perspectives regardless of whether those perspectives aligned with their own.</p> <hd id="AN0191453681-21">Researcher Positionality</hd> <p>The primary researcher's background, training, and lived experiences inform how she views and interprets the world. She recognized that her viewpoint includes biases and views that contributed to this study's design and findings. She is an able-bodied White woman who is a mother of two children with disabilities and mental health concerns. As a K–12 special education teacher with experience working on an inpatient pediatric psychiatric unit, she worked with families for more than 20 years, aiding advocacy efforts to ensure that children have adequate schooling and mental health services. Currently, she is a doctoral student employed as a graduate research assistant. Although she may have experience in working with individuals with disabilities and mental health concerns, she relied on data obtained via policy documents as well as that from CBMH center administrators and their lived experiences working with the policy documents to address study aims.</p> <hd id="AN0191453681-22">Results</hd> <p></p> <hd id="AN0191453681-23">Phase I: Policy Documents</hd> <p>The content policy analysis revealed that policies are heavily organization-focused (81%), with a small sphere of child-focused policies (13%) and an even smaller overlap with family-focused ones (6%). Across both sites, 6% of the submitted text elevated family-focused practices aligning with elements of the family resilience framework. The policies focused on six of the nine key family processes described in the framework, specifically those family processes characterized by organizational processes and communication (see Table 3 for a review of the six family-focused processes that were identified and promoted in the policy documents, accompanied by example text). The most common processes identified in the family-focused policy were <emph>flexibility to client care and treatment</emph> (under organizational processes) and <emph>collaborative problem-solving</emph> (under communication). Conversely, processes such as <emph>open emotional sharing</emph> and <emph>connectedness</emph> appeared less frequently. Notably, although an important part of the family resilience theory, none of the policy text elevated the category of belief systems, which include <emph>making meaning out of adversity</emph>, using a <emph>positive outlook</emph>, and engaging with <emph>transcendence and spirituality</emph>. While family belief systems may be engaged in clinical treatment based on clinician training and preference, no formal policies focused on this dimension of family resilience promotion.</p> <p>Table 3 Coding categories and excerpts connected to the family resilience framework (Walsh, [<reflink idref="bib57" id="ref72">57</reflink>])</p> <p> <ephtml> &lt;table rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Framework area&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Coding category and policy document excerpt&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;Organizational processes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="3"&gt;&lt;p&gt; Flexibility to client care and treatment&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Sensitive to Family Income&lt;/p&gt;&lt;p&gt;"State pays daily fee based on client's level of need; private pay required to pay as much as Medicaid."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Targeted Family Treatment&lt;/p&gt;&lt;p&gt;"The assessment reports the family history... the family dynamics and their impact on the individual's current needs... and evaluate family dynamics as a factor in discharge planning."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Sensitive to Culture and Disability&lt;/p&gt;&lt;p&gt;"Receive services regardless of race, gender identification, age, sexual orientation, religion, disability, national origin, social status, diagnostic category, or length of residence."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Connectedness&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Support for Caregivers, Siblings, and Family&lt;/p&gt;&lt;p&gt;"Assessment of the need for other services required by any statutes including, but not limited to, peer and family/caregiver support services, targeted case management, and psychiatric rehabilitation services."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mobilize Social and Economic Resources&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Access to Outside Therapeutic Support&lt;/p&gt;&lt;p&gt;"Our team works with you, with your medical providers and across our own programs to connect you to counseling, training and resources to restore hope."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;Communication&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt; Clarity&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Communicating Financial Responsibility and Bills&lt;/p&gt;&lt;p&gt;"I am required to maintain my account in a current status. Services may be suspended if I do not."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Communicating Client Progress with Family&lt;/p&gt;&lt;p&gt;"The results of these tools shall be discussed with the recipient and/or their lawful representative."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Open Emotional Sharing&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Family Therapy,&lt;/p&gt;&lt;p&gt;"Options for programs to offer family therapy."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="3"&gt;&lt;p&gt; Collaborative Problem Solving&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Goal Development with Family&lt;/p&gt;&lt;p&gt;"Care coordination should be provided, as appropriate, in collaboration with the family/caregiver."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Resolution, Negotiation, and Collaboration&lt;/p&gt;&lt;p&gt;"You have the right to appeal decisions about your care and treatment at Site 1."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Category: Seek Client Input in Assessment&lt;/p&gt;&lt;p&gt;"During such contacts, the family's expectations and Site 1's expectations regarding their roles in the child or adolescents' treatment is clarified."&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Text focused on belief systems, another dimension of this framework, was not identified in the policy documents</p> <p>Figure 1 provides a graphical overview of the content focused on in these policy documents, with an in-depth focus on the family-focused policy. Overall, while organization-centered policies received considerable attention in the policy documents, family-specific services received comparatively less attention.</p> <p>Graph: Fig. 1 By category in the family resilience framework| percentage of text</p> <p>Phase 1 focused on analyzing policy documents using the family resilience framework to understand the extent of family-focused policy in CBMH centers. This phase revealed gaps in policies related to family engagement, especially in promoting family resilience. However, these findings provided a foundational understanding that required further validation from the perspective of the administrators directly responsible for implementing the policies. Hence, Phase 2, centered on administrator interviews, was designed to complement the document analysis by capturing the lived experiences of administrators. Through thematic content analysis, Phase 2 explored how these policies are perceived, operationalized, and adapted by administrators, as well as the barriers they face in promoting family-focused care.</p> <hd id="AN0191453681-24">Phase 2: Findings from Thematic Analysis of Policy Administrator Interviews</hd> <p>The thematic content analysis of policy administrator interviews highlighted various aspects of family-focused care within CBMH centers. Three themes emerged: barriers to family-centered care, diverse priorities in the creation and redesign of policies, and strategies for enhancing family-centered care in CBMH centers. Of note, when considering the concept of supporting family resilience, or supporting families, the policy administrators used the phrase "family-centered." Thus, that phrase is used throughout the presentation of Phase 2 results.</p> <hd id="AN0191453681-25">Theme 1: Barriers to Family-Centered Care</hd> <p>Administrators described barriers that influence the provision of family-centered care including local context, workforce challenges, privacy protection, and insurance coverage.</p> <hd id="AN0191453681-26">Local Context and Resources Define Treatment Capacity</hd> <p>Local context, including funding, access to partner organizations, and local attitudes about mental health, impact CBMH centers' capacity for treatment. Both administrators, who represented different regions, emphasized the crucial role of funding in their operations. For instance, one administrator noted the inability to pay competitive wages for interns, while another administrator shared the benefits of serving counties that prioritize local funding. Local context also determines access to partner organizations with mental health training to which clients could be referred for additional support and resources. Further, local attitudes or stigma towards clients with complex challenges or certain forms of insurance coverage may contribute to service demand from the CBMH center. One administrator described a growing difficulty in meeting the service demands prompted by other mental health organizations refusing to treat difficult patients:That's where clientele comes from because nobody else wants to deal with them because they have Medicaid, because they're challenging, because they're homeless, because they "no show" for their appointment. Policies and procedures are set up so that those people fail in [to our services]; they can't continue care [outside of CBMB services].</p> <hd id="AN0191453681-27">Workforce Challenges Limit Services</hd> <p>Administrators face workforce challenges that directly contribute to barriers starting with a shortage of therapists. This shortage leads to long waitlists and misalignment between service hours and family schedules. One administrator pointed out a 3-month waitlist for services stemming from a shortage of therapists. Another administrator shared the difficulty that limited CBMH center hours pose for families: "[We have problems with] accessibility of the service for parents and being able to take time off work to be able to come and provide consents and update paperwork."</p> <p>Another barrier to family-centered care is a lack of qualified staff trained in the importance of involving the family during treatment. As one administrator explained, "Those with a practitioner background, depending on how they are trained, do a great job at including family and try to help train their staff to also be inclusive in that way." Not all therapeutic staff members receive training in family-centered care, however. Another administrator emphasized that "sometimes getting the staff on board is your biggest piece." Currently, practitioners, not policies, are levers to foster a family-centered approach to care, which creates variations in how, and to what extent, families are engaged and supported in the treatment process.</p> <hd id="AN0191453681-28">Privacy Protection Constrains Collaboration</hd> <p>Barriers to family-centered care also stem from external policy requirements, such as privacy regulations (i.e., HIPAA), and difficulties in coordinating care with families and across different providers. Navigating the balance between protecting patient privacy and fostering essential collaboration poses a challenge for administrators. One administrator described privacy laws as burdensome when therapists feel that family should be included, stating, "HIPAA absolutely affects how I am able to involve the family, especially when we're talking about older teenagers because sometimes they like to exercise that right and really tie your hands." This restriction has been hard for parents, as another administrator highlighted: "As a therapist, you can't even acknowledge that their child is here [in residential psychiatric care]. It's extremely distressing to the parents because their child won't sign a release." Coordination problems among providers also occur due to privacy concerns. As one administrator explained, "We knew this little girl was on the wrong medication, but we couldn't get the release form signed to contact the pediatrician. Our hands were tied for a long time."</p> <hd id="AN0191453681-29">Insurance Coverage Restricts Therapeutic Options</hd> <p>Insurance policies restrict services based on specific policy benefits and impact the ability of CBMH centers to provide family-centered care. Administrators shared examples of how insurance limitations prevent them from offering necessary services, such as eating disorder groups or in-home services. Despite the recognized importance of providing comprehensive services to families, administrators are often constrained by insurance company funding restrictions, even when they believe that they should be able to offer these services for free as a CBMH center. One administrator acknowledged that they do not even send in referrals if insurance has denied the service in the past.</p> <hd id="AN0191453681-30">Convergence and Divergence Among Shared Administrator Perspectives in Theme 1</hd> <p>While both administrators identified similar categories of barriers, their emphasis and specific concerns differed in meaningful ways (see Table 4). For the administrator at Site 1, local funding context emerged as a critical barrier, particularly highlighting how counties that prioritize local funding provided better service capacity than those without such prioritization. In contrast, the Site 2 administrator placed less emphasis on local funding, stating that their county provided strong supplemental funding exceeding that in other counties. Despite these differences, both administrators converged on workforce challenges, specifically the difficulties of recruiting qualified staff trained in family-centered approaches and concerns about privacy regulations, particularly the challenges with older teenagers exercising their right to privacy.</p> <p>Table 4 Theme prevalence across participants</p> <p> <ephtml> &lt;table rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Theme/subtheme&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Administrator 1&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Administrator 2&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Barriers to family-centered care&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Local context&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Workforce challenges&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Privacy protection&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Insurance restrictions&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Policy creation and redesign&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; External drivers&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Change process complexity&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Recommendations&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Family-centered model&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Streamlined consent&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&amp;#10003;&amp;#10003;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>In this table, a single checkmark (✓) indicates that the theme was mentioned by the administrator, while a double checkmark (✓✓) indicates that the theme was discussed at length, suggesting greater perceived importance</p> <hd id="AN0191453681-31">Theme 2: Diverse Priorities in the Creation and Redesign of Policies</hd> <p>In addition to the barriers to family-centered care, CBMH centers must also navigate complex policy dynamics that influence the development and implementation of policies. This section explores these dynamics.</p> <hd id="AN0191453681-32">External Drivers Influence Internal Policies</hd> <p>CBMH centers operate in a complex and ever-changing regulatory landscape, which creates challenges for compliance, flexibility, and innovation. State and federal requirements, such as Medicaid regulations, shape the policy environment and service delivery. External factors, including lawsuits, further pressure CBMH centers to ensure compliance and protect themselves from liability. Administrators spoke of the need to balance requirements from multiple sources as hindrances to applying the flexibility essential for family-centered care.</p> <p>At the same time, changes in government policies and regulations produce opportunities for CBMH centers to advocate for more family-centered approaches and to adapt their practices accordingly. For example, administrators mentioned that changes in state-level policies, particularly in children's services, have prompted them to update their policies and practices. As one administrator noted: "We've had some changes from the state level [because of a lawsuit], particularly with children's services. We decided to update across the board and not just add the new program information." One administrator shared that their policies shifted to a more family-centered approach because they are working to become a certified community behavioral health clinic. When organizational policies shift to emphasize family-centered care, policies can propel services to encompass a more family system-centered approach to care.</p> <hd id="AN0191453681-33">Handling Complicated Change Process</hd> <p>The policy change process in CBMH center settings is often complex and challenging, involving multiple stakeholders, competing priorities, and administrative hurdles. Administrators reported a tension arising from the needs to (a) meet basic policy requirements from external stakeholders (e.g., Medicaid, private insurance) and (b) provide comprehensive family-centered care, resulting in (c) clients being supported, as a general practice, with the minimum required level of care to meet policy requirements. One administrator noted, "We are limited. As an agency, we will do the minimum that's required by policy. I am uncomfortable with that, but it is the reality."</p> <p>Administrators also reported that the process is time-consuming and multilayered, from review to approval and implementation of changes. The complex interplay of CBMH centers' organizational policies and those of external stakeholders generates uncertainty in the process and disjointed communication, as noted by one administrator:And what I see with the feedback loop right now is it is kind of scattered, where if sometimes it feels like it's really quick. And I also think it's going to depend on the severity of the concern. And what else is happening contextually amongst all of the other things within the agency or within other programs and other departments.</p> <hd id="AN0191453681-34">Convergence and Divergence Among Shared Administrator Perspectives in Theme 2</hd> <p>Administrators exhibited different perspectives on policy development priorities (see Table 4). The Site 1 administrator emphasized how external factors, particularly lawsuits, have pressured CBMH centers to update their policies, particularly with children's services. The Site 2 administrator, while noting the lawsuit and those pressures, focused more on the organizational change process itself. Both administrators acknowledged that external drivers influence internal policies, but Site 2 more explicitly recognized the potential opportunity within these changes to advocate for more family-centered approaches.</p> <hd id="AN0191453681-35">Theme 3: Strategies for Enhancing Family-Centered Care in CBMH Centers</hd> <p>While navigating barriers and policy dynamics presents its own set of challenges, administrators provided recommendations for enhancing family-centered care in CBMH centers and supporting families with a child in mental health treatment. These insights offer strategies for improving service delivery and policy implementation.</p> <hd id="AN0191453681-36">Recommendation 1</hd> <p>Develop and promote a comprehensive family-centered model that integrates a range of services and expands the focus of services to the entire family system. This effort may involve offering flexible service hours and telehealth options, collaborating with community providers, and providing family-focused interventions such as parent education and sibling support programs. One administrator recommended the following:Bring on primary care to [the site] for the kids to be like a one stop shop like a Walmart. Get your therapy, see a dentist, you can see that the primary care doctor. A place offering all they need, not putting a cap on offering parents support groups. Making it truly a family focused place and offering childcare for the little bitty ones.</p> <hd id="AN0191453681-37">Recommendation 2</hd> <p>Streamline consent and documentation requirements by implementing less complicated-information sharing approaches that maintain compliance with privacy regulations (e.g., HIPAA). Both administrators suggested exploring options for verbal consent to help reduce the paperwork burden on families. One administrator noted that, "If being able to accept verbal parent consent for someone else to bring a child in for support, yes! That'd be amazing."</p> <hd id="AN0191453681-38">Convergence and Divergence Among Shared Administrator Perspectives in Theme 3</hd> <p>When suggesting strategies for improvement, the administrators offered complementary visions. Both administrators advocated strongly for comprehensive services and a focus on operational improvements, particularly in the streamlining of consent processes and documentation requirements. Additionally, both administrators agreed on the importance of developing family-centered models and improving staff training, but their specific recommendations reflected their different organizational contexts and the unique barriers they perceived as most pressing in their respective centers.</p> <hd id="AN0191453681-39">Discussion</hd> <p>The present study critically examined the extent to which CBMH center policies in Alabama explicitly involve and support families when their child undergoes mental health treatment. The theory-driven content analysis in Phase 1 revealed that only 6% of the CBMH centers' policy documents directly related to the promotion of family resilience as defined by the family resilience framework (Walsh, [<reflink idref="bib57" id="ref73">57</reflink>]). While some aspects of the family resilience framework are addressed in the sites' policies, organizational policies (e.g., security procedures for medication, procedures to ask for paid time off) dominate over child- and family-focused ones. The thematic analysis of administrator interviews in Phase 2 highlighted the desire for family-centered care, complexities encountered in policy implementation, and recommendations for system change. In particular, local context (i.e., funding and support from external organizations) and practitioner training (e.g., trained to use a systemic lens and engage multiple family members) were seen as critical factors in the conversation surrounding the capacity to promote family resilience. The limited integration of family resilience principles in CBMH center policies calls for conversations regarding organizational priorities and consideration of policies that underscore those priorities. This study also emphasizes the importance of greater alignment between policies and practice to effectively support family resilience in CBMH centers. While some aspects of family-centered care are being addressed, there are significant gaps and barriers that require a multifaceted approach to overcome. While several areas, such as addressing insurance restrictions, could be targeted for change, this discussion focuses on leverage points over which the CBMH centers have some degree of control, centering particularly on family needs and equipping families with tools to support their child. The discussion also highlights local context, including workforce challenges, and explores opportunities to leverage existing policy and family-centered opportunities, such as becoming a certified community behavioral health clinic.</p> <p>The findings from this study align with and extend the social organization theory of action and change (Mancini et al., [<reflink idref="bib30" id="ref74">30</reflink>]) in several meaningful ways. First, the results confirm the theory's assertion that formal systems—here, including CBMH centers—serve as critical components in community capacity building. The administrators' identification of local context as a key barrier supports the theory's emphasis on the importance of geographical and cultural conditions in shaping organizational effectiveness. The barriers identified—workforce challenges, privacy regulations, and insurance restrictions—represent what Mancini and Bowen ([<reflink idref="bib29" id="ref75">29</reflink>]) described as structural constraints that limit the ability of formal systems to enhance community resilience. These findings extend the theory by identifying specific policy mechanisms through which CBMH centers could better strengthen their connections with family systems, particularly through streamlined consent processes and comprehensive family-centered models that acknowledge families' central role in treatment outcomes.</p> <p>Previous research has emphasized the importance of family involvement and support in child mental health treatment (Foster et al., [<reflink idref="bib19" id="ref76">19</reflink>]), and both CBMH center administrators noted the desire to elevate family engagement. Administrators articulated a vision for integrated service models that provided comprehensive care that includes childcare and operates as a one-stop-shop for families' diverse needs. Examples from other family-centered mental health practices, such as <emph>family-focused practice</emph> and <emph>integrated behavioral health</emph>, provide examples to initiate this effort. Family-focused practice is a collaborative model of care that centers the family in the treatment when a child is undergoing mental health treatment (Foster et al., [<reflink idref="bib19" id="ref77">19</reflink>]; McGorry et al., [<reflink idref="bib35" id="ref78">35</reflink>]). Child mental health providers have implemented family-focused practice in some areas of the United States and across many countries (i.e., Canada, Ireland, the United Kingdom, and Norway, see Nicholson et al., [<reflink idref="bib38" id="ref79">38</reflink>]). In those instances, relapse rates reduced by as much as 20% while also increasing aspects of self-care and emotional functioning (Glynn et al., [<reflink idref="bib22" id="ref80">22</reflink>]). Most such programs included a coordinated system of care that began with involving the family in the treatment plan by providing them with a full suite of services (Foster et al., [<reflink idref="bib19" id="ref81">19</reflink>]). Previous research on <emph>integrated behavioral health</emph>, i.e., healthcare models where pediatricians work in direct concert with mental health providers while centering the caregiver's involvement, showed strong treatment outcomes; practitioners also felt greater work fulfillment when engaged in coordinated care (Greene et al., [<reflink idref="bib23" id="ref82">23</reflink>]; Stolper et al., [<reflink idref="bib48" id="ref83">48</reflink>]). To become more supportive of family processes, and in turn, family resilience, the field should consider interdisciplinary collaboration among mental health professionals, policy actors, and administrators and also seek feedback from families with lessons learned from existing family-centered programs to further support family resilience.</p> <p>Supported by the social organization theory of action and change, the local context of practitioner training is a critical factor in supporting families (Gafni-Lachter &amp; Ben-Sasson, [<reflink idref="bib20" id="ref84">20</reflink>]; Mancini &amp; Bowen, [<reflink idref="bib29" id="ref85">29</reflink>]). Improving local workforce development needs to be considered in the decision-making process when developing and implementing family-centered policies and practices (Gafni-Lachter &amp; Ben-Sasson, [<reflink idref="bib20" id="ref86">20</reflink>]; Mancini &amp; Bowen, [<reflink idref="bib29" id="ref87">29</reflink>]). Investing in staff training and support to enhance family engagement skills emerged as a potential area to address in strengthening family-centered practices, and research has demonstrated success for such efforts (Buka et al., [<reflink idref="bib5" id="ref88">5</reflink>]). Targeted training programs can enhance mental health professionals' skills in family engagement, and resilience support is crucial for translating policies into practice (Candelaria et al., [<reflink idref="bib7" id="ref89">7</reflink>]; Wissow et al., [<reflink idref="bib59" id="ref90">59</reflink>]). This investment in human capital is essential for translating policies into practice and improving outcomes for children and families. While staff development alone is insufficient to support family-centered care, practitioner training is a key component.</p> <p>In this study, administrators recognized the necessity to update policies to be more inclusive and responsive to whole-family needs. Existing external opportunities to change policies to engage the family in the treatment process can be a lever to meet this need. Administrators articulated that becoming a certified community behavioral health clinic, an opportunity provided through the federal Substance Abuse and Mental Health Services Administration (SAMHSA), is one example of an external opportunity for improvement. Two of the nine elements required for becoming certified are family-focused: (a) person- and family-centered treatment planning and (b) peer family support and counselor services (SAMHSA, [<reflink idref="bib49" id="ref91">49</reflink>]). Leveraging this external opportunity will require a sustained commitment to align policies and practice, build staff capacity, and engage families as partners in care.</p> <hd id="AN0191453681-40">Considerations in National Policy Development</hd> <p>This study emphasizes the importance of fostering interdisciplinary collaboration among mental health professionals, policy actors, researchers, and families to develop an approach to supporting child mental health, in large part, by promoting family resilience. Researchers have documented that strong collaboration focused on child mental health services and addressing family psychosocial needs makes a difference (Wissow et al., [<reflink idref="bib59" id="ref92">59</reflink>]).At the federal level, specific policy mechanisms could include (a) establishing dedicated funding streams CBMH centers that demonstrate family-centered approaches, (b) creating national standards for family engagement in child mental health treatment while allowing local implementation flexibility, and (c) developing federal incentives for workforce development programs that increase the number of practitioners trained in family systems approaches.</p> <p>Addressing policy and the interplay of the multiple entities and layers of public organizations in any move towards improvement, Richard Elmore ([<reflink idref="bib16" id="ref93">16</reflink>]), a leader in policy development and reform, wrote, "Complexity is probably the most troubling aspect of modern government. Nowhere is the effect of complexity more apparent than in the translation of legislation (including policies) into administrative action" (p. 1). His backward mapping approach has been recommended by subsequent scholars, particularly when managing multilevel policies and expectations. The rationale of backward mapping is to prioritize <emph>local voices</emph> in the construction of policies by addressing the problematic behavior, first by identifying the desired behaviors and outcomes and then by working backward to create policies that enable and reinforce those practices (Elmore, [<reflink idref="bib15" id="ref94">15</reflink>]).</p> <p>As observed in this study, administrators called out organizational capacity barriers (i.e., funding, operating hours that match family schedules, and practitioners with training in attending to the family system during treatment). Given this emphasis, it is advised that all levels of government and organizations, including national advocacy groups, research organizations, and healthcare leaders, prioritize collaboration centered on local needs. Policymakers should strive to create national policies that are inclusive of the local context and foster local flexibility and adaptation.</p> <hd id="AN0191453681-41">Practical Implications for CBMH Center Leadership and Policymakers</hd> <p>CBMH center leaders and policymakers at local, state, and national levels are encouraged to prioritize developing and implementing evidence-informed policies that align with the principles of family resilience. This effort requires investing in workforce development to enhance mental health professionals' skills in family engagement and resilience support (Candelaria et al., [<reflink idref="bib7" id="ref95">7</reflink>]; Sunseri, [<reflink idref="bib50" id="ref96">50</reflink>]) and fostering interdisciplinary collaboration among mental health professionals, policy actors, researchers, and families. Leaders can facilitate fostering an organizational environment that values and supports family engagement and resilience through (a) clear communication of priorities, (b) recognition of best practices, and (c) the creation of structures and processes that facilitate collaboration and shared decision-making.</p> <p>To ensure that policies are responsive to the unique challenges of children and families, policymakers ought to adopt a more localized approach that allows for flexibility within the framework (Kutcher et al., [<reflink idref="bib27" id="ref97">27</reflink>]). As policymakers engage in discussions and decision-making processes centering on the local family needs, they shape policies to support family processes. This effort involves advocating for increased resources, promoting evidence-based practices, and creating a supportive legislative environment that enables the delivery of comprehensive and family-centered mental health services. Leaders and policymakers can optimize mental health outcomes by creating a supportive organizational environment and legislative framework that values family engagement and resilience.</p> <hd id="AN0191453681-42">Practical Implications for Researchers</hd> <p>By examining both written policies and administrator perspectives, this study makes a unique contribution to the field by (a) documenting the degree to which family resilience principles are incorporated into CBMH center policies, (b) identifying barriers to family-centered care from the administrative perspective, and (c) illuminating potential pathways for policy improvement that could strengthen family systems during child mental health treatment. This dual-source approach provides a more comprehensive understanding of both the current status of family-centered policies and the practical challenges administrators face during implementation.</p> <p>Researchers ought to explore the dynamics of such collaborations and identify best practices for effective policy implementation across disciplines (Clemons &amp; McBeth, [<reflink idref="bib10" id="ref98">10</reflink>]). In addition, researchers can provide clarity to pinpoint barriers and openings for improvement, particularly when considering evidence-based models (Buka et al., [<reflink idref="bib5" id="ref99">5</reflink>]). Prior studies have demonstrated that research informs crucial policy development conversations to improve child mental health (Garland et al., [<reflink idref="bib21" id="ref100">21</reflink>]; Kutcher et al., [<reflink idref="bib27" id="ref101">27</reflink>]). While the family resilience framework encompasses a wide range of family processes, it is unclear whether policies can effectively correspond to all dimensions, particularly those such as belief systems and meaning-making. Future research should (a) explore the extent to which policies can address these more abstract aspects of family resilience and (b) focus on developing and implementing systematic methods for the ongoing evaluation and refinement of CBMH center policies to ensure they continue to meet the evolving needs of families and align with best practices in family-centered care.</p> <p>The study also shares the significance of understanding local context in shaping the effectiveness of family-centered policies. Because the field of understanding how policy changes impact child mental health warrants further exploration (Purtle et al., [<reflink idref="bib44" id="ref102">44</reflink>]), researchers would benefit from adopting a context-sensitive approach. Employing diverse methodologies, such as mixed-methods designs and participatory action research, can help capture the complexities of family resilience and policy implementation. Engaging families and practitioners as active partners in the research process has the capacity to ensure that the findings are grounded in lived experiences and have practical relevance.</p> <hd id="AN0191453681-43">Limitations</hd> <p>Study findings are noted alongside study limitations, particularly sampling, contextual limitations, and addressing bias. First, study findings may be specific to the context of the two CBMH centers studied. The study's limited recruitment success must be understood within the broader legal context affecting mental health services in the state. At the time of data collection, community providers faced litigation that created apprehension about external scrutiny of organizational policies and practices. This climate contributed to centers' willingness to participate in research initiatives. While the final sample of two CBMH centers is small, these organizations serve diverse communities across multiple counties. Comprehensive data from these centers provided depth and nuance in understanding how policies address family resilience—a quality that might be diluted in broader but shallower sampling approaches. This exploratory study provides a foundation for future research that could include more CBMH centers as well as private practice settings to broaden understanding of how families are systematically integrated into service provision for children and youth.</p> <p>Second, the methodological approach may have inherently introduced selection bias. The participating CBMH centers might represent organizations with stronger family-centered orientations, as evidenced by their willingness to share internal policies and engage in critical examination of their practices. Centers with less developed family engagement policies or those concerned about scrutiny may have systematically excluded themselves from participation. Future research should employ stratified sampling techniques or incentive structures designed to engage a more representative cross-section of mental health service providers, including those from private practice settings, to develop a more comprehensive understanding of family integration in youth mental health services.</p> <p>Additionally, despite efforts to ensure a strong study design and coding reliability, subjective interpretations of researchers influence decision-making, coding, and analysis of qualitative data. Transparency in procedures allows others to collect similar data and to examine patterns in policy documents and administrator input. Furthermore, the family resilience framework (Walsh, [<reflink idref="bib58" id="ref103">58</reflink>]) was used to guide the interpretation of the degree to which policy documents promote family engagement and resilience. While comprehensive, this framework may have limitations in addressing the needs of toxic or unsafe families. As Walsh ([<reflink idref="bib56" id="ref104">56</reflink>]) posited, families experiencing abuse or neglect may require additional support and intervention beyond what is typically encompassed in resilience-focused policies. It is crucial to acknowledge that families are at different points of readiness to help their child, and policies should be flexible enough to accommodate these varied needs. Additionally, this theory may not fully capture all aspects of family resilience policies and practices in CBMH centers. The framework may have its own limitations or biases that could influence the interpretation of the findings.</p> <p>Further, the policy analysis did not fully capture how policies are implemented in practice, and discrepancies between written policies and actual practices could limit the transferability of the findings. The analysis did not explore the underlying factors that shape policies and practices, such as historical, political, or economic influences, which could lead to an incomplete interpretation of the findings. Finally, the absence of family voices may limit understanding how policies and practices impact family resilience. The inclusion of family perspectives is warranted in future research.</p> <hd id="AN0191453681-44">Conclusion</hd> <p>This study highlights the importance of prioritizing supportive family processes and promoting family resilience in CBMH policies and practices through interdisciplinary collaboration among mental health professionals, policymakers, researchers, and families. Investing in workforce development and fostering an organization that values family engagement in the clinical process are crucial steps for improving outcomes for children and families. Stakeholders are encouraged to advocate for policy change and resource allocation to establish a more responsive and effective system of care.</p> <p>This analysis reveals the complex interplay of barriers, policy dynamics, and local contexts that shape the delivery of family-centered care in CBMH centers. The findings underline the importance of a comprehensive, multilevel, local policy approach to addressing obstacles and promoting effective, family-centered services. By providing insights into the challenges and opportunities involved, this study can inform ongoing policy development at the local and national levels, helping policymakers understand the context necessary to support family resilience and remove barriers to treatment. In doing so, communities will be better equipped to foster resilience and support families with children in mental health treatment.</p> <hd id="AN0191453681-45">Declarations</hd> <p></p> <hd id="AN0191453681-46">Conflict of interest</hd> <p>The authors declare that they have no conflict of interest. The authors have no relevant financial or non-financial interests to disclose.</p> <hd id="AN0191453681-47">Ethical Approval</hd> <p>This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of Auburn University (Date/No: 9/19/2023; #23-464).</p> <hd id="AN0191453681-48">Informed Consent</hd> <p>Informed consent was obtained from all individual participants included in the study. Contact the corresponding author regarding datasets generated and analyzed during the study.</p> <hd id="AN0191453681-49">Supplementary Information</hd> <p>Below is the link to the electronic supplementary material.</p> <p>Graph: Supplementary file1 (DOCX 48 KB)</p> <hd id="AN0191453681-50">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0191453681-51"> <title> References </title> <blist> <bibl id="bib1" idref="ref10" type="bt">1</bibl> <bibtext> Alabama Department of Mental Health. (n.d.). Mental illness community programs. 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| Items | – Name: Title Label: Title Group: Ti Data: Family Involvement in Child Mental Health: Exploring Policies and Practices from Community-Based Mental Health Centers – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Sheila+Sjolseth%22">Sheila Sjolseth</searchLink> (ORCID <externalLink term="http://orcid.org/0009-0006-6875-4038">0009-0006-6875-4038</externalLink>)<br /><searchLink fieldCode="AR" term="%22Mallory+Lucier-Greer%22">Mallory Lucier-Greer</searchLink><br /><searchLink fieldCode="AR" term="%22Cory+Cobb%22">Cory Cobb</searchLink><br /><searchLink fieldCode="AR" term="%22Elena+Gagliano%22">Elena Gagliano</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Child+%26+Youth+Care+Forum%22"><i>Child & Youth Care Forum</i></searchLink>. 2026 55(1):177-204. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 28 – Name: DatePubCY Label: Publication Date Group: Date Data: 2026 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Family+Involvement%22">Family Involvement</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Client+Characteristics+%28Human+Services%29%22">Client Characteristics (Human Services)</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health+Programs%22">Mental Health Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Community+Centers%22">Community Centers</searchLink><br /><searchLink fieldCode="DE" term="%22Policy%22">Policy</searchLink><br /><searchLink fieldCode="DE" term="%22Resilience+%28Psychology%29%22">Resilience (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Implementation%22">Program Implementation</searchLink><br /><searchLink fieldCode="DE" term="%22Well+Being%22">Well Being</searchLink><br /><searchLink fieldCode="DE" term="%22Interdisciplinary+Approach%22">Interdisciplinary Approach</searchLink><br /><searchLink fieldCode="DE" term="%22Cooperation%22">Cooperation</searchLink><br /><searchLink fieldCode="DE" term="%22Labor+Force+Development%22">Labor Force Development</searchLink> – Name: Subject Label: Geographic Terms Group: Su Data: <searchLink fieldCode="DE" term="%22Alabama%22">Alabama</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10566-025-09872-6 – Name: ISSN Label: ISSN Group: ISSN Data: 1053-1890<br />1573-3319 – Name: Abstract Label: Abstract Group: Ab Data: Background: Outlined by the social organizational theory of action and change, community organizations such as community-based mental health (CBMH) centers play a crucial role in improving child mental health outcomes. However, the effectiveness of CBMH center policies in supporting families and bolstering family resilience during treatment remains underexplored. Objective: This dual-site, multi-informant qualitative study examined CBMH centers' policies and related practices around family support and involvement during child mental health treatment in Alabama Methods: A content analysis was conducted using two data sources: (a) CBMH center policies, and (b) interviews with CBMH policy administrators Results: The theory-driven analysis revealed that 6% of the policy textual data aligned with the family resilience framework. Thematic analysis of transcribed interviews identified barriers to family-centered care, complexities in managing policy dynamics, and recommendations for improvement. Key barriers included workforce challenges, privacy regulations, and insurance restrictions. Administrators emphasized the need for comprehensive family-centered models, streamlined consent processes, and improved staff training Conclusions: The analysis revealed notable gaps in addressing family resilience within CBMH policies and practices. By addressing identified barriers and implementing recommendations, CBMH centers can create a more family-centered approach that promotes family well-being and optimizes child mental health outcomes. This study highlights the importance of prioritizing family resilience through interdisciplinary collaboration, addressing local context, enhancing workforce development, and leveraging external opportunities to facilitate family-inclusive treatment. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2026 – Name: AN Label: Accession Number Group: ID Data: EJ1505872 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1007/s10566-025-09872-6 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 28 StartPage: 177 Subjects: – SubjectFull: Family Involvement Type: general – SubjectFull: Children Type: general – SubjectFull: Mental Health Type: general – SubjectFull: Client Characteristics (Human Services) Type: general – SubjectFull: Mental Health Programs Type: general – SubjectFull: Community Centers Type: general – SubjectFull: Policy Type: general – SubjectFull: Resilience (Psychology) Type: general – SubjectFull: Barriers Type: general – SubjectFull: Program Implementation Type: general – SubjectFull: Well Being Type: general – SubjectFull: Interdisciplinary Approach Type: general – SubjectFull: Cooperation Type: general – SubjectFull: Labor Force Development Type: general – SubjectFull: Alabama Type: general Titles: – TitleFull: Family Involvement in Child Mental Health: Exploring Policies and Practices from Community-Based Mental Health Centers Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Sheila Sjolseth – PersonEntity: Name: NameFull: Mallory Lucier-Greer – PersonEntity: Name: NameFull: Cory Cobb – PersonEntity: Name: NameFull: Elena Gagliano IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2026 Identifiers: – Type: issn-print Value: 1053-1890 – Type: issn-electronic Value: 1573-3319 Numbering: – Type: volume Value: 55 – Type: issue Value: 1 Titles: – TitleFull: Child & Youth Care Forum Type: main |
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