Family Empowerment as a Mediator between Family-Centered Systems of Care and Changes in Child Functioning: Identifying an Important Mechanism of Change

We investigated the associations among perceived fidelity to family-centered systems of care, family empowerment, and improvements in children's problem behaviors. Participants included 79 families, interviewed at two time points across a one-year period. Paired samples t-tests indicated that problem behaviors decreased significantly across a one-year period. Hierarchical multiple regressions indicated that both fidelity to family-centered systems of care and family empowerment independently predicted positive change in children's problem behavior over a one-year period. However, when family empowerment is entered first in the regression, the relationship between fidelity to family-centered systems of care and change in children's problem behavior drops out, indicating that family empowerment mediates the relationship between family-centered care and positive changes in problem behaviors. Consistent with other literature on help-giving practices, family empowerment appears to be an important mechanism of change within the system of care philosophy of service delivery. Implications for practice and staff training are discussed. Article: The emerging trend toward positive psychology and resiliency shifts the conceptual focus from a more deficit-based philosophy to a more family-centered, strengths-based philosophy of service delivery for children's mental health (Akos, 2001; Dunst, Boyd, Trivette, & Hamby, 2002). One innovative model of mental health service delivery lies within the system of care philosophy (Stroul & Friedman, 1986, 1996). Based on a family-centered program model, the system of care philosophy views families as fully capable of making informed choices given that professionals provide the additional support and resources needed to empower families and foster the development of new skills to create long-term change (Stroul & Friedman, 1986). However, little is known about the specific elements within family-centered care models that are the “active ingredients” of change among children and their families. A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations so that services and supports are, (a) effective, (b) build on the strengths of individuals, and (c) address each person's cultural and linguistic needs. A system of care helps children and families function better at home, in school, and in the community. A system of care typically provides services to a specific population of children, namely those children identified by mental health professionals as having a serious emotional disturbance (SED). Occurring in people between the ages of 1-to-21 years old, SED is defined as having at least one clinical diagnosis, functional impairment, and disturbances across multiple domains within the child's life (e.g., school, home, community) (Pumariega & Winters, 2003). The SED population is estimated to encompass approximately 4.5 to 6.3 million children (6–8%) in the United States (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1999). As a family-centered program model, the system of care philosophy views parents as partners in the treatment process in an effort to facilitate family empowerment (Dunst, Boyd, Trivette, & Hamby, 2002; Stroul & Friedman, 1996). Although there are many elements within familycentered care models in addition to empowerment (e.g., expanding social supports, utilizing family strengths, providing individually-tailored resources, delivering services consistent with cultural values and beliefs), empowerment is viewed by many as being the most important element for treatment success. For example, as Dunst, Trivette, and Deal (1994) explain, “it is not simply a matter of whether or not family needs are met, but rather the manner in which needs are met that is likely to have empowering consequences” (p. 3). By empowering families to develop possible solutions to problems or needs, the professional is not only helping with the current situation, but also helping the family develop skills to solve future problems independently. As family empowerment increases, the family unit becomes more competent and capable rather than dependent on service providers. Thus, it is possible that the construct of family empowerment is a possible mechanism of positive change above and beyond the positive influence of family-centered care. Conceptually, it is not counter-intuitive that characteristics associated with empowerment such as promoting help-seeker independence and cultural relevance would influence not only treatment efficacy, but also have a positive influence on the family (Dunst & Trivette, 1996). Previous research (e.g., Dunst & Trivette, 1996; Dunst et al., 1994) has documented that the concept of empowerment has three main components. First, there is an underlying assumption that all people have existing strengths and are able to build upon these strengths. Second, a family's difficulty with meeting their needs is not due to their inability to do so, but rather, the unsupporting social systems surrounding the family that do not create opportunities for the family to acquire or display competencies. Third, in order for empowerment to have a positive influence on families, a family member who attempts to apply skills and competencies also must perceive the observed change as due at least in part to their efforts (Dunst et al., 1994). These main components have been more extensively researched and supported in several other studies. Coates, Renzaglia, and Embree (1983) reported that if service providers undermine a family's sense of competence or control over their life, learned helplessness can result. These patterns can not only produce dependence on professionals (Merton, Merton, & Barber, 1983), but also can decrease self-esteem and solicit negative feelings toward other family members (Nader & Mayseless, 1983). Although there is a literature focused on the construct of empowerment, there is a dearth of research that examines empowerment in the context of community mental health service delivery for children with SED and their families. Since the development of the Family Empowerment Scale (FES; Koren, DeChillo, & Friesen, 1992), which assesses family perceptions of empowerment within the context of mental health services for their children, only a few studies have been published that utilize clinical populations, and these studies mostly have examined family empowerment in isolation of child functioning. For example, Curtis and Singh's (1996) cross-sectional study focused on demographic correlates of family empowerment, Singh et al.'s (1997) cross-sectional study focused on whether child diagnosis, demographic correlates, or parent support group membership influenced family empowerment, and Heflinger and Bickman's (1997) study focused on the use of a parent group curriculum to enhance family empowerment. Although all of these studies are important, there is limited information available as to how changes in family empowerment might be linked to changes in child functioning across time. One longitudinal study found that change in family empowerment predicted change in children's externalizing problems only (Taub, Tighe, & Burchard, 2001), but that study did not consider how the influence of family empowerment might be confounded with the positive influence of family-centered care overall. The only other longitudinal study that has been conducted with a clinical sample receiving family-centered, system of care services was correlational in nature (baseline and discharge empowerment correlations were reported in isolation) and did not examine how change in family empowerment influences change in child functioning (Resendez, Quist, & Matshazi, 2000). To our knowledge, no studies have been conducted that examine the importance of family empowerment independent of the presumed positive influence of providing family-centered care. One previous study began to address this gap by documenting that there is a strong link between perceived fidelity to the system of care philosophy with both positive child outcomes and satisfaction with services (Graves, 2005). However, there continues to be a lack of information regarding the specific mechanisms of change. That is, what is it about delivering services consistent with a family-centered, system of care philosophy that leads to better outcomes? Our study explores family empowerment as one possible mechanism of change. Based upon previous research and theory (e.g., Dunst et al., 2002; Graves, 2005; Stroul & Friedman, 1996; Taub et al., 2001), we hypothesized that, (1) children's problem behaviors would decrease over a one-year period while levels of family empowerment would increase, (2) greater family perceived fidelity to the family-centered elements of the system of care philosophy would be linked to greater positive change in child functioning, (3) greater levels of family empowerment would be linked to greater positive change in child functioning, and (4) family empowerment would mediate the relationship between family-centered care and positive change in child functioning.