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Elevating stakeholder voice: Considering parent priorities in model development for community mental health center services

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Elevating stakeholder voice: Considering parent priorities in model development for community mental health center services
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  Elevating stakeholder voice: Considering parent priorities in modeldevelopment for community mental health center services Kaela Byers ⁎ , Toni Johnson, Sharah Davis-Groves, Kathy Byrnes, Tom McDonald University of Kansas, School of Social Welfare, 1545 Lilac Lane, Twente Hall, Lawrence, KS 66045 USA a b s t r a c ta r t i c l e i n f o  Article history: Received 13 November 2013Received in revised form 28 March 2014Accepted 15 May 2014Available online 23 May 2014 Keywords: Peer-supportChildren with SEDCommunity mental healthFamily-driven care Peer-support services, including Parent Support and Training, have traditionally subscribed to a strict de fi nitionofwhatitmeanstoqualifyasapeer,andthereforeasaprovideroftheseservices.Thisarticleexaminesviewsof peerandnon-peerstakeholdersinKansasCMHCsonadditionalcharacteristicsof  “ peer-ness. ” The fi ndingsofthisanalysisresultinacallforabroadeningofthede fi nitionof  “ peer ” inordertocreativelymeettheneedsoffamiliesin the current service climate while still providing support for upholding the family-driven paradigm thatbrought about inclusion of parent voice in the treatment process — a hallmark of the PST service.© 2014 Elsevier Ltd. All rights reserved. 1. Introduction ParentSupportandTraining(PST)isapeer-to-peerserviceprovidedintheKansasCommunityMentalHealthCenters(CMHC)childservicessystem of care for parents of children experiencing serious emotionaldisturbance(SED).The purposeof PST is toprovidesupport,education,and assistance navigating the mental health system from a peer whohas previously experienced similar challenges. Central to thephilosophy behind the intervention is the idea that parents shouldhave a voice at the table as an equal part of the treatment team in theprovision of mental health services to their children.In the spirit of this family-driven value, parents of children with aserious emotional disorder (SED) who were either providing orreceivingPST services were included as a stakeholder group in a recentstudy using Concept Mapping methodology to establish stakeholderconsensus on the core components of the model of PST service asprovided in CMHCs in Kansas ( Johnson, Byers, Byrnes, Davis-Groves, &McDonald, 2013). Including this group of stakeholders ensured theinclusion of parent voice not only in the provision of services but alsoin the development of a service model. This process was successful inestablishing stakeholder consensus on the core components of theKansas PST model. However, some differences arose consistent withdifferences in the literature regarding what provider quali fi cationsidentify one as a  “ peer. ”  These differences led to additional researchquestionsinanefforttoexplorethisissueandimplicationsforpractice.The following research questions are examined in this article: 1) Aretheresigni fi cantmeandifferencesinimportanceratingsofPSTproviderquali fi cations for different stakeholder groups, speci fi cally parents of children with SED who are receiving or providing PST services versusall other stakeholders? 2) Are there signi fi cant differences inimportance ratings of PST provider quali fi cations within the caregiverstakeholder group? This article empirically examines these differencesin an effort to elevate parent voices for consideration in ongoingmodel development and implementation, thus upholding the family-driven principles underlying Parent Support and Training Services. 2. Background  2.1. History of family-driven support services Family involvement within mental health treatment for childrenwith emotional or behavioral disturbances has advanced substantiallyin the past 20 years. Historically, children with serious emotionaldisturbance (SED) were thought to come from dysfunctional familieswith parents contributing to the problem (Friesen & Koroloff, 1990;Knitzer, 1993; Osher, Van Kammen, & Zaro, 2001). The children'smental health systems of care and family movements of the late1980s dispelled that myth, heralding a paradigm shift in which familymembers began to be recognized as experts who possess knowledgefor solutions to challenges (Osher & Osher, 2002). Both movementsasserted that parents have a right to be involved in the design anddelivery of services and supports necessary for their youth to livein communities rather than institutions. Both also advocated thatparents cope more effectively when adequate, individualized supports Children and Youth Services Review 43 (2014) 124 – 130 ⁎  Corresponding author. Tel.: +1 785 864 3824; fax: +1 785 864 5277. E-mail addresses:  kaela@ku.edu (K. Byers), tkjohns@ku.edu (T. Johnson), shdavis@ku.edu (S. Davis-Groves), kbyrnes@ku.edu (K. Byrnes), t-mcdonald@ku.edu (T. McDonald).http://dx.doi.org/10.1016/j.childyouth.2014.05.0090190-7409/© 2014 Elsevier Ltd. All rights reserved. Contents lists available at ScienceDirect Children and Youth Services Review  journal homepage: www.elsevier.com/locate/childyouth  are available (Friesen, Griesbach, Jacobs, Katz-Leavy, & Olson, 1988;Friesen & Koroloff, 1990; Stroul & Friedman, 1988). Then in 1989, the  fi rst national organization was formed torepresent family voices in provision of mental health services — TheNationalFederationof Families forChildren's MentalHealth(NFFCMH)(Spencer, Blau, & Mallery, 2010). This was followed by the establish-ment of funding by family advocates to develop a national network of state-level, family-run organizations to provide information andsupport to families and youth with mental health needs (Spenceret al., 2010). Momentum continued to build for honoring family voicein mental health systems of care when in 2002 a family leader  –  JaneAdams, from the Kansas Chapter of NFFCMH and Board President  – participated in the New Freedom Commission on Mental Health.The work of the Freedom Commission produced goals to transformmental health care in America, including a speci fi c goal stating that “ mental health care must be consumer and family driven ”  (Spenceret al., 2010 p 177; NFC, 2003). Subsequently, in 2004, The SubstanceAbuse Mental Health Services Administration (SAMHSA) asked theNFFCMHtode fi neFamilyDrivencare(Spenceretal.,2010).Inresponse tothisrequest,thefollowingde fi nitionoftheterm “ FamilyDriven ” wasdeveloped:Familydrivenmeansfamilieshaveaprimarydecisionmakingroleinthecareof theirownchildrenaswellasthepoliciesandproceduresgoverningcareforallchildrenintheircommunity,state,tribe,terri-tory,andnation.Thisincludes:choosingculturallyandlinguisticallycompetent supports, services, and providers; setting goals; design-ing, implementingand evaluating programs; monitoringoutcomes;and partnering in funding decisions (Spencer et al., 2010 p. 177).  2.2. Parent support services de  fi ned Parent support and training services and programs operationalizethe family-driven paradigm as they are designed to attend to theneeds of parents of children with emotional and behavioral distur-bances through a variety of formats — individual vs. group, clinician- vs.peer-led, paid provider vs. volunteer (Gyam fi  et al., 2010; Hoagwoodet al., 2010). Numerous parent-to-parent peer support services of thistype have been developed through a variety of partnerships betweenchildren's mental health systems of care initiatives, family-runchildren's mental health advocacy organizations af  fi liated with theNFFCMH, and/or state mental health authorities (Gyam fi  et al., 2010;NFFCMH, 2008). The predominant model has been a parent-to-parentsupport service provided to parents in need by veteran parents whohave navigated the mental health system with their child and who areemployed by family run organizations.ThepeeraspectofthisserviceisgenerallyregardedasthekeytothePST service. This concept is supported by the synthesis of the literatureon peer-to-peer parent support (in mental health, disability or chronicillness, or general parenting) and peer support in adult mental healthpublished by the Research and Training Center for Children's MentalHealth (Robbins et al., 2008) suggesting that the parent-to-parent or “ consumer ”  aspect allows unique relationships to develop betweennewlyreferredparentsandveteranparentsresultinginhigherrecipient “ self-reported satisfaction, quality of life, and social functioningoutcomes ”  (Solomon & Drain, 2001 p. 25) as compared to those receiving other non-peer services.Inasubsequentreview,Hoagwoodetal.(2010)narrowedthefocusto those parent support programs for parents/caregivers of youth withmentalhealthneeds,whileexpandingtheirsearchtoincludeprogramsdelivered not just by peer family members, but also by clinicians orparent – clinicianteams.Reviewofthesestudiesshowedlittleconsistencyin outcomes selected to evaluate the effectiveness of the programsmaking comparison dif  fi cult. This review also highlighted the needfor future research on parent support services to include: 1) acomprehensive service model with a clear conceptual framework;2) a theory of change describing what changes to expect and howthey are expected to occur through implementation of the program;and 3) outcome measures that are best suited to assess expectedchanges(Hoagwoodetal.,2010).Inaddition,whilethisreviewconductedby Hoagwood et al. (2010) included programs with a variety of peerinvolvement models, it did not compare outcomes of variousprogram based on how peer providers were incorporated into theprogram model, likely due to the inconsistency of outcomes measuredby various studies in the review which made comparison amongprograms dif  fi cult.Thereforethereissomeempiricalsupportintheliteratureforvariedapplications of peer-to-peer support models as reported in the reviewconducted byRobbinsetal. (2008)demonstratingincreases intheout-comespreviouslydiscussedwhenusingpeer-providermodels.Howev-er, these outcomes were not compared in their review across otherprograms using various de fi nitions of   “ peer-ness ”  to determine if anyparticular peer de fi nition or model exceeded others in terms of im-proved outcomes. Additionally, though Hoagwood et al. (2010) didbroadenthescopeoftheirinquirytoincludedifferenttypesofpeerpro-grams they were not able to compare outcomes across programs andtherefore similar results have not yet been con fi rmed in the children'smental health services literature. So while use of a peer support modelisconceptuallyimportantasitconformstothefamily-drivenparadigm,thereisnotyetapreponderanceofempiricalevidencesupportinguseof these programs in children's mental health in general or for anyparticular model of peer support speci fi cally.  2.3. Parent support quali  fi cations — or   “   peer-ness ”  In addition to the absence of empirical support for the use of aparticular de fi nition of   “ peer ”  in parent support services in children'smental health, there is also no current consensus on what constitutesa  “ peer ”  and quali fi es one to provide a peer-provided service. In aneffort to articulate a clear conceptual framework for Parent SupportServices, The Federation of Families for Children's Mental Healthrecently developed materials that identify the core competencies of Parent Support Providers. The core competencies are built upon theknowledge that caregivers have gained from  “ raising a child withemotional, developmental, behavioral, substance use or mental healthchallenges ”  (Purdy, 2010). Thus the Federation promotes that Parent Support Providers must  fi rst have this shared experience and be ableto articulate their lessons learned to parents in need of support.Incontrast,insomestates – suchasKansas – Medicaidreimbursableservices have been developed to sustain and expand Parent Supportprograms within public behavioral health systems. With this statewideexpansion, the Parent Support service has evolved to include a broaderde fi nitionofpeerprovidersaswellaswaysinwhichtheservicemaybedelivered. This administration of Parent Support Services was a naturalprogressionstatewide,asagenciesrecruitedandhireddedicatedParentSupport and Training Providers. For example, some mental healthagencies in Kansas started to employ foster parents of youth withemotional or behavioral disorders/special needs, and other familymembers of youth with special needs — such as siblings, aunts, uncles,or grandparents. These and other deviations from the Federation'sde fi nition of   “ peer ”  in hiring practices in Kansas are a result of manyfactors, including the rural and frontier make-up of a large portion of the state which presents signi fi cant challenges to service implementa-tion. Some challenges faced by mental health center administrators for fi lling these roles with traditionally quali fi ed peer support providershaveincludedlimitedapplicantpoolsandtheneedtohireoneproviderto ful fi ll multiple service roles due to the low population density. Inthese cases service providers delivering PST services in Kansas may bemore loosely identi fi ed as a peer through other types of quali fi cations.While thesepracticesare incontrast to thede fi nitionof  “ peer-ness ” setforth bytheFederationof FamiliesforChildren's MentalHealth,it is 125 K. Byers et al. / Children and Youth Services Review 43 (2014) 124 – 130  our contention that rather than being at odds with the Federation'smodel of parent support, these various de fi nitions of   “ peer-ness ”  existon a spectrum of shared experiences; all of which allow the providerto join with the family and provide services while still adhering to thefamily-driven paradigm that was the catalyst and philosophical basisfor this service. This article examines the views of peer and non-peerstakeholders in Kansas CMHCs on additional characteristics of  “ peer-ness ”  in an effort to understand if a broader de fi nition of peer can still uphold the family-driven paradigm according to stake-holders while honoring parent voice in all aspects of behavioralhealth planning and service delivery. 3. Method  3.0.1. Research design Concept Mapping (Kane & Trochim, 2007), a mixed-methodparticipatory action evaluation approach was used for the purposesof establishing stakeholder consensus on the critical components of the Parent Support and Training service ( Johnson et al., 2013).During the analysis phase of this project, researchers noted differencesin ratings betweenstakeholders on the cluster of statements about PSTprovider quali fi cations. The differences in this cluster drew our atten-tion in particular because all other statement clusters in this analysisdemonstrated high levels of agreement between groups, and becausethese quali fi cation statements with low agreement directly relate tothe family-driven aspect of the PST service which we deemedparticularly important. A pattern match was conducted on this state-ment cluster and provides a visual representation of these differences(see Fig. 1).A pattern match display is a  “ ladder graph ”  representation of thedata and is so named because a perfect correlation between two  pat-terns  would display as straight lines between statements, like rungson a ladder (Kane & Trochim, 2007). This pattern match presents pair-wise comparisons of ratings given by the Caregiver Group andthe Provider/Administrator Group on statements made about PSTprovider quali fi cations. The more the graph looks like a ladder, thestronger the agreement between the two groups. A correlationalvalue known as the Pearson product – moment correlation ( r   value)representing the relationship between the two groups is displayedat the bottom of the graph. These values typically range from zerotoonewithhigh r  values(closertoone)representingastrongagreementorrelationshipbetweentwovariables.Valuesclosertozeroornegative r  values would represent lack of agreement between two variables. Thepattern match illustrated in Fig. 1 indicates higher average importanceratingsforthecaregivergrouponallstatementsexceptone.Bothgroupshadverysimilaraverageimportanceratingsforthestatement “ ThePSTisa Parent. ”  The low  r   value of this pattern match ( − .07) along with thedifference in ratings means that there is a difference in perspectivesbetween the caregiver group and the provider/administrator group onthe quali fi cations needed for an effective PST provider.Though these differences did not impact  fi ndings of consensusresearchers found it conceptually important to further explore andunderstandthesedifferencesduetothenatureoftheitemsinquestion;astheuniquepeeraspectoftheserviceisgenerallyregardedasthekeyto the PST service as we previously discussed, and because carefulconsideration of family views in model development is essential toadheringtothefamily-drivenparadigm.Thisarticleusesvariousmulti-variate analyses to further explore these data and answer the researchquestions:1 Are there signi fi cant mean differences in importance ratings of PSTprovider quali fi cations for different stakeholder groups, speci fi callyparents of children with SED who are receiving or providing PSTservices versus all other stakeholders?2 Aretheresigni fi cantdifferencesinimportanceratingsofPSTproviderquali fi cations within the caregiver stakeholder group?  3.0.2. Study participants Participants were recruited from across geographical areas of thestate and across stakeholder roles in collaboration with threegeographically diverse CMHC sites and the Kansas PST StatewideNetwork ( N   = 62). Participants represented key stakeholder groupsincludingconsumers,serviceproviders,andstateandagencyadmin-istrators. For the purposes of this analysis, the stakeholders weredivided in to two distinct groups: 1) the caregiver group consistingof consumers of parent support services and providers who arefamily members of a child with SED and identify themselves as apeer-providers ( N   = 18); and 2) the service provider/administratorgroupconsistingofstateandagencyadministrators,agencysupervisors,non-peerprovidersofPSTservices,andprovidersofotherdirectservices( N   = 43). One case was eliminated from this analysis due to non-reporting of role, for a total  fi nal sample of   N   = 61 (see Table 1).The sample was adequately geographically representative withsome minor variation which further testing con fi rmed did not signi fi -cantlyimpactconsensus fi ndings.However,geographiclocationwasre-ported by participants as one of four regions of the state rather than bycountyorCMHCinordertoconcealandprotectidentifyinginformation.Additionally, each of the four regions included a variety of populationdensitycharacteristics,thusimpedingourabilitytodeterminepreciselytherurality/urbanicityofthesample.However,alargeproportionofthestateasawhole(84percentofallKansascounties)arefrontier,rural,ordensely-settled rural  –  asare theindividual regionswith whichpartici-pants were identi fi ed  –  which we therefore propose had implicationsfor how the  fi ndings of this analysis were interpreted. Table 2 includesa summary of the population density of the state as a whole, as well asof the four regions used for this study. The ethnic/racial makeup of thesample included 53 white (85.48% of the sample), 4 African American(6.45%), and 2 Latino (3.23%) participants, 1 participant who identi fi edas Asian/Paci fi c Islander (1.61%), and 1 participant of mixed race(1.61%).Thesamplepopulationapproximatedtheethnic/racialmakeupof the state, with the exception of the Latino/a population, who wereslightly underrepresented (State of Kansas = 9 percent versus StudySample = 3.23 percent; U.S. Census Bureau, 2008). The sample alsoconsisted of 53 female and 8 male respondents.  3.1. Data collection DatacollectionforConceptMappinganalysisconsistsoftwoactivities;rating and sorting. Both of these activities were carried out for thepurposes of the consensus phase of the project ( Johnson et al.,2013) however, this article focuses primarily on data obtained fromthe rating activity. Participants were invited in person and viaemail to participate in the study. Participants completed online orhard copy surveys ( N   = 62) rating 49 statements representingideas of core components thought to be essential in the provisionof PST services. These statements were rated on Likert scales on:(1) the importance of each statement as a component of providingquality Parent Support and Training Services (5 =  Very Important  to 1 =  Not at all Important  ); and (2) How frequently the statementwas demonstrated in Parent Support and Training Services (5 =  VeryFrequent  to1= NotatallFrequent  ).Additionally,asubgroupofthesam-ple ( N   = 21) also completed the sorting activity, grouping individualstatements in a way that made conceptual sense to them in order toclassify the components into major themes. This resulted in the six-cluster solution of concepts important to the provision of services( Johnson et al., 2013). These six clusters included: 1) Immediate Prior-ities;2)InitialEngagement;3)EffectiveIntervention;4)UnderstandingFamily's Needs; 5) Quali fi cations/Characteristics of a PST; and 6) Origi-nal Family Centered System of Care (FCSC) Policy. Each cluster is madeup of various related statements of core components.This article examines the importance ratings of some of the itemscontainedincluster fi ve, Quali  fi cations/CharacteristicsofaPST  ,thatspec-ify provider attributes that may qualify them as a  peer   provider of  126  K. Byers et al. / Children and Youth Services Review 43 (2014) 124 – 130  services. Theitemsinthis clusterforconsideration are: 1) The PST has achildwithSED ;2) ThePSThasachildwithspecialneeds ;3)  APSTwhodoesnot have a child with SED has worked with children with SED for at least  2 years or is quali  fi ed by his/her education ; 4)  The PST is a parent  ; and5)  The PST is a family member of a child with SED/special needs . Thisclusteralsocontainedtwoadditionalstatementswhichwereillustratedin the pattern match (Fig. 1): 1) PSTs who are also parents of childrenwithSED/specialneedsmaysharepersonalinformationwiththefamilyin a way that helps the family trust the PST; and 2) PSTs who are alsoparentsofchildrenwithSED/specialneedsmaysharepersonalinforma-tion with the family in a way that helps the family feel hopeful. Both of these statements were grouped in cluster  fi ve during the consensusphase as conceptually related to the other quali fi cation statementsandwereimportanttoconsiderforthepurposesofestablishingconsen-sus in the previous analysis ( Johnson et al., 2013). However, these twostatementswerenotretainedforthepurposesofthisanalysisastheyil-lustrate  how  a PST who is a parent of a child with SED may deliver thisservice rather than  what quali  fi es one  to deliver this service. As speci fi cquali fi cations of a PST provider were the focus of this analysis, onlythose  fi ve statements referring to provider quali fi cations wereconsidered.  3.2. Analysis Aone-wayMANOVAanalysiswithfollowuptestswasconductedtoexamine the differences identi fi ed between stakeholder group ratingson PST quali fi cation statements. Additionally, a one-way within-subject ANOVA was used to examine within group differences amongthe caregiver stakeholder group ( N   = 18) made up of caregivers andprovidersconsideredtobepeerproviderstodetermineifanyparticularde fi nition of   “ peer ”  is viewed as signi fi cantly more important by thisgroup than other de fi nitions of this concept.  3.3. Results Researchers hypothesized that the analysis comparing meanimportance ratings between stakeholder groups would revealmean importance ratings on PST provider quali fi cation statementsthat were statistically signi fi cantly higher for the caregiver groupthan for the service provider/administrator group. A one-way multi-variate analysis of variance (MANOVA) was conducted to determinethe effect of the group membership on the  fi ve dependent variables;statements about PST provider quali fi cations. The results of this  Table 1 Sample stakeholder roles ( N   = 62). N   PercentageFamily/Consumer groupFamily member/caregiver receiving PST services 7 11.48PST specialist/family member 11 18Total 18 29.5Provider administrator groupAdvocate 1 .02Direct service staff member 8 13.1PST specialist/non-family member 4 .07PST supervisor 8 13.1State administrator 8 13.1Funder/Policymaker 1 .02Agency administrator/director 13 21.3Total 43 70.5Unknown 1 .02 Fig.1. Participantsrepresentingavarietyofstakeholderrolesweredividedinto two groups – Family/Consumer(N=18)andProvider/Administrator(N=43)inorderto considercon-sumer voice in our examination of PST provider quali fi cations.127 K. Byers et al. / Children and Youth Services Review 43 (2014) 124 – 130  analysis, Wilks's  Λ   = .63,  F  (5, 55) = 6.57,  p  b  .01, con fi rm ourhypothesis that caregiver ratings of importance are signi fi cantlyhigher than importance ratings from the other stakeholder group.Additionally,themultivariate  η  2 basedonWilks's Λ  wasquitestrong,at .37. Analysis of variances (ANOVA) on the dependent variableswas conducted as follow-up tests to the MANOVA. Using theBonferroni method, each ANOVA was tested at the .01 level. TheANOVA tests on all but one of the PST quali fi cation statementswere signi fi cant with modest to moderate effects sizes. Means andstandard deviations for both groups are reported in Table 3. Thesigni fi cant ANOVA results are as follows: 1)  The PST has a childwith SED ,  F  (1, 59) = 13.49,  p  = .001,  η  2 = .186; 2)  The PST hasa child with special needs ,  F  (1, 59) = 32.97,  p  = .000,  η  2 = .358;3)  The PST is a parent  ,  F  (1, 59) = 10.47,  p  = .002,  η  2 = .151;and 4)  The PST is a family member of a child with SED or specialneeds ,  F  (1, 59) = 12.536,  p  = .001,  η  2 = .175. The ANOVA forthe statement  “ PSTs who do not have a child with SED haveworked with children with SED for at least 2 years or are quali fi edby his/her education ”  was not statistically signi fi cant,  F  (1, 59) = .295,  p  = .589,  η  2 = .005.A one-way within-subjectANOVA was also conducted with the fac-tor de fi ned astypes of peer quali fi cation and thedependentvariable asthe importance rating assigned by the caregiver subgroup of each typeof peerquali fi cation.The means and standarddeviationsof importancescores for this group are reported in the caregiver/peer provider groupcolumn of  Table 3. The results of this ANOVA indicate a non-signi fi canteffect,Wilks's Λ  =.62, F  (4,14)= 2.14,  p =.13,multivariate  η  2 =.38.Theseresultssuggestthatthoughvariationsinimportancerat-ings exist, overall, caregivers and peer-providers of PST services do notclassify any particular type of peer quali fi cation as signi fi cantly moreimportant than other characteristics that may qualify one as a peer torecipients of this service.  3.4. Implications The results of these analyses reveal potentially substantial implica-tions for practice and administration of Parent Support and Trainingservices once supported by additional research as discussed in thelimitations section of this article. While all stakeholder groups onaverage rated statements about PST provider quali fi cations as at least Important   on a 5-point Likert scale (5 =  Very Important   to 1 =  Not at all Important  ), the mean rating for these statements was signi fi cantlyhigher for the caregiver group than for the other stakeholder group.This high overall level of importance from both groups on thesestatements re fl ects the perception of some advocates that the experi-ence of parenting a child with SED and/or sharing typical parentingchallenges is a fundamental component of the PST service (Davis,Scheer, Gavazzi, & Uppal, 2010; Munson, Hussey, Stormann, & King,2009), as well as the general consensus in the literature that the peeraspect of PST service is the unique component of the service that con-tributes to positive parent and youth outcomes (Ireys, Chernoff, Stein,DeVet, & Silver, 2001; Silver, Ireys, Bauman, & Stein, 1997). But impor- tantly,thishighratingofimportanceassignedbyallstakeholdergroupsto all of these statements also appears to acknowledge potential valueand acceptance by peer and non-peer stakeholders of a broadened def-inition of   “ peer ”  that moves beyond the de fi nition outlined by theNFFCM that strictly de fi nes peer as a caregiver of a child experiencingemotional, behaviors, mental health, developmental or substanceabuse disorders.Bydemonstratingstakeholderacceptanceof a broaderarray of   “ peer ”  quali fi cations, this may reveal that deviation from thetraditional de fi nition of peer, as demonstrated in Kansas, may be anac-ceptable adaptation that can be implemented without compromisingthe family-driven philosophy of the service, rather than unacceptablemodel drift. While further researchis neededto support these fi ndings,weproposethatthisadaptationmaybea promisingapproachformoresystematic implementation in Kansas as well as replication in otherprograms beyond the Kansas CMHC system.Additionally, it is our contention that the slightly lower importancerating given by administrators and non-peer providers is not due to aperceivedlackofimportanceofthesecomponentsdespitethestatisticalsigni fi cance of this difference, but rather may be a result of theirconsideration of pragmatic constraints to service provision, reportedby agency administrators, in the current  fi scal climate that contributeto issues such as lack of resources for staf  fi ng separate peer positionsto  fi ll this role. Furthermore, these differences may also be attributableto administrative considerations resulting from geography or size of catchment area, particularly for individual rural and frontier CMHCs,which have precipitated changes in the way PST services are providedin Kansas in recent years. While changes in services may arise fromsuch constraints it is important to carefully consider the voice of consumers in developing or modifying services and strike a balancebetween family voice and practical concerns so as to uphold thefamily-driven principles underlying community based services,while still providing ef  fi cient, quality services that are sustainable.Forexample,inoneagencythatparticipatedinvariousphasesofthisresearch, agency administrators reported requiring non-peer providersof other community-based services to provide PST services to augmentservices provided by one dedicated peer staff member assigned to  Table 2 Kansas population density (percentage of square miles).Frontier ( b 6 peopleper square mile)Rural (6 – 19.9 peopleper square mile)Densely-settled rural (20 – 39.9people per square mile)Semi-urban (40 – 149.9people per square mile)Urban (150 or morepeople per square mile)Region 1 72 22 6 0 0Region 2 6 37 25 5 5Region 3 60 25 15 0 0Region 4 15 33 30 18 4Total State 34 30 20 10 6  Table 3 Means and standard deviations for types of peer quali fi cation between groups.Peer Quali fi cation Caregiver/Peer provider group Administrator/Non-peer group M   SD M SD1. PST is a parent of a child with SED. 4.28 .75 3.19 1.162. PST has a child with special needs. 4.33 .77 2.77 1.043. PST who do not have a child with SED has worked with children withSED for at least 2 years or is quali fi ed by his/her education.3.67 1.57 3.86 1.134. PST is a parent. 4.44 .98 3.28 1.395. PST is a family member of a child with SED or special needs. 3.94 1.06 2.98 .94128  K. Byers et al. / Children and Youth Services Review 43 (2014) 124 – 130
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