Q Study

The following Q Study was conducted during CAPES’s six month pilot program
in order to document the value of the CAPES program design:

Perceptions of Health Care Providers who are working with children and adolescents with moderate to severe problems in two or more areas affecting their development physically, emotionally, or educationally.

By Danny Stout, MHR  and  Mary Rineer, Ph.D.

The purpose of this study was to investigate patterns of perception of Health Care Providers who serve children and or adolescents who present with moderate to severe problems in two or more areas relating to their development.

Q-methodology, a technique for extracting subjective attitudes, was used for data collection and analysis. Participants were asked to sort statements on issues associated with their perceptions of coordination of care provided to children and adolescents with moderate to severe problems in two or more areas affecting their development. Factor analysis was applied to identify patterns in the ranking of statements. Participants were 11 individuals involved in the delivery of services to the children and adolescents participating in a Pilot Study. The disciplines included as member participants in the expert panel follow, Speech and Language Therapist, Elementary Classroom Teacher, Pediatrician, Audiologist, Occupational Therapist, Special Education Teacher, Psychiatrist, Psychologist, Family Therapist, Administrative Assistant and Licensed Professional Counselor.

When we think of a child or adolescent we must remain mindful of the fact that unlike adults, children and adolescents are in the process of continual developmental change. To the extent that we as Health Care Providers do not offer state of the art care for these children and adolescents their developmental trajectory is negatively impacted.

Children and adolescents who present to Health Care Providers with moderate to severe problems in two or more areas pose a significant problem for the Health Care Provider.

The problem which this creates for the Provider is created by a service delivery design which does not encourage or establish a format for consultation and collaboration between the providers of service.

Children/adolescents who present with moderate to severe problems in two or more areas are precisely the situation which requires that the Health Care Providers work in a collaborative system.

When Health Care Providers are unable due to the service delivery design to address the needs or problems presented as interrelated and as existing within a larger system the overall care for the child or adolescent is diminished. This diminished care leads to significant delays in resolution of the presenting problems and in a less than optimum outcome for the child and adolescent as well as the family involved in the resolution.

The typical trajectory for this journey in search of assistance is that a parent would identify an issue related to their child or adolescent and seek assistance, or a health care provider would observe an area of need and refer the family to an appropriate professional. The long journey in search of assistance begins at this point. Families typically travel this hazardous path alone moving with best intentions from one professional to the next.

Within the current delivery model if a child or adolescent experiences moderate to severe educational, physical and or mental health problems, their parents may be required to make separate appointments with pediatricians, psychiatrists, psychologists, educational experts, family therapists, audiologists, speech/language pathologists, occupational therapists, etc.

The common current experience includes the families moving from one professional to the next professional without a comprehensive plan in place. In many situations families do not engage with professionals from a variety of professional backgrounds who routinely interact with one another on the child’s behalf.

This lack of engagement /collaboration with a variety of professionals is not due to lack of desire or need on the part of the professionals to interact. The lack of interaction/collaboration with professionals from diverse backgrounds and training is due to the fact that a framework for such interaction does not currently exist.

The results of the Q Study completed by the CAPES panel documents agreement with the findings of the recent study completed and reported in the article, Managing Childhood Chronic Illness Parent Perspective and Implications for Parent – Provider Relationships published in the Family Systems and Health Journal in 2009

Both the results of the Q Study completed by the CAPES panel of experts and the above cited study support the existence of the problems faced by families of children and adolescents who present with significant problems; social isolation, stressed family relationships and ongoing difficulty with communication regarding health and educational needs.

Method

This study included ten practicing care professionals who work with children and adolescents with moderate to severe problems in two or more areas affecting their development physically, emotionally, or educationally.  This sample of ten professionals included two males and eight females who completed two sorts for two conditions of instruction resulting in twenty sorts.  Selection of these participants was purposeful, including all participants in a collaborative service delivery network called CAPES.  This sampling method created a rough factorial design needed for a study utilizing Q-methodology design (McKeown & Thomas, 1988).

A concourse of 36 Q statements was developed for this study in alignment with the research conducted by O’Neil, Ideishi, Nixon-Cave, and Kohrt (2008) regarding family and provider perspectives in care coordination services and the thematic development of the included focus groups.  The themes identified in these focus groups included:  Information Exchange About Child Health Issues, Approaches Toward Child and Family Care, Supporting Family Social and Emotional Needs, Perceptions of Service Provider Roles, Communication Among Parents and Providers and Understanding Service Delivery Systems.  Through this lens, three sets of statements were developed which corresponded to the three areas of service provided by CAPES, including Educational Needs, Physical Health and Mental Health.  Four statements for each theme were developed for each of the three areas of service provided by CAPES resulting in the concourse of 36 Q statements (Table 1).


Table 1:  Q Statements

Educational Needs

  1. Information exchange regarding child/adolescent educational needs is facilitated.
  2. A family and child approach is taken to meet educational needs of the child/adolescent.
  3. I understand the educational service delivery system.
  4. I do not understand the role of educational service providers.
  5. Family social needs are NOT addressed surrounding educational needs of the child/adolescent.
  6. Family emotional needs are NOT addressed surrounding educational needs of the child/adolescent.
  7. Coordinated care provides better educational services.
  8. It is difficult to provide coordinated care for educational needs.
  9. Coordinated care is a barrier to meeting educational needs of a child/adolescent.
  10. Families and the child/adolescent work together to meet educational needs.
  11. The families do not understand the unique educational needs of the child/adolescent.
  12. Families do not get stressed while meeting the educational needs of the child/adolescent.

Physical Health

  1. Information exchange regarding child/adolescent physical needs is facilitated.
  2. A family and child approach is taken to meet the physical health needs of the child/adolescent.
  3. Communication between the family and health providers is challenging.
  4. I understand the physical health delivery system.
  5. I do not understand the role of physical health service providers.
  6. Family social needs are NOT addressed surrounding physical health needs of the child/adolescent.
  7. Family emotional needs are NOT addressed surrounding physical health needs of the child/adolescent.
  8. Coordinated care provides better physical health services.
  9. It is difficult to provide coordinated care for physical health needs.
  10. Coordinated care is a barrier to meeting physical health needs of a child/adolescent.
  11. The families do not understand the unique physical health needs of the child/adolescent.
  12. Families do not get stressed while meeting the physical health needs of the child/adolescent.

Mental Health

  1. A family and child approach is taken to meet mental health needs of the adolescent.
  2. Communication between the family and mental health providers is challenging.
  3. I understand the mental health delivery system.
  4. I do not understand the role of mental health service providers.
  5. Family social needs are NOT addressed surrounding mental health needs of the child/adolescent.
  6. Family emotional needs are NOT addressed surrounding mental health needs of the child/adolescent.
  7. Coordinated care provides better mental health services.
  8. It is difficult to provide coordinated care for mental health needs.
  9. Coordinated care is a barrier to meeting mental health needs of a child/adolescent.
  10. Families and the child/adolescent work together to meet mental health needs.
  11. The families do not understand the unique mental health needs of the child/adolescent
  12. Families do not get stressed while meeting the mental health needs of the child/adolescent.


 Procedure

The 36 Q statements were placed on small square pieces of white paper and placed into an envelope, one for each of the ten participants in the study.  The participants were given this envelope, a Q sort form board and Q sort score sheet.  The participants were first asked to sort the Q statements according to the condition of instruction, “What was your perception of providing care prior to CAPES?”  The participants placed these statements on the Q sort form board which had nine columns with a -4 score for the two items in the left-most column and a +4 score for the two items in the right-most column.  The negative (left) columns represented statements that were most like the participant and the positive (right) columns represented statements that were most unlike the participants.  The number of statements in each column was 2, 4, 4, 5, 6, 5, 4, 4, and 2, respectively.  After recording their results, the participants were asked to sort the statements again, according to the condition of instruction, “What was your perception of providing care after CAPES?”  After completion of this sort and recording of results, the score sheets were collected for analysis.

Data Analysis

As there were only ten participants in this study, a small sampling technique such as Q methodology is most appropriate for the study of subjectivity (McKeown and Thomas, 1988).  With two conditions of instruction for each participant, a total of 20 sorts were included in the analyses.  Each statement was numbered and recorded on the individual score sheets, and according to the ordering by the participants was assigned a score of -4 to +4.  These results were entered into PQMethod software which was developed by Peter Schmolck in 2002 specifically for Q analyses.  The best fit for the data resulted from Principal Components Factor Analysisw ith Varimax rotation (Table 2).  To allow for appropriate interpretation of results in Q methodology, four sorts are needed for each factor.  This also allows for interpretation of factors (Brown, 1980).  This solution provided nine sorts on the first factor and five sorts on the second factor, with a factor score correlation of R = -0.1345.  This low correlation between factor scores is an indicator that there are two discrete, mostly unrelated factors underlying the perceptions of this group.  After retaining these two factors, z-scores for each statement were calculated, producing a factor array, or theoretical Q sort, for each view to be subsequently interpreted.

Table 2:  Factor Matrix

Participant Factor A Factor B
Female Participant 1: After X     0.7607 -0.0483
Female Participant 1: Before X    -0.5257 0.2091
Female Participant 2: After X     0.7514 -0.2839
Female Participant 3: After X     0.7789 0.1244
Female Participant 4: After X     0.6075 -0.1688
Female Participant 5: After X     0.8342 0.1413
Female Participant 7: After X     0.8806 -0.2411
Male Participant 9: After X     0.7143 0.2453
Female Participant 10: After X     0.8317 -0.1898
Female Participant 2: Before -0.2938 X     0.7908
Female Participant 4: Before -0.1585 X     0.6961
Female Participant 5: Before 0.1392 X     0.8379
Male Participant 9: Before 0.1374 X     0.5584
Male Participant 6: Before -0.0389 X     0.6942
Female Participant 3: Before -0.6534 0.5188 (confounded)
Male Participant 6: After 0.4883 0.3911 (confounded)
Female Participant 7: Before -0.0052 0.2280 (not significant)
Female Participant 8: After 0.7010 0.3099 (confounded)
Female Participant 8: Before 0.4696 0.4240 (not significant)
Female Participant 10: Before 0.7287 0.3775 (confounded)

Results

The two resulting factors represent perceptions of care professionals’ ability to provide coordinated care, which is recognized as the most effective method of delivering an array of care to children who have two or more mental health issues, and their families.  These factors were interpreted as Independent/Restricted and Bureaucracy/Restricted.  In both factors, the professionals are knowledgeable about the roles of other service delivery professionals working within the system.  The similarities between the factors stop there and it is the statements that are disparate which aid in understanding the factors beyond the obvious familiarity.

 

Factor A:  Independent/Unrestricted

Participants with this view tend to be those who work in an independent environment and are not bound by the restrictions which are placed on professionals working in a bureaucratic environment.  Unlike people who hold the views of factor B, people with views of Factor A report that information exchange is facilitated, that a family and child approach is taken in providing mental health and educational needs and that both the children and their families work together to meet their educational needs.  Moreover, family emotional needs are met surrounding educational and mental health needs and family social needs are also addressed surrounding educational needs.


Table 3:  Factor A

Independent/Resolution Oriented (After CAPES)\

 

Value Most Like My Perceptions
-4 A family and child approach is taken to meet educational needs.
-4 A family and child approach is taken to meet mental health needs
-3 Information exchange regarding child/adolescent educational needs.
-3 Information exchange regarding physical needs is facilitated.
-3 A family and child approach is taken to meet the physical needs.
-3 Families and the child work together to meet the educational needs
Value Most Unlike My Perceptions
+4 Family emotional needs are not addressed surrounding educational needs.
+4 Family emotional needs are not addressed surrounding mental health needs.
+3 I do not understand the role of educational service providers.
+3 Family social needs are not addressed surrounding educational needs.
+3 I do not understand the role of mental health service providers.
+3 I do not understand the role of physical health service providers.

 

Factor B:  Bureaucracy/Restricted

Participants with this view tend to be those who work in bureaucratic environment and are bound by the restrictions which are placed on professionals working in this environment.  As opposed to people who hold the views of factor A, people with views of Factor B report that it is difficult to provide coordinated care for physical and mental health needs, information exchange is not facilitated, family social needs are not addressed surrounding educational and physical health needs, and families get stressed while meeting mental health needs.  At the same time, these people recognize that coordinated care provide better mental and physical health services while it is difficult, they are still able to meet the mental health needs of their patients.

 

Table 4:  Factor B

Bureaucracy/Restricted (Before CAPES)

 

Value Most Like My Perceptions
-4 Coordinated care provides better physical health services.
-4 Coordinated care provides better mental health services.
-3 Family social needs are not addressed surrounding educational needs.
-3 Family social needs are not addressed surrounding physical health needs.
-3 It is difficult to provide coordinated care for mental health needs.
-3 It is difficult to provide coordinated care for physical health needs.
Value Most Unlike My Perceptions
+4 I do not understand the role of physical health service providers.
+4 Families do not get stressed while meeting mental health needs.
+3 Information exchange regarding child/adolescent educational needs is facilitated.
+3 Information exchange regarding physical needs is facilitated.
+3 Coordinated care is a barrier to meeting mental health needs.
+3 I do not understand the role of mental health service providers.


Before vs. After

There were two conditions of instruction included in this study reflecting the participants experience before CAPES and after CAPES  It is interesting to note that the sorts of all 5 people who comprise Factor B are all sorts reflecting the condition of instruction for before CAPES.  When completing the condition of instruction related to their experience after CAPES, all five of these people move from a perception relating to Factor B to a perception relating to Factor A, four with significance and one resulting in a confounded result.  It appears that through working within the CAPES model, these people who are bounded by the restrictions of working within a bureaucracy are able to transcend those restrictions.  The one person who moved from Factor B to Factor A, but resulted in a non-significant, confounded result, still works in highly bureaucratic environment.

 

Discussion

The people whose views represent Factor B recognize that a solution is available.  However, the current system in which they practice is not designed to meet the unique needs of the children and adolescents and the families who need care for moderate to severe problems in two or more areas affecting their development physically, emotionally or educationally.  Through working within the CAPES model, these people are able to team with those professionals who represent Factor A, and provide comprehensive care for these children and their families.  Additional, people who represent Factor A have higher factor loadings while working within the CAPES model, representing the increased ability of this team of professionals to provide care to those they serve.

 

Limitations

Limitations for this study included a small sample size.  Q Methodology is a small sampling technique which usually calls for 40 sorts (McKeown and Thomas, 1988).  For this study there were only 20.  However, there is only a small correlation between factor scores which represents two underlying, distinct factors.  Moreover, four sorts for each factor were identified which is the minimum needed to define the factors.  This study meets that requirement.

 

Future

How can this current trajectory for families be changed? CAPES INC. is a partial response to the fact that Tulsa does not have a program or facility that integrates and coordinates the dynamic perspective of multiple service providers from different professional areas of expertise while consistently maximizing communication between providers, school personnel and families.

The design of the CAPES program is intended to meet the needs of families with children or adolescents who present with significant problems in two or more areas.

Current information supports both the need and the benefit of a collaborative approach for the delivery of services to children and adolescents.

The CHILD AND ADOLESCENT PROGRAM ENRICHMENT SERVICES (CAPES) program has developed the following mission statement. CAPES provides high quality, comprehensive, innovative, compassionate, and coordinated educational, physical and mental health recommendations to parents for children and adolescents. The inspiration for CAPES was the lack of coordinated analysis and collaboration regarding the childhood and adolescent educational, physical and mental health needs among providers.

The CAPES panel of experts gathers in one room at the same time, and provides the parents an opportunity to present the history, current status and issues affecting the child or adolescent, as well as their desired resolution. This approach allows for a detailed and coordinated analysis to be developed for the proposed series of recommendations.

The following procedures are in place…..

STEP ONE
At a scheduled meeting of CAPES the parents of a child or adolescent meet with the CAPES panel of experts. At each CAPES meeting, the panel will be composed of (1) a psychiatrist (2) a pediatrician, (3) a psychologist (4) an audiologist (5) a licensed professional counselor (6) an educational expert (7) a speech/language therapist (8) an occupational therapist, (9) a family therapist. The parents will present to the CAPES panel of experts the child/adolescent history, current status, and their desired resolution.

STEP TWO
Immediately after the presentation by the parents, the panel meet (without the parent/guardian) to discuss the child/adolescent’s case and to make a series of preliminary recommendations.

STEP THREE
For a period of approximately one week after the initial meeting, the CAPES panel of experts continues to discuss and refine the proposed series of recommendations. The CAPES panel of experts spend countless hours between meetings discussing, developing and refining the series of recommendations which will be offered to the family.

STEP FOUR
After the final series of recommendations are derived by the CAPES panel of experts, the recommendations are composed in written format.

STEP FIVE
After the final series of recommendations are composed in written format, the parents meet again with two or more members of CAPES panel of experts and the recommendations are shared. The proposed recommendations do not refer the child/adolescent to any particular provider, setting forth only the series of recommendations. The parents then choose provider(s) for implementation of the recommendations presented.

STEP SIX
The parents proceed with recommendations with their chosen providers.

STEP SEVEN
Three to six months subsequent to the last meeting between the CAPES panel of experts and the parents, the CAPES panel of experts and the parent/guardian reconvene and review current status and improvements and discuss further recommendations if appropriate.

 

References

Brown, S. (1980). Political subjectivity:  Applications of Q methodology in political science.  New Haven, CT:  Yale University Press.

Kazak, A., Weisz, J., Krafochwill, T., Banez,G., Hoagwood, K., Hood, K., Vargas,L. (2010).  A meta-systems approach to evidence-based practice for children and adolescents.  American Psychologist, February-March, 2010.

Kratz, L., Uding, N., Trahms, C., Villarealle, N., Keickheffer, G., (2009). Managing childhood chronic illness: Parent perspectives and implications for parent-provider relationships.  Family Systems & Health, 27(4), 303-313.

McKeown, B., & Thomas, D. (1988).  Q Methodology.  University paper series on quantitative application in the social sciences, series no. 07-066.  Thousand Oaks, CA:  Sage

O’Neil, M., Ideishi, R., Ideishi, R., Nixon-Cave, K., & Kohrt, A. (2008).  Care coordination between medical and early intervention services:  Family and provider perspectives. Family Systems & Health, 26(2), 119-134.