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A comprehensive review of structured family support programs in children's mental health was conducted in collaboration with leadership from key national family organizations. The goals were to identify typologies of family support services for which evaluation data existed and identify research gaps. Over 200 programs were examined; 50 met criteria for inclusion. Programs were categorized by whether they were delivered by peer family members, clinicians, or teams. Five salient components of family support were identified: (a) informational, (b) instructional, (c) emotional, (d) instrumental, and (e) advocacy. Clinician-led programs were heavily represented (n = 33, 66%), followed by family-led (n = 11, 22%), and team-delivered (n = 6, 12%) programs. Key differences between programs delivered by clinicians or by peer family members were found in the degree of emphasis, research methodology, and outcomes. However, the content of the components was similar across all three program types. There are both important differences in emphasis across typologies of family support provided by clinicians, family members, or teams as well as important similarities in content. Family-delivered support may be an important adjunct to existing services for parents, although the research base remains thin. A research agenda to promote more rigorous evaluations of these services especially those delivered by peer family members is critical.

There is a widespread recognition that the mental health system is not effective in meeting the needs of the children, adolescents, and families who seek its services. In response to this recognition, researchers and policy makers are developing and implementing strategies to transform mental health systems. This paper suggests that transformational interventions should not proceed faster than our understanding of the complexities of a mental health system. In a complex system, all component parts are interactive and interdependent. Problems with one component cannot be solved in isolation from other components. The inter-relationships between problems create inter-dependencies; and changes in the balance of these inter-dependencies can cause dramatic shifts in policy priorities, such as when managers of mental health systems respond to budget reductions in a recessionary economy. This paper examines the problem domains in mental health systems that are affected by complexity dynamics, and proposes that a well-built infrastructure is a necessary foundation for structural change in a child-adolescent mental health system. The concept of metastructure is proposed to account for the rule-based processes that govern the actions of agents within a system.

Evidence suggests that the current mental health system is failing in the provision of quality mental health care for diverse children and families. This paper discusses one critical domain missing to improve care: serious attention given to diversity, culture, and context. It discusses what we mean by understanding culture and context at the individual, family, organizational, and societal level. Focusing on key predictors of children's adjustment in natural contexts would increase attention to building community and family capacities that strengthen children's mental health. To conclude, we suggest changes in organizational culture to build natural supports to enhance children's mental health.