Journal of Child and Family Studies

, Volume 16, Issue 2, pp 183–196

Treatment Engagement with Caregivers of At-risk Children: Gaps in Research and Conceptualization


    • College of Social WorkUniversity of Tennessee
Original Paper

DOI: 10.1007/s10826-006-9077-2

Cite this article as:
Staudt, M. J Child Fam Stud (2007) 16: 183. doi:10.1007/s10826-006-9077-2


The high rates of dropping out and other engagement problems are significant concerns in the delivery of mental health and adjunct services to the families of at-risk children. Consequently, researchers have examined the correlates of attrition and have developed interventions to increase engagement and retention. However, the lack of a clear definition of engagement and gaps in theory about the relationship of engagement to other treatment processes hinder knowledge development. In this paper the behavioral and attitudinal aspects of engagement are disentangled. Current knowledge about treatment barriers and interventions to increase appointment keeping is summarized. A preliminary conceptualization of the engagement process is presented and research needs and practice implications are discussed.


EngagementRetentionService useTreatment processAt-risk children

Client participation in treatment is related to outcomes (Baydar, Reid, & Webster-Stratton, 2003; Braswell, Kendall, Braith, Carey, & Vye, 1985; Gorin, 1993; Meyer et al., 2002; Nye, Zucker, & Fitzgerald, 1999). Clients will not fully benefit from treatment when they drop-out prematurely or otherwise do not fully participate. The high rates of premature termination and “no-shows” across different populations of children and families are, therefore, of much concern. The drop-out rates in outpatient child guidance clinics are reported at 38.5% (Kazdin, Mazurick, & Bass, 1993), 45% (Armbruster & Fallon, 1994), and 47.5% (Kazdin & Mazurick, 1994). Only 30% of families who received traditional family therapy and 62% of families who received multifamily group therapy because of child abuse/neglect had a planned termination (Meezan & O’Keefe, 1998). In an urban mental health center serving many minority and low-income families, 36% of families who requested services never came to an appointment; in a similar sample of families who used the services, 45% of the scheduled appointments were not kept (McKay, Pennington, Lynn, & McCadam, 2001). Even in home-based services, where transportation and some other logistic barriers are reduced or eliminated, many families do not fully participate in services (Donohue & Van Hasselt, 1999; Lutzker, Bigelow, Doctor, & Kessler, 1998). Subsequently, research has been directed to learning the correlates of drop-out (Firestone & Witt, 1982; Kazdin & Mazurick; Kazdin, Mazurick, & Bass), testing interventions to increase the rates of engagement (McKay, Nudelman, McCadam, & Gonzales, 1996; Prinz & Miller, 1994; Santisteban et al.,1996), and developing measures of engagement (Kroll & Green, 1997; Yatchmenoff, 2005).

It is clearly important to learn more about the factors that affect engagement by the families of at-risk children. However, the lack of a clear definition of engagement limits knowledge development. There is also a lack of theory on the concept and its relationship to other treatment processes (Dearing, Barrick, Dermen, & Walitzer, 2005; Macgowan, 1997, 2000).

The purpose of this paper is to offer some preliminary ideas on the definition and conceptualization of engagement and to recommend future research needed to fill knowledge gaps. The focus is on the parents (or other primary caregivers) of at-risk children. The rationale for this is that children usually do not ask for services; rather, either parents seek, or professionals refer them to, services (Costello, Pescosolido, Angold, & Burns, 1998). Moreover, parents (and other primary caregivers) may need mental health or related services to resolve their own difficulties, increase appropriate parenting, and provide for the safety and well-being of their children.

The concept of engagement

Engagement, participation, and other terms (for example, adherence, and compliance) are used interchangeably in the literature and frequently refer to clients keeping appointments and staying in treatment (Littell, Alexander, & Reynolds, 2001). Hansen and Warner (1994) described adherence as attendance, participation in the session (i. e., talking about relevant topics, practicing new skills), and completion of homework assignments. Engagement was defined similarly by Cunningham and Henggeler (1999): session attendance, homework completion, emotional involvement in sessions, and progress toward goals. Yatchmenoff (2005) differentiated between compliance, described as “going through the motions” and engagement or full participation, described as “positive involvement in a helping process.” In a discussion of early home visitation services, Guterman (2001) stated that “family participation has traditionally been conceived as consisting of two components, namely, their engagement and retention…” (p. 107). Once families are engaged, their participation in services will vary (Guterman, 2001). Prinz and Miller (1991) defined engagement as the “participation necessary to obtain optimal benefits from an intervention” (p. 382), including regular attendance, cooperation and involvement during sessions, and effort outside of sessions. Even this cursory review shows that different terms are used to refer to the same client attitudes and behaviors and that these terms are not differentiated; for example, participation may be used to define engagement and vice versa. Moreover, some definitions of engagement operationalize it as the alliance or include the therapeutic alliance as one of its components (Dearing, Barrick, Dermen, & Walitzer, 2005; Yatchmenoff, 2005), thus it is not clear whether and how engagement is different from the alliance.

Client behaviors are often used to measure engagement, but practitioners have a primary role to play in the engagement process (Cunningham & Henggeler, 1999; Liddle, 1995; McGinty, Diamond, Brown, & McCammon, 2003; McKay, Bennet, Stone, & Gonzales, 1995; Santisteban & Szapocznik, 1994). (Practitioners refer to helping professionals employed by mental health and social service agencies, including social workers, therapists, psychologists, psychiatrists, case managers, counselors, and caseworkers). A definition of engagement that points to a higher order construct and explicitly includes both practitioners and clients is: “the process by which families and providers develop and maintain a connection, while simultaneously demonstrating and communicating information, needs, attitudes, and values” (McGinty et al., p. 489). This definition suggests that engagement is an ongoing process necessary to develop and keep a positive alliance.

It is important to note that engagement is a process because it has also been conceptualized as occurring in the initial treatment phase and defined as client return after the first interview (Tryon & Winograd, 2002). The initial treatment phase is important because clients are likely to drop-out without early hope of treatment benefit and the promise of a positive helping relationship. But, engagement is an ongoing and dynamic process that is not limited to the first phase of treatment (Coatsworth, Santisteban, McBride, & Szapocnik, 2001; Liddle, 1995). Although the early stage of treatment is critically important to engagement, it cannot be assumed that “once engaged, always engaged.”

Most of the definitions of engagement (and related terms) include behaviors (session attendance, homework completion) and either explicitly reference, or allude to, an attitudinal component. As discussed below, it is important to disentangle these two components. In the following sections the two components of engagement are described; barriers to engagement for the families of at-risk children are discussed; research findings on interventions to increase appointment keeping are summarized; and a preliminary conceptual framework of the engagement process is offered.

Two components of engagement

It is important to differentiate two primary components of engagement. One component is behavioral and consists of client performance of the tasks that are necessary to implement treatment and to ultimately achieve outcomes. Appointment keeping is a common and necessary task across settings and service types. Other tasks will vary across client groups, treatment settings, and theoretical orientations, but often include completing homework, discussing feelings, and responding to the requests of the practitioner (Karver, Handelsman, Fields, & Bickman, 2005).

The second component of engagement is attitudinal. It refers to the emotional investment in and commitment to treatment that follow from believing that it is worthwhile and beneficial. Clients who are emotionally invested in treatment have a positive attitude toward treatment and perceive it as an endeavor that is worth their time and energy. Another way of saying this is that clients are “ready” for the treatment in the context that it is offered and provided. A problem in the provision of services to low-income families with environmental and personal stresses is that they may perceive that the costs “outweigh the potential benefits” (Webster-Stratton, 1998, p. 184). Clients will not engage in treatment unless they perceive the benefits as outweighing the costs.

Yatchmenoff (2005) refers to clients investing in treatment and their expectations of benefit from it as “buy-in.” Some of the items that operationalize “buy-in” on Yatchmenoff's engagement scale (completed by child protective service clients) are: “I believe my family will get the help we really need from (name of agency),” “I think things will get better for my children because (name of agency) is involved,” “I ask (name of agency) for the help or services we need,” “I’m just doing whatever it takes to get (name of agency) out of my life,” and “I really want to make use of the services (name of agency) is offering me.” (The other scales of the engagement measure are receptivity to receiving help, the working relationship, and mistrust of the provider agency or practitioner).

The distinction between the attitudinal and behavioral components of engagement is not trivial. In some settings it is not unusual that judges and caseworkers, when making decisions, consider treatment completion by families more than they do whether families have achieved outcomes; in fact, participating in mental health treatment and other services (such as parenting groups) may be considered the outcome (Smith & Donovan, 2003). Clients may participate in services (for example, attend sessions, perfunctory perform other tasks) to get child protective services or others “off their back,” without ever fully engaging in services (Azar, 2000; Staudt, Scheuler-Whitaker, & Hinterlong, 2001). This is a significant concern because outcomes cannot ensue in the absence of treatment engagement, and session attendance alone does not constitute engagement. DiClemente and Hughes (1990) stated “not everyone who arrives for treatment actually shows up” (p. 218). Clients may keep appointments (or perfunctorily perform other tasks) for many different reasons, but this does not necessarily mean that they are engaged in the therapeutic enterprise. Although it seems reasonable to assume that clients who have a positive attitude toward treatment will keep appointments and complete agreed upon tasks, legitimate barriers exist to doing so, especially for the families of at-risk children. And, research findings consistently show a negative relationship between perceived barriers and session attendance and service use (Farmer, Stangl, Burns, Costello, & Angold, 1999; Flisher et al., 1997; Kazdin, Holland, & Crowley, 1997; Kruzich, Jivanjee, Robinson, & Friesen, 2003; MacNaughton & Rodrigue, 2001). The following section describes some of the treatment barriers experienced by the families of at-risk children.

Barriers to engagement

The barriers to engagement for the families of at-risk children exist at multiple levels, including the child, family, agency, neighborhood, and community (McKay et al., 1995). The families of at-risk children are often confronted with personal and social stresses that interfere with treatment engagement (Miller & Prinz, 1990), practitioners may lack training in working with and engaging the families of at-risk children (Azar, 2000; McGinty, Diamond, Brown, & McCammon, 2003), and the structure of social service and mental health agencies, and the policies by which they must abide, present constraints and obstacles to the provision of high-quality services (Smith & Donovan, 2003; Yoo, 2002). Moreover, some families may be court-ordered to treatment and not even, at least initially, identify a need for or want help. This is an important obstacle to overcome because acknowledging problems and perceiving a need for help are related to attending treatment sessions (Haskett, Nowlan, Hutceson, & Whitworth, 1991; Viale-Val, Rosenthal, Curtiss, & Marohn, 1984).

Some research findings show that socioeconomic and ethnic minority variables are associated with premature termination from treatment. Morrissey-Kane and Prinz (1999, p. 184) suggested that the “mechanism by which these variables operate is related to different class-linked or culturally linked beliefs and expectations for treatment.” Reis and Brown (1999) used the phrase “perspective divergence” to suggest that clients, especially those who are economically and socially disadvantaged, may have treatment expectations that differ from those of practitioners. If not addressed and resolved, perspective divergence results in dropping out and engagement failure. Moreover, parent cognitions and attributions about their parenting behavior and their children's behavior are likely to affect their motivation for and continuance in treatment (Morrissey-Kane & Prinz, 1999). Parents with low expectations for child change or little confidence in their ability to effect child change are not likely to be motivated to seek or engage in treatment (Morrissey-Kane & Prinz, 1999). Indeed, parents with higher levels of discipline problems were significantly less likely to keep their first mental health appointment (Harrison, McKay, & Bannon, 2004; McKay et al., 2001), and helplessness and negativity were associated with dropping out during the intake stage of parent behavior training (Frankel & Simmons, 1992).

Client attitude toward services and the perceived relevance of services also affect engagement. Mary McKay et al. (2001) found that parents with a positive attitude toward services were more likely to keep initial appointments at a mental health clinic. Kazdin's research findings consistently show relationships between treatment barriers (including the perceived relevance of treatment, stresses and obstacles that compete with treatment, problems with the therapeutic relationship, and treatment demands) and treatment acceptability and dropping out by families of children with oppositional behaviors (Kazdin, 2000; Kazdin et al., 1997). Kazdin and Wassell (2000) found that the perceived relevance of treatment and the perceived demands of treatment were especially salient in predicting improved child outcomes.

Variables related to social support and stress are also correlated with keeping appointments. Families with more than one adult in the home kept more of their children's mental health appointments, whereas families with higher levels of stress missed more of their children's mental health appointments (McKay et al., 2001). Social support was associated with keeping initial appointments at a mental health clinic (Harrison et al., 2004), and social support from friends was related to outcomes of parent management training (Dadds & McHugh, 1992); earlier studies also found a relationship between social support and treatment outcomes (Dumas & Wahler, 1983; Wahler, 1980; Webster-Stratton, 1985). Moreover, parental psychopathology, depression, lower quality of life, stress, and parenting problems are associated with a higher level of perceived treatment barriers (Kazdin & Wassell, 2000; Owens et al., 2002; Yeh, McCabe, Hough, Dupuis, & Hazen, 2003).

Some barriers to treatment engagement for the caregivers of at-risk children are less obvious than those already mentioned. One mother, when asked by her therapist to keep a diary, was unable to do so because she did not have a private place in her home to write in it or store it without fear of her husband learning of this activity. This lower income mother did not have the time or space to safely complete this homework assignment and was fearful of her husband's reaction should he find the diary. Also, it is not uncommon that families receive multiple services and must find time for, and contend with making, multiple appointments that do not conflict. Little time or energy may be left for those services that families perceive to be the least relevant and helpful to their immediate concerns (or even for those that they deem potentially helpful).

In summary, barriers to treatment for the families of at-risk children include: (1) cognitions and beliefs about the problem, the treatment, and the need for and potential for change, (2) problems in the relationship with the practitioner, and (3) stresses of daily living, including those associated with lack of basic resources, family conflicts, relationships with social systems (schools, agencies), lack of social support, and personal issues (such as depression, anxiety, problems with relationships). Even though the barriers to engagement are many and varied, research findings suggest that practitioner behaviors can increase appointment keeping by the families of at-risk children.

Research findings on increasing engagement

Interventions to increase appointment-keeping by the families of at-risk children have been implemented in parent management training, an inner-city mental health clinic, and in family treatment for adolescents who use alcohol and drugs. In addition, an earlier line of research focused on preparatory techniques.

Prinz and Miller (1994) compared standard family treatment (SFT) with enhanced family treatment (EFT) in parent management treatment for the families of 4-9 year-old boys with conduct problems. EFT, but not SFT, included eliciting and discussing parent expectations about treatment, their reactions about being in treatment, and personal concerns not directly related to the parent training, for example, work problems and other stresses. There were significantly fewer drop-outs in EFT (29.2%) than in SFT (46.7%). Moreover, almost 60% of families with high adversity dropped out of SFT, compared to 29.6% from EFT. Thus, EFT helped the families most at-risk of dropping out to stay in treatment. Families who dropped out were queried about their reasons for doing so. Compared to the families who received EFT, those who received SFT were significantly more likely to state they were not satisfied with the intervention. Kazdin and Whitley (2003) added five sessions of parent problem-solving (PPS) to parent management and problem-solving skills training for families of children with conduct disorder. PPS consisted of problem-solving the stressors in the parent's life and teaching coping strategies to deal with the stresses. PPS did not impact treatment attendance, but families who received PPS had more change in child and parent outcomes and perceived fewer barriers to treatment participation than the families who did not receive the PPS.

Mary McKay and her colleagues trained therapists from an inner-city mental health clinic in a first-interview engagement intervention consisting of: (1) clarifying the helping process, including eliciting client perceptions of the helping process, describing service options, and explaining the role of therapists and clients, (2) developing a collaborative helping relationship, including eliciting client's stories in their own words, (3) focusing on practical concerns of caregivers, including coordinating with schools and other systems and scheduling a second appointment earlier than one week, if needed, and (4) problem-solving barriers to keeping appointments, such as lack of transportation, prior negative experiences with services, lack of support from significant others, and differences in race and ethnicity between the client and therapist (McKay et al., 1996, 1998). Therapists trained in the engagement intervention had five families (15%) drop out by the third appointment. Therapists not trained in the engagement intervention had 35 families (47%) drop out by the third session (McKay et al., 1996). Families who received the engagement intervention kept significantly more appointments than the families who did not receive the engagement intervention (62% and 51%, respectively). In a related study, a thirty minute telephone engagement intervention was compared to a combined telephone engagement and first-interview engagement intervention (McKay et al., 1998). The telephone intervention consisted of: (1) clarifying the need for treatment, (2) increasing the caregiver's investment in services and parenting efficacy by addressing a problem prior to the first appointment, and (3) identifying and problem-solving barriers to service use. Both of the engagement interventions improved initial appointment keeping above and beyond services as usual. The combined engagement intervention resulted in a higher proportion of kept appointments over either the engagement telephone intervention alone or services as usual.

Brief Strategic Family Therapy (BSFT) includes an integrated engagement component and has increased the retention rate of families (many of them Hispanic) with adolescents (aged 12–14) with problem behaviors, including alcohol or drug use (Coatsworth et al., 2001). BSFT is based on the premise that the family's reluctance to engage in treatment is a symptom of the same interactions that sustain the problem for which the family is seeking treatment (Coatsworth et al., 2001; Santisteban et al., 1996; Szapocznik et al., 1988). The practitioner uses interventions based on strategic, structural and systems concepts to join the family and restructure family interactions to facilitate treatment engagement. The specific strategies depend on the dynamics that maintain treatment resistance, but include joining, establishing alliances, helping the caller to implement strategies to increase other family member's willingness to engage in treatment, contacting family members other than the caller, and making visits to the family or individual members (Santisteban et al., 1996). Eighty-one percent of families randomly assigned to receive BSFT attended the intake and the first therapy session, compared to 61% of the families assigned to services as usual (Coatsworth et al., 2001). Of the families who attended intake and the first session, 72% and 42% were retained in BSFT and services as usual, respectively. These findings replicate those of earlier studies that showed significantly increased attendance at intake and first appointment for families who received the strategic structural systems engagement over those who did not receive it (Santisteban et al., 1996; Szapocznik et al. 1988).

The second type of relevant research is that on preparatory techniques. In general, these techniques provide information (via videotapes or pre-therapy preparation sessions) about what to expect from treatment, client and therapist roles, and appropriate client behaviors. Preparatory techniques are consistent with the theory that cognitions and expectations affect treatment engagement. Research findings indicate that preparatory techniques increase appropriate treatment expectations and knowledge, and may increase attendance and retention (Bonner & Everett, 1986; Coleman & Kaplan, 1990; Day & Reznikoff, 1980; Holmes & Urie, 1975; Wenning & King, 1995).

In summary, some practitioner behaviors that may increase appointment-keeping are: (1) addressing practical problems and daily stresses, (2) eliciting client view of the problem, the goals, treatment expectations, and current and prior experiences with helpers, (3) explaining what treatment consists of and the roles of practitioners and clients, (4) addressing class/ethnic differences and other issues (for example, that treatment may be court-ordered) that may interfere with the helping relationship, (5) asking about the role of family and significant others and enlisting them to support the client, and (6) asking what will interfere with keeping appointments and problem-solving these obstacles.

A conceptual framework of engagement

The mechanisms by which engagement interventions influence client attitudes and behaviors are largely unknown, and assumptions about how they work need to be empirically tested. As seen in Fig. 1, it is hypothesized that the pathway by which practitioner behaviors influence increased appointment-keeping is through their influence on clients’ attitudes toward, and readiness for, treatment. As a result of the practitioner behaviors that comprise engagement interventions, clients are more likely to develop a positive attitude toward treatment (or at least remain neutral and be willing to give it a chance) and to view treatment as worth their time and energy. As a consequence of their positive attitude toward treatment, clients keep appointments, participate in sessions, do homework, and complete other agreed upon tasks. Session attendance and other treatment behaviors are not so much indicators of engagement as they are a result of engagement. The attitudinal component of engagement is the “heart” of engagement, and is necessary to clients’ meaningful behavioral participation in treatment. However, attending sessions and performing other tasks do not necessarily mean that clients are engaged. As already noted, clients may participate by “going through the motions,” but this type of participation is not likely to lead to successful treatment implementation and the attainment of outcomes. Behavioral engagement that stems from a positive attitudinal stance toward treatment is required for successful treatment implementation and outcome attainment.
Fig. 1

Conceptual framework of the engagement process

The question remains of how practitioner behaviors impact client attitude toward treatment. Based on the review of treatment barriers and engagement interventions, Fig. 1 shows that interventions to increase appointment keeping have been successful because of their impact on several interrelated dimensions that are necessary for clients to meaningfully engage in treatment. First, clients must view the treatment as relevant and acceptable to their needs. Treatment acceptability is defined as how “reasonable, justified, fair, and palatable” the treatment is perceived to be (Kazdin, 2000, p. 158). Kazdin and Wassell (2000) suggested that practitioners should explain the rationale for the treatment procedures and help clients link what happens in treatment to the desired outcomes. Second, clients must have a positive relationship with the practitioner and see the practitioner as someone who is caring and genuinely concerned about them. It is well known that a positive alliance is related to retention (Garcia & Weisz, 2002; Kazdin et al., 1997) and outcomes (Horvath & Bedi, 2002). Third, many caregivers of at-risk children experience multiple stresses. The stresses and hassles of daily life must be “manageable enough” so there is time and energy left for treatment. Otherwise, treatment will not be seen as relevant because of the other life issues demanding attention. Clients may like the practitioner and perceive the services as potentially helpful, but the stresses they are experiencing may mean treatment is not doable or acceptable. Fourth, daily stresses may impede treatment engagement, but there may also be additional barriers associated with treatment. Some examples of these include lack of insurance and family member disagreement about the need for services. Fifth, cognitions and beliefs about the problem and treatment may be a barrier to engagement.

It is important to note that clients may be engaged, but still experience barriers to keeping appointments, completing homework, and performing other tasks. Therefore, lack of participation does not necessarily mean that clients are not engaged or that they are resistant to services. Recall the example of the mother whose environmental constraints did not allow her to keep a diary; in addition, appointments may not be kept because of lack of transportation, work conflicts, or simply being too overwhelmed or tired.

Engagement is a complex process, but Fig. 1 is deceptively simple. It does not provide a sense of the many “twists and turns” that treatment and engagement take, both across and within sessions. It is not known whether and how the type of barrier varies by treatment phase and different client problems and groups. Nor is it known which practitioner behaviors are most salient in helping clients to engage in treatment. Also, the dimensions of engagement shown in Fig. 1 are related and overlap with each other (and undoubtedly do so with other treatment variables as well). For example, when practitioners help clients address treatment barriers and help them cope with daily stresses, then they are also beginning to develop a positive alliance.

It seems plausible and logical that clients’ readiness to engage in treatment is because of some combination of those dimensions shown in Fig. 1. The rub, though, is that there is often a mismatch between what seems logical and what the empirical evidence eventually supports. For example, Kazdin and Whitley (2003) found that the implementation of an intervention to address parent stress resulted in fewer perceived barriers and better outcomes, but stress did not mediate outcomes. It was some other pathway besides that of reduced stress that was responsible for the effects of the intervention. The nature by which practitioner behaviors affect engagement attitudes and behaviors are likely far more complex and sequenced than shown in Fig. 1. Moreover, engagement interventions may have a direct affect on outcomes as well as influencing outcomes through increasing rates of attendance and other behaviors (see Fig. 1). The bottom line is that much remains to be learned about the processes and mechanisms by which engagement interventions affect appointment keeping and other engagement behaviors and attitudes.


The necessary (but not sufficient) component of engagement is attitudinal; the behavioral component of engagement is a consequence of the client's positive attitude toward treatment. Behaviors alone do not constitute engagement, but engagement generated behaviors are necessary for treatment to be implemented and outcomes to be attained. The formulation of engagement presented in this paper is preliminary, but several implications emerge and are now discussed.

First, some have placed the onus for engagement squarely on the shoulders of practitioners (Cunningham & Henggeler, 1999; Liddle, 1995). This is reasonable since professionals are ultimately responsible for the course of treatment. However, practitioners need the support of employing agencies and policies to successfully implement behaviors that will increase the likelihood of client engagement. Henggeler, Pickrel, Brondino, and Crouch (1996) noted that multisystemic therapy (MST) results in low rates of drop-out because therapists have low caseloads and the needed time to develop relationships with families; moreover, appointments are available to accommodate the family's schedule. Many settings, though, do not provide optimal conditions for practitioners to successfully engage clients. For example, some mental health clinics may require practitioners to schedule seven or eight clients a day. It is not likely that practitioners will be predisposed to follow up with clients who miss appointments when “no-shows” provide much needed time to complete paper work and return phone calls. In addition to high caseloads, practitioners may receive no or poor supervision, have inadequate training, receive low pay and little appreciation for their work, have few resources for staff development, and have too few resources in the community to draw on to help families. All of these are obstacles that may hinder practitioners in the process of engagement with the families of at-risk children. Much more research is needed about how agency and organizational factors influence practitioner behaviors and client engagement.

Second, even though practitioners are responsible for doing all they can to problem-solve obstacles to client engagement, it must be remembered that clients have the right to decide whether they need to or want to engage in treatment. Clients may have very legitimate reasons for not engaging in treatment and it is certainly their right to “opt out” of treatment. It seems unlikely that 100% of clients who seek or initiate treatment from a specific provider will continue with that provider. Clients may find informal or other formal sources of help or simply decide that the initial problems they sought help for aren't so bad after all, or that the problem is more palatable than the time and cost of treatment. Further research will shed light on why clients choose not to pursue or continue in treatment and in what situations practitioners need to be more active in engaging clients and in what situations practitioners need to “opt out” of further engagement efforts.

Third, the review of engagement strategies provided in this paper do not convey the skill, sensitivity, and knowledge that are required to successfully engage the families of at-risk children. Practitioners who are not well-trained and supervised may fail to grasp the situations of lower income and multi-stressed families and how these affect their ability to engage in treatment. Supervisors, and educators in human service programs, must be aware of common misconceptions and assumptions that prevent practitioners from fully engaging with the families of at-risk children. Examples of misconceptions include thinking that clients who miss appointments are not motivated, are resistant, or hard-to-reach, and that it is not the role of therapists to help clients meet survival needs by referring them to food banks or housing resources. Practitioners may assume that clients understand what treatment consists of and their role in it, but this assumption may often be unwarranted. Just as clients do, students and practitioners have cognitions and beliefs about treatment that may be deeply held but that may interfere with their ability to engage clients. Many challenges remain for training programs to adequately prepare the future practitioners who will work with the families of at-risk children (McCammon, Cook, & Kilmer, 2002; McGinty et al., 2003). Moreover, most studies of engagement interventions have been conducted with families who voluntarily sought help because of their children's needs. A gap in the field is how to engage parents who are court-ordered and where the treatment focus is on the parent. Even when the reason for seeking treatment was because of child behavior, maltreated children had a higher rate of attrition from mental health treatment than did the children not maltreated (Lau & Weisz, 2003). Engagement efforts need to be developed to reach maltreated children and their families.

Fourth, the outcome of interest in most studies of engagement interventions is appointment keeping and retention. This is reasonable given the early stage of this research. Appointment-keeping is direct and relatively easy to measure, whereas attitudinal measures are more subjective and difficult to attain. Furthermore, initial appointments must be kept for clients to get enough exposure to the practitioner and the treatment to decide whether they even want to engage. However, because appointment-keeping can also result from simply “complying,” it will eventually be important for researchers to include measures that tap the attitudinal component of engagement as well as outcomes. This will contribute to increased understanding about the underlying mechanisms of the engagement process. It will also be important to know what practitioner behaviors are necessary to various engagement dimensions and whether and how these vary for different groups of at-risk children and their families. Moreover, it needs to be learned why engagement interventions are successful for some families and not for others. Among families who received engagement interventions, 17% to 29% dropped out of treatment and 26% to 51% of appointments were missed (Staudt, 2003).

The fifth implication comes in the form of a caveat. The assumption has been (at least it has been my assumption) that efforts to increase engagement are good and beneficial. Care must be taken that engagement efforts do not become or are not viewed by clients as coercive or intrusive. In the future it will be important to assess client and practitioner acceptability of engagement efforts. This will provide information on whether efforts to engage families are seen as helpful or intrusive.

Finally, the research agenda for engagement must proceed hand in hand with efficacy and effectiveness research. It makes no sense to be concerned with engagement unless treatments and interventions result in positive outcomes for children and families. At the same time, research on interventions must include their acceptability to clients and their potential to reach and engage the families of at-risk children (Ringeisen & Hoagwood, 2002).


Preparation of this article was supported by Grant 5K01MH068473 from the National Institute of Mental Health. The author extends appreciation to David Patterson, Christy Hickman, and Jill Shoffner for their contributions to the article, and to Jennifer Kuczmarski for help in manuscript preparation.

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© Springer Science+Business Media, Inc. 2006