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10 Opportunities for Innovative Reforms and Knowledge Development SUMMARY Research Opportunities • An analysis of the available evidence in addressing the problem of parental depression reveals gaps in the knowledge base and iden- tifies opportunities to improve the care of depressed parents and their children. Creating Learning Environments That Support Innovation • General guidelines exist—largely focused on other health care and business areas—that provide initial guidance for the widespread implementation of complex, multidisciplinary, two-generation, large-scale programs for depression care. However, challenges in the dissemination and implementation of innovative strategies re- main, including the complexity and resource requirements of new service models; training considerations (cognitive load and con- text dependency); and the structure, culture, and leadership of the adopting organization or system. ____________________ In earlier chapters the committee described the extensive literature on the relationship of parental depression, parenting practices, and the healthy 09

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0 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN development of children. This analysis evaluated the levels of evidence that are needed to show (1) associations between parental depression, parenting practices, and child outcomes and (2) the efficacy of screening, treatment, and prevention strategies and policies on the negative effects of parental depression on children in diverse settings and populations. On the basis of this analysis, the committee then described an ideal vision of a depression care intervention system (Chapter 8), highlighting important components of this system that are emerging in selected service settings as well as through state, federal, and European initiatives. The clues that are emerging from these initiatives also highlight three major barriers associated with imple- menting these innovative approaches that must be addressed as outlined by the committee (Chapter 9), including a variety of systemic, workforce, and fiscal policies. Chapter 10 now provides an overview of two separate areas in which next steps can be taken in the design and implementation of the ideal pre- vention and depression system for parental depression described in Chapter 8 if the systemic, workforce, and fiscal challenges can be overcome. The two areas are (1) developing a research agenda that highlights priorities for new knowledge development and (2) creating policy and learning environ- ments that contribute to successful dissemination and implementation of effective practices for improving the quality of care for depressed parents and their children. Each area involves diverse and challenging issues that require attention from policy makers, the research community, and program administrators. A common goal is to develop evidence-based programs and collaborative strategies, as well as to create incentives to adopt innovative approaches within learning environments that strive to reach those who are in greatest need and those who are most difficult to serve. RESEARCH OPPORTUNITIES In addition to strengthening the systemic, workforce, and fiscal policy approaches outlined in the previous chapter, the committee outlines a research agenda that builds on four fundamental challenges faced in at- tempting to address the problem of parental depression: (1) integrating knowledge, (2) applying a developmental framework, (3) conceptualizing the problems as two-generation in nature, and (4) acknowledging the pres- ence of the constellation of risk factors, context, and correlates associated with depression (see Chapter 2). The committee now focuses on specific content areas that represent significant research opportunities.

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 OPPORTUNITIES FOR INNOVATIVE REFORMS Etiology of Depression Much is known about risk factors for depression, but further research is needed to test models of how multiple biological and psychosocial factors work together and to clarify the mechanisms by which stressful experiences lead to depressive reactions in individuals and in the family context. Resil- iency, despite exposure to parental depression and other adverse conditions is complex, and research will benefit from developmentally sensitive (i.e., age of the child) and integrative models that can be tested over a longitu- dinal course. We need to know more about optimal timing and methods of intervention to prevent the development and escalation of depression in those at greatest risk—especially young people during their formative fam- ily and career years. Interaction of Depression, Parenting, and Child Health and Development Although strong evidence now supports the breadth and extent of as- sociations between depression in parents and adverse outcomes in children, there remain many unanswered questions. In particular, many questions remain regarding mediation and moderation of those associations. In terms of mediation, more studies are needed to test specific aspects of parenting and other potential mediators of associations between depression in par- ents and child functioning. In this regard, the committee noted the strong potential of studies designed to test the effectiveness of interventions aimed at reducing the level of constructs that have been found to mediate associa- tions between depression in parents and outcomes in children, for example, particular aspects of parenting. Such experimental designs can be strong tests of mediation. In terms of moderation, more studies are needed to reveal which chil- dren of depressed parents are more or less likely to develop problems and which parents with depression are more or less likely to have problems with parenting. Moderators might include parent characteristics, including severity, duration, and impairing qualities of their depression, social con- text variables, child characteristics, and others. For example, the moderat- ing roles of the child’s sex and ages at times of exposure are still not well understood, with findings suggesting that boys and girls may be affected differently depending on their ages at the times of exposures. More broadly, we need more studies to quantify percentages of children who are affected (with specific outcomes) and those who are not and what distinguishes them. The committee noted the potential knowledge to be gained by further studies that target interventions to subsets of children with greater or lesser risk (degree of presence of moderators) to determine whether interven-

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN tions need to be addressed to children at all levels of risk (do they benefit equally?) or might be focused on children at greater risk. The committee also noted several gaps in the literature related to physi- cal health of the children of depressed parents. More tracking is needed of health care utilization, missed school days, and other aspects of daily func- tioning in association with depression in parents. In particular, we found that more research is needed to understand the role of maternal depression in the health outcomes of children. Furthermore, both psychological and physical health outcomes need to be addressed in longitudinal studies of healthy and chronically ill children in order to know how physical health outcomes relate to psychological outcomes. Finally, tracking of avoidable and desirable health care utilization is needed to understand the impact on health services. In addition to the research gaps in terms of unanswered questions, the committee also found gaps in relation to study design. First, tests of mediation are most informative when conducted on data from longitudinal designs and with measures of depression, parenting, and child functioning at multiple time points in order to capture the pathways. A second meth- odological issue concerns the measurement of depression in parents. The committee recognizes the staffing and time constraints that often prohibit the use of diagnostic interviews, yet we encourage their use whenever pos- sible. Important questions remain about differences in association with parenting and child outcomes when parents’ depression exceeds clinical diagnostic criteria. Differences in parenting and child outcomes between those two groups need to be understood. Third, more studies from a developmental perspective are needed. Such studies need not be longitudinal, but they require an understanding of child development in their theoretical model, hypotheses, design (especially in terms of the ages of the children studied), and in the selection and psycho- metric properties of the measures. Fourth, the research literature would benefit from improving on the measurement of depression in population-based surveys, particularly those that capture information on the whole family, to enhance their potential value to address these research gaps. Specifically, the committee recognized the limitations of a single symptom rating scale score, typically reflecting the previous week or two in a parent’s life, when the hypotheses typically concern significantly longer term effects on children of exposure to depres- sion in a parent. Fifth, more research studies are needed to test hypotheses derived from transactional models. As just one example, more studies are needed of child factors that contribute to the development or maintenance of depression in parents, for example, premature birth, chronic or acute health problems, “difficult” temperament, conduct problems.

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 OPPORTUNITIES FOR INNOVATIVE REFORMS Finally, as noted throughout this chapter, more studies are needed that examine the differences in parenting styles and children’s behavior of the full range of parents who experience depression, including those from dif- fering cultural and ethnic groups and income levels, fathers, and grandpar- ents who are primary caregivers of their grandchildren. Screening, Treatment, and Prevention Tools and Interventions Screening Although evidence supports the effectiveness of brief screening mea- sures for adult depression in clinical and community settings, there remain many unanswered questions. For example, more evidence is needed on the effectiveness of universal screening of parents with depression, including moving beyond the perinatal period. Furthermore, more research is needed to develop brief clinical screening measures for key parenting skills that relate to depression. More specifically, studies are needed that measure depression in parents with both diagnostic interviews and symptom scales that examine differences in parenting and in child functioning that might be related to measurement approach, severity, impairment, and other clinical characteristics of depression. In terms of outcomes, research is lacking on the outcomes of screen- ing parents as part of a two-generation, comprehensive, depression care program that addresses issues for both parent and child. The next stage is translational research to determine if comprehensive screening programs can ultimately influence parental mental health, parenting, or adverse out- comes in child development. More specifically, studies of the effectiveness rather than the efficacy of the implementation of programs are needed in community and clinical settings. They should examine the impact of each step in the care process, from screening, education, and parent engagement, through parent treatment preferences and choices made, to referrals made and completed, to clinical outcomes. More research is needed to determine the most optimal ways to inte- grate parental depression screening with the assessment of parenting and child development and behavioral status for all children but especially in high-risk populations (e.g., with substance use disorders, low-income sta- tus, at risk for abuse). Treatment While there is evidence available on the safety and efficacy of therapeu- tic and delivery approaches to treating depression and preventing relapse in adults, little is known about the impact of the successful treatment of

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN depression for (1) racial and ethnic minority populations, (2) non-English or limited English speakers, and (3) adults who are parents, and its effects on the functioning and well-being of their children (e.g., prevention of adverse outcomes). In order to maintain a variety of therapeutic treatments to choose from to satisfy patient preference, further research is needed on the safety and efficacy of therapeutic treatments specifically for depressed parents (i.e., antidepressants, therapy, alternative medicine). Specifically, research is needed on (1) culturally and linguistically competent, evidenced-based models, (2) the appropriate duration of perinatal depression interventions, including indications for prophylactic treatment, (3) the long-term effects of antidepressants on the growth and development of children exposed in utero, and (4) the safety and efficacy of alternative treatments for perinatal depression (e.g., herbal medications or supplements, ultraviolet light). With regard to delivery approaches for parents with depression, more research is needed in understanding the effectiveness of certain settings in which parents and their children are regularly seen (e.g., pediatric, obstet- ric, and gynecological settings, community-based centers, home) and the effectiveness of alternative delivery mechanisms that can reduce barriers ro receiving needed treatment (e.g., web-based therapy and follow-up for depressed parents, especially during pregnancy and postpartum periods), as well as the effectiveness of integrating treatment for depression and substance abuse disorders. Prevention More research is needed on the prevention of adverse outcomes in families with depressed parents. Although there is preliminary support for interventions that prevent adverse effects for depressed parents and their children, most of these approaches need further evaluation, replication, and longitudinal studies before widespread implementation is warranted. Many of these studies target only a particular area (e.g., parenting, child development), and only a limited number of interventions have targeted both parents and their children. Therefore, additional research is needed to further support these existing preventive interventions for families with depressed parents. For the programs and practices that have already been found to be most promising in randomized trials, larger scale effectiveness studies and implementation and dissemination trials need to be pursued. In addition, there is a need to develop new interventions that are targeted to the comprehensive needs of families with depression as well as adaptations or enrichments of more broad intervention approaches to enhance their effectiveness in these families. Because families with paren- tal depression may present with depression as the primary problem or as

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 OPPORTUNITIES FOR INNOVATIVE REFORMS part of a constellation of risk factors, there is a need for more research on identifying, engaging, and providing appropriate prevention interventions to families with depressed parents not only in mental health services but also in a variety of settings where they may seek services. This is particu- larly relevant to low-income and ethnic-minority populations, given that they are at increased risk for depression but are less likely to seek mental health services. Although these targeted approaches are likely to be most promising, more evidence is also needed to determine whether universal programs focused on wellness and mental health promotion can lead to reductions in depression in parents and the subsequent adverse effects in children. The following types of programs need more research with attention to depression in parents: • programs targeted at preventing depression in parents with chil- dren at all developmental stages; • prevention programs targeted at improving parenting; • prevention programs targeted at enhancing protective factors and reducing risk in children; • multigenerational and multicomponent programs; • prevention programs in settings in which families with depression and their children are readily accessed, such as schools and com- munity settings; and • policy and social welfare interventions and other broad-based pro- grams that target vulnerable families and children. In all of these programmatic approaches, prevention research for fami- lies with parental depression needs to incorporate three major principles: recognition and treatment of parental depression, enhancement and support for parenting, and a focus on the developmental outcomes of children. A number of areas of focus are needed in these research efforts. First, programs designed to assist children when parents are depressed need to focus not only on symptoms and diagnoses in children but also on strength- based strategies that help children accomplish appropriate developmental tasks (staying in school, relationships, and acquiring skills). In addition, intervention research is needed that can serve to identify the characteristics of parenting by depressed parents that is of sufficient quality (e.g., sufficient levels of warmth and structure) to reduce adverse outcomes in children. For evidence-based, preventive, intervention strategies and prevention-focused service programs that are not specifically targeted to depressed families, future research needs to consider parental depression in intervention design, assess depression in families, and track outcomes in families with depres- sion as a subgroup in their evaluations. Whenever possible, these interven-

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN tions should examine the effects of parental depression on parenting and on child outcomes. Additional research is also needed on the effectiveness of including specific intervention components to enrich the overall program for depressed parents. This research will elucidate how the effects of these interventions differ in families with depression and what adaptations or enhancements are needed to maximize the effectiveness of interventions for them. Although attention to prevention is warranted for children of depressed parents at all developmental stages, because of the rapid course of brain development during the first 5 years of life, increased focus is needed on evaluations and implementation trials of interventions during this stage of development. This can include interventions in pregnancy and the post- partum period, parent-child interaction interventions in infancy and early childhood, home visitation, and early childhood education. Vulnerable Populations The research opportunities outlined in this section highlight the fact that there is a general lack of research that includes particularly vulnerable populations—those with low income, those from a racial/ethnic minority, and those with co-occurring conditions or family adversity. Given the con- siderable evidence about the social determinants of health in general and its effects on parental depression in particular, it is important that intervention research to address depression in parents should assess relative effectiveness in families with low income, families in high-risk neighborhoods, families with unstable housing, and families from varied cultural and linguistic backgrounds, as well as adaptations or enhancements to target these vulner- able populations. This research will help to elucidate the need to address these interrelated factors to successfully intervene to improve depression, parenting, and child outcomes as well as the need to address depression in order to make other interventions for these vulnerable families more successful. Greater recognition is needed of the vast level of heterogeneity of the groups who are particularly vulnerable to depression or need depression services in the United States. Research studies that report the population subgroups studied with greater specificity will help policies and practices to be more effective. For example, in regard to screening, more research is needed to determine the optimal ways to integrate parental depression screening with the assessment of parenting and developmental and behav- ioral status for all children but especially those in high-risk populations (e.g., with substance use disorders, low-income status, at risk for abuse). For treatment, little is known about the impact of successful treatment of depression for racial/ethnic minority populations or non-English or limited

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 OPPORTUNITIES FOR INNOVATIVE REFORMS English speakers. Even when interventions are not designed to address these populations, population and socioeconomic demographics should be clearly reported so that studies can be placed in the proper context, the amount of risk properly assessed, and analyses of relative effectiveness in high-risk subpopulations can be conducted. Trials are also needed of specific ways to offer identification, outreach, engagement, and treatment and prevention services to vulnerable families who face multiple risks. Specifically, research is needed on culturally and linguistically competently evidenced-based models as well as models that integrate treatment of co-occurring conditions, such as marital conflict, domestic violence, and exposure to trauma and co-existing mental and substance abuse disorders. Furthermore, studies that include large samples of vulnerable populations are needed in community and other real-world settings that explore adaptations or research strategies that are appropriate and sensitive to their needs. Finally, there should be more research studies that seek to understand the deterioration in mental health of immigrants based on tenure in the United States. This research on immigrants should seek to understand the environmental, psychological, and social changes that seem to factor into this deterioration and help preserve the protective factors at work. Innovative Strategies While evidence is emerging about ways to improve and strengthen the quality of treatment programs for depressed adults, little is known about the extent to which these quality improvement efforts apply to the par- ticular needs of adults who are parents or to their children. Furthermore, research presented in the preceding chapters suggests that children are directly affected by a parent’s depression. Their needs are not addressed in a care system that focuses solely on improving treatment effectiveness without regard for the vulnerable persons (especially very young children) whose care and relationships may be disrupted by the disorder. Research is therefore needed to examine how quality improvement ef- forts contribute to enhancing the relationships and outcomes of parents and their children when compared with the general population of non-parent- ing adults who participate in treatment programs and should incorporate three major principles: recognition and treatment of parental depression, enhancement and support for parenting, and a focus on the developmen- tal outcomes of children. Research resources should be dedicated to un- derstanding common as well as unique problems in designing treatment services for parents with children at different stages of development, such as infants, toddlers, school-age children, and adolescents. Once optimal

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN strategies are identified, research is needed for the dissemination of these programs into the care settings that match these developmental stages. Furthermore, many individuals who screen positive for depression de- cline mental health services. For widespread implementation of programs that are shown to be effective for families with depression, there is a need for more work on issues of engagement and barriers to access to services as most families with depressed parents do not receive adequate intervention. Research on depression care models should therefore identify characteris- tics of individuals who accept services and individuals who decline them to determine how well a given model fits with the cultural and socioeconomic characteristics of the relevant community. Research opportunities may exist to engage individuals in treatment that is directly relevant to distinct stages of parenting, such as those noted above: preconception, prenatal, post- partum, and later stages, as well as comparing the outcomes of first-time parents with those who are raising older children or children in blended families The comparative effectiveness of treatment strategies that are tar- geted on these developmental stages deserves to be tested when designing future quality improvement research studies. Interventions centered on parenting are particularly compelling because engagement is a crucial step to effectively intervening in families with depression. Programs that address parenting needs offer great promise as a highly effective way to engage par- ents and, when needed, trigger services that can address their depression, parenting, and prevention of adverse outcomes in children. Trials are also needed of specific ways to offer additional identification, outreach, engage- ment, and treatment and prevention services to those vulnerable families who face multiple risks. Finally, families with depressed parents are most likely to be recognized in a variety of settings. As described in Chapter 7, targeted intervention approaches are likely to be most promising. Therefore, in addition to interventions for parents who present with depression for mental health services, research is needed on how best to identify parental depression and provide services within a range of settings in which families at high risk for depression seek services (such as Head Start; the special Supplement Nutrition Program for Women, Infants, and Children; preschool). Thus, resources need to be available in these settings to identify parental depres- sion and to assist families in getting treatment and prevention services. This is most relevant to low-income and ethnic-minority populations given that they are at increased risk for depression but are less likely to seek mental health services.

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9 OPPORTUNITIES FOR INNOVATIVE REFORMS Summary The research priorities highlighted above provide direction and guid- ance for building a knowledge base that can enhance the development of fu- ture programs, policies, and professional practice. But overcoming systemic, workforce, and fiscal challenges and developing new knowledge to help in the design and implementation of innovative strategies are not sufficient to ensure its use in the routine efforts of service providers and practitioners to identify, treat, and prevent parental depression and to reduce the impact of this disorder on children. The application of evidence-based knowledge requires explicit attention to dissemination, implementation, and the cre- ation of an organizational culture, often termed a “learning organization,” which is intentionally receptive to new research. The next section explores the features associated with learning organi- zations that may foster the use of science in the prevention and treatment of parental depression and in calling attention to children who may be af- fected by this disorder. A key feature of these learning organizations is the development of processes and training programs that stimulate innovative practice. CREATING LEARNING ENVIRONMENTS THAT SUPPORT INNOVATION The science of dissemination and implementation lags considerably behind the science that undergirds evidence-based practices and promis- ing programs in the identification, treatment, and prevention of parental depression. Not surprisingly, the complexity of dissemination and imple- mentation has also thwarted the development of useful theories. Although various conceptual approaches exist, none could be described as compre- hensive, coherent, or testable (Fixsen et al., 2005; Glasgow, Lichtenstein, and Marcus, 2003; Kilbourne et al., 2007; Mendel et al., 2008; Racine, 2006). The result is a scattered and largely noncumulative pattern of a knowledge base associated with dissemination and implementation. Some relevant theory development and empirical work, with relevance to interventions that strive to improve parenting or to enrich the social environments of children of parents who are depressed, are emerging, as described in Chapter 8. The time may be ripe to combine these early experimental examples with the broader literature on dissemination and implementation derived from research in business organizations. The com- bination could provide guidance on strategies for pursuing wider use of what works in identifying, treating, and preventing depression among parents. This section begins with an overview of the process of adopting an

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20 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN innovation. We then review major issues related to the adoption, imple- mentation, and dissemination of evidence-based parental depression care programs. Next, a guide to adopting innovations prepared the by Agency for Healthcare Research and Quality (AHRQ) is discussed (Brach et al., 2008). The AHRQ guide serves as an example of the generic resources available to planners and community partners seeking pragmatic infor- mation on the implementation of new health care programs. The section concludes with a research agenda to help support innovation, dissemina- tion, and implementation of evidence-based depression care programs for depressed parents and their children across a wide range of venues. The Mechanisms of Learning Dissemination and implementation of promising models draw explicit attention to the mechanisms of learning, such as assimilation and use. Improved outcomes from depression care require that planners and prac- tioners assimilate and skillfully use evidence-based practices and promising programs. Individual practitioners tasked with providing depression care for parents and children need opportunities to share their experience with new practices and programs with each other and with their service organi- zations and systems. Despite significant advances in other fields, the importance of learning through the assimilation and use of evidence-based approaches has gone underappreciated in the health care and human services literature. Two emerging principles (cognitive load and context dependence), in particular, appear germane to the challenge of implementing practices and programs in depression care. The first reflects the realization that the human ability to learn is constrained by cognitive load (Singley and Anderson, 1989). While some knowledge, such as the use of language, comes naturally and easily (except in unusual circumstances), most knowledge, when first received, has to be processed through the brain’s working memory (Geary, 2002). Although the capacity of working memory varies across individuals, it is unreason- able to expect that the knowledge entailed in often complex interventions can be converted into constructive actions among diverse clinicians on a reliable basis. Effective learning in organized settings generally takes time (Levitt and March, 1988). Clinical care guidelines have had a mixed record of uptake and effective use (Cabana et al., 1999; Grimshaw et al., 2004; Solberg et al., 2000; Stone, Sonnad, and Schweikhart, 2001), and the adop- tion of depression care guidelines, especially among clinicians who do not specialize in mental health, may be impaired in the absence of clear strategy to foster their use. A second principle emerging from research is that learning always oc-

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2 OPPORTUNITIES FOR INNOVATIVE REFORMS curs in a specific time and place and thus is to some extent “sticky” (von Hippel, 1994) or dependent on context (Anderson, Reder, and Simon, 1996). A clinician who learns a new practice is essentially learning two things at one time: first, the generalizable means-ends logic of the practice (i.e., do this and get that result) and, second, the social knowledge (e.g., organizational conditions, environmental cues) accompanying that logic in the context in which it is learned (Anderson et al., 2004; Anderson, Reder, and Simon, 1996; Argote, 1999; Glisson et al., 2008; Taatgen et al., 2008). Many parental depression prevention/screening/community treatment models operate as adjuncts to existing programs that are primarily tasked with providing other services, such as home visitation; primary pediatric or family medical care; daycare; Head Start; and community, social, and faith-based services. As such, adjunctive parental depression programs face the challenge of effective integration within these different settings and co- ordination of services with the primary program’s organizational structure, mission, and goals. Organizational Structure, Leadership, and Climate The structure and processes of an organization can affect its assimila- tion and use of knowledge in adopting an evidence-based practice. Some fixity in how work is organized and conducted offers a learning advantage, even in highly dynamic situations in which a lack of defined structure and process would seem to foster greater adaptability and creativity (Brown and Eisenhardt, 1997). Evidence indicates that some formalization (e.g., the degree of established standards and rules, standardized procedures, defined roles) is necessary to facilitate implementation (Adler and Borys, 1996; Jansen, Van den Bosch, and Volberda, 2005; Knott, 2001; Rosenheck, 2001; Zollo and Winter, 2002). With appropriate structures and routines in place, cognitive and relational effort can be concentrated on the new initiative (Gittell, 2002). Apart from control or influence over resources, organizational leader- ship, particularly in larger organizations, tends to play a more symbolic, tone-setting role than at the group or team level (Sabherwal, Jeyaraj, and Chowa, 2006; Senge, 1990). Research in health care quality improvement suggests that organizational leaders must demonstrate commitment and persistence for their messages about quality to motivate and to be observed by hospital staff (Rousseau and Tijoriwalla, 1999). The culture (shared beliefs about how things are done) and climate (perceptions of the work environment) of organizations have received a good deal of attention from researchers interested in the implementation of evidence-based interventions (Glisson et al., 2008; Hemmelgarn, Glisson,

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22 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN and James, 2006; Saldana et al., 2007; Shortell et al., 2000, 2001). These studies suggest that health care and human services organizations are gov- erned more by institutional factors, such as compliance with professional norms and public regulation, than by market competition factors associated with the behavior of commercial firms (Glisson et al., 2008; Mendel et al., 2008; Scott, 2001; Selznick, 1957). Dissemination Strategies Practices and programs are unlikely to be adopted if people have no knowledge of them. For example, a lack of awareness has been one of the reasons that physicians opt to not follow recommended care guide- lines (Cabana et al., 1999). Intentions are more likely to lead to behavior change if they are coupled with plans for how and when the change will be implemented (Webb and Sheeran, 2006). This finding suggests that dissemination activities that encourage and support potential adopters in thinking through how they would implement it in their context will make the adoption of a new program or practice more likely (Frambach et al., 1998; Glennan, 1998). For example, the Agricultural Cooperative Exten- sion Agent is a model of an iterative, facilitated dissemination in the United States that reaches every county in the United States and has nearly 100 years of proven, rapid dissemination that transformed American farms. Developed by the Agricultural Extension Service, this model was developed to build bridges from land-grant universities doing agricultural science, to the university regional director, to the local field office, to the farmers in the field (Vastag, 2004). In 2009 the American Recovery and Reinvestment Act included a health information technology extension agent function that could be broadened as a method for clinical practice quality improvement and research dissemination (Rural Health Resource Center, 2009). Attributes That Facilitate Program Adoption Diffusion of innovation theory has been a popular way to frame the adoption of innovations in health care and social services (Berwick, 2003; Rogers, 1995). The theory emphasizes five attributes that improve the chances of adoption of an innovation: 1. its relative advantage over existing practice and other, similar innovations; 2. its compatibility with what people already believe and value; 3. its complexity; 4. the extent to which it can be observed in operation; and

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2 OPPORTUNITIES FOR INNOVATIVE REFORMS 5. whether it can be tried on a small scale before a decision needs to be made to implement it fully. Three of the five—relative advantage, compatibility, and complexity—have received more attention than the other two in health care dissemination research (Greenhalgh et al., 2004a). Across a wide range of studies, the evidence of their impact can best be characterized as inconsistent (for re- views, see Damanpour and Schneider, 2006; Greenhalgh et al., 2004b; Rye and Kimberly, 2007). The development of most evidence-based practices and programs fre- quently focuses on the technical knowledge that people need to learn. But the social component of knowledge, without which the technical knowledge remains inert, typically receives relatively little or sometimes no systematic attention or elaboration (Glisson et al., 2008; Ramanujam and Rousseau, 2006). Accordingly, when practices and programs are offered for replica- tion or wider use, the adapters often scramble to figure out how to convert the technical abstractions of the intervention into reliable, concrete action (Olds et al., 2003; Racine, 2004). The vagueness and complexity of the social components also may make it more prone to error during imple- mentation, which in turn may interfere with the intended application of the intervention’s technical requirements. An Example of Guidelines for Adopting Innovations One useful model that illustrates how innovative practices can be intro- duced and sustained in complex organizations involves guidelines prepared by the Agency for Healthcare Research and Quality (AHRQ). Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations strives to assist health care providers and community planners in determining whether or not a given innovation will address their needs and is feasible (Brach et al., 2008). The guide provides generic, but pragmatic, advice on the issues and steps that potential adopters should consider. The guide is organized around four core questions, features active links to websites that contain in-depth information on related topics, and provides a hyperlinked index of public domain implementation tools and an appendix of four case studies. The first core question potential adopters need to consider is “Does the innovation fit?” Related key questions include: Does it work? Where else has it been tried? What—and how good—is the evidence that it works? Does it address fundamental problems and achieve organizational goals? Is it compatible with the organization’s mission, vision, values, and cul- ture? Can it be successfully adapted to improve compatibility with the organization? Each of these key questions is examined in more detail with links to

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN websites providing tools and case studies. One relevant example is the link to an AHRQ website detailing the failure of a program that faxed real-time pharmacy data to alert physicians that patients were not complying with their antidepressant medication regimen. An evaluation found that the criti- cal programmatic weakness was a failure to train physicians and nurses in what to do with the faxed information. Nor was there follow-up with the physicians about what they did with the faxed information. The second core question for potential adopters is “Should we do it here?” Key questions include: What are the benefits? Will these benefits be visible and convincing for stakeholders? What are the necessary resources and costs? Are there potential offsets to the costs, and what is the opportu- nity cost associated with adopting the innovation? How does one prepare a business case? How can potential risks be assessed? Links are provided, for example, to websites containing tools and templates for assessing risk over different timeframes. The third core question is: “Can we do it here?” This section focuses on organizational readiness and the willingness of staff to make the neces- sary changes in what they do. It also considers ways to assess the impact of change on the organization’s stakeholders, such as patients and families, board members, and community partners. What sort of structural, process, and workforce changes will be needed to implement the innovation? Can champions be identified who will promote the innovation by generating enthusiasm, fostering change, bridging communication gaps, and solving problems as they arise? What can the organization learn from its past ef- forts at adopting innovations? Can we do it in time? Examples include links to websites on how to use Gantt charts to plan and track implementation progress. The final core question is “How will we do it here?” Key questions include: How should the program be evaluated? What constitutes mean- ingful measurement of success, and what is the burden of data collection? In response to these questions, links are provided to websites discussing measurement issues as well as to the AHRQ Measures Clearinghouse, a public repository of public domain measures and measure sets. What are the advantages and disadvantages of first trying the innovation for a short period of time or on a small scale? How do we manage change to get staff and stakeholder buy-in? And, finally, how do we sustain an innovation that proves worthy of adoption? Guidelines such as the AHRQ guide lay out the basic principles, com- mon issues, and first steps that should be considered by planners seeking new programs to address unmet needs. However, the generic nature of such guidelines means that potential adopters must creatively interpret their ap- plication to specific programs and settings. Indeed, most evidence-based and promising depression care programs lack detailed implementation manu-

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2 OPPORTUNITIES FOR INNOVATIVE REFORMS als. Nor has there been much effort to systematically study the replication of a given depression care program across multiple sites. Future research involving the replication of a specific program in multiple settings should devote resources to identifying common and unique implementation issues and tasks raised across different sites. A Research Agenda for Dissemination and Implementation of Innovative Strategies The scope and compelling nature of depression in parents and its ef- fects on their family calls for experimentation with programs that have not yet met the highest standard of evidence—that is, longitudinal randomized controlled clinical trials, efficacy and effectiveness studies, effects on clini- cal depression compared with effects on depressive symptoms, and cultural considerations and generalizability. Interventions should be categorized as promising—that is, those with early evidence in some areas that they are effective but are compromised by areas that need further research—or those that are ready to be taken to scale. Both conceptual principles and promising practices should guide large- scale efforts, but large-scale efforts should be undertaken in a staged, sequential fashion. A stage-wide sequential model targeting a few sites in a demonstration area and then gradually moving to scale with careful as- sessment of the first stage of sites is likely to be most valuable. The ultimate goal should be to have system-wide programs for parental depression that incorporate multiple points of entry, employ flexible strategies, and allow for the amounts of services and prevention to be tailored to individual needs and families. We think systems ready for consideration for such dis- semination projects are county health departments, city health departments, specific geographic catchment areas, and those covered by particular kinds of insurance. The following criteria offer guidance in identifying the most fruitful opportunities for dissemination and implementation efforts: • Research-informed interventions tested on majority populations should be adapted, tested, or drawn from more culturally diverse and vulnerable populations in diverse settings and communities. This is especially important given the disparities in access and treatment and the increased prevalence among some groups for depression as well as limits to research and evaluation resources. • Focus the effort to improve depression care to capture the expe- riences and challenges of early adopters and to identify critical components that contribute to success and sustainability, such as leadership, resources, organizational culture, and community support. Expect developers of effective practices and promising

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN programs to define the absorptive capacity that adopters should possess to learn, efficiently and effectively, how to use these inter- ventions as designed. • Expect developers of new depression care models to use their re- search to elaborate the social knowledge required for these models to be assimilated and used effectively. • By aligning quality improvement studies that help improve the approach, those that support implementation of these strategies across diverse programs and settings, and those that support imple- mentation and dissemination of evidence-based programs, it may be possible to clarify where additional work is needed in that par- ticular system and how to extend these programs to other popula- tions and throughout other systems of care. CONCLUSION The research priorities highlighted above provide direction and guid- ance for building a knowledge base that can enhance the development of future programs, policies, and professional practice. But overcoming systemic, workforce, and fiscal challenges as well as the development of new knowledge is not sufficient to ensure its use in the routine efforts of service providers and practitioners to identify, treat, and prevent parental depression and to reduce the impact of this disorder on children. The ap- plication of evidence-based knowledge requires explicit attention to dis- semination, implementation, and the creation of an organizational culture that is intentionally receptive to new research. However, the dissemination and implementation research literature points to no simple paths for ex- tending the reach of effective forms of depression care. Although general guidelines exist to help potential adopters ask pertinent questions, the answers required for the implementation of complex, multidisciplinary, two-generation, large-scale prevention care programs must be drawn by inference from a limited body of research largely focused on other health care and business areas. RECOMMENDATION This chapter highlights priorities for new knowledge development as well as creating policy and learning environments that contribute to suc- cessful innovation, dissemination, and implementation of evidence-based strategies. Together, they identify issues and areas that require attention from policy makers, the research community, and program administrators in order to develop effective programs and collaborative strategies. On the basis of these research opportunities, the committee makes one recommen-

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2 OPPORTUNITIES FOR INNOVATIVE REFORMS dation intended to build the knowledge base and to create incentives to adopt innovative approaches in learning environments that strive to reach those who are in greatest need and those who are most difficult to serve. Promote and Support Research Recommendation 7: Federal agencies, including the National Institutes of Health, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration, should support a collaborative, multiagency research agenda to increase the understanding of risk and protective factors of depression in adults who are parents and the in- teraction of depression and its co-occurring conditions, parenting prac- tices, and child outcomes across developmental stages. This research agenda should include the development and evaluation of empirically based strategies for screening, treatment, and prevention of depressed parents and the effects on their children and improve widespread dis- semination and implementation of these strategies in different services settings for diverse populations of children and their families. In carrying out this recommendation, these federal agencies should consider partnerships with private organizations, employers, and payers to support this research agenda. REFERENCES Adler, P.S., and Borys, B. (1996). Two types of bureaucracy: Enabling and coercive. Adminis- trative Science Quarterly, , 61–89. Anderson, J.R., Bothell, D., Byrne, M.D., Douglass, S., Lebiere, C., and Qin, Y. (2004). An integrated theory of mind. Psychological Bulletin, , 1036–1060. Anderson, J.R., Reder, L.M., and Simon, H.A. (1996). Situated learning and education. Edu- cational Researcher, 2, 5–11. Argote, L. (1999). Organizational Learning: Creating, Retaining, and Transferring Knowl- edge. Norwell, MA: Kluwer Academic. Berwick, D.M. (2003). Disseminating innovations in health care. Journal of the American Medical Association, 29, 1969–1975. Brach, C., Lensfestey, N., Rouseel, A., Amoozegar, J., and Sorenson, A. (2008). Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations. (AHRQ Pub. No. 08-0051.) Rockville, MD: Agency for Healthcare Research and Quality. Brown, S.L., and Eisenhardt, K.M. (1997). The art of continuous change: Linking complexity theory and time-paced evolution in relentlessly shifting organizations. Administrative Science Quarterly, 2, 1–34. Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P.C., and Rubin, H.R. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association, 22, 1458–1465.

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