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Evidence-Based Practices in School-Based Mental Health. Polly Nichols, PhD Adjunct Assistant Professor Child & Adolescent Psychiatry University of Iowa Hospitals & Clinics 319-356-3777 polly-nichols@uiowa.edu. Children’s Mental Health Problems.

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evidence based practices in school based mental health

Evidence-BasedPractices in School-Based Mental Health

Polly Nichols, PhD

Adjunct Assistant Professor

Child & Adolescent Psychiatry

University of Iowa Hospitals & Clinics

319-356-3777

polly-nichols@uiowa.edu

children s mental health problems
Children’s Mental Health Problems
  • 21% of school-age children & adolescents have a “diagnosable mental health problem”
  • 11% have a “significant functional impairment”
  • 5% have an “extreme functional impairment”
children s adolescents mental health diagnoses are unstable
Children’s & adolescents’ mental health diagnoses are unstable
  • Developmental relativity of symptoms
  • Discontinuity of disorders
  • Comorbidity
  • DSM-IV rooted in adult psychopathology
easier to see in retrospect
Easier to see in retrospect . . .

According to the largest survey ever of the nation’s mental health, published in the June 6, 2005 issue of the Archives of General Psychiatry. . .

“One-half of all lifetime cases of mental illness begin by age 14, and despite effective treatments for the disorders, there are long delays between the onset of symptoms and seeking treatment,”

national comorbidity survey replication
National Comorbidity Survey Replication
  • Disorders that emerge in childhood are associated with the longest delays in treatment,even though childhood disorders are often more serious than those that strike later in life. . .

The pattern appears to be

that the earlier in life the disorder

begins, the slower an

individual is to seek therapy.

national comorbidity survey replication6
National Comorbidity Survey Replication

Dangers associated with untreated disorders that strike at a young age:

• school failure,

• teenage childbearing,

• unstable employment,

• early marriage,

• marital instability • and violence.

national comorbidity survey replication7
National Comorbidity Survey Replication
  • Early treatment is simpler and could prevent“enormous disability” later.
  • It also halts the development of co-occurring disorders, which are particularly difficult to get under control, especially as they accumulate.
schools the primary providers of mental health services for children
Schools–the primary providers of mental health services for children
  • 75-80% get no specialized services.
  • Those with diagnoses and functional impairments were 7 times more likely to get services.
  • Of those who did receive services,

70% received them from the schools;for nearly half, schools the sole provider.

slide9
They are psychiatric, psychological, or other such clinical therapeutic services that are . . .

• provided in school facilities

• by qualified mental health professionals

• to groups or individuals

• identified or diagnosed as at-risk or disordered

• and paid for by insurance, family or community funding.

What is SBMH? What are School-Based Mental Health Services?The Licensed Mental Health Provider’s View
what is sbmh what are school based mental health services the educational view
THE EDUCATOR’S VIEW

They are preventive or corrective programs to promote social & emotional development and to prevent violence & aggression

• provided school-wide, to vulnerable groups, or to individuals

• educative in format, taught from manuals

• taught by trained teachers, counselors, school psychologists & social workers

• may be advised or trained by mental health professionals

• largely funded by schools and school- related grants

What is SBMH? What are School-Based Mental Health Services?The Educational View
what is sbmh what are school based mental health services the systems of care view
They are collaborative programs, interconnecting family, community, and school.

• Fully integrated school/community programs for prevention, early intervention, crisis management

• Adelman and Taylor, Mary Armstrong, SAMHSA supported model

• Family centered, strengths- based, comprehensive, Wraparound planning

• Flexibly funded by multiple public & private agencies

What is SBMH? What are School-Based Mental Health Services?The Systems of Care View
slide12

System of Care

Community

Supports

Child

Welfare

Family

Supports

Child &

Family

§©

§©

§©

Behavioral

Health

§©

Juvenile

Justice

§©

§©

School

System

slide13

Behavioral Health Funding Streamsfor Children & Families in the Public Sector

  • MEDICAID
  • Medicaid Inpatient
  • Medicaid Outpatient
  • Rehab Option Svs
  • Medicaid EPSDT
  • MENTAL HEALTH
  • MH General Revenue
  • MH Medicaid Match
  • MH Block Grant
  • EDUCATION
  • ED General Revenue
  • ED Medicaid Match
  • Student Services
  • SUBSTANCE ABUSE
  • SA General Revenue
  • SA Medicaid Match
  • SA Block Grant
  • CHILD WELFARE
  • CW General Revenue
  • CW Medicaid Match
  • IV-E
  • IV-B
  • Adoption and Safe Families Act
  • OTHER
  • TANF
  • Children’s MedicalServices
  • Mental Retardation/Developmental Disabilities
  • Title XXI
  • Local Funds
  • JUVENILE JUSTICE
  • JJ General Revenue
  • JJ Medicaid Match
  • JJ Federal Grants
soc principles sub domain areas of measurement
SOC Principles/Sub-domain Areas of Measurement
  • Children have access to a comprehensive array of services.
  • The system promotes early identification & intervention.
  • Services are received within the least restrictive environment.
  • Services are integrated & coordinated.
  • Children are ensured a smooth transition to adult services when they reach maturity.
  • Services are individualized.
  • Families are included as full participants in service planning & delivery.
  • Case management is provided to ensure service coordination & system navigation.
  • Children receive services regardless of race, religion, national origin, sex, physical disability, or other characteristics.
  • The rights of children are protected.

Stroul & Friedman, 1994

what is sbmh what are school based mental health services the applied behavior analysis view
They are based on data analysis of the behaviors of the total school, from the trouble-free to the SED.

• Positive Behavior (& Intervention) Supports PBS or PBIS, Horner and Sugai, IDEA supported

• Functional behavioral assessment (FBA), behavior intervention plans (BIPs), all behavioral expectations taught and reinforced

• School-wide (universal) , at-risk (targeted), & chronic-severe (intensive) levels of prevention & intervention included

• 80% of staff must support PBS to start

What is SBMH? What are School-Based Mental Health Services?The Applied Behavior Analysis View
slide17

Tertiary Prevention:

Specialized

Individualized

Systems for Students with High-Risk Behavior:

Functional Behavioral Analysis (FBA); Behavior Intervention Plan(BIP)

CONTINUUM OF

SCHOOL-WIDE

POSITIVE BEHAVIOR

SUPPORT (PBS)

Average MS/HS

~5%

~15%

Primary Prevention:

School-/Classroom-

Wide Systems for

All Students,

Staff, & Settings

Secondary Prevention:

Specialized Group

Systems for Students with At-Risk Behavior

~80% of Students

slide18

PBS

POSITIVE

BEHAVIOR

SUPPORTS

(1 - 7%)

(5 - 15%)

(80 - 90%)

Sugai, 1997

10 principles of wraparound
Family voice and choice

Team Based

Natural Supports

Collaboration

Community based

Culturally competent

Individualized

Strengths based

Persistence

Outcomes based

10 Principles of Wraparound

NWI – National Wraparound Initiative, Portland State University. www.rtc.pdx.edu

slide20
Evidence Based Practice

• use of therapies/programs (academic, psychoeducational, cognitive behavioral, pharmacological, alone or in combinations)

• that have been shown by data from two or more careful research studies (or professional boards of review when more suitable) from more than one center

• to be more effective than placebo, the passage of time, or the benefits of special sets of relationships.

• Expected outcomes and methods are clearly described and replicable.

What are School-Based Mental Health Services?NO-CHILD-LEFT-BEHIND’S & THE FEDERAL & IOWA LEGISLATURE’S VIEW
school based mental health iowa pbs school family community view
Who Are The Students?

(In school terms, PBS data terms social/environmental terms,

functional terms, DSM-IV or other diagnostic terms)

Wraparound Suitable:

Others:

5%

Intense

needs

?2.5-3%

Wraparound

suitable

School-Based Mental Health Iowa PBS School/Family/Community view
slide22

CONTINUUM OF

SCHOOL-WIDE

POSITIVE BEHAVIOR

SUPPORT

Iowa Juvenile Home—Toledo

Tertiary Prevention:

-Level III Services

-3:1 Student to teacher ratio

-Functional Behavior Assessments

-Highest level of supervision and security

32%

Secondary Prevention:

-Level II Services

-5:1 Student to teacher ratio

-Limited integration into general education classes

-Targeted Interventions

Primary Prevention:

-General Education

-8:1 Student to teacher ratio

-School-Wide PBS

-Problem Solving Process

-AEA Support Services

-Vocational Programs

Staff, & Settings

~46%

Tertiary

~ 25%

Secondary Prevention

Primary Prevention:

-Level I Services

-8:1 Student to teacher ratio

-School-Wide PBS

-Paraprofessional support

~29%

Primary Prevention

evidence based practices rones hoagwood 2000
Evidence-Based Practices -Rones & Hoagwood, 2000
  • Developmentally appropriate strategies
  • Multi-component programs — for parents, teachers, caregivers
  • Multiple approaches — (e.g., informal sessions combined with skill training)
  • Targeting specific behaviors and skills better than broad, unfocused interventions
  • Strategies integrated into the classroom
  • Consistently implemented; followed with fidelity
evidence based practices
Evidence-Based Practices
  • Developing protective factorsbetter than reducing pre-existing negative behaviors
  • Strategies enhanced when they are sound theoretical foundations
  • Fear-inducing tactics and giving information in lecture format were generally ineffective
  • Long-term strategies more effective thapresence of adult staff or mentors
  • Based on sound research: i.e., have randomly controlled trials, are internally valid and clinically relevant, are clearly described, and have been replicated in more than one site.
schools the primary providers of mental health services for children25
Schools–the primary providers of mental health services for children
  • Offering treatment in schools improves access and reduces early termination from treatment.
  • IDEA and Medicaid Early Periodic Screening Diagnosis and Treatment (EPSDT) dollars have made funding possible.
what about the evidence base for school based mental health services overall
What about the evidence base for school-based mental health services overall?
  • No differences between those seen in clinics and in schools on measures of life stress, violence, family support, self-concept, and emotional behavioral disturbance.
  • Those with high scores on measures of internalizing problems were less likely to have had services in the past. So SBMH may reach children and youth who otherwise would not receive services.

Weist et al, 1999.

what is the evidence for offering mental health care in schools overall
What is the evidence for offering mental health care in schools overall?
  • SBMH greatly enhances mental health program use in disadvantaged areas (Catron et al, 1998);
  • Services are viewed positively by clients (Nabors et al, 1999);
  • They are at least as effective as clinic-based services as measured on the CGAS and GAF for children and the CAFAS and Achenbach for adolescents (Armbruster & Lichtman, 1999);
  • They lead to positive outcomes. (Weist et al, 1996).
summary of the effectiveness for youth of evidence based psychotherapy weisz et al 2005
Summary of the effectiveness for youth of evidence-based psychotherapy -Weisz et al, 2005
  • Average treated child was functioning better than 75% of control group
  • Beneficial treatment effects still evident 6 months later
  • Treatment effects larger for specific targeted problem than for global problems not addressed in treatment
  • Meta analyses of Cognitive Behavior Therapy show substantial effects.
summary of the effectiveness for youth of evidence based psychotherapy weisz et al 200529
Summary of the effectiveness for youth of evidence-based psychotherapy -Weisz et al, 2005
  • Studies of treatment “as usual”in settings in which therapists were able to use their clinical judgment as they saw fit, not constrained by evidence-based interventions or manuals, and in which there was a comparison of their treatment to a “control group” were found to have no treatment benefit.
  • Linking multiple treatments together such as those promoted under systems of care have yet to demonstrate positive effects at the clinical level.
references
References

Armbruster, P., & Lichtman, J. (1999). Are school based mental health services effective? Evidence from 36 inner city schools. Community Mental Health Journal, 35(6),493-504.

Bruns, E.J. (2004) The evidence base and wraparound. (2004). Presentation at the 11th Annual Building of Family Strengths Conference. Portland, OR: Portland State University.

Chapter 3: Children and mental health. U.S. Department of Health and Human Services. Mental Health:A Report of the Surgeon General. (1999). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Mental Health, 1999.

slide31
Grisso, T., (2004). Double Jeopardy: Adolescent offenders with mental disorders.Chicago: University of Chicago Press.

Hunter, L. (2002). School-based interventions for attention deficit and disruptive behavior disorders: A critical review. Draft II. Columbia University. Retrieved from http://pdftohtml.ganjalinux.org/pdf2html.php?url=http%3A%2F%2Fwww.ktgf.org%2FCritical%2520Review%2520Lisa%2520Hunter. pdf

Kutash, K., Duchnowski, A.J. & Lynn, N., (2006). School-based mental health: An empirical guide for decision-makers. Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health institute,Reasearch and Training Center for Children’s Mental Health.

slide32
Osher, D., Dwyer, K., & Jackson, S. (2004). Safe, Supportive, and Successful Schools Step by Step.Longmont, Co: Sopris West.

Policy Leadership Cadre for Mental Health in Schools (2001). Mental health in schools: Guidelines, models, resources, & policy considerations. Los Angeles: Center for Mental Health in Schools at UCLA. Richardson, K. E. (Ed.) (2004). Advances in school-based mental health interventions: Best practices and program models. Kingston, NJ: Civic Research Institute.

Rones, M. & Hoagwood, K. (2000). School-based mental health services: A research review. Clinical Child and Family Psychology Review, 3, 223-241.

slide33
Weist, M. D., Paskewitz, D. A.,Warner, B. S., & Flaherty, L.T. (1996). Treatment outcome of school-based mental health services for urban teenagers. Community Mental Health Journal, 32(2),149-157.