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Implementing a Mental Health-Schools-Families Shared Agenda: Translating Evidence-based Practices into Schools

Implementing a Mental Health-Schools-Families Shared Agenda: Translating Evidence-based Practices into Schools. Kimberly Hoagwood, Ph.D. Columbia University May 5, 2003. Key Points. 1. Why schools matter in children’s mental health

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Implementing a Mental Health-Schools-Families Shared Agenda: Translating Evidence-based Practices into Schools

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  1. Implementing a Mental Health-Schools-Families Shared Agenda: Translating Evidence-basedPractices into Schools Kimberly Hoagwood, Ph.D. Columbia University May 5, 2003

  2. Key Points 1. Why schools matter in children’s mental health 2. Major federal activities related to school-based mental health 3. Status of evidence-based practices (EBPs) in children’s mental health 4. Challenges: Caregiver engagement and empowerment 5. Challenges: Organizational context and the fit between EBPs and schools 6. Implications for research, policy and practice

  3. Why Schools Matter in Children’s Mental Health • 76% of children with an identified mental health need receive no treatments or services (Sturm et al., 2001) • 70-80% of children who receive mental health services receive them in the schools (Burns, et al, 1995) • Unmet need is highest among minority children (NIMH, 2001; Sturm, et al., 2001)

  4. World Health Organization: Leading categories of childhood disabilities in established market economies for children and adolescents under 15 years of age Congenital anomalies Perinatal conditions Unintentional injuries Respiratory diseases 19902020 23.5 19.6 21.1 15.8 16.8 16.1 5.0 5.7 1990 ….. 10.2% 2020 ….. 15.6% Neuropsychiatric conditions

  5. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% White African- Latino Other American Unmet Need for Mental Health Services Sturm et al., 2000 (from NHIS)

  6. Major Federal Activities on Children’s Mental Health • Mental Health: A Report of the Surgeon General (1999) • Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda (2000) • Youth Violence: A Report of the Surgeon General (2001) • National Strategy for Suicide Prevention (2001) • Blueprint for Change: Research on Child and Adolescent Mental Health (NIMH, 2001) • Mental Health, Schools & Families Working Together: NASMHPD and NASDSE, 2002

  7. Common Themes of Federal Initiatives: Implications for School-based Mental Health • Public health perspective on mental health • Public health implies prevention, risk reduction, early intervention • Schools: key link to the broad health community • Science base on assessment, prevention, and treatments exists but is rarely applied: opportunities for schools • Schools – key venue for reducing stigma

  8. Evidence-based Practices: Status of the Science Base on Effective Interventions Psychosocial Treatments • APA’s Division 12 Review of evidence-based therapies, 1998 • Kazdin, Psychotherapy for children and adolescents • Oxford, 2000 School-Based Approaches Rones & Hoagwood, School-based mental health services, Clinical Child and Family Psychology Review, 2000 Journal of School Psychology: Special Issue, 2003 Psychopharmacology JAACAP special issue on psychopharmacology, 1999 Weisz & Jensen, Mental Health Services Research, 1999 Treatments, Preventive Interventions, and Services • Surgeon General’s Mental Health Report, 1999 • Surgeon General’s Youth Violence Report, 2001 • Burns & Hoagwood (Eds), Community Treatment for Youth, • Oxford U Press, 2002 • Burns, Hoagwood, Mrazek Child Clinical and Family • Psychology Review 2000

  9. 12 Major Reviews of Evidence-based Interventions (1998-2002) • Chambless & Hollon (1998) Defining empirically-supported therapies. Journal of Consulting & Clinical Psychology • Surgeon General’s Mental Health Report, 1999 • Weisz & Jensen (1999) Mental Health Services Research • Journal of the Am. Academy of Child/Adol. Psychiatry, 1999 • Olds et al., (1999) Review of Preventive Interventions, Center for Mental Health Services • Greenberg, et al., (1999) Review of the Effectiveness of Prevention Programs, CMHS

  10. A Dozen Reviews (cont’d) • Burns, Hoagwood, & Mrazek (2000) Effective treatments for mental disorders in children and adolescents, Child Clinical and Family Psych Rvw • Rones & Hoagwood (2000) School based mental health services review. Clinical Child and Family Psychology Review • Kazdin (2000) Psychotherapy for children and adolescents Oxford University Press • Greenberg, et al., (2001) Prevention of mental disorders in school-aged children. Prevention & Treatment • Surgeon General’s Youth Violence Report, 2001 • Burns & Hoagwood (2002) Community treatments for youth: Oxford University Press

  11. Strength of the Evidence on Prevention, Treatment, & Services • Two major reviews of preventive intervention trials in past 3 years; 34 effective interventions cited by Greenberg et al, 1999, focused largely on parenting and school-delivered interventions • Reviews of school-based services (Rones & Hoagwood, 2000) identified 47 school programs targeting risk reduction and treatments • More than 1500 published clinical trials on outcomes of psychotherapies for youth • 6 meta-analyses of psychotherapy • More than 300 published clinical trials on safety/efficacy of psychotropic medications • Approx 50 field trials of community-based services

  12. What is Evidence?APA Psychotherapy Reviews (1998) • At least two controlled group design studies or a large series of single-case design studies • Minimum of two investigators • Use of a treatment manual • Uniform therapist training and adherence • True clinical samples of youth • Tests of clinical significance of outcomes • Functioning outcomes plus symptoms • Long-term outcomes beyond termination Adapted from Lonigan, Elbert, & Johnson, 1998; and Chambless, et al., 1998.

  13. What is Evidence? Youth Violence Report (2001) • Model • Rigorous experimental/quasi-experimental design • Significant deterrent effects on: • Level 1: violence or serious delinquency • Level 2: strong risk factors (effect size >0.3) • Replication with demonstrated effects • Long-term sustainability (1 year)

  14. Outpatient Psychotherapies (Externalizing) Well-Established Probably Efficacious ADHD • Behavioral Management • Training • Behavioral Parent Training • Behavioral Interventions in • the Classroom DISRUPTIVE BEHAVIOR Preschool • Delinquency Prevention • Program • Parent-Child Interaction • Therapy • Parent Training Program • Time-Out Plus Signal Seat Treatment • Living with Children • Videotape Modeling Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998

  15. Outpatient Psychotherapies (Externalizing) Well-Established Probably Efficacious DISRUPTIVE BEHAVIOR School Age • Anger Coping Therapy • Problem Solving Skills Training Adolescence • Anger Control Training • with Stress Inoculation • Assertiveness Training • Multisystemic Therapy • Rational-Emotive Therapy Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998

  16. Outpatient Psychotherapies (Internalizing) Well-Established Probably Efficacious DEPRESSION • Self-Control (children) • Coping with Depression • (adolescents) • None ANXIETY • Cognitive-Behavioral • Imaginal and In Vivo • Desensitization • Live or Filmed Modeling • None • Participant Modeling • Reinforced Practice PHOBIAS Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998

  17. Intensive case management (including wraparound) Multisystemic therapy (MST) 5 RCTs and 1 quasi-experimental less restrictive placements some increased functioning 22 studies (effect size .38-1.5; above .80 for 5) 70-90% remain with family reduced aggression, fiscal savings Comprehensive Community-Based Interventions (cont’d)

  18. Comprehensive Community-Based Interventions 4 RCTs • more rapid improvement • decreased aggression • better post-discharge outcomes 1 RCT • increased knowledge and self-efficacy 1 RCT • less substance use and aggression; • better school, peer, and family functioning 1 quasi-experimental • fewer placements • reduced family stress 0 controlled, 1 pre-post • placement prevented in 60-90% of cases Treatment Foster Care Family Education and Support Mentoring Respite Services Crisis Services

  19. Moving beyond lists • The role of parents/caregivers as partners in service delivery • Engagement • Empowerment

  20. Challenge: Family Engagement • 40-60% families may drop out of services before their formal completion (Kazdin et al., 1997) • Children from vulnerable populations are less likely to stay in treatment past the 1st session (Kazdin, 1993) • Factors related to drop-out: Stressors associated with treatment, treatment irrelevance, poor relationship with therapist (Kazdin et al., 1997)

  21. Telephone Engagement Intervention • 30 minute telephone intervention • Relies on an understanding of child, family, community and system level barriers to mental health care • Goals: 1) clarify the need for mental health care; 2) increase caregiver investment and efficacy M. McKay, 1999

  22. Family Engagement StudyMcKay et al., 1999 M. McKay, 1999

  23. Parent Empowerment • 1 randomized trial: Bickman & Heflinger • Professionally-delivered empowerment training for parents • Results: significant improvement at 1 year in self-efficacy, knowledge, & skills among parents • Next: Parent-driven empowerment: Put empowerment program in the hands of parent advocates.

  24. Improving Children’s Mental Health Through Parent and Community Empowerment Manual for Parent Advocates and Parents Center for the Advancement of Children’s Mental Health

  25. Goals of Manual • Improve the mental health of children by promoting: • parent/mental health provider partnerships • parent/teacher partnerships • Enhance parent advocates’ ability to: • Engage parents who are seeking help • Provide support and advocacy • Understand children’s mental health problems • Provide information about specific child mental health problems and evidence-based treatments

  26. Goals of Manual - - continued • Teach parents treatment management skills • Increase parents’ knowledge about their child’s mental health needs and evidence-based service delivery options • Strengthen parents’ self-efficacy in their interactions with mental health service providers • Improve the communication and assertiveness skills of parents

  27. Next steps: Moving Beyond Lists: 3 New Initiatives • Casey Foundation Project on Evidence-Based Practices for Antisocial Youth • Hawaii Experiment (Chorpita et al., 2002) • MacArthur Network on Youth Mental Health

  28. Casey Foundation • Can Multisystemic Therapy (MST), Functional Family Therapy (FFT), and Multidimensional Treatment Foster Care (TFC) be integrated to create a continuum of services?

  29. Hawaii Levels of Evidence • Review science base collaboratively • 14-member team of parents, state-policy, researchers • School-based delivery • Level 1: Best support • Level 2: Good support • Level 3: Some support • Level 4: No support • Level 5: Known risks

  30. Example: Efficacy (Chorpita et al., 2002) Problem Level 1 best support Level 2 good support Level 3 some support Level 4 no support Level 5 known risks Anxiety CBT; Exposure; Modeling CBT+ parents; Ed support None EMDR; Play Tx; GIST None ADHD Behavior Therapy None None Biofeedback; Play Tx; GIST None Autism None None ABA; FCT Play Therapy; GIST None Conduct None Multisystemic Therapy None Juvenile Justice; Individual Tx Group Therapy Depression CBT CBT + parents; IPT; Relaxation None Family Tx; Individual Tx None Oppositional Parent/Teacher Training Anger Coping; Assertiveness; PSST None Relaxation; Individual Tx Group Therapy Substance CBT Behavior Tx; Family Tx None Individual Therapy Group Therapy

  31. Example: Clinical application • 14 year old • Depressed • Puerto Rican • Male • Late in semester

  32. Evidence: Interventions for Depression Intervention Finish Age Ethn Staff Length Setting Effect Level 1 CBT 94% 9 to 18 84% NS; 18%PR; 3%AA MA; PhD 5 to 16 weeks Clinic; school 1.74 Level 2 CBT + parents 88% 14 to 18 NS MA; PhD 7 to 8 weeks clinic 1.40 Interpersonal 85% 12 to 18 49% PR; 41% HA; 10% C MA; PhD; MD 12 weeks clinic 1.51 Relaxation 100% 11 to 18 NS MA; PhD 5 to 8 weeks school 1.48

  33. Evidence: Interventions for Depression Intervention Finish Age Ethn Staff Length Setting Effect Level 1 CBT 94% 9 to 18 84% NS; 18%PR; 3%AA MA; PhD 5 to 16 weeks Clinic; school 1.74 Level 2 CBT + parents 88% 14 to 18 NS MA; PhD 7 to 8 weeks clinic 1.40 Interpersonal 85% 12 to 18 49% PR; 41% HA; 10% C MA; PhD; MD 12 weeks clinic 1.51 Relaxation 100% 11 to 18 NS MA; PhD 5 to 8 weeks school 1.48

  34. MacArthur Foundation Network • Phase 1: National review of effective interventions for youth mental health—Cochrane Collaborative “good housekeeping seal” • Phase 2: Test impact of modularized, component driven interventions vs manualized • Phase 3: Examine variations in organizational readiness for uptake of innovative practices

  35. Strategy: Distillation into Components (Chorpita, 2000) • Cross tabulate studies with intervention elements • Use all studies; code each study • Yields a matrix demonstrating protocol overlaps

  36. Example All Int Ext A/P Dep Anxiety and Phobias Depression

  37. Organizational Constructs in Mental Health • Organizational climate reflects perceptions of the work environment and has been linked with child outcomes in studies of child welfare agencies (Glisson &Himmelgarn, 1998) • Organizational culture refers to the ways things are done in a work environment—the norms and shared expectations • Organizational structure refers to the hierarchy of power

  38. Organizational Climate Factor Analysis(from Glisson & Himmelgarn, 1998) • 5 factors account for 50% of variance in organizational climate • Factor 1= Clarity of roles,responsibilities • Factor 2 = Depersonalization • Factor 3 =Unfair/inequitable practice • Factor 4 = Role overload • Factor 5 = Growth & advancement

  39. Organizational Impact on Children’s Mental Health • Relationship between organizational characteristics and effective implementation of new technologies can be identified (Glisson, 1996), but is rarely incorporated into studies of EBPs and their translation into practice. • The strongest predictor of child improvement in a study of child casework agencies was organizational climate (Glisson & Himmelgarn, 1998) • But organizational culture, not climate, explained variations in service quality (Glisson & James, 2002)

  40. Organizational Constructs in School Literature • School climate=perceptions of the physical and psychological environment (Reynolds, 1989) • Teacher-student relationships, admin leadership, security/maintenance, student academic orientation, parent/school relationships, principal behaviors, collegiality (Kelley, 1986; Hoy, Tarter, Kottkamp, 1991) • Affects school adjustment, school achievement, self-esteem, motivation to learn, student learning (Beane & Lipka, 1984; Esposito, 1999; Hoge, Smit, Hanson, 1990; Jaertel & Walberg, 1997; Moos, 1987)

  41. School ethos • Rutter et al 1979: school ethos (internal org of school) predicted school achievement, attendance, & behavior • Factors predicting outcomes: degree of academic emphasis, availability of incentives and rewards, degree to which students could take responsibility in school

  42. Differences in models • School literature: no studies of organizational culture—i.e., the normative expectations about behavior, values, and assumptions • No studies of power structure within schools and within school districts (such as flexibility, discretion, hierarchy of authority, division of labor)

  43. Implications for research • Measure impact of mental health programs on educational outcomes. • Measure impact of educational interventions on mental health outcomes. • Examine impact of school organizational culture, climate, structure and readiness on mental health outcomes • Organizational factors that may matter: leadership style, school links to other healthcare systems, teacher attitudes, teacher stress, clarity of roles, autonomy

  44. Implications for practice • EBPs need adaptation to fit within school context. The process of adaptation can be measured and monitored • EBP development from the bottom up: evidence-farming; parent and youth involvement • Must be developed and implemented collaboratively

  45. Implications for policy • Attend to incentive/disincentive structures that may reward or punish adoption of new EBP technologies • Fiscal flexibility needed: Adoption/improvement may stand or fall upon fiscal policies that are aligned or misaligned with new EBP technologies

  46. Implications for the structure of thought • “New technologies alter the structure of our interests: the things we think about. They alter the character of our symbols: the things we think with. And they alter the nature of community: the arena in which thoughts develop.” (Neil Postman, Technopoly, p. 20)

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