SchoolBased Mental Health: Complementary or Synergistic

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School-Based Mental Health Complementary or
Synergistic?

• Marc S. Atkins, Ph.D.
• and Elizabeth Talbott, Ph.D.
• University of Illinois at Chicago

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Key Collaborators

• Jaleel Adil, Carl Bell, Dina Birman, Lucille
  Eber, David Farmer, Stacy Frazier, Robert
  Gibbons, Patricia Graczyk, Colette Lueck, Mary
  McKay, Peter Nierman
• National Institute of Mental Health
• R01MH56491, R01MH62629, R21MH067361

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Presentation Goals

• Review limitations of dominant school-based
  mental health models
• Present rationale for alternative model with
  synergistic mental health and educational goals
• Present data from two studies in Chicago Public
  Schools and ongoing collaboration with Illinois
  Office of Mental Health

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Mental Health System Failing Children

• 7.5 million U.S. children with unmet mental
  health need
• Only 21 of children in need receive services
  within year
• Uninsured especially vulnerable

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EffectivenessBridging Science and Service

• Gap in effectiveness from university-based to
  community-based
• Need for research that informs clinical practice
• Need for sustainable services that work in the
  real world

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Why School-Based Mental Health?

• Consistently available resource
• De facto mental health provider
• Children readily available for services

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Clinic-Based School Consultation

• Used inconsistently in clinics despite prominence
  of school problems in clinic-referred children
• Targeted to referred students only and therefore
  difficult to engage teachers
• Recommendations often too complex for teachers to
  manage

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School-Based Mental HealthSchool Health Clinics

• Increase from 120 in 1988 to 1200 in 1998
• Serve 1.1 million students (2 of students)
• Shift from CBMH to hospitals
• Primarily individual counseling
• Parents less involved in services

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Prevention Programs

• Universal interventions primarily focused on
  substance abuse and violence
• Strong evidence for effectiveness when used with
  high fidelity to program goals
• Sustainability difficult to obtain
• Adoption by schools often through school
  improvement plan but fidelity not clear

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Social Emotional Learning

• Emotion regulation, social problem-solving,
  self-control, friendship skills
• Teacher implemented often through character
  education
• Need for teachers to incorporate communication
  and problem-solving into every day interactions
• Links to achievement not confirmed

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Rationale for Synergistic Model

• Schools under tremendous pressure, especially in
  urban communities
• School goals are mental health goals
• Collaboration can benefit both education and
  mental health

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Schools Under Pressure

• Inclusion
• Academic accountability
• Gap between rich and poor

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Inner City Schools Need Help4th Grade Reading
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School ViolenceNational Center for Education
Statistics

• 57 of public schools reported one or more
  violent incident
• 45 of parents fear for childs safety at school
• 40 of teens blame school shootings on peer
  problems

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School ReformMany Players, Few Answers

• Theory should be as simple as possible but no
  simpler. John Tukey
• For every complex problem there is a simple
  solution that is wrong. H. L. Mencken

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School Goals Are Mental Health Goals

• Schooling critical to childrens long-term
  adjustment
• Learning problems evident in 20 to 60 of
  children referred for mental health concerns
• School provides opportunity to impact
  socialization

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Synergistic GoalsPredictors of School Success

• Effective instruction
• Classroom management
• Positive teacher-student relationships
• Parental involvement

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Ecological Models Study of reciprocal relations
among natural elements in an environment

• Context drives behavior
• Multiple influences on behavior
• Enhance existing systemic resources
• Individualized and flexible services

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Ecological Model for School-Based Mental Health
Services

• Improve access for families
• Impact school functioning
• Reliance on indigenous resources

NIMH (R01MH56491)
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PALS Intervention Model
Teacher-centered classroom-based
Systematic Assessment
Collaborative Partnership
Engagement
Family-linked
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Experimental Design

• K-4 children with DBD referred by teachers
• Random assignment of classrooms within grades to
  PALS vs. clinic-based services
• All services billed through Medicaid
• 3 schools, 32 classrooms, 127 families

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Service UsePALS versus Clinic
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Service UseFollow-Up
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You are invited to the PALS Parent Party
Talk about Getting involved with your kids
education
Gladstone Elementary School Thursday, March 18,
1999 Drop in 400pm - 600pm
Child care will be provided.
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Parent ServicesMultiple Opportunities
Percent
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Teacher Retention1-Year

• Teachers describe staff as helpful, supportive,
  and advocates for students
• In year 3, active focus on academic goals in
  addition to behavioral goals

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Teacher Collaboration

• Resistance is bidirectional
• Passive No vs. Active No
• Expert power vs. referent power

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PALS Teachers Target Behaviors
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Mental Health Collaboration

• Year 2 focused on classroom management
• Year 3 added curriculum-based assessment and
  reciprocal peer tutoring

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Impacting Academics Peer Mentoring

• Cross-age tutoring
• At-risk students as effective as others
• Popular with teachers and students

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Impacting Academics Desk Organization Game

• 3rd Grade
• Posted rules
• Demonstration and practice
• Random checks
• Earn 1-7 points
• Classwide reward

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School-Based Services Effects
End of year partial correlations controlling for
pretest scores
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Negative Classroom Behavior Effects

• End of year deterioration (monthly reports
  indicated progress)?
• Worst behaved students get most mental health
  attention?
• Mental health recommendations not appropriate for
  these teachers?
• Clinicians lack influence?

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Teacher Key Opinion LeadersStudy Goals

• To study the influence of KOL teachers on the
  diffusion of information regarding classroom
  behavior management practices
• To facilitate use of recommended strategies by
  classroom teachers for ADHD students in urban low
  income schools
• NIMH (R01MH629591)

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Social Diffusion Theory

• Innovative interventions often initiated by a
  relatively small segment of opinion leaders
• Via modeling, innovations are diffused through
  the population, influencing others
• Rogers (1983) noted that despite their knowledge,
  professional change agents often have little or
  no influence

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Social Diffusion TheoryHistory

• Rogers (1993) observed farmers use of innovative
  techniques
• Coleman et al. (1966) studied diffusion of new
  medicine through social network of physicians
• Kelly et al. (1991, 1992) used popular patrons of
  gay bars to diffuse safe-sex information to gay
  men
• Not studied in schools

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Study Procedures

• Random selection of 10 schools from 64
• Identify KOL teachers through sociometric surveys
  with classroom teachers (n 159)
• KOL teachers mental health staff attend course
  on ADHD best practices
• Study whether KOL teachers are more influential
  with classroom teachers than are mental health
  providers

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KOL TeachersSimilar to Other Teachers
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KOL TeachersBut More Experienced
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Web-based CourseCPS ADHD Manual

• 1 semester graduate course CE credit
• Co-taught in education and psychiatry
• Teachers and mental health providers participated
• Discussion practice
• Academic behavioral strategies

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Year 2Naturalistic Study

• Monitored KOL diffusion efforts (classroom
  teacher reports)
• No mental health provider support
• Classroom teachers
• KOL n 30, Control n 32

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Recommended Strategies

• Peer tutoring
• Curriculum based assessment
• Individual rewards and accommodations
• Class-wide rewards
• School-home notes
• Good behavior game
• Response cost

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KOL Teachers Opportunities to Share
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Type of KOL Support

• Instrumental Support
• Recommended interventions
• Shared materials
• Modeled interventions
• Social Support

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KOL Support Teachers Use of Interventions
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Year 3 KOL Activation Year

• School-wide ADHD in-service training at each
  school
• Mental health provider support provided to all
  teachers
• Classroom Teachers
• KOL n 34, Control n 42

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KOL Involvement

• Participated in ADHD in-service training at their
  school
• Met weekly with mental health staff to consult on
  classroom practices
• Encouraged to provide direct consultation with
  teachers

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Teachers Use of Interventions
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Specific StrategiesProbability of Use by Group
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Mean Effectiveness Across Groups
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Mechanism for KOL Influence

• High correspondence between instrumental and
  social support suggesting a social network effect
• Mental health support not significantly
  associated with teachers use of strategies in
  either condition
• KOL influence appears to accelerate timing of use
  but not effectiveness

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KOL Next Steps

• Activate full mental health support
• Identify strategies to promote KOL modeling and
  coaching through professional development
• Target four predictors of effective teaching

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Bringing It All TogetherIDMH CPS
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Systems of Care-Chicago

• 6 year SAMHSA grant to evaluate system of care
  model for inner city
• Link community mental health agency with
  neighborhood school
• Prevention and intervention
• Tension School goals vs. mental health goals

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Mental Health and School Change in Urban
Communities
Individual
Intensive 10
Level 3
Classroom-based
Targeted 40
Level 2
School-wide
Universal 50
Level 1
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Effective CollaborationComplementary or
Synergistic?

• Should universal interventions focus on
  predictors of student learning or social
  emotional learning?
• Should targeted interventions focus on at-risk
  students or at-risk teachers?
• Should intensive interventions address school or
  family stressors?
• Can we do it all?

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Teacher SupportWhat Can MH Staff Do?

• Supportive and therapeutic relationships
• Link teachers to each other
• Support students learning
• Skill development (classroom management, stress
  management, parent involvement, curriculum
  development)

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ConclusionComplementary or Synergistic?

• Urban schools and mental health system have
  pressing needs for strong collaboration
• Key indicators of effective learning are
  appropriate goals for childrens mental health
• Synergistic school and mental health goals can
  improve both systems by integrating mental health
  services into the ongoing context of childrens
  development