Implementing a Mental HealthSchoolsFamilies Shared Agenda: Translating Evidencebased Practices into

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Implementing a Mental Health-Schools-Families
Shared Agenda Translating Evidence-basedPractic
es into Schools

• Kimberly Hoagwood, Ph.D.
• Columbia University
• May 5, 2003

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Key Points

• 1. Why schools matter in childrens mental health
• 2. Major federal activities related to
  school-based mental health
• 3. Status of evidence-based practices (EBPs) in
  childrens 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

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Why Schools Matter in Childrens 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)

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World Health Organization Leading categories of
childhood disabilities in established market
economies for children and adolescents under 15
years of age
1990 2020

• Congenital anomalies
• Perinatal conditions
• Unintentional injuries
• Respiratory diseases

23.5 19.6 21.1 15.8 16.8 16.1 5.0 5.7
1990 .. 10.2 2020 .. 15.6
Neuropsychiatric conditions
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Unmet Need for Mental Health Services
Sturm et al., 2000 (from NHIS)
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Major Federal Activities on Childrens Mental
Health

• Mental Health A Report of the Surgeon General
  (1999)
• Report of the Surgeon Generals Conference on
  Childrens 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

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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

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Evidence-based Practices Status of the Science
Base on Effective Interventions

•  Psychosocial Treatments
• APAs 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 Generals Mental Health Report, 1999
• Surgeon Generals Youth Violence Report, 2001
• Burns Hoagwood (Eds), Community Treatment for
  Youth,
• Oxford U Press, 2002
• Burns, Hoagwood, Mrazek Child Clinical and
  Family

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12 Major Reviews of Evidence-based Interventions
(1998-2002)

• Chambless Hollon (1998) Defining
  empirically-supported therapies. Journal of
  Consulting Clinical Psychology
• Surgeon Generals 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

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A Dozen Reviews (contd)

• 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 Generals Youth Violence Report, 2001
• Burns Hoagwood (2002) Community treatments for
  youth Oxford University Press

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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

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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.
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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)

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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
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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
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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
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Comprehensive Community-Based Interventions
(contd)

• 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

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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
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Moving beyond lists

• The role of parents/caregivers as partners in
  service delivery
• Engagement
• Empowerment

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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)

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

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Improving Childrens Mental Health Through Parent
and Community Empowerment

• Manual for Parent Advocates and Parents
• Center for the Advancement of Childrens Mental
  Health

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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 childrens mental health problems
• Provide information about specific child mental
  health problems and evidence-based treatments

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Goals of Manual - - continued

• Teach parents treatment management skills
• Increase parents knowledge about their childs
  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

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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

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Casey Foundation

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

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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

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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
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Example Clinical application

• 14 year old
• Depressed
• Puerto Rican
• Male
• Late in semester

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

• Phase 1 National review of effective
  interventions for youth mental healthCochrane
  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

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Strategy Distillation into Components (Chorpita,
2000)

• Cross tabulate studies with intervention elements
• Use all studies code each study
• Yields a matrix demonstrating protocol overlaps

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Example
All
Ext
Int
Dep
A/P
Anxiety and Phobias
Depression
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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 environmentthe norms and
  shared expectations
• Organizational structure refers to the hierarchy
  of power

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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

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Organizational Impact on Childrens 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)

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Organizational Constructs in School Literature

• School climateperceptions 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)

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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

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Differences in models

• School literature no studies of organizational
  culturei.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)

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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

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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

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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

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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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