implementing a mental health- schools-families shared agenda: translating evidence-based practices...

Implementing a Mental Health-Implementing a Mental Health-Schools-Families Shared Agenda: Schools-Families Shared Agenda:

Translating Evidence-basedTranslating Evidence-basedPractices into SchoolsPractices into Schools

Implementing a Mental Health-Implementing a Mental Health-Schools-Families Shared Agenda: Schools-Families Shared Agenda:

Translating Evidence-basedTranslating Evidence-basedPractices into SchoolsPractices into Schools

Kimberly Hoagwood, Ph.D.

Columbia University

May 5, 2003

Kimberly Hoagwood, Ph.D.

Columbia University

May 5, 2003

Key PointsKey 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

Why Schools Matter in Children’s Why Schools Matter in Children’s Mental HealthMental Health

Why Schools Matter in Children’s Why Schools Matter in Children’s Mental HealthMental 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)

World Health Organization: Leading categories World Health Organization: Leading categories of childhood disabilities in established market of childhood disabilities in established market economies for children and adolescents under economies for children and adolescents under

15 years of age15 years of age

Congenital anomalies

Perinatal conditions

Unintentional injuries

Respiratory diseases

1990 ….. 10.2%

2020 ….. 15.6%Neuropsychiatric conditions

23.519.6

21.115.8

16.816.1

5.0 5.7

1990 2020

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

White African-American

Latino Other

Sturm et al., 2000 (from NHIS)

Unmet Need for Mental Health Services

Unmet Need for Mental Health Services

Major Federal Activities on Major Federal Activities on Children’s Mental HealthChildren’s Mental Health

Major Federal Activities on Major Federal Activities on Children’s Mental HealthChildren’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

Common Themes of Federal Common Themes of Federal Initiatives: Implications for School-Initiatives: Implications for School-

based Mental Health based Mental Health

Common Themes of Federal Common Themes of Federal Initiatives: Implications for School-Initiatives: Implications for School-

based Mental Health 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

Psychosocial Treatments

APA’s Division 12 Review of evidence-based therapies, 1998 Kazdin, Psychotherapy for children and adolescents

Oxford, 2000School-Based Approaches

Rones & Hoagwood, School-based mental health services, Clinical Child and Family Psychology Review, 2000Journal 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

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

Interventions

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

Interventions

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

A Dozen Reviews (cont’d)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

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

Strength of the Evidence on Strength of the Evidence on Prevention, Treatment, & ServicesPrevention, Treatment, & Services

What is Evidence?What is Evidence?

APA Psychotherapy Reviews (1998)APA Psychotherapy Reviews (1998)

What is Evidence?What is Evidence?

APA Psychotherapy Reviews (1998)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

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 Adapted from Lonigan, Elbert, & Johnson, 1998; and Chambless, et al., 1998.al., 1998.Adapted from Lonigan, Elbert, & Johnson, 1998; and Chambless, et Adapted from Lonigan, Elbert, & Johnson, 1998; and Chambless, et al., 1998.al., 1998.

What is Evidence?What is Evidence? Youth Violence Report (2001) 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)

Well-Established Probably Efficacious

Behavioral Parent Training Behavioral Interventions in the Classroom

ADHD ADHD Behavioral Management Training

Living with Children Videotape Modeling

Delinquency Prevention Program Parent-Child Interaction Therapy Parent Training Program Time-Out Plus Signal Seat Treatment

DISRUPTIVE BEHAVIORPreschool

DISRUPTIVE BEHAVIORPreschool

Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998

OutpatientPsychotherapies (Externalizing)

OutpatientPsychotherapies (Externalizing)


School AgeSchool Age Anger Coping Therapy Problem Solving Skills Training

AdolescenceAdolescence Anger Control Training with Stress Inoculation Assertiveness Training Multisystemic Therapy Rational-Emotive Therapy

DISRUPTIVE BEHAVIORDISRUPTIVE BEHAVIOR


Outpatient Psychotherapies(Externalizing)

Outpatient Psychotherapies(Externalizing)


None

DEPRESSIONDEPRESSION Self-Control (children) Coping with Depression (adolescents)

None

Participant Modeling Reinforced Practice

ANXIETY

ANXIETY

Cognitive-Behavioral

Imaginal and In Vivo Desensitization Live or Filmed Modeling


Outpatient Psychotherapies(Internalizing)

Outpatient Psychotherapies(Internalizing)

PHOBIASPHOBIAS

Cost Benefit AnalysisCJS and Crime

Costs Per Victim Benefit PerParticipant Dollar of Cost

Early Childhood ProgramsPerry Pre-School (P) $ 13,938.00 $ 1.50Syracuse Family Development (P) 45,092.00 0.34Olds Nurse Home Visitation (BP) 7,403.00 1.54

Middle Childhood ProgramsSeattle Social Development Project (P) 3,017.00 1.79

Adolescent (Non-Offender) ProgramsQuantum Opportunities (BP) 18,292.00 0.13Big Brothers/Big Sisters (BP) 1,009.00 2.12

Juvenile Offender ProgramsMulti-Systemic Therapy (BP) 4,540.00 13.45Functional Family Therapy (BP) 2,068.00 10.99Aggression Replacement Training 404.00 31.40Adolescent Diversion Project 1,509.00 13.61Multidimensional Treatment 1,934.00 22.58

Foster Care (BP)Juvenile Intensive Supervision 1,500.00 1.49Juvenile Boot Camp 1,964.00 0.26

Comprehensive Community-Based Interventions (cont’d)Comprehensive Community-Based Interventions (cont’d)

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 InterventionsComprehensive Community-Based InterventionsComprehensive Community-Based InterventionsComprehensive Community-Based Interventions

Treatment Foster CareTreatment Foster Care

Family Education and SupportFamily Education and Support

MentoringMentoring

Respite Services Respite Services

Crisis ServicesCrisis Services

Treatment Foster CareTreatment Foster Care

Family Education and SupportFamily Education and Support

MentoringMentoring

Respite Services Respite Services

Crisis ServicesCrisis Services

4 RCTs4 RCTs•more rapid improvementmore rapid improvement•decreased aggressiondecreased aggression•better post-discharge outcomesbetter post-discharge outcomes

1 RCT1 RCT•increased knowledge and self-efficacyincreased knowledge and self-efficacy

1 RCT1 RCT•less substance use and aggression;less substance use and aggression;•better school, peer, and family better school, peer, and family

functioningfunctioning

1 quasi-experimental1 quasi-experimental•fewer placementsfewer placements•reduced family stressreduced family stress

0 controlled, 1 pre-post0 controlled, 1 pre-post•placement prevented in 60-90% of placement prevented in 60-90% of

casescases

4 RCTs4 RCTs•more rapid improvementmore rapid improvement•decreased aggressiondecreased aggression•better post-discharge outcomesbetter post-discharge outcomes

1 RCT1 RCT•increased knowledge and self-efficacyincreased knowledge and self-efficacy

1 RCT1 RCT•less substance use and aggression;less substance use and aggression;•better school, peer, and family better school, peer, and family

functioningfunctioning

1 quasi-experimental1 quasi-experimental•fewer placementsfewer placements•reduced family stressreduced family stress

0 controlled, 1 pre-post0 controlled, 1 pre-post•placement prevented in 60-90% of placement prevented in 60-90% of

casescases

Moving beyond listsMoving beyond lists

The role of parents/caregivers as partners in service delivery

Engagement Empowerment

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)

Challenge: Family EngagementChallenge: Family Engagement

Telephone Engagement Telephone Engagement InterventionIntervention

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

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

0

20

40

60

80

100

120

Accepted 1st appt 2nd appt 3rd appt

% for first interview(n=33)

% for comparison(n=74)

M. McKay, 1999

Parent EmpowermentParent 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.

Improving Children’s Mental Improving Children’s Mental Health Through Parent and Health Through Parent and Community EmpowermentCommunity Empowerment

Manual for Parent Advocates and Parents

Center for the Advancement of Children’s Mental Health

Goals of ManualGoals 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

Goals of Manual - - continuedGoals 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

Next steps: Moving Beyond Lists: Next steps: Moving Beyond Lists: 3 New Initiatives3 New Initiatives

Casey Foundation Project on Evidence-Based Practices for Antisocial Youth

Hawaii Experiment (Chorpita et al., 2002) MacArthur Network on Youth Mental

Health

Casey FoundationCasey Foundation

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

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

Hawaii Levels of EvidenceHawaii Levels of Evidence

Autism

Conduct

Depression

Oppositional

Substance

None

None

CBT

Parent/Teacher Training

CBT

None

Multisystemic Therapy

CBT + parents; IPT; Relaxation

Anger Coping; Assertiveness;

PSST

Behavior Tx; Family Tx

ABA; FCT

None

None

None

None

Play Therapy; GIST

Juvenile Justice; Individual Tx

Family Tx; Individual Tx

Relaxation; Individual Tx

Individual Therapy

ADHDBehavior Therapy

None NoneBiofeedback;

Play Tx; GISTNone

None

Group Therapy

None

Group Therapy

Group Therapy

AnxietyCBT; Exposure;

ModelingCBT+ parents;

Ed supportNone

EMDR; Play Tx; GIST

None

ProblemLevel 1

best supportLevel 2

good supportLevel 3

some supportLevel 4

no supportLevel 5

known risks

Example: Efficacy (Chorpita et al., 2002)

Example: Clinical applicationExample: Clinical application

14 year old Depressed Puerto Rican Male Late in semester

Level 2

CBT + parents

Interpersonal

Relaxation

88%

85%

100%

MA; PhD

MA; PhD; MD

MA; PhD

clinic

clinic

school

CBT 94% MA; PhDClinic; school

1.74

1.40

1.51

1.48

Level 1

Intervention Finish

14 to 18

12 to 18

11 to 18

9 to 18

Age Staff Setting Effect

NS

49% PR; 41% HA;

10% C

NS

84% NS; 18%PR; 3%AA

Ethn

7 to 8 weeks

12 weeks

5 to 8 weeks

5 to 16 weeks

Length

Evidence:Interventions for Depression

MacArthur Foundation NetworkMacArthur 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

Strategy: Distillation into Strategy: Distillation into Components (Chorpita, 2000)Components (Chorpita, 2000)

Cross tabulate studies with intervention elements

Use all studies; code each study Yields a matrix demonstrating protocol

overlaps

0%20%40%60%80%100%

Directed PlayLimit Setting

Time OutCost Response

Educational SupportActivity Scheduling

MaintenceSkill Building

Social Skills TrainingTherapist Praise/Rew ards

Natural and Logical ConsequencesCommunication Skills

Assertiveness TrainingParent-monitoring

ModelingIgnoring or DRO

Parent PraiseProblem Solving

Parent copingPsychoed-Parents

RelaxationTangible Rew ards

Self-monitoringCognitive/CopingPsychoed-Child

Exposure

0% 20% 40% 60% 80% 100%

Anxiety and Phobias Depression

ExampleExampleAll

DepA/P

ExtInt

Organizational Constructs in Constructs in Mental HealthMental Health

Organizational Constructs in Constructs in Mental HealthMental 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

Organizational Climate Organizational Climate Factor AnalysisFactor Analysis

(from Glisson & Himmelgarn, 1998)(from Glisson & Himmelgarn, 1998)

Organizational Climate Organizational Climate Factor AnalysisFactor Analysis

(from Glisson & Himmelgarn, 1998)(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

Organizational Impact on Children’s Mental HealthOrganizational 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)

Organizational Constructs in Organizational Constructs in School LiteratureSchool 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)

School ethosSchool 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

Differences in modelsDifferences 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)

Implications for researchImplications 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

Implications for practiceImplications 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

Implications for policyImplications 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

Implications for the structure of Implications for the structure of thoughtthought

“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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