The Problem: The Gaps Between What We Know vs. What we Do for Children’s Mental Health

1. New Wine in Old Bottles? Challenges in Implementing New Practices in Old SystemsPeter S. Jensen, MDRuane Professor of Child Psychiatry, Center for the Advancement of Children’s Mental Health Columbia University College of Physicians and Surgeons New York State Psychiatric Institute

2. The Problem: The Gaps Between What We Know vs. What we Do for Children’s Mental Health • Unmet need as high now as 20 years ago • Unmet need highest among minority youth • System fragmentation major barrier to access (still) • Only 1/3 to 1/5 of children with most severe needs get MH services • Knowledge about child mental health has greatly increased over the past decade—esp. in neurogenesis, behavioral science, prevention, clinical treatments and services

3. National Averages of MH Need National Average MH Need for Children at 6-17: 7.09% Data Source: NSAF wave 1 and 2

4. Geographic Variations in Unmet Need Unmet MHNeed Among Children 6-17: 64.7%

5. Most children with need do not receive any MH services Data from NSAF

6. Unmet need highest among Hispanic children Qualitative insights from comparisons remain valid even if absolute numbers are biased Data from NSAF

7. Non-traditional family structure not associated with more unmet need Data from NSAF

8. Extent of Mental Disorders InU.S. Children and Adolescents 8.0% 7.8% 5.6% 5.0% 1.0% 0.5% Source: Office of the Surgeon General, andNational Institute of Mental Health, 1999

9. The path to long-term negative outcomes for at-risk children and youth

10. Risks of not meeting children’s mental health needs If children’s mental health needs go untreated, the risks are great: • Suicide • School failure and dropout • Injuries, hospitalization • Chronic mental illness • Drug and alcohol use • Violence • Divorce, family break-up • Lifelong dependence on welfare

12. Challenge: Psychotherapies as Provided in Routine Clinic Settings Have Little to No Effect Children & Adolescents Adults University Mean Effect Sizes Clinic settings Weisz et al., 1995

13. So what do we know about: • …the obstacles to dissemination of proven approaches, and where are these obstacles located across the various levels of “the system?” • …what works, in terms of • effective assessment and treatment interventions • effective (vs. ineffective) service models (as well as ineffective models) • effective organizational strategies • effective policies • …how to bring about change in parents, “providers,” policy-makers, organizations • …specific strategies and potential next steps that we can start to do now

14. Barriers vs. “Enhancers” to Delivery of Effective MH Services Three Levels: Child & Family Factors: e.g., Access & Acceptance “Provider” (school, MH) Factors: e.g., Skills, Use of EB, Attitudes Systemic and Societal Factors: e.g., Organizations, Funding Policies EfficaciousTreatments “Effective” Services

15. PARENT Example (MTA): Would You Recommend this Treatment to Another Parent? Medmgt Comb Beh Not recommend 9% 3% 5% Neutral 9% 1% 2% Slightly Recommend 4% 2% 2% Recommend 35% 15% 24% Strongly recommend 43% 79% 67%

16. PROVIDER Example:Treatment Effects on Inattention (teacher)(Community Controls Separated By Med Use) Key Differences, MedMgt vs. CC: Initial Titration Dose Dose Frequency #Visits/year Length of Visits Contact w/schools

17. ORGANIZATIONAL Example: Glisson & Himmelgarn (1998) Parameter Estimates for Hypothesized Six-Variable Model Service Outcomes (problem levels) Organizational Climate -.13* .12* -.24* .02 -.05 Interorganizatnl Services Coordination County Demographics Service Quality -.03 -.36* -.20* .06 .01 Interorganizational Relationships * p < .05

18. Organizational Impact on Children’s Mental Health • The strongest predictor of child improvement was organizational climate (Glisson & Himmelgarn, 1998) • But organizational culture, not climate, explained variations in service quality (Glisson & James, 2002) • Relationship between organizational characteristics and effective implementation of new technologies can be identified, but rarely incorporated into studies of EBPs and their translation into practice • 15,000 Hours: Rutter et al., impact of school environments on children’s outcomes

19. How Has Change Been Attempted? The Bad, the Good, and the Ugly • Parent/Family Approaches • Bad: Finger-wagging, blame, transfer, attrition • Good: Engagement, empowerment • Ugly: Current situation mostly reflects bad strategies • Provider (mental health, schools/clinics) • Bad: CME, CEU, journals • Good: Academic detailing, hands on, MC/II • Ugly: Drug companies only using effective methods • System • Bad: System of Care as the sole answer • Good: MST, Wraparound, Co-location • Ugly: Current fragmentation

20. The Ugly • 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. Barriers to Participation • Triple threat: poverty, single parent status and stress • Concrete obstacles: time, transportation, child care, competing priorities • Attitudes about mental health, stigma • Previous negative experiences with mental health or institutions M. McKay, 1999

22. How Has Change Been Attempted? The Bad: • Parent/Family Approaches • Bad: • Finger-wagging: “you should…” • Blame: “The family is non-compliant and dysfunctional” or “You need to do this, or else I can’t help you.” • Loss by transfer, attrition (“…maybe the family will move away or just stop coming…”) • Ugly: the current situation

23. The Good: Engagement Interventions • Focused telephone procedures associated with increased initial show rates • Structural family therapy telephone engagement intervention associated with 50% decrease in initial no-show rates and a 24% decrease in premature terminations (Szapocznik, 1988; 1997) M. McKay, 1999

24. The Good:Family Engagement Study M. McKay, 1999

25. Other Examples of “the Good” – the “5 Es” • Engage, Evaluate: Elicit concerns, Respond to emotions, Build rapport, Keep questions open-ended, Do not interrupt. • Elicit: How does patient explain illness? • Educate: Tell, Ask: “I think you have…”, “What do you know about...?”, “Let me tell you more about…”, “Can you repeat what I said…?” • Enlist/Negotiate/Review: “Would you be willing to…?” Negotiate: “Why don’t we agree on…?”

26. Implications re: Parents/families • Participation rates can be increased by intensive engagement interventions that are tailored to specific populations • Collaboration, engagement, family input and choice, active problem solving are key M. McKay, 1999

27. THE UGLY: Model vs. Typical Treatments for ADHD Key Differences, MedMgt vs. CC: Initial Titration Dose Dose Frequency #Visits/year Length of Visits Contact w/schools

28. The Good and the Bad: Effectiveness of Interventions by Intervention Type No. of Interventions demonstrating positive or negative/inconclusive change Davis, 2000

29. Implications re: Changing Provider Behaviors • Summary: Changing professional performance is complex - internal, external, and enabling factors • No “magic bullets” to change practice in all circumstances and settings (Oxman, 1995) • Multifaceted interventions targeting different barriers more likely effective than single interventions (Davis, 1999) • Adult learning methods: learner-centered, active, relevant to needs, learn-work-learn • “readiness to change,” Prochaska & DiClemente, 1983 • Little to no theory-based studies, yet are desperately needed due to excessive costs, lack of progress in field • Consensus guideline approach necessary, but not sufficient. Lack of fit w/physicians’ mental models

30. The Good and the Bad: Systems of Care • Ideological commitment to integration of services, family involvement, cultural competence • CASSP--state mh child/adolescent services • Fort Bragg Demonstration Project • Stark County Project

31. System of Care Studies: (Bickman et al.) • Comprehensive and coordinated range of services • Fort Bragg = $94 million, 5 year Demonstration funded by the Army • Quasi-experimental - Demonstration and control sites • Longitudinal - 7 waves of data collection • Sample 1 = 984 families= “outcome sample” • Sample 2 = 8,813 families= “ service use pop”

32. The Good: Demonstration of Increased Access % Served Start of Demonstration June 1, 1990

33. The Good: Fewer drop-outs • More than 3 times as many outpatient clients had only one visit at the comparison (24%) than at the demonstration (7%)

34. The Good: Better continuity of care (fewer breaks in care) At 6 months % in Continuous Care

35. The Good: Parent satisfaction greater • Most aspects of intake and assessment services • Most aspects of outpatient services • Transition and discharge issues in inpatient and outpatient services

36. The Good: Demonstration Sites were rated as having: • Fewer reported system-level problems • Greater quality of mental health services available • Better service system performance • Better adherence to the goals of an ideal service system

37. The Good? Service System Coordination greater High Low

38. The Bad: Outcomes • Child Behavior Checklist (CBCL & YABL) • Youth Self Report (YSR & YASR) • Vanderbilt Functioning Index (VFI) -parent and youth versions • Caregiver Strain Index (CSI) • Family Assessment Device (FAD) • Individualized Measures - most severe subscale, presenting problem - parent and youth

39. The Bad: YSR No differences

40. The Bad: Vanderbilt Functioning Index Shows No Differences

41. More of the The Bad: Average Cost Per Treated Child Higher in DemonstrationN = 8,813 Children Average Cost in $100 Dollars

42. Implications re: Systems Change • Demonstration increased access • Demonstration used less restrictive settings • Greater client satisfaction at Demonstration • But, no differences in clinical outcomes • Clients got better at both sites equally • Relapse was significant and unexplained • Costs significantly higher at Demonstration K. Hoagwood, 2003

43. The Good: 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 2 dozen effective programs targeting risk reduction and treatments • More than 1500 published clinical trials on outcomes of psychotherapies for youth • 6 meta-analyses of their effects • More than 300 published clinical trials on safety/efficacy of psychotropic medications • Approx 50 field trials of community-based services K. Hoagwood, 2003

44. The Good: Available Summaries of Evidence-based Interventions Surgeon General’s Mental Health Report, 1999 Surgeon General’s Youth Violence Report, 2001 Surgeon General’s Report on Culture, Race & Ethnicity, 2002 Weisz & Jensen (1999) Mental Health Services Research Burns, Hoagwood, Mrazek (2000) Child Clinical and Family Psychology Review Burns & Hoagwood (2002) Eds. Evidence-based treatments for youth. Oxford University Press

45. Barriers vs. “Enhancers” to Delivery of Effective MH Services Three Levels: Child & Family Factors: e.g., Access & Acceptance “Provider” (school, MH) Factors: e.g., Skills, Use of EB, Attitudes Systemic and Societal Factors: e.g., Organizations, Funding Policies EfficaciousTreatments “Effective” Services

46. Redesign Attempts to Circumvent Multiple Levels of Obstacles: Wraparound and MST: Common Characteristics • Comprehensive community-based interventions for severe emotional and behavioral disorders • System of care values • Provided at home, in schools, and neighborhoods • Operated within any human service sector • Developed and studied in the ‘real world’ • Trainers and training materials developed • Outcomes monitored • Less expensive than residential care • Fidelity measures

47. Multi-systemic Therapy (MST) Model HOME BASED MODEL (vs. outpatient, inpatient) • Low case load (4-6 families/therapist) • 24 hr./7 day availability of clinicians • Target children at risk of placement • Services provided to the family (& individuals) • Time limited (average 4 months)

48. Consistent MST clinical outcomes In Comparison with Control Groups, MST: • Improved family relations and functioning • Increased school attendance • Decreased adolescent psychiatric symptoms • Decreased adolescent substance use • Decreased long-term rates of rearrest 25% to 70%

49. Missouri Delinquency Project

50. The Good with the Bad: Effective Community-based Services Cost $dollars • 5 RCTs and 1 quasi-experimental • less restrictive placements • some increased functioning • 7 RCTs and 1 quasi-experimental • fewer arrests • fewer placements • decreased aggressive behavior Intensive Case Management (including Wraparound) Cost: $2,500 - 35,000 per year Multisystemic Therapy Cost: $5,063 per year