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Evidence-Based Practices in School-Based Mental Health

Evidence-Based Practices in School-Based Mental Health. Polly Nichols, PhD Adjunct Assistant Professor Child & Adolescent Psychiatry University of Iowa Hospitals & Clinics 319-356-3777 polly-nichols@uiowa.edu. Children’s Mental Health Problems.

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Evidence-Based Practices in School-Based Mental Health

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  1. Evidence-BasedPractices in School-Based Mental Health Polly Nichols, PhD Adjunct Assistant Professor Child & Adolescent Psychiatry University of Iowa Hospitals & Clinics 319-356-3777 polly-nichols@uiowa.edu

  2. Children’s Mental Health Problems • 21% of school-age children & adolescents have a “diagnosable mental health problem” • 11% have a “significant functional impairment” • 5% have an “extreme functional impairment”

  3. Children’s & adolescents’ mental health diagnoses are unstable • Developmental relativity of symptoms • Discontinuity of disorders • Comorbidity • DSM-IV rooted in adult psychopathology

  4. Easier to see in retrospect . . . According to the largest survey ever of the nation’s mental health, published in the June 6, 2005 issue of the Archives of General Psychiatry. . . “One-half of all lifetime cases of mental illness begin by age 14, and despite effective treatments for the disorders, there are long delays between the onset of symptoms and seeking treatment,”

  5. National Comorbidity Survey Replication • Disorders that emerge in childhood are associated with the longest delays in treatment,even though childhood disorders are often more serious than those that strike later in life. . . The pattern appears to be that the earlier in life the disorder begins, the slower an individual is to seek therapy.

  6. National Comorbidity Survey Replication Dangers associated with untreated disorders that strike at a young age: • school failure, • teenage childbearing, • unstable employment, • early marriage, • marital instability • and violence.

  7. National Comorbidity Survey Replication • Early treatment is simpler and could prevent“enormous disability” later. • It also halts the development of co-occurring disorders, which are particularly difficult to get under control, especially as they accumulate.

  8. Schools–the primary providers of mental health services for children • 75-80% get no specialized services. • Those with diagnoses and functional impairments were 7 times more likely to get services. • Of those who did receive services, 70% received them from the schools;for nearly half, schools the sole provider.

  9. They are psychiatric, psychological, or other such clinical therapeutic services that are . . . • provided in school facilities • by qualified mental health professionals • to groups or individuals • identified or diagnosed as at-risk or disordered • and paid for by insurance, family or community funding. What is SBMH? What are School-Based Mental Health Services?The Licensed Mental Health Provider’s View

  10. THE EDUCATOR’S VIEW They are preventive or corrective programs to promote social & emotional development and to prevent violence & aggression • provided school-wide, to vulnerable groups, or to individuals • educative in format, taught from manuals • taught by trained teachers, counselors, school psychologists & social workers • may be advised or trained by mental health professionals • largely funded by schools and school- related grants What is SBMH? What are School-Based Mental Health Services?The Educational View

  11. They are collaborative programs, interconnecting family, community, and school. • Fully integrated school/community programs for prevention, early intervention, crisis management • Adelman and Taylor, Mary Armstrong, SAMHSA supported model • Family centered, strengths- based, comprehensive, Wraparound planning • Flexibly funded by multiple public & private agencies What is SBMH? What are School-Based Mental Health Services?The Systems of Care View

  12. System of Care Community Supports Child Welfare Family Supports Child & Family §© §© §© Behavioral Health §© Juvenile Justice §© §© School System

  13. Behavioral Health Funding Streamsfor Children & Families in the Public Sector • MEDICAID • Medicaid Inpatient • Medicaid Outpatient • Rehab Option Svs • Medicaid EPSDT • MENTAL HEALTH • MH General Revenue • MH Medicaid Match • MH Block Grant • EDUCATION • ED General Revenue • ED Medicaid Match • Student Services • SUBSTANCE ABUSE • SA General Revenue • SA Medicaid Match • SA Block Grant • CHILD WELFARE • CW General Revenue • CW Medicaid Match • IV-E • IV-B • Adoption and Safe Families Act • OTHER • TANF • Children’s MedicalServices • Mental Retardation/Developmental Disabilities • Title XXI • Local Funds • JUVENILE JUSTICE • JJ General Revenue • JJ Medicaid Match • JJ Federal Grants

  14. SOC Principles/Sub-domain Areas of Measurement • Children have access to a comprehensive array of services. • The system promotes early identification & intervention. • Services are received within the least restrictive environment. • Services are integrated & coordinated. • Children are ensured a smooth transition to adult services when they reach maturity. • Services are individualized. • Families are included as full participants in service planning & delivery. • Case management is provided to ensure service coordination & system navigation. • Children receive services regardless of race, religion, national origin, sex, physical disability, or other characteristics. • The rights of children are protected. Stroul & Friedman, 1994

  15. Iowa Instructional Supports

  16. They are based on data analysis of the behaviors of the total school, from the trouble-free to the SED. • Positive Behavior (& Intervention) Supports PBS or PBIS, Horner and Sugai, IDEA supported • Functional behavioral assessment (FBA), behavior intervention plans (BIPs), all behavioral expectations taught and reinforced • School-wide (universal) , at-risk (targeted), & chronic-severe (intensive) levels of prevention & intervention included • 80% of staff must support PBS to start What is SBMH? What are School-Based Mental Health Services?The Applied Behavior Analysis View

  17. Tertiary Prevention: Specialized Individualized Systems for Students with High-Risk Behavior: Functional Behavioral Analysis (FBA); Behavior Intervention Plan(BIP) CONTINUUM OF SCHOOL-WIDE POSITIVE BEHAVIOR SUPPORT (PBS) Average MS/HS ~5% ~15% Primary Prevention: School-/Classroom- Wide Systems for All Students, Staff, & Settings Secondary Prevention: Specialized Group Systems for Students with At-Risk Behavior ~80% of Students

  18. PBS POSITIVE BEHAVIOR SUPPORTS (1 - 7%) (5 - 15%) (80 - 90%) Sugai, 1997

  19. Family voice and choice Team Based Natural Supports Collaboration Community based Culturally competent Individualized Strengths based Persistence Outcomes based 10 Principles of Wraparound NWI – National Wraparound Initiative, Portland State University. www.rtc.pdx.edu

  20. Evidence Based Practice • use of therapies/programs (academic, psychoeducational, cognitive behavioral, pharmacological, alone or in combinations) • that have been shown by data from two or more careful research studies (or professional boards of review when more suitable) from more than one center • to be more effective than placebo, the passage of time, or the benefits of special sets of relationships. • Expected outcomes and methods are clearly described and replicable. What are School-Based Mental Health Services?NO-CHILD-LEFT-BEHIND’S & THE FEDERAL & IOWA LEGISLATURE’S VIEW

  21. Who Are The Students? (In school terms, PBS data terms social/environmental terms, functional terms, DSM-IV or other diagnostic terms) Wraparound Suitable: Others: 5% Intense needs ?2.5-3% Wraparound suitable School-Based Mental Health Iowa PBS School/Family/Community view

  22. CONTINUUM OF SCHOOL-WIDE POSITIVE BEHAVIOR SUPPORT Iowa Juvenile Home—Toledo Tertiary Prevention: -Level III Services -3:1 Student to teacher ratio -Functional Behavior Assessments -Highest level of supervision and security 32% Secondary Prevention: -Level II Services -5:1 Student to teacher ratio -Limited integration into general education classes -Targeted Interventions Primary Prevention: -General Education -8:1 Student to teacher ratio -School-Wide PBS -Problem Solving Process -AEA Support Services -Vocational Programs Staff, & Settings ~46% Tertiary ~ 25% Secondary Prevention Primary Prevention: -Level I Services -8:1 Student to teacher ratio -School-Wide PBS -Paraprofessional support ~29% Primary Prevention

  23. Evidence-Based Practices -Rones & Hoagwood, 2000 • Developmentally appropriate strategies • Multi-component programs — for parents, teachers, caregivers • Multiple approaches — (e.g., informal sessions combined with skill training) • Targeting specific behaviors and skills better than broad, unfocused interventions • Strategies integrated into the classroom • Consistently implemented; followed with fidelity

  24. Evidence-Based Practices • Developing protective factorsbetter than reducing pre-existing negative behaviors • Strategies enhanced when they are sound theoretical foundations • Fear-inducing tactics and giving information in lecture format were generally ineffective • Long-term strategies more effective thapresence of adult staff or mentors • Based on sound research: i.e., have randomly controlled trials, are internally valid and clinically relevant, are clearly described, and have been replicated in more than one site.

  25. Schools–the primary providers of mental health services for children • Offering treatment in schools improves access and reduces early termination from treatment. • IDEA and Medicaid Early Periodic Screening Diagnosis and Treatment (EPSDT) dollars have made funding possible.

  26. What about the evidence base for school-based mental health services overall? • No differences between those seen in clinics and in schools on measures of life stress, violence, family support, self-concept, and emotional behavioral disturbance. • Those with high scores on measures of internalizing problems were less likely to have had services in the past. So SBMH may reach children and youth who otherwise would not receive services. Weist et al, 1999.

  27. What is the evidence for offering mental health care in schools overall? • SBMH greatly enhances mental health program use in disadvantaged areas (Catron et al, 1998); • Services are viewed positively by clients (Nabors et al, 1999); • They are at least as effective as clinic-based services as measured on the CGAS and GAF for children and the CAFAS and Achenbach for adolescents (Armbruster & Lichtman, 1999); • They lead to positive outcomes. (Weist et al, 1996).

  28. Summary of the effectiveness for youth of evidence-based psychotherapy -Weisz et al, 2005 • Average treated child was functioning better than 75% of control group • Beneficial treatment effects still evident 6 months later • Treatment effects larger for specific targeted problem than for global problems not addressed in treatment • Meta analyses of Cognitive Behavior Therapy show substantial effects.

  29. Summary of the effectiveness for youth of evidence-based psychotherapy -Weisz et al, 2005 • Studies of treatment “as usual”in settings in which therapists were able to use their clinical judgment as they saw fit, not constrained by evidence-based interventions or manuals, and in which there was a comparison of their treatment to a “control group” were found to have no treatment benefit. • Linking multiple treatments together such as those promoted under systems of care have yet to demonstrate positive effects at the clinical level.

  30. References Armbruster, P., & Lichtman, J. (1999). Are school based mental health services effective? Evidence from 36 inner city schools. Community Mental Health Journal, 35(6),493-504. Bruns, E.J. (2004) The evidence base and wraparound. (2004). Presentation at the 11th Annual Building of Family Strengths Conference. Portland, OR: Portland State University. Chapter 3: Children and mental health. U.S. Department of Health and Human Services. Mental Health:A Report of the Surgeon General. (1999). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Mental Health, 1999.

  31. Grisso, T., (2004). Double Jeopardy: Adolescent offenders with mental disorders.Chicago: University of Chicago Press. Hunter, L. (2002). School-based interventions for attention deficit and disruptive behavior disorders: A critical review. Draft II. Columbia University. Retrieved from http://pdftohtml.ganjalinux.org/pdf2html.php?url=http%3A%2F%2Fwww.ktgf.org%2FCritical%2520Review%2520Lisa%2520Hunter. pdf Kutash, K., Duchnowski, A.J. & Lynn, N., (2006). School-based mental health: An empirical guide for decision-makers. Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health institute,Reasearch and Training Center for Children’s Mental Health.

  32. Osher, D., Dwyer, K., & Jackson, S. (2004). Safe, Supportive, and Successful Schools Step by Step.Longmont, Co: Sopris West. Policy Leadership Cadre for Mental Health in Schools (2001). Mental health in schools: Guidelines, models, resources, & policy considerations. Los Angeles: Center for Mental Health in Schools at UCLA. Richardson, K. E. (Ed.) (2004). Advances in school-based mental health interventions: Best practices and program models. Kingston, NJ: Civic Research Institute. Rones, M. & Hoagwood, K. (2000). School-based mental health services: A research review. Clinical Child and Family Psychology Review, 3, 223-241.

  33. Weist, M. D., Paskewitz, D. A.,Warner, B. S., & Flaherty, L.T. (1996). Treatment outcome of school-based mental health services for urban teenagers. Community Mental Health Journal, 32(2),149-157.

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