· --
17th Annual Research Conference
Exploring the Research Base on Resilience:
Implications for Systems of Care
A System of Care for
Children's Mental Health:
Expanding the Research Base
A Workshop
Wednesday, March 3. 2004
9:00 A.M. - 12:00 Noon
Nancy J. Davis , Ed.D.
Public Health Advisor
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Division of Prevention, Traumatic Stress. & Special Programs
Prevention Initiatives and Priority Programs Development Branch
February 29 - March 3, 2004
Tampa, Florida
2
NO's Credo
SAMHSA Mission
There is no magic here; resitient children have
been protected by the actions of adults, by
good nurturing, by their assets, and by
opportunities to succeed. The great danger I
see in the idea of resilience is in expecting
children to overcome deprivation and danger
on their own....We cannot stand by as the
infrastructure for child development collapses in
this nation, expecting miracles.
Building Resilience
&
Facilitating Recovery
Dr. Ann Masten , 1996
www.samhsa .gov
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Resilience & preventio~
J
• Listen to Karol Kumpfer: ./
'if .QN
Entangled Definitions
Resilience - Listen to Ann Masten & BobFriedman.
P rom otion & Prevention - Listen to the Australians:
Luckily, although not specifically designed to
increase resilience. most prevention
programs logicall y or intuitively focus on
increasing protective mechanisms. Many
of these protective mechani sms are
synonymous with resilience mechanisms.
Menta l health promot ion needs to be seen in ."'0 contexts : promoting
positive me ntal health and prenDling th e development of mental
health problems and disorders. T hese two contexts a rc Inextrtcebty
linked ••• to the extent th at initiatives aiming to promote positive
me ntal healt h will a lso im pact upon th e prevention of menta l health
problems a nd disord ers. Simila rly, initiatives aiming to prevent
mental heaUb problems lind disorders will also impact upon
prom oling pcs m ve me ntal heallb (Sca nlon er al.. 1997, p. 7).
5
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Protective Factors/Processes
Resilience & Prevention, cont'd
Listen to Martin Seligman & Mihaly
Csikszentmihalyi (2000) :
Protective buffers...seem to be helpful fa us
(as) members of the human race.... They
appear fa make a more profound impact on
fhe life course of individuals who grow up
and overcome adversity than do specific
risk factors.
What psychologists have learned over 50 years is
that the disease model does not move psychology
closer to the prevention of these serious
problems. Indeed. the major strides in
prevention have come largely from a perspective
focused on systematically buildin g competency.
not on correcting weakness.
Dr. Emmy Werner, 1996
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2
What is resilience?
Resilience in Development
From Research to Action
Ann S. Masten
University of Minnesota
August 14, 2003
~
Think of someone
~
Two judgments
- Life is going OK
- Serious adversity or risk
~
Not a new phenomenon!
(Masten, 2003)
.
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Defining Resilience For Research
Criteria For "Doing OK"
.... Criter ia for " doing ok"
~
Competence - A pattern of effective
functioning in developmental ta sks for given
age, culture, and time in history.
~
Normal range or symptoms
~
Who Decides?
~
Meas ures of risk or adversity
~ Measu res
of what might make a difference
- Att r ibutes of person or environment
• Assets and protective factors
(Masten, 2003)
(Masten, 2003)
NO: Behaviors only or feelings as well?
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3
Threats To Adaptation and
Development
Examples of Competence
In Maj or Developmental Tasks
~
~
Early Childhood
•
•
•
Attachm ent
Language
Emerging : compliance, se lf-control. peer relations
~
School age (through adolescence)
•
•
Academic achievem ent
Getting along with peers and having friends
•
Conduct accordi ng to ru les
•
Emerging roman tic relationships, work
•
•
•
....
•
•
•
•
(Masten. 2003)
Risk Factors
Predicting undesirable outcomes
From risk markers to causes and processes
Cumulative risk and pile-up
Ad verse life experiences
Acute and chronic
Independent and cont rollable
In family and community
Massive trauma
(Masten, 2003)
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Clues to What Matters The Short List
Models of Risk & Resilience
~ What
~ Can
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Ordinary parents
Connections to competent & caring adults
Good intell ectual skills
Positive self-perceptions - 1H.. I,->l\t ..........~ ~
Spiri tuality, faith, or religious affiliations
Social attractiveness
Talents valued by self or othe rs
Socioeconomic advantage
Effective Schools
Effective comm unities
(Mas ten, 2003)
matters?
we intervene?
(Masten, 2003)
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~
16
'--'----------~
~t'
~
v-r'
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Implications:
A Resilience Framework for Action
Examples of Protective Systems
For Development and Resilience
Attachment system
CNS capacity for learning & problem solving
System s for self-regulating
Mastery motivational system (self-efficacy)
Family system
Communities
Religion
(Masten, 2003)
• Mission
• Models
• Measures
• Methods
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Mission:
Fr aming Objectives
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Models
• Positive statements of goals
• Competence as well as symptoms or problems
• Promoting competence to prevent problems
• Protective factors as well as vulnerabilities
• Marketing appeal to stakeholders
• Assets and resources as well as risks
(Masten, 2003)
(Masten, 2003)
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Strategies to Foster Resilience
Measures
Risk-focused strategies
•
•
•
Assess the positive as well as the negative
•
Streng ths in the child, the family; the com munity
•
Potential sources of resources and protective factors
•
Asset-focused strategies
•
Evaluate positive and negative outcomes
•
•
Pre vent or reduce risk
Increase resources oraccess
• Process-foc used strategies
Gains, achievement s
Competence domains as well as symptom domains
•
Restore or mobilize the power
of human adaptational systems
(M asten. 2(03)
(Masten, 2(03)
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Risk-Focused Strategies
Examples
•
•
Preven t low birth weight
Prevent child abuse or neglect
•
Redu ce bullying in schools
•
•
•
•
•
•
•
• Redu ce neighb orhood violence or crime
• Prevent homeless episodes
• Clean up asbestos, lead, land-mine dangers
•
Avert war and war atrocities
(Masten, 2003)
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Provide tutor or home visiting nurse
Provide medical and dental care
Improve teacher training
Educate parents
Build school, rec center, playground, library
Restore community services
Increase opportunities for prosocial activities
(Masten, 2003)
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6
...
Process-Focused Strategies
Examples
Process lOCused Strategies
More Examples
Improve bonds with competent/caring adults
Specific preparation for specific threats
•
•
•
Mentor ing programs
Parent-child relat ionship programs
Nurture brain development
•
•
Encourage friendships with prosocial peers
Invest in general child health
En r ich learning env ironments
•
Build self-efficacy through competence
•
Spor ts, clubs, performing arts
Support cultural trad itio ns that provide children with adaptive
rituals and opportunities to connect with prosocial adults
Opportunities to succeed, develop tal ents
Teach prosocial self-regulation
•
Prepare for surgery, terrorism, tornadoes
•
Elders teachi ng traditions dance, meditation, mu sic
A new frontier
(Masten, 2003)
(M lISten , 2OU3)
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Lessons From Resilience
Observed
~
~
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Lessons continued...
~
Promoting positive deve lopment also prevents
problems .
Children who make it have more adaptive capacity
or resources in the self & the context.
No child is invulnerable.
• As risk levels rise, resilience becomes less co mmon.
• There are conditions under which no child can flourish.
~
Risk and protective processes occur at every
level.. .cells to societies.
~
As children grow up, the role of their OWn agency
in risk and resilience increases.
(Masten, 2003 )
~The
greatest threats to children threaten the adaptive
system s that normally protect adaptation and
development.
(Masten. 2003 )
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Danger Lessons
Relationship Lessons
~
~
Relationships are central to human
adaptation.
Adults play a central role in the
developmental of all protective systems for
children.
(Masten, 2003)
~ Beware
of blaming the victim.
~ Beware
of "resiliency" and the "right stuff' myth.
~ Beware
of magic bullets.
~ Beware
of focusing only on services for the
consequences of preventable risks.
~ Beware
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of minimizing the burden or risk on
children worldwide.
(Masten, 2003)
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ND' s Observations about Research
Since 1998:
I.
2.
3.
4.
5.
Resilience-Building Prevention
Programs that Work
Field trying to get itself organized
Moveme nt from the WHAT to the How
Biological/Ne urological Issues
More attention to mediating & moderating
factors
More focu s on perception s
3t
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8
SAMHSA's National Registry ot Effective
Programs & Practices
NREPP
EVIDENCE-BASED PROGRAMS:
-Originally developed for substance abuse prevention programs.
WHAT'S THE BIG DEAL????
-cntertc are now being adapted for
mental health treatment programs
programs for co-occurrlng disorders
mental health promotion and prevention programs
substance abuse treatment programs
NREP Prevention Portal: www.preventionregistrv.org
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NREPP Designations
A Major Contribution of NREPP
Model programs have been Implemented under scientifically
rigorous conditions, demonstrate consistenfly positive results,
and have support for dissemination.
All programs are provided
feedback on
each review criterion.
Effective programs have been implemented under scientifically
rigorous conditions and demonstrate consistently positive
results, but they do not have the same dissemination capability
as do model programs.
Promising programs have shown mixed results or have modest
problems with implementation and/or evaluation.
Insufficient cunent support means that the programs have not
yet produced a sufficient evidence base to demonstrate
efficacy and effectiveness.
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9
Other Places to Look tor Programs
NREPP Programs for Both Mental Disorders
and Substance Abuse
Olds, D., Robinson, J.. Song , N., Little, C.. & Hill, P. (1999).
Reducing risks tor m ental disorders du ring the first five ye ars of
life : A review of pre ventive intervention s. Available at
www.sshsoc .o rg I PDFflIes/ Red ucing Risks.pdf .
A 2003 review of 29 of the 45 NREPP "model
substance abuse prevention programs" tound
9 programs that also decrease risk tactors
and/or increa se protective facto rs for
dep ression, anxiety, and conduct d isorders.
Greenberg , M.T., Dcmltrcvich, C.• Bumbarger, 8. (1999) .
Preven ting m ental disorde rs in school-age children : A review
of the effec#veness of p re vention proglOms. Available at
htto:llwww.preven tion .psu.edu.
Anothe r 10 p rograms decrease risk facto rs
and/or increase protective facto rs fo r both
conduct disorders and substance abuse.
Catalano, Ric hard F., Berg lund M. Lisa. Ryan, Jeanne A.M .,
tonczc k. Heather S.• Hawkins, J David. (2002). Positive Youth
Dev elopment In the United States: Research findings on
Evaluations of Positive Youth Development Programs .
Preven tion and Treatment. 5, 1-106
37
Mental Hea lth Problems Often Preceed
Subs tance Abuse Problems
38
Nipping Ea rly Risk Factors in the Bud
TO DDLER/PRE.'i CItOO L AGE
ELEMENTARV SCIIOO L AGE
I.
""nnting Fad,,"
Hars b & ..." «11"4/.... """i.. skilt.
Cond uct problems predict the initiation of a lcohol use as well as
greate r escalations of alcohol use ove r tim e (Costello et al., 1999;
Hussong, e t al..I 998).
Poor m.mit,," . .
....w a>t:Di!i•• , t1_
booo n
Sd,ool & Peer I'lOdOf'S
I"dlm ;", l..,;bn'
Oild FKloon
First gra de rs with th e com bina tion of hyp eractlvny and social
probl em-sojvieg d eficits hav e been found to have a greatly
increased ra te of drug a nd alcohol use when th ey are 11-12 )'ea rs
old (Ka plow et al, 2002).
'3.
4.4.
Classnoo .. aR:reWcon
I'oc>r soc:laI skilb
Dniol nlpnn
l onpukl . it" . tklllico.. de tldt
di.sc>rdrr, & d irrlc:u.lIlem pn1l ..... n1
Poor " ' _...... wit b P""'nU
Pen' njedicln
. Cc>nd....1 I'n>ble_
.... ... Khlll.lraldi _
La ngUll!:' & IelIr ninc delli, s
First grade chil d re n with conduct probl ems, anxiety /depression,
or ADHO ha ve a pp roxi mately twice the risk of firs t to bacco use
du ring grades 4-7 of children with ou t these ea rly emotional
d isorders (McMahon et al , 2002).
Soc ia l impair me nt in ch ildhood is a critica l predictor for later
substa nc e use disorders (G reene et al•• 1999).
n:5J'OCl'f'$
P...... CCKlIIid_ ... ~_n15ki1k
Co nlext WllIFa mily r a{ton
•
PO'e rty
"" re nt {rimlnllillcil vity
Pan:nt
5 ubs lB n~
ab Lrl'
\ Webstu Stra lton & Tayklrl
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Resilience Bilding Prevention
Programs that Work: Some Examples
Nurse-Family Partnerships, cont'd
Nurse Family Pa rtner ships
The Elmira 15.year follow-up child outcomes show a
significa nt impact on some of the most serious forms of
adolescent behavior:
Co mpa red to t he co nt rol grou p, pre g nan t wom en in
th e hom e visitation group:
Red uce d t heir s muklng
Improved thei r diet
Had fewer kid ney infections
Incre ased th eir social s uppo rt
Incre ase d th eir use of forma l se r vices
••
••
..
Had 75% fewer pr eterm deliveries
Ga ve birth to infa nts with hig her birth weig hts
(Hill. 1998)
Reductions in adolescent cigarette and alcohol use
Reductions in adolescent run-away
Reductions in adolescent arrests and
con victions/probation violations (Hill, 1998)
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Another example:
Perry Preschool Program
Another example:
Strengthening Families Program
• Universal
• Ages 3-4
• In school, increased school bonding, increased
points on IQ tests, better GPAs, more high school
graduations. At 27, fewer lifetime arrests.
• In constant 1992 dollars discounted at 3%, net
savings to gove rnment was $18,492 per
participant.
• Every dollar spent on program saved taxpayers
$7.16.
• Universal, Selective, & Indicated
• 3- 12 y.o., plus version for high school students
who are parents. Tested with diverse populati ons.
• Reductions in depre ssion, obsessive-compulsive
behavior, phobias , psycho- somatic complaints,
hostility, aggression, parental depre ssion &
substance abuse
• Increases in social competence, parenting &
family functioning , affect regulation, self-esteem,
commitment to school.
-- Kumpfer
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Example: PATHS -- Promoting
Alternative Thinking Strategies
Example: The Incredible Years
• Universal, Selective, & Indicated
• Ages 2-10
• Compon ents for children, parents, teachers, &
others who work with children
• Prevents aggression, oppositional defiant
behavior, and conduct disorders .
• Decreases risk & increases protect ive factors for
depression, anxiety, substance abuse.
• Increases social & academic competence, affec t
regulatio n, paren ting skills, marita l & family
functioning.
• Universal- Elementary school children
• Tested with diverse populati ons, including
deaf children
• Prevents aggression, depression, anxiety
• Helps manage ADHD symptoms
• Harrisb urg, PA Story
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Common Elements of Suc cessful Initiatives
Common Elements of Suc c essful Initiatives
(c ontinued)
1. There is no single program compone nt that
ca n p revent multiple hig h-risk behavio rs. A
package 01coordinated, colloborohve
programs is req uired in each community.
2. Shorl-term p reve ntive lntervennons produce
tim e- limited benefits, at besl , wll h ai-risk
groups whereas mul tl-veor programs are more
lik ely 10 losler endu ring beneflfs.
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3.
Preventive interventions shoul d be directed at risk
and protective factors rather than at categorical
problem behaviors. With this perspective, it is both
feasible and cost-effective to target mult iple nega tive
outcomes in the co ntext of a coordinated set of
programs.
4.
Interventions should be aimed at cha nging
institutions, environments, and individuals
(Dry toos, 1990)
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Prevention Pays!!!
Economic Benetits from Reductions in the
Cost of Crime Alone
1. Promotion of protective factors including attitudinal and
behaviorallile skills.
2. Empha sis on bUilding connectedness to positiv e peers and
adults through team and Interpersona l activities.
3. Coherent program design, training, and Implementation
within a c lea rly articulated and c oherent prevention theory .
4. Introspective orientation that encourage youth to use self~
reflec tio n In examining their be haviors and ho w they impact
others or themse lves.
Inte nsive contact 014 hours o r mor e per week with you th.
Programs that delivered fewer than 20 hours total did not
achiev e meanlngtW effec ts, regardless 01other
characteristics (SAMHSA, 2002).
Benetits per $1 .00 at Cost
Nurse-Family Partnership
$3.06
Early Childhood Education tor
Disadvantaged youth: A MetaAnalysis at 4 Programs
1.78
4.25
Seattle Social Development Proiec t
Quantum Opportunities program
1.87
5.29
Big Brothe rs/Big Sisters
National Job Corps
1.28
15.
(AO S at 01., 200 1)
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Prevention Pays!ll
Mult/systemic Therapy, Functional Family Therapy,
Aggression Replacement Training produce benefitto -c ost rat/os tha t exceed 20 to I.
Why can't we create a program from scratch?
That is, a dollar spent on these programs today can
be expected to retum to taxpayers and c rime
victims twenty or more dollars in the years ahead.
1. Why bother when so many effective ones
already ex ist?
Imagine what the returns would be it benefits had
been calculated tor decreased mental health and
substance abuse services or inc reased educational
attainment!!!!!
2. You're going to have your hands full keeping
your coalition functioning well and
integrating services from different agencies.
(Aos et aI., 200I )
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Characteristics of Successful Community
Coalitions
WHAT CAN CONCERNED CITIZENS DO?
1. A comprehensive vision thaf covers all segments
of the community and aspecfs of community life.
If is commonly held that youth are mentally and
physically healthier in neighborhoods where
adults talk to each other.
2. A widely held vision agreed upon by groups and
individuals across fhe community.
The message: Collaborate, Collaborate, CollaborateIII
3. A sfrong core of commiffed partners from the
outset .
4. An inclusive and broad-based membership,
welcoming all segments of the community.
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Characteristics of Successful
Community Coalitions, cont'd
54
Never doubt that a small group of
dedicated citizens can change the
world. indeed, it is the only thing
that ever has.
5. Avoidance or resolution ot severe conflicf fhat
mighf reflect misunderstandings abouf a
partnership's basic purpose.
6. Decentralized unifs thaf encourage participation and action at srnou-orec or
neighborhood levels.
7. Reasonable, non-dlsrupfive sfaff tumover.
8. Extensive prevention activities and support for
local prevention policies, reaching a large
number of people for as many exfended
confact hours as possible
Dr. Margaret Mead
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