Making A Difference for
Children, Youth, and Families
TALCS Annual Conference
David Osher, Ph.D.
Center for Effective Collaboration & Practice,
& Technical Assistance Partnership for Child and Family
Mental Health (www.air.org/tapartnership) American
Institutes for Research
October 28, 2002
The Logic of Leaving No Child Behind
Adapted from: Beth Doll, University of Nebraska
www.air.org/cecp
Where To Go For:
– Resources,
– Links, &
– Overheads
Outline
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What Do We Know
Where Do We Intervene
How Do We Intervene
Interventions
Sum Up – New Paradigm
Some Resources
What Do We Know About the
Kids
Context
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Unclaimed Children (1982)
CASSP and Conceptualization of System of Care (1984)
Beyond the Schoolhouse Door (1990)
National Agenda For Improving Results for Children and Youth with
Serious Emotional Disturbance (1994)
Prevention of Mental Disorders (1994)
Early Warning, Timely Response (1998)
White House Conference on Mental Health (1999)
Surgeon General’s Reports (1999-2001)
Surgeon General’s Conference on Children’s Mental Health (2000)
World Federation of Mental Health (2001-2)
From Neurons to Neighborhoods (2001)
President’s Independence Commission (2002)
Improved Knowledge Base
• Conceptual, empirical, & practical
– What works (e.g., Appendix to Resource Kit for Safe Schools)
– What may not work (e.g., Youth Violence)
– What is iatrogenic (e.g., Dishon, McCord, & Poulan, “When
Interventions Harm: Peer Groups and Problem Behavior”)
– Evidenced based treatments;
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Prevention science;
Behavioral interventions;
Psycho-social treatments;
Implementation (e.g., Matt Miles, Nan Tobler, John
Weisz); and
• Longitudinal data (cross-sectional and experimental).
What Do We Know About the
Kids
• Kids are complex – co-occurrence and co-
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morbidity are the norm
Development matters
Ecology matters
Transaction matters
Stigma matters
Acceptability of treatment matters
Culture matters
Psychiatric Diagnosis and
Disruptive Behavior
• ADHD - Impulsivity, hyperactivity
(50% co-morbid with CD/ODD)
• Mood disorders – Irritable Mood (30% comorbid with CD/ODD)
• Anxiety Disorders—Restlessness,
irritability (25% co-morbid with CD/ODD)
• Schizophrenia-Agitation (30% co-morbid
with CD/ODD)
What Do We Know About the
Kids
• Mental health problems & disorders are prevalent
• Most children and youth are not served
• Of those who are served, many served later than
necessary
• Of those who are served, many drop out of
treatment
• Of those who are served, many receive
inappropriate treatment
• Poor Outcomes
Mental Health Impacts of Poor
Social Policy
 School & Community polices often set the stage and
reinforce an increasing cascade of negative school and
community outcomes
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Increased problem behavior;
Diminished learning opportunities for students;
Lack of attachment to school and family;
The socialization of anti-social behavior;
Suspensions, expulsions, and push or drop out;
Delinquency; and
Disproportionate outcomes for some children and youth.
Challenges
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Budget Cuts;
Managed Care and the Current Fee for Service System;
The needs and behavior of children & youth;
Other people’s children (and students) & Stigma;
Adult capacity
Community capacity;
The structure and culture of schools;
The structure and culture of agencies; and
Increase in factors that place youth at risk.
Challenges
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Increased suspension and expulsion;
Disparities
Impact of terrorism;
Impact of recession and changing allocation of resources;
and
• Research to practice gap
– Knowledge use challenges
– Efficacy vs. Effectiveness data
• Institutionalizing Change
• Going to Scale
Where to Intervene
Risk & Protection
• Risk Factors
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Individual
Social (Family, Peers)
Institutional (Schools; Facilities)
Societal
• Protective Factors
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Individual
Social
Institutional
Societal
Association of Risk and Protective Factor Levels
with Marijuana Use (past 30 days) From
Communities That Care
40%
Prevalence
Protection, Level 0
Protection, Level 1
30%
Protection, Level 2
Protection, Level 3
20%
Protection, Level 4
10%
0%
L=0
© Developmental Research and Programs, Inc, 1999
L=1
L=2
Risk Level
* Six-state student survey of sixth through twelfth graders, public schools
L=3
L=4
Where To Intervene
Societal
Macrosystems
Proximal
Social Contexts
Close
Interpersonal
Relations
Individual
Factors
A nested ecological system of influences on youth
behavior. Adapted from “Prevention of
Delinquency: Current status and issues” by P. H.
Tolan and N. G. Guerra, 1994, Applied and
Preventive Psychology, 3, p. 254.
Where to Intervene
Prevention
Child
Welfare
Youth
Development
Justice
Substance
Abuse
Services
Heath
Schools
Mental
Health
Recreation
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Building Blocks
Few
Intensive Interventions
Some
All
Adapted from: National Resource Center for Safe Schools
Northwest Regional Educational Laboratory - 101 SW Main Street, Suite 500 Portland, Oregon 97204
Early intervention
Universal Interventions
How To Intervene
• The National Agenda
• Systems of Care
• Systems of Prevention
& Care
National Agenda for Achieving Better Results for Children
and Youth with Serious Emotional Disturbance: CrossCutting Themes
• Prevention
• Cultural Competence
• Empowering All Stakeholders
National Agenda for Achieving Better Results for Children
and Youth with Serious Emotional Disturbance
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Expand Positive Learning Opportunities & Results
Improve School & Community Capacity
Value & Address Diversity
Collaborate with Families
Promote Appropriate Assessment
Provide Ongoing Skill Development & Support
Create Comprehensive & Collaborative Systems
Relationship Between Schools, Communities,
& Effective Prevention Strategies
PREVENTION OVER TIME AND SPACE: INTEGRATING
PREVENTION SCIENCE STRATEGIES
DEVELOPMENTAL
EPIDEMIOLOGY:
COMMUNITY
PREVENTION:
directed at
early proximal targets
directed at community
& school proximal
targets
INTEGRATED
STRATEGIES
MORE IMMEDIATE
RISK:
COMMUNITY /
SOCIETAL:
directed at
more recent
proximal targets
directed at
policies & laws as
proximal targets
Sheppard G. Kellam, M.D.
Does Prevention Make a Difference?
6
5
4
Antisocial
Personality
Disorder
Drug Use
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2
1
0
GBG
No
GBG
Impact of Good Behavior Game in 1st & 2nd Grade on most aggressive
children at ages 19-21.
Do Teachers Have an Impact?
58.7
60
50
40
Well-managed
standard classroom
Chaotic standard
classroom
30
20
10
2.7
0
Odds ratio
The Impact of First Grade Teacher Capacity on 7th Grade Behavior
(Kellam, Ling, Merisca, Brown, & Ialongo, 1998)
Disparities and the need for
Cultural Competence
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Health
Mental Health
Education
Juvenile Justice
Child Welfare .
Five Elements of Cultural
Competence
• Value Diversity
• Capacity For Self Assessment
• Consciousness of the Dynamics When Cultures
Interact
• Willingness to Engage in Ongoing Professional
Development
• Change Behavior to Reflect an Understanding of
Diversity Between and Within Cultures.
System of Care Values
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Access to Comprehensive Services
Individualized Services
Home, School, and Community Based Services
Integrated Services
Case Management
Family-Professional Partnerships
Culturally Competent
Clinically appropriate services.
Why a System of Care
• Needs of Children with SED and their
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Families
Standard Treatment
The Challenge of Fragmentation
The Challenge of Stigma
Outcomes.
Texas Federal System of Care
Grantees
• Travis County – Children’s Partnership
• Fort Worth -- Texas / Community
Solutions
• El Paso County -- The Border Children’s
Mental Health Initiative
Individualized Services
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Build on individual strengths
Address individual needs
Develop individualized service plans
Wraparound as a model.
Wraparound
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Community Based
Individualized
Culturally Competent
Deliver Supports & Services to Natural
Environments
Family Focused
Strengths Based
Needs Based
Child & Family Driven.
Wraparound Cont’d
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Collaborative Planning Process
Solution Oriented
Zero Eject & Unconditional Care
Plan for Contingencies in Advance
Flexible balance of Natural and Professional
Supports
• Data Driven
• Ongoing Monitoring and Refinement.
Home, School, and
Community Based Services
• Least restrictive
• Clinically appropriate
• Need Array of Options
• Bring Services and Supports to
Child, Family, and Setting.
Integrated Services
• Mechanisms for:
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planning services
developing services
coordinating services
funding
monitoring and evaluating services.
Case Management
• A function not a title
• Ensure that multiple services are delivered in
a coordinated and therapeutic manner
• Ensure that services can adjust to the child’s
changing needs and strengths.
Family-Professional Partnerships
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Planning
Implementing
Managing
Service Delivery
Evaluation.
Clinically Appropriate Services
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The Message of Stark County
The Challenge of Standard Practice
The Logic of Evidence Based Practice
The Need to Integrate Physical and Mental
Health.
The Logic of Universal
Intervention
• You cannot identify all at risk
• Children affect each others’ behavior
and development
• No stigma
• No self-fulfilling prophecies
• Low Risk
•Per Child Cost Less.
All
Universal Interventions
Building a Community
Foundation
• Foundations are move than “universals”
• Supports for Families and Children
– E.g., access to quality health care and child care
• Healthy Environments
– E.g, eliminating the impact of led
• Social Capital
– E.g., strong neighborhoods
• Universal Interventions
– E.g., Seattle Social Development Project
Early Intervention
Selective
Indicated
Selective interventions for individuals who is a member of a
subgroup of the population whose risk of illness or poor
outcomes is above average (e.g., single teenage mothers)
Indicated interventions for individuals who exhibit a risk
factor or condition that identifies them, individually, as being
at high risk for the development of illness or poor outcomes
Early Intervention Models &
Examples
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Nurse Home Visitation
High Scope Preschool Curriculum
Regional Intervention Program (RIP)
First Step to Success
Functional Assessment (See Addressing Student
Problem Behaviors)
• Effective Mentoring
• STEP
Selective Intervention: Houston
Parent-Child Development Center
• Recruited Mexican-American mothers of healthy
1 year olds living in poverty (90% with father in
household)
• 2 Years-bilingual and culturally appropriate
– 1: 20-30 1/12 hour visits focus on parent-child
interaction + 4 weekend workshops for fathers
– 2: 4 mornings of nursery school + 3 hour classes for
mothers + monthly evening workshops for both parents
• When children 8-11, more pro-social, less problem
behavior (impulsive, disruptive, & fighting)
Intensive Intervention and
Treatment
•Individualized
•Address multiple risk factors &
cross multiple domains
•Linguistically & culturally competent
•Child & family driven
•Intensive & sustained.
Intensive Intervention Models
• Wraparound planning and strengths –based
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individualized interventions;
Multisystemic therapy;
Multidimensional Treatment Foster Care;
Medication Management
RE-ED
Short term residential; and
Systems of Care.
Wraparound Milwaukee
• Reduced residential treatment from 360/day
to 135 per day
• Reduced psychiatric hospitalizations- 80%
• Reduced arrests of delinquent youth –70%
in follow-up year
MST
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Arrests, SC,
1 year
Re-arrest,
MO, 5 year
Multidimensional Treatment
Foster Care
140
120
100
80
60
40
20
0
Percent
Completing
Percent Not
Re-arrested
Days
Incarcerated
Percent of Children with ADHD Normalized
in Multimodal Treatment Study (MTA)
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Community Comparison
Behavioral Intervention
Medication Management
Combined Treatment
Forness & Kavale, 2001
25%
34%
56%
68%
Criteria for Selecting
Interventions
• The program must have documented effectiveness and be based on
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sound theory
The program must have data that demonstrates effectiveness or
ineffectiveness with particular groups of children and youth.
Data must indicate that the program has a positive impact on behavior
at home, school (including academic) and in the community
Program developers/sponsors must demonstrate that subscribing
schools/ communities receive sufficient technical assistance.
Program components must focus on promoting positive solutions to
behavioral and emotional problems.
Intervention
Selection Calculus
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X Intervention works with
Y Children and Youth
In Z context
When you do:
–a
–b
–c
Program Evaluation Criteria
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Outcome evidence;
Fiscal costs;
Personnel and staffing implications;
Program outcomes with diverse
populations;
• Flexibility; and
• External support.
Moving From Research to Practice:
Institutionalizing Changes in Structure,
Practice, Culture
Sustaining System-,
Community-, State-wide
Becoming Core &
Going to Scale
Sustainability
Effectiveness
Efficacy
A Paradigm Shift
Source of Solutions
Professionals and Agencies
Child, Family, and their Support
Team
A Paradigm Shift
Relationship
Child and family viewed
as a dependent client
expected to carry out
instructions
Partner/ Collaborator in
decision making,
service provision, and
accountability
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A Paradigm Shift
Orientation
Isolating and “fixing” a
problem viewed as
residing in the child or
family
Ecological approach
enabling the child and
family to do better in
the community
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A Paradigm Shift
Assessment
Deficit Oriented
Strengths based
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A Paradigm Shift
Planning
Resource-based
Individualized for each child
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A Paradigm Shift
Expectations
Low to modest
High
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A Paradigm Shift
Access to Services
Limited by
agencies menus,
funding streams,
and staffing
schedules
Comprehensive
and provided
when and where
the child and
family require
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A Paradigm Shift
Outcomes
Based on agency
function and
symptom relief
Based on quality
of life and
desires of child
and family
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Doing it Right
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Comprehensive
Integrative
Collaborative
Strategic
Efficient
Accountable
Data and Outcome
Driven
Doing it Right
• Develop An
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Infrastructure
Plan for the Long Haul
Support Change
Monitor
Evaluate
www.air.org/cecp
Where To Go For:
– Resources,
– Links, &
– Overheads
Center For Effective
Collaboration & Practice
• Safe, Drug Free, & Effective Schools: What Works
• Addressing Student Problem Behavior (3 parts plus video)
• Teaching and Working With Children with Emotional and
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Behavioral Challenges (Sopris West)
Early Warning, Timely Response
Safeguarding Our Children: An Action Guide
Safe, Supportive, & Successful Schools: Step by Step
(Sopris West)
Promising Practices in Children’s Mental Health (13 vols.)
Exploring the Relationship between and Juvenile Justice
Outcomes (7 vols.).
Relevant AIR TA & Research
Centers
• Behavioral Health Technical Assistance Center
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(SAMHSA)
Safe and Drug Free School Coordinators TA Center
(SDFS)
Neglected and Delinquent Youth TA & Evaluation Center
(Office of Elementary and Secondary Education)
Technical Assistance Partnership for Child and Family
Mental Health (SAMHSA)
Center for Integrating Prevention and Education Research
(NIH).