Implementing a Mental HealthSchools-Families Shared Agenda:
Translating Evidence-based
Practices into Schools
Kimberly Hoagwood, Ph.D.
Columbia University
May 5, 2003
Key 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
Mental 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 of
childhood disabilities in established market economies
for children and adolescents under 15 years of age
Congenital anomalies
Perinatal conditions
Unintentional injuries
Respiratory diseases
1990 2020
23.5 19.6
21.1
15.8
16.8
16.1
5.0
5.7
1990 ….. 10.2%
Neuropsychiatric
conditions
2020 …..
15.6%
Unmet Need for
Mental Health Services
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
White
AfricanAmerican
Latino
Other
Sturm et al., 2000 (from NHIS)
Major Federal Activities on
Children’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
Initiatives: Implications for Schoolbased 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
Evidence-based Practices: Status of
the Science Base on Effective
Interventions
Psychosocial Treatments
APA’s Division 12 Review of evidence-based therapies, 1998
 Kazdin, Psychotherapy for children and adolescents
Oxford, 2000
School-Based Approaches
Rones & Hoagwood, School-based mental health services,
Clinical Child and Family Psychology Review, 2000
Journal 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
12 Major Reviews of Evidence-based
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)






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
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 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
What is Evidence?
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
Adapted from Lonigan, Elbert, & Johnson, 1998; and Chambless, et
al., 1998.
What is Evidence?
Youth Violence Report (2001)

Model
 Rigorous experimental/quasiexperimental 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)

Outpatient
Psychotherapies (Externalizing)
Well-Established
Probably Efficacious
ADHD
Behavioral Parent Training
 Behavioral Interventions in
the Classroom


Behavioral Management
Training
DISRUPTIVE BEHAVIOR
Preschool
 Delinquency Prevention
 Living with Children
Program
 Videotape Modeling
 Parent-Child Interaction
Therapy
 Parent Training Program
 Time-Out Plus Signal Seat
Treatment
Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998
Outpatient Psychotherapies
(Externalizing)
Well-Established
Probably Efficacious
DISRUPTIVE BEHAVIOR
School Age
Anger Coping Therapy
 Problem Solving Skills
Training

Adolescence
Anger Control Training
with Stress Inoculation
 Assertiveness Training
 Multisystemic Therapy
 Rational-Emotive Therapy

Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998
Outpatient Psychotherapies
(Internalizing)
Well-Established
Probably Efficacious
DEPRESSION

Self-Control (children)
 Coping with Depression
(adolescents)

None
ANXIETY


None
PHOBIAS
Participant Modeling
 Reinforced Practice

Cognitive-Behavioral
Imaginal and In Vivo
Desensitization
 Live or Filmed Modeling

Source: Journal of Clinical Child Psychology, Volume 27, Number 2, 1998
Cost Benefit Analysis
Early Childhood Programs
Perry Pre-School (P)
Syracuse Family Development (P)
Olds Nurse Home Visitation (BP)
Costs Per
Participant
CJS and Crime
Victim Benefit Per
Dollar of Cost
$
$
Middle Childhood Programs
Seattle Social Development Project (P)
Adolescent (Non-Offender) Programs
Quantum Opportunities (BP)
Big Brothers/Big Sisters (BP)
Juvenile Offender Programs
Multi-Systemic Therapy (BP)
Functional Family Therapy (BP)
Aggression Replacement Training
Adolescent Diversion Project
Multidimensional Treatment
Foster Care (BP)
Juvenile Intensive Supervision
Juvenile Boot Camp
13,938.00
45,092.00
7,403.00
1.50
0.34
1.54
3,017.00
1.79
18,292.00
1,009.00
0.13
2.12
4,540.00
2,068.00
404.00
1,509.00
1,934.00
13.45
10.99
31.40
13.61
22.58
1,500.00
1,964.00
1.49
0.26
Comprehensive Community-Based Interventions
(cont’d)


Intensive case
management
(including
wraparound)
Multisystemic therapy
(MST)
5 RCTs and 1 quasiexperimental

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 Interventions
Treatment Foster Care
4 RCTs
• more rapid improvement
• decreased aggression
• better post-discharge outcomes
Family Education and Support
1 RCT
• increased knowledge and self-efficacy
Mentoring
1 RCT
• less substance use and aggression;
• better school, peer, and family
functioning
Respite Services
1 quasi-experimental
• fewer placements
• reduced family stress
Crisis Services
0 controlled, 1 pre-post
• placement prevented in 60-90% of
cases
Moving beyond lists

The role of parents/caregivers as partners
in service delivery

Engagement
Empowerment

Challenge: Family Engagement

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)
Telephone Engagement
Intervention
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 Study
McKay et al., 1999
120
100
80
% for first interview
(n=33)
% for comparison
(n=74)
60
40
20
0
Accepted
1st appt
2nd appt
3rd appt
M. McKay, 1999
Parent 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
Health Through Parent and
Community Empowerment
Manual for Parent Advocates
and Parents
Center for the Advancement of Children’s Mental
Health
Goals 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 - - 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:
3 New Initiatives



Casey Foundation Project on EvidenceBased Practices for Antisocial Youth
Hawaii Experiment (Chorpita et al., 2002)
MacArthur Network on Youth Mental
Health
Casey Foundation

Can Multisystemic Therapy (MST),
Functional Family Therapy (FFT), and
Multidimensional Treatment Foster Care
(TFC) be integrated to create a continuum
of services?
Hawaii Levels of Evidence



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
Example: Efficacy (Chorpita et al., 2002)
Problem
Level 1
best support
Level 2
good support
Level 3
some support
Level 4
no support
Level 5
known risks
Anxiety
CBT; Exposure;
Modeling
CBT+ parents;
Ed support
None
EMDR; Play
Tx; GIST
None
ADHD
Behavior
Therapy
None
None
Biofeedback;
Play Tx; GIST
None
Autism
None
None
ABA; FCT
Play Therapy;
GIST
None
Conduct
None
Multisystemic
Therapy
None
Juvenile Justice;
Individual Tx
Group Therapy
Depression
CBT
CBT + parents;
IPT; Relaxation
None
Family Tx;
Individual Tx
None
Oppositional
Parent/Teacher
Training
Anger Coping;
Assertiveness;
PSST
None
Relaxation;
Individual Tx
Group Therapy
Substance
CBT
Behavior Tx;
Family Tx
None
Individual
Therapy
Group Therapy
Example: Clinical application





14 year old
Depressed
Puerto Rican
Male
Late in semester
Evidence:
Interventions for Depression
Intervention
Finish
Age
Ethn
Staff
Length
Setting
Effect
94%
9 to 18
84% NS;
18%PR;
3%AA
MA; PhD
5 to 16
weeks
Clinic;
school
1.74
88%
14 to 18
NS
MA; PhD
7 to 8
weeks
clinic
1.40
MA;
PhD; MD
12 weeks
clinic
1.51
MA; PhD
5 to 8
weeks
school
1.48
Level 1
CBT
Level 2
CBT + parents
Interpersonal
85%
12 to 18
49% PR;
41% HA;
10% C
Relaxation
100%
11 to 18
NS
Evidence:
Interventions for Depression
Intervention
Finish
Age
Ethn
Staff
Length
Setting
Effect
94%
9 to 18
84% NS;
18%PR;
3%AA
MA; PhD
5 to 16
weeks
Clinic;
school
1.74
88%
14 to 18
NS
MA; PhD
7 to 8
weeks
clinic
1.40
MA;
PhD; MD
12 weeks
clinic
1.51
MA; PhD
5 to 8
weeks
school
1.48
Level 1
CBT
Level 2
CBT + parents
Interpersonal
85%
12 to 18
49% PR;
41% HA;
10% C
Relaxation
100%
11 to 18
NS
MacArthur 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
Components (Chorpita, 2000)



Cross tabulate studies with intervention
elements
Use all studies; code each study
Yields a matrix demonstrating protocol
overlaps
All
Example
Int
A/P
Anxiety and Phobias
Depression
Exposure
Psychoed-Child
Cognitive/Coping
Self-monitoring
Tangible Rew ards
Relaxation
Psychoed-Parents
Parent coping
Problem Solving
Parent Praise
Ignoring or DRO
Modeling
Parent-monitoring
Assertiveness Training
Communication Skills
Natural and Logical Consequences
Therapist Praise/Rew ards
Social Skills Training
Skill Building
Maintence
Activity Scheduling
Educational Support
Cost Response
Time Out
Limit Setting
Directed Play
100%
80%
60%
40%
20%
0%
0%
20%
40%
60%
80%
100%
Ext
Dep
Organizational Constructs in
Mental 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
Factor Analysis
(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 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
School 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 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 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 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 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 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
thought

“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)