Enhancing schools' capacity to support children in poverty: an ecological model of school-based mental health services

Therapist and supervisor perspectives about two train-the-trainer implementation strategies in schools: A qualitative study

Background

Train-the-trainer (TT) implementation strategies (in which designated clinicians are trained to then train others in an intervention) are promising approaches to support mental health clinician use of evidence-based interventions in school contexts. However, there is little evidence to date examining clinicians' perceptions of the acceptability and feasibility of TT strategies, or comparing clinicians' perceptions of different types of TT strategies.

Methods

The current study was conducted as part of a larger hybrid effectiveness-implementation trial, in which school-based therapists and supervisors received one of two different types of implementation support to implement cognitive behavioral therapy (CBT) groups for anxiety: TT (i.e., initial training for therapists and supervisors) or enhanced TT (TT+; i.e., initial training for therapists and supervisors, and ongoing external consultation for supervisors). We used applied thematic analysis to compare qualitative interview transcripts from 28 therapist interviews and 33 supervisor interviews from therapists and supervisors who received TT or TT+ support and report themes that were similar and different across the two groups.

Results

Most themes were similar across the TT and TT+ conditions: therapists and supervisors in both conditions perceived the group anxiety intervention as acceptable and viewed supervision as acceptable, helpful, and feasible. Therapists and supervisors in both conditions had mixed impressions of the contextual appropriateness of the group anxiety intervention, and some reported logistical challenges with weekly supervision. Some unique themes were identified among the TT+ condition, including supervisors experiencing professional growth, and therapists and supervisors perceiving supervision as critically important and enjoyable.

Conclusions

These results suggest that TT implementation support, using a model in which an internal supervisor receives initial training and then provides ongoing supervision, is acceptable and feasible to support a group CBT intervention in schools. The results also highlight additional benefits that therapists and supervisors perceived when supervisors received ongoing consultation.

Clinical Trial Registration Information

The clinical trial from which these data were derived was registered at ClinicalTrials.gov (https://clinicaltrials.gov/) prior to the time of first patient enrollment. The registration number is: NCT02651402.

Providers as Stakeholders in Addressing Implementation Barriers to Youth Mental Healthcare

Research has shown that youth with mental health disorders often do not receive adequate care. School- and community-based mental health organizations are integral to implementing evidence-based mental healthcare to the vast majority of youth. It is therefore important to understand the perspectives of this stakeholder group, to determine how to improve access to high-quality care. A series of three focus groups with community mental health providers and three school counselors and social workers focus groups were conducted to get their perspective on existing barriers that prevent youth who need mental health services from being treated. A grounded theory inductive qualitative analysis revealed six major themes (Lack of Services, Lack of Knowledge, Stigma, Logistics, Poor Past Experiences with Mental Health, and Poor Coordination of Services). Each of these themes are discussed and implications are framed within the context of implementation science.

Associations Between School Mental Health Team Membership and Impact on Service Provision

Schools are the most common venue in which children and youth receive mental health services. To organize delivery of mental health care to such a large number of children, use of school teams is often recommended. Yet, there is limited empirical literature about the composition of school mental health teams or teams’ relations to service provision. This study investigated team composition, including team multidisciplinarity (number of different types of professionals) and the presence of a community provider, and the relations of these two variables to service provision at Tier 1 (mental health promotion), Tier 2 (early intervention) and Tier 3 (intensive treatment) for 386 schools representing different school sizes, locations, and urbanicity. Results suggested team multidisciplinarity and the presence of a community provider were related to more frequent endorsement of service provision at schools. Practice and research implications are discussed including possible application to hiring decisions and further research with longitudinal data and information on service quality.

Supporting South African High School Teachers' Implementation of a Prevention Program via Abridged Consultation: Outcomes and Moderators

Research is lacking on consultation support for school-based evidence-based programs (EBP) intended to prevent youths' risky behaviors in schools in low-resourced settings like high schools surrounding Cape Town, South Africa. Thus, this study's objective was to examine implementation outcomes and moderators of an abridged consultation condition for supporting teachers in better implementing HealthWise, an EBP for preventing youth risky sexual and substance use behaviors. Twenty-one schools with 33 teachers receiving abridged consultation (i.e., three consultation meetings, text message reminders, lesson plans, and support kits) were compared to 26 schools with 41 teachers that did not receive any consultation. Teachers with abridged consultation self-reported delivering more HealthWise content. Moderation analyses found teachers with lower educational degrees, who received abridged consultation reported more student interest in HealthWise. When there was higher school-level risk, teachers who received abridged consultation marginally self-reported adapting HealthWise more. Findings suggest consultation support that is abridged or a lower dose than is typical can be feasible in such a low-resourced, overburdened setting while still being associated with EBP coverage, student interest, and adaptation. However, moderation findings suggest contextual factors should be considered to match teachers/schools to the implementation support that best suits them.

Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety

Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports in school settings and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.

CORE: Compassion Oriented Reflection and Engagement to Guide Academic-Community Partnership

Estimates in dissemination, implementation, and services (DIS) research continue to present a 17-year lag for implementation of only 14% of evidence-based clinical services and technologies in practice (Chambers, 2018) - especially troubling for communities characterized by disproportionately high rates of poverty, crime and mental health need (Yoshikawa, Aber, & Beardslee, 2012). Academic-community partnerships offer pathways by which to speed the transport of evidence-based innovations; however, a range of challenges can disrupt implementation and adoption (Damschroder et al., 2009). This manuscript presents Compassion-Oriented Reflection and Engagement (CORE), a framework to inform academic collaborators’ perspectives and practices towards building flexible, responsive partnerships with youth-serving community-based organizations.

Stakeholders' perceptions of child and adolescent mental health services in a South African district: a qualitative study

Background

In order to develop a district child and adolescent mental health (CAMH) plan, it is vital to engage with a range of stakeholders involved in providing CAMH services, given the complexities associated with delivering such services. Hence this study sought to explore multisectoral dynamics in providing CAMH care in one resource-constrained South African district as a case study, towards informing the development of a model for district mental health plan and generating lessons for mental health systems strengthening to support CAMH services using the Health Systems Dynamics (HSD) framework. HSD provides a suitable structure for analysing interactions between different elements within the health system and other sectors.

Methods

Purposive sampling of 60 key informants was conducted to obtain an in-depth understanding of various stakeholders' experiences and perceptions of the available CAMH services in the district. The participants include stakeholders from the Departments of Health (DoH), Basic Education (DBE), community-based/non-governmental organizations and caregivers of children receiving CAMH care. The data was categorized according to the elements of the HSD framework.

Results

The HSD framework helped in identifying the components of the health systems that are necessary for CAMH service delivery. At a district level, the shortage of human resources, un-coordinated CAMH management system, lack of intersectoral collaboration and the low priority given to the CAMH system negatively impacts on the service providers' experiences of providing CAMH services. Services users' experiences of access to available CAMH services was negatively impacted by financial restrictions, low mental health literacy and stigmatization. Nevertheless, the study participants perceived the available CAMH specialists to be competent and dedicated to delivering quality services but will benefit from systems strengthening initiatives that can expand the workforce and equip non-specialists with the required skills, resources and adequate coordination.

Conclusions

The need to develop the capacity of all the involved stakeholders in relation to CAMH services was imperative in the district. The need to create a mental health outreach team and equip teachers and caregivers with skills required to promote mental wellbeing, promptly identify CAMH conditions, refer appropriately and adhere to a management regimen was emphasized.

Decomposing differences in depressive symptoms between older rural-to-urban migrant workers and their counterparts in mainland China

Background

There has been an increase in older rural-to-urban migrant workers (aged 50 and above) in mainland China, little known about their depressive symptoms. The aim of this study was to identify depressive symptoms among older rural-to-urban migrant workers, as well as explored the factors leading to differences in depressive symptoms between older rural-to-urban migrant workers and their rural counterparts (older rural dwellers) and urban counterparts (older urban residents) in mainland China. The results provided a comprehensive understanding of the depressive symptoms of older rural-to-urban migrant workers, and had great significance for improving the depressive symptoms for this vulnerable group.

Methods

Data were derived from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2015, and coarsened exact matching (CEM) method was employed to control confounding factors. This study employed a Chinese version 10-item short form of the Center for Epidemiologic Studies-Depression Scale (CES-D 10) to measure depressive symptoms, and used the Social-Ecological Model as a framework to explore influential factors related to depressive symptoms. Specifically, the approach of Fairlie’s decomposition was used to parse out differences into observed and unobserved components.

Results

After matching, our findings indicated that the prevalence of depressive symptoms in older rural-to-urban migrant workers was lower than older rural dwellers; and the prevalence of depressive symptoms in older rural-to-urban migrant workers was higher than older urban residents. Fairlie’s decomposition analysis indicated that type of in-house shower, sleeping time at night and ill in the last month were proved to be major contributors to the differences in depressive symptoms between older rural-to-urban migrant workers and older rural dwellers; self-reported health and sleeping time at night were proved to be major contributors to the differences in depressive symptoms between older rural-to-urban migrant workers and older urban residents.

Conclusions

Differences in depressive symptoms between older rural-to-urban migrant workers and their rural and urban counterparts did exist. Our findings contributed to a more reliable understanding in depressive symptoms among older rural-to-urban migrant workers. Our findings would be of referential significance for improving older rural-to-urban migrant workers’ depressive symptoms.

Youth and weapons: Patterns, individual and neighborhood correlates of violent crime arrests in Miami-Dade County, Florida

This study uses arrest data from the Miami-Dade County Police Department (n = 13 districts) for 2014-2017 to identify census tracts in which weapon violence arrests among young people aged 10-24 is high, and models area-level predictors of the total number of violent weapons crimes by census tract (greenness and socioeconomic status indices, population density and weapon dealers), after adjusting for arrestee-level factors (age, race and gender). Combined, handguns and firearms accounted for 23.2% (n = 1330) of all arrests (including murder and non-negligent manslaughter, rape, robbery, and aggravated assault). Arrests for weapon -related violent crime are concentrated in census tracts located in the north and south neighborhoods of Miami-Dade County. Findings indicate that arrestee factors and a neighborhood greenness index are more important than population density, weapon dealers and poverty in predicting arrests for weapon-related violent crime at the census tract level.

Mental health of transitional aged youth in Nicaragua: Perceptions and experiences of educators

Mental illnesses contribute to a large proportion of the disease burden in children and adolescents in low and middle-income countries (LMICs). There is limited research completed in LMICs about paediatric mental health, particularly related to youth. School is a place where many adolescents first seek mental health support. This study examined how educators in Nicaragua view youth mental health and how mental health can be supported in LMIC schools. Focus groups were completed with teachers serving youth from a variety of socioeconomic settings within León, Nicaragua. The study was completed from an Interpretivist theoretical paradigm and coding of qualitative data was completed consistent with Constructivist Grounded Theory. Educators described their roles in as detecting mental health problems and liasing with other supports; they noted barriers as cross-sector integration and social challenges. Educators felt that youth would be better served by improving integration of care, addressing structural factors, and providing more teacher supports. A model for addressing youth mental health in LMICs could include a stepped-care approach with schools providing preventative programming as well as developing within school referral strategies for youth with higher needs. There may be a role for the use of community health promoters.

Supporting ethical practice in community-engaged research with 4R: Respond, Record, Reflect, and Revise

Efforts towards adaptation, dissemination, and implementation of culturally robust, evidence-informed mental healthcare rely on community-engaged research (CEnR). Academic-community partnerships help bring science to service for vulnerable and historically disenfranchised populations (e.g., communities of color and those characterized by poverty). A growing literature supports the development of a framework of ethics for CEnR. This article examines ethical tensions in the context of the American Psychological Association Ethics Code General Principles - Beneficence and Nonmaleficence; Fidelity and Responsibility; Integrity; Justice; and Respect for People's Rights and Dignity - and presents the 4R action plan to support application of APA guidelines to academic-community partnership with youth-serving organizations.

A population health approach in education to support children's early development: A Critical Interpretive Synthesis

The primary objective of this review is to investigate what is currently known about early childhood education planning, population health models and their relation to children's development. A systematic review using the Critical Interpretive Synthesis method was undertaken, guided by a preliminary research question, "How can a population heath approach be applied to educational planning to support children's early development?" which acted as a compass and guide throughout the process. The initial search yielded 20,122 results, of which 42 were included in the review. Four synthetic constructs emerged (1) Elements of population health models exist within communities and can help improve outcomes for more children, (2) Inter-disciplinary collaboration and partnerships possess unique opportunities to influence children's development, (3) Children's development can be influenced at a variety of levels, and (4) System change requires a range of drivers and supports. Within education, there are several models which are used to improve outcomes for children and families. Although a population health approach to planning does not explicitly exist, the results from this review indicate that it would indeed be plausible to adapt the population health approach to sites and schools, and that doing so would be advantageous for children's development. However, implementing such an approach requires more than desire for change and demands system changes and supports. A protocol for the review was published on the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018098835 on 31st July 2018.

Two-Year Changes in Neighborhood Juvenile Arrests After Implementation of a Park-Based Afterschool Mental Health Promotion Program in Miami-Dade County, Florida, 2015-2017

Objectives. To examine the association of Fit2Lead, an afterschool park-based youth mental health promotion program, and neighborhood juvenile arrests (2015-2017) in Miami-Dade County, Florida. Methods. We tracked juvenile (ages 12-17 years) arrest rates over 2 years of program implementation across zip codes matched by (1) park and (2) baseline sociodemographics and youth arrests. Fit2Lead mental and physical health, meditation, resilience, and life skills activities were offered in 12 high-need areas for youths (n = 501) aged 12 to 17 years. We tested the association of Fit2Lead implementation (binary variable) and change in juvenile arrest rates by zip code, adjusting for area-level gender, age, race/ethnicity, single-parent households, and poverty. Results. Fit2Lead was offered in areas composed of 48% male youths, 60% Hispanics, 29% non-Hispanic Blacks, 33% single-parent households, and 33% of residents living in poverty. After covariate adjustment, zip codes with Fit2Lead implementation showed a significant mean reduction (P < .001) in youth arrests per 10 000 youths aged 12 to 17 years per year compared with zip codes without program implementation (b = -6.9; 95% confidence interval = -9.21, -4.65). Conclusions. Park-based programs may have the potential to promote mental health and resilience, and also to prevent violence among at-risk youths.

A qualitative study to explore paraprofessionals' role in school-based prevention and early intervention mental health services

This study explored the role of paraprofessionals within a school-based prevention and early intervention program to promote children's engagement in learning and positive parenting practices. Study aims were designed to understand how paraprofessionals perceive their role in high-need communities and how they define their work within schools. Two focus groups were conducted with school family liaisons (SFLs) during the 2015-2016 school year. Transcribed audio recordings were coded using thematic analysis wherein 2 authors coded independently, followed by audited discussion and final consensus codes. SFLs acknowledged the importance of serving high-need communities and relationship building was central to their role. They leveraged contextual knowledge (culture, language, and neighborhood) to engage parents, allowing them to serve as effective advocates for parents/families in the school setting. Findings support the importance of paraprofessionals in prevention-focused services and highlight how leveraging shared experiences and prioritizing relationship building facilitates their work as advocates within schools.

Teacher Job Stress and Satisfaction in Urban Schools: Disentangling Individual-, Classroom-, and Organizational-Level Influences

Schools remain among the most frequent providers of children's mental health services, particularly in low-income urban settings. Several decades of research have focused on training teachers to implement evidence-based interventions for minimizing disruptive behavior. Studies consistently demonstrate robust improvements in student behavior and learning; however, the impact on teachers' work-related stress or satisfaction is not well understood. Six urban, high-poverty elementary schools were randomly assigned to a school mental health services model (Links to Learning; L2L) for referred, disruptive students or to services and professional development as usual (SAU). Teachers (n = 71, K-4 general education teachers) in L2L schools participated in professional development and consultation in two universal and two targeted interventions to reduce disruptive behaviors and promote learning. Teachers (n = 65) in SAU schools participated in professional development as usual. Multiple regression models examined teacher reports of individual-level self-efficacy, classroom-level student functioning, and school-level organizational health as predictors of stress and satisfaction. Findings revealed no significant difference between conditions on teacher work-related stress or satisfaction. Organizational health was the strongest predictor of stress and satisfaction. Training on and implementation of evidence-based classroom interventions did not appear to significantly impact teachers' work-related stress or satisfaction. Instead, findings point to organizational climate and teacher connectedness as potential levers for change, supporting prior work on teacher stress and satisfaction in schools. The significance of targeting organizational factors may be particularly significant in urban school districts.

What Makes Research Useful for Public School Educators?

In this study, we explored the extent to which educators discuss and prioritize Rogers' (Diffusion of innovations, The Free Press: New York, 1995) five attributes of innovations-relative advantage, compatibility, complexity, observability, and trialability-in the context of research use. Using a directed content analysis of 54 semi-structured interviews and exemplar quotes, we describe how educators mentioned compatibility most frequently, but also commonly invoked observability and complexity in their discussions of research use. Our results also revealed key differences between educators in executive and non-executive roles. We discuss the implications of our findings for closing the research-practice gap in school-based mental health services and psychosocial interventions.

Innovative Clinical Training Site for Psychiatric Mental Health Nurse Practitioner Students: Elementary School-Based Group Therapy (Manuscript ID UMHN-2017-0143)

The aim of this clinical training site innovation is to develop accessible pediatric mental health clinical training sites for psychiatric mental health nurse practitioner (PMHNP) students. Mental health services in school settings provide treatment in the child's community and create opportunities for innovation and collaboration with teachers, school counselors, and school psychologists. School settings provide opportunities for early recognition of anxiety symptoms and accessible treatment that can help close the gap in clinical training sites for this population. Mild and moderate symptoms of anxiety often go untreated and may affect academic performance negatively. Cognitive behavioral play therapy is an effective treatment modality provided by PMHNP students and supports the roles of school personnel.

The Effectiveness of School-Based Mental Health Services for Elementary-Aged Children: A Meta-Analysis

OBJECTIVE

Given problems and disparities in the use of community-based mental health services for youth, school personnel have assumed frontline mental health service roles. To date, most research on school-based services has evaluated analog educational contexts with services implemented by highly trained study staff, and little is known about the effectiveness of school-based mental health services when implemented by school professionals.

METHOD

Random-effects meta-analytic procedures were used to synthesize effects of school-based mental health services for elementary school-age children delivered by school personnel and potential moderators of treatment response. Forty-three controlled trials evaluating 49,941 elementary school-age children met the selection criteria (mean grade 2.86, 60.3% boys).

RESULTS

Overall, school-based services demonstrated a small-to-medium effect (Hedges g = 0.39) in decreasing mental health problems, with the largest effects found for targeted intervention (Hedges g = 0.76), followed by selective prevention (Hedges g = 0.67), compared with universal prevention (Hedges g = 0.29). Mental health services integrated into students' academic instruction (Hedges g = 0.59), those targeting externalizing problems (Hedges g = 0.50), those incorporating contingency management (Hedges g = 0.57), and those implemented multiple times per week (Hedges g = 0.50) showed particularly strong effects.

CONCLUSION

Considering serious barriers precluding youth from accessing necessary mental health care, the present meta-analysis suggests child psychiatrists and other mental health professionals are wise to recognize the important role that school personnel, who are naturally in children's lives, can play in decreasing child mental health problems.

Schooling and Children's Mental Health: Realigning Resources to Reduce Disparities and Advance Public Health

Schools have long been the primary setting for children's mental health services but have neither the resources nor the expertise to manage these services independently. The critical importance of school success for children's adjustment provides a strong rationale for schooling as an essential component of children's mental health services. In this article, we review evidence for how schooling and mental health coalesce, suggesting an alignment of school and community mental health resources that prioritizes successful schooling as a key mental health outcome. We describe collaborative principles and ecological practices that advance a public health focus on children's mental health while also reducing the burden on schools to maintain mental health services. We close with a model of mental health services illustrating these principles and practices in high-poverty urban schools and propose future directions for research and practice to promote positive mental health for all children and youth.

Building Resilience After School for Early Adolescents in Urban Poverty: Open Trial of Leaders @ Play

Leaders @ Play is a park after-school program for urban middle school youth designed to leverage recreational activities for social emotional learning. Mental health and park staff co-facilitated sports and games to teach and practice problem solving, emotion regulation, and effective communication. Additional practice occurred during multi-family groups and summer internships as junior camp counselors. We examined feasibility and promise via an open trial (n = 3 parks, 46 youth, 100 % African American, 100 % low-income, 59 % female, M = 13.09 years old). Improvements in social skills and reductions in problem behaviors lend support to after school programs as a space for mental health promotion.

Common elements of adolescent prevention programs: minimizing burden while maximizing reach

A growing number of evidence-based youth prevention programs are available, but challenges related to dissemination and implementation limit their reach and impact. The current review identifies common elements across evidence-based prevention programs focused on the promotion of health-related outcomes in adolescents. We reviewed and coded descriptions of the programs for common practice and instructional elements. Problem-solving emerged as the most common practice element, followed by communication skills, and insight building. Psychoeducation, modeling, and role play emerged as the most common instructional elements. In light of significant comorbidity in poor outcomes for youth, and corresponding overlap in their underlying skills deficits, we propose that synthesizing the prevention literature using a common elements approach has the potential to yield novel information and inform prevention programming to minimize burden and maximize reach and impact for youth.

Increasing the Delivery of Preventive Health Services in Public Education

The delivery of prevention services to children and adolescents through traditional healthcare settings is challenging for a variety of reasons. Parent- and community-focused services are typically not reimbursable in traditional medical settings, and personal healthcare services are often designed for acute and chronic medical treatment rather than prevention. To provide preventive services in a setting that reaches the widest population, those interested in public health and prevention often turn to school settings. This paper proposes that an equitable, efficient manner in which to promote health across the life course is to integrate efforts from public health, primary care, and public education through the delivery of preventive healthcare services, in particular, in the education system. Such an integration of systems will require a concerted effort on the part of various stakeholders, as well as a shared vision to promote child health via community and institutional stakeholder partnerships. This paper includes (1) examination of some key system features necessary for delivery of preventive services that improve child outcomes; (2) a review of the features of some common models of school health services for their relevance to prevention services; and (3) policy and implementation strategy recommendations to further the delivery of preventive services in schools. These recommendations include the development of common metrics for health outcomes reporting, facilitated data sharing of these metrics, shared organization incentives for integration, and improved reimbursement and funding opportunities.

Implementation of Teacher Consultation and Coaching in Urban Schools: A Mixed Method Study

Guided by implementation science scholarship and school mental health research, the current study uses qualitative and quantitative data to illuminate the barriers, opportunities, and processes underlying the implementation of a teacher consultation and coaching model (BRIDGE) in urban elementary schools. Data come from five public elementary schools, 12 school mental health staff (BRIDGE consultants), and 18 teachers participating in a classroom-randomized trial of BRIDGE. Findings from directed content analysis of teacher focus group and interview data suggest that aspects of the BRIDGE intervention model, school organization and classroom contexts, and teachers/consultants and their relationship were relevant as implementation facilitators or barriers. In addition, case study analysis of intervention materials and fidelity tools from classrooms with moderate-to-high dosage and adherence suggest variation in consultation and coaching by initial level of observed classroom need. Results illuminate the need for implementation research to extend beyond simple indicators of fidelity to the multiple systems and variation in processes at play across levels of the implementation context.

Mapping the Social World of Classrooms: A Multi-Level, Multi-Reporter Approach to Social Processes and Behavioral Engagement

Understanding the social context of classrooms has been a central goal of research focused on the promotion of academic development. Building on the current literature on classroom social settings and guided by a risk and protection framework, this study examines the unique and combined contribution of individual relationships and quality of classroom interactions on behavioral engagement among low-income Latino students in kindergarten to fifth grade (N = 111). Findings indicate that individual relationships with teachers and peers and classroom quality, each independently predicted behavioral engagement. Moreover, high-quality classrooms buffered the negative influence of students' difficulties in individual relationships on behavioral engagement. Findings illuminate the need to consider multiple layers of social classroom relationships and interactions and suggest the potential benefit of targeting classroom quality as a mechanism for improving behavioral engagement in urban elementary schools.

Fostering SMART partnerships to develop an effective continuum of behavioral health services and supports in schools

The education sector offers compelling opportunities to address the shortcomings of traditional mental health delivery systems and to prevent and treat youth mental, emotional, and behavioral (MEB) problems. Recognizing that social and emotional wellness is intrinsically related to academic success, schools are moving to adopt multi-tier frameworks based on the public health model that provide a continuum of services to all children, including services to address both academic and MEB problems. In this article, we review the potential value of multi-tier frameworks in facilitating access to, and increasing the effectiveness of, mental health services in schools, and review the empirical support for school-based mental health interventions by tier. We go on to describe a community-academic partnership between the Seattle Public Schools and the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center that exemplifies how multi-tier educational frameworks, research and evidence, and purposeful collaboration can combine to improve development and implementation of a range of school-based strategies focused on MEB needs of students. Finally, we present a set of 10 recommendations that may help guide other research and practice improvement efforts to address MEB problems in youth through effective school mental health programming. (PsycINFO Database Record

Redesigning community mental health services for urban children: Supporting schooling to promote mental health

OBJECTIVE

This study examined a school- and home-based mental health service model, Links to Learning, focused on empirical predictors of learning as primary goals for services in high-poverty urban communities.

METHOD

Teacher key opinion leaders were identified through sociometric surveys and trained, with mental health providers and parent advocates, on evidence-based practices to enhance children's learning. Teacher key opinion leaders and mental health providers cofacilitated professional development sessions for classroom teachers to disseminate 2 universal (Good Behavior Game, peer-assisted learning) and 2 targeted (Good News Notes, Daily Report Card) interventions. Group-based and home-based family education and support were delivered by mental health providers and parent advocates for children in kindergarten through 4th grade diagnosed with 1 or more disruptive behavior disorders. Services were Medicaid-funded through 4 social service agencies (N = 17 providers) in 7 schools (N = 136 teachers, 171 children) in a 2 (Links to Learning vs. services as usual) × 6 (pre- and posttests for 3 years) longitudinal design with random assignment of schools to conditions. Services as usual consisted of supported referral to a nearby social service agency.

RESULTS

Mixed effects regression models indicated significant positive effects of Links to Learning on mental health service use, classroom observations of academic engagement, teacher report of academic competence and social skills, and parent report of social skills. Nonsignificant between-groups effects were found on teacher and parent report of problem behaviors, daily hassles, and curriculum-based measures. Effects were strongest for young children, girls, and children with fewer symptoms.

CONCLUSION

Community mental health services targeting empirical predictors of learning can improve school and home behavior for children living in high-poverty urban communities.

Classroom risks and resources: Teacher burnout, classroom quality and children's adjustment in high needs elementary schools

The current paper presents two related sets of findings on the classroom context in high needs elementary schools. First, we investigated change over one school term in teacher burnout (emotional exhaustion, depersonalization, personal accomplishment) and classroom quality (emotional and instructional support, organization) and assessed the degree to which burnout and classroom quality co-varied over the term with each other and with aggregate externalizing behaviors (average child externalizing behaviors in the classroom). These analyses describe the classroom context in which the children are nested. Second, we examined change over one school term in children's social adjustment (relationship quality with teachers and friends) and academic adjustment (school engagement, literacy skills) and assessed how adjustment co-varied over time with child externalizing behaviors and was predicted by teacher burnout, classroom quality and aggregate externalizing behaviors. These models were tested with a sample of low-income, ethnically diverse children in kindergarten to grade 3 and their teachers. The children and teachers were assessed three times over one school term. Personal accomplishment co-varied positively with overall classroom quality. Reciprocally, classroom organization co-varied positively with overall teacher burnout. Aggregate externalizing behaviors co-varied positively with depersonalization and negatively with personal accomplishment and overall classroom quality, including emotional support and organization. In turn, teacher burnout interacted with aggregate externalizing behaviors to predict change in child social and academic adjustment. Alternatively, classroom quality interacted with aggregate and child externalizing behaviors to predict change in child social and academic adjustment.

Expanding the Toolkit or Changing the Paradigm: Are We Ready for a Public Health Approach to Mental Health?

Kazdin and Blase aptly describe the enormous mental health burden facing our nation and suggest several ways to reform the workforce, setting, and content of services to address this long-standing unmet need. We propose that current health care reform legislation and associated advances in service delivery provide a unique and timely opportunity for a paradigm shift in mental health research, practice, and training to support services that are comprehensive, readily accessible, and relevant to a broad range of mental health needs and capacities. Using the recent public health initiative to contain the H1N1 virus for comparison, and informed by a long-standing and extensive literature documenting the need for a public health model for mental health, we describe the rationale for a three-tiered public mental health model, illustrated with examples from ongoing research, to minimize universal risk for mental health difficulties via capacity building in natural settings; reduce onset and severity of symptoms by prioritizing high-risk groups via screening and services for targeted populations; and reduce psychiatric impairment among individuals with more intensive needs via individual, family, and group interventions. New priorities for clinical science to support a public health approach are proposed.

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.

Youth Mentoring Relationships in Context: Mentor Perceptions of Youth, Environment, and the Mentor Role

Youth mentoring is primarily understood as a relationship between mentor and mentee, yet mentors often enter into home, school, and other community settings associated with youth they serve, and interact regularly with other people in mentees' lives. Understanding how and why mentors negotiate their role as they do remains underexplored, especially in relation to these environmental elements. This qualitative study drew on structured interviews conducted with professional mentors (N = 9) serving youth at risk for adjustment problems to examine how mentors' perceptions of their mentees and mentee environments informed their sense of how they fulfilled the mentoring role. Mentors commonly characterized problems youth displayed as byproducts of adverse environments, and individual-level strengths as existing "in spite of" environmental inputs. Perceptions of mentees and their environments informed mentors' role conceptualizations, with some mentors seeing themselves as antidotes to environmental adversity. Mentors described putting significant time and effort into working closely with other key individuals as well as one-on-one with mentees because they identified considerable environmental need; however, extra-dyadic facets of their roles were far less clearly defined or supported. They described challenges associated with role overload and opaque role boundaries, feeling unsupported by other adults in mentees' lives, and frustrated by the prevalence of risks. Community-based mentoring represents a unique opportunity to connect with families, but mentors must be supported around the elements of their roles that extend beyond mentor-mentee relationships in order to capitalize more fully on the promise of the intervention.

Clearing Hurdles: The Challenges of Implementation of Mental Health Evidence-Based Practices in Under-resourced Schools

Schools have become the main provider of services to children with mental health needs. Although there is substantial literature on barriers to implementation of evidence-based practices (EBPs) in under-resourced school districts, less has been written on how to overcome those barriers. Providing mental health services in the school setting presents a tremendous opportunity to increase access to quality mental health care for underserved youth. This review provides a brief overview of the barriers to successful implementation and sustainment of EBPs in under-resourced public schools and provides recommendations for overcoming them. The discussion is organized around an established conceptual framework adapted for the delivery of services in under-resourced schools that focuses on interdependent factors that exist at the individual-, team, school-, and macro-levels. This manuscript explores some recommendations and strategies for effectively addressing challenges related to implementation of EBPs. Research ideas are offered to bridge the research-to-practice gap that impacts many under-resourced public school districts.

Not just a walk in the park: efficacy to effectiveness for after school programs in communities of concentrated urban poverty

This study examined a model for mental health consultation, training and support designed to enhance the benefits of publicly-funded recreational after-school programs in communities of concentrated urban poverty for children's academic, social, and behavioral functioning. We assessed children's mental health needs and examined the feasibility and impact of intervention on program quality and children's psychosocial outcomes in three after-school sites (n = 15 staff, 89 children), compared to three demographically-matched sites that received no intervention (n = 12 staff, 38 children). Findings revealed high staff satisfaction and feasibility of intervention, and modest improvements in observed program quality and staff-reported children's outcomes. Data are considered with a public health lens of mental health promotion for children in urban poverty.

A cluster randomized trial to evaluate external support for the implementation of positive behavioral interventions and supports by school personnel

Background

Urban schools lag behind non-urban schools in attending to the behavioral health needs of their students. This is especially evident with regard to the level of use of evidence-based interventions with school children. Increased used of evidence-based interventions in urban schools would contribute to reducing mental health services disparities in low-income communities. School-wide positive behavioral interventions and supports (SWPBIS) is a service delivery framework that can be used to deliver universal preventive interventions and evidence-based behavioral health treatments, such as group cognitive behavioral therapy. In this article, we describe our ongoing research on creating internal capacity for program implementation. We also examine the cost-effectiveness and resulting school climate when two different levels of external support are provided to personnel as they implement a two-tier SWPBIS program.

Methods/Design

The study follows six K – 8 schools in the School District of Philadelphia randomly assigned to consultation support or consultation-plus-coaching support. Participants are: approximately 48 leadership team members, 180 school staff and 3,900 students in Tier 1, and 12 counselors, and 306 child participants in Tier 2. Children who meet inclusion criteria for Tier 2 will participate in group cognitive behavioral therapy for externalizing or anxiety disorders. The study has three phases, baseline/training, implementation, and sustainability. We will measure implementation outcomes, service outcomes, child outcomes, and cost.

Discussion

Findings from this study will provide evidence as to the appropriateness of school-wide prevention and treatment service delivery models for addressing services disparities in schools. The effectiveness and cost-effectiveness analyses of the two levels of training and consultation should help urban school districts and policymakers with the planning and deployment of cost-effective strategies for the implementation of evidence-based interventions for some of the most common behavioral health problems in school children.

Trial registration

ClinicalTrials.gov identifier: NCT01941069

Neighborhood crime and school climate as predictors of elementary school academic quality: a cross-lagged panel analysis

Past research has found negative relationships between neighborhood structural disadvantage and students' academic outcomes. Comparatively little work has evaluated the associations between characteristics of neighborhoods and schools themselves. This study explored the longitudinal, reciprocal relationships between neighborhood crime and school-level academic achievement within 500 urban schools. Results revealed that higher neighborhood crime (and particularly violent crime) predicted decreases in school academic achievement across time. School climate emerged as one possible mechanism within this relationship, with higher neighborhood crime predicting decreases in socioemotional learning and safety, but not academic rigor. All three dimensions of school climate were predictive of changes in academic achievement. Although this research supports a primarily unidirectional hypothesis of neighborhoods' impacts on embedded settings, additional work is needed to understand these relationships using additional conceptualizations of neighborhood climate.

TEACHING THROUGH INTERACTIONS: Testing a Developmental Framework of Teacher Effectiveness in over 4,000 Classrooms

Validating frameworks for understanding classroom processes that contribute to student learning and development is important to advance the scientific study of teaching. This article presents one such framework, Teaching through Interactions, which posits that teacher-student interactions are a central driver for student learning and organizes teacher-student interactions into three major domains. Results provide evidence that across 4,341 preschool to elementary classrooms (1) teacher-student classroom interactions comprise distinct emotional, organizational, and instructional domains; (2) the three-domain latent structure is a better fit to observational data than alternative one- and two-domain models of teacher-student classroom interactions; and (3) the three-domain structure is the best-fitting model across multiple data sets.