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 ( American Institutes for Research October 28, 2002

The Logic of Leaving No Child Behind Adapted from: Beth Doll, University of Nebraska

Where To Go For: – Resources, – Links, & – Overheads

Outline 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 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 ( ) 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; 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- 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% co- morbid 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  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 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 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 –Individual –Social (Family, Peers) –Institutional (Schools; Facilities) –Societal Protective Factors –Individual –Social –Institutional –Societal

© Developmental Research and Programs, Inc, 1999 * * Six-state student survey of sixth through twelfth graders, public schools Association of Risk and Protective Factor Levels with Marijuana Use (past 30 days) From Communities That Care

Societal Macrosystems Proximal Social Contexts 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 Close Interpersonal Relations Where To Intervene Individual Factors

Schools Where to Intervene 18 Mental Health Justice Child Welfare Heath Substance Abuse Services Recreation Prevention Youth Development

All Few Some Building Blocks Universal Interventions Early intervention Intensive 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: Cross- Cutting Themes Prevention Cultural Competence Empowering All Stakeholders

National Agenda for Achieving Better Results for Children and Youth with Serious Emotional Disturbance 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

DEVELOPMENTAL EPIDEMIOLOGY: directed at early proximal targets MORE IMMEDIATE RISK: directed at more recent proximal targets COMMUNITY PREVENTION: directed at community & school proximal targets COMMUNITY / SOCIETAL: directed at policies & laws as proximal targets INTEGRATED STRATEGIES PREVENTION OVER TIME AND SPACE: INTEGRATING PREVENTION SCIENCE STRATEGIES Sheppard G. Kellam, M.D.

Does Prevention Make a Difference? Impact of Good Behavior Game in 1 st & 2 nd Grade on most aggressive children at ages

Do Teachers Have an Impact? The Impact of First Grade Teacher Capacity on 7 th Grade Behavior (Kellam, Ling, Merisca, Brown, & Ialongo, 1998)

Disparities and the need for Cultural Competence 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 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 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 Build on individual strengths Address individual needs Develop individualized service plans Wraparound as a model.

Wraparound Community Based Individualized Culturally Competent Deliver Supports & Services to Natural Environments Family Focused Strengths Based Needs Based Child & Family Driven.

Wraparound Cont’d 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: –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 Planning Implementing Managing Service Delivery Evaluation.

Clinically Appropriate Services The Message of Stark County The Challenge of Standard Practice The Logic of Evidence Based Practice The Need to Integrate Physical and Mental Health.

All The Logic of Universal Intervention Universal Interventions 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.

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

Selective Indicated Early Intervention 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 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: /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 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

Multidimensional Treatment Foster Care

Percent of Children with ADHD Normalized in Multimodal Treatment Study (MTA) Community Comparison25% Behavioral Intervention34% Medication Management56% Combined Treatment68% Forness & Kavale, 2001

Criteria for Selecting Interventions The program must have documented effectiveness and be based on 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 X Intervention works with Y Children and Youth In Z context When you do: –a–a –b–b –c–c

Program Evaluation Criteria 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 Efficacy Effectiveness Sustainability Becoming Core & Going to Scale

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 23

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 24

A Paradigm Shift Assessment Deficit Oriented Strengths based 25

A Paradigm Shift Planning Resource-basedIndividualized for each child 26

A Paradigm Shift Expectations Low to modestHigh 26

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 27

A Paradigm Shift Outcomes Based on agency function and symptom relief Based on quality of life and desires of child and family 28

Doing it Right Comprehensive Integrative Collaborative Strategic Efficient Accountable Data and Outcome Driven

Doing it Right Develop An Infrastructure Plan for the Long Haul Support Change Monitor Evaluate

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 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 (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).