Overcoming Barriers to Collaboration Between Basic Behavioral Scientists and Public Health Scientists in Research on Mental Disorders

The behavioral and public health sciences both have a long and rich history supporting basic, translational, and applied research aimed at improving human lives and reducing human suffering. Through the complementary expertise of these disciplines, investigators have contributed to significant, worldwide improvements in mental and physical health. Further gains can be achieved through collaborative research among scientists in these 2 fields. Unfortunately, there are a number of barriers to such collaboration originating in different intellectual traditions, research methods, and the structure and values of academia. We identify these barriers and potential strategies for overcoming them. Several areas for future collaborative research appear promising, especially comorbid mental and physical disorders, adherence to interventions, stigma, and emotional processes. Theory-guided preventive interventions may represent especially fertile areas of collaborative effort.     

Applying Utilization Management Principles to a Comprehensive Service System for Children with Emotional and Behavioral Disorders and Their Families: A Feasibility Study

The Comprehensive Services Act for At Risk Youth and Families of Virginia (CSA), is a service, funding, and organizational reform initiative designed to improve the provision of child centered and family focused services within a community setting. We conducted this study in order to assess the feasibility of applying utilization management principles to the CSA in order to improve the appropriateness, quality, and cost effectiveness of this service delivery system. Data were gathered through focus groups, surveys, clinical profiling, and analysis of costs, and service utilization. While overall program costs increased since inception of the program, the costs per child served rose less than the rate of inflation. CSA appeared to be serving children with a high degree of emotional and behavioral difficulties. There was considerable variation among localities in placement patterns. A majority of survey and focus group respondents were willing to consider the application of utilization management principles to the CSA as long as decision making remained within localities. We concluded that there is a constructive role for utilization management approaches to improve the appropriateness and quality of services as well as enhancing efficiency in child mental health.     

Strengthening the Capacity of Schools and Communities to Serve Students with Serious Emotional Disturbance

Target 2 of the National Agenda for Improving Results for Children and Youth with Serious Emotional Disturbance stipulates that communities and schools serve children and youth with emotional needs in their neighborhood homes and regular classrooms by developing the capacity of teachers, schools, and communities to provide supports and resources. This statement is partially based upon the idea that children and youth who are placed out-of-district for special needs and services are often alienated from their neighborhoods and their communities. The Westerly, RI, and Alliance, OH, school districts, service delivery agencies and families collaborated to implement system-wide change, so as to accomplish two main goals. First, they intended on retaining students with emotional needs in their neighborhood schools and in regular classrooms. Second, they aimed to increase their effectiveness in addressing the needs of all students by providing a range of integrated resources. Both communities were strongly driven by the underlying objective: to improve the educational, economic, and social outcomes for all children.     

Developing Black Mental Health Provision: Challenging Inequalities in Partnership

This article describes and comments upon the process of developing the Sanctuary project in London, a project that will provide two community-based crisis support services for African and African-Caribbean women and men in mental crisis and distress. This initiative is informed by the extensive research documenting the ways in which mainstream, mental health services fail Black people, and by evidence suggesting that innovations in service provision for Black people are often vulnerable and limited in their impact. In an effort to avoid replicating these problems, considerable emphasis has been given to developing the project in partnership with the main stakeholders—in this instance statutory and Black voluntary sector agencies as well as Black users, carers and community members. Within this context, issues relating to inequalities can be proactively addressed, thereby reducing the risk that they undermine the effectiveness of service provision at a later stage. However, working in partnership can also hinder or delay service developments if discussions between stakeholders become protracted or conflicts unresolved. The author draws on experience gained from this project to identify the potential as well as the difficulties of using a partnership approach to developing effective Black mental health provision. The author's role in the development of these projects has been as representative of one of the partners, the King's Fund Centre for Development.     

A Developmental Framework for Collaboration in Child-Serving Agencies

Collaboration for the purpose of interdependent problem solving represents a fundamental reform of services for children with serious emotional disturbance and their families, which have typically been categorical, poorly coordinated, costly, overly restrictive, and frequently provided outside of the children's home communities. This article presents a developmental framework for collaboration that is based on the experience of families, service providers, administrators, and community members who have been involved in local collaborative processes in their own communities. The framework provides those interested in building collaboration a clear identification of the stages of collaborative development, defining characteristics of each stage, collaborative activities typical of that stage, and identification of the catalyst for change to the next stage. The results of this project indicate that while well-developed professional collaboration is a necessary component of collaboration, it is not sufficient in and of itself. The sites participating in this project related their experiences in building collaborative processes to both the development of strong interagency collaborations and the development of family participation. Their experience indicates that these two processes must be fully developed and woven together to achieve the goal of true collaboration.     

Predicting Resource Utilization by Children with Serious Emotional Disturbance and Their Families

Our study represents a rural case management agency's use of its data to aid in its transition from being funded by federal grant funds to self-sustainment. We wanted to learn if some characteristics of those children served could predict the resources needed to serve them. We analyzed data on 90 children and adolescents living in a rural community. Using multiple regression analysis we found that CAFAS total and CBCL total problem scores predicted Medicaid reimbursements but not flexible funds spending or case management hours. History of psychiatric hospitalization, however, predicted flexible funds spending and case management hours. Using one-way ANOVA and post hoc analysis we found that the staff members' assessments of each child and family's level of service needs were reflected in differences in mean CAFAS total scores, Medicaid reimbursements and case management hours, but not CBCL total problem scores or flexible funds spending.     

Evaluating School Readiness to Implement Positive Behavioral Supports

ABSTRACT

One state's efforts to assess school readiness to implement a comprehensive mental health innovation are described. To determine the likelihood of achieving success with positive behavioral supports (PBS), a process to identify school buildings ready for planned organizational change was designed and implemented within a large-scale system of care initiative in southeastern Kentucky. The salient features of the innovation are discussed, the process used to design and implement the approach is delineated, and limitations and implications of this method are considered. This multi-systemic intervention can serve as an example of the practice of organizational school psychology.     

Enrichment and Stress in Families Caring for a Child with a Serious Emotional Disorder

We examined enrichment and stress in 214 families who had children with severe emotional disorders. Caregivers' ratings of enrichment and stress were obtained through a newly developed instrument, the Effects of the Situation Questionnaire, which used parallel items covering 17 life areas. While ratings of stress were generally higher than enrichment, caregivers reported some enrichment in areas encompassing self concept and family relationships, Bivariate and multivariate analyses using various child, family, and service-system variables revealed that stress was notably associated with severity of the child's disorder, low empowerment, and a lack of coordination among service providers. Enrichment was unrelated to severity but associated with high empowerment and spiritual support. Our findings suggest that families' experiences of caregiving can have both positive and negative aspects and that a comprehensive approach to serving and studying families should take both into account.     

School-Based Mental Health Services: A Research Review

This paper provides a synthetic review of research on school-based mental health services. Schools play an increasingly important role in providing mental health services to children, yet most school-based programs being provided have no evidence to support their impact. A computerized search of references published between 1985 and 1999 was used to identify studies of school-based mental health services for children. Study inclusion was determined by (i) use of randomized, quasi-experimental, or multiple baseline research design; (ii) inclusion of a control group; (iii) use of standardized outcome measures; and (iv) baseline and postintervention outcome assessment. The application of these criteria yielded a final sample of 47 studies on which this review is based. Results suggest that there are a strong group of school-based mental health programs that have evidence of impact across a range of emotional and behavioral problems. However, there were no programs that specifically targeted particular clinical syndromes. Important features of the implementation process that increase the probability of service sustainability and maintenance were identified. These include (i) consistent program implementation; (ii) inclusion of parents, teachers, or peers; (iii) use of multiple modalities; (iv) integration of program content into general classroom curriculum; and (v) developmentally appropriate program components. Implications of these findings and directions for future research are discussed.     

A Review of Self-Management Interventions Targeting Academic Outcomes for Students with Emotional and Behavioral Disorders

The purpose of this review was to report on the effectiveness and focus of academic self-management interventions for children and adolescents with emotional and behavioral disorders. Twenty-two studies published in 20 articles and involving 78 participants met inclusionary criteria. The overall mean effect size (ES) across those studies was 1.80 (range –0.46 to 3.00), indicating effects were generally large in magnitude and educationally meaningful. Self-monitoring interventions were the predominant type of self-management technique used by researchers. The mean ES for intervention types were self-evaluation (1.13), self-monitoring (1.90), strategy instruction techniques (1.75), self-instruction techniques (2.71), and multiple-component interventions (2.11). Interventions targeted improvement in math calculation skills more than any other area. The mean ES by academic area were math interventions (1.97), writing (1.13), reading (2.28), and social studies (2.66). There was evidence to support a claim of the generalization and maintenance of findings. Implications, limitations, and areas for future research are discussed.     

Family involvement and empowerment in mental health service provision for children with emotional and behavioral disorders

Involvement of families is a critical component in effective systems of care for children with disabilities and their families. We investigated the sociodemographic correlates of family involvement in mental health services for children who have emotional and behavioral disorders. Further, we investigated the relationship between family involvement and family empowerment. The Family Involvement Scale-Family Version was used to measure involvement of families in the provision of mental services for their children and the Family Empowerment Scale was used to measure pempowerment in families with children who have emotional and behavioral disorders. In additions, demographic data concerming family composition, race, education, incone, membership in a parent support group, and the mental health status of the children were also collected. The results showed that mothers, as well as respondents with less formal education, reported greater involvement in services for their children than fathers and those who were more educated. Further, the knowledge subscale of empowerment was significantly correlated with all, subscales of family involvement and personal empowerment was significantly correlated with the treatment subscale of family involvement.     

Correlates of Victimization in a Juvenile Justice Population

The Practical Adolescent Dual Diagnostic Interview is a structured diagnostic interview designed to gather basic information about mental health conditions; past emotional, physical, and sexual abuse; suicide attempts; and substance use disorders. This instrument was administered to 435 males and 61 females in juvenile justice facilities and adolescent diversion courts to assess prevalence of mental health and substance use disorders relative to maltreatment (defined as physical, sexual, and/or emotional abuse). Results showed that the majority of juveniles who experienced maltreatment were more likely to have diagnostic indications of behavioral health conditions. Additionally, for both males and females the odds of the individual having attempted suicide were more than twice as high for those acknowledging some form of maltreatment.     

Working with Mental Health Service Users to Change Mental Health Services

During the last ten years in the UK, service user consultation and collaboration has gradually entered the vocabulary of people providing and purchasing mental health services. However, we are not convinced that much needed change in mental health services will be achieved as a function of increased commitment to market consumerism. We argue here that service user consultation and collaboration should take account of the effects of social inequalities on mental health and on mental health services. This perspective highlights the need for fundamental change in mental health services, and helps us to appreciate the strength of resistance to change, and to understand some of the dynamics involved. We describe here how this perspective has motivated and shaped our own efforts to collaborate responsibly with service users to change mental health services.     

Factors Predicting Attrition Within a Community Initiated System of Care

We designed this study to elucidate child, family, and service level characteristics that may influence attrition from a continuum of care developed and maintained by a community initiated collaboration of local clinics and agencies. Subjects included 117 children and adolescents referred to the Middlesex County system of care from 1992–1999. Data were collected through a retrospective case review. The strongest predictors of attrition from the system of care both before and after the establishment of an individualized service plan included depressed/isolated symptoms, substance abuse, general risk for psychiatric problems, number of referral reasons and urgency status at program intake. Among youth exiting residential placement, those completing recommended services were more likely to be returned home earlier or within the expected time frame than were dropouts. Our study presents important preliminary findings regarding characteristics related to treatment adherence within a community initiated systems of care.     

Professional and Provider Perspectives on Family Involvement in Therapeutic Foster Care

Therapeutic foster care (TFC) offers a promising community-based treatment option for children with serious emotional and behavioral disorders in the child welfare system. Family involvement is believed to contribute to achieving the goal of family reunification in TFC, but there has been little attention to family involvement in TFC. I present findings of a qualitative study of child welfare professionals' and TFC providers' perspectives on family involvement. Respondents' views of parent-child contact, parent-professional communication and information sharing, and family involvement in decision making were examined. Values and attitudes toward family involvement, practices related to family involvement, barriers to involvement, and strategies to promote involvement emerged as themes. Professionals in this study believed in the value of family involvement, but there were challenges at the organizational level and related to some TFC providers' lack of training to work with families.     

Recognition of Facial Expressions of Emotion by Children with Emotional and Behavioral Disorders

Interpreting and responding appropriately to facial expressions of emotion are important aspects of social skills. Some children, adolescents, and adults with various psychological and psychiatric disorders recognize facial expressions less proficiently than their peers in the general population. We wished to determine if such deficits existed in a group of 133 children and adolescents with emotional and behavioral disorders (EBD). The subjects were receiving in-patient psychiatric services for at least one of substance-related disorders, adjustment disorders, anxiety disorders, mood disorders or disruptive behavior disorders. After being read stories describing various emotional reactions, all subjects were tested for their ability to recognize the 6 basic facial expressions of emotion depicted in Ekman and Friesen's (1976) normed photographs. Overall, they performed well on this task at levels comparable to those occurring in the general population. Accuracy increased with age, irrespective of gender, ethnicity, or clinical diagnosis. After adjusting for age effects, the subjects diagnosed with either adjustment disorders, mood disorders, or disruptive behavior disorders were significantly more accurate at identifying anger than those without those diagnoses. In addition, subjects with mood disorders identified sadness significantly more accurately than those without this diagnosis, although the effect was greatest with younger children.     

Outcomes in a System of Care for Youths with Emotional and Behavioral Disorders: An Examination of Differential Change Across Clinical Profiles

We assessed the utility of an empirically-derived classification system for youths with emotional and behavioral disorders in a system of care with a strong representation of juvenile delinquents. Eighty-seven youths served in a system of care were categorized by variables related to past history, current behavioral functioning, and current psychological functioning into four clinical clusters. We evaluated preliminary clinical outcomes after six months of interagency involvement for youths within each cluster and across the four clusters. Results indicated that youths in different clusters improved significantly in need-specific areas. Trends in our data indicated differential change in clinical outcomes across clusters. We discuss our findings within the context of emerging outcomes of youths involved in comprehensive community-based programs and consider implications for outcome research, treatment of juvenile delinquents, and mental health policy.     

The effects of fixed-time reinforcement schedules on problem behavior of children with emotional and behavioral disorders in a day-treatment classroom setting

The current study assessed the effects of fixed-time reinforcement schedules on problem behavior of students with emotional-behavioral disorders in a clinical day-treatment classroom setting. Three elementary-aged students with a variety of emotional and behavioral problems participated in the study. Initial functional assessments indicated that social attention was the maintaining reinforcer for their verbally disruptive behavior. Baseline phases were alternated with phases in which attention was provided on fixed-time schedules in the context of an ABAB design. The results indicated that the provision of attention on fixed-time schedules substantially reduced the participants' rate of verbal disruptions. These decreases were maintained during initial thinning of the schedules. The results provide one of the first examples that such an intervention can be successfully implemented in a classroom setting.     

Children with SED and Their Families in an Urban Public Mental Health System: Characteristics, Needs, and Expectations

We present information with implications for the design of comprehensive systems of care for children with severe emotional disturbance and their families. Combining quantitative data derived from children and caregivers on multiple standardized assessments and qualitative data based on the caregivers' personal comments, we provide a detailed account of child clinical status, service needs, involvement in normative childhood activities, aspects of family coping and functioning, and expectations of mental health services. Research participants were from a random sampling of children, 9 to 11 years of age, receiving an above average number of services from a large urban public mental health system. Results from this comprehensive needs assessment demonstrate the serious nature of the children's disabilities, illuminate the corresponding challenges for families, and provide direction for enhancing the system of care. The caregivers rated recreation and after school programs as their first priority. Since traditional mental health services are fairly well articulated and evolved, we concentrate on using information about child functioning and family context to inform the development of recreation and after school programs that can accommodate children with extremely challenging behaviors.