Overcoming Challenges to Using Evidence-Based Interventions in Schools

Holistic Functioning from a Developmental Perspective: A New Synthesis with a Focus on a Multi-tiered System Support Structure

While research in specific academic disciplines has individually advanced knowledge and practice for promoting multiple aspects of health and well-being in children and adolescents, still missing is an understanding of the interconnectedness of many critical aspects of development and how to intentionally weave these factors to advance a more holistic approach. The need for a more holistic and inclusive approach to child and adolescent development is increasingly evident to promote long-term health and well-being as the overall percentage of children, adolescents, and adults who suffer from mental health disorders is increasing. To address this issue, our authorship team consists of researchers in the areas of developmental psychology, neuroscience, motor development, exercise science, and mental health. The collective ideas outlined in this paper are aligned to address the need to remove disciplinary-specific boundaries and elucidate synergistic linkages across multiple research domains that support holistic development and lifespan health and wellness. We propose a conceptual framework that comprehensively addresses the integration of physical, cognitive, psychological, social, and emotional domains of child and adolescent development. In addition, we also provide a holistic preventative approach that is aligned with a contemporary intervention structure (i.e., Multi-tiered Systems of Support) to promote, from a developmental perspective, positive trajectories of health and well-being across childhood and adolescence.

Influence of Classroom-Level Factors on Implementation Fidelity During Scale-up of Evidence-Based Interventions

As evidence-based interventions (EBIs) become more widely disseminated, fidelity of implementation (FOI) often wanes. This study explores the association between FOI and malleable variables within classrooms that could be targeted to optimize resources without compromising FOI as school-based EBIs are disseminated across real-world settings. We utilized process evaluation data from a national dissemination project of the Botvin LifeSkills Training (LST) middle school program, a universal prevention intervention shown to reduce substance use. The sample included 1,626 teachers in 371 schools across 14 states. Hierarchical linear models examined the relationship between observational measures of implementation factors and three domains of fidelity (e.g., adherence, student responsiveness, and quality of delivery). Findings suggest that curriculum modifications, student misbehavior, and shortage of time to implement the LST middle school program were factors most associated with lower FOI. Class size, access to program materials, and whether LST was delivered in a traditional classroom setting that is well-suited for instruction (versus in a less structured environment such as the school cafeteria) are less predictive. In scale-up of classroom-based universal interventions targeting behavioral health outcomes, our findings indicate that carefully vetting modifications, supporting classroom management strategies, and ensuring sufficient class time for implementation of highly interactive EBIs such as LST are important considerations. Since changes to EBIs are inevitable, efforts are needed to guide facilitators in making adjustments that improve program fit without compromising the essential intervention activities deemed necessary to produce desired outcomes.

The Evidence-Based Practice (EBP) Instrument (School Version): Development and Initial Psychometrics of a New Interdisciplinary Scale

This article presents the psychometric properties of the evidence-based practice (EBP) instrument (School Version), a new interdisciplinary measure for understanding and measuring EBP use that can be understood and used across the three professions who provide the most mental health services in schools. The instrument was developed based on theory, review of the literature, expert review (N = 12), pilot study (N = 20), and national study (N = 303). While the measure may have applicability for other groups of mental health providers in other settings, this study focused on the perspectives of mental health providers in schools, specifically school psychologists, school counselors, and social workers. Initial psychometric examination resulted in a 13-item, one factor model and indicated preliminary evidence for strong validity and internal reliability. No significant difference in total score among groups of mental health professionals was found, suggesting similarities of comprehension and application of EBP regardless of professional discipline. This instrument is the only one of its kind and provides a helpful first step towards common language and common goals when conceptualizing what it means for mental health providers to use best practice. Implications for school professionals and future research are offered.

Pilot Study for the Fidelity, Acceptability and Effectiveness of a PBIS Program plus Mental Health Supports in Under-resourced Urban Schools

This paper describes implementation (fidelity, perceived acceptability) and tier 1 and tier 2 outcomes of a school-wide positive behavior interventions and supports approach (PBIS) including mental health supports at tier 2 in two K-8 urban schools. Interventions for tier 2 consisted of three manualized group cognitive behavioral therapy (GCBT) protocols for externalizing behavior problems, depression and anxiety. tier 1 and tier 2 interventions were implemented with fidelity but program feasibility for tier 2 was in question because school personnel needed a great deal of external support in order to implement the interventions. tier 1 interventions were associated with a decrease in office discipline referrals. Students participating in GCBT showed a significant decrease in mental health diagnostic severity at post-treatment. A discussion of perceived and actual implementation barriers and how they were addressed is provided. Implications for practice in low-income urban schools are discussed.

Evidence-Based Psychotherapy: Advantages and Challenges

Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide range of psychiatric conditions. Psychiatric disorders are prevalent worldwide and associated with high rates of disease burden, as well as elevated rates of co-occurrence with medical disorders, which has led to an increased focus on the need for evidence-based psychotherapies. This chapter focuses on the current state of evidence-based psychotherapy. The strengths and challenges of evidence-based psychotherapy are discussed, as well as misperceptions regarding the approach that may discourage and limit its use. In addition, we review various factors associated with the optimal implementation and application of evidence-based psychotherapies. Lastly, suggestions are provided on ways to advance the evidence-based psychotherapy movement to become truly integrated into practice.

Improving impulse control: using an evidence-based practice approach

School social workers in a suburban school district implemented a two-year collaboration to identify empirically effective interventions and apply them to their own practice. During the first year of the project, the workers and the consultant discussed the use of evidence-based practice and developed strategies and tools for monitoring and evaluating practice. In the second year, each worker monitored the progress of one student using a standardized intervention. Five social workers completed the project; collected data on outcomes showed improved self-control for all participants. Limits on measurement and adaptations to individualize interventions make it impossible to be certain that the intervention was the primary cause of these outcomes. After the project the workers were not yet completely comfortable with the use of evidence-based practice to monitor and evaluate their practice. Recommendations for improving implementation of new evidence-based practice programs include providing ongoing discussion and feedback to workers, encouraging flexibility in implementation of curricula, simplifying record keeping so data reporting is consistent, and increasing baseline and follow-up measurements to strengthen the research.

Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health

This article reviews the progression of a research program designed to develop, implement, and study the implementation of "achievable" evidence-based practices (EBPs) in schools. We review challenges encountered and ideas to overcome them to enhance this avenue of research. The article presents two federally funded randomized controlled trials involving comparison of a four-component targeted intervention (Quality Assessment and Improvement, Family Engagement and Empowerment, Modular Evidence-Based Practice, Implementation Support) versus a comparison intervention focused on personal wellness. In both studies, primary aims focused on changes in clinician attitudes and behavior, including the delivery of high-quality EBPs and secondary aims focused on student-level impacts. A number of challenges, many not reported in the literature, are reviewed, and ideas for overcoming them are presented. Given the reality that the majority of youth mental health services are delivered in schools and the potential of school mental health services to provide a continuum of mental health care from promotion to intervention, it is critical that the field consider and address the logistical and methodological challenges associated with implementing and studying EBP implementation by clinicians.

Evidence-based youth psychotherapy in the mental health ecosystem

Five decades of randomized trials research have produced dozens of evidence-based psychotherapies (EBPs) for youths. The EBPs produce respectable effects in traditional efficacy trials, but the effects shrink markedly when EBPs are tested in practice contexts with clinically referred youths and compared to usual clinical care. We considered why this might be the case. We examined relevant research literature and drew examples from our own research in practice settings. One reason for the falloff in EBP effects may be that so little youth treatment research has been done in the context of everyday practice. Researchers may have missed opportunities to learn how to make EBPs work well in the actual youth mental health ecosystem, in which so many real-world factors are at play that cannot be controlled experimentally. We sketch components and characteristics of that ecosystem, including clinically referred youths, their caregivers and families, the practitioners who provide their care, the organizations within which care is provided, the network of youth service systems (e.g., child welfare, education), and the policy context (e.g., reimbursement regulations and incentives). We suggest six strategies for future research on EBPs within the youth mental health ecosystem, including reliance on the deployment-focused model of development and testing, testing the mettle of current EBPs in everyday practice contexts, using the heuristic potential of usual care, testing restructured and integrative adaptations of EBPs, studying the use of treatment response feedback to guide clinical care, and testing models of the relation between policy change and EBP implementation.

Building mental health literacy: opportunities and resources for clinicians

Youth mental health is increasingly recognized as a key concern with significant impact on youth and society. School is the one setting where professionals are consistently available to monitor how children are functioning and learning and intervene and support. School psychiatry has expanded beyond individual mental health problems to school-wide and community issues including school violence, sexual harassment, bullying, substance abuse, discrimination, and discipline. This article describes the importance of mental health literacy in health outcomes and research in school-based mental health programs to better position the clinician to advocate at the individual and/or system level.

The President’s New Freedom Commission: Capitalizing on Opportunities to Advance School-Based Mental Health Services

The report from President George W. Bush's New Freedom Commission on Mental Health (NFC), Achieving the Promise: Transforming Mental Health Care in America(2003), proposes goals and recommendations for improving mental health services. This report has significant implications for the delivery of mental health services through the schools. A focused discussion of the potential opportunities and challenges of implementing NFC recommendations related to school-based mental health is presented. Strategies for addressing five key areas at the intersection of school mental health and the Commission's recommendations include: stigma reduction, suicide prevention, expansion and improvement of school mental health, and screening and treatment of co-occurring mental health and substance abuse disorders.

Fulfilling the promise of school-based mental health: moving toward a Public Mental Health Promotion approach

School-based mental health (SBMH) programs and services are growing progressively in the United States for many reasons. However, the SBMH field is young and tenuously supported, and challenges are being confronted on many levels. There are major needs to continue to bring research-supported interventions into schools, and to better equip educators and mental health programs and staff in schools to function effectively. Articles in this special issue present the many challenges well and point to important directions for advancing SBMH. To truly advance the field a Public Mental Health Promotion approach is needed. Elements of this approach, in advancing training, quality assessment and improvement (including empirically supported practice), and advocacy and policy influence are discussed, as are strategic connections to the Community Science perspective and to the development of a growing Community of Practice in SBMH.