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

What Do We Know About Depression Among Youth and How Can We Make Progress Toward Improved Understanding and Reducing Distress? A New Hope

This paper summarizes many findings about depression among children and adolescents. Depression is prevalent, highly distressing, and exerts considerable burden worldwide. Rates surge from childhood through young adulthood and have increased over the last decade. Many risk factors have been identified, and evidence-based interventions exist targeting mostly individual-level changes via psychological or pharmacological means. At the same time, the field appears stuck and has not achieved considerable progress in advancing scientific understanding of depression's features or delivering interventions to meet the challenge of youth depression's high and growing prevalence. This paper adopts several positions to address these challenges and move the field forward. First, we emphasize reinvigoration of construct validation approaches that may better characterize youth depression's phenomenological features and inform more valid and reliable assessments that can enhance scientific understanding and improve interventions for youth depression. To this end, history and philosophical principles affecting depression's conceptualization and measurement are considered. Second, we suggest expanding the range and targets of treatments and prevention efforts beyond current practice guidelines for evidence-based interventions. This broader suite of interventions includes structural- and system-level change focused at community and societal levels (e.g., evidence-based economic anti-poverty interventions) and personalized interventions with sufficient evidence base. We propose that by focusing on the FORCE (Fundamentals, Openness, Relationships, Constructs, Evidence), youth depression research can provide new hope.

A comparison of two group cognitive behavioral therapy protocols for anxiety in urban schools: appropriateness, child outcomes, and cost-effectiveness

Background

Cognitive behavioral therapy (CBT) for pediatric anxiety is efficacious for reducing anxiety symptoms and improving functioning, but many children are unable to access CBT for anxiety in community settings. Schools are an important setting in which children access mental health care, including therapy for anxiety. In this setting, therapy is usually delivered by Masters-level therapists.

Objectives

Friends for Life (FRIENDS), a 12-session, manualized, group CBT program for anxiety has demonstrated effectiveness when implemented in schools. However, prior research has also found challenges regarding feasibility and cultural fit when delivering FRIENDS in the urban school context. To address these challenges, we adapted FRIENDS for implementation in the school setting so that it might be more feasible and culturally appropriate for low-income, urban schools in the United States, while maintaining the core components of treatment. The current study uses a mixed-method approach to compare the effectiveness, cost-effectiveness, and perceived appropriateness of FRIENDS and CATS when delivered by Masters-level therapists with train-the-trainer support.

Materials and methods

First, we compared change scores for student outcomes (i.e., child-report MASC-2 total score, parent-report MASC-2 total score, teacher-report Engagement and Disaffection subscale scores) from pre- to post- treatment between students receiving FRIENDS and students receiving CATS to assess whether the two conditions resulted in equivalent outcomes. Second, we compared the cost and cost-effectiveness between the groups. Finally, we used an applied thematic analysis to compare appropriateness of the interventions as perceived by therapists and supervisors.

Results

The mean change score for the child-reported MASC-2 was 1.9 (SE = 1.72) points in the FRIENDS condition and 2.9 (SE = 1.73) points in the CATS condition; results indicated that the conditions were similar in their treatment effects, and symptom reductions were small in both groups. The modified protocol, CATS, was shown to cost significantly less to implement compared to FRIENDS and showed greater cost-effectiveness. Finally, compared to therapists and supervisors in the CATS condition, therapists and supervisors in the FRIENDS condition more strongly described aspects of the intervention that were not appropriate for their context and in need of more extensive adaptations.

Conclusion

Relatively brief, group CBT for anxiety, with adaptations to improve cultural fit, is a promising approach to treat youth anxiety symptom when delivered by school-based therapists with train-the-trainer implementation support.

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.

Bridging simulation technology with positive behavioral supports to promote student engagement and behavior

Simulation technology provides opportunities for teachers to engage in extended practice using positive behavioral supports to promote student engagement and behavior. These training models are rapidly emerging and if effective, create an infrastructure for scaling up positive behavioral supports in classrooms and schools. However, there is limited research examining teacher skill transfer or student outcomes. This study examined the incremental benefits of Interactive Virtual Training for Teachers (IVT-T) in combination with professional learning communities (PLCs) in one high poverty school district. Using a quasi-experimental design, teachers (N = 90; n = 52 IVT-T + PLC condition; n = 38 PLC condition) and students (N = 100; n = 60 IVT-T + PLC condition; n = 40 PLC only) participated across six K-8 schools. Both training conditions were rated as moderately acceptable. One and two-level generalized linear models indicated teachers who used IVT-T increased their use of praise (b = 0.75, p = .03) and decreased their use of behavioral corrective feedback (b = -0.32, p = .02). Their students were also more passively engaged (b = 0.42, p = .05) and showed fewer inappropriate physical behaviors (b = -0.87, p = .002). IVT-T hours predicted increases in praise statements (b = 0.07, p < .001) and decreases in vague directives (b = -0.07, p = .006) whereas PLC hours predicted increases in teachers' use of vague directives (b = 0.07, p = .05). There was a significant positive effect of IVT-T hours on student passive engagement (b = 0.04, p = .01) and a negative effect of PLC hours on rates of inappropriate physical behaviors (b = 0.1, p = .04). Study limitations and future directions for research and practice are discussed.

Contextual determinants associated with children's and adolescents' mental health care utilization: a systematic review

Determinants at the contextual level are important for children's and adolescents' mental health care utilization, as this is the level where policy makers and care providers can intervene to improve access to and provision of care. The objective of this review was to summarize the evidence on contextual determinants associated with mental health care utilization in children and adolescents. A systematic literature search in five electronic databases was conducted in August 2021 and retrieved 6439 unique records. Based on eight inclusion criteria, 74 studies were included. Most studies were rated as high quality (79.7%) and adjusted for mental health problems (66.2%). The determinants that were identified were categorized into four levels: organizational, community, public policy or macro-environmental. There was evidence of a positive association between mental health care utilization and having access to a school-based health center, region of residence, living in an urban area, living in an area with high accessibility of mental health care, living in an area with high socio-economic status, having a mental health parity law, a mental health screening program, fee-for-service plan (compared to managed care plan), extension of health insurance coverage and collaboration between organizations providing care. For the other 35 determinants, only limited evidence was available. To conclude, this systematic review identifies ten contextual determinants of children's and adolescents' mental health care utilization, which can be influenced by policymakers and care providers. Implications and future directions for research are discussedPROSPERO ID: CRD42021276033.

Performance of a Supervisor Observational Coding System and an Audit and Feedback Intervention

Workplace-based clinical supervision is common in community based mental health care for youth and families and could be a leveraged to scale and improve the implementation of evidence-based treatment (EBTs). Accurate methods are needed to measure, monitor, and support supervisor performance with limited disruption to workflow. Audit and Feedback (A&F) interventions may offer some promise in this regard. The study-a randomized controlled trial with 60 clinical supervisors measured longitudinally for 7 months-had two parts: (1) psychometric evaluation of an observational coding system for measuring adherence and competence of EBT supervision and (2) evaluation of an experimental Supervisor Audit and Feedback (SAF) intervention on outcomes of supervisor adherence and competence. All supervisors recorded and uploaded weekly supervision sessions for 7 months, and those in the experimental condition were provided a single, monthly web-based feedback report. Psychometric performance was evaluated using measurement models based in Item Response Theory, and the effect of the SAF intervention was evaluated using mixed-effects regression models. The observational instrument performed well across psychometric indicators of dimensionality, rating scale functionality, and item fit; however, coder reliability was lower for competence than for adherence. Statistically significant A&F effects were largely in the expected directions and consistent with hypotheses. The observational coding system performed well, and a monthly electronic feedback report showed promise in maintaining or improving community-based clinical supervisors' adherence and, to a lesser extent, competence. Limitations discussed include unknown generalizability to the supervision of other EBTs.

Eficácia Docente e Dificuldades Emocionais/Comportamentais Infantis: Resultados do Programa FAVA

Resumo Este estudo quase-experimental avaliou os resultados do programa FAcilitando o conVívio com Alunos - FAVA, destinado a professores do ensino fundamental I, visando a promoção da eficácia docente e a redução de problemas emocionais/comportamentais infantis, aferidos pela Escala de Avaliação das Crenças de Eficácia do Professor e pelo Questionário de Capacidades e Dificuldades, respectivamente. O FAVA contemplou a psicoeducação sobre o modelo cognitivo, o desenvolvimento socioemocional e a modificação de comportamentos. Comparação entre os grupos experimentais (GE1, que recebeu intervenção completa, e GE2, sem o modelo cognitivo) e o grupo de comparação evidenciou a promoção da eficácia pessoal docente (GE2) e a redução da percepção das dificuldades emocionais/comportamentais infantis (GE1). Ressalta-se a contribuição do modelo cognitivo e da aprendizagem socioemocional em intervenções com professores.

Caregiver Strain, Social Support and Mental Health Service Use Among Urban African American Mothers

Caregiver strain and social support have been identified as both facilitators and deterrents to parental mental health service use on behalf of their children. This study focused on the relationship between caregiver strain, social support, and mental health service use among African American mothers of children at-risk or meeting criteria for a disruptive behavioral disorder and living in urban communities of concentrated poverty. Mothers (n = 89), participating in a five-year NIMH funded study of school-based community mental health services, completed measures at baseline of caregiver strain and both perceived and received social support. Service use was calculated as the sum total of services (sessions) received. Associations between caregiver strain and service use were examined, and perceived and received social support were explored as potential moderators. Baseline covariates included child's age, gender, symptom severity, and maternal employment status. Findings highlighted child symptom severity as the strongest predictor of caregiver strain and perceived social support as moderating the association between caregiver strain and service use. Mothers were more likely to utilize services when experiencing relatively high levels of perceived support or high caregiver strain but not both, highlighting the importance of their interrelationship. Received support did not moderate the association between strain and service use. In addition, mothers utilized services more often for sons than daughters and when unemployed. Implications for research and practice are discussed.

A randomized controlled trial of instructional coaching in high-poverty urban schools: Examining teacher practices and student outcomes

Job-embedded professional development is needed to effectively and efficiently enhance teachers' use of evidence-based practices in high-poverty urban communities. This study employed a three-cohort, waitlist controlled, randomized block design to investigate the effectiveness of the Classroom Strategies Coaching Model (CSC) in 14 high-poverty urban elementary schools. The CSC Model is guided by observations of teachers' instructional and behavioral management practices as measured by the Classroom Strategies Assessment System. Primary dependent measures included teacher use of evidence-based practices, student academic engagement, and teacher ratings of class wide student academic and behavior functioning along with perceived instrumental support, emotional support, and stress. The sample included 2195 students and 106 teachers randomly assigned to CSC coaching or waitlist control. Multilevel negative binomial modeling revealed that teachers in the CSC coaching condition had significant improvements in the frequency of academic praise (used 1.74 times more frequently) and behavior praise (used 2.10 times more frequently) as compared to teachers in the waitlist control condition. Multilevel linear models revealed that, relative to the waitlist control condition, teachers in the CSC coaching condition demonstrated significant improvements in quality of instruction (d = 0.52), behavior management (d = 0.60), and class wide student academic engagement (d = 0.41). Teachers reported significant improvements in class wide student academic (d = 0.96) and behavioral functioning (d = 1.24), instrumental support (d = 0.90) and emotional support (d = 1.04). No change was found for teacher stress. Implications for research and practice are reviewed.

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.

Engaging Parents in Mental Health Services: A Qualitative Study of Community Health Workers' Strategies in High Poverty Urban Communities

Empirical engagement-promoting strategies in child and family mental health services have been identified largely within the context of clinic-based services delivered by mental health professionals. However, the magnitude of unmet youth mental health need necessitates expanding the scope of mental health services, and the associated engagement strategies, beyond traditional models and service providers. The present study aimed to extend our understanding of engagement strategies to a school-based mental health service model, using a community health worker (CHW) workforce implementing an early intervention program with parents and school-aged children (K-4) in high poverty urban communities. Qualitative semi-structured individual interviews were conducted with 16 CHWs to capture their descriptions of the engagement strategies they utilized with parents throughout program implementation. Transcripts were coded and themes were identified following procedures for thematic analysis. Thematic analyses revealed ten themes describing a range of engagement strategies falling into two overarching categories: (1) rapport building, and (2) responsive delivery. Themes within the rapport building category included non-judgmental supportive listening, increasing social proximity, praise, privacy and confidentiality, and leveraging relationships. Themes within the responsive delivery category included flexibility, consistency, advocacy, incentives, and meeting needs. Findings provide preliminary evidence regarding the ability of CHWs to identify and implement a range of engagement strategies with parents and families that parallel empirically-based engagement strategies in traditional services. These findings speak to the potential of this workforce to engage underserved families in mental health services, underscoring the important role for CHWs in reducing mental health disparities.

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to Improve Collaboration in School Mental Health: Protocol for a Mixed Methods Hybrid Effectiveness-Implementation Study

BACKGROUND

Public schools in the United States are the main providers of mental health services to children but are often ill equipped to provide quality mental health care, especially in low-income urban communities. Schools often rely on partnerships with community organizations to provide mental health services to students. However, collaboration and communication challenges often hinder implementation of evidence-based mental health strategies. Interventions informed by team science, such as Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), have the potential to improve treatment implementation and collaboration within schools.

OBJECTIVE

The objective of this study is to improve communication and collaboration strategies among mental health and school staff by adapting an evidence-based team science intervention for school settings. We present a protocol for a hybrid effectiveness-implementation study to adapt TeamSTEPPS using stakeholder feedback, develop a tailored implementation plan, and pilot the adapted content in eight schools.

METHODS

Study participants will be recruited from public and charter schools and agencies overseeing school mental health services in the local metro area. We will characterize current services by conducting a needs assessment including stakeholder interviews, observations, and review of administrative data. Thereafter, we will establish an advisory board to understand challenges and develop possible solutions to guide additional TeamSTEPPS adaptations along with a complementary implementation plan. In aim 3, we will implement the adapted TeamSTEPPS plus tailored implementation strategies in eight schools using a pre-post design. The primary outcome measures include the feasibility and acceptability of the adapted TeamSTEPPS. In addition, self-report measures of interprofessional collaboration and teamwork will be collected from 80 participating mental health and school personnel. School observations will be conducted prior to and at three time points following the intervention along with stakeholder interviews. The analysis plan includes qualitative, quantitative, and mixed methods analysis of feasibility and acceptability, school observations, stakeholder interviews, and administrative data of behavioral health and school outcomes for students receiving mental health services.

RESULTS

Recruitment for the study has begun. Goals for aim 1 are expected to be completed in Spring 2021.

CONCLUSIONS

This study utilizes team science to improve interprofessional collaboration among school and mental health staff and contributes broadly to the team science literature by developing and specifying implementation strategies to promote sustainability. Results from this study will provide knowledge about whether interventions to improve school culture and climate can ready both mental health and school systems for implementation of evidence-based mental health practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04440228; https://clinicaltrials.gov/ct2/show/NCT04440228.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26567.

Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children

OBJECTIVE

This study investigated a quality indicator for children's mental health, caregiver attendance in youth psychotherapy sessions, within a system-driven implementation of multiple evidence-based practices (EBPs) in children's community mental health services.

METHOD

Administrative claims from nine fiscal years were analyzed to characterize and predict caregiver attendance. Data included characteristics of therapists (n = 8,626), youth clients (n = 134,368), sessions (e.g., individual, family), and the EBP delivered. Clients were primarily Latinx (63%), male (54%) and mean age was 11; they presented with a range of mental health problems. Three-level mixed models were conducted to examine the association between therapist, youth, service, EBP characteristics and caregiver attendance.

RESULTS

Caregivers attended, on average, 46.0% of sessions per client for the full sample and 59.6% of sessions for clients who were clinically indicated, based on age and presenting problem, to receive caregiver-focused treatment. Following initial EBP implementation, the proportion of caregiver attendance in sessions increased over time. Caregivers attended a higher proportion of youth psychotherapy sessions when clients were younger, had an externalizing disorder, were non-Hispanic White, and were male. Further, higher proportions of caregiver attendance occurred when services were delivered in a clinic setting (compared with school and other settings), by bilingual therapists, and the EBP prescribed caregiver attendance in all sessions.

CONCLUSIONS

Overall, the patterns of caregiver attendance appear consistent with evidence-informed practice parameters of client presenting problem and age. Yet, several improvement targets emerged such as client racial/ethnic background and service setting. Potential reasons for these disparities are discussed.

Implementation of targeted mental health interventions in urban schools: Preliminary findings for impact of training strategy on program fidelity

School-based mental health programs are increasingly recognized as methods by which to improve children's access to evidence-based practices (EBPs), particularly in urban under resourced communities. School-wide positive behavior interventions and supports (PBIS) is one approach to integrating mental health services into school-based programming; however, school providers require training and support to implement programs as intended. We have conducted a randomized controlled trial to compare two models for training school-based personnel to deliver group EBPs to children at high risk of developing internalizing or externalizing problems. School personnel (N = 24) from 6 schools in a large urban school district were trained with either a basic training and consultation strategy, or an enhanced training and consultation strategy. Preliminary findings show that the enhanced strategy resulted in 9% higher content fidelity than the basic strategy. School personnel who were switched to the basic strategy had slightly lower content fidelity for the last two years of the trial and school personnel who continued to receive basic consultation during the step-down phase saw their fidelity decline. The two conditions did not differ with regard to process fidelity.

Patterns of treatment for psychiatric disorders among children and adolescents in Mississippi Medicaid

The nature of services for psychiatric disorders in public health systems has been understudied, particularly with regard to frequency, duration, and costs. The current study examines patterns of service reception and costs among Medicaid-covered youth newly diagnosed with anxiety, depression, or behavioral disturbance in a large data set of provider billing claims submitted between 2015-2016. Eligibility criteria included: 1) identification of an initial diagnosis of a single anxiety, unipolar mood, or specific behavioral disorder; 2) continuous Medicaid eligibility over the duration of the time period studied; and 3) under 18 years of age on the date of initial psychiatric diagnosis. The final cohort included 7,627 cases with a mean age of 10.65 (±4.36), of which 58.04% were male, 57.09% were Black, 38.97% were White, and 3.95% were of other ethnicities. Data indicated that 65.94% of the cohort received at least some follow-up services within a median 18 days of diagnosis. Of those, 54.27% received a combination of medical and psychosocial services, 32.01% received medical services only, and 13.72% received psychosocial services only. Overall median costs for direct treatment were $576.69, with wide discrepancies between the lowest (anxiety = $308.41) and highest (behavioral disturbance = $653.59) diagnostic categories. Across all categories the frequency and duration of psychosocial services were much lower than would be expected in comparison to data from a well-known effectiveness trial. Overall, follow-up to psychiatric diagnosis could be characterized as highly variable, underutilized, and emphasizing biomedical treatment. Understanding more about these patterns may facilitate systematic improvements and greater cost efficiency in the future.

Three-Year Outcomes of a School-Hospital Partnership Providing Multitiered Mental Health Services in Urban Schools

BACKGROUND

From the perspective of schools, children's mental health is essential to academic success. Multitiered systems of support (MTSS) that provide prevention/promotion, early identification/intervention, and clinical treatment services have been embraced as a promising means to deliver mental health services in the school setting.

METHODS

A school-hospital partnership tested the implementation over 3 consecutive academic years of an MTSS model for elementary through high-school students enrolled in 6 urban public schools. The model was designed to embed whole-school and classroom-level prevention/promotion programs alongside small group and individual services for selected youth. Utilization, satisfaction, and student- and school-level outcomes were assessed.

RESULTS

Students participating in early intervention had significantly improved social-emotional competencies and coping skills (particularly those students at highest risk), and students with mental health disorders who participated in clinical treatment had significantly improved symptoms and functioning. Schools significantly enhanced their capacity to provide mental health services across prevention/promotion, early identification/intervention, and crisis management domains. These findings were replicated across 3 consecutive years of program implementation.

CONCLUSIONS

A school-hospital partnership using an MTSS model was found to be feasible, valued, and effective in improving students' mental health status and schools' capacities to provide mental health services.

Collaboration with Urban Community Stakeholders: Refining Paraprofessional-led Services to Promote Positive Parenting

This paper describes the process of a community-academic partnership to navigate implementation challenges for a school-based service model led by paraprofessionals to promote positive parenting in high poverty urban communities. We describe the process by which we (a) identified implementation challenges, (b) sustained a university-community collaboration to redesign the paraprofessional service model, and (c) assessed the feasibility of the new model involving four social service agencies in 16 schools with over 600 families. The structure and process of the collaboration and refinement are described with attention to who was best positioned to engage in the collaboration and how the partnership worked to balance scientific rigor with responsiveness to paraprofessional workforce strengths. Feasibility data indicated that the revised model was successfully implemented by paraprofessional staff; 92.2% of possible staff monthly reports were completed and discussion of key goals was incorporated into 94.2% of interactions. Continual monitoring provided critical feedback from stakeholders as we drew on and interpreted these various sources of information to build and refine the service model. We suggest that these processes are critical steps to bridge the research-to-practice gap, by promoting practices that are aligned with the needs of children and families, and the staff who serve them.

Children and Adolescents Mental Health: A Systematic Review of Interaction-Based Interventions in Schools and Communities

Background: There is growing evidence and awareness regarding the magnitude of mental health issues across the globe, starting half of those before the age of 14 and have lifelong effects on individuals and society. Despite the multidimensional nature of this global challenge, which necessarily require comprehensive approaches, many interventions persist in seeking solutions that only tackle the individual level. The aim of this paper is to provide a systematic review of evidence for positive effects in children and adolescents' mental health resulting from interventions conducted in schools and communities in which interaction among different agents is an integral component. Methods: An extensive search in electronic databases (Web of Knowledge, SCOPUS, ERIC, and PsycINFO) was conducted to identify interventions in which interactions between peers, teachers, families or other community members or professionals played a role. Their effects on children and adolescents' mental health were also reviewed. We carried out a systematic review of papers published from 2007 to 2017. Eleven studies out of 384 met the inclusion criteria. Seven of the articles reviewed focus on interventions conducted in schools and promote supportive interactions involving students, teachers, families and mental health professionals. Four of the articles develop interventions that engage community members in dialogic interactions with children and adolescents. Results: Interventions in schools and communities implement strategies that foster supportive interactions among diverse actors including teachers, parents, community members, and other professionals. The effects of the mental health interventions reported on children and adolescents' problems include a decrease in disruptive behaviors and affective symptoms such as depression and anxiety, together with an increase in social skills, as well as an improvement in personal well-being. Conclusions: There is evidence of a positive effect on the mental health of children and adolescents, both in decreasing symptoms of mental disorder and in promoting emotional well-being. Whereas, interactions among different actors seem to be a relevant aspect across the interventions, more research is needed to conclude its effect on the outcomes of the studies reviewed.

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.

Efficacy of behavioral classroom programs in primary school. A meta-analysis focusing on randomized controlled trials

OBJECTIVE

This meta-analysis evaluated the efficacy of behavioral classroom programs on symptoms of Attention-deficit Hyperactivity Disorder or Oppositional Defiant and/or Conduct Disorder in primary school children.

METHOD

Online database searches (in PubMed, Embase, Psycinfo, and Eric) yielded nineteen randomized controlled trials (N = 18,094), comparing behavioral classroom programs (including multimodal programs involving a classroom program) to no treatment/treatment as usual. Random-effects meta-analyses were conducted for teacher-rated and classroom-observed disruptive classroom behavior and for classroom-observed on-task behavior. Post-hoc analyses investigated whether effects depended on type and severity of problem behavior. Meta-regressions studied the moderating effects of age, gender, and intervention duration.

RESULTS

Small positive effects were found on teacher-rated disruptive behavior (d = -0.20) and classroom-observed on-task behavior (d = 0.39). Program effects on teacher-rated disruptive behavior were unrelated to age, gender, type and severity, but negatively associated with intervention duration (R2 = 0.43).

CONCLUSION

Behavioral classroom programs have small beneficial effects on disruptive behavior and on-task behavior. Results advocate universal programs for entire classrooms to prevent and reduce disruptive classroom behavior.

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.

Sample size determination for multilevel hierarchical designs using generalized linear mixed models

A unified statistical methodology of sample size determination is developed for hierarchical designs that are frequently used in many areas, particularly in medical and health research studies. The solid foundation of the proposed methodology opens a new horizon for power analysis in presence of various conditions. Important features such as joint significance testing, unequal allocations of clusters across intervention groups, and differential attrition rates over follow up time points are integrated to address some useful questions that investigators often encounter while conducting such studies. Proposed methodology is shown to perform well in terms of maintaining type I error rates and achieving the target power under various conditions. Proposed method is also shown to be robust with respect to violation of distributional assumptions of random-effects.

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.

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.

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.