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School-based Brief, Targeted Interventions for Students at Risk of Developing Emotional/Behavioral Disorders Doug Cheney, PhD Eric Bruns, PhD College of.

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Presentation on theme: "School-based Brief, Targeted Interventions for Students at Risk of Developing Emotional/Behavioral Disorders Doug Cheney, PhD Eric Bruns, PhD College of."— Presentation transcript:

1 School-based Brief, Targeted Interventions for Students at Risk of Developing Emotional/Behavioral Disorders Doug Cheney, PhD Eric Bruns, PhD College of Education School of Medicine University of Washington, Seattle

2 Background, Current School Topics Multi-tiered systems of support in vanguard Public visibility of violent events in schools Improve mental health systems of support Enhance and revise discipline approaches in schools – disproportionality Achievement gap Emphasis on use of Evidence Based Practices


4 What is a Targeted Intervention? Schoolwide Positive Behavior Support Approaches: An intervention (or set of interventions) known by all staff & available for students who are not responding to Tier 1. Intervention provides additional student support in academic, organizational, and/ or social support areas Interventions are: efficient (similar across students) & effective (decrease behavior problems)

5 Evidence-based Tier 2 Interventions Behavior Education Program – Check-in and Check-out (CICO) Check & Connect – Check, Connect, and Expect Coping Power Fast Track First Steps to Success Think Time

6 Check, Connect, & Expect (CCE) (2004-2010) Based on 15 years of research and practice from: – Oregon’s Technical Assistance Center on Positive Behavior Support (Horner & Sugai, 2002) – Check and Connect (Sinclair, Christenson, Evelo, & Hurley, 1998), U. Minnesota – The Behavior Education Programs (BEP; Crone, Horner, & Hawken, 2010) U. Oregon/Utah. CCE emphasizes these features: – a positive caring adult – daily positive interactions with teachers & other adults – supervision and monitoring of students – teaching social skills to students – reinforcement/acknowledgement for success

7 Screening for Students for Behavior Problems

8 Systematic Screening for Behavior Disorders (SSBD; Walker & Severson, 1992) Research in the 1980s on behavioral predictors Multiple gating procedures: Teacher Nomination & Rating of Student Behavior Two dimensions: Externalizing and Internalizing Evidence of efficiency, effectiveness, & cost benefits Exemplary, evidence-based practice US Office of Special Education, Council for Children with Behavior Disorders, National Diffusion Network

9 Graduation Self-Monitoring Basic Plus Program (as needed) Program Phases Daily Program Routine Student Passes Gate 2 SSBD Morning Check-in Parent Feedback Basic Program Teacher Feedback Afternoon Check-out

10 CCE Program Student check-in and check-out Teacher Feedback/Daily Progress Report Problem solving if needed Parent communication Reinforcement & Criterion Shift for non- responders If needed: Weekly problem solving and social skills sessions

11 Checking In 95% of 14,000 times Success

12 Student: ___________________ Date: ____________ Goal: _________ Reading Math Super Road Runner Way to Go! (4): Met expectations with positive behavior. DAILY TOTAL_______ Good (3): Met expectations with only 1 reminder or correction. OK (2): Needed 2-3 reminders or corrections. Tough Time (1): Needed 4 or more reminders or corrections. Parent Signature: ______________________ Comments: Teacher: ___________ Comments: Checked inYesNo Checked outYesNo Parent SignatureYesNo ExpectationTough Time OKGoodWay to Go! Be Safe 1234 Show Respect 1234 Be Responsible 1234 Social Studies/Science/Art Specialist ExpectationTough Time OKGoodWay to Go! Be Safe 1234 Show Respect 1234 Be Responsible 1234 ExpectationTough Time OKGoodWay to Go! Be Safe 1234 Show Respect 1234 Be Responsible 1234 ExpectationTough Time OKGoodWay to Go! Be Safe 1234 Show Respect 1234 Be Responsible 1234

13 Acknowledge Success

14 Self-monitoring (SM) After 8 weeks of success in Program Students check-in and out and receive DPR Students rate their own behavior on DPR with teacher reliability checks Coach checks for rating agreement (80%) Coach reviews SM progress with student/teacher for 4 weeks

15 Progress Monitoring Red When Below Criteria Green When Above Criteria

16 Two Year Summary Cheney, Stage, Hawken, Lynass, Mielenz, & Waugh (2009) About 80-90% of students responsive to the intervention Office Discipline Referrals Decrease over time (4-2.7) CCE may prevent Special Ed Referrals – Of 104 students, 8 (8%) eligible for special education in year 1 and 12 (11% of total) in year 2; 31% of the comparisons. – Lower rates of identification for CCE students Graduates of CCE and comparison groups show differences in teacher ratings on problem behaviors Academic Achievement on the WJ-R III (literacy and math subscales) in normative range

17 Brief Intervention for School Clinicians: A Modularized Evidenced-informed Mental Health Treatment Collaborative Team: US Department of Education/IES, UW, Seattle Public Schools, Seattle/KC Public Health and Community Partners Group Health Cooperative, International Community Health Services, Navos, Neighborcare, Seattle Children's’ Hospital, Swedish Hospital, Sound Mental Health BRISC Brief Intervention for School Clinicians

18 Evidence-Based Practice (EBP) in School Mental Health School-based mental health (SBMH) offers accessible services, particularly for historically underserved youth (Burns et al., 1995; Kataoka et al., 2007; Lyon et al., under review ) – SBMH offers reduced stigma for service seeking (Nabors & Reynolds, 2000) SBMH can lead to improvements in a variety of mental health, academic, and other functional outcomes – E.g., improved GPA for users vs. similar non-users (Walker et al., 2010)

19 EBPs in School: Room for Improvement School-based services are unlikely to be evidence-based (Evans & Weist, 2004; Rones & Hoagwood, 2000) Recent meta-analysis of SBMH programs for low-income, urban youth revealed low levels of effectiveness, some iatrogenic effects (Farahmand et al., 2011) Growing emphasis on increasing the use of EBP in SMH

20 Few interventions delivered in schools have been designed for or tested in authentic education sector service delivery settings (Wong, 2008) Simultaneously… – EBP developers have paid insufficient attention to the school context and how it might influence effective service delivery (Ringeisen et al., 2003) EBPs in School: Room for Improvement

21 Questions about transporting EBP is particularly relevant to school MH Commonly-cited concerns about the transportability of EBP to new contexts are relevant to SBMH – Substantial need for flexibility – Treatment engagement / duration variability – Ability of EBP to address the full range of client problems (type and severity) – SBMH service accessibility may make concerns about the cultural relevance of EBP even more important

22 Overarching Goal Develop and pilot test an evidenced- informed and feasible mental health intervention designed to address the unique characteristics and needs of the school context BRISC Brief Intervention for School Clinicians

23 Evolving Goal Enhanced integration of mental health service/care models with education based approaches supporting student academic and social/emotional development BRISC Brief Intervention for School Clinicians

24 BRISC System Integration

25 School-Based Usual CareBRISC Intervention is often crisis-driven (Langley et al., 2010) Structured / systematic identification of treatment targets Focused on providing nondirective emotional support (Lyon et al., 2011) Focused on skill building / problem solving Interventions do not systematically use research evidence (Evans & Weist, 2004; Rones & Hoagwood, 2000) All intervention elements are evidence-based Standardized assessments are used infrequently (Weist, 1998; Lyon et al., under review-a) Utilizes standardized assessment tools for progress monitoring

26 BRISC Intervention and Rationale Based on common elements of evidence-based MH treatments for children and youth Responsive to typical presenting problems and help-seeking behaviors of high school students seeking/needing help

27 BRISC Intervention and Rationale Tailored to the typical workflow, caseloads, supervision structures, and client engagement and follow-up strategies of SBMH clinicians Well-integrated with typical school structures and connected to other types of school-based social and behavioral supports

28 BRISC Intervention and Rationale Integrates support technologies found to enhance outcomes of treatment including a measurement feedback system (MFS) that monitors fidelity components as well as youth outcomes.

29 Project Overview Year 1: 2012-13 Study 1: Expert Input: Key Informants and Summit Revise BRISC ProtocolStudy 2: Initial Feasibility Testing (Project Personnel) Analyze findings: i.e. behavioral change, response to BRISC Revise BRISC Protocol

30 Study 1 Revise BRISC Protocol Revised BRISC protocol to reflect Summit input:  BRISC as a targeted intervention within existing tiered system  Incorporate academic interventions/focus on monitoring academic success  Student voice in development/target  ID academic and socio-emotional outcomes to focus on, e.g. Top Problems Checklist  Make use of existing school data systems  Establish “readiness” criteria for schools as a way to measure school’s ability to integrate the program

31 Revised BRISC Common Factors 1.Agenda Setting  Collaborative  Focus/structure session  Manage the time 2.Problem Solving Framework  Clinician helps student identify specific problems  Empowers student to address/change  Brainstorming solution – anything goes  Important to prepare for/address internal and external barriers  No failure – any attempt provides useful information in implementing other solutions

32 Revised BRISC Common Factors 3.Progress Monitoring and Feedback  Weekly stress rating - generally and then related to identified problem (0=low to 10=high)  Useful in identifying targets to address /monitoring progress (i.e. it’s like a ruler to measure change) 4.Practice Exercises  Tracking targets—moves from therapy to real life application  Helps identify barriers to change  Doing something that is slightly out of their comfort zone and different from what they would ordinarily do (not something too hard or drastic)

33 Session One  Engagement/rapport building  Problem identification—including academic issues  Include the need for identifying additional services as soon as possible to begin groundwork  Administer standardized assessment  Introduction to stress rating  Convey helpfulness  Informal monitoring BRISC Brief Intervention for School Clinicians

34 Teaching Tools 1 st 2 nd Class+/_How are you doing? Attendance/H omework What is it like… Peers/ Activities Home/ Neighborhoo d Brief Academic and Function ReviewProblem Solving Steps: 1. Clarify problem 2 Generate a list of possible solutions ______________________________________ 3. Evaluate possible solutions 4. Pick one to try—TRY IT Prepare for possible obstacles Rate level of stress Rate your ability to change situation Who can support you

35 Teaching Tools

36 Session Two  Review and reinforce informal monitoring  Recap problem list/identify problem to target  Connect stress rating to identified problem  Psychoeducation about stress  Introduce problem solving steps  Assign practice exercise based on selected solution BRISC Brief Intervention for School Clinicians

37 Session Three  Review new problem solving strategy and connect to stress rating  Based on outcome and challenges/barriers to implementing new strategy and identified problem, select and implement module (see flow chart to help with module identification)  Assign practice exercise based on module implemented BRISC Brief Intervention for School Clinicians

38 Session Three: Modules  Handling hard feelings—emotion/stress management skills  Dealing with a hard situation I can’t change—cognitive restructuring skills  Getting along with other people—communication skills  Just don’t feel like it – unhappy with a current situation but lacking motivation to do anything different—motivational enhancement  Problem solving—PS skills BRISC Brief Intervention for School Clinicians

39 Module Selection

40 Session Four: What was accomplished and where to go from here...  Stress rating  Review skill practice exercise:  Assess the outcome of the module: What did they do? How did they do it? What was the result? How did they feel? Explore difficulties with implementation. Fine turn approach they might try next time. Praise student for efforts and successes.  Administer and review brief standardized assessment measure: Attribute changes to what the student has worked on and done differently and/or discuss what additional services the student might need going forward.  Review progress/Next Steps BRISC Brief Intervention for School Clinicians

41 Pilot Study Implementation and Findings AgeGradeGenderEthnicityProblem Area 1.1712thF Black/African AmericanAnxiety 2.159thF Hispanic/Puerto Rican American Depression 3.1812thF CaucasianAcademics 4.1911thF Black/AfricanSexual Trauma 5.1610thF CaucasianDepression 6.1712thF CaucasianPeer Problems 7.1711thF CaucasianPeer/Academics 8.1510thM CaucasianAcademics 9.1611thF Black/African AmericanRelationship Issues 10.1812thF Hispanic/Mexican American Academics/Depression 11.1711thFCaucasianAcademics 12.1610thFBlack-FilipinoTruancy

42 Participant Characteristics Participants:  50% self-referred  63.6% clinically significant elevation on problem scale—most depression or anxiety  Many reported poor academic performance, 58% had failed 1 or more classes in the prior semester Engagement:  9 completed the 4-session BRISC intervention; 1 dropped out after 2 sessions, 1 never engaged, and 1 is still in treatment BRISC Brief Intervention for School Clinicians

43 Participant Responses to Intervention Acceptability:  Participants reported that their motivation to attend sessions increased incrementally for each successive session  Median ratings of experience of counseling and helpfulness of homework/practice was 7 out of a possible positive rating of 10 Clinical Outcomes:  Pre-post student assessments of depression, anxiety and functional impairment--promising improvements in all areas BRISC Brief Intervention for School Clinicians

44 BRISC Implementation Adherence  Interventionists demonstrated high levels of adherence to the BRISC protocol including:  identifying and monitoring problems  introducing and conducting stress/mood rating  planning problem monitoring  introducing problem-solving,  assessing barriers,  assigning practice exercises. BRISC Brief Intervention for School Clinicians

45 Lessons Learned  Able to recruit and engage youth  Youth indicated overall satisfaction  Therapists able to deliver protocol with fidelity  BRISC worked well as a way to engage youth, reduce mental health problems, and assess needs BRISC Brief Intervention for School Clinicians

46 Lessons Learned—Case examples  Four core pathways identified 1. Come back if you need it 16 yr. AA anger/relationship issues, teaching-stress cycle, PS re other ways to respond, communication strategies—listening and “I” statements 2. Supportive monitoring 15 yr old, referred by parent/school counselor re academic performance, PS focused on managing academic demands (cell phone use, etc), ongoing check ins with school counselor to reinforce progress

47 Lessons Learned—Case examples  Four core pathways identified 3. Continue BRISC or other TAU 15 yo Hispanic female, depression/dysthymia and academic difficulties. Attempted some initial school interventions and identified significant barriers related to mood. Addressed handling hard feelings (including a referral for psychiatry), then client was able to more effectively engage in problem solving around academic issues.

48 Lessons Learned—Case examples 4. More intensive services – (referral to other services (i.e. special education, psychiatry, trauma treatment, family therapy, DBT, eating disorder treatment, etc.) 19 yo African female, referred by nurse practitioner for trauma and some initial SI, worked on problem solving and handling hard feelings - reducing harmful/problematic coping behaviors (i.e. eating chalk and excessively taking pain meds) and problematic school/peer concerns, and connecting to more intensive outside services making a "warm hand-off" with an outside agency

49 What’s next? IES BRISC Project End Year 1: Revise BRISC protocol Year 2: Protocol validation w/school based mental health providers in 8 SPS High Schools Year 3: Study 4: Randomized pilot study in Seattle and other area high schools

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