David Pruitt

Funding a full continuum of mental health promotion and intervention programs in the schools

PURPOSEnTo assess the availability of public and private financing sources to support comprehensive school mental health programs. The paper focuses on expanded school mental health (ESMH) programs, which provide a full array of mental health promotion and intervention services to youth in general and special education through school-community partnerships.nnnMETHODSnA range of strategies to fund ESMH services are reviewed, including fee-for-service funding, as well as grants, contracts, and other mechanisms from federal, state, local, and private sources.nnnRESULTSnAn objective national study of the characteristics and financing of ESMH programs has yet to be conducted. Existing evidence suggests that funding for these programs is patchy and tenuous. Many programs are being funded through fee-for-service programs, which generally only support the provision of more intensive services (e.g., assessment, therapy) and are associated with significant bureaucracy and other concerns (e.g., the need to diagnose students). As programs move to enhance funding for preventive and mental health-promoting activities and services, there is an increasing need for grants, contracts, and other sources of support.nnnCONCLUSIONnProgress in the national movement toward ESMH will be promoted through an interconnected agenda of quality improvement, evaluation of program effectiveness, and the advancement of advocacy. These developments will facilitate policy improvements and increased funding for the full continuum of mental health promotion and intervention in the schools.

Early Identification of Seclusion and Restraint Patterns During Adolescents' Course of Residential Treatment

Early identification of youth who will exhibit the most challenging behavior during the course of a residential stay would allow clinicians to allocate limited resources to best manage these youth. Seclusion/restraint procedures were examined for 156 youth in two public residential facilities from July 2000–September 2005. Few seclusion/restraints occurred in the first month, but this peaked in months two and three. Youth subgroups with different trajectories for the frequency of seclusion/restraint use were distinguishable by the first 60 days. By the second month in residence clinicians can identify youth who will continue to exhibit challenging behavior.

Telemental Health in Schools

OBJECTIVEnThe purpose of this study was to describe the potential and limits of school telemental health (TMH) to support a full continuum from mental health promotion to intervention, particularly for students less likely to access community care.nnnMETHODSnA review of school TMH literature and model programs, and of data from focus groups with child psychiatry fellows, was undertaken to inform best practices and future directions for TMH in schools.nnnRESULTSnExisting data suggest that TMH with children and adolescents is promising and well received. Child and adolescent psychiatrists use various models for conducting school-based TMH, which differ in the level of direct care and types of services provided. Literature review and focus group data suggest that advantages of school TMH include greater efficiency, the capacity for higher volume, and increased access to care for many students who would be unlikely to reach traditional community mental healthcare because of barriers such as transportation and healthcare coverage. Disadvantages of school TMH service provision include patient concerns about their own privacy as well as concerns related to the psychiatrists ability to effectively engage families in care without being present in person. Fellows also noted that the training experience of physically being in the school building and experiencing the school expectations and culture helps them move toward greater appreciation and understanding of the structures, policies, and opportunities and challenges for schools and school-based professionals. Most agreed that a hybrid model of care, with some in-person and some TMH care may be most beneficial to all parties, promoting both engagement and efficiency simultaneously.nnnCONCLUSIONSnSchool TMH should be considered as part of a comprehensive service delivery system for students, in order to address shortages and gaps in specialty child and adolescent mental healthcare, and to maximize efficiency and productivity.

Antipsychotic Treatment Patterns and Aggressive Behavior Among Adolescents in Residential Facilities

This study examined the association between acute aggressive behavior patterns of 145 adolescents in residential treatment facilities with use of and changes in antipsychotic medication for the chronic management of aggression. Seclusion/restraint (S/R) frequency over 12xa0months was used to categorize youth into none, low, moderate, and high S/R groups. Data were analyzed using longitudinal mixed effects logistic regression models that allowed for intra-subject variability over time. The high and moderate S/R groups were significantly more likely to receive antipsychotics, get higher doses, and have changes in medication compared with the none S/R group. Increases in antipsychotic dose were associated with a lower likelihood of changes in antipsychotic medication over time. Despite persistent antipsychotic use at higher doses, youth in the high and moderate S/R groups continued to be secluded/restrained frequently. The findings question the adequacy of these medications in managing aggressive behavior.

Does Early Mentorship in Child and Adolescent Psychiatry Make a Difference? The Klingenstein Third-Generation Foundation Medical Student Fellowship Program

ObjectiveThere is a critical shortage of child and adolescent psychiatrists in the United States. Increased exposure, through mentorship, clinical experiences, and research opportunities, may increase the number of medical students selecting child and adolescent psychiatry (CAP) as a career choice.MethodBetween 2008 and 2011, 241 first-year participants of a program to increase exposure to CAP, funded by the Klingenstein Third-Generation Foundation (KTGF) at 10 medical schools completed baseline surveys assessing their opinions of and experiences in CAP, and 115 second-year participants completed follow-up surveys to reflect 1 year of experience in the KTGF Program.ResultsStudents reported significantly increased positive perception of mentorship for career and research guidance, along with perceived increased knowledge and understanding of CAP.ConclusionsResults suggest that the KTGF Program positively influenced participating medical students, although future studies are needed to determine whether these changes will translate into more medical students entering the field of CAP.

Dissemination and implementation science in program evaluation: A telemental health clinical consultation case example

Increased attention has been placed on evaluating the extent to which clinical programs that support the behavioral health needs of youth have effective processes and result in improved patient outcomes. Several theoretical frameworks from dissemination and implementation (D&I) science have been put forth to guide the evaluation of behavioral health program implemented in the context of real-world settings. Although a strong rationale for the integration of D&I science in program evaluation exists, few examples exist available to guide the evaluator in integrating D&I science in the planning and execution of evaluation activities. This paper seeks to inform program evaluation efforts by outlining two D&I frameworks and describing their integration in program evaluation design. Specifically, this paper seeks to support evaluation efforts by illustrating the use of these frameworks via a case example of a telemental health consultation program in pediatric primary care designed to improve access to behavioral health care for children and adolescents in rural settings. Lessons learned from this effort, as well as recommendations regarding the future evaluation of programs using D&I science to support behavioral health care in community-based settings are discussed.

When Behavioral Health Concerns Present in Pediatric Primary Care: Factors Influencing Provider Decision-Making

Primary care providers (PCPs) frequently encounter behavioral health (BH) needs among their pediatric patients. However, PCPs report variable training in and comfort with BH, and questions remain about how and when PCPs address pediatric BH needs. Existing literature on PCP decisions to address pediatric BH in-office versus referring to subspecialty BH is limited and findings are mixed. Accordingly, this study sought to examine parameters and contextual factors influencing PCP decisions and practices related to BH care. Qualitative interview results with 21 PCPs in Maryland indicated that decisions about how and when to address pediatric BH concerns are influenced by the type BH service needed, patient characteristics, the availability of BH services in the community, and possibly PCPs’ perceptions of BH care as a distinct subspecialty. Findings suggest that efforts to support individual PCPs’ capacity to address BH within primary care must be balanced by efforts to expand the subspecialty BH workforce.