Kristy Ludwig

Using Modular Psychotherapy in School Mental Health: Provider Perspectives on Intervention-Setting Fit

The “fit” or appropriateness of well-researched interventions within usual care contexts is among the most commonly cited, but infrequently researched, factors in the successful implementation of new practices. The current study was initiated to address two exploratory research questions: How do clinicians describe their current school mental health service delivery context? and How do clinicians describe the fit between modular psychotherapy and multiple levels of the school mental health service delivery context? Following a year-long training and consultation program in an evidence-based, modular approach to psychotherapy, semistructured qualitative interviews were conducted with 17 school-based mental health providers to evaluate their perspectives on the appropriateness of implementing the approach within a system of school-based health centers. Interviews were transcribed and coded for themes using conventional and directed content analysis. Findings identified key elements of the school mental health context including characteristics of the clinicians, their practices, the school context, and the service recipients. Specific evaluation of intervention-setting appropriateness elicited many comments about both practical and value-based (e.g., cultural considerations) aspects at the clinician and client levels but fewer comments at the school or organizational levels. Results suggest that a modular approach may fit well with the school mental health service context, especially along practical aspects of appropriateness. Future research focused on the development of methods for routinely assessing appropriateness at different stages of the implementation process is recommended.

Patterns and Predictors of Mental Healthcare Utilization in Schools and Other Service Sectors Among Adolescents at Risk for Depression

This study examined racial/ethnic and socioeconomic differences in service utilization across sectors (specialty mental health, school, primary care) for youth at risk for depression. Our sample included 362 adolescents who were enrolled in a larger project examining the effects of an indicated school-based depression prevention program. Service use across sectors mirrored national trends and previous research findings in which the education sector was most frequently utilized for mental health services. Race/ethnicity was significantly associated with parent-reported specialty mental health service utilization, even when controlling for other predictors of use. The study also suggests that racial disparities in service access generally appear to be reduced through the availability of education sector mental health services. Socioeconomic status was not associated with service use in any sector when controlling for other predictors. Parent–child agreement was moderate for report of specialty mental health service use and low for report of use of services within the education and primary care sectors.

The Contextualized Technology Adaptation Process (CTAP): Optimizing Health Information Technology to Improve Mental Health Systems

AbstractHealth information technologies have become a central fixture in the mental healthcare landscape, but few frameworks exist to guide their adaptation to novel settings. This paper introduces the contextualized technology adaptation process (CTAP) and presents data collected during Phase 1 of its application to measurement feedback system development in school mental health. The CTAP is built on models of human-centered design and implementation science and incorporates repeated mixed methods assessments to guide the design of technologies to ensure high compatibility with a destination setting. CTAP phases include: (1) Contextual evaluation, (2) Evaluation of the unadapted technology, (3) Trialing and evaluation of the adapted technology, (4) Refinement and larger-scale implementation, and (5) Sustainment through ongoing evaluation and system revision. Qualitative findings from school-based practitioner focus groups are presented, which provided information for CTAP Phase 1, contextual evaluation, surrounding education sector clinicians’ workflows, types of technologies currently available, and influences on technology use. Discussion focuses on how findings will inform subsequent CTAP phases, as well as their implications for future technology adaptation across content domains and service sectors.

“ If It’s Worth My Time, I will Make the Time”: School-Based Providers’ Decision-Making About Participating in an Evidence-Based Psychotherapy Consultation Program

This study evaluated influences on school-based clinicians’ decision-making surrounding participation in a modular psychotherapy training and consultation program lasting one academic year. Clinicians were recruited from three participation groups: those who never engaged, those who engaged and then discontinued, and those who participated fully. Qualitative interviews explored influences on initial and continued participation, as well as differences in decision-making by participation group, knowledge about evidence-based practices, and attitudes toward evidence-based practices. Eight major themes were identified: time, practice utility, intervention/training content, training process, attitudes toward training, social influences, commitment to training, and expectations. Some themes were discussed universally across all comparison groups, while others varied in frequency or content. Recommendations for increasing participation are presented, based on the findings.

Taking Evidence-Based Practices to School: Using Expert Opinion to Develop a Brief, Evidence-Informed School-Based Mental Health Intervention.

School-based mental health services offer unparalleled opportunities for providing accessible care to children and adolescents. Research indicates that services available in schools are rarely based on evidence of effectiveness and are typically disconnected from the larger school context. To address these issues, the current paper presents initial studies to inform the development of a brief, evidence-based, flexible mental health intervention that fits the school context while maintaining clear structure. Results from two qualitative research studies – key informant interviews with school mental health experts and a nominal group decision-making process with stakeholders – are presented, both of which were aimed at informing intervention development and testing assumptions about how best to design an effective, context-specific mental health intervention that can be flexibly applied in educational settings. An explicit focus on educational outcomes within the context of mental health service delivery was identified as a key component of this integration. The paper concludes with a discussion of how this research has influenced the ongoing development of the intervention protocol, exemplifying a collaborative and iterative approach to developing school-based programmes.

Student perceptions of the acceptability and utility of standardized and idiographic assessment in school mental health

Evidence-based assessment (EBA) comprises the use of research and theory to select methods and processes that have demonstrated reliability, validity and clinical usefulness for prescribed populations. EBA can lead to positive clinical change, and recent work has suggested that it is perceived to be useful by school mental health providers. However, virtually nothing is known about student perceptions of assessment use. Semi-structured interviews were conducted with 31 ethnically diverse middle and high school students (71% female) receiving mental health services in school-based health centers. Findings indicated that the majority of students found assessments to be useful, and perceived three primary functions of assessments: structuring the therapy session, increasing students’ self-awareness and improving communication with the provider. Barriers to acceptability were also found for a minority of respondents. Some students found the nature of standardized assessments to be confining, and others expressed that they wanted more feedback from their counselors about their responses. Idiographic assessments demonstrated especially high acceptability in this sample, with students reporting that tracking idiographic outcomes increased self-awareness, spurred problem-solving and helped them to reach behavioral goals. Implications for school mental health service improvements are discussed.

A Digital Feedback System to Support Implementation of Measurement-Based Care by School-Based Mental Health Clinicians

Evidence supports the utility of measurement-based care (MBC) to improve youth mental health outcomes, but clinicians rarely engage in MBC practices. Digital measurement feedback systems (MFS) may reflect a feasible strategy to support MBC adoption and sustainment. This pilot study was initiated to evaluate the impact of a MFS and brief consultation supports to facilitate MBC uptake and sustainment among mental health clinicians in the education sector, the most common mental health service delivery setting for youth. Following an initial training in MBC, 14 clinicians were randomized to either a digital MFS and brief consultation supports or control. Baseline ratings of MBC attitudes, skill, and use were collected. In addition, daily assessment ratings tracked 2 core MBC practices (i.e., assessment tool administration, provision of feedback) over a 6-month follow-up period. Clinicians in the MFS condition demonstrated rapid increases in both MBC practices, whereas the control group did not significantly change. For clinicians in the MFS group, consultation effects were significant for feedback and approached significance for administration. Over the follow-up period, average decreases in the current study were moderate with only 1 of the 2 outcome variables (administration) decreasing significantly. Inspection of individual clinician trajectories revealed substantial within-group trend variation. MFS may represent an effective MBC implementation strategy beyond initial training, although individual clinician response is variable. Identifying feasible and impactful implementation strategies is critical given the ability of MBC to support precision health care.

Anxiety in Youth: Assessment, Treatment, and School-Based Service Delivery

Anxiety is a natural, protective, and normal part of childhood. Temporary fears are developmentally typical; however, fears and worries that persist and impair functioning may be indicative of an anxiety disorder (Muris, Merckelbach, Mayer, & Prins, 2000). Anxiety disorders are the most common mental health problem in children and youth and are a significant source of distress for those afflicted (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Merikangas et al., 2011).