Philip J. Leaf

Mental Health Service Use in the Community and Schools: Results from the Four-Community MECA Study

ABSTRACT Objective To describe the use of mental health and substance abuse services by children and adolescents as reported from the four community sites included in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Method As part of the MECA survey, questions were developed to identify children and adolescents utilizing mental health and substance abuse services. Youths aged 9 through 17 years and a parent/ caretaker were interviewed. Because the investigators had concerns about the capacities of the younger children in the study to describe their use of mental health services, more extensive questions were asked of parents than of youths. Results The procedures developed by the MECA project identified patterns of service use that varied in the four communities surveyed. Agreement between reports of parents and youths regarding the use of mental health and substance abuse services showed substantial Inconsistencies, similar to reports of psychiatric disorders. At three of the four sites, the majority of children meeting criteria for a psychiatric disorder and scoring 60 or less on the Childrens Global Assessment Scale reported some mental health–related service in the previous year, although at two of the sites fewer than 25% of these youths were seen in the mental health specialty sector. Conclusion Community surveys show great promise for monitoring the need for mental health and substance abuse services and for identifying patterns of use.

Examining the Effects of Schoolwide Positive Behavioral Interventions and Supports on Student Outcomes: Results from a Randomized Controlled Effectiveness Trial in Elementary Schools.

Schoolwide Positive Behavioral Interventions and Supports (SWPBIS) is a universal, schoolwide prevention strategy that is currently implemented in over 9,000 schools across the nation to reduce disruptive behavior problems through the application of behavioral, social learning, and organizational behavioral principles. SWPBIS aims to alter school environments by creating improved systems and procedures that promote positive change in student behavior by targeting staff behaviors. This study uses data from a 5-year longitudinal randomized controlled effectiveness trial of SWPBIS conducted in 37 elementary schools to examine the impact of training in SWPBIS on implementation fidelity as well as student suspensions, office discipline referrals, and academic achievement. School-level longitudinal analyses indicated that the schools trained in SWPBIS implemented the model with high fidelity and experienced significant reductions in student suspensions and office discipline referrals.

Multiple imputation by chained equations: what is it and how does it work?

Multivariate imputation by chained equations (MICE) has emerged as a principled method of dealing with missing data. Despite properties that make MICE particularly useful for large imputation procedures and advances in software development that now make it accessible to many researchers, many psychiatric researchers have not been trained in these methods and few practical resources exist to guide researchers in the implementation of this technique. This paper provides an introduction to the MICE method with a focus on practical aspects and challenges in using this method. A brief review of software programs available to implement MICE and then analyze multiply imputed data is also provided. Copyright

Barriers to Children's Mental Health Services

OBJECTIVE To examine the characteristics associated with barriers to childrens mental health services, focusing on the effect of childrens psychosocial problems on parents. METHOD Data come from a first-grade, prevention-intervention project conducted in Baltimore, Maryland. Analyses were restricted to 116 families who participated in seventh-grade interviews and indicated the index child needed services. The Services Assessment for Children and Adolescents was used to measure barriers to childrens mental health services. RESULTS More than 35% of parents reported a barrier to mental health services. Types of barriers included those related to structural constraints, perceptions of mental health, and perceptions of services (20.7%, 23.3%, and 25.9%, respectively). Although parenting difficulties were associated with all barriers (structural: OR = 10.63, 95% CI: 2.37, 47.64; mental health: OR = 8.31, 95% CI: 1.99, 34.79; services: OR = 5.22, 95% CI: 1.56, 17.51), additional responsibilities related to attendance at meetings was associated only with structural barriers (OR = 5.49, 95% CI: 1.22, 24.59). CONCLUSIONS Researchers and policymakers interested in increasing childrens access to mental health services should consider strategies to reduce barriers related to perceptions about mental health problems and services, in addition to structural barriers. Particular attention should be given to programs that focus on the needs of families who are most affected by their childs psychosocial problems.

A Multilevel Study of Predictors of Student Perceptions of School Climate: The Effect of Classroom-Level Factors

A positive school climate is an important component of successful and effective schools and thus is often an aim of schoolwide initiatives. Climate has traditionally been conceptualized as a school-level factor and is often assumed to be related to other school-level factors (e.g., school size). The current study examines variation in perceptions of climate based on individual-, classroom-, and school-level factors to determine the influence of predictors at multiple levels. Data come from 2,468 5th graders from 37 public elementary schools. Two aspects of students’ perception of school climate, order and discipline, and achievement motivation are examined. Multilevel analyses in hierarchical linear modeling indicate that individual-level factors (race and sex) accounted for the largest proportion of variance in perceptions of school climate. School-level factors (e.g., school size and faculty turnover) and several classroomlevel factors (e.g., characteristics of the teacher, class size, and the concentration of students with behavior problems) were also significant predictors of perceptions of climate. These findings suggest that characteristics of the classroom environment are important to consider when aiming to improve school climate.

Feasibility and Preliminary Outcomes of a School-Based Mindfulness Intervention for Urban Youth

Youth in underserved, urban communities are at risk for a range of negative outcomes related to stress, including social-emotional difficulties, behavior problems, and poor academic performance. Mindfulness-based approaches may improve adjustment among chronically stressed and disadvantaged youth by enhancing self-regulatory capacities. This paper reports findings from a pilot randomized controlled trial assessing the feasibility, acceptability, and preliminary outcomes of a school-based mindfulness and yoga intervention. Four urban public schools were randomized to an intervention or wait-list control condition (n = 97 fourth and fifth graders, 60.8% female). It was hypothesized that the 12-week intervention would reduce involuntary stress responses and improve mental health outcomes and social adjustment. Stress responses, depressive symptoms, and peer relations were assessed at baseline and post-intervention. Findings suggest the intervention was attractive to students, teachers, and school administrators and that it had a positive impact on problematic responses to stress including rumination, intrusive thoughts, and emotional arousal.

Maximizing the Implementation Quality of Evidence-Based Preventive Interventions in Schools: A Conceptual Framework

Increased availability of research-supported, school-based prevention programs, coupled with the growing national policy emphasis on use of evidence-based practices, has contributed to a shift in research priorities from efficacy to implementation and dissemination. A critical issue in moving research to practice is ensuring high-quality implementation of both the intervention model and the support system for sustaining it. The paper describes a three-level framework for considering the implementation quality of school-based interventions. Future directions for research on implementation are discussed.

Altering School Climate through School-Wide Positive Behavioral Interventions and Supports: Findings from a Group-Randomized Effectiveness Trial

Positive Behavioral Interventions and Supports (PBIS) is a universal, school-wide prevention strategy that is currently implemented in over 7,500 schools to reduce disruptive behavior problems. The present study examines the impact of PBIS on staff reports of school organizational health using data from a group-randomized controlled effectiveness trial of PBIS conducted in 37 elementary schools. Longitudinal multilevel analyses on data from 2,596 staff revealed a significant effect of PBIS on the schools’ overall organizational health, resource influence, staff affiliation, and academic emphasis over the 5-year trial; the effects on collegial leadership and institutional integrity were significant when implementation fidelity was included in the model. Trained schools that adopted PBIS the fastest tended to have higher levels of organizational health at baseline, but the later-implementing schools tended to experience the greatest improvements in organizational health after implementing PBIS. This study indicated that changes in school organizational health are important consequences of the PBIS whole-school prevention model, and may in turn be a potential contextual mediator of the effect of PBIS on student performance.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology.

OBJECTIVE A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents. METHOD Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization. RESULTS More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend. CONCLUSIONS These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

Differences in the use of psychiatric outpatient services between the United States and Ontario

BACKGROUND The relation between health insurance and the use of mental health services is unclear. We compared the use of outpatient services for psychiatric problems in the United States and Ontario, Canada, among young and middle-aged adults according to self-reports of disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) and to other indicators of need. METHODS We analyzed two general-population surveys carried out separately in the United States and Ontario in 1990 that used identical assessments of need for services and questions about their use by persons 15 to 54 years of age. RESULTS Respondents in the United States were significantly more likely than those in Ontario to report having had psychiatric disorders, poor mental health, or workdays lost or cut short because of psychiatric problems in the previous year. A significantly higher proportion of respondents in the United States (13.3 percent) than in Ontario (8.0 percent) had obtained outpatient treatment in the previous 12 months for psychiatric problems. However, an analysis of subgroups found that the higher probability of the use of services in the United States was confined to people with less severe mental illness. The average number of visits did not differ significantly between the two countries among patients who had similar numbers of psychiatric disorders over the same time periods. There was a stronger match in Ontario than in the United States between the use of services and the measures of perceived need we considered. CONCLUSIONS Although the mental health care system in the United States provides treatment to a larger proportion of the population than that in Ontario, the match between some measures of need and treatment is not as strong in the United States. Any plans to expand coverage for psychiatric disorders in the United States must address this problem.