May 2016

Researchers Building Better Behavioral Health Services for Urban Schools

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When children from low-income, urban backgrounds gather their backpacks to start each school day, they also bring with them weighty issues that can carry over to their classrooms. Anxiety disorders and aggressive and antisocial behavior are common among inner city students, but counselors in their schools usually are scarce, overextended, and lack adequate training to provide effective behavioral health services.

Enter into the equation researchers at The Children’s Hospital of Philadelphia who teamed up with two schools in North Philadelphia in a pilot study to implement evidence-based prevention practices as part of School-Wide Positive Behavioral Interventions and Supports (SW-PBIS). The program has two tiers: Tier 1 aims to improve schools’ climates overall; Tier 2 provides small group-based services to children who are identified as being at high risk for mental disorders.

Interventions for Tier 2 are based on group cognitive behavioral therapy, which teaches children to pay attention to their bodies and their thoughts and use them as cues to engage in coping strategies and problem-solving. For example, if a child recognizes that he is beginning to feel anxious or fearful on the playground, instead of acting out because he is agitated, he can learn to manage his emotions using relaxation techniques and practicing positive self-talk: “Deep breaths. Take it easy. I can handle this.”

The intervention’s initial success led principal investigator Ricardo Eiraldi, PhD, a psychologist in the department of Child and Adolescent Psychiatry and Behavioral Sciences and program director of the Behavioral Health in Urban Schools program at CHOP, to expand his research to more schools in the Philadelphia School District, including a new grant that he received this year from the National Institute of Mental Health. For two decades, Dr. Eiraldi’s research career has focused on addressing mental health services disparities.

“Low income, ethnic, minority children are much less likely to receive high quality mental health services compared to those in the middle class who are not ethnic minorities, so schools can play a very major role in addressing mental health issues in children,” said Dr. Eiraldi, who also is an associate professor of Clinical Psychology in the division of Developmental and Behavioral Pediatrics at Perelman School of Medicine, University of Pennsylvania.

In an article published in Behavior Modification, Dr. Eiraldi and his study team reported that the pilot study, called Project ACCESS (Advancing Collaboration for Children’s Emotional and School Success) showed children with a diagnosis of depression, anxiety, or behavior problems who received the small group–based services over 14 once-a-week sessions showed a decrease in their diagnostic severity level.

The researchers’ next step was to determine the best ways to train school personnel to execute Tier 1 and Tier 2 interventions on a long-term basis and deliver the program’s components with a high level of fidelity, integrity, and clinical effectiveness. With grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, they launched a study in 2013 involving six Philadelphia schools, grades kindergarten through eight. Two school personnel in each school, usually a counselor and a special education teacher, received initial training during a workshop as well as consultation for session preparation or the initial training plus consultation and ongoing coaching for Tier 2 interventions.

“The idea is to create internal capacity within under-resourced schools to be able to provide mental health services to children.” Dr. Eiraldi said.

The study’s results showed that schools in both support strategies successfully delivered and promoted the adoption of SW-PBIS. As in the pilot project, the schools had fewer discipline referrals overall, and school personnel implemented all of the interventions with high levels of fidelity. Jennifer Mautone, PhD, a psychologist in the department of Child and Adolescent Psychiatry and Behavioral Science and an assistant professor of School Psychology in the department of Psychiatry at Penn, was the project director.

But it was not an “easy A” for the study team to get. During the first year of the project, all of the counselors in the school district were laid off due to severe budget problems. Half of the counselors eventually returned to their positions, and in the meantime, the researchers had learned a valuable lesson.

“The project outcomes were very positive, but there are always barriers,” Dr. Eiraldi said. “It is difficult to work with large schools and have everyone involved for a long period of time. There is a lot of turnover, so you have to work with and train new people every year or establish a relationship with a new principal.”

Like all good students, the study team applied this knowledge when constructing their new study. While the two prior studies showed that working with school counselors could be effective, this approach was not very feasible because they often were stretched too thin. In some schools, only one counselor was available for more than 1,000 students.

Instead of focusing on school counselors, the new study will use a “train the trainer” approach to train clinical supervisors and therapists of eight mental health agencies that partner with Philadelphia schools. All children who are eligible for Medicaid and are having some mental health problem can potentially receive school therapeutic services provided by these agencies.

The researchers will compare two updated versions of a cognitive based therapy program (eight sessions vs. 12 sessions), concentrating on children with anxiety. They also will test two ways of implementing the program. The first method is to train the mental health agency supervisors who then will teach and deploy the therapists who work directly with the children in the schools. The second method is the same model, with additional coaching and support provided by the research team to the supervisors.

Eighteen schools in Philadelphia will be chosen for participation, and the researchers expect to enroll 534 students in grades four through eight who present excessive anxiety. By the conclusion of the five year grant, the study team aims to report on the children’s outcomes, implementation outcomes, and cost-effectiveness. Billie Schwartz, PhD, a postdoctoral Fellow in Clinical Psychology at CHOP, is the project director.

“This area of research is called implementation science, which NIH is greatly interested in,” Dr. Eiraldi said. “Lots of money has been spent on research to develop and test effective treatments, but they are either never used in community settings, or they’re used 20 years later. Implementation science is about taking those evidence-based treatments to the community and finding out if they’re effective when implemented by actual clinicians in the real world.”

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