Emotional & Behavioral Disorders in Youth

REPORT ON Emotional & Behavioral Disorders in YouthTM EVIDENCE-BASED A SSESSMENTS • INTERVENTIONS FOR THE REAL WORLD

Volume 17, No. 4 Pages 81 - 104 ISSN 1531–5479 Fall 2017 Motivational Interviewing Training Editors’ Corner and Assessment System (MITAS) for The Patient- School-Based Applications ...... 86 Centered by Andy J. Frey, Jon Lee, Jason W. Small, Outcomes Hill M. Walker, and John R. Seeley Research Building Strong Partnerships: Education and Mental Health Systems Institute Working Together to Advance Behavioral (PCORI) Health Screening in Schools ...... 93 and Support by Kathleen Lynne Lane, Wendy Peia Oakes, for School John Crocker, and Mark D. Weist From the Literature: Behavioral What’s Hot . . . What’s Not ...... 102 Health by Michelle Charlin This is the fourth quarterly issue Calendar of Events ...... 104 of a year-long publication effort of the Report on Emotional & Behav- ioral Disorders in Youth (EBDY ) that highlights the tenants of the Patient- Centered Outcomes Research Institute (PCORI). PCORI is an independent nonprofit organization created by Congress to fund research that helps patients and their families make informed healthcare decisions. It supports studies that compare which treatment options work best for different people based on the outcomes that are most important to the patients and their families. This approach, known as Patient-Centered Outcomes Research, or PCOR, requires the engagement of patients, caregivers, insurers, clinicians, and others across the healthcare community throughout the research process (PCORI, 2016). As noted by

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Weist and Stevens (2017) in the fi rst issue of Engagement Award to our group in 2015, felt should be emphasized as the SSBHC this series ( EBDY, Vol. 17, No. 1), we use the we believe this diverse and deep stakeholder develops. We determined that we should: term “school behavioral health” (SBH) to involvement is leading to innovation and 1. Improve collaboration among families, refl ect more comprehensive mental health practice improvements in SBH. educators, clinicians, and other youth- programs in schools (Weist et al., 2014), Prior to receiving support from PCORI, serving system staff; working closely with systems of posi- the SSBHC held two conferences focusing tive behavioral interventions and supports on SBH in South Carolina—in Columbia 2. Enhance school-wide approaches for (Horner & Sugai, 2015) to develop inter- in 2014 and in Charleston in 2015 (Weist prevention and intervention; connected programs that result in greater & Stevens, 2017). With a view toward 3. Improve the quality of services; depth and quality of multi-tiered prevention, PCORI funding, we convened a forum at 4. Increase implementation support for early intervention, and treatment efforts the conference in Charleston with diverse effective practices; and to achieve enhanced student and school stakeholders to gain their recommendations 5. Enhance cultural humility and reduce outcomes (Barrett, Eber & Weist, 2013). on key themes for advancing SBH in the racial, ethnic, and other disparities. With the support of PCORI, a key goal state and region. The forum was supported in the work to advance SBH has been to by the Medical University of South Caro- We developed a plan for addressing these engage all relevant stakeholders in provid- lina (MUSC) Clinical and Translational themes in our application for the Eugene ing guidance on needed enhancements Research Institute (SCTR), which pro- Washington PCORI Engagement Award, and directions regarding research, policy, vided guidance about which stakeholders to which we received in 2015. and practice. A community-of-practice involve and which questions to ask. More Eugene Washington PCORI Engage- approach (see Wenger, McDermott & than 20 stakeholders, refl ecting most of the ment Awards provide funds to groups that Snyder, 2002) is being used to build the stakeholder groups referenced above, gath- conduct projects that increase the mean- Southeastern School Behavioral Health ered for this meeting. Questions asked were: ingful engagement of patients, caregivers, Community (SSBHC; see www.schoolbe- clinicians, and other healthcare stakehold- • What outcomes of SBH programs are havioralhealth.org ), and we have priori- ers in comparative Clinical Effectiveness most important to students, families, tized involving diverse stakeholder groups Research (CER), and Patient-Centered and schools? in this community. These groups include Outcomes Research (PCOR) by expand- students and families who have emotional/ • How can diverse stakeholders work bet- ing their knowledge and skills and creating behavioral (EB) concerns, family and youth ter together to improve SBH? opportunities for them to build connections advocates, and leaders and staff from the • What barriers are getting in the way of and to share research findings (PCORI, full range of relevant youth-serving sys- stakeholder partnerships? 2016). The 2015 award received by SSBHC tems, including education, mental health, • How can these barriers be overcome? specifically supported the Southeastern juvenile justice, child welfare, disabilities, School Behavioral Health Conferences in • What critical themes should be focused primary healthcare, and allied health ser- April 2016 and F2017, which were held in on to most effectively advance the field? vices, as well as leaders from the faith and Myrtle Beach with more than 400 diverse business communities. As emphasized and These questions resulted in the identifi - participants each year and strong and posi- supported by a Eugene Washington PCORI cation of fi ve key themes that stakeholders tively rated conference programs.

REPORT ON Emotional & Behavioral Disorders in YouthTM

Guest Editors: Editorial Board Mark D. Weist, Ph.D. and Robert Stevens, Ph.D. Marc Atkins, Ph.D., Department of Psychiatry, University of Mary McKay, Ph. D., Professor, Silver School of Social Work at NYU; Illinois at Chicago, Chicago, IL Director, McSilver Institute for Poverty Policy and Research, New York, NY Publisher & Editorial Director: Eric J. Bruns, Ph.D., Associate Professor, University of Washington Hill Walker, Ph.D., Professor of Special Education, Institute on Violence Deborah J. Launer School of Medicine, Department of Psychiatry and Behavorial Sciences, and Destructive Behavior, University of Oregon, Eugene, OR Managing Editor: Division of Public Behavioral Health and Justice Policy, Seattle, WA Mark D. Weist, Ph.D., Professor, Clinical-Community and School Margaret B. Riccardi Steven W. Evans, Ph.D., Professor, Department of Psychology, Psychology, and Director of Clinical-Community Training, Department Contributing Editor: Ohio University, Athens, OH of Psychology, University of South Carolina, Columbia SC Lorraine Dubuisson Steven R. Forness, Ed.D., Professor Emeritus, UCLA Neuropsychiatric John Weisz, Ph.D., Professor of Psychology, Harvard University, Hospital, Los Angeles, CA Cambridge, MA Kimberly Hoagwood, Ph.D., Vice Chair for Research, Department of Child and Adolescent Psychiatry, New York University Peter S. Jensen, M.D., President, CEO, The REACH Institute, Affi liations shown for identifi cation purposes only. Opinions expressed New York, NY; Co-Director, Division of Child Psychiatry & Psychology, do not necessarily refl ect the positions or policies of a writer’s agency or The Mayo Clinic, Rochester, MN association. The information in this publication is not intended to replace the services of a trained legal or health professional. Neither the editor, nor the contribu- tors, nor Civic Research Institute, Inc. is engaged in rendering legal, psychological, health or other Report on Emotional & Behavioral Disorders in Youth is published quarterly by Civic Research Institute, Inc., 4478 U.S. Route 27, P. O. Box 585, Kingston, professional services. The editors, the contribu- NJ 08528. Periodicals postage pending at Kingston, NJ and at additional mailing offi ces. Subscriptions: $165 per year in the United States and Canada. $30 tors and Civic Research Institute, Inc. specifically additional per year elsewhere. Vol. 17 No. 4, Fall 2017. Copyright © 2017 by Civic Research Institute, Inc. All rights reserved. POSTMASTER: Send address disclaim any liability, loss or risk, personal or changes to Civic Research Institute, Inc., P.O. Box 585, Kingston, NJ 08528. Report on Emotional & Behavioral Disorders in Youth is a trademark owned by otherwise, which is incurred as a consequence, Civic Research Institute, Inc., and may not be used without express permission. directly or indirectly, of the use and application of For information on subscribing or other service questions contact customer service: (609) 683-4450 or [email protected] any of the contents of this publication.

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Our engagement effort was intended • Improve processes within teams to roles for all to enable greater involvement not simply to hold conferences and create assure consistent, well-planned, and exe- in prevention and intervention. publications to provide information about cuted meetings with strong follow-up; effective SBH. It was meant to engage all • Assure active, ongoing, and high-quality Theme 4: Improve stakeholders in a meaningful way so as to professional development for all school Implementation Support change the cultures of research, practice, staff, collaborating with staff from men- • Involve family members and students and policy from being driven by university tal health and other systems, and for in training on EBPs within the MTSS; and systems leaders to being broadly driven students and families; • Systematically focus on improving the by diverse stakeholders. To accomplish • Improve sharing of information and functioning of teams and on assuring true stakeholder engagement, we provided team planning to support students from effective plans for providing ongoing multiple opportunities for stakeholder one grade to the next; coaching support for EBPs; input. Prior to the 2016 conference, we held a stakeholder pre-conference to dis- • Develop messaging and social market- • When implementing interventions with cuss the ﬁ ve key conference themes. We ing strategies to assure broad buy-in and families, enhance empathy and acknowl- subsequently held research forums (focus support for multi-tiered SBH efforts edge that they may feel “blamed” for groups) on each theme separately, and we and prominently involve families in this presenting problems in their children; are currently conducting formal qualitative social marketing; • Provide broad training on common chal- analyses of the focus group data. Following • Implement school-wide approaches lenges people have had, such as adverse are highlights from ideas generated for each to train students and staff on mental childhood experiences (ACES) and the of the ﬁ ve themes from notes taken at the health and behavioral health promotion, impact these have on functioning; pre-conference and during each forum. Theme 1: Improve Collaboration and Partnerships Our effort was intended . . . to engage all stakeholders • Reduce stigma and shaming and blam- in a meaningful way so as to change the cultures ing of students and families presenting with mental health problems; of research, practice, and policy from being driven • Provide broad training on mental health by university and systems leaders to being promotion for all groups: school staff, students, families, and community broadly driven by diverse stakeholders. collaborators; • Increase peer-to-peer support for stu- integrated with less stigmatizing health dents and for family members; • Provide pragmatic support to families, promotion strategies (e.g., stress man- giving them information on available • Involve family members in making deci- agement, improving coping, and improv- school and community programs and sions about choosing evidence-based ing nutrition, sleep, and exercise). resources and actively helping them practices (EBPs) to implement within the connect with these resources; multi-tiered system of support (MTSS); Theme 3: Enhance the Quality of Services • Identify exemplars of effective imple- • Increase student leadership within all mentation of EBPs at each of the tiers tiers of the MTSS, including Tier 1 • Improve systems of crisis response to and develop communication strategies (promotion/prevention), Tier 2 (early enable greater involvement of clinical about these exemplar sites and about intervention), and Tier 3 (intervention); staff in Tier 1 and Tier 2 programs and how they are overcoming barriers to • Increase the role of family advocates and strategies; EBP implementation. provide advocacy training; • Increase family engagement and • Improve abilities of parents to effec- empowerment strategies, treat families Theme 5: Promote Cultural tively and consistently communicate as collaborators, and assure that Tier 3 Humility and the Reduction with school and SBH staff; services are evidence based and actually of Disparities • Increase parent-to-parent support for supportive of families; • Move away from the “us versus them” managing emotional/behavioral (EB) • Enhance the impact of SBH through bet- idea of mental health challenges, rec- problems in children; ter connections with health promotion; ognizing that everyone has challenges, • Increase time options for services for fam- • Increase training and support for trau- whether personally or with a family ilies, including during afterschool hours; ma-sensitive practices; member or friend; • Connect mental health promotion in • Develop guides for resources available • Broaden and improve mental health edu- schools to physical health promotion. to students and families in the school cation for all groups, including specific and in the community and keep these approaches to reduce stigma; Theme 2: Strengthen School-Wide resources up to date (e.g., through an • Improve cultural awareness and under- Approaches evolving website); standing for all groups: What cultural, • Improve the inclusiveness of teams • Analyze the roles of school-employed men- ethnic groups are represented in the to include all stakeholder groups and tal health staff (e.g., counselors, psycholo- school? What are their needs, priori- youth and families; gists, social workers) and work to expand ties, and recommendations? How can

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SBH programming be enhanced to families, youth, mental health and educa- be doing, youth are now helping to co-create include such cultural awareness and tion staff, and other stakeholder groups programs with family members and with understanding? from the southeastern region of the United adults from the full range of youth-serving • Increase efforts to understand issues and States as well as other states and coun- systems (Hart, 1997). dynamics occurring within students’ tries. The keynote address from the 2016 The conferences emphasize “leading neighborhoods; conference—which focused on school- by convening” (Cashman et al., 2014), wide wellness (Lever, Mathis & Mayworm, helping diverse groups to meet with one • Involve diverse people on MTSS teams 2017)—and the address from the 2017 another and enter discussion, with a goal for and in advising the school on effective conference—which focused on precision in some groups to move beyond discussion to SBH programming; our behavioral science approach in the cur- dialogue, collaboration, policy change, and • Provide ongoing training and implemen- rent national climate (Sugai et al., 2017)— resource enhancement. This is facilitated tation support on cultural humility and have been important contributions to this by the SSBH conference listserv, which responsiveness for all staff and stake- EBDY series, and all of the articles published has grown to nearly 15,000 stakehold- holders involved in SBH; in the series have a connection to one of ers, primarily from seven states (Florida, • Integrate self-assessment of cultural these two conferences. The intention for Georgia, Kentucky, North Carolina, South humility and responsiveness into quality these SSBH conferences was to provide Carolina, Tennessee, and Virginia) in the improvement efforts; a forum for training and dissemination of southeastern region of the United States, and a conference website ( www.schoolbe- havioralhealth.org ) that also serves as a In contrast to the norm of having adults lead almost repository of key documents, presentations, and lessons learned from the community. all efforts and telling students what they should be The SSBHC is also embracing techno- logical advances, using all forms of social doing, youth are now helping to co-create programs media (e.g., Facebook, Instagram, Twit- with family members and with adults from the full ter) to publicize community events, and a conference app ( advancingSBH) that was range of youth-serving systems. extremely popular at the 2017 meeting. It is our hope that the SSBH community and conferences continue to gain strength in • Identify problematic policies within information on cutting-edge issues in the the years to come, providing a platform for schools and youth-serving systems that SBH field and to promote coherence in diverse stakeholders to collaborate on the contribute to negative outcomes for partic- research, practice, and policy agendas within advancement of SBH in the region. ular cultural/ethnic groups (e.g., the social the region and the participating states. Our maladjustment exclusion from special goal was for each state to send representa- This Four-Issue Volume of EBDY education for youth presenting “willful tives, including families and youth and all of Consistent with the priorities of the misconduct”; see Becker et al., 2011). the stakeholder groups mentioned above, for Eugene Washington PCORI Engagement During the pre-conference of the 2017 the sharing of information and best practices Award on training and dissemination as SSBH Conference, a group of more than and the adoption of these practices across guided by patients and diverse stakehold- 30 diverse stakeholders reacted to the points community and state boundaries, refl ect- ers, we are grateful for the opportunity to from each of the fi ve themes. Attention then ing “multi-scale learning” to escalate the have published this 2017 four-issue volume focused on improving SBH for three priority pace of positive change. As mentioned, a of EBDY (Volume 17, Nos. 1–4). As noted, underserved populations: youth in the child community-of-practice approach has been all articles published in the journal this year welfare system, youth with connections to used (Wenger, McDermott & Snyder, 2002), have a connection to the SSBH conferences the juvenile justice system, and youth from based on the recognition that the system- and cover diverse concepts relevant to the military families. At the time of this writing, atic work (e.g., evidence-based SBH in all advancement of SBH. In addition to the four research forums are scheduled to occur with schools in a district) rests on the foundation editorials providing general background on diverse stakeholder representatives focusing of genuine collaborative relationships. the SSBH and on cross-system and intercon- on advancing SBH for each of these three In addition, with support from WestEd nected approaches to SBH (Barrett, Eber & priority populations. There will also be an (https://www.wested.org/ ), the Federation of Weist, 2013), articles have focused on school emphasis on connecting key points of the Families of South Carolina (http://fedfamsc. and staff wellness, classroom behavior man- fi ve critical themes for service improvement org/ ), and the South Carolina Clinical and agement, SBH programming, and adverse for each of these three populations. Translational Research Institute (SCTR) at childhood experiences (EBDY , Vol. 17, the Medical University of South Carolina No. 1), universal screening, social and emo- The 2016 and 2017 Southeastern (MUSC), both conferences prioritized youth tional learning programs, and afterschool School Behavioral Health leadership and included youth summits for programs ( EBDY, Vol. 17, No. 2), and climate students from local high schools. Our goal and precision in behavioral sciences, effec- Conferences is to increase the numbers of youth who feel tive implementation, and social exclusion With the support of PCORI, the 2016 invested in the SBH agenda. In contrast to and peer rejection ( EBDY , Vol. 17, No. 3). and 2017 SSBH conferences each included the norm of having adults lead almost all This fi nal issue for 2017 (EBDY , Vol. 17, more than 400 diverse participants from efforts and telling students what they should No. 4) includes two important articles, both

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of which reinforce the need for the concept support and guidance. We also express our Lever, N., Mathis, E., & Mayworm, A. (2017). of patient centeredness when developing appreciation to Deborah Launer, of the School mental health is not just for students: Why teacher and school staff wellness matters. Report effective practices. Civic Research Institute, for the opportu- on Emotional & Behavioral Disorders in Youth, In the fi rst article, Andy Frey and col- nity to publish these four issues and for her 17(1), 6–12. leagues present the Motivational Inter- visionary work in founding and leading Patient-Centered Outcomes Research Institute viewing Training and Assessment System EBDY since its inception in 2000. (2016). Better Research Through Engagement. (MITAS), an evidence-based strategy for Available at http://www.pcori.org/sites/default/files/ counselors to improve student engagement. PCORI-Better-Research-Through Engagement.pdf . The article documents the feasibility of the References Siceloff, E.R., Bradley, W.J., & Flory, K. (2017). Barrett, S., Eber, L., & Weist, M.D. (2013). Advanc- MITAS and the large gains to be made in Universal behavioral/emotional health screening in ing Education Effectiveness: An Interconnected schools: Overview and feasibility. Report on Emo- school counselor competencies through its Systems Framework for Positive Behavioral Inter- tional & Behavioral Disorders in Youth, 17(2), 32–38. implementation, providing a new direction ventions and Supports (PBIS) and School Mental Sugai, G., Freeman, J., Simonsen, B., LaSalle, T., & for enhancing student engagement in SBH. Health. Center for Positive Behavioral Interventions and Supports (funded by the Offi ce of Special Edu- Fixsen, D. (2017). National climate change: Dou- The second article, by Kathleen Lane cation Programs, U.S. Department of Education). bling down on our precision and emphasis on preven- and colleagues, builds on an earlier article Eugene, OR: University of Oregon Press. tion and behavioral sciences. Report on Emotional & Behavioral Disorders in Youth, 17(3), 58–63. in EBDY by Siceloff, Bradley, and Flory Becker, S.P., Paternite, C.E., Evans, S.W., Andrews, (2017; EBDY , Vol. 17, No. 2) and discusses C., Christensen, O.A., Kraan, E.M., & Weist, M.D. Weist, M.D., Lever, N., Bradshaw, C., & Owens, the importance of early identification of (2011). Eligibility, assessment and educational J.S. (2014). Further advancing the fi eld of school problems through behavioral health screen- placement issues for students classifi ed with emo- mental health. In M. Weist, N. Lever, C. Bradshaw tional disturbance: Federal and state-level analyses. & J. Owens (Eds.). Handbook of School Mental ing. Through school, family, and mental School Mental Health, 3(1), 24–34. Health: Research, Training, Practice, and Policy health system partnerships, screening strate- (2nd ed., pp. 1–16). New York: Springer. Cashman, J., Linehan, P., Purcell, L., Rosser, M., gies including teacher- and student-report Schultz, S., & Skalski, S. (2014). Leading by Con- Weist, M.D., & Stevens, R. (2017). Advancing are presented, along with pragmatic ideas vening: A Framework for Authentic Engagement. school behavioral health. Report on Emotional & for accomplishing these screenings and for Alexandria, VA: National Association of State Behavioral Disorders in Youth, 17(1), 1–5. providing directions for future research, Directors of Special Education. Wenger, E., McDermott, R.A., & Snyder, W. (2002). practice, and policy. Hart, R. (1997). Children’s Participation: The Cultivating Communities of Practice: A Guide As we conclude this 2017 volume of Theory and Practice of Involving Young Citizens in for Managing Knowledge. Boston, MA: Harvard Community Development and Environmental Care . Business School. EBDY, we extend our thanks to PCORI for London: Earthscan. its support of the advancement of SBH in —Mark D. Weist Horner, R.H., & Sugai, G. (2015). School-wide the southeastern region of the United States, PBIS: An example of applied behavior analysis ( [email protected] ) and and to PCORI project offi cers Lia Hotchkiss implemented at a scale of social importance. Behav- Robert Stevens and Marina Broitman for their ongoing ior Analysis in Practice, 8(1), 80–85. ( [email protected] ) Q

A Note From the Publisher Mark D. Weist, Ph.D., is a professor in the Department of Psychology at the University of South Carolina. Prior to joining USC, he was on the faculty of the University of Maryland School of Medicine, where he helped to found and direct the Center for School Mental Health, one of two national centers providing leadership for the advancement of school mental health (SMH) policies and programs in the United States. Dr. Weist has published and presented widely in the SMH ﬁ eld and has edited or coedited nine books. Robert Stevens, Ph.D., is coordinator of stakeholder engagement for Health Sciences South Carolina (HSSC), leadership team member of the South Carolina Association for Positive Behavior Support Network, and patient investigator for the Mid-South Clinical Data Research Network at Vanderbilt University. Professor Weist will lead the School Behavioral Health Dissemination and Engagement Project within the School Mental Health Team (SMHT) of USC’s Department of Psychology, with co-director Stevens providing leadership of the project through his role as leadership team member of the South Carolina Association for Positive Behavior Support Network. The Civic Research Institute is pleased to welcome Professors Weist and Stevens as coeditors of this fourth of four consecutive issues of EBDY . From the Editors Work on this four-issue volume of the Report on Emotional & Behavioral Disorders in Youth (Winter, Spring, Summer, Fall 2017) is supported by a grant from the Patient-Centered Outcomes Research Institute (PCORI) through the Eugene Washington PCORI Conference Award for the School Behavioral Health Dissemination and Engagement Project (#EAIN 2874; 2016-2018). We also convey our appreciation to the South Carolina Department of Mental Health and to the South Carolina Department of Education for their support of the community of practice and conference, and for efforts to link together education and mental health priorities and strategies through well-executed SBH programs. Finally, thanks are extended to Josh Bradley, Allison Farrell, Lee Fletcher, Elaine Miller, and Ashley Quell of the University of South Carolina School Behavioral Health Team, and to the Civic Research Institute for the opportunity to publish these four consecutive issues of EBDY .

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Motivational Interviewing less likely it is that he or she will change. situations, MI has also been infl uential as Miller and Rollnick (2012, p. 29) defi ne MI helps accelerate the change process “by a guiding framework for developing the motivational interviewing (MI) as “a col- literally talking oneself into change” (Miller intervention protocol (Frey et al., 2014; laborative, goal-oriented style of com- & Rollnick, 2012, p. 168). Reinke et al., 2008, 2011; Strait et al., 2012; munication with particular attention to Several studies have shown that when MI Terry et al., 2013). Additionally, coaching the language of change . . . designed to is used in substance abuse and health care procedures based on the MI approach have strengthen personal motivation for and settings, the clients are more likely to stay been employed to improve implementation commitment to a specifi c goal by eliciting in treatment longer, put forth more effort fi delity of well-established interventions and exploring the person’s own reasons for during treatment, adhere more closely to the such as First Step to Success (Lee, Frey, change within an atmosphere of acceptance intervention protocol or recommendations, Walker, et al., 2014), Parent Coping Power and compassion.” MI is based on empirical and experience signifi cantly more improved (Herman et al., 2012), and Promoting Alter- native Thinking Skills (Reinke et al., 2012). The promise of MI’s effective use within The more someone talks about or argues for change, the context of school-based intervention research and practice is substantial and is the more likely it is that he or she will change. likely to be the focus of considerable future research and practice. Conversely, the more one verbalizes reasons against Relatively little is currently known about the feasibility of establishing MI compe- change, the less likely it is that he or she will change. tency among school personnel or how to evaluate it. Yet, the successful transfer of MI’s full impact and advantages into edu- evidence that documents the basic principle outcomes than clients who receive identi- cational settings will likely depend on the that the way people talk about change can be cal treatment without the MI component extent to which specialized instructional related to the way they act. Simply stated: (Aubrey, 1998; Bien et al., 1993; Brown support providers (e.g., school social work- The more someone talks about or argues & Miller, 1993; Saunders et al., 1993). ers, school psychologists, school counsel- for change, the more likely it is that he Recently, adaptations of MI, created for use ors, behavioral coaches) implement the or she will change. Conversely, the more with parents of children in mental health set- approach competently. To date, few studies one verbalizes reasons against change, the tings, have demonstrated promise for remov- have examined training procedures and MI ing motivational barriers and producing skill acquisition of school-based person- *Andy J. Frey, Ph.D., is a professor in the University desirable changes in adult behavior. These nel. Burke, Da Silva, Vaughan, and Knight of Louisville’s Kent School of Social Work. Jon Lee, positive effects have been associated with (2005) conducted a single MI training Ph.D., is an assistant professor in the University of subsequent changes in child behavior (Con- session on the principles of MI with high Cincinnati’s School of Education. Jason W. Small, nell, et al., 2008; Dishion et al., 2008, 2010; school counselors. From anecdotal coun- B.A, is a data analyst at the Oregon Research Insti- Gardner et al., 2009; Lunkenheimer et al., selor reports, they concluded that the par- tute, in Eugene. Hill M. Walker, Ph.D., is a professor 2008; Shaw et al., 2006; Smith et al., 2013). ticipants had identifi ed several benefi ts of of special education in the University of Oregon’s learning the MI approach. As well, Caldwell College of Education and director of the university’s Motivational Interviewing and Kaye (2014) employed a single-group Center on Human Development. John R. Seeley, in Schools post-test-only design in which 84 student Ph.D., is a professor in the Special Education and Clinical Sciences Department at the University of MI has important potential applicability services staff were able to demonstrate Oregon’s College of Education. Andy J. Frey can be to address similar problems related to par- limited MI skills when presented with a reached by mail at the Kent School of Social Work, ent, teacher, and student engagement and structured student role play following a one- University of Louisville, Louisville, KY 40292, and poor implementation of evidence-based day training. Caldwell and Kaye advocate by email at [email protected]. practices within schooling contexts. Several continued learning opportunities as well An Institute of Education Sciences, U.S. Depart- research groups have leveraged MI as a as integration of skills development into ment of Education grant (R324A090237) to the mechanism of change within educational everyday practice to sustain acquired skills. University of Louisville was utilized as partial settings to improve the social and academic Finally, Frey, Lee et al. (2013) reported that support for the development of this article. The functioning of students who are at risk interventionists demonstrated acceptable opinions expressed are those of the authors and levels of MI profi ciency via conversations do not represent views of the Institute or the U.S. of developing emotional and behavioral Department of Education. The authors would also disorders that interfere with their academic with teachers and parents following partici- like to thank their partners in the early childhood performance and formation of social sup- pation in a developmental grant to infuse MI program in the Jefferson County Public School port networks (Frey et al., 2011; Herman principles into the First Step to Success early (Louisville, KY) system. et al., 2014; Reinke et al., 2013). In some intervention program (Frey et al., 2014).

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There are several key questions that must 4. Exchanging Information, Sustain Talk, they code audio recordings using the MITI be addressed before MI can be considered a Discord and Evoking Confidence; and and discuss the successes and challenges viable approach to improve implementation 5. Planning for Change. of implementation. The professional learn- fi delity within school settings (Herman et ing communities start with support from During the workshops, several didac- al., 2014). They are: an MI expert, which is faded as learning tic and interactive teaching methods are communities gain confi dence with their • How much training, supervision, and used, including lectures, discussions of coding skills. As indicated in this descrip- practice are required to improve one’s key concepts, modeling (through video tion, tools that can be used to measure MI proficiency? and live demonstration), and role playing. competency in MI are necessary to evalu- • What level of competency is sufficient Workshops are available in one-hour, six- ate the effi cacy of the training component to affect teacher, parent, or adolescent hour, and 15-hour options. A summary of of the MITAS. behavior change? the guiding principles and objectives of MI workshops is provided in Table 1. • What standards should be used to evalu- The MITAS Assessment ate MI competency? Prior to the in vivo coaching feedback sessions, school personnel audio record a Component The MITAS Training Component 20-minute conversation with teachers, par- The MITAS assessment component This article describes the Motivational ents, or adolescents during which they use contains measures to determine engage- Interviewing Training and Assessment MI in support of the participant’s consid- ment and satisfaction, MI competency, MI System (MITAS), and presents the results eration of behavior change. An MI expert proficiency, self-efficacy, and perceived of a feasibility study conducted to evaluate evaluates the recording and then provides profi ciency. some of the questions posed by Herman performance feedback via a 30-minute Engagement and Satisfaction. The and colleagues. coaching session. The Motivational Inter- facilitator’s checklist requires facilitators Miller and Moyers’ (2006) eight-stage viewing Treatment Integrity (MITI) Code to indicate which training components the model of learning MI has been the pri- 4.0 (Moyers et al., 2014), described in the participant attended and to assess the partici- mary theoretical framework guiding MI next section, is used to code the session and pant’s engagement in the learning process. professional development efforts to date. provide data that can be used for individu- The six engagement items are rated on a Hartzler and colleagues (2010) suggest that alized feedback to participants using the fi ve-point Likert scale. Facilitators report on the development of MI competency is a Elicit-Provide-Elicit framework (E-P-E; each participant’s engagement in the training multi-stage process whereby relational and Miller & Rollnick, 2012). The E-P-E by responding to fi ve items assessing: approach is a strategy to provide feedback, technical skill development occurs in con- 1. Attentiveness during training sessions; trived settings with practice and feedback. and also to promote refl ection. Specifi cally, 2. Responsiveness to comments during Profi ciency, which is defi ned by the applica- the facilitator begins the coaching session feedback sessions; tion of these skills within context-specifi c by eliciting the participant’s perception of clinical encounters, is, however, developed the audio recording, providing a limited 3. Overall motivation to participate; in later stages. amount of data from the coding (e.g., ratio 4. Willingness to ask questions; and of open-ended questions to close-ended The MITAS contains a training compo- 5. Willingness to try new techniques. nent and an assessment component. Both are questions), and then elicits the participant’s described below and depicted in Figure 1. reaction to the data. Thus, the MITI data The MITAS satisfaction survey consists The training component consists of a provide a structure through which the of 17 items, scored on a fi ve-point scale multi-session workshop, delivered fl exibly, MI expert can analyze the recording and from Strongly Disagree to Strongly Agree. depending on the needs of the participants. provide performance feedback. During Items examine participants’ perceptions of The training component may also include the professional learning communities, program usability, effectiveness, and value up to three individualized coaching sessions school personnel bring in audio recordings based on impact within the school setting in which participants receive performance of their use of MI in conversations about for the five workshops (overall satisfac- feedback on their use of MI from a practi- behavior change with teachers, parents, tion; nine items) and the feedback sessions tioner who is well versed in school-based and adolescents. During these meetings, (eight items). MI. Finally, the training component may include monthly consultation groups, or professional learning communities, in Figure 1: Motivational Interviewing Training and Assessment which school personnel come together to code conversations they have had with System for School-Based Applications teachers, parents, or adolescents and to discuss the successes and challenges of implementation. The workshop topics, which are derived from the four MI processes described by Miller and Rollnick (2012), cover the following topics: 1. Introduction to MI; 2. OARS and Values; 3. Focusing and Evoking;

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Table 1: MITAS Guiding Principles and Workshop Objectives I. Introduction to MI Guiding Principles √ The way in which persons are engaged can either block or support the likelihood of their changing their behavior. √ We all experience ambivalence around change; how we talk about this affects what we do. √ A client-centered, non-authoritarian approach increases the client’s level of engagement and willingness to consider change. √ Client-centered skills (OARS) are necessary, but not sufficient for MI. √ Using client-centered skills and evoking the client’s ideas about change involves doing the opposite of what we are trained and naturally inclined to do. Because the clients are the experts, they—not we—should do most of the talking (i.e., articulating the reasons for change). Objectives 1. Compare and contrast the motivational interviewing approach to predominately directing and following styles. 2. Identify the definition of MI and the components of the MI spirit. 3. Identify and describe each of the client-centered counseling skills (OARS). II. OARS and Values Guiding Principle √ Discrepancy between a current behavior and a core value can be a powerful motivator for change when explored in a safe and supportive atmosphere. Objectives 1. In the context of work with teachers, demonstrate the use of open-ended questions and affirmations. 2. Define/describe simple and complex reflections. 3. Demonstrate the use of reflection in the context of a support staff-teacher interaction. 4. Define/describe a summary and demonstrate its use in the context of a support staff-teacher interaction. 5. Identify the critical role of values in any discussion of change. 6. Generate at least two open-ended values questions. 7. Identify OARS skills within a verbatim transcript. III. Evoking and Focusing Guiding Principles √ Evoking involves guiding the client to voice their arguments for change. √ Change talk can be significantly increased depending on how the interviewer responds. √ MI involves a process for developing and maintaining a specific direction (toward one or more change goals) in the conversation about change. Objectives 1. Identify at least two methods of evoking change talk. 2. Demonstrate at least two MI adherent responses to change talk. 3. Identify the choices for focus most frequently on the table in working with teachers and parents. 4. Demonstrate the use of agenda mapping. IV. Exchanging Information, Sustain Talk & Discord, Evoking Confidence Guiding Principle √ It is easy to overestimate how much information and advice clients need. When needed, these must be given in a way that honors the clients’ expertise and autonomy. √ Sustain talk can be decreased (or increased) depending on how the interviewer responds. √ The way in which discord is handled significantly affects future engagement. √ Client reluctance may be related to the importance of change and/or to clients’ confidence in their ability to change. Objectives 1. Demonstrate the use of elicit-provide-elicit technique. 2. Distinguish between change and sustain talk in client statements. 3. Demonstrate at least one MI-adherent response to sustain talk. 4. Identify at least one origin of and one MI-adherent way to respond to discord. 5. Demonstrate the use of at least one technique for evoking hope and confidence. V. Planning for Change Guiding Principle √ When clients reach a point where they are ready to change, MI involves developing commitment to change and a plan of action. √ For some, deciding to make the change is enough to lead to substantial and lasting change, even without treatment or educational intervention. Objectives 1. Provide experiences in recognizing readiness for change. 2. Demonstrate negotiating a plan and consolidating commitment. 3. Introduce steps to closure for each (a) premature, (b) no plan selected, and (c) plan selected.

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MI Competency. We used recom- motivational MI, including engaging, focus- available MI literature and a modifi cation mended steps for scale development from ing, evoking, and planning (Moyers et al., of currently available tools so that they are McCoach et al., (2013) and DeVellis (2011) 2014). Sessions without a specifi c change applicable in schools. In order to determine to identify and adapt two assessment mea- target or goal may not be appropriate for if the MITAS is useful for training school sures to evaluate MI competency. These evaluation with the MITI, although some of personnel to use MI to enhance intervention steps include (1) conceptual defi nition and the elements may be useful for evaluating fi delity, we employed a single group, pre-/ literature review, (2) pre-test, (3) expert and giving feedback about engaging skills. post-test design to assess the feasibility of panel review, and (4) pilot test (see Small The MITI has two components: the global and satisfaction with the MITAS. Research et al., 2014). Following the conceptual scores and the behavior counts. According questions were: defi nition and literature review, we identi- to Moyers and colleagues (2016), interrater 1. To what extent will participants engage fi ed the Helpful Response Questionnaire reliability based on interclass correlations and participate in the MITAS training (HRQ; Miller et al., 1991) and the Video (ICC) ranged from 0.77 to 0.86 for global component? Assessment of Simulated Encounters- ratings, from 0.58 to 0.88 for behavior Revised (VASE-R; Rosengren et al., 2008) counts, and from 0.53 to 0.92 for MITI 2. To what extent is the training poten- as promising measures for adaptation in summary measures. tially efficacious for improving MI the context of school-based intervention Motivational Interviewing Self- skill? practice and research. Effi cacy. Young (2010) developed the MI 3. Do participants perceive the training to The Written Assessment of Simulated Knowledge Questionnaire (MIQ) to assess be socially valid? Encounters-School Based Applications (WASE-SBA; Lee, Small & Frey, 2013), formerly the HRQ, measures a person’s ability to generate reflective responses The study participants attended five three-hour and is scored by rating each response on workshops and completed and received performance fi ve-point scale, with a rating of 1 being indicative of weak refl ective practice con- feedback on audio recordings of their practicing taining MI-non-adherence skills, 3 being indicative of simple refl ective practice, and MI in consultation with teachers or parents. 5 being indicative of complex reflective practice that infers potential parent, teacher, or adolescent behavior change. The scores counselor trainees’ understanding of the Study Sample for each of the six responses can be com- basic ideas and principles of MI and their Early childhood support staff, who regu- bined to refl ect the overall level or degree feelings of profi ciency in their ability to use larly consult with parents and teachers of refl ective practice across the measure. MI in practice. The original MIQ consists within a large, urban early childhood pro- The WASE-SBA contains directions, item of 12 questions that participants respond to gram in the Midwest were recruited during stems and prompts, a scoring guide, and a using a fi ve-point Likert scale ranging from a 30-minute overview presentation of the scoring form. 1 (Strongly Disagree) to 5 (Strongly Agree). study. Of the 35 support staff who were The Video Assessment of Simulated Our adapted version of the questionnaire invited to participate, 15 consented and Encounters-3-School Based Applications uses the seven items that assess respondent’s 12 completed the training. The mean age (VASE-3; Lee, Frey & Small, 2013) is a perceived ability to use MI. of the 12 participants was 48 (SD = 9.0). modifi ed version of the VASE-R (Rosen- Perceived Profi ciency. The Measure of Eleven participants were female, three gren et al., 2008). The VASE-3 uses three Perceived Profi ciency (MOPP) consists of were African-American, and nine were video-recorded vignettes with eight oppor- 10 items assessing a participant’s perceived Caucasian. Six participants had earned tunities to respond in each vignette (24 items profi ciency at implementing MI-specifi c master’s degrees in education, counseling, total). Respondents are prompted to gener- skills. The MOPP assesses 10 MI-specifi c or social work. The participants represented ate written responses consistent with the MI skills explicitly taught during workshops the following job titles: curriculum resource skills. The measure contains four subscales: and reinforced during individualized feed- teacher (N = 3), disability liaison (N = 3), open-ended questions, affi rmations, refl ec- back sessions with participants. Items are special education resource teacher (N = 3), tions, and summaries. All responses are scaled on a five-point rating scale rang- and social worker (N = 3). They had an aver- rated on a three-point scale with 1 refl ecting ing from 1 (I am not highly competent at age of 9.1 (SD = 10.6) years of experience responses of Elicits/Reinforces Sustain Talk doing this) to 5 (I am highly competent in their current position, had been teaching or Engenders Discord, 2 refl ecting responses at doing this). The measure is collected on average 14.6 (SD = 9.4) years, and all that were neutral, and 3 refl ecting responses from participants and the coach (who will were former classroom teachers. None of of Elicits/Reinforces Change Talk. Subscale report the participant’s level of profi ciency) the participants reported having had any scores are derived for each skill, as is a total and triangulated with observation data (i.e., prior training or exposure to MI. score from the sum of the subscale scores. MITI) to facilitate identifi cation of gaps The VASE-3 also contains directions, item between a participant’s perceived and actual stems and prompts, a scoring guide, and a profi ciency, identify points of agreement Study Procedures scoring form. between perceived proficiency and skill The study participants attended fi ve three- MI Profi ciency. The Motivational Inter- level, and encourage self-refl ection. hour workshops and completed and received viewing Treatment Integrity Code (MITI The training and assessment components performance feedback on audio recordings 4.0) evaluates component processes within of the MITAS were based on the extensive of their practice of MI in consultation with

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teachers or parents, as described in the which included renaming the WASE and the this instrument by creating vignettes that training component section. Facilitators led VASE-3, as described above. The adapted were judged relevant to school-based sup- the workshops and provided individualized version of the HRQ consisted of six written port staff, and we also modifi ed the scoring feedback to the participants through coach- paragraphs that simulate conversations with criteria (see Small et al., 2014). We collected ing sessions. The fi rst two authors of this teachers who have specifi c concerns. After a version of the VASE-R (as modifi ed from manuscript served as two of the facilitators. each paragraph, the participant was asked Rosengren et al., 2008) adapted for use with to write a helpful response. Responses were school-based personnel that utilizes three Study Measures scored on a fi ve-point ordinal scale, rating video-recorded portrayals of two teachers We used adapted versions of the HRQ the nature and quality of the coach’s use of and a parent commenting on specifi c con- and VASE-R for this pilot study. The pilot client-centered counseling techniques (i.e., cerns. Coaches were prompted to identify study was completed before the description open-ended questions, affi rmations, refl ec- or generate written responses consistent of the MITAS was fi nalized for this manu- tions, and summaries). The original HRQ with particular MI principles. The VASE- script. These pilot data were used to make has high interrater agreement (Martino et R includes 18 items (six per vignette) that subsequent changes to the study measures, al., 2006). Prior to the study, we modifi ed produce a total score and five subscale scores (i.e., Refl ective Listening, Respond- ing to Resistance, Summarizing, Eliciting Table 2: Outcome Summary by Participant Change Talk, and Developing Discrepancy). Participant responses were coded using a HRQ VASE-R three-point system, with response options Pre Post Pre-Post Pre Raw Post Raw Pre/-Post including 0 (Confrontational or Likely to CID M(SD) M(SD) Change Score Score Change Engender Resistance), 1 (Neutral or Inac- curately Represents the Content of the Cli- 101 14 21 +7 — 33 — ent’s Speech), and 2 (Accurately Refl ects the 102 6 16 +10 10 24 +14 Content of the Client’s Speech). 103 13 22 +3 24 29 +5 Data Collection and Statistical 201916+71217+5Analyses 202 6 19 +13 7 14 +7 At baseline, participants completed the 203 6 21 +15 11 19 +8 adapted HRQ and VASE-R. Following the last workshop, the participants again com- 301 10 12 +2 11 22 +11 pleted the HRQ and VASE-R. Additionally, 302 6 16 +10 10 24 +14 the facilitators completed the facilitator’s 303 9 21 +12 17 27 +10 checklist, and participants completed the MITAS satisfaction survey. For interrater 401 7 18 +11 7 — — reliability, we calculated intra-class corre- 402 9 22 +13 17 28 +11 lations (ICC) using two-way mixed effects models (Shrout & Fleiss, 1979). We used 403 13 16 +3 27 27 0 Cicchetti’s (1994) recommendations to Total/Mean 9.0 (3.0) 18.3 (3.2) 14.60 (6.6) 23.10 (5.0) assess ICC suffi ciency. We examined within-subject effects for the HRQ and VASE- R in an analysis of variance (ANOVA) Table 3: Mean Baseline and Post-VASE-R Subscale and Total framework using the general linear model (GLM) procedure in SPSS 19. We report Scores and Effect Sizes partial point-biserial r as a measure of effect Baseline Post size (Rosnow & Rosenthal, 2008). Effect F P-Value r M (SD) M (SD) part sizes of 0.14, 0.36, and 0.51 are considered small, medium, and large, respectively, Total score 14.6 (6.6) 23.1 (5.0) 37.26 < 0.001 0.90 for the derived partial r (Cohen, 1988). Reflective 2.0 (2.1) 5.0 (1.4) 31.15 < 0.001 0.88 Descriptive statistics were used to evaluate listening social validity. Responding to 2.7 (2.5) 5.4 (1.8) 15.58 0.003 0.80 Study Results resistance Our first research question addressed Summaries 1.5 (1.7) 3.3 (1.2) 16.57 0.003 0.80 participants’ engagement in the training Eliciting 2.0 (1.2) 2.8 (1.6) 3.27 0.104 0.52 component of the MITAS. We answered change talk this question using a facilitator checklist. Developing On average, participants attended 4.8 (SD = 3.4 (1.5) 3.5 (1.2) 0.04 0.847 0.07 discrepancy 0.4) of the workshops. Ten of 12 participants attended all fi ve workshops. The remain- Affirmations 3.0 (1.7) 3.1 (1.4) 0.04 0.840 0.07 ing two participants participated in four of

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fi ve workshops. All participants attended participant ratings of satisfaction. The satis- The MITAS provides a framework for workshop sessions two through four. Over- faction mean rating for the workshops was the promising transfer of MI from substance all, participants attended an average of 2.7 4.6 (SD = 0.4), with scores ranging from abuse and health settings to school-based (SD = 0.5) coaching sessions. 3.9 to 5.0; the mean rating for the feedback applications. It is our hope that this frame- Workshop facilitators assessed each par- sessions (also a fi ve-point Likert scale) was work will help facilitate the interpretation ticipant’s engagement in the MITAS using 4.7 (SD = 0.5), ranging from 3.5 to 5.0. of school-based MI research and also help the facilitators’ checklist. We computed a to answer the critical questions Herman and mean rating across the six items with higher Discussion colleagues (2014) posed: scores indicating higher levels of engage- We have been encouraged with the suc- 1. How much training, supervision, and ment. The mean engagement rating (fi ve- cessful infusion of MI into school-based practice are required to improve one’s point Likert scale) was 4.40 (SD = 0.4). practices. Few studies to date, however, have MI proficiency? The second research question addressed trained school-based personnel to use MI 2. What level of competency is sufficient the effi cacy of the MITAS training proce- skillfully or have measured their MI profi - to affect teacher, parent, or adolescent dures. The coeffi cient alpha for the HRQ ciency as a component of implementation behavior change? across the two raters was 0.71 and 0.76; for fi delity within the context of intervention the VASE-R scale, coeffi cient alpha was research. The ability to evaluate MI qual- 3. What standards should be used to eval- 0.81 and 0.77. HRQ item level, intra-class ity, and to eventually scale up MI efforts, uate MI competency? correlations were all in the acceptable range will depend on the emergence of training We believe all researchers using MI as a (i.e., ICC > 0.40). Interrater reliability was and assessment infrastructures supporting component of their intervention framework lowest for items one and two (ICCs = 0.58 skill acquisition and maintenance. We have should include MI fi delity assessment as a and 0.54, respectively), with considerably higher ICCs for the remaining four items (mean ICC = 0.90; range = 0.82–0.95). For Also noteworthy are the encouraging skill the HRQ total score, interrater reliability was excellent (ICC = 0.92). ICCs for the gains they showed from pre- to post-test, VASE-R subscales ranged from 0.79 for the Change Talk subscale to 0.99 for the Refl ec- a result suggesting that the training component tive Listening and Developing Discrepancy subscales. The intra-class correlation for the of the MITAS is potentially efficacious. VASE-R total score was 0.99. VASE-R total scores and HRQ total scores were highly correlated (r = 0.89). reported here a small but important step in process measure. The MITAS provides a Participants’ scores from pre-test to post- developing MI staff training methods and readily available and fl exible framework test on both measures are shown in Table 2. measures that preliminary data suggest may for training and assessing MI competency Total HRQ scores increased from 9.0 (SD = be feasible, sustainable, effective, and per- and profi ciency. 3.0) to 18.3 (SD = 3.2). The gains ranged from ceived as needed by school professionals. Future research should examine the effi - +2 to +15 on the HRQ and from +5 to +18 on This feasibility study is the fourth attempt cacy of the MITAS by employing designs the VASE-R. All participants improved from that we know of to train school personnel that control for threats to internal validity. baseline to post-test. The within-subject par- to use an MI approach (Burke et al., 2005; Additionally, future research should use all tial r effect size was 0.92 (large). The average Caldwell & Kaye, 2014; Frey, Walker et the measures contained in the MITAS in ICC at the item level was 0.79 (range = 0.54 al., 2013). Our results indicate that the par- the assessment component. Finally, it will to 0.95). All 10 participants who completed ticipants attended a majority of the MITAS eventually be important to demonstrate that baseline and post-test VASE-R assessments training sessions (e.g., workshops and changes in the behavior of school person- improved on this measure; specifi cally, the feedback sessions) and that the facilitators nel are associated with positive changes total mean VASE-R scores increased from rated these MI participants’ engagement as in teacher, parent, or adolescent behavior. 14.60 (SD = 6.6) at baseline to 23.10 (SD = high. This is noteworthy, given the amount 5.0) at post-test, with a within-subject partial of time required to participate fully in the References r effect size of 0.90 (large). In addition to MI training coupled with the very busy Aubrey, L.L. (1998). Motivational Interviewing with examining the overall VASE-R scores, we schedules maintained by most school per- Adolescents Presenting for Outpatient Substance also examined the subscale scores. As can be sonnel. Because participation was volun- Abuse Treatment . Albuquerque, NM: University seen in Table 3, the largest effect sizes were tary, the high level of participation suggests of New Mexico. obtained in the Refl ective Listening (0.88), that learning these skills was important to Becker, K.D., & Domitrovich, C.E. (2011). The Responding to Resistance (0.80), and Sum- the participants. Also noteworthy are the conceptualization, integration, and support of maries (0.80) subscales. Minimal changes encouraging skill gains they showed from evidence-based interventions in the schools. School Psychology Review, 40, 582–589. were noted in the Developing Discrepancy pre- to post-test, a result suggesting that Bien, T.H., Miller, W.R., & Boroughs, J.M. (1993). (0.07) and Affirmations (0.07) subscales. the training component of the MITAS is Motivational interviewing with alcohol outpatients. The ICCs for the VASE-R ranged from 0.79 potentially effi cacious. These results must Behavioural and Cognitive Psychotherapy, 21, to 0.99 across the subscales. be interpreted with caution, however, due to 347–356. The third research question addressed the the small sample size and failure to control Brown, J.M., & Miller, W.R. (1993). Impact of moti- workshops and the coaching sessions using for threats to internal validity in this study. vational interviewing on participation and outcome

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Motivational Strait, G.G., Smith, B.H., McQuillin, S., Terry, J., Interviewing: Helping People Change (Applications Frey, A.J., Small, J.W., Lee, J., Walker, H.M., Seeley, Swan, S., & Malone, P.S. (2012). A randomized of Motivational Interviewing) (3rd ed.). New York: J.R., Feil, E.G. & Golly, A. (2014). Expanding the trial of motivational interviewing to improve middle Guilford. range of the First Step to Success intervention: school students’ academic performance. Journal of Tertiary-level support for teachers and families. Moyers, T.B., Manuel, J.K., & Ernst, D. (2014). Community Psychology, 40, 1032–1039. Early Childhood Research Quarterly . Motivational Interviewing Treatment Integrity Cod- Terry, J., Smith, B., Strait, G., & McQuillin, S. ing Manual 4.0. Unpublished manual. Frey, A.J., Walker, H.M., Seeley, J., Lee, J., Small, (2013). Motivational interviewing to improve J., Golly, A., & Feil, E. (2013). Tertiary First Step to Moyers, T.B., Rowell, L.N., Manuel, J.K., Ernst, D., middle school student’ academic performance: A Success Resource Manual . Available at http://first- Houck, J.M. (2016). The Motivational Interview- replication study. Journal of Community Psychol- steptosuccess.org/Tertiary%20First%20Step%20 ing Treatment Integrity Code (MITI 4): Rationale, ogy, 41, 902–909. to%20Success%20Resource%20Manual.pdf . preliminary reliability and validity. Journal of Young T. (2010). The effect of a brief training Gardner, F., Connell, A., Trentacosta, C., Shaw, D.S., Substance Abuse Treatment, 65, 36–42. in motivational interviewing on client outcomes Dishion, T.J., & Wilson, M. (2009). Moderators of Reinke, W.M., Frey, A.J., Herman, K.C., & Thomp- and counselor skill development. Ph.D. diss., outcome in a brief family-centered intervention son, C. (2013). Improving engagement and imple- University of Central Florida, Orlando. Available for preventing early problem behavior. 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Behavioral Challenges in Students Although many individuals errone- to this framework is the use of systematic ously conclude that students with EBDs tools to feasibly and accurately detect stu- Students with emotional and behav- will access special education services under dents with externalizing and internalizing ioral disorders (EBDs) include a large the emotional disturbance (ED) category, behavioral challenges. School leaders and diverse group of children and youth the Individuals with Disabilities Education are responding to this need (Oakes et al., who have a range of externalizing (e.g., Improvement Act (IDEA, 2004) suggests forthcoming). aggressive, noncompliant) and internal- this is most often not the case. Forness and Moreover, many national and state lead- izing (e.g., anxious, withdrawn) behav- colleagues (2012) report 20% of school-age ers have recognized the importance of iors. Externalizing behaviors are often youth experience mild to severe EBDs and meeting students’ mental health needs. For easily detected in the school setting given 12% of students exhibit moderate to severe example, in 2014, Michael Yudin offered a that the overt nature of these behaviors challenges. Moreover, evidence suggests compelling keynote address at the Positive frequently disrupts the learning environ- the majority of adults with EBDs experi- Behavior Intervention and Support Imple- ment and impedes instruction (Lane & enced characteristic behaviors during their menter’s Forum, in which he urged all edu- Walker, 2015). In contrast, internalizing school years (Merikangas et al., 2010). cators to place as much priority on students’ behaviors are less often recognized—at Considering fewer than 1% of school-age behavioral and social skills as they put on least initially—because the covert nature of students receive special education services academic skills. Kansas Commissioner of these behaviors rarely impedes the learning environment until the characteristic behaviors become quite severe (McIn- tosh et al., 2014). Inquiries by Achenbach Yet, studies of teachers’ experiences suggest general (1991) and Willner, Gatzke-Kopp, and Bray (2016), suggest students frequently education teachers feel less than optimally prepared have co-occurring behavioral challenges to effectively support students with EBDs. in both domains. These students suffer from both externalizing and internalizing behavior challenges and demonstrate the under the ED category, the general educa- Education Randy Watson (2015), called for greatest need for intervention or support. tion community must be prepared to support a similar emphasis on “soft skills” following Left unchecked, these behavioral chal- the behavioral and mental health needs of a one-year listening tour across the state lenges result in a range of diffi culties for the majority of students with EBDs. Yet, during which he learned from employers students, their teachers, their families, and studies of teachers’ experiences suggest that students graduating from K-12 schools society as a whole. Descriptive studies general education teachers feel less than lacked the requisite soft skills to excel in have demonstrated students with and at optimally prepared to effectively support employment. Given that lifetime mental risk for EBDs experience a host of neg- students with EBDs. Teachers indicate their health challenges begin during students’ ative outcomes, such as peer rejection, teacher preparation experiences did not school years (Merikangas et al., 2010), it impaired interpersonal relationships, aca- suffi ciently empower them with the skill is encouraging to see schools prioritize demic underachievement, limited school sets needed to meet students’ behavioral graduating students with a comprehensive engagement, unemployment and underem- and social-emotional needs (Greenberg et set of skills, empowering them to succeed ployment, and high need for mental health al., 2014). In fact, the absence of adequate academically, behaviorally, and socially. supports (Wagner & Newman, 2015). classroom management skills is one of the These developments indicate we are well main reasons teachers leave the fi eld. positioned to build strong partnerships *Kathleen Lynne Lane, Ph.D., BCBA-D, is a profes- There have also been concerns about between education and mental health sys- sor in the School of Education at the University of the lack of connections between school tems to advance behavioral health screening Kansas. Wendy Peia Oakes, Ph.D., is an assistant and mental health systems, leaving well- in schools and that these efforts are being professor at the Mary Fulton Teachers College at intentioned individuals struggling to meet guided by the full range of stakeholders Arizona State University. John Crocker, M.Ed., students’ academic, behavioral, and social- with interests in this critical work, especially is director of guidance for the Methuen Public emotional needs. Many individuals are youth and families contending with EBDs Schools, Methuen, Massachusetts. Dr. Crocker received permission to name the district used in seeking a framework for providing students (Weist et al., 2017). the second illustration. Mark D. Weist, Ph.D., is a with the full scope of supports needed In this article, we introduce a key chal- professor in the Department of Psychology at the within effective and effi cient partnerships lenge confronting the fi elds of education University of South Carolina. Kathleen Lane can be between educational and mental health pro- and mental health: the need for early detec- reached by email at [email protected]. fessionals (Santiago et al., 2014). Essential tion. We also offer a potential solution:

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prioritizing strong, integrated partnerships more prominent concerns, and expecta- measurement error, namely, false positives between education and mental health sys- tions across classrooms and school settings (saying a student has a concern such as tems (Weist et al., 2014). We offer two become more varied (Farmer et al., 2015). internalizing behaviors, when in reality examples of behavioral health screening Thus, “early” detection refers not only to they do not) and false negatives (saying a in schools. The fi rst involves teacher-com- early in a student’s school experience, but student does not have a concern, when in pleted screenings within a Comprehensive, also to the early stages of a student’s mani- reality they do have the concern of inter- Integrated, Three-Tiered (Ci3T) model festation of behavioral challenges. est). In prevention efforts, a false positive is of prevention at the elementary level; the Fortunately, a number of systematic preferred to avoid overlooking a student in second involves self-reported measures screening tools are now available for use need of assistance, and this “screening in” of anxiety and depression by high school across the PK-12 grade span. Some of results in additional support and/or supple- students. We close the discussion with a these are: mental instruction (e.g., self-monitoring, call to action and considerations for next • Behavior Assessment System for Chil- cognitive restructuring; Vannest, Reynolds, steps for researchers, practitioners, and dren, 3rd Edition: Behavioral & Emo- & Kamphaus, 2015). policymakers. tional Screening System (BASC-3: We emphasize that it is also important BESS; Kamphaus & Reynolds, 2015); to select a tool feasible for use within a district, with attention to access to high- The Challenge: A Need for • Social, Academic, and Emotional quality professional learning to support all Early Detection Behavior Risk Screener© (SAEBRS; stakeholders in understanding the rationale Kilgus et al., 2013); Given the breadth of externalizing and as well as the logistics for conducting internalizing behavior patterns, the magnitude • Social Skills Improvement System–Per- systematic screenings. We encourage the of these challenges for school-age youth, and formance Screening Guide (SSiS-PSG; interested reader to see Oakes et al. (forth- the long-term negative outcomes associated Elliott & Gresham, 2008a); coming) to learn more about the screening tools available to detect social, emotional, and behavioral concerns in students as well When selecting a screening tool, it is important to as the practical considerations and recommendations for selecting and installing such choose a tool with established reliability and validity systematic screening tools. In the fi rst illustration that follows, we to accurately detect students with and at risk for both focus on teacher-completed screening procedures. Teachers completed the select- externalizing and internalizing disorders. ed screening tool for all students in their assigned class three times a year: in the fall, winter, and spring. Screenings were with these disorders, early detection is critical. • Strengths and Difficulties Questionnaire conducted as part of regularly scheduled Negative behavior patterns (e.g., persistent (SDQ; Goodman, 2001); faculty meetings so as not to encumber negative thoughts, aggression) are more • Student Risk Screening Scale (SRSS; instructional or planning time. Unlike aca- amenable to intervention before they have Drummond, 1994); demic screening tools, teacher-completed become ingrained through years of practice behavior screening tools do not require any • Student Risk Screening Scale–Inter- (Walker, Forness & Lane, 2014). time with students to administer. Teach- nalizing and Externalizing (SRSS-IE; Early detection is a core feature of pre- ers independently complete these brief Drummond, 1994; Lane & Menzies, vention frameworks, and “early” means screenings following specifi ed procedures 2009); and more than just early in a students’ educa- and then use the composite scores in con- tional career (e.g., preschool and kinder- • Systematic Screening for Behavior junction with other data collected as part garten). “Early” also means early in the Disorders (SSBD; Walker, Severson & of regular school practices (e.g., academic onset of the behavioral concern (Lane et Feil, 2014). screening scores, attendance, offi ce disci- al., 2013). For example, rather than wait- These screening tools provide a range pline referrals [ODRs]) to inform instruc- ing for aggressive behaviors to emerge and of behavioral health screening options and tion. For example, these data can be used then responding with evidence-based prac- capabilities, including some free-access to examine the overall level of student risk tices such as functional assessment-based tools (e.g., SDQ, SRSS, and SRSS-IE) to in a school building, inform the use of low- interventions (FABI; Umbreit et al., 2007), ensure all schools have a screening option intensity teacher-delivered supports (e.g., one could focus on detecting precursors to while being fiscally responsible (Lane, instructional choice), and connect students aggression such as noncompliance or peer Oakes, et al., 2017). When selecting a with relevant strategies, practices, and pro- rejection (Farmer et al., 2015; Moore et al., screening tool, it is important to choose a grams should primary prevention efforts be 2017). Such behaviors may emerge for the tool with established reliability and valid- insuffi cient for meeting a student’s multiple fi rst time in early childhood or as students ity to accurately detect students with and at needs (Lane, Oakes, Ennis & Hirsh, 2014). are transitioning from the elementary to risk for both externalizing and internalizing Data from screening tools can be used middle school years. This transition, as disorders. We encourage decision makers to facilitate communication among a range well as the transition to high school, can to carefully review the evidence for each of individuals committed to supporting be challenging for even the most talented tool’s psychometric properties to ensure students’ academic, behavioral, and social- students as curricula become more precise, an appropriate selection for the population emotional health (Lane et al., 2012). This social standing and peer acceptance become of interest. All tools have some degree of helps to address the challenge of wide-ranging

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terminologies and definitions among and evaluated in a number of districts for As part of their design and implementa- education, research, and mental health 20 years, with initial development in Cali- tion processes, school-site Ci3T leadership communities that have served to impede fornia to system-wide implementation in teams and district decision makers selected communication between professionals, as a number of districts in Alabama, Kansas, a validated curriculum to support students’ well as to increase barriers for students to Missouri, Tennessee, and Vermont. social and emotional development accord- receive needed supports (Weist et al., 2012). As part of a practitioner-researcher part- ing to school board and community priori- Fortunately, many school systems across nership grant funded by the Institute of ties. The decision-making process occurred the country are emphasizing behavioral Education Sciences (IES), Ci3T is cur- in two phases: fi rst, for elementary students, and social-emotional competencies in rently being implemented districtwide in a and then, for middle and high school stu- addition to academic competencies (Lane, medium-size district in the Midwest. Spe- dents for year one Ci3T implementation. Oakes, Menzies & Germer, 2014; Weist et cifi cally, elementary schools (ES; n = 14) In the next section, we offer an illustration al., 2014). To this end, they are construct- designed Ci3T models in the 2013–2014 of Ci3T in action at the elementary level. ing tiered systems to provide a graduated continuum of supports that include primary (Tier 1) prevention efforts for all, secondary (Tier 2) prevention efforts for some, and As part of their design and implementation processes, tertiary (Tier 3) prevention efforts for a few. school-site Ci3T leadership teams and district decision Ideally, each level of prevention is composed of evidence-based practices (Cook & makers selected a validated curriculum to support Tankersley, 2013), with movement between the levels determined by data-informed students’ social and emotional development according decision making. There is a wide variety of tiered systems, to school board and community priorities. such as Response to Intervention (RTI; Fuchs et al., 2010) emphasizing academic performance and Positive Behavioral Inter- academic year; traditional middle schools In our partnership work, elementary ventions and Supports (PBIS; Horner & (MS; n = 4) and high schools (HS; n = 2) Ci3T leadership teams engaged in a system- Sugai, 2015). More recently, an emphasis designed models in 2014–2015; and the atic process for selecting a behavior screen- has been placed on developing systems with College and Career Center designed a ing tool and Tier 1 social skills curriculum. integrated approaches such as: model in 2015–2016. At the launch of this The process followed similar steps: • Multi-Tiered Systems of Support practitioner-researcher partnership, all 20 1. Team review of options and a short list (MTSS; McIntosh & Goodman, 2015); PK-12 schools were in the fi rst or second of recommendations; year of implementing Ci3T models in 2015– • The Interconnected Systems Framework 2. Review of published evidence of tools 2016, and the College and Career Center (ISF; Barrett et al., 2013); and and curricula for evidence to support their was preparing for year one implementation. intended use and expected outcomes; • Comprehensive, Integrated, Three- At this time, all schools are implement- Tiered models (Ci3T; Lane et al., 2010; ing Tier 1 practices according to their indi- 3. Discussion by district and school leaders; integrating academic, behavioral, and vidual Ci3T plans with many common 4. Examination of materials and struc- social domains). district-guided elements. For example, all tures for implementation; and schools have: 5. Adequacy of resources to support Illustration 1: Teacher-Completed implementation. Systematic Screening Within 1. Established leadership teams with district representatives; The selection of a social skills curricu- Ci3T Models lum followed a process by which Ci3T Ci3T models provide a framework 2. Clearly defined roles and responsibili- leadership teams first reviewed informa- designed to meet students’ academic, ties for stakeholders; tion from the What Works Clearinghouse behavioral, and social skill needs and to 3. Clearly defined expectations, a system (WWC; U.S. Department of Education), the support strong, positive productive partner- for teaching them, and a uniform sys- National Registry of Effective Programs and ships between education and mental health tem for providing reinforcement; Practices (NREPP) of the Substance Abuse communities. As part of Tier 1 efforts in the 4. Procedures for monitoring using dis- and Mental Health Services Administra- social domain, all students have access to trict-level systems for implementing tion (SAMHSA), and the Collaborative for primary prevention efforts targeting social academic and behavior screenings; Academic, Social, and Emotional Learning and emotional learning. During the Ci3T (CASEL) to identify effective—and feasi- 5. A system for responding to student design process, school-site Ci3T leadership ble—social-emotional curricula. Next, each needs at Tiers 2 and 3; teams and district-level decision makers col- team provided its district decision makers laborate to select a validated curriculum to 6. Regular communication from the dis- with a list of its top three curricula for further install at Tier 1 (primary prevention) along trict partner leadership team and prin- review. The compiled list was shared with with validated strategies and practices at cipal leaders; and the district leadership team and the principal Tier 2 and Tier 3 to assist students requiring 7. Professional development for Ci3T leadership team, who conducted additional more than primary prevention efforts. Ci3T leadership teams and faculty and staff research by reviewing publisher websites, models have been designed, implemented, district wide. reviewing articles of treatment-outcome

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studies published in refereed journals, and pacing to provide year-long instruction). schools partnered with university collabo- contacting publishers to access and review Second, they secured a complete Positive rators to install and test the efﬁ cacy and sample curricular materials. The curricula Action curriculum with a kit for each teacher social validity of two Tier 2 social skills were listed in order based on their meeting and counselor to ensure intervention agents interventions using a validated curricu- of the priorities and needs of the district had the full scope of materials needed for lum: the Positive Action and Social Skills students, evidence for effectiveness, and instruction. Third, they created optional Improvement Systems–Intervention Guide feasibility given district resources. The top professional learning sessions prior to and (SSiS-IG; Elliott & Gresham, 2008b; see two curricula were made available to school during summer break, followed by a required Figure 1 for one intervention grid; Lane, counselors, teachers, and Ci3T leadership elementary-wide professional learning ses- Common, et al., 2017). team members (which included one par- sion a few days before students returned. During the same time, the mental health ent on each team) for review. Then, in the Those responsible for teaching the curricu- facilitator collaborated with community spring of their designing year, a decision lum could attend any or all opportunities, mental health providers to create trans- was made to adopt and install Positive but they were required to attend at least one parent access for Tier 3 supports. As part Action (2008) at Tier 1 the following fall. professional learning session. of their initial conversation, community Positive Action is a social-emotional learn- To ensure high-ﬁ delity implementation health providers learned about the Ci3T ing program developed for students in and a coordinated effort for all behavioral models in place at each school so they elementary and middle schools and has been and mental health supports, the district could understand the Tier 1 experience shown to improve school climate as well as invested in a new position, a mental health for all students and be able to incorporate to improve student behavior. A classroom- facilitator. The mental health facilitator common language systems to program for based curriculum (which includes teacher- supported implementation by developing generalization. The goal was three-fold, to: and counselor-taught lessons) teaches social structures to monitor treatment integrity, 1. Ensure students are exposed to primary and self-management skills, with universal meeting regularly with counselors assigned prevention efforts through the use of support of program implementation school- to each building, and providing ongoing validated social skills curricula to pre- wide (Flay & Allred, 2003). professional learning in suicide preven- vent challenges from occurring; To support installation, district lead- tion, crisis training, trauma-informed ers offered multiple professional learning practices, and social skills instruction. The 2. Create opportunities within the school opportunities to prepare teachers for fall professional learning provided an under- day to support students who have soft implementation. First, they allowed each standing of the “why” for school-wide signs for externalizing and internal- Ci3T leadership team to establish its own implementation and created structures izing behaviors; and implementation schedule, providing district- to support equitable, transparent access 3. Establish strong partnerships with com- guided expectations for implementation to Tier 2 and Tier 3 supports for students munity-based mental health providers (e.g., school-wide instruction by teachers and requiring more than primary prevention available for offering Tier 3 supports school counselors, a minimum number of efforts. For example, during the third for students with intensive intervention teacher-taught and counselor-taught lessons, year of implementation, four elementary needs in social-emotional learning.

Figure 1: Sample Elementary School Comprehensive Integrated Three-Tiered (Ci3T) Model of Prevention Intervention Grid School-Wide Data: Entry Support Description Data to Monitor Progress Exit Criteria Criteria Social Skills Improvement Counselors and/or social Behavior Student measures Review student progress System (SSiS): Counselor-led workers will lead small group SRSS-E7 score: Moderate • SSiS-Rating Scale (Pre/Post) at end of 24 sessions small group SSiS sessions for (4–8) and/or • Skills for Greatness Team agrees goals have approximately 30 to 40 SRSS-I5 score: Moderate (Pre/Post) been met or no further minutes 2 to 3 days per week. (2–3) • Daily behavior report SSiS small group Students will acquire new AND (DBR; daily) sessions are warranted skills, learn how to engage 2 or fewer absences in first • Attendance and tardies SRSS-E7 and I5 scores are more fully in instructional 3 months of school in the low-risk category experiences, and learn how AND Social validity to meet more school-wide Evidence of teacher • Teacher: IRP-15 expectations. Small groups implementation of Ci3T • Student: CIRP will run for up to 24 sessions primary (Tier 1) plan (8 to 12 weeks depending (treatment integrity: direct Treatment integrity on the number of sessions observation) • Daily completion of conducted per week) using a AND component checklist of key subset of SSiS lessons Parent permission lesson practices appropriate for student AND • Tier 1 Ci3T Treatment skillsets as identified using Academic integrity: Direct observation SSiS-Rating Scale (teacher Student is in grade 2 or 3 (30 minutes) and parent version).

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For these most intensive intervention well-being of all students, including those in a manner that was less threatening to the efforts, it is important for schools, com- with EBDs. larger population in Methuen. munity providers, and families to partner A number of questions arose as the dis- closely with a carefully constructed plan for Illustration 2: Districtwide Mental trict mental health team began planning to assisting students who require community- pilot mental health screening. Associated based supports. Health Screening in a Mid-Sized costs, consent, selection of tools, method As illustrated in the Tier 2 intervention Urban School District of administration, staff readiness, and the grid (see Figure 1), systematic screening Methuen Public Schools (permission was ways in which collected data would be used plays a key role in the early detection obtained to share the name of the district; were all considerations that needed to be of who may need these tiered supports. Crocker, personal communication, 2017) addressed prior to making mental health Namely, systematic screening data are used is a district located approximately 30 miles screening a reality. For this reason, the dis- in conjunction with other data collected as north of Boston, Massachusetts. The district trict started small and began rapidly testing part of regular school practices to connect serves approximately 700 students across at the micro-level to ensure that practices students to relevant Tier 2 and Tier 3 sup- four K-8 grammar schools and one high and resources could be vetted using a qual- ports. We emphasize that screening data school of approximately 2,000 students. ity improvement approach prior to scaling also provide important information about The district’s focus on school mental health up implementation. Plan-Do-Study-Act the overall level of risk for all students has dramatically increased over the past two cycles were completed regularly to assess in a school for monitoring the intended years, owing in large part to its selection to the effi cacy of new practices and to evaluate effects of Tier 1 prevention and that the participate in the University of Maryland’s next steps for implementation (Associates data inform teachers’ use of low-intensity Center for School Mental Health (CSMH) in Process Improvement, 2017). supports to facilitate engagement and minimize the occurrence of challenging behaviors (Lane et al., 2016). For example, By designing and implementing Ci3T models, in each elementary school, following each behavior screening window, Ci3T schools prioritize healthy academic, behavioral, and leadership teams reviewed the percentage of students whose scores indicated low, social-emotional development for all learners. moderate, and high risk for externalizing and internalizing behavior challenges for the school as a whole as well as for each School Mental Health Collaborative for Individual students were screened after grade level. These data were analyzed with Improvement and Innovation Network securing consent from their guardians as treatment integrity data to determine (1) (CoIIN). Through its participation in the part of the first phase of testing mental if Tier 1 efforts were in place as planned CoIIN, the district has sought to adopt the health screening. As mental health staff and (2) how students were responding to CSMH’s School Mental Health National reported back their findings, questions primary prevention efforts. Performance Measures and to establish related to the utility of the data gathered Ci3T leadership teams also encouraged a Comprehensive School Mental Health were posed, including how the collection their teachers to review screening data for System (CSMHS). The impetus to imple- of psychosocial data could inform progress their class as a whole. If the percentage of ment mental health screening in Methuen monitoring efforts, serve as a measure of students in their class at moderate or high stemmed from the district’s self-assessment the effectiveness of interventions, and, risk exceeded 20%, the teachers selected during the initial phase of the CoIIN work when aggregated, serve as an ongoing and implemented low-intensity supports that no formal method of collecting, analyz- mental health needs assessment. It became (e.g., increased opportunities to respond). ing, or utilizing psychosocial data existed apparent early on that the collection of If these low-intensity, teacher-delivered and that this lack posed a considerable barri- psychosocial data had various meaningful supports were insuffi cient, students requir- er to improving the quality and sustainabili- applications that supported the decision to ing additional assistance were connected ty of Methuen’s CSMHS. The mental health begin scaling up to groups of students and, to Tier 2 or Tier 3 supports according to team identifi ed the high school as the pilot eventually, to whole grade levels. individual needs. site for conducting mental health screening As the practice of screening students By designing and implementing Ci3T after considering the information gained scaled up, preparing for the first large models, schools prioritize healthy aca- through needs assessments and counsel- administration became a focus. Selecting demic, behavioral, and social-emotional ing logs, which indicated mental health the specifi c screening tool and the means of development for all learners. Schools’ Ci3T concerns were most prevalent in grades 9 administering the screening were identifi ed implementation manuals make transparent through 12. Additionally, logistical consid- as priorities, and the team also considered roles and responsibilities, expectations, erations, such as availability of technology the degree to which staff were prepared to procedures for teaching, reinforcing, and and number of available mental health staff provide follow-up services to students who monitoring, and Tier 2 and Tier 3 supports. members at the high school factored into scored in the moderate and severe ranges These transparencies facilitate communica- the decision as well. The team also decided on the measures used. At this phase of tion among all stakeholders: teachers, coun- that introducing mental health screening implementation, a number of key practice selors, administrators, parents, community to an older population at the outset of the and policy implications were adopted that mental health staff, and community mem- pilot, as opposed to students in the grammar have been identifi ed as having a signifi cant bers. The intended outcome is to support the or middle schools, would serve to normal- impact on the quality and sustainability of social, emotional, behavioral and academic ize the idea of mental health screening the screening program in Methuen.

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Methuen Public Schools sought to use concerns. The idea of directly addressing survey, or screener that they are not only free assessments in the public domain and openly discussing school mental health interested in taking and you can opt- when designing the mental health screening was still a relatively novel concept for a large out your son or daughter at any time program in order to ensure that sustainabil- percentage of the population in Methuen. by contacting the Guidance Office ity of the program would not be affected by The mental health team thus took steps of your son’s/daughter’s school or fl uctuations in the local budget. The district toward normalizing the idea of mental health filling out the opt-out form here. A dedicated time and staffi ng to ensure that screening in a manner that was safe for the list of the questionnaires, surveys, the practice of mental health screening larger population and that would serve as a and screeners is available below for was implemented successfully; however, it foundation for future expansion of the type you to review. We are committed is worth noting that there is no dollar cost and frequency of screenings. to ensuring your son or daughter is supported academically, socially, and associated with sustaining this practice in Securing consent to administer stu- emotionally, and we look forward to the future. Neither the assessments used dent-completed mental health screening in partnering with each of you toward nor the means of administering them have schools is a major consideration for any dis- achieving this goal. associated costs that are contingent on the trict considering implementing this practice. local budget. During the initial phase of implementation The opt-out procedures that were Through an analysis of needs assess- in which select students were identifi ed for established constitute a major success of ments that were conducted in the 2013–2014 pilot screening, active consent was secured Methuen’s screening program. Because and 2014–2015 school years, measures from the students’ parents/guardians. As the fewer than 1% of parents/guardians have were selected that matched the student fi rst large-scale administration was being opted out of mental health screening, the population’s reported areas of greatest need. planned, the mental health team decided to mental health team has been able to proactively screen the vast majority of the adolescent student population in Methuen. As an added measure to ensure buy-in Because fewer than 1% of parents/guardians from the larger community and account for have opted out of mental health screening, student input, prior to the administration of all screenings, a slightly adapted message the mental health team has been able to proactively is read to students, which indicates students may opt out of completing any screeners screen the vast majority of the adolescent that they are uncomfortable taking. One practice adopted early on and piloted student population in Methuen. for the fi rst large-scale screening was the use of computer-based administration for screening. This practice constituted one Unsurprisingly, anxiety and depression adopt a passive consent, or opt-out, proce- of the greatest innovations associated with were identifi ed as the top areas of concern dure. This practice involved notifying all implementation of mental health screening reported by students and mental health staff, parents/guardians in the district that mental in Methuen because it served to establish and this fi nding led to the selection of mea- health screening would be taking place and an efficient system for the administra- sures that focused on these two presenting creating a process that would provide them tion of screening, collection of data, and concerns. The decision to use more targeted with the opportunity to opt out of mental identification of students who required measures also supported the belief that by health screening. follow-up. Methuen High School has made using multiple measures across several A message was developed that described a signifi cant investment in technology in screenings, a robust dataset could be com- the purpose and intent of implementing recent years, the hallmark of which is the piled that would lend itself to a richer and mental health screening in Methuen, as issuing of iPads to all students at the high more comprehensive understanding of the well as procedures for accessing the opt-out school. During the high school advisory needs of the students in Methuen. form on the district’s webpage and other block, the adapted opt-out message was For the fi rst large-scale administration, methods for opting out one’s son/daughter. read to students, and they were then given the mental health team selected a measure The statement read as follows (Methuen an opportunity to complete the screener on that focuses on symptoms of generalized Public Schools, 2017): their school-issued iPad. anxiety disorder (GAD-7; Patient Health Owing to the use of computer-based In an effort to promote the health and Questionnaire [PHQ] Screeners, 2017a). administration, data were readily acces- well-being of students in Methuen Because school mental health had become Public Schools, students will be sible to mental health staff immediately a much greater topic of conversation in periodically provided with ques- following the screenings. Student responses the recent past when screening was being tionnaires, surveys, and screeners populated a secure data sheet that could be implemented, the team decided to select a that address issues related to mental fi ltered by score to produce a referral list for targeted measure that focused on a present- health. The information gained will mental health staff to use in order to conduct ing problem that would leverage the greatest support the school’s ability to provide follow-up clinical interviews. The need to amount of support from the parent, student, comprehensive and timely support for hand-score screeners, organize the results, and larger community and that would broach your son or daughter if they require and generate a referral list has traditionally the issue of mental health screening in any assistance. Students can opt- posed a signifi cant barrier to scaling up this schools in a manner that would not trigger out of filling out any questionnaire, practice in many districts; however, the use

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of computer-based screening allowed for a the psychosocial functioning of students (e.g., hyperactivity and peer problems), coordinated follow-up to be conducted with and the effectiveness of the therapeutic with both measures also having adequate identifi ed students approximately 20 min- interventions provided are continually psychometric properties. The fi rst screening utes following the screening administration. being assessed, which improves the quality using the PHQ-9 underscored the degree to Additionally, collecting data in this manner of the services provided and adds a layer which depression was also a considerable allowed the mental health team to quickly of accountability to the system. As previ- concern in Methuen. Of the 852 students aggregate results to assess the needs of the ously discussed, aggregated results serve who completed the PHQ-9 in April 2016, larger population. as an ongoing needs assessment to deter- approximately 20% scored in the moderate Follow-up and response are of primary mine which Tier 2 and Tier 3 interventions to severe ranges for depression. importance when considering a district’s would best serve the needs of the student Plans for administering mental health readiness to engage in mental health screen- population. screening in the 2016–2017 school year ing (Weist et al., 2007). Therefore, it is Data from each screening yielded impor- included replicating the previous two imperative to determine whether or not the tant information about the prevalence of screenings and adding a third administra- school has the mental health staffi ng not mental health concerns in Methuen. The fi rst tion using the SDQ. In October 2016, only to administer screenings, but also to large-scale screening was conducted in Jan- students completed the SDQ, with 12.5% conduct follow-up interviews and provide uary of the 2015–2016 school year and used (N = 1,344) of students scoring in the high services to students who are identified. the GAD-7 anxiety screener, a widely used or very high range on total difficulties. Implementation of mental health screening measure in the public domain with adequate Following that screening, students were is not recommended if a school lacks the psychometric properties (Spitzer et al., administered the PHQ-9 in November 2016, capacity to respond to identifi ed students’ 2006). Of the students screened (N = 839), resulting in a larger sample (N = 1,135) needs. It is inadvisable and highly question- approximately 22.5% scored in the moder- completing the screening and approximate- able from an ethical standpoint to screen for ate to severe ranges for anxiety. These fi nd- ly 16% of students scoring in the moderate the sake of screening or as a means of solely ings supported not only the identifi cation of to severe range for depression. Finally, the collecting data. specifi c students who would require mental GAD-7 was administered in January 2017. Professional development was provided health services and supports, but also a larg- A sample of 943 students was screened, to the mental health staff in Methuen in er understanding of the population’s needs with 18.5% of students scoring in the mod- preparation for and throughout the process of and an underscoring of the importance of erate to severe ranges for anxiety (Table 1). scaling up mental health screening. Addition- designing and implementing interventions School staff reached out to all of the ally, procedural manuals were developed that that would directly address the prevalence above students with identifi ed anxiety and/ outlined best practices related to conducting of anxiety in schools. or depression concerns and connected a clinical interview, interpreting screening The success of the first large-scale them, as appropriate, with treatment ser- results, and referring students for therapeutic screening prompted the mental health vices matched to the intensity of presenting services. The readiness of the staff allowed team to scale up this practice to include needs. Without these data, the degree to for the adherence to follow-up procedures additional measures, including the PHQ-9 which a district can document and report that were established at the outset of the (PHQ Screeners, 2017), a screener that on the impact of the therapeutic interven- planning phase. All students who scored focuses on symptoms of depression, and tions being offered is limited, and the level in the moderate to severe ranges received the Strengths and Diffi culties Questionnaire of need of the student population is dif- follow-up by a mental health staff member (SDQ; Goodman, 2001; Youth in Mind, fi cult to ascertain. Through the adoption of within 72 hours. As screening scaled up and 2017), a global scale that yields a total dif- practices that generate psychosocial data, other measures were used that contained fi culties score and a number of subscales the ability to generate a data-rich account- questions related to suicidal ideation, the that are focused on specifi c problem areas ability system for the CSMHS has become corresponding window of time for follow- up was significantly reduced, resulting in students who indicated any level of self-harm or suicidal ideation receiving follow-up on Table 1: Summary of Elevated Mental Health Screening the same day as the screening. Additionally, as a proactive measure, local mental health Scores by Administration agency partners were alerted in advance of % of Students in the screenings to ensure they were prepared Screening Measure Screening Date N the Moderate or to manage a potential uptick in referrals for Severe Ranges evaluation following the screenings. Generalized Anxiety Disorder (GAD-7) Jan. 2016 839 22.53 Aside from the obvious use of screening Patient Health Questionnaire (PHQ-9) Apr. 2016 852 20.07 data to identify students who may require Strengths and Difficulties services, mental health screening supports Oct. 2016 1,344 12.73 a number of other important features of Questionnaire (SDQ) a healthy and well-functioning CSMHS. Patient Health Questionnaire (PHQ-9) Nov. 2016 1,135 16.04 Individual results serve as a baseline for ongoing progress monitoring, which is Generalized Anxiety Disorder (GAD-7) Jan. 2017 943 18.56 conducted using the same tools that are Note: The Moderate and Severe score ranges for each measure are as follows: GAD-7: Moderate (10–14) and Severe (15–21); PHQ-9: used for the screenings. In this manner, Moderate (10–14), Moderately Severe (15–19), and Severe (20–27); SDQ: High (18–19) and Very High (20–40).

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a reality. Progress monitoring data related to externalizing and internalizing behav- differences in the screening measures used students receiving Tier 2 and 3 supports is ioral challenges as well as academic in the two illustrations are important. The used to highlight the effi cacy of therapeutic challenges. fi rst illustrates universal behavior screening interventions offered, and aggregated data • Provide high-quality, ongoing profes- conducted as part of regular school practices gathered at key points throughout the year sional learning to support the installation to inform instruction. Teacher-completed show how the level of need of the larger of systematic screening tools along with screeners are based on observed student student population changes as a function explicit instruction on how to use these behaviors, with screening as a way to mea- of the services offered through the tiered data to inform instruction and provide sure and monitor teachers’ observations. system of mental health. tiered supports within the school setting The second illustrates the use of mental and through community partnerships. health screening (student self-report). Addi- A Call to Action: Considerations tional protections for self-report measures • Build and implement with integrity for Next Steps must be afforded, such as parent/guardian tiered systems of support composed of permission and opt-out options as discussed As we move forward with the goal of evidence-based practices, with data- in the high school illustration. prioritizing strong, integrated partnerships informed decision making conducted Finally, we have offered a call to action, between education and mental health sys- using data from systematic screening posing considerations for next steps for tems, we offer the following considerations tools to connect teachers and students researchers, practitioners, and policymak- for implementing districtwide screening to appropriate supports. and response systems using tiered sys- ers. We hope this concluding article in • Commit to a systems change perspective tems such as Ci3T models of prevention the four-issue 2017 volume of the Report that supports high-quality implementa- as a framework to structure and facilitate on Emotional & Behavioral Disorders in tion of systematic screening, honoring service delivery within these partnerships. Youth will help to propel improvements the lessons learned from implementation We respectfully offer the following consid- in research, practice, and policy of the science literature about the time needed erations for research, practice, and policy. foundational issue of early identifi cation (two to three years) for high-fidelity of students in need of successful school Research implementation before seeing desired behavioral health programs. • Design, test, and install free-access and shifts in student performance. low-cost screening tools that are reliable, • Create systems for transparency in prac- References valid, and feasible for use in detecting tices and a fully informed parent/guard- Achenbach, T.M. (1991). The Child Behavior Checklist: Manual for the Teacher’s Report Form. preschool through 12-grade students ian community. Burlington, VT: University of Vermont, Department with characteristic patterns of external- • Develop practices that are responsive to of Psychiatry. izing and internalizing disorders. parent/guardian and community concerns. Associates in Process Improvement (2017). Plan, • Design, test, and install feasible on- Do, Study, Act Cycle Description . Available at http:// Policy demand resources for professional www.apiweb.org/ . learning for various stakeholders (e.g., • Make transparent state and federal laws Cook, B.G., & Tankersley, M. (Eds.) (2013). Effec- administrators, general and special that support early detection efforts. tive Practices in Special Education . Boston, MA: Pearson. education teachers, related service pro- • Enhance communication between edu- viders, clinicians from the community, Barrett, S., Eber, L., & Weist, M.D. (2013). Advanc- cation and mental health systems by ing Education Effectiveness: An Interconnected parents, community members, and stu- committing to common language frame- Systems Framework for Positive Behavioral Inter- dents) to learn more about the rationale, works to ensure transparency and clarity ventions and Supports (PBIS) and School Mental procedures, and uses for conducting in communication among educators, Health. Center for Positive Behavioral Interventions behavior screenings in schools. mental health providers, and families. and Supports (funded by the Offi ce of Special Edu- cation Programs, U.S. Department of Education). • Design, test, and install district-level • Address issues of funding to provide for Eugene, OR: University of Oregon Press. data structures that enable efficient students’ access to needed mental health Drummond, T. (1994). The Student Risk Screening access by teachers, principals, and dis- supports within the regular school day. Scale (SRSS). Grants Pass, OR: Josephine County trict leaders to multiple sources of data Mental Health Program. (e.g., academic and behavioral screening Summary Elliott, S.N., & Gresham, F. (2008a). Social Skills scores, ODRs, and attendance) in an In this article, we have introduced a key Improvement System (SSiS)—Performance Screen- integrated manner to inform decision ing Guide . San Antonio, TX: PsychCorp Pearson challenge confronting the fi elds of educa- Education. making. tion and mental health: the need for early Elliott, S.N., & Gresham, F. (2008b). Social Skills • Develop, test, and install effective and detection of EBDs among students and Improvement System (SSiS)—Intervention Guide . socially valid interventions for general a framework for early response to their San Antonio, TX: PsychCorp Pearson Education. and special education communities to needs. Next, we offered a potential solution: Farmer, T.W., Irvin, M.J., Motoca, L.M., Leung, support PK-12 students who are expe- prioritizing strong, integrated partnerships M.C., Hutchins, B.C. Brooks, D.S., & Hall, C.M. riencing externalizing and internalizing between education and mental health sys- (2015). Externalizing and internalizing behavior behavior challenges. tems. Following this discussion, we provid- problems, peer affi liations, and bullying involve- ed two illustrations (1) teacher-completed ment across the transition to middle school. Practice Journal of Emotional and Behavioral Disorders, behavior screening within a Ci3T model of 23(1), 3–16. • Select and install systematic screening prevention in an elementary school setting Flay, B.R., & Allred, C.G. (2003). Long-term effects three times per year (fall, winter, and and (2) student self-reported mental health of the Positive Action program. American Journal of spring) to support early detection of screening in the high school setting. The Health Behavior, 27(Suppl 1), S6–S21.

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EEBD-1704.inddBD-1704.indd 101101 88/22/2017/22/2017 2:15:022:15:02 PMPM Page 102 Emotional & Behavioral Disorders in Youth Fall 2017 From the Literature: What’s Hot . . . What’s Not by Michelle Charlin*

Social Emotional Learning to “reactive and remedial strategies.” The Saad, K., Abdel-Rahman, A.A., Elserogy, authors propose that school districts, youth Y.M., Al-Atram, A.A., Cannell, J.J., Bjørklund, Effects of a Summer Learning clubs, and communities work together to G., Abdel-Reheim, M.K., Othman, H.A., Program for Students at Risk pay for and provide summer programs with El-Houfey, A.A., Abd El-Aziz, N.H., Abd for Emotional and Behavioral SEL components. El-Baseer, K.A., Ahmed, A.E., and Ali, A.M. Disorders Nutritional Neuroscience Risperidone and ADHD Zeng, S., Benner, G.J., and Silva, R.M. 19(8): 346–351, 2016 Education and Treatment of Children Comparison of the Effects This study furthered the research on the 39(4): 593–616, 2016 of Methylphenidate and the role of vitamin D defi ciency in people with It is common for students to regress Combination of Methylphenidate autism spectrum disorder (ASD) by focus- academically during the summer. Sum- and Risperidone in Preschool ing on children, using controls, and hav- mertime learning programs, categorized ing a large sample size. One hundred and Children With Attention-Deficit twenty-two Egyptian children aged three as afterschool programs (ASPs), can be a Hyperactivity Disorder preventative measure. This study demon- to nine with ASD and 100 healthy controls strated the effectiveness of integrating social Safavi, P. Dehkordi, A.H., and Ghasemi, N. of similar age, sex, and social status were emotional learning (SEL) into a literacy Journal of Advanced Pharmaceutical Tech- screened and classified by DSM-IV-TR program for low-income, incoming fourth nology & Research criteria and the Childhood Autism Rating graders at risk for emotional and behavioral 7(4): 144–148, 2016 Scale (CARS). The fi rst part of the study disorders (EBDs) and is the fi rst to docu- Few controlled clinical trials have inves- was conducted during May and June to ment “summer social emotional backslide.” tigated the psychopharmacological treat- prevent the infl uence of seasonal fl uctua- In groups of fi ve to six students per teacher, ment of preschool-age children. In 2015, tions in vitamin D levels. the control group and treatment group both Iranian children aged three to six who had A mere 16 of the study group participants received two and a half hours of literacy ADHD comorbid with disruptive behavior were found to have normal serum 25-OHD instruction per day for five weeks. The disorders (DBDs) were divided randomly concentration (>30 ng/ml); more than control group’s program lasted half a day. into two groups. Over a period of six weeks, half were defi cient in vitamin D (<20 ng/ The treatment group spent the entire day one group received methylphenidate, a psy- ml), and 30% had vitamin D insuffi ciency at a Boys & Girls Club of America (BGC) chostimulant commonly known as Ritalin; (20–30 ng/ml). Eighty-three subjects com- site in the northwestern United States. Their the other group received methylphenidate plied with taking oral vitamin D3 (300 IU/ day included three hours of enrichment and risperidone, an atypical antipsychotic. kg/day, which did not exceed 5,000 IU/ activities as part of each literacy session. Conners’ rating scale total and subscale day) for three months. Because this was an The additional activities were based on the scores were signifi cantly reduced, but there open-label trial, parents and children were BGC’s Triple Play program, which pro- was no signifi cant difference between the aware of what was being administered. Side motes healthy habits, physical activity, and two groups. effects such as skin rashes, itching, and behavioral skills. Among the topics taught The authors had hoped to and did fi nd diarrhea were mild and short-lived. After were emotional regulation, appropriate peer that the addition of risperidone lessens supplementation, the CARS scores of 16 interaction, and confl ict resolution. At the methylphenidate’s side effects such as children with fi nal serum 25-OHD levels end of the program, there was no signifi cant insomnia and anorexia and lowers the >40 ng/ml had gone down by 3.5 to 6.5 difference between the reading and writing dosage of methylphenidate required for points. Scores of 31 of the 49 youth with improvements of the groups. However, the ADHD improvement. Only five of the fi nal serum 25-OHD levels between 30 ng/ treatment group’s social emotional behavior 47 participants had to withdraw from the ml and 39 ng/ml decreased by 1.5 to 4.5 significantly improved while the control study before its completion because of points. Comparisons of aberrant behavior group’s behavior declined with regard to side effects. Other studies had investigated checklist (ABC) subscales before and after emotional symptoms and peer problems. this drug combination but not with this age treatment showed statistically signifi cant Post-surveys of the treatment group indi- group. The authors’ fi ndings differed from improvements in irritability, lethargy/social cated that 64% of students believed they those of earlier work in that the symptoms withdrawal, hyperactivity, and stereotypic were thinking more positively and 68% felt of children in the current study did not behavior. they were better able to understand friends’ signifi cantly improve with the addition of Screening for Anxiety feelings. Parental responses concurred. Not risperidone. Quantifying Risk for Anxiety attending to the social emotional needs of ASD and Vitamin D youth during long academic breaks can lead Disorders in Preschool Children: Vitamin D Status in Autism A Machine Learning Approach Spectrum Disorders and *Michelle Charlin has a B.A. in English from Emory Carpenter, K.L.H., Sprechmann, P., Calder- University and an M.L.I.S. from the University of the Efficacy of Vitamin D bank, R., Sapiro, G., and Egger, H.L. South Carolina. She can be reached by email at Supplementation in Autistic PLOS ONE [email protected]. Children 11(11): e0165524, 2016

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Preschool children who have signifi- and greater mental health service use. Social Skills Training cant anxiety issues are likely to become However, very few studies have investigated youth and adults who suffer from anxi- whether neighborhood social cohesion is Social Skills Training for ety and mood disorders. Although early associated with mental health problems in Children and Adolescents With intervention could be of great benefi t to adolescence. This study recruited a total of Autism Spectrum Disorder: A these preschoolers, few will be screened 14,541 women and 13,988 children from Randomized Controlled Trial or treated. It is expensive to use current the Avon Longitudinal Study of Parents Olsson, N.C., Flygare, O., Coco, C., Gör- diagnostic tools such as the Preschool and Children (ALSPAC), a birth cohort ling, A., Råde, A., Chen, Q., Lindstedt, K., Age Psychiatric Assessment (PAPA). The study of children born to women in Avon Berggren, S., Serlachius, E., Jonsson, U., interviewer must be highly trained, and (Bristol, UK) from April 1, 1991 through Tammimies, K., Kjellin, L., and Bölte, S. hours are required for the questions to be December 31, 1992, and followed them Journal of the American Academy of Child asked, answered, and coded. The authors of from pregnancy onward through self-report & Adolescent Psychiatry this study, mental health professionals and questionnaires and clinic visits. 56(7): 585–592, 2017 engineers, are using an alternating decision The main exposure variables were tra- trees algorithm (ADtrees) to develop brief jectories of neighborhood social cohesion, Although social skills group training screening tools that could one day be used neighborhood discord, and neighbor- (SSGT) for children and adolescents with to calculate risk scores for two frequently hood stress as reported by the mother by autism spectrum disorder (ASD) is widely occurring anxiety disorders: generalized questionnaire during pregnancy, at eight applied, its effectiveness in practice has anxiety disorder (GAD) and separation months postpartum, and when the child was not been properly evaluated. This 12-week anxiety disorder (SAD). At sites where young children receive primary medical attention, caregivers Children who were persistently exposed to greater could be asked questions such as: “Does your child ever get up at night to check neighborhood social adversity had higher odds that family members are OK?” (SAD) or “When your child is anxious or fright- of reporting psychotic experiences and depressive ened, do his/her muscles get tensed up?” (GAD). Yes/No responses to questions symptoms at 13 and 18 years. could be followed by: “How often does this occur?” or “When did this start?” Over the past 10 years, data from two dif- approximately two, three, fi ve, seven, and randomized controlled trial of SSGT com- ferent PAPA studies of children aged two 10 years old. At each point, mothers were pared to standard care alone was conducted at to fi ve from Durham, North Carolina, and asked the same set of questions about their 13 child and adolescent psychiatry outpatient its rural surrounds have shown that higher relationship with neighbors and the overall units in Sweden. Twelve sessions of manual- risk scores for SAD were associated with rating of the neighborhood. From the time ized SSGT were delivered by regular clinical greater sensory hypersensitivities, sleep children reached two years of age, mothers staff to 296 patients aged eight to 17 years disturbances, and irritability. Higher GAD were asked about the quality of the physical who had been diagnosed as having ASD with- and SAD risk scores were associated with and social environment. Data on psychotic out intellectual disability. Eighty-eight of the increased rates of conduct disorder and experiences and depressive symptoms were participants were females, 208 were males; oppositional defi ant disorder. It is hoped collected at 13 and 18 years of age during 172 were children and 124 were adolescents. that refi nement of the machine learning clinic assessments The primary outcome was the Social process and the evidence it provides will The authors found that children who Responsiveness Scale rating by parents lead to additional services being offered to were persistently exposed to greater neigh- and blinded teachers. Secondary outcomes this age group. borhood social adversity had higher odds included parent- and teacher-rated adaptive of reporting psychotic experiences and behaviors, trainer-rated global functioning Environment and Depression depressive symptoms at 13 and 18 years and clinical severity, and self-reported child Trajectories of Neighborhood after controlling for a number of con- and caregiver stress. Assessments were Cohesion in Childhood, and founders including maternal depriva- made at baseline, post-treatment, and three- tion, family socioeconomic status, and Psychotic and Depressive month follow-up. Moderator analyses were area-level deprivation. The specifi c type conducted for age and gender. Signifi cant Symptoms at Age 13 and 18 Years of neighborhood adversity associated treatment effects on the primary outcome Francesca S., Colman, I., Weeks, M., Lewis, with adolescent mental health varied. At were limited to parent ratings for the ado- G., and Kirkbride, J.B. 13 years, neighborhood stress emerged lescent subgroup and females. Secondary Journal of the American Academy of Child as the strongest predictor of psychotic outcomes indicated moderate effects on & Adolescent Psychiatry experiences and depressive symptoms, adaptive functioning and clinical severity. 56(7): 570–577, 2017 whereas at 18 years, lower neighborhood Although the authors concluded that SSGT Children and adolescents living in social cohesion and higher neighborhood for children and adolescents with ASD in reg- deprived neighborhoods seem to experience stress were more strongly associated with ular mental health services is feasible and safe, worse mental health outcomes than their depressive symptoms than with psychotic the modest and inconsistent effects underscore peers from more affl uent areas, including experiences, which were predicted by the importance of continued efforts to improve more internalizing and psychotic symptoms greater neighborhood discord. SSGT beyond current standards. Q

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Calendar of Events, November 2017 – January 2018

November

Oct 31- Youth Development Symposium. Chicago, IL. Sponsor: National Association of Workforce Development Professionals. Website: Nov 2 http://www.nawdp.org/Training/YouthDevelopmentSymposium.aspx

6-8 44th Annual Conference for Middle Level Education. Philadelphia, PA. Sponsor: Association for Middle Level Education. Website: http://www.amle.org/annual/Home/tabid/244/Default.aspx?gclid=CLTGoabh_9QCFVFffgodx9MIpA

9-12 National Federation of Families for Children’s Mental Health 28th Annual Conference. Orlando, FL. Sponsor: NFFCMH. Website: https://www.ffcmh.org/conference

December

11-14 World Congress on Special Needs Education. University of Cambridge, UK. Sponsor: WCSNE. Website: http://csmh.umaryland. edu/Conferences/

January

10-12 Beyond Housing: A National Conversation on Child Homelessness and Poverty. New York, NY. Sponsor: Institute for Children, Poverty, and Homelessness. Website: http://www.cvent.com/events/beyond-housing-2018/event-summary-6d083e57e642485cb- c3f48f9f5211217.aspx?p=10

17-19 2018 ACSSW Advancing School Social Work Practice National Institute, Makin’ It Real: Moving Beyond the Basics. New Orleans, LA. Sponsor: American Council for Social Work. Website: http://www.acssw.com/

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