A Framework for Considering Prevention and Early Intervention Nancy Peña Director, Santa Clara...

A Framework for Considering Prevention and Early Intervention

Nancy PeñaDirector, Santa Clara County Mental Health Services

Eleanor CastilloDirector of Outcomes and Quality Assurance

EMQ Children and Family Services

CMHACYMay 4, 2006

CMHACY 2

Objectives Definition National Trends/Conceptualization

Systems-focused Evidence-Based Models

Program-based Conclusion

Take-Home MessagesQuestion and Answer

CMHACY 3


Systems-focused Evidence-Based Models Conclusion

Take-Home MessagesQuestion and Answer Program-focused

CMHACY 4

Primary Prevention:Interventions for

All

Secondary Prevention:Specialized Group

Interventions for Youth with At-Risk Behavior

Tertiary Prevention:Specialized

IndividualizedIntervention for Youth

with High-Risk Behavior

Public Health

Approach

CMHACY 5

Prevention:Interventions to avert the initial onset of a mental disorder. Similar to PH

primary prevention.

Treatment: Identification and

treatment of individuals with mental disorders and treatment which

may include interventions to reduce the likelihood of future co-occurring disorders.

Maintenance:To reduce relapse and recurrence and provide

rehabilitation. Incorporates PH

secondary and all forms of tertiary prevention

Institute of Medicine:

Core Activities

CMHACY 6

3 Forms of Preventive Intervention

Universal- Interventions that target the general public or a whole population group that has not been identified on the basis of individual risk.

Selective- Interventions that target individuals or subgroup whose risk of developing mental disorders is significantly higher than average (Early Intervention).

Indicated- Interventions that target individuals who are identified as having signs, symptoms, or genetic markers related to mental disorders, but do not yet meet diagnostic criteria.

CMHACY 7

Characteristics of a Public Health Approach

Universal interventions Targeting risk AND protective factors Dissemination of information/services in

multiple locationsDoctor’s office/Health ClinicsLibrariesCommunity Centers

CMHACY 8


Systems-Focused Evidence-Based Models

Program-Based Conclusion

Take-Home MessagesQuestions and Answers

CMHACY 9

National Institute of Mental Health

NIMH. (1998). Priorities for Prevention Research at NIMH: A Report by the National Advisory Mental Health Council Workgroup on Mental Health Disorders Prevention Research. NIH Publication No. 98-4321.

CMHACY 10

National Institute of Mental Health

Prevention Science- Prevention, early intervention, and treatment must be provided within a public health context, along a continuum, and must address risk and protective factors (analyses of risk and protective factors)

Find a way to make all system efforts fit into the mental health spectrum

CMHACY 11

Greenberg, M. (2002) Prevention of Mental Disorders in School Aged Children: Making the Connection. Presentation at SAMHSA/CMHS and National Association of State Mental Health Program Directors Prevention Roundtable, March 14, 2002.

Ecological Perspective

CMHACY 12

Ecological Perspective(Greenberg, M., 2002)

Philosophy: Every child is important and kids with challenges are failing. Strategies need to be adjusted Yale study (2005) reported that Pre-K students are

expelled at a rate 3x that of children K-12

Early Childhood Community- Perceive role and influence the development of social-emotional competencies

CMHACY 13

SAMHSA: Mental Health Status Continuum

Positive Mental Health:Positive Mental Health: Mental Health Problem:Mental Health Problem: Mental Disorder:Mental Disorder:

High-level capacity of the Disruption in interactions Medically diagnosable illnessindividual, group, and between individual, group,, that results in significant environment to interact & and environment, impairment of cognitive, to promote well-being, producing a diminished affective, or relational abilitiesoptimal development, and state of positive mental healthuse of mental abilities

Scanlon, K., Williams, M., & Raphael, B. (1997). Mental Health Promotion in NSW: Conceptual framework for developing initiatives. NSW Health Department, Sydney, Australia.

CMHACY 14

SAMHSA: Mental Health Continuum

Broaden view to include promotion & prevention During a lifetime one can move back and forth along

the continuum Family members could be at different points along the

continuum Redefine Mental Health as “Social Emotional

Competencies”- a facet Primary Care Physicians and Child Care Providers

should be part of the resource and interventionists along the continuum

CMHACY 15

SAMHSA: 5 Principles Individuals, especially children need to be viewed and

understood within developmental framework Individuals, especially, children are a part of families, so

families need to be viewed and understood holistically Prevention, early intervention, and treatment must be

provided within a public health context, along a continuum and must address risk and protective factors

Services and supports for individuals and their families should be family-driven and individual-guided; culturally and linguistically competent; individualized and strengths-based; and community-based (person centered)

Behavioral health care needs to be comprehensive, coordinated, and integrated across multiple individual-and-family-serving systems

CMHACY 16

American Psychological Association

Community

Family

Culture

Universal Prevention

Health Promotion / PositiveDevelop.

SelectivePrevention

IndicatedPrevention

Time-limitedTherapy

EnhancedTherapy

Continuing Care

InpatientUnit

Residential Facility

Home

School

Neighborhood Agency

Primary care Clinic

Day TreatmentProgram

Note: Primary strengths reside in youths, families, communities, and cultures (center), supported and protected by effective interventions (examples in upper semicircle) delivered within an array of life settings (examples in lower semicircle). Intervention strategies are arrayed from most universally applicable (i.e., for general population groups not identified as having specific risk factors, problems, or disorders) at left to narrowly focused (i.e., for youths with rarer persistent long-term conditions) at the right. Intervention settings are arrayed from least restrictive on the left to most restrictive on the right. The upper portion of the figure is adapted from “Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research” (p. 23), by P. J. Mrazek and R. J. Haggerty, 1994, Washington, DC; National Academies Press. Copyright 1994 by National Academies Press. Adapted with permission.

Youth

OutpatientMental Health

Weisz, J.R., Sandler, I.N., Durlak, J.A., & Anton, B.S. (2005). Linking prevention and treatment within an integrated model. American Psychologist, 60 (6), 628-648.

CMHACY 17





CMHACY 18

General Trends

Collaborative SystemsSystems Approach vs Program Approach

Strengthening Families Cultural Competence Maximizing Current Resources Collaboration Between Families and

School

CMHACY 19

EDUCATION

JUVENILE PROBATIONCHILD

WELFARE

Various Resources

MENTAL HEALTH

FIRST FIVE

CMHACY 20

SCHOOL

Violence & Crime

Prevention

Drug Services

Juvenile Court

Services

Social Services

Child Protection Services

Special Education

Pupil Services Health

Services

Mental Health

Services

Drug Prevention

Community Based

Organizations

Clinic

After-School

Programs

Adapted from: Health is Academic: A guide to Coordinated School Health Programs (1998). Edited by E. Marx & S.F. Wooley with D. Northrop. New York: Teachers College Press.

Fragmented Policy Fragmented Practices

CMHACY 21

EDUCATION

JUVENILE PROBATION DEPT

EDUCATION+

MENTAL HEALTH

MENTAL HEALTH

MENTAL HEALTH

+ JUVENILE

PROBATION DEPT

ED+MH+JPD

CHILD WELFARE

CHILD WELFARE +

JPD

EDUCATION+ MENTAL HEALTH+ CHILDWELFARE

+ JPD

ED+CW+JPD

ED+MH+CW

EDUCATION+ CHILD

WELFARE

JPD+ MH+CW

Resource Overlap

CMHACY 22

When policy focuses on schools, public services, and communities working together, it is important

to recognize that we are talking about three major and separate reform movements.

School Improvement Public Service Agency Reform

And, it is especially important to understand the implications of this!

CMHACY 23

System Approach Examples from other states

New York and Illinois Guidelines

Oregon Legislation

Iowa and Illinois Positive Behavioral Interventions and Support

Washington Universal School-Based “Emotional Health Check-

Up”

CMHACY 24

System Approach Sample of Efforts Within California

First 5 CommissionBehavioral, Developmental, and Emotional

Screening and Treatment by Primary Care Providers in Medi-Cal Managed Care (BEST)

Riverside County- Youth Crime Prevention Red Team

Early Mental Health Initiative

CMHACY 25

Partnering with Primary Care

PRIMARY CARE

Pediatrician

PRIVATE INSURANCE

MH

EDUCATION

JUVENILE PROBATION DEPT

EDUCATION+ MENTAL HEALTH

ED+MH+JPD

CHILD WELFARE

CHILD WELFARE +

JPD

EDUCATION+ MENTAL HEALTH+

CHILD WELFARE +

JPDED+CW+JPD

EDUCATION+

CHILD WELFARE JPD+

MH+CW

MENTAL HEALTH

ED+MH+CW

MENTAL HEALTH

+ JUVENILE

PROBATION DEPT

CMHACY 26

Examples of Programs that Combine Strategies Across Family, School, and

Community Across Ages Adolescent Transitions Project First Step to Success Project Northland Promoting Alternative Thinking Strategies (PATHS) Schools and Families Educating Children (SAFE

Child Program) Woodrock Youth Development Project

CMHACY 27





CMHACY 28

Why Evidence-Based or Best/Emerging Practices

Governmental organizations at the national level have endorsed the importance of evidence-based practices and programs (National Advisory Mental Health Council, 2001; President’s New Freedom Commission on Mental Health, 2003; U.S. Public Health Service, Office of the Surgeon General, 1999; 2004).

Family advocacy groups and patient organizations have become increasingly vocal in advocating for interventions that produce good outcomes plus youth and family satisfaction with the care provided.

Access and satisfaction within a system of care has improved, but treatment outcomes need to better improve.

CMHACY 29

Sample Resources There are over 800 outcome studies on prevention and health

and 250 more on drug abuse prevention. www.effectivechildtherapy.com.

The evidence-base for universal prevention indicates addressing drug use, pregnancy, child maltreatment, and health promotion are well documented in the literature. www.oslc.org/spr/apa/summaries.html

http://preventionpathways.samhsa.ogv/mrepp/adv_search.cfm Evaluation of program based approach to evaluation of

systems approaches Web site for the National Registry of Effective Programs and

Practices (see www.mentalhealth.samhsa.gov ) shows that 91% of those (prevention) programs (i.e., 58 of the 64 programs listed) identify multiple ethnic groups as their target population.

http://www.cimh.org/downloads/multicultural/Final%20Summary%20Matrix%209-15-05%20v%201%20_2_.pdf

CMHACY 30

Program Approach

Early Childhood Programs Trauma Developmental Approaches

Natural Transitions Community Engaged Programs

Positive Youth Development programs

CMHACY 31

Important Features of Effective Family Intervention Programs

(Oregon Research Institute, 2005)

Skill-building as an explicit focus, not just education, knowledge, discussion, or support- Includes skill practice, role-playing, videotaped models, and home practice.

Interactive and collaborative approach, rather than didactic. Focus on social learning principles, not just parenting strategies. Explicit education and support related to other issues, including

marital adjustment and problem solving. Start early and capitalize on natural transitions, which are times

of opportunity and vulnerability (e.g., birth, preschool). Build skills in effectively managing children’s behavior. Monitor and supervised activities. Consistent discipline. Build positive parent-child relationships. Self-control for parents. Consistent parenting between parents.

CMHACY 32

System and Program Approaches: Accountability and Outcomes

Focus on OUTCOMES based on a logic model and QUALITY IndividualProgramSystems

When measuring impact, school readiness is an important indicator.25% of children are not ready to enter schools

CMHACY 33

Logic Model

Youth, Family, and System Conditions

Program Components/

Service Activities

Outcomes

CMHACY 34

System and Program Approaches: Cultural Competence

Organization/Systems ConsiderationsOrganizational Cultural Competence Individual Cultural Competence

CMHACY 35

System and Program Approaches: Cultural Competence

Consumer Considerations Internal complexities with ethnic demographics Various cultural identities Generalization of statistics Models of health and illness Approaches and receptivity of interventions Causal and contributing factors of illness Language History

CMHACY 36





CMHACY 37

Take-Home Messages

Address risk factors and protective factors Need for systemic and programmatic

approaches Implementation of services/interventions

based on research Accountability, Outcomes, and Quality

Little Hoover Commission Know the community being served

CMHACY 38





Contact Information

Eleanor Castillo: [email protected]

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