School-based Brief, Targeted Interventions for Students at Risk of Developing Emotional/Behavioral...

School-based Brief, Targeted Interventions for Students at Risk of Developing Emotional/Behavioral Disorders

Doug Cheney, PhD Eric Bruns, PhD College of Education School of Medicine

University of Washington, Seattle

Background, Current School Topics

• Multi-tiered systems of support in vanguard• Public visibility of violent events in schools• Improve mental health systems of support• Enhance and revise discipline approaches in

schools – disproportionality• Achievement gap• Emphasis on use of Evidence Based Practices

What is a Targeted Intervention?

Schoolwide Positive Behavior Support Approaches:• An intervention (or set of interventions) known by all

staff & available for students who are not responding to Tier 1.

• Intervention provides additional student support in academic, organizational, and/ or social support areas

• Interventions are: efficient (similar across students) & effective (decrease behavior problems)

Evidence-based Tier 2 Interventions

• Behavior Education Program– Check-in and Check-out (CICO)

• Check & Connect– Check, Connect, and Expect

• Coping Power• Fast Track• First Steps to Success• Think Time

Check, Connect, & Expect (CCE)(2004-2010)

• Based on 15 years of research and practice from:– Oregon’s Technical Assistance Center on Positive

Behavior Support (Horner & Sugai, 2002)– Check and Connect (Sinclair, Christenson, Evelo, &

Hurley, 1998), U. Minnesota– The Behavior Education Programs (BEP; Crone, Horner,

& Hawken, 2010) U. Oregon/Utah.• CCE emphasizes these features:

– a positive caring adult – daily positive interactions with teachers & other adults – supervision and monitoring of students – teaching social skills to students– reinforcement/acknowledgement for success

Screening for Students for Behavior Problems

Systematic Screening for Behavior Disorders (SSBD; Walker & Severson, 1992)

• Research in the 1980s on behavioral predictors• Multiple gating procedures: Teacher Nomination &

Rating of Student Behavior• Two dimensions: Externalizing and Internalizing• Evidence of efficiency, effectiveness, & cost benefits• Exemplary, evidence-based practice

• US Office of Special Education, Council for Children with Behavior Disorders, National Diffusion Network

Graduation

Self-Monitoring

Basic Plus Program (as needed)

Program Phases Daily Program Routine

Student Passes Gate 2 SSBD

Morning Check-in

ParentFeedback

Basic Program

Teacher Feedback

AfternoonCheck-out

CCE Program

• Student check-in and check-out• Teacher Feedback/Daily Progress Report• Problem solving if needed• Parent communication• Reinforcement & Criterion Shift for non-

responders• If needed: Weekly problem solving and social

skills sessions

Checking In95% of 14,000 times Success

Student:___________________ Date:____________ Goal:_________

Reading Math

Super Road Runner

Way to Go! (4): Met expectations with positive behavior. DAILY TOTAL_______Good (3): Met expectations with only 1 reminder or correction. OK (2): Needed 2-3 reminders or corrections.Tough Time (1): Needed 4 or more reminders or corrections.

Parent Signature:______________________Comments:

Teacher: ___________ Comments:

Checked in Yes No

Checked out Yes No

Parent Signature Yes No

Expectation Tough Time

OK Good Way to Go!

BeSafe

1 2 3 4

ShowRespect

1 2 3 4

Be Responsible

1 2 3 4

Social Studies/Science/Art Specialist


OK Good Way to Go!

BeSafe

1 2 3 4

ShowRespect

1 2 3 4

BeResponsible

1 2 3 4


OK Good Way to Go!

BeSafe

1 2 3 4

ShowRespect

1 2 3 4

BeResponsible

1 2 3 4


OK Good Way to Go!

BeSafe

1 2 3 4

ShowRespect

1 2 3 4

BeResponsible

1 2 3 4

Acknowledge Success

Self-monitoring (SM)• After 8 weeks of success in Program• Students check-in and out and receive DPR• Students rate their own behavior on DPR

with teacher reliability checks• Coach checks for rating agreement (80%)• Coach reviews SM progress with

student/teacher for 4 weeks

Progress Monitoring

Red When BelowCriteria

Green WhenAbove Criteria

Two Year SummaryCheney, Stage, Hawken, Lynass, Mielenz, & Waugh (2009)

• About 80-90% of students responsive to the intervention• Office Discipline Referrals Decrease over time (4-2.7)• CCE may prevent Special Ed Referrals

– Of 104 students, 8 (8%) eligible for special education in year 1 and 12 (11% of total) in year 2; 31% of the comparisons.

– Lower rates of identification for CCE students • Graduates of CCE and comparison groups show differences in

teacher ratings on problem behaviors• Academic Achievement on the WJ-R III (literacy and math

subscales) in normative range

Brief Intervention for School Clinicians: A Modularized Evidenced-informed Mental

Health Treatment

Collaborative Team:US Department of Education/IES, UW, Seattle Public Schools,

Seattle/KC Public Health and Community Partners Group Health Cooperative, International Community Health

Services , Navos, Neighborcare, Seattle Children's’ Hospital, Swedish Hospital, Sound Mental Health

BRISCBrief Intervention for School Clinicians

Evidence-Based Practice (EBP) in School Mental Health

• School-based mental health (SBMH) offers accessible services, particularly for historically underserved youth (Burns et al., 1995; Kataoka et al.,

2007; Lyon et al., under review)– SBMH offers reduced stigma for service seeking (Nabors &

Reynolds, 2000)

• SBMH can lead to improvements in a variety of mental health, academic, and other functional outcomes– E.g., improved GPA for users vs. similar non-users (Walker et

al., 2010)

EBPs in School: Room for Improvement

• School-based services are unlikely to be evidence-based (Evans & Weist, 2004; Rones & Hoagwood, 2000)

• Recent meta-analysis of SBMH programs for low-income, urban youth revealed low levels of effectiveness, some iatrogenic effects (Farahmand et al., 2011)

• Growing emphasis on increasing the use of EBP in SMH

• Few interventions delivered in schools have been designed for or tested in authentic education sector service delivery settings (Wong, 2008)

• Simultaneously…– EBP developers have paid insufficient attention to

the school context and how it might influence effective service delivery (Ringeisen et al., 2003)

EBPs in School: Room for Improvement

Questions about transporting EBP is particularly relevant to school MH

• Commonly-cited concerns about the transportability of EBP to new contexts are relevant to SBMH

– Substantial need for flexibility– Treatment engagement / duration variability– Ability of EBP to address the full range of client

problems (type and severity)– SBMH service accessibility may make concerns

about the cultural relevance of EBP even more important

Overarching Goal

Develop and pilot test an evidenced-informed and feasible mental health intervention designed to address the unique characteristics and needs of

the school context


Evolving Goal

Enhanced integration of mental health service/care models with education

based approaches supporting student academic and social/emotional

development


Framework for BRISC Integration into Existing Systems

BRISC

Tier 3

Tier 2

Tier 1

BRISC Inputs (from the school & other systems) Seeks school staff

(e.g., teacher, administrator) input / assessment about presenting problems and optimal pull-out timing for individual students

Promptly evaluates student academic functioning to determine whether psych Sx are interfering / if academic Fx should be an explicit target

Assesses/understands where BRISC fits into existing approaches to dealing with Bx’l health and options (e.g., PBIS)

BRISC Outputs (into the school & other systems) Develops individualized

teacher-communication plans for students and coaches them through their execution

Communicates directly with teachers and parents about BRISC skill targets and methods of supporting them.

Provides a post-BRISC progress report to key school staff.

Provides an everyday language description of the BRISC program (for parents, teachers, etc.)

Referral to or coordination with intensive services during or following

(for MH) BRISC implementation

Links individual BRISC targets to relevant existing universal programs and communicates with program liaisons

Note: Tiers 1, 2, & 3 within the Education context are largely comparable to Primary, Secondary, and Tertiary Prevention

Indiv. Student Level

Indiv. Student Level

System Level

System Level

BRISC System Integration

School-Based Usual Care BRISC

Intervention is often crisis-driven (Langley et al., 2010)

Structured / systematic identification of treatment targets

Focused on providing nondirective emotional support (Lyon et al., 2011)

Focused on skill building / problem solving

Interventions do not systematically use research evidence (Evans & Weist, 2004; Rones & Hoagwood, 2000)

All intervention elements are evidence-based

Standardized assessments are used infrequently (Weist, 1998; Lyon et al., under review-a)

Utilizes standardized assessment tools for progress monitoring

BRISC Intervention and Rationale

• Based on common elements of evidence-based MH treatments for children and youth

• Responsive to typical presenting problems and help-seeking behaviors of high school students seeking/needing help


• Tailored to the typical workflow, caseloads, supervision structures, and client engagement and follow-up strategies of SBMH clinicians

• Well-integrated with typical school structures and connected to other types of school-based social and behavioral supports


• Integrates support technologies found to enhance outcomes of treatment including a measurement feedback system (MFS) that monitors fidelity components as well as youth outcomes.

Project Overview

Year 1: 2012-13Study 1: Expert Input: Key Informants and Summit Revise BRISC Protocol

Study 2: Initial Feasibility Testing (Project Personnel)Analyze findings: i.e. behavioral change, response to BRISC

Revise BRISC Protocol

Study 1 Revise BRISC Protocol

Revised BRISC protocol to reflect Summit input: BRISC as a targeted intervention within existing tiered

system Incorporate academic interventions/focus on monitoring

academic success Student voice in development/target ID academic and socio-emotional outcomes to focus on, e.g.

Top Problems Checklist Make use of existing school data systems Establish “readiness” criteria for schools as a way to

measure school’s ability to integrate the program

Revised BRISC Common Factors

1. Agenda Setting Collaborative Focus/structure session Manage the time

2. Problem Solving Framework Clinician helps student identify specific problems Empowers student to address/change Brainstorming solution – anything goes Important to prepare for/address internal and external barriers No failure – any attempt provides useful information in

implementing other solutions

Revised BRISC Common Factors

3. Progress Monitoring and Feedback Weekly stress rating - generally and then related to identified

problem (0=low to 10=high) Useful in identifying targets to address /monitoring progress (i.e.

it’s like a ruler to measure change)4. Practice Exercises

Tracking targets—moves from therapy to real life application Helps identify barriers to change Doing something that is slightly out of their comfort zone and

different from what they would ordinarily do (not something too hard or drastic)

Session One

Engagement/rapport building Problem identification—including academic issues Include the need for identifying additional services as

soon as possible to begin groundwork Administer standardized assessment Introduction to stress rating Convey helpfulness Informal monitoring


Teaching Tools

• • 1st

• • • • • • • • • 2nd

• • • • •

Class +/_ How are you doing?

Attendance/Homework

What is it like…

Peers/Activities

Home/Neighborhood

Brief Academic and Function Review Problem Solving

Steps: 1. Clarify problem

2 Generate a list of possible solutions•______________________________________•______________________________________•______________________________________3. Evaluate possible solutions 4. Pick one to try—TRY IT Prepare for possible obstacles

• Rate level of stress• Rate your ability to change situation • Who can support you

Teaching Tools

Session Two

Review and reinforce informal monitoring Recap problem list/identify problem to target Connect stress rating to identified problem Psychoeducation about stress Introduce problem solving steps Assign practice exercise based on selected solution


Session Three

Review new problem solving strategy and connect to stress rating

Based on outcome and challenges/barriers to implementing new strategy and identified problem, select and implement module (see flow chart to help with module identification)

Assign practice exercise based on module implemented


Session Three: Modules

Handling hard feelings—emotion/stress management skills Dealing with a hard situation I can’t change—cognitive

restructuring skills Getting along with other people—communication skills Just don’t feel like it – unhappy with a current situation but

lacking motivation to do anything different—motivational enhancement

Problem solving—PS skills


Module Selection

Session Four: What was accomplished and where to go from here . . .

Stress rating Review skill practice exercise: Assess the outcome of the module: What did they do? How did they do

it? What was the result? How did they feel? Explore difficulties with implementation. Fine turn approach they might try next time. Praise student for efforts and successes.

Administer and review brief standardized assessment measure: Attribute changes to what the student has worked on and done differently and/or discuss what additional services the student might need going forward.

Review progress/Next Steps


Pilot Study Implementation and FindingsAge Grade Gender Ethnicity Problem Area

1. 17 12th F Black/African American Anxiety

2. 15 9th F Hispanic/Puerto Rican American

Depression

3. 18 12th F Caucasian Academics

4. 19 11th F Black/African Sexual Trauma

5. 16 10th F Caucasian Depression

6. 17 12th F Caucasian Peer Problems

7. 17 11th F Caucasian Peer/Academics

8. 15 10th M Caucasian Academics

9. 16 11th F Black/African American Relationship Issues

10. 18 12th F Hispanic/Mexican American

Academics/Depression

11. 17 11th F Caucasian Academics

12. 16 10th F Black-Filipino Truancy

Participant Characteristics

Participants: 50% self-referred 63.6% clinically significant elevation on problem scale—most

depression or anxiety Many reported poor academic performance, 58% had failed 1

or more classes in the prior semester Engagement:

9 completed the 4-session BRISC intervention; 1 dropped out after 2 sessions, 1 never engaged, and 1 is still in treatment


Participant Responses to Intervention

Acceptability: Participants reported that their motivation to attend

sessions increased incrementally for each successive session

Median ratings of experience of counseling and helpfulness of homework/practice was 7 out of a possible positive rating of 10

Clinical Outcomes: Pre-post student assessments of depression, anxiety and

functional impairment--promising improvements in all areas BRISC

Brief Intervention for School Clinicians

BRISC Implementation

Adherence Interventionists demonstrated high levels of adherence to

the BRISC protocol including: identifying and monitoring problems introducing and conducting stress/mood rating planning problem monitoring introducing problem-solving, assessing barriers, assigning practice exercises.


Lessons Learned

Able to recruit and engage youth Youth indicated overall satisfaction Therapists able to deliver protocol with

fidelity BRISC worked well as a way to engage youth,

reduce mental health problems, and assess needs


Lessons Learned—Case examples

Four core pathways identified1. Come back if you need it 16 yr. AA anger/relationship issues, teaching-stress cycle, PS re

other ways to respond, communication strategies—listening and “I” statements

2. Supportive monitoring 15 yr old, referred by parent/school counselor re academic

performance, PS focused on managing academic demands (cell phone use, etc), ongoing check ins with school counselor to reinforce progress


Four core pathways identified3. Continue BRISC or other TAU15 yo Hispanic female, depression/dysthymia and academic

difficulties. Attempted some initial school interventions and identified significant barriers related to mood. Addressed handling hard feelings (including a referral for psychiatry), then client was able to more effectively engage in problem solving around academic issues.


4. More intensive services – (referral to other services (i.e. special education, psychiatry, trauma treatment, family therapy, DBT, eating disorder treatment, etc.)

19 yo African female, referred by nurse practitioner for trauma and some initial SI, worked on problem solving and handling hard feelings - reducing harmful/problematic coping behaviors (i.e. eating chalk and excessively taking pain meds) and problematic school/peer concerns, and connecting to more intensive outside services making a "warm hand-off" with an outside agency

What’s next? IES BRISC Project

End Year 1: Revise BRISC protocolYear 2: Protocol validation w/school based

mental health providers in 8 SPS High SchoolsYear 3: Study 4: Randomized pilot study in

Seattle and other area high schools

School-based Brief, Targeted Interventions for Students at Risk of Developing Emotional/Behavioral...

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