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
Objectives Definition National Trends/Conceptualization
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
Objectives Definition National Trends/Conceptualization
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
Objectives Definition National Trends/Conceptualization
Systems-Focused Evidence-Based Models
Program-Based Conclusion
Take-Home MessagesQuestions and Answers
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
Objectives Definition National Trends/Conceptualization
Systems-Focused Evidence-Based Models
Program-Based Conclusion
Take-Home MessagesQuestions and Answers
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
Objectives Definition National Trends/Conceptualization
Systems-Focused Evidence-Based Models
Program-Based Conclusion
Take-Home MessagesQuestions and Answers
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
Objectives Definition National Trends/Conceptualization
Systems-Focused Evidence-Based Models
Program-Based Conclusion
Take-Home MessagesQuestions and Answers
Contact Information
Eleanor Castillo: [email protected]
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