Creating a Statistical Analysis Plan to Continually Evaluate Intervention Adaptations that Arise in Real-World Implementation.

Evidence-based health interventions are frequently translated into real-world settings where practical needs drive changes to intervention protocols. Due to logistical and resource constraints, these naturally arising adaptations are rarely assessed for comparative effectiveness using a randomized trial. Nevertheless, when observational data are available, it is still possible to identify beneficial adaptations using statistical methods that adjust for differences among intervention groups. As implementation continues and more data are collected and assessed, we also require analysis methods that ensure low statistical error rates as multiple comparisons are made over time. This paper describes how to create a statistical analysis plan for evaluating adaptations to an intervention during ongoing implementation. This can be done by combining methods commonly used in platform clinical trials with methods used for real-world data. We also demonstrate how to use simulations based on previous data to decide the frequency with which to conduct statistical analyses. The illustration uses data from large-scale implementation of a school-based resilience and skill-building preventive intervention to which several adaptations were made. The proposed statistical analysis plan for evaluating the school-based intervention has potential to improve population-level outcomes as implementation scales up further and additional adaptations are anticipated.

"They Just Helped Save My Life:" Client Perspectives on the Los Angeles County Full Service Partnership (FSP) Program for Serious Mental Illness.

The purpose of this qualitative study was to elicit client perspectives on the Los Angeles County Full Service Partnership (FSP) program - an adaptation of Assertive Community Treatment (ACT). Semi-structured interviews were conducted with 20 FSP clients. Qualitative data were analyzed using thematic analysis. Two major themes were identified from the interview data: (1) Clients' acknowledgement of the material benefits of the FSP program; and (2) FSP's impact on restoring and stabilizing clients' social and treatment relationships. Interviewees greatly valued the material (i.e., basic needs, housing assistance) and relational (i.e., relationships with providers, restored personal relationships) aspects of the program, but did not ascribe the same degree of value to mental health treatment. Interviewees' emphases on material and relational aspects reflect the status of assertive mental health treatment as an intervention on intermediary determinants of health in the lives of persons diagnosed with serious mental illness.

Encouraging "Positive Views" of Mental Illness in High Schools: An Evaluation of Bring Change 2 Mind Youth Engagement Clubs.

"Bring Change 2 Mind" (BC2M) high school clubs may destigmatize mental illness among club members, but clubs' (1) reach and impact on non-club members at the same school, (2) connection to student help-seeking attitudes, and (3) mechanisms by which they destigmatize mental illness, are unknown. This community-partnered evaluation involved pre/post surveys of predominantly Latino (72%) students at three urban public schools and focus groups and interviews with a sample of club members (n = 26/65, 40%) and all club staff (n = 7, 100%). Multivariate regressions tested relationships between variables. In 84% of the student body responded in the Fall (n = 1,040) and Spring (n = 1,031). Non-club member engagement in BC2M (reach) increased from 25% (Fall) to 44% (Spring) (p < .01). Engagement with BC2M clubs was associated with decreased stigma among members (p < .05) but not non-members (p = .19). Decreased stigma was associated with help-seeking attitudes (p < .01). Possible BC2M mechanisms identified by students and staff include the following: (1) fostering a positive campus climate, (2) normalizing mental health discussions, (3) increasing peer support and help-seeking, and (4) increasing awareness of positive coping behaviors. While BC2M clubs likely reduce stigma for members, effects did not reach non-members, challenging the potential of BC2M clubs as a schoolwide strategy to destigmatize mental health services. Future projects could investigate how to reach non-BC2M members, complement BC2M with other school climate interventions to increase impact, and measure BC2M impact alongside other outcomes relevant to schools, such as academic achievement.

Pilot Study of the MAP Curriculum for Psychotherapy Competencies in Child and Adolescent Psychiatry.

OBJECTIVE: This pilot study aimed to evaluate the relevance, feasibility, acceptability, and instructional efficacy of the Managing and Adapting Practice (MAP) curriculum for enhancing the teaching of psychotherapy to child and adolescent psychiatry (CAP) fellows. MAP is a system of resources and decision models that supports practitioners in selecting and implementing psychotherapeutic interventions for children and adolescents. The MAP curriculum includes modules to guide education about psychotherapeutic procedures (e.g., behavioral activation) common in evidence-based treatments for an array of childhood problems and to support development of competencies in assessment, treatment planning, and reflective practice. METHODS: Curriculum coding was used to examine the relevance of MAP's core components to the skills articulated in the Accreditation Council for Graduate Medical Education (ACGME) CAP milestones. Feasibility, acceptability, and learning outcomes were examined after delivery of the MAP curriculum to 12 CAP fellows at two sites, with instructional features tailored according to faculty preferences and training program structure. RESULTS: Coding suggested that the MAP curriculum was relevant to 95% of the 21 ACGME CAP training subcompetencies. Feasibility was indicated by the successful delivery of 100% of the planned MAP curriculum across the two sites. Acceptability was supported by positive feedback from the CAP fellows, and psychotherapy knowledge increased significantly. Finally, case review scores (mean±SD=2.21±0.15) showed positive posttraining application of MAP to two patients and exceeded scores achieved by other samples of mental health professionals. CONCLUSIONS: This pilot study demonstrated the potential for the MAP curriculum to support CAP education. MAP's versatility as a curriculum supports broader adoption, with continuing rigorous empirical evaluation.

Community Interventions to Promote Mental Health and Social Equity.

PURPOSE OF REVIEW: We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions. RECENT FINDINGS: There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

A Cross-Site Partnership to Examine Implementation and Sustainability of a School-Based Trauma Program.

Objectives: Schools have been identified as an ideal setting for increasing access to mental health services particularly for underserved minority youth. The emerging field of implementation science has begun to systematically investigate strategies for more efficiently integrating evidence-based practices into community settings. Significantly less translational research has focused specifically on the school setting. To address this need, we examined the implementation of a school-based trauma intervention across three distinct regions. Design: We conducted key informant interviews guided by Mendel's Framework of Dissemination in Health Services Intervention Research with multiple school stakeholders to examine what school organizational characteristics influence the adoption and implementation process and sustainability of Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Participants were selected from schools in three geographic regions in the United States: Western, Midwestern, and Southern. Results: Our findings reveal that while sites had some common organizational factors that appeared to facilitate implementation, regions differed in how they compensated for less robust implementation domains. Across all regions, school stakeholders recognized the need for services to support students impacted by trauma. In the Western region, there was no centralized district policy for implementation; therefore, implementation was facilitated by school-level change agents and supervision support from the district mental health unit. In the Midwestern region, centralized district policies drove implementation. In both the Midwestern and Southern regions, implementation was facilitated by collaboration with a local mental health agency. Conclusions: This study contributes to the paucity of empirical information on the organizational factors that influence the implementation of evidence-based mental health interventions in schools. Our findings reveal that different implementation strategies across policies, structures, and resources can result in implementation of a school-based intervention. Frameworks such as Mendel's can be helpful in identifying areas of strength and improvement of implementation within a school organization.

Voices from Minority Youth on Help-Seeking and Barriers to Mental Health Services: Partnering with School-Based Health Centers.

Objective: Schools and school-based health centers (SBHCs) play an important role in reducing disparities in access to mental health treatment. However, there is a need to increase student engagement in school mental health services. This study sought to understand the perceptions of low-income minority youth on help-seeking and barriers to mental health services at SBHC sites. Setting: A network of SBHCs, called Wellness Centers, developed as part of a strategic plan to serve students and community members in under-resourced areas of a large urban school district. Participants and Procedures: We conducted focus groups with 76 middle and high school students at nine SBHC sites through a community-academic partnered approach from January to May 2014. The focus groups were audio-recorded, transcribed, and major themes coded with Atlas.ti.5.1. Results: Students identified teachers as a primary source of support for mental health issues, followed by peers and mental health counselors. Students felt that trust and connection were vital for help-seeking. Barriers to using SBHCs included: embarrassment; fear of judgment; concerns about confidentiality; a sense that they should keep things inside; and lack of awareness. Conclusions: Despite the resources available at SBHCs, students face barriers to help-seeking. SBHCs can help teachers and school staff gain awareness of mental health issues and services available to students. The students' recommendations-making SBHCs more comfortable, raising mental health awareness, and bolstering connections with school and SBHC staff-may improve engagement in mental health services at schools with SBHCs.

Stakeholder Perspectives on the Social Determinants of Mental Health in Community Coalitions.

Objective: Although evidence supports the potential for community coalitions to positively address social determinants of mental health, little is known about the views of stakeholders involved in such efforts. This study sought to understand county leaders' perspectives about social determinants related to the Health Neighborhood Initiative (HNI), a new county effort to support community coalitions. Design: Descriptive, qualitative study, 2014. Setting: Community coalitions, located in a large urban city, across eight service planning areas, that serve under-resourced, ethnic minority populations. Procedures: We conducted key informant interviews with 49 health care and community leaders to understand their perspectives about the HNI. As part of a larger project, this study focused on leaders' views about social determinants of health related to the HNI. All interviews were audio-recorded and transcribed. An inductive approach to coding was used, with text segments grouped by social determinant categories. Results: County leaders described multiple social determinants of mental health that were relevant to the HNI community coalitions: housing and safety, community violence, and employment and education. Leaders discussed how social determinants were interconnected with each other and the need for efforts to address multiple social determinants simultaneously to effectively improve mental health. Conclusions: Community coalitions have an opportunity to address multiple social determinants of health to meet social and mental health needs of low-resourced communities. Future research should examine how community coalitions, like those in the HNI, can actively engage with community members to identify needs and then deliver evidence-based care.

Applying a Trauma Informed School Systems Approach: Examples from School Community-Academic Partnerships.

Objectives: Schools can play an important role in addressing the effects of traumatic stress on students by providing prevention, early intervention, and intensive treatment for children exposed to trauma. This article aims to describe key domains for implementing trauma-informed practices in schools. Design: The Substance Abuse and Mental Health Administration (SAMHSA) has identified trauma-informed domains and principles for use across systems of care. This article applies these domains to schools and presents a model for a Trauma-Informed School System that highlights broad macro level factors, school-wide components, and tiered supports. Community partners from one school district apply this framework through case vignettes. Results: Case 1 describes the macro level components of this framework and the leveraging of school policies and financing to sustain trauma-informed practices in a public health model. Case 2 illustrates a school founded on trauma-informed principles and practices, and its promotion of a safe school environment through restorative practices. Case 3 discusses the role of school leadership in engaging and empowering families, communities, and school staff to address neighborhood and school violence. Conclusions: This article concludes with recommendations for dissemination of trauma-informed practices across schools at all stages of readiness. We identify three main areas for facilitating the use of this framework: 1) assessment of school staff knowledge and awareness of trauma; 2) assessment of school and/or district's current implementation of trauma-informed principles and practices; 3) development and use of technology-assisted tools for broad dissemination of practices, data and evaluation, and workforce training of clinical and non-clinical staff.

Community Partnering for Behavioral Health Equity: Public Agency and Community Leaders' Views of its Promise and Challenge.

Objective: To understand potential for multi-sector partnerships among community-based organizations and publicly funded health systems to implement health improvement strategies that advance health equity. Design: Key stakeholder interviewing during HNI planning and early implementation to elicit perceptions of multi-sector partnerships and innovations required for partnerships to achieve system transformation and health equity. Setting: In 2014, the Los Angeles County (LAC) Board of Supervisors approved the Health Neighborhood Initiative (HNI) that aims to: 1) improve coordination of health services for behavioral health clients across safety-net providers within neighborhoods; and 2) address social determinants of health through community-driven, public agency sponsored partnerships with community-based organizations. Participants: Twenty-five semi-structured interviews with 49 leaders from LAC health systems, community-based organizations; and payers. Results: Leaders perceived partnerships within and beyond health systems as transformative in their potential to: improve access, value, and efficiency; align priorities of safety-net systems and communities; and harness the power of communities to impact health. Leaders identified trust as critical to success in partnerships but named lack of time for relationship-building, limitations in service capacity, and questions about sustainability as barriers to trust-building. Leaders described the need for procedural innovations within health systems that would support equitable partnerships including innovations that would increase transparency and normalize information exchange, share agenda-setting and decision-making power with partners, and institutionalize partnering through training and accountability. Conclusions: Leaders described improving procedural justice in public agencies' relationships with communities as key to effective partnering for health equity.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity.

Objective: We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans. Setting: A community-academic partnership across Los Angeles County and New Orleans. Methods: Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN. Findings: Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings. Conclusion: The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

MAP as a model for practice-based learning and improvement in child psychiatry training.

Not only is there a growing literature demonstrating the positive outcomes that result from implementing evidence based treatments (EBTs) but also studies that suggest a lack of delivery of these EBTs in "usual care" practices. One way to address this deficit is to improve the quality of psychotherapy teaching for clinicians-in-training. The Accreditation Council for Graduate Medical Education (ACGME) requires all training programs to assess residents in a number of competencies including Practice-Based Learning and Improvements (PBLI). This article describes the piloting of Managing and Adapting Practice (MAP) for child psychiatry fellows, to teach them both EBT and PBLI skills. Eight child psychiatry trainees received 5 full days of MAP training and are delivering MAP in a year-long outpatient teaching clinic. In this setting, MAP is applied to the complex, multiply diagnosed psychiatric patients that present to this clinic. This article describes how MAP tools and resources assist in teaching trainees each of the eight required competency components of PBLI, including identifying deficits in expertise, setting learning goals, performing learning activities, conducting quality improvement methods in practice, incorporating formative feedback, using scientific studies to inform practice, using technology for learning, and participating in patient education. A case example illustrates the use of MAP in teaching PBLI. MAP provides a unique way to teach important quality improvement and practice-based learning skills to trainees while training them in important psychotherapy competence.

Reimagining Social and Emotional Supports in Schools for Immigrant Students: A Contextual and Structural Approach.

Immigrant students and families experience disproportionate exposure to trauma, immigration-related stress, structural inequities, and poor access to mental health and social services which can lead to mental health inequities. Immigrant students and their families also have many strengths that can buffer potential negative mental health outcomes. Schools, which address social and emotional development in addition to academic achievement, are critical institutions that can play a unique role in enhancing the strengths and responding to the needs of immigrant students and families. In this review, we adapt the Behavioral Model for Vulnerable Populations to acknowledge the contextual and macro-level factors (e.g., relevant policies, environmental influences, and structural factors) and the predisposing, enabling, and need factors that immigrant students and families experience and impact access to school mental health and social services. We discuss school-based interventions that show efficacy for improving mental health outcomes and focus on addressing acculturative stress among immigrant students. We also discuss models to address social determinants of health need among immigrant students and families within schools, including the community schools model applied to immigrant students and families. We conclude this review by providing recommendations and strategies for pediatricians and schools to transform school-based supports for immigrant students and families and promote equitable outcomes. Our recommendations include incorporating multi-level school supports for addressing mental health, social need, and acculturative stress among immigrant students, along with reinforcing the strengths of immigrant students, and promoting school collaborations with pediatricians, school-based health centers, and trusted community partners.

Understanding and Addressing the Needs of Students in Special Education Through a Trauma-Informed Resilience Curriculum.

This school program evaluation aims to highlight the mental health needs of students in special education with behavioral and emotional challenges and describe the implementation of a resilience curriculum with this population. We evaluated district mental health data from a convenience sample of 814 students in grades 5-12 special education to identify risk for mental health symptoms, violence exposure, and substance use. School social workers provided feedback on the implementation of the resilience curriculum to inform program evaluation. Students reported significant risk for traumatic stress, anxiety, and depressive symptoms, and high rates of violence exposure and substance use. School social workers described adaptations to the resilience curriculum and gave recommendations for future implementation. Students receiving special education services for behavioral and emotional challenges had high mental health need, including high rates of violence exposure, and may benefit from a trauma-informed school-based resilience curriculum adapted for their needs.

Building Better Bridges: Outcomes of a Community-Partnered New School Transition Intervention for Students on the Autism Spectrum.

New school transitions can be challenging for students on the autism spectrum. No published, evidence-based interventions exist to support families and teachers of students transitioning to elementary and secondary school during this critical period. Using Community Partnered Participatory Research, we developed Building Better Bridges (BBB), a caregiver coaching intervention that includes training on effective school communication, educational rights, advocacy, and child preparation strategies. We compared BBB (n = 83) to a module/resources-only comparison (n = 87) in a four-site randomized controlled trial in racially and ethnically diverse, under-resourced communities. In our intent-to-treat analysis, caregivers and teachers in BBB rated students' transitions to the new classroom as more positive, relative to the comparison group. Results suggest this low-cost intervention can improve the transition process for families and students at high risk of poor transitions.

"It's Taboo to Talk About It": Korean American Clergy Members' Views of Mental Health.

Korean Americans are more likely to seek guidance from church leaders than to use traditional mental health services. Through semistructured key informant interviews with 16 Christian clergy members serving later-generation Korean Americans, the authors explored clergy members' perceptions of the mental health needs of their congregants. Insights from the study suggested that communication and collaboration between mental health professionals and church leaders may be helpful in addressing the Korean American community's emotional and mental health needs.

Implementing depression care in under-resourced communities: a school-based family resilience skill-building pilot randomized controlled trial in the United States.

Introduction: Youth in under-resourced communities are more likely to have greater social risk factors for mental health needs yet have less access to needed care. School-based mental health services are effective in treating common disorders such as adolescent depression; however, few have a family-centered approach, which may especially benefit specific populations. Methods: Utilizing a community-partnered approach, we adapted an established, trauma-informed, resilience skill-building family intervention for adolescents with depression. We conducted a small randomized controlled feasibility pilot of an adapted intervention in a large school district that serves predominately low-income, Latinx students in the Southwest United States between 2014-2017. Youth between the ages of 12-18 years old with a Patient Health Questionnaire (PHQ-8) score of 10 or higher, who spoke English or Spanish, were recruited from 12 school mental health clinics. Twenty-five eligible adolescents with depression and their participating caregivers were enrolled and randomly assigned to receive either the adapted intervention, Families OverComing Under Stress for Families with Adolescent Depression (FOCUS-AD), or usual care, Cognitive Behavioral Therapy (CBT) only. Most of the sample was Latinx and female. We evaluated feasibility, acceptability, and preliminary effectiveness. Results: Among participants who completed standardized assessments administered at baseline and approximately five months post-randomization (n = 10 FOCUS-AD, n = 11 CBT only), effectiveness was explored by identifying significant changes over time in adolescent mental health within the FOCUS-AD and CBT only groups and comparing the magnitude of these changes between groups. Nonparametric statistical tests were used. We found the FOCUS-AD intervention to be feasible and acceptable; participant retention was high. Adolescent symptoms of depression (measured by the PHQ-8) improved significantly from baseline to follow-up for youth in both FOCUS-AD (median decrease [MD] = 10, p = 0.02) and control (MD = 6, p = 0.01) groups, with no significant difference across the two groups. Results were similar for symptoms of PTSD (measured by the Child PTSD Symptom Scale; FOCUS-AD MD = 12.5, p = 0.01; CBT only MD = 7, p = 0.04; no significant difference between groups). Conclusion: Family-centered approaches to depression treatment among adolescents living in under-resourced communities may lead to improved mental health, although further research is warranted.

Teaching the Legacy of Slavery in American Medicine and Psychiatry to Medical Students: Feasibility, Acceptability, Opportunities for Growth.

Introduction: Understanding the legacy of slavery in the United States is crucial for engaging in anti-racism that challenges racial health inequities' root causes. However, few medical educational curricula exist to guide this process. We created a workshop illustrating key historical themes pertaining to this legacy and grounded in critical race theory. Methods: During a preclinical psychiatry block, a second-year medical school class, divided into three groups of 50-60, attended the workshop, which comprised a 90-minute lecture, 30-minute break, and 60-minute small-group debriefing. Afterwards, participants completed an evaluation assessing self-reported knowledge, attitudes and beliefs, and satisfaction with the workshop. Results: One hundred eighty students watched the lecture, 15 attended small-group debriefings, and 132 completed the survey. Seventy-six percent (100) reported receiving no, very little, or some prior exposure to the legacy of slavery in American medicine and psychiatry. Over 80% agreed or strongly agreed that the workshop made them more aware of this legacy and that the artwork, photographs, storytelling, and media (videos) facilitated learning. Qualitative feedback highlighted how the workshop improved students' knowledge about the legacy of slavery's presence in medicine and psychiatry. However, students criticized the lecture's scripted approach and requested more discussion, dialogue, interaction, and connection of this history to anti-racist action they could engage in now. Discussion: Though this workshop improved awareness of the legacy of slavery, students criticized its structure and approach. When teaching this legacy, medical schools should consider expanding content, ensuring opportunities for discussion in safe spaces, and connecting it to immediate anti-racist action.

Youth violence across multiple dimensions: a study of violence, absenteeism, and suspensions among middle school children.

OBJECTIVE: To determine how multidimensional measures of violence correlate with school absenteeism and suspensions among middle school youth. STUDY DESIGN: A cross-sectional survey was conducted in 2004 with 28 882 sixth graders from an urban school district. Data were collected on role (witness, victim, perpetrator) and mode (verbal, physical, weapons) of past-year violence exposures, and absences and suspensions over 1 academic year. Associations between violence and absenteeism and suspension were estimated using generalized linear models. RESULTS: ORs for suspension increased from witnessing to victimization to perpetration and then victimization-perpetration. Among those exposed to weapons, victims (OR(boys) = 1.45; OR(girls) = 1.38) had similar or slightly higher ORs for absenteeism than perpetrators (OR(boys) = 1.39; OR(girls) = 1.17). Boy victims and witnesses of physical violence had similar absenteeism patterns as those unexposed to physical violence. Of all exposed girls, victim-perpetrators had the highest ORs for absenteeism (OR = 1.76). CONCLUSION: Exposure to violence correlated with absenteeism and suspension. The strength of these relationships depended on mode and role in exposure. Our cross-sectional data limits our ability to establish causality. Findings have implications for prevention.