Rates of Mental Health Service Utilization by Children and Adolescents in Schools and Other Common Service Settings: A Systematic Review and Meta-Analysis.

A meta-analysis was conducted to examine the relative rates of youth mental health service utilization across settings among the general population and among those with elevated mental health symptoms or clinical diagnoses. Rates of school-based mental health were compared to outpatient, primary care, child welfare, juvenile justice, and inpatient. Nine studies presented rates of mental health service use for general-population youth in the U.S., and 14 studies presented rates for youth with elevated symptoms or clinical diagnoses. Random effects meta-analysis was used to calculate mean proportions of youth receiving care in each sector. Of general population youth, 7.28% received school mental health services. Rates for other sectors are as follows: 7.26% in outpatient settings, 1.76% in primary care, 1.80% in inpatient, 1.35% in child welfare, and 0.90% juvenile justice. For youth with elevated mental health symptoms or diagnoses, 22.10% of youth were served by school-based mental health services, 20.56% outpatient settings, 9.93% primary care, 9.05% inpatient, 7.90% child welfare, and 4.50% juvenile justice. Schools and outpatient settings are the most common loci of mental health care for both the general population and samples of youth with elevated symptoms or clinical diagnoses, although substantial amounts of care are also provided in a range of other settings. Results hold potential for informing resource allocation, legislation and policy, intervention development, and research. Given that mental health services are delivered across many settings, findings also point to the need for interconnection across child-serving sectors, particularly schools and outpatient clinics.

Middle and High School Student Perspectives on Digitally-Delivered Mental Health Assessments and Measurement Feedback Systems.

Implementation of measurement-based care (MBC) by child-serving community mental health providers, particularly school-based providers, is low. To inform user-centered design of measurement feedback systems (MFSs) and MBC implementation more broadly, semi-structured interviews were conducted with 61 middle and high school students. Interviews explored student preferences for and perceived helpfulness of different assessment methods and use of MFS in counseling. Results indicate that student preference for digitally-administered assessment is equivocal, with preferences being influenced by student perceptions of the ease of use, impersonalization, and confidentiality. Students with exposure to the MFS found it helpful when used by their provider to share assessment feedback.

Twelve-Month Outcomes of a Randomized Trial of the Positive Thoughts and Action Program for Depression Among Early Adolescents.

This study was conducted to examine the 12-month effects on depression and depressive symptoms of a group-based cognitive-behavioral preventive intervention for middle school students (Positive Thoughts and Actions, or PTA), relative to a brief, individually administered supportive intervention (Individual Support Program, or ISP). A randomized clinical trial was conducted with 120 early adolescents (73 girls and 47 boys; age 12-14 years) drawn from a school-based population who had elevated depressive symptoms. Youths completed measures of depressive symptoms at baseline, post-intervention, and 6 and 12 months into the follow-up phase. Measures of internalizing problems, externalizing problems, school adjustment, interpersonal relationships, and health behavior were obtained from parents and/or youth. Multilevel models indicated that the effect of PTA on youth-reported depressive symptoms persisted until 12-month follow-up; d = 0.36 at post-intervention, d = 0.24 at 6-month follow-up, and d = 0.21 at 12-month follow-up. PTA youths also reported lower internalizing symptoms at post-intervention, d = 0.44, and at 12-month follow-up, d = 0.39. Time-limited effects were found for parent-reported internalizing symptoms and health behavior. Onset of new depressive episodes did not differ based on intervention group (21 % ISP; 17 % PTA). Results demonstrate support for the long-term efficacy of PTA, a cognitive-behavioral preventive intervention in which youths engage in personal goal-setting and practice social-emotional skills.

Exposure to Violence in the Community Predicts Friendships with Academically Disengaged Peers During Middle Adolescence.

Adolescents who have been exposed to violence in the community often experience subsequent difficulties with academic achievement. Because competence in the classroom is a salient developmental task during the adolescent years, outcomes in this critical context can then have broader implications for social and psychological functioning. In the current study, we tested a hypothesized progression in which the association between violence exposure and deficient achievement is presumed to potentiate friendships with academically disengaged peers. We followed 415 urban adolescents (53 % girls; average age of 14.6 years) for a one-year period, with two annual assessment of psychosocial functioning. Exposure to violence in the community and academic engagement were assessed with a self-report inventory; reciprocated friendships were assessed with a peer interview; and achievement was indexed based on a review of school records. Consistent with our hypotheses, neighborhood violence was associated with deficient classroom achievement. Poor achievement, in turn, mediated associations between community violence exposure and low academic engagement among friends. Our findings highlight pathways though which exposure to community violence potentially predicts later dysfunction.

A peer-nomination assessment of electronic forms of aggression and victimization.

The perpetration and receipt of electronic aggression have largely been assessed with self-report questionnaires. Using a sample of 573 adolescents, the current study compared the psychometric properties of a peer-nomination measure of electronic aggression and victimization to the more widely used self-report approach. Estimates of the reliability, stability, and concordance of peer- and self-report assessments were adequate, mirroring those from research on aggressive exchanges in school. Analyses of validity and utility revealed that peer-nominations, compared to self-reports, provide overlapping and distinct information on adolescents' social, emotional, and academic adjustment. Overall, these findings provide evidence that peer-nominations are a reliable, valid, and useful means for measuring electronic aggression and victimization. Future work will benefit from their incorporation into multi-method assessments.

Academic achievement, same- and cross-ethnic positive peer regard among Asian American and Latinx adolescents.

This article presents a short-term longitudinal study examining bidirectional associations between academic achievement and positive peer regard among Asian American and Latinx adolescents. Specifically, our investigation distinguished between positive peer regard within and across different ethnic groups in a diverse school setting. Three hundred and thirty-five middle school students (52.8% girls; 65% Asian American, 35% Latinx; assessment at the first time point Mage = 12.27 years, SD = 0.71) were followed across two consecutive school years. Participants completed a peer-nomination inventory assessing multiple dimensions of positive peer regard (i.e., reciprocal friendship, social acceptance, and respect), and grades were obtained from school records. Academic achievement was predictive of prospective positive peer regard received from same-ethnic peers only for Asian American adolescents. In contrast, academic achievement predicted prospective positive peer regard received from cross-ethnic peers only for Latinx adolescents. These results suggest that academic achievement was linked to social gains with peers from different ethnic backgrounds for Asian American and Latinx students. The findings underscore the importance of disentangling the sources of positive peer regard in multiethnic school environments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A randomized trial of the Positive Thoughts and Action program for depression among early adolescents.

This study was conducted to compare the outcomes of a group-based cognitive-behavioral preventive intervention (Positive Thoughts and Actions [PTA]) tailored to youth in middle school with a brief, individually administered supportive intervention (Individual Support Program [ISP]). A randomized, controlled trial was conducted with 120 early adolescents (72 girls, 48 boys; age = 11-15 years) who had elevated depressive symptoms and were selected from a school-based population. Measures of internalizing problems, externalizing problems, personal adjustment, school problems, and interpersonal relations were obtained from parents, youth, and/or teachers at preintervention (Time 1) and postintervention (Time 2, 5-7 months after preintervention). General linear model repeated measures analyses yielded a significant Group × Time interaction on youth-reported, but not parent-reported, depressive symptoms and internalizing symptoms. Youth in the PTA group showed greater decreases following intervention compared to youth who received ISP, yielding effect sizes (Cohen's d) of 0.36 for depressive symptoms, 95% CI [-.02, .73], and 0.44, 95% CI [.05, .82], for internalizing symptoms. PTA youth also showed improvements in their personal adjustment (sense of inadequacy, self-esteem), and parent-reported social skills, but no differences emerged between groups for externalizing symptoms, school problems, or interpersonal relationships. Cognitive-behavioral preventive interventions in which youth engage in personal goal-setting and practice social-emotional skills, such as PTA, may be beneficial for the reduction of depressive symptoms over and above general support and empathy.

Do academically-engaged adolescents experience social sanctions from the peer group?

Existing theoretical perspectives suggest that adolescents who are characterized by high achievement may experience social sanctions from peers. The central premise is that, in many North American settings, adolescent peer groups are characterized by negative attitudes toward the school environment. To test these hypotheses, we examined associations between indicators of low social power (unpopularity and victimization by peers) and academic competence for 415 adolescents (193 boys; 222 girls) attending an urban high school. This school served neighborhoods that were characterized by a moderate degree of economic distress and the students were predominately of Hispanic American descent. A short-term longitudinal design was used, with two waves of data collected over consecutive school years. The adolescents completed a peer nomination inventory assessing relational and overt victimization by peers, unpopularity, and social rejection. In addition, we obtained math and language arts grades from school records, and we assessed behavioral engagement in school with a self-report inventory. Structural equation models did not reveal a strong pattern of longitudinal change in social standing with peers or academic functioning. However, we found positive correlations between academic achievement and problematic peer relationships in both years of the project. We also found evidence that gender moderates these associations, with the effects reaching significance only for boys. Our results provide evidence that, in some settings, high achieving adolescents can be prone to negative treatment or marginalization by peers.

Longitudinal Effects of a Motivationally Focused Strategy to Increase the Yield of Training and Consultation on Teachers' Adoption and Fidelity of a Universal Program.

Group-based didactic training is a cornerstone implementation strategy used to support the adoption and delivery of evidence-based prevention programs (EBPP) by teachers in schools, but it is often insufficient to drive successful implementation. Beliefs and Attitudes for Successful Implementation in Schools for Teachers (BASIS-T) is a theory-based, motivational implementation strategy designed to increase the yield of EBPP training and consultation. The purpose of this study was to examine the longitudinal effects of BASIS-T on hypothesized mechanisms of behavior change (e.g., attitudes toward EBPP, self-efficacy, intentions to implement) and implementation and student outcomes associated with a well-established universal prevention program-the good behavior game (GBG). This pilot trial included 82 elementary school teachers from nine public elementary schools who were randomly assigned at the school-level to the BASIS-T (n = 43) or active comparison (n = 39) condition, with both conditions receiving training and consultation of the good behavior game by a third-party purveyor. Analyses included mixed-effects and multilevel growth modeling of adoption, mechanisms of behavior change, and student behavior outcomes. Meaningful effects were found favoring BASIS-T on immediate adoption of the GBG within the first month of school (74% vs. 40%) and self-efficacy (p < 0.05). These findings advance our understanding of the type of implementation strategies that complement pre-implementation training and post-training consultation in schools by identifying the importance of task self-efficacy as a mechanism of behavior change related to adoption for prevention programming. Supplementary Information: The online version contains supplementary material available at 10.1007/s12310-022-09536-z.

A Cluster Randomized Pilot Trial of the Equity-Explicit Establish-Maintain-Restore Program among High School Teachers and Students.

Student-teacher relationships are important to student outcomes and may be especially pivotal at the high school transition and for minoritized racial/ethnic groups. Although interventions exist to improve student-teacher relationships, none have been shown to be effective among high school students or in narrowing racial/ethnic disparities in student outcomes. This study was conducted to examine the effects of an equity-explicit student-teacher relationship intervention (Equity-Explicit Establish Maintain Restore, or E-EMR) for high school teachers and students. A cluster-randomized pilot trial was conducted with 94 ninth grade teachers and 417 ninth grade students in six high schools. Teachers in three schools were randomized to receive E-EMR training and follow-up supports for one year. Teachers in three control schools conducted business as usual. Student-teacher relationships, sense of school belonging, academic motivation, and academic engagement were collected via student self-report in September and January of their ninth-grade year. Longitudinal models revealed non-significant main effects of E-EMR. However, there were targeted benefits for students who started with low scores at baseline, for Asian, Latinx, multicultural, and (to a lesser extent) Black students. We also found some unexpected effects, where high-performing and/or advantaged groups in the E-EMR condition had less favorable outcomes at post, compared to those in the control group, which may be a result of the equity-explicit focus of E-EMR. Implications and directions for future research are discussed.

Expect the Unexpected: A Qualitative Study of the Ripple Effects of Children's Mental Health Services Implementation Efforts.

Background: Strategies to implement evidence-based interventions (EBIs) in children's mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects are outcomes caused by EBI implementation efforts that are unplanned, unanticipated, and/or more salient to stakeholders other than researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children's mental health services, to be used for implementation planning, research, and quality improvement. Methods: Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants, each representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregivers, and youth. A partially directed conventional content analysis with consensus decision making was used to code ripple effects. Results: Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Categories include general knowledge, skills, attitudes, and confidence about using EBIs; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one's own life. Conclusions: This research advances the field by providing children's mental health implementers, researchers, funders, policy makers, and consumers with a menu of potential ripple effects. It can be a practical tool to ensure compliance with guidance from Quality Improvement/Quality Assurance, Complexity Science, and Diffusion of Innovation Theory. Future phases will match potential ripple effects with salient children's mental health implementation strategies for each participant role.

User testing to drive the iterative development of a strategy to improve implementation of evidence-based practices in school mental health.

Research has produced a steady stream of evidence-based practices (EBP) that can promote youth behavioral health, but widespread implementation is often poor. To narrow the "science to practice gap," an implementation strategy was developed to enhance school-based mental health providers' intentions to implement EBP. The current study adopted a user-testing approach to inform the iterative development of this implementation strategy, which consisted of strategic education, social influence techniques, and motivational interviewing. Segments of the implementation strategy were demonstrated live for a representative sample of the intended audience. Participants rated each segment on acceptability, appropriateness, and likely impact on intentions to use EBP. Ratings were tallied in real time and presented to participants to spur discussion. Qualitative input was coded via conventional content analyses. Results indicated that that implementation strategies may need to be tailored to the specific EBP. In addition, implementation goal setting was well-received by some participants but not others, suggesting a difficulty of conducting motivational interviewing in group settings. Participants also perceived themselves as familiar with EBP and strong advocates of school mental health services. The paper concludes with a discussion of how this research has influenced the ongoing development of the strategy and implications for EBP implementation efforts.

A Mixed Methods Pilot Study of an Equity-Explicit Student-Teacher Relationship Intervention for the Ninth-Grade Transition.

BACKGROUND: Student-teacher relationships are associated with the social and emotional climate of a school, a key domain of the Whole School, Whole Community, Whole Child Model. Few interventions target student-teacher relationships during the critical transition to high school, or incorporate strategies for enhancing equitable relationships. We conducted a mixed-methods feasibility study of a student-teacher relationship intervention, called Equity-Explicit Establish-Maintain-Restore (E-EMR). METHODS: We tested whether students (N = 133) whose teachers received E-EMR training demonstrated improved relationship quality, school belonging, motivation, behavior, and academic outcomes from pre- to post-test, and whether these differences were moderated by race. We also examined how teachers (N = 16) integrated a focus on equity into their implementation of the intervention. RESULTS: Relative to white students, students of the color showed greater improvement on belongingness, behavior, motivation, and GPA. Teachers described how they incorporated a focus on race/ethnicity, culture, and bias into E-EMR practices, and situated their relationships with students within the contexts of their own identity, the classroom/school context, and broader systems of power and privilege. CONCLUSIONS: We provide preliminary evidence for E-EMR to change teacher practice and reduce educational disparities for students of color. We discuss implications for other school-based interventions to integrate an equity-explicit focus into program content and evaluation.

Brief teacher training improves student behavior and student-teacher relationships in middle school.

Despite research demonstrating the importance of student-teacher relationships for student functioning, little is known about strategies to enhance such relationships, particularly in secondary school. The current study examined effects of a professional development for middle school teachers on the Establish-Maintain-Restore (EMR) approach. EMR aims to enhance teachers' skills in cultivating relationships with students and involves brief training (3 hr) and ongoing implementation supports. In a randomized controlled trial, 20 teachers and 190 students were assigned to EMR or control. Observers rated academically engaged time and disruptive behavior, and teachers reported on relationship quality. Multilevel models showed that EMR resulted in significant improvements in student-teacher relationships (Hedge's g = .61, 95% CI [0.21, 1.02]), academically engaged time (g = .81, 95% CI [0.01, 1.63]), and disruptive behavior (g = 1.07, 95% CI [0.01, 2.16]). Results indicate potential promise for EMR. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The influence of a blended, theoretically-informed pre-implementation strategy on school-based clinician implementation of an evidence-based trauma intervention.

BACKGROUND: Individual-level implementation determinants, such as clinician attitudes, commonly influence the successful adoption of evidence-based practices, but few explicit strategies have been tested with regard to their ability to impact these key mechanisms of change. This paper reports on an initial test of a blended, theoretically informed pre-implementation strategy designed to target malleable individual-level determinants of behavior change. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a brief and pragmatic pre-implementation strategy that uses strategic education, social influence techniques, and group-based motivational interviewing to target implementation attitudes, perceived social norms, perceived behavioral control, and behavioral intentions to implement among mental health clinicians working in the education sector. METHODS: As part of a pilot trial, 25 school mental health clinicians were randomized to BASIS (n = 12) or an attention control placebo (n = 13), with both conditions receiving training and consultation in an evidence-based intervention for youth experiencing trauma (the Cognitive Behavioral Intervention for Trauma in Schools). Theorized mechanisms of change (attitudes, perceived social norms, perceived behavioral control, and behavioral intentions) were assessed at baseline, post-training, and 4-month follow-up. Clinician participation in post-training consultation and intervention adoption were also tracked. RESULTS: A series of regression models and independent sample t tests indicated that BASIS had significant, medium to large effects on the majority of its proximal mechanisms from baseline to post-training. BASIS was also associated with a greater latency between initial training in the intervention and discontinuation of participation in post-training consultation, with clinicians in the BASIS condition persisting in consultation for an average of 134 days versus 32 days for controls, but this difference was not statistically significant. At 4-month follow-up, most differences in the theorized mechanisms had attenuated, and approximately the same small number of BASIS clinicians adopted the trauma intervention as controls. CONCLUSION: Findings suggest that the brief BASIS pre-implementation strategy had a significant influence on its proximal mechanisms of change, but that these changes did not persist over time or translate into adoption of the trauma intervention. Implications for theory refinement, revisions to the BASIS protocol, and next steps for research surrounding individual-level implementation strategies are discussed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03791281 . Registered 31 December 2018-Retrospectively registered.

Peer relationships and academic achievement as interacting predictors of depressive symptoms during middle childhood.

This article reports a longitudinal investigation that examines academic and social difficulties as predictors of depressive symptoms during middle childhood. Participants were 199 elementary school children (M=9.1 years) who were followed for 2 consecutive school years. In both years of the project, children completed a questionnaire assessing depressive symptoms and a peer nomination inventory assessing friendships and social standing. Grade point averages (GPAs) were obtained from a review of school records. Low GPAs were predictive of depressive symptoms, but this effect did not hold for children who had numerous friends. Similarly, children who had relatively few friends tended to experience depressive symptoms. However, the effect was attenuated for children with high GPAs. Taken together, the findings suggest that competencies in 1 domain can moderate the risks associated with difficulties in the other domain.

Student Perceptions of the Acceptability and Utility of Standardized and Idiographic Assessment in School Mental Health.

Evidence-based assessment (EBA) comprises the use of research and theory to select methods and processes that have demonstrated reliability, validity, and clinical usefulness for prescribed populations. EBA can lead to positive clinical change, and recent work has suggested that it is perceived to be useful by school mental health providers. However, virtually nothing is known about student perceptions of assessment use. Semi-structured interviews were conducted with 31 ethnically diverse middle and high school students (71% female) receiving mental health services in school-based health centers. Findings indicated that the majority of students found assessments to be useful, and perceived three primary functions of assessments: structuring the therapy session, increasing students' self-awareness, and improving communication with the provider. Barriers to acceptability were also found for a minority of respondents. Some students found the nature of standardized assessments to be confining, and others expressed that they wanted more feedback from their counselors about their responses. Idiographic assessments demonstrated especially high acceptability in this sample, with students reporting that tracking idiographic outcomes increased self-awareness, spurred problem-solving, and helped them to reach behavioral goals. Implications for school mental health service improvements are discussed.

Mediators and Moderators of a School-Based Cognitive-Behavioral Depression Prevention Program.

This study tested potential moderators and mediators of an indicated depression prevention program for middle school students, Positive Thoughts and Actions (PTA). Participants were 120 students randomly assigned to PTA, or a brief, individually administered supportive intervention (Individual Support Program, or ISP). Youths completed measures of depressive symptoms at baseline, post-intervention, and 12-month follow-up. Hierarchical regression was used to test three moderators-ethnic minority status, gender, and baseline depressive symptoms-and three mediators representing functional outcomes targeted by PTA-parent-child communication, attitude towards school, and health behavior. Ethnic minority status did not moderate PTA effects at post-intervention but did moderate PTA effects at 12-month follow-up. At 12 months, PTA appeared to be more effective for White participants than ethnic minority youth. Follow-up analyses suggested this moderation effect was due to the tendency of ethnic minority youth, especially those with fewer symptoms at baseline, to drop out by 12 months. Neither gender nor baseline depressive symptoms moderated the effects of PTA. Although PTA improved health behavior and attitudes toward school, there was no evidence that any of these functional outcomes measured mediated the impact of PTA on depressive symptoms. Future directions are discussed.

Fostering SMART partnerships to develop an effective continuum of behavioral health services and supports in schools.

The education sector offers compelling opportunities to address the shortcomings of traditional mental health delivery systems and to prevent and treat youth mental, emotional, and behavioral (MEB) problems. Recognizing that social and emotional wellness is intrinsically related to academic success, schools are moving to adopt multi-tier frameworks based on the public health model that provide a continuum of services to all children, including services to address both academic and MEB problems. In this article, we review the potential value of multi-tier frameworks in facilitating access to, and increasing the effectiveness of, mental health services in schools, and review the empirical support for school-based mental health interventions by tier. We go on to describe a community-academic partnership between the Seattle Public Schools and the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center that exemplifies how multi-tier educational frameworks, research and evidence, and purposeful collaboration can combine to improve development and implementation of a range of school-based strategies focused on MEB needs of students. Finally, we present a set of 10 recommendations that may help guide other research and practice improvement efforts to address MEB problems in youth through effective school mental health programming. (PsycINFO Database Record

Brain stem evoked response to forward and reversed speech in humans.

Speech stimuli played in reverse are perceived as unfamiliar and alien-sounding, even though phoneme duration and fundamental voicing frequency are preserved. Although language perception ultimately resides in the neocortex, the brain stem plays a vital role in processing auditory information, including speech. The present study measured brain stem frequency-following responses (FFR) evoked by forward and reverse speech stimuli recorded from electrodes oriented horizontally and vertically to measure signals with putative origins in auditory nerve and rostral brain stem, respectively. The vertical FFR showed increased amplitude due to forward speech. It is concluded that familiar phonological and prosodic properties of forward speech selectively activate central brain stem neurons.