Trauma-informed care in school-based health centers: A mixed methods study of behavioral health screening and services.

An explanatory, parallel mixed method design was used to examine trauma screening and behavioral health service rates in urban school-based health centers (SBHCs) and SBHC personnel's experiences providing culturally responsive, trauma-informed care. Logistic regressions were performed with electronic medical records from N = 4,794 patients ages 12-22 receiving care in a SBHC using trauma screening rates and service use as dependent variables. Quantitative analyses were supplemented with semistructured interviews with medical providers and behavioral health clinicians (N = 9) from eight SBHCs. The overall trauma screening rate across the SBHCs was 69.2%. Screening rates were higher for older and Spanish-speaking youth. The rate of behavioral health use was 32.9%, with higher rates among students screened for trauma at a prior medical visit, recent immigrant, and female youth. This suggests that trauma screening is feasible and facilitates access. Additionally, English-speaking youth were more likely to use behavioral health services than Spanish-speakers. Qualitative analyses suggested a strong sense of mission, collaboration, and beliefs that trauma screening facilitated access to care all facilitated trauma-focused screening. Barriers included staffing shortages and language translation challenges. Analysis also highlighted the importance of culturally responsive practices (e.g., interpreters, culture-specific assessment tools, knowledge of population needs). Mixed methods integrative analysis highlighted the ways in which barriers and facilitators aligned with the overall rates of access to screening and behavioral health care, and factors that helped the SBHCs tailor care to diverse youth. Limitations and implications for practice are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Impact of the COVID-19 Pandemic on Adolescents: An Opportunity to Build Resilient Systems.

The impact of the COVID-19 pandemic on adolescents is significant. Educational progress and mental health, in particular, have been negatively affected. Among youth from vulnerable communities, pre-existing academic and health disparities have been exacerbated. Youth outcomes are often attributed to individual resilience - or lack thereof; in this paper, we describe how failure to adapt and effectively cope at the system level (ie, lack of system resilience) is implicated in the current dual educational and mental crisis. We describe opportunities to make our systems more nimble and better-equipped to support youth moving forward.

Supporting teachers during the COVID-19 pandemic: A community-partnered rapid needs assessment.

Using a community-partnered research framework, the goal of this study was to rapidly assess coronavirus disease (COVID-19) impact on teachers, students, and families and guidance received to navigate distance learning. Participants were teachers (N = 430) working in elementary schools (n = 301), middle schools (n = 56), high schools (n = 60), and other schools (n = 13) in two large urban school districts heavily impacted by COVID-19. Results indicated teacher concerns regarding student instructional loss and exposure to direct and indirect COVID-related trauma. There were mean differences in teacher concern by school level (p = .001, η² = .033) with elementary teachers reporting the greatest concerns regarding instructional loss. Over 40% of teachers reported that more than 20% of their students had a family member infected with COVID-19 or employed as a frontline healthcare worker. Approximately 99% of teachers reported a significant gap in student access to the internet and distance learning devices. Teachers reported receiving more school than district guidance regarding distance learning, student engagement, and using social emotional learning (SEL) programs. Results informed professional development priorities for educators and immediate supports needed for students and families. Study limitations and future directions for research and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Psychological, Academic, and Economic Impact of COVID-19 on College Students in the Epicenter of the Pandemic.

Initial research has indicated that college students have experienced numerous stressors as a result of the pandemic. The current investigation enrolled the largest and most diverse sample of college students to date (N = 4714) from universities in New York (NY) and New Jersey (NJ), the epicenter of the North American pandemic in Spring 2020. We described the impact on the psychological, academic, and financial health of college students who were initially most affected and examined racial/ethnic group differences. Results indicated that students' mental health was severely affected and that students of color were disproportionately affected by academic, financial, and COVID-related stressors. Worry about COVID-19 infection, stressful living conditions, lower grades, and loneliness emerged as correlates of deteriorating mental health. COVID-19's mental health impact on college students is alarming and highlights the need for public health interventions at the university level.

Trauma in Schools: An Examination of Trauma Screening and Linkage to Behavioral Health Care in School-Based Health Centers.

BACKGROUND: This study examined trauma screening and behavioral health linkage rates in school-based health centers (SBHCs). METHODS: Participants included 4161 English- and Spanish-speaking patients between the ages of 12 and 22 across 8 urban SBHCs 2 years. Screening rates at medical visits and linkage to additional behavioral health screening and services were assessed via electronic medical records and a chart audit. RESULTS: Medical providers administered the Primary Care-PTSD screen to 66.3% of patients in year 1 and 46.7% of patients in year 2. Rates of positive trauma screens were 27.5% and 32.1%, respectively, with more girls screening positive than boys. Few (year 1; 8.1%; year 2: 9.6%) adolescents received additional trauma screening by a behavioral health clinician. However, the majority were linked to services (year 1: 66%; year 2: 74%). Lack of documentation (year 1: 24%; year 2: 33%) was a common gap in the charts of patients who did not receive a second stage trauma screening. Demographic differences in screening rates were minimal. CONCLUSION: The current study supports the feasibility of traumatic stress screening and linkage within an integrated care setting. Process improvement efforts should, however, address communication gaps around trauma assessment and its integration into ongoing care.

A Mixed Methods Study of the Stages of Implementation for an Evidence-Based Trauma Intervention in Schools.

A mixed methods study was conducted to examine the implementation process of 26 urban school-based mental health clinics that took part in a training and implementation support program for an evidence-based school trauma intervention. Implementation process was observed using the Stages of Implementation Completion (SIC) measure. Qualitative interviews were conducted with clinic leaders in order to gain insight into clinic processes related to the SIC. Results showed that almost all of the clinics engaged in some activities related to pre-implementation (engagement, feasibility, and readiness), but only 31% of the sites formally started delivering the program to youth. Completing more pre-implementation activities, particularly those related to readiness, predicted program start-up. Qualitative analysis comparing those that implemented the program to those that did not revealed critical differences in decision-making processes, leadership strategies, and the presence of local champions for the program. This study documented the patterns of clinic behavior that occurs as part of large-scale training efforts, suggests some unique challenges that occur in schools, and highlights the importance of engaging in particular implementation activities (i.e., readiness planning, stakeholder consensus and planning meetings) as part of program start-up. Findings indicate that pre-implementation and readiness-related consultation should be employed as part of broad-scale implementation and training efforts.

Statewide implementation of an evidence-based trauma intervention in schools.

The goal of the current article is to describe the implementation and outcomes of an innovative statewide dissemination approach of the evidence-based trauma intervention Cognitive Behavioral Intervention for Trauma in Schools (CBITS). In the context of a 2-year statewide learning collaborative effort, 73 CBITS groups led by 20 clinicians from 5 different school-based mental health provider organizations served a total of 350 racially and ethnically diverse (66.9% Hispanic, 26.2% Black/African American, 43.7% White, and 30.1% Other), majority female (61%) children, averaging 12.2 years (SD = 2.4, range 8-19). Of the 350 children who began CBITS, 316 (90.3%) successfully completed treatment. Children demonstrated significant reductions in child posttraumatic stress disorder (PTSD) symptoms (42% reduction, d = .879) and problem severity (25% reduction, d = .396), and increases in child functioning, t(287) = -3.75, p < .001 (5% increase, d = .223). Findings point to the need, feasibility, and positive impact of implementing and scaling up school-based interventions for students suffering from posttraumatic stress. (PsycINFO Database Record

Long-Term Effects of Pre-Placement Risk Factors on Children's Psychological Symptoms and Parenting Stress Among Families Adopting Children From Foster Care.

This exploratory longitudinal study examined behavioral outcomes and parenting stress among families with children adopted from foster care, taking into account environmental and biological risk factors. Child internalizing and externalizing problems and parenting stress were assessed in 82 adopted children and their families at 2 months post-placement, 12 months post-placement, and then yearly until 5 years post-placement. A history of abuse/neglect predicted significantly higher externalizing and internalizing problems at a borderline level of statistical significance. In the initial stages after placement, externalizing problems were significantly higher among children who were 4 years or older at placement versus those who were younger than 4, although differences were no longer significant 5 years post-placement. Statistical trends in parenting stress reflected reduced stress in the first 12 months followed by a plateau for parents who adopted older children and greater stress for parents who adopted younger children. Familiar limitations for observational cohort data apply. Nonetheless, the availability of longitudinal follow-up on a sizable sample of children adopted from foster care adds insight to the psychological dynamics for adoptive families and suggests that families of children adopted from the foster care system may have unique needs for ongoing support around behavioral issues.

Using a Theory-Guided Learning Collaborative Model to Improve Implementation of EBPs in a State Children's Mental Health System: A Pilot Study.

Learning collaboratives (LCs) are used widely to promote implementation of evidence-based practices. However, there has been limited research on the effectiveness of LCs and models vary widely in their structure, focus and components. The goal of the present study was to develop and field test a theory-based LC model to augment a state-led, evidence-based training program for clinicians providing mental health services to children. Analysis of implementation outcomes contrasted LC sites to matched comparison sites that participated in the clinical training program alone. Results suggested that clinicians from sites participating in the LC were more highly engaged in the state-led clinical training program and were more likely to complete program requirements.

Development and Piloting of a Classroom-Focused Measurement Feedback System.

The present study used a community partnered research method to develop and pilot a classroom-focused measurement feedback system (MFS) for school mental health providers to support teachers' use of effective universal and target classroom practices related to student emotional and behavioral issues. School personnel from seven urban elementary and middle school classrooms participated. Phase I involved development and refinement of the system through a baseline needs assessment and rapid-cycle feedback. Phase II involved detailed case study analysis of pre-to-post quantitative and implementation process data. Results suggest that teachers who used the dashboard along with consultation showed improvement in observed classroom organization and emotional support. Results also suggest that MFS use was tied closely to consultation dose, and that broader support at the school level was critical. Classroom-focused MFSs are a promising tool to support classroom improvement, and warrant future research focused on their effectiveness and broad applicability.

Implementing a Measurement Feedback System in Community Mental Health Clinics: A Case Study of Multilevel Barriers and Facilitators.

Measurement feedback systems (MFSs) have been proposed as a means of improving practice. The present study examined the implementation of a MFS, the Contextualized Feedback System (CFS), in two community-based clinic sites. Significant implementation differences across sites provided a basis for examining factors that influenced clinician uptake of CFS. Following the theoretical implementation framework of Aarons et al. (Adm Policy Mental Health Mental Health Serv Res 38(1):4-23, 2011), we coded qualitative data collected from eighteen clinicians (13 from Clinic U and 5 from Clinic R) who participated in semi-structured interviews about their experience with CFS implementation. Results suggest that clinicians at both clinics perceived more barriers than facilitators to CFS implementation. Interestingly, clinicians at the higher implementing clinic reported a higher proportion of barriers to facilitators (3:1 vs. 2:1); however, these clinicians also reported a significantly higher level of organizational and leadership supports for CFS implementation. Implications of these findings are discussed.

School Personnel Experiences in Notifying Parents About Their Child's Risk for Suicide: Lessons Learned.

BACKGROUND: Schools across the nation are increasingly implementing suicide prevention programs that involve training school staff and connecting students and their families to appropriate services. However, little is known about how parents are engaged in such efforts. METHODS: This qualitative study examined school staff perspectives on parent involvement in the implementation of a district-wide suicide prevention program by analyzing focus group and interview data gathered on the program implementation processes. Participants included middle school teachers, administrators, and other school personnel. RESULTS: Study results revealed that in the immediate wake of a crisis or concern about suicide, school staff routinely contacted parents. However, substantial barriers prevent some students from receiving needed follow-up care (eg, lack of consistent follow-up, financial strain, parental stress, availability of appropriate services). Despite these challenges, school staff identified strategies that could better support parents before, during, and after the crisis. In particular, school-based services increased the success of mental health referrals. CONCLUSIONS: Our study suggests that systematic postcrisis follow-up procedures are needed to improve the likelihood that students and families receive ongoing support. In particular, school-based services and home visits, training and outreach for parents, and formal training for school mental health staff on parent engagement may be beneficial in this context.

What Predicts Clinician Dropout from State-Sponsored Managing and Adapting Practice Training.

Dropouts from system-wide evidence-based practice trainings are high; yet there are few studies on what predicts dropouts. This study examined multilevel predictors of clinician dropout from a statewide training on the Managing and Adapting Practice program. Extra-organizational structural variables, intra-organizational variables and clinician variables were examined. Using multivariable logistic regression analysis, state administrative data and prospectively collected clinician participation data were used to predict dropout. Two characteristics were predictive: younger clinicians and those practicing in upstate-rural areas compared to downstate-urban areas were less likely to drop out from training. Implications for research and policy are described.

De-adoption of an evidence-based trauma intervention in schools: A retrospective report from an urban school district.

The de-adoption of evidence-based practices (EBPs) is a largely understudied topic. The present study examined factors related to the de-adoption of an EBP for students exposed to traumatic events in a large urban school district. Qualitative interviews conducted with school clinicians and district administrators two years after the district embarked on a large-scale roll-out of the EBP distinguished between factors that impacted partial de-adoption after one year (phase 1) and complete de-adoption by the district after two years (phase 2). Phase 1 factors included organizational consistency, workforce stability, prior success, positive student outcomes, school- and district- level supports, innovation-setting fit, and innovation-related issues. Phase 2 factors included district-level leadership changes, financial and workforce instability, and shifting priorities. Study results suggest that sustainment-enhancing strategies should be included in the early stages of program implementation to most effectively adapt to school- and system- level changes.

Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.

OBJECTIVE: To determine the relationships between adverse childhood experiences (ACEs) and mental health, chronic medical conditions, and social development among young children in the child welfare system. METHODS: This cross-sectional study used a nationally representative sample of children investigated by child welfare (National Survey of Child and Adolescent Well-Being II) from 2008 to 2009. Our analysis included caregiver interviews and caseworker reports about children aged 18 to 71 months who were not in out-of-home care (n = 912). We examined the associations between ACEs and mental health (measured by the Child Behavior Checklist [CBCL]), reported chronic medical conditions, and social development (measured by the Vineland Socialization Scale) in bivariate and multivariate analyses. RESULTS: Nearly all children (98.1%) were reported to have had an ACE in their lifetime; the average number of ACEs was 3.6. For every additional reported ACE, there was a 32% increased odds of having a problem score on the CBCL (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.14, 1.53) and a 21% increased odds of having a chronic medical condition (OR 1.21, 95% CI 1.05, 1.40). Among children aged 36 to 71 months, for every additional reported ACE, there was a 77% increased odds of a low Vineland Socialization score (OR 1.77, 95% CI 1.12, 2.78). CONCLUSIONS: ACEs were associated with poor early childhood mental health and chronic medical conditions, and, among children aged 3 to 5, social development. Efforts are needed to examine whether providing early intervention to families with multiple stressors mitigates the impact of ACEs on children's outcomes.

A literature review of learning collaboratives in mental health care: used but untested.

OBJECTIVE: Policy makers have increasingly turned to learning collaboratives (LCs) as a strategy for improving usual care through the dissemination of evidence-based practices. The purpose of this review was to characterize the state of the evidence for use of LCs in mental health care. METHODS: A systematic search of major academic databases for peer-reviewed articles on LCs in mental health care generated 421 unique articles across a range of disciplines; 28 mental health articles were selected for full-text review, and 20 articles representing 16 distinct studies met criteria for final inclusion. Articles were coded to identify the LC components reported, the focus of the research, and key findings. RESULTS: Most of the articles included assessments of provider- or patient-level variables at baseline and post-LC. Only one study included a comparison condition. LC targets ranged widely, from use of a depression screening tool to implementation of evidence-based treatments. Fourteen crosscutting LC components (for example, in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in quality improvement methods) were identified. The LCs reviewed reported including, on average, seven components, most commonly in-person learning sessions, plan-do-study-act cycles, multidisciplinary quality improvement teams, and data collection for quality improvement. CONCLUSIONS: LCs are being used widely in mental health care, although there is minimal evidence of their effectiveness and unclear reporting in regard to specific components. Rigorous observational and controlled research studies on the impact of LCs on targeted provider- and patient-level outcomes are greatly needed.

Scaling up evidence-based practices for children and families in New York State: toward evidence-based policies on implementation for state mental health systems.

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the children's mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

Implementation Science in School Mental Health: Key Constructs in a Developing Research Agenda.

In this paper, we propose an implementation science research agenda as it applies to school mental health (SMH). First, we provide an overview of important contextual issues to be considered when addressing research questions pertinent to the implementation of mental health interventions in schools. Next, we critically review three core implementation components: (a) professional development and coaching for school professionals regarding evidence-based practices (EBPs); (b) the integrity of EBPs implemented in schools; and (c) EBP sustainment under typical school conditions. We articulate research questions central to the next generation of research in each of these areas as well as methods to address such questions. Our intent in doing so is to contribute to a developing blueprint to guide community-research partnerships as well as funding agencies in their efforts to advance implementation science in SMH.

Academic achievement among immigrant and U.S.-born Latino adolescents: Associations with cultural, family, and acculturation factors.

This study examined proximal risk and protective factors that contribute to academic achievement among 130 Latino students. Participating students were 56.2% female and 35.3% foreign-born (mean age = 11.38, SD = .59). Acculturative stress, immigrant status, child gender, parental monitoring, traditional cultural values, mainstream values, and English language proficiency were explored in relation to academic achievement. Higher levels of parental monitoring, English language proficiency, and female gender were associated with higher grades, while mainstream values were associated with lower grades. In addition, a significant interaction between acculturative stress and immigrant status was found, such that higher acculturative stress was related to poorer grades for U.S.-born students in particular. Thus, parental monitoring and female gender are potential protective factors, while identification with mainstream values and low English language proficiency are risk factors for poor grades. U.S.-born students may be particularly vulnerable to the effects of acculturative stress.

Understanding the components of quality improvement collaboratives: a systematic literature review.

CONTEXT: In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level. METHODS: A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative. FINDINGS: We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust. CONCLUSIONS: Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.