1. Marc
S.
Atkins,
Ph.D.
University
of
Illinois
at
Chicago
Institute
for
Juvenile
Research

2. Presenta(on
Goals
 Review
concerns
with
current
system
of
children’s
mental
health
care
in
U.S.
 Ecological
principles
and
public
health
framework
as
justification
for
focus
on
schooling
 Present
experimental
intervention
model
and
preliminary
results
 Future
directions

3. Dulal
Bhaumik,
Ph.D.
Runa
Bhaumik,
Ph.D.
University
of
Illinois
Chicago
Center
for
Health
Sta(s(cs
Marc Atkins,
Ph.D.
Robert
Gibbons
Tara
Mehta,
Ph.D.
University
of
Chicago
Elisa
Shernoff,
Ph.D.
Ane
Marinez-­‐Lora,
Ph.D.
Department
of
Health
Studies
David
Henry,
Ph.D..
Amy
Starin,
Ph.D.
University
of
Illinois
Chicago
University
of
Illinois
Chicago
Ins(tute
for
Health
Research
and
Ins(tute
for
Juvenile
Research
Policy
Charles
Glisson,
Ph.D.
Anthony
Hemmelgarn,
Ph.D.
D.Bridget
Hamre,
Ph.D.
University
of
Tennessee,
Knoxville
University
of
Virginia
Children’s
Mental
Health
Services
Research
Center
Center
for
Advanced
Study
in
Teaching
and
Learning
Sonja
Schoenwald,
Ph.D.
Ashli
Sheidow,
Ph.D.
Elise
Cappella,
Ph.D.
Stacy
Frazier,
Ph.D.
Jason
Chapman,
Ph.D.
New
York
University
Florida
Interna(onal
University
Medical
University
of
South
Carolina
Steinhardt
School
of
Educa(on
Center
for
Children
and
Families
Family
Services
Research
Center
and
Culture
Developing
Center
for
Innova(on
in
Services
and
Interven(on
Research
(NIMH
P20
MH078458)

4. Drilling
Deeper
 Social
Rela(ons
 Teachers
 Students
 Organiza(onal
Theory
 Culture
 Climate
 Mental
Health
Prac(ce
 Teachers
 Parents

5. Na(onal
Focus
on
Children s
Mental
Health
 First
ever
Surgeon
General
report
on
mental
health
(2001)
 Established
mental
health
needs
of
children
as
national
priority
 Current
system
inadequate
to
meet
needs
 President s
New
Freedom
Commission
on
Mental
Health
(2003)
 Mental
health
services
fragmented,
disconnected,
and
inadequate.

6. 7.5
Million
U.S.
Children
with
Unmet
Mental
Health
Need
Kataoka
et
al.
Am.
J.
Psychiatry
2002;
159:1548-­‐1555
6

7. Service
Use
by
Sector
Great
Smokey
Mountain
Study
90
80
70
60
Child
Welfare
50
Health
40
Mental
Health
30
Education
20
10
0
None
Mild
SED
Mental
Health
Need

8. Institute of Medicine
Prevention Children’s Mental Health Disorders
2009

9. Ins(tute
of
Medicine
One factor lurks in the background of
every discussion of the risks for
mental, emotional, and behavioral
disorders and antisocial behavior:
poverty ... Although not the focus of
this report, there is evidence that
changes in social policy that reduce
exposure to these risks are at least
as important for preventing mental,
emotional and behavioral disorders
in young people as other
preventive interventions. We are
persuaded that the future mental
health of the nation depends
crucially on how, collectively, the
costly legacy of poverty is dealt
with.

10. Na(onal
Spotlight
on
Schools
 No
Child
Left
Behind
 No
Child
Left
Untested
 School
violence
 Not
just
in
urban
communities
anymore
 Global
marketplace
 China
and
India
rising
 Another
Sputnik
moment?
• U.S
Ranking
of
30
Countries
 25th
in
Math
 21st
in
Science

13. Teacher
Stress
Low
morale,
depressed,
feeling
unfairly
blamed
for
the
ills
of
society?
You
must
be
a
teacher.
-­‐
NY
Times
Educa(onal
Supplement
(1997)
 50%
of
teachers
in
high
poverty
schools
leave
within
3-­‐5
years
(20%
of
all
teachers)
Shernoff
et
al.,.
School
Mental
Health
2011;
3:59-­‐69

14. What
Do
We
Know
About
Urban
Schools?
•
Overcrowding
and
large
class
sizes
•
Deteriora(ng
condi(ons
•
Significant
unmet
mental
health
needs
(Boyd
&
Shouse,
1997;
Cappella
et
al.,
2008
)

15. What
Do
We
Know
About
Teacher
A7ri9on?
•
Teacher
shortages
due
to
migra(on
and
afri(on
•
Up
to
20%
of
public
school
teachers
leave
within
their
first
5
years
•
New
teachers
ogen
placed
in
hardest-­‐to-­‐staff
schools
•
Behavior
management
most
common
reason
(Barnes,
Crowe
&
Schaefer,
2007;
Guarino
et
al.,
2006;
Smith
&
Ingersoll,
2004)

16. School Goals Are Mental
Health Goals
 Predictive of delinquency:
 Academic failure
 Low school bonding
 Truancy
 Low grades and aggression
in first grade highly predictive of not graduating
high school (ES = .78
 Academic achievement protective for urban
children
Ensminger & Slusarcick. Sociology of Education 1992, 65:95-113.
Spencer et al., Educational Psychologist 2001; 36:1, 21-30

17. Ecological Principles:
Services Support Settings
 Consider primary mission of setting (e.g.,
different goals for schools vs. after school)
 Consider these goals as mental health goals
(don t ask setting to change goals)
 Consider how mental health resources can be
reallocated to support setting goals
 Always think sustainability (no shortcuts)
Atkins & Frazier. Perspectives on Psychological Science 2011; 6: 483-487.

18. Ecological
Theory
 Interacting
nature
of
natural
contexts
and
their
impact
on
growth
and
development
 Reciprocal
relations
among
natural
elements
in
an
environment

19. Sustainability
 Able
to
be
maintained
at
a
certain
rate
or
level
 Conserving
an
ecological
balance
by
avoiding
depletion
of
natural
resources
 Able
to
be
upheld
or
defended

20. Diffusion of Innovation
• Innovative interventions
initiated by a relatively small
segment of opinion leaders
• Via modeling, innovations are
diffused through the
population, influencing others
• Rogers (1983) noted that
despite their knowledge,
professional change agents
often have little or no influence

21. Social Networks: Burt s Two-
Step Diffusion Theory
Step
1
Informa(on
is
spread
via
cohesion
(key
informants)
Step
2
Adop(on
and
use
spread
via
structural
similarity
(compe(tors
or
partners)

22. Teacher Key Opinion Leader (KOL)
Influence Network

23. Influence
of
KOL
Teachers
Classroom
Prac(ces
Atkins
et
al.,
Journal
of
ConsulEng
and
Clinical
Psychology
2008;,
76:
905-­‐908.

24. Watling-­‐Neal
et
al.,
Social
Development
2011;
20:376-­‐393.

25. Links
to
Learning
 Unite teacher, parent,
and MH provider around
predictors of learning
 Link MH providers with
indigenous resources to
support teachers and
parents
 Sustain services
through fee-for-service
Medicaid billing
NIMH R01 MH073749 (PI: Atkins)

26. Links to Learning Service Model
KOL Teachers
School
Teachers Behavior
Effective Instruction
CR Management
Parent Outreach
MH Academic
Providers
Achievement
Parents
Home-Based
School-Linked
Home
Behavior
Parent Advocates

27. Sample
Characteris(cs
• 7
high
poverty
poor
performing
CPS
schools
!Baseline!(Parent!Report)
• 4
CMH
agencies
• 171
students
(104
Links,
67
100
80
control)
grades
K
-­‐4
75 68
76
• 136
teachers
(71
Links
65
50 43
Control)
25
0
• 3
year
interven(on

28. Dissemination to Teachers and
Mental Health Providers
 KOL teachers identified by sociometric interview and
enrolled with MH providers enrolled in on-line
graduate course on best practices
 Site based workshop
 10 week schoolwide professional learning series
hosted by KOL teachers and MH providers in KOL
teacher’s classroom for district CEU credit
 KOL classroom was laboratory for MH providers and
other teachers
 MH providers follow-up in classrooms of teachers of
students on their caseload
28
Watling-Neal et al.,The Community Psychologist 2008, 41:2, 53-57

29. Classroom
Interven(on
Strategies
 Universal
 Good
Behavior
Game
 Peer-­‐Assisted
Learning
 Targeted
 Daily
Report
Cards
 Individual
Tutoring
 Good
News
Note

30. Parent
Curriculum
• Home
rou(nes
that
support
learning
• Homework
• Reading
materials
• Reading
opportuni(es
• Home-­‐school
communica(on
• Conferences
• School-­‐home
notes

31. Mental
Health
Service
Use
100"
90"
80"
70"
Percentage)
60"
50" Links"
40" TAU"
30"
20"
10"
0"
Entered" 6"Months" 1"Year" 2"Year" 3"Year"

32. Teachers
Use
of
Strategies
Links
Only
20
18
16
14
12
10
Targeted
8
Universal
6
4
2
0
Spring,
Year
1
Fall,
Year
2
Winter,
Year
2
Spring,
Year
2
Fall,
Year
3
Winter,
Year
3
Spring,
Year
3
32

33. Dependent
Measures
 Child
behavior
 Academic
performance
 Parent
involvement
 Parent
and
teacher
report
(Fast
Track)
 Parent
and
teacher
stress
 Parent
report
(Caregiver
Strain
Q)
 Teacher
report
(Quality
of
Teacher
Work
Life)
33

34. Random
Effects
Models
yit = λ0t η0i + λ1t η1i +εit
η0i = υ0 +γ0 zi +ζ0i
η1i = υ1 +γ1 zi +ζ1i
yit -­‐ individual i at occasion t
λ1t -­‐ time of measurement
η0i -­‐ individual intercept with expectations υ0 and residuals ζ0i
η1i -­‐ individual slope with expectations υ1 and residuals ζ1i
γ0, γ1 -­‐ effects of time-­‐invariant covariate on the initial level
and linear slope
εit ~ N(0,σε2)
Random components are independent
34

35. Classroom Observations:
Year 1
Academic
Engagement
70
65
Percent of Intervals
60
55 Links
Control
50
Links PC
45 Control PC
40
35
30
BL Spring

36. 3
Year
Classroom
Observa(ons
Peer
Comparisons
Engagement
Scores
80
75
Mean
Percentage
of
Time
Observed
Engaged
70
Target
Children
65
Peer
Comparisons
60
55
50
45
40
35
30
Fall
Yr
1
Spring
Yr
1
Fall
Yr
2
Spring
Yr
2
Fall
Yr
3
Spring
Yr
3
36

37. Classroom
Observa(ons
Peer
Comparisons
Off
–Task
Behavior
80
75
70
65
Target
Children
60
Peer
Comparisons
55
50
45
40
35
30
Fall
Yr
1
Spring
Yr
1
Fall
Yr
2
Spring
Yr
2
Fall
Yr
3
Spring
Yr
3

38. Curriculum
Based
Measures
Three
Years
Links
vs.
Controls
Reading
60
55
50
45
Links
40
Control
35
30
25
Fall
Yr
1
Winter
Spring
Fall
Yr
2
Winter
Spring
Fall
Yr
3
Winter
Spring
Yr
1
Yr
1
Yr
2
Yr
2
Yr
3
Yr
3
38

39. Curriculum
Based
Measures
Year
3:
Links
vs.
Controls
Reading
60
58
56
54
52
50
Links
48
Control
46
44
42
40
Fall
Yr
3
Winter
Yr
3
Spring
Yr
3
39

40. Teacher
Ra(ngs
3
Years
Links
vs.
Controls
 Academic
Competence
4
3.5
3
2.5
Links
Control
2
1.5
1
Fall
Yr
1
Spring
Yr
1
Fall
Yr
2
Spring
Yr
2
Fall
Yr
3
Spring
Yr
3
40

41. Parent
Report
3
Year
SSRS
Social
Skills
41

42. Ongoing
Studies
 Retaining
early
career
teachers
(Shernoff)
 Connectedness
and
Effec(veness
(IES
Goal
II)
 The
Classroom
Project
(Frazier)
 Teacher
prac(ces,
classroom
climate,
student
outcomes
 8
schools,
77
teachers,
620
students
 Family
Student
Liaison
(Starin)
 Community
members
suppor(ng
parents
to
support
their
children s
learning
 The
Bridge
Project
(Cappella)
 Mental
health
consulta(on
to
enhance
posi(ve
classroom
emo(onal
climate

43. Project
Bridge
 Trained
community
MH
providers
in
NYC
public
schools:
 Links
to
Learning
for
universal
and
targeted
mental
health
programs
 MyTeachingPartner
(MTP)
web-­‐based
teacher
instruction
for
classroom
organization,
emotional
climate,
&
student
relations
 Random
assignment:
MTP
or
MTP
+
Links
 36
classrooms
(K
to
5th
grade),
n
=
364
 Implementation
January
through
April
43

44. Project Bridge
Cappella, Hamre et al. JCCP 2012; 80:4, 597-610

45. Summary
 The LINKS Center focuses on a program of
research to improve the mental health of children
living in high poverty urban communities
 Links to Learning is a Medicaid fee-for-service
mental health service model implemented by
community mental health staff in high poverty
urban schools
 Results suggest that services led to modest
improvements in children s learning and behavior
 Ongoing studies will expand the model to
activate indigenous resources in schools to
provide additional support to students, teachers,
and families

46. Final
Thoughts
But
in
urban
schools
Given
the
large
needs
for
this
requires
afen(on
to
mental
health
services
in
the
unique
social
high
poverty
communi(es,
con(ngencies
that
and
the
importance
of
inform
and
promote
schooling
for
children’s
school
success
and
the
development,
schools
are
ac(va(on
of
indigenous
an
ideal
semng
to
resources
to
support
promote
urban
children’s
semng
goals
health
and
well
being.
The
goal
is
to
relieve
schools
from
the
job
of
providing
mental
health
services
by
making
successful
schooling
the
job
of
mental
health
services