Realigning Implementation Research with Public Health

to Improve Children’s Mental Health

Kimberly Eaton Hoagwood, PhD2015 National PBIS Leadership Forum

October 23, 2015

Key Points

Continued increase in prevalence of mental health problems among children

Service use increasing but quality of services still poor

Evidence base on effective clinical, preventive and service interventions is strong

Healthcare policies offer new structures and reimbursement options to address disparities in children’s mental health

Types of questions driving health services and implementation research misaligned for either informing healthcare policy or improving children’s mental health

Realignment = collective shift. 5 dimensions

Children & Adolescents at Risk (Halfon 2015)

4-8%Significant Disabilities

14-18%Special Health

Care Needs

30-40%Behavioral,

Mental Health Learning Problems

50-60% Good Enough

What % are thriving ?

30% ?

40% ?

50% ?

Children/Adolescents: Mental Health Need and Use of

Services 22.8 % of adolescents have a mental disorder with

impairments (Merikangas KR et al JAACAP 2010)

Inpatient mental health and substance abuse admissions increased 24% between 2007-2010 (Olson et al JAMA Psych 2014)

Rate of outpatient visits resulting in mental health diagnosis among children increased from 7.8% to 15.3% between 1995 and 2010. (Olson et al JAMA Psych 2014)

Prevalence of all mental disorders in children enrolled in Medicaid rose 40% to 8.2 M from 2001 to 2010 (National Academies of Medicine, Engineering, and Science, 2015)

Impairments due to Mental Health/Neurodevelopmental

Conditions for U.S. Children, 1960-2008

Source: Halfon & Houtrow, 2014; IOM Presentation, Disability in Childhood: Trends and Lifecourse Complications

Quality of Services: Penetration rates of evidence-based treatments by state MH authorities are

small (Bruns et al., 2015)

65-80% of states use selected adult EBTs Median clients served in these states 400-700 Penetration rates = 1.5% - 3.0% of estimated adults

with SMI

25%-50% of states use selected child EBTs Median clients served in these states 250-400 Penetration rates = 0.75% - 2.5% of all youths with SED

Several EBTs showed increases in early 2000s followed by decreases or flattening from 2007-2012

Achievement Gaps (Too Many Children Left Behind: Bradbury,

Corak, Waldfogel & Washbrook, 2015)

Over time achievement gaps emerge between low and high SES children who start school with same level of reading ability. High SES children always develop an advantage.

60% of the SES reading gap in 8th grade is attributed to differences in ability present in kindergarten; 40% is a result of children from different SES groups following different trajectories after kindergarten.

Gaps in language/reading skills at age 5 are largest in the U.S.

Inequality in language/reading skills at age 5 is greater in U.S. than in other comparable countries

The National Context: Healthcare Quality and

Accountability Important Federal Initiatives

2008: Mental Health Parity and Addiction Equity Act 2010: The Patient Protection and Affordability Care Act (ACA)

Expansion of Medicaid coverage New Incentives for care coordination, electronic data systems, pay for performance

Impact on States1. Medicaid Managed Care 2. Shift from separate MH authority to combined health, MH, SA, welfare etc.3. Concern with costly services, high end users, access4. Growing involvement of consumers5. Workforce shortages and task shifting6. Health homes and care coordination7. Data monitoring, EHRs 8. Focus on quality measures, accountability, and outcomes

Research Context

NIMH funding tripled from 1991 to 2001 for children/adolescents

Built strong knowledge base on clinical, preventive and service interventions

Evidence-Based Practice Registries*

APA, Div 53, Evidence-based Mental Health Treatment for Children & Adolescents

National Child Traumatic Stress Network National Guideline Clearinghouse, Agency for Healthcare Research and Quality The National Implementation Research Network New Zealand Guidelines Group National Registry of Evidence-based Programs and Practices (NREPP) Oregon Addiction and Mental Health Services (AMH) Promising Practices network (PPN) What Works, Wisconsin Evidence-based Parenting Program Directory Office of Juvenile Justice and Delinquency Prevention (OJJDP) The Campbell Collaboration Child Trends “What Works” The Cochrane Collaboration OTseeker, The University of Queensland Social Care Institute for Excellence (SCIE) Social Programs That Work, Coalition for Evidence-Based Policy Suicide Prevention Resource Center (SPRC) PracticeWise (Managing and Adapting Practice) California Evidence-Based Clearinghouse National Alliance on Mental Illness Model Programs Guide at the Office of Juvenile Justice and Delinquency

Prevention

*Not an inclusive list; only a sampling of registries.

 

Washington State Institute for Public Policy (WSIPP) Benefit-Cost Model

WSIPP’s benefit-cost model is an integrated set of computational routines designed to produce benefit-cost summary statistics for policy options: net present valuebenefit-to-cost ratio;measure of risk associated with these bottom-line

estimates.

Each of the summary measures derives from the same set of cash or resource flows over time.

WSIPP Best Bets in Children’s Mental Health

Top 5 Programs, Greatest Chances of Benefits > Costs

Program Name

Review Date

Total Benefits

Taxpayer Benefits

Non-taxpayer Benefits

Costs Benefits-Costs NPV

Benefit to Cost Ratio

Chances Benefits > Costs

Triple P Positive Parenting (Lvl 4, Grp)

4/2012 $1,015 $203 $811 $550 $1,565 n/a 100%

Remote CBT for anxious children

4/2012 $22,720 $6,746 $15,974 $777 $23,497 n/a 99%

Group CBT for anxious children

4/2012 $7,380 $2,167 $5,213 $411 $7,792 n/a 99%

Parent CBT for anxious children

4/2012 $1,845 $461 $1,384 $637 $2,483 n/a 99%

CBT Models for Child Trauma

4/2012 $6,169 $1,837 $4,333 $332 $6,501 n/a 98%

WSIPP Best Bets in Children’s Mental Health Top 5 Programs, Largest $$ Benefits (Net Present Value)

Program Name

Review Date

Total Benefits

Taxpayer Benefits

Non-taxpayer Benefits

Costs Benefits-Costs NPV

Benefit to Cost Ratio

Chances Benefits > Costs

Remote CBT for anxious children*

4/2012 $22,720 $6,746 $15,974 $777 $23,497 n/a 99%

EMDR for Child Trauma

4/2012 $9,260 $2,783 $6,477 $162 $9,422 n/a 82%

Group CBT for anxious children*

4/2012 $7,380 $2,167 $5,213 $411 $7,792 n/a 99%

CBT Models for Child Trauma*

4/2012 $6,169 $1,837 $4,333 $332 $6,501 n/a 98%

Group CBT depressed children

5/2015 $4,638 $1,314 $3,325 ($567)

$5,205 ($8.19) 74%

*Also one of top 5 programs where chances benefits > costs are greatest.

Questions that remain: How to Get Effective Care

ImplementedStrong evidence base on clinical, prevention,

and services. But gap between children’s mental health needs

and use of services remains; and • 17 year delay between research prioritization and

practice change

The 17-Year Odyssey

Green L, Ottoson J, García C, Hiatt R. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health2009;30:151–74; in Altman D, Goodman S. Transfer of technology from statistical journals to the biomedical literature: past trends and future predictions. JAMA 1994;272:129–32

Source: Adapted from Chambers, David. Dissemination and Implementation Research: Building the Mental Health System of the Future. University of Pennsylvania CMHPSR Seminar Series, May 2013.

The Typical Research Trajectory: A Linear Model

Source: Aarons, Hurlburt & Horwitz, 2011

STATE SYSTEMS

CHILD & FAMILY

OUTCOMES

Implementation and Dissemination R01 Funding by

NIH Institutes(2005-2012)

NIMH Funding, D&I (2005-2015)

PA/PAR Title Funding Opportunity

Total $$

PA-14-131 Improving Delivery of HIV Prevention & Tx Through Imp Science & Translational Research

ONLY PAR TO NOT LIST

BARRIERS $1,075,601

PAR-13-055 D & I Research in Health (R01) $4,610,359

PAR-13-056 D & I Research in Health (R03) -0-

PAR-13-054 D & I Research in Health (R21) $588,754.00

PAR-10-038 D & I Research in Health (R01) $22,018,4360

PAR-10-039 D & I Research in Health (R03)

$311,456PAR-10-040 D&I Research in Health (R21)

$3,290,730 PAR-07-086 D & I Research in Health (R01)

$9,242,802 PAR-06-039 D & I Research in Health (R01)

$11,739,962 PAR-06-520 D & I Research in Health (R03) -0-

PAR-06-521 D & I Research in Health (R21)

$1,711,449. TOTAL NIMH

TOTAL D & I FUNDING $54,589,550

Source: NIH Reporter Search, 9.30.15, all PARS listed.

99% of NIMH FUNDING for D&I focuses on barriers research in the funding opportunity aims.

NIH Funding for D&I ResearchA recent analysis provides information on NIH emphasis in D&I research (Tinkle et al 2013) ---almost half of the R01 studies funded did not utilize D&I theories or models (FY 2005-2012)

Realignment and Relevance: A Collective Shift

Deguild

Drive with data

Distill

Democratize

Disentangle social determinants

Collective Shifts: The 5 D’s

Emphasis on team-based and parent-partnered approaches. Task-shifting and workforce development. Deguild

Use of E-health tools for real-time tracking and quality improvement. Drive with data

Briefer service and training models. Common factors. Distill

Focus on ecology not programs (Atkins et al., 2015). Avoid proprietary nonsense. Democratize

Target social policies and their implementation rather than implementation of programs. Disentangle social determinants

1. Deguild: Task Shifting and Team-based Services

Engagement strategies to reduce no-shows (McKay et al., 2010)

Workforce development: Parent peer advisors (Kutash et al., 2013; Hogan et al., 2002; Olin et al., 2010)

Key opinion leaders (Atkins et al., 2005; 2015)

Team-based models (Kutash et al., 2013; Epstein et al., 2006)

Family-based services

Psychoeducation (Fristad et al., 2006)

Multi-family groups (McKay et al.)

Family Support (Olin et al., 2010)

Parent Partners and Workforce Development: Multi-Family

Groups (McKay, Hoagwood et al)

Parent partner training: 400+ parent partners trained and certified in NYS (Rodriguez et al 2011)

Multiple Family Group (MFG): service delivery strategy to enhance child service use and outcomes for urban, low-income children of color (McKay et al 2011)

NIMH-funded (R01MH072649) randomized effectiveness trial of MFG vs. services as usual in 10 outpatient clinics across NYC; Youth 7 to 11 and their families Met criteria for ODD or CD Majority of families with low household income and of African

American and/or Latino descent

Parent Partners and Workforce Development: Multi-Family

Groups (continued)

MFG content and process designed in collaboration with parents and providers (McKay et al 2011)

Involves 6 to 8 families; At least two generations of a family are present in each session

Knowledge sharing and practice activities foster both within family and between family learning/interaction

Second R01 in the field in 2015 to further replicate MFG model, funded by NIMH (R01MH106771-01)

MFG Evidence-Informed Targets

Strengthens parenting skills and family relationship processes Child management skills Family communication Within family support Parent/child interaction

Addresses factors affecting service use and outcomes Parental stress Use of emotional and parenting support Stigma associated with mental health care

In the words of families…

Multiple family groups should focus on: (4Rs) . . . Rules Roles and Responsibilities Respectful communication Relationships

. . . As well as the 2Ss Stress Support

Study Participants and Analyses

(Gopalan et al 2015; Chacko et al 2015) Adult caregivers: 87% female; low income; ½ completed

high school; 45% employed 47% African American; 42% Latino

Families had an average of 3 children living with them

Youth average age = 9.5 years

Random coefficient modeling to examine change over time and differences between MFG and Service as Usual

Time modeled as months from baseline using measurements from 4 time points: Baseline Mid-test (midway through intervention) Post-test (following intervention) 6-month follow-up

Outcome Variable B SE Z p ES

Child Disruptive Behavior -1.2 .51 -2.4 .02 .35

Impairment in peer relationships -.41 .20 -2.1 .04 .28

Impairment in self esteem -.42 .20 2.1 .03 .29

Overall severity/impairment in functioning

-.41 .17 -2.4 .02 .37

Social Skills1 3.5 1.5 2.4 .02 .33

Total parenting stress -6.0 3.2 -2.4 .06 .27

Perceptions of child as difficult -3.0 1.3 -2.4 .02 .35

Child rearing distress -5.0 2.2 -2.3 .02 .33

Adult caregiver depression2 -4.8 1.8 -2.7 .01 .42

Positive parent/child involvement3 7.6 3.7 2.1 .04 .91

Family organization4 3.1 .96 3.2 .01 .28

Primary Outcomes

1 2 3 4 effect for youth/adults with clinical needs at baseline

2. DISTILL: Training alone will not suffice

Chorpita et al. (2011) identified 395 evidence-based protocols of over 750 psychosocial treatments tested in controlled clinical trialsEven if a practitioner knew 395 EBTs, it would only

cover 1/3 of the children receiving usual carePractice elements and component-driven EBPs

(Chorpita et al., 2002; Weist et al, 2006)

EBP Training and Overload

Source: Chorpita & Daleiden, 2009

Distill into Common Practice Elements (Chorpita & Daleiden, 2009)

CognitivePsychoeducational-Child

Activity SchedulingMaintenance/Relapse Prevention

Problem SolvingSelf-Monitoring

Goal SettingSocial Skills Training

Communication SkillsSelf-Reward/Self-Praise

RelaxationBehavioral Contracting

Guided ImageryPsychoeducational-Parent

Talent or Skill BuildingTherapist Praise/Rewards

ModelingStimulus Control or Antecedent Management

Assertiveness TrainingRelationship/Rapport Building

Tangible Rewards

0% 25% 50% 75% 100%

Frequency of Practice Element: Depression

3. Drive with Data: Managing and Adapting Practice

(MAP)

The MAP system (Chorpita & Daleiden)

Three tools support practice:

PracticeWise Evidence-Based Services (PWEBS) Database. Online database that can make recommendations about formal evidence-based programs OR about specific components of evidence-based treatments (based on client characteristics)

Practitioner Guides. Provides user-friendly measurement tools and clinical protocols

Clinical Dashboard. Tracks outcomes and practices on a graphical clinical dashboard

*Source: PracticeWise website, www.practicewise.com

Sample Clinical DashboardProgress and Practice Monitoring Tool Clear All Data

Age (in years): 13.4 Gender: Male Yes Redact FileNoTo Today

Progress Measures: To Last Event Left Scale

Anxiety SUDS Yes Anxiety SUDS

Yes Depression Suds

Yes Getting to School

Yes Talking to others

Yes Measure 5

Right Scale

Depression Suds

Getting to School

Talking to others

Measure 5

Engagement w ith Child

Engagement w ith Caregiver

Relationship/ Rapport Building

Goal Setting

Monitoring

Self-Monitoring

Caregiver Psychoed: Anxiety

Child Psychoed: Anxiety

Exposure

Cognitive: Anxiety

Modeling

Child Psychoed: Depression

Caregiver Psychoed: Depression

Problem Solving

Activity Selection

Relaxation

Social Skills

Skill Building

Cognitive: Depression

Caregiver Psychoed: Disruptive

Praise

Attending

Rew ards

Response Cost

Commands/ Effective Instruction

Dif. Reinforce./ Active Ignoring

Time Out

Antecedent/ Stimulus Control

Communication Skills: Advanced

Assertiveness Skills

Communication Skills: Early Dev

Maintenance

Other

Other

Other

Days Since First Event

Display Time:

To today

Display Measure:

Primary Diagnosis: Social Anxiety Ethnicity: Caucasian

0 20

40

60

80

100

120

140

160

180

0

1

2

3

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0 20

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4. Democratize Access to Innovations

Where Good Ideas Come From: The Natural History of Innovation(Steven Johnson, 2010)

Johnson’s seven ideas to promote innovation• Adjacent possible• Liquid networks• Slow hunch: The deep dive• Serendipity or generative chaos• Error: Fail faster• Exaptation• Emergent Platforms

Mar

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50

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ons

Adapted from Steven Johnson, Where Good Ideas Come From (2010)

Problem of Proprietary Ownership “The best ideas come from networked associations

with others in non proprietary environments” (S. Johnson) or Give the tools of psychology away (G. Miller)

Costs to one agency for training on 6 of the strongest EBTs (for anxiety, depression, trauma, ODD, CD, and ADHD). How much for one agency to train 8 therapists?

Between $160K and $190K Why is this a problem beyond practicality and

feasibility? Ethical: Children are suffering. Moral: Taxpayers are being stiffed. Intellectual: It stifles innovation.

Alternative: Incentives to promote EBP implementation and fidelity

Change the incentive system: Instead of government incentivizing intellectual property, which encourages commercialization of programs, what if:

Developers were paid for their time to train

User agreements were crafted so that agencies could use programs for free if they agreed to share data on implementation.

National funding agencies for services supported open access/data sharing on implementation and maintained an electronic repository, constantly updated, to share data on use, adaptations, outcomes, and costs

5. Address Social Determinants: Policies not programs

The majority of the SES achievement gap is already present at school entry (Bradbury, et al., 2015)

Gap is greater in US than in Canada, Australia, UK

Social policies to address the gap Evidence-based parenting programs Universal preschool programs Income support

School reform policies: Improve quality of teaching and learning: Recruiting, supporting and adequately compensating effective

teachers; implementing more rigorous curricula; raising expectations and providing more support for low achieving children

Poverty and children’s mental health: Break the poverty-disability cycle

Mental Disorders and Disability among Children: Report from the National Academies of Medicine, Engineering and Science, 2015

Poverty is a risk factor for child disability and child disability is a risk factor for family poverty

Children in poverty more likely than children in general population to have mental disorders and more likely to have severe impairments.

Among SSI Medicaid enrollees, the percentage of children with a mental disorder diagnosis increased from 29.2% to 38.6%. The most common mental health diagnosis was ADHD, which showed an increase from 10.7% to 17.7% over this time period.

Child Poverty and SSI

2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50000

100000

150000

200000

250000

300000

350000

Allowances for 10 selected Mental Disorders

Determinations for 10 selected mental disorders

2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

5000

10000

15000

20000

25000

30000

35000

Children under 200% FPL in thousands CPS

Children under 100% FPL in thousands CPS

Source: Mental Disorders and Disabilities among Low-Income Children, Figures 5-2 and 5-3.

From: Costello et al. Relationships Between Poverty and Psychopathology:  A Natural Experiment

JAMA. 2003;290(15):2023-2029. doi:10.1001/jama.290.15.2023

Conclusion Healthcare redesign requires a focus on practical issues

related to quality of services, costs, and collaborative models that cross systems (mh/ed/pc/jj/cw/sa).

Team-based and family-centered approaches: Task-shifting. Redefine roles for parent partners as part of the workforce. Deguild.

E-health tools for real-time quality improvement. Drive with data.

Briefer service and training models. Common factors. Distill.

Avoid proprietary nonsense (Hoagwood, in press). Focus on ecology not programs (Atkins et al., 2015). Democratize.

Study implementation of social policies not programs. Disentangle social determinants.

The IDEAS Centerhttp://www.ideas4kidsmentalhealth.org

The Community Technical Assistance Center

http://www.ctacny.com

Kimberly.Hoagwood@nyumc.org