A Framework for
Considering Prevention
and Early Intervention
Nancy Peña
Director, Santa Clara County Mental Health Services
Eleanor Castillo
Director of Outcomes and Quality Assurance
EMQ Children and Family Services
CMHACY
May 4, 2006
Objectives
Definition
 National Trends/Conceptualization

 Systems-focused

Evidence-Based Models
 Program-based

Conclusion
 Take-Home
Messages
 Question and Answer
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Objectives
Definition
 National Trends/Conceptualization

 Systems-focused
Evidence-Based Models
 Conclusion

 Take-Home
 Question
Messages
and Answer Program-focused
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Tertiary Prevention:
Specialized
Individualized
Intervention for Youth
with High-Risk Behavior
Public Health
Approach
Secondary Prevention:
Specialized Group
Interventions for Youth
with At-Risk Behavior
Primary Prevention:
Interventions for
All
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Maintenance:
To reduce relapse and
recurrence and provide
rehabilitation.
Incorporates PH
secondary and all forms
of tertiary prevention
Institute of
Medicine:
Core Activities
Treatment:
Identification and
treatment of individuals
with mental disorders
and treatment which
may include
interventions to reduce
the likelihood of future
co-occurring disorders.
Prevention:
Interventions to avert the
initial onset of a mental
disorder. Similar to PH
primary prevention.
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3 Forms of Preventive Intervention

Universal- Interventions that target the general public
or a whole population group that has not been
identified on the basis of individual risk.

Selective- Interventions that target individuals or
subgroup whose risk of developing mental disorders is
significantly higher than average (Early Intervention).

Indicated- Interventions that target individuals who
are identified as having signs, symptoms, or genetic
markers related to mental disorders, but do not yet
meet diagnostic criteria.
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Characteristics of a
Public Health Approach
Universal interventions
 Targeting risk AND protective factors
 Dissemination of information/services in
multiple locations

 Doctor’s
office/Health Clinics
 Libraries
 Community
Centers
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Objectives
Definition
 National Trends/Conceptualization

 Systems-Focused

Evidence-Based Models
 Program-Based

Conclusion
 Take-Home
Messages
 Questions and Answers
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National Institute of Mental Health
NIMH. (1998). Priorities for Prevention Research at NIMH: A Report by the National Advisory Mental
Health Council Workgroup on Mental Health Disorders Prevention Research. NIH Publication No. 98-4321.
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National Institute of Mental Health


Prevention Science- Prevention, early intervention, and
treatment must be provided within a public health
context, along a continuum, and must address risk and
protective factors (analyses of risk and protective
factors)
Find a way to make all system efforts fit into the mental
health spectrum
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Ecological Perspective
Greenberg, M. (2002) Prevention of Mental Disorders in School Aged Children: Making the Connection.
Presentation at SAMHSA/CMHS and National Association of State Mental Health Program Directors Prevention
Roundtable, March 14, 2002.
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Ecological Perspective
(Greenberg, M., 2002)

Philosophy: Every child is important and kids
with challenges are failing.
 Strategies
need to be adjusted
 Yale study (2005) reported that Pre-K students are
expelled at a rate 3x that of children K-12

Early Childhood Community- Perceive role and
influence the development of social-emotional
competencies
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SAMHSA:
Mental Health Status Continuum
Positive Mental Health:
High-level capacity of the
individual, group, and
environment to interact &
to promote well-being,
optimal development, and
use of mental abilities
Mental Health Problem:
Disruption in interactions
between individual, group,,
and environment,
producing a diminished
state of positive mental health
Mental Disorder:
Medically diagnosable illness
that results in significant
impairment of cognitive,
affective, or relational abilities
Scanlon, K., Williams, M., & Raphael, B. (1997). Mental Health Promotion in NSW: Conceptual framework for developing
initiatives. NSW Health Department, Sydney, Australia.
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SAMHSA:
Mental Health Continuum





Broaden view to include promotion & prevention
During a lifetime one can move back and forth along
the continuum
Family members could be at different points along the
continuum
Redefine Mental Health as “Social Emotional
Competencies”- a facet
Primary Care Physicians and Child Care Providers
should be part of the resource and interventionists
along the continuum
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SAMHSA: 5 Principles





Individuals, especially children need to be viewed and
understood within developmental framework
Individuals, especially, children are a part of families, so
families need to be viewed and understood holistically
Prevention, early intervention, and treatment must be
provided within a public health context, along a continuum
and must address risk and protective factors
Services and supports for individuals and their families
should be family-driven and individual-guided; culturally
and linguistically competent; individualized and
strengths-based; and community-based (person
centered)
Behavioral health care needs to be comprehensive,
coordinated, and integrated across multiple individualand-family-serving systems
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American
Psychological
Association
Indicated
Prevention
Selective
Prevention
Universal
Prevention
Timelimited
Therapy
Culture
Community
Enhanced
Therapy
Continuing
Care
Family
Health
Promotion /
Positive
Develop.
Weisz, J.R., Sandler,
I.N., Durlak, J.A., &
Anton, B.S. (2005).
Linking prevention and
treatment within an
integrated model.
American Psychologist,
60 (6), 628-648.
Youth
Inpatient
Unit
Home
Residential
Facility
School
Neighborhood
Agency
Primary
care
Clinic
Outpatient
Mental
Health
Day
Treatment
Program
Note: Primary strengths reside in youths, families, communities, and cultures (center), supported and protected by effective interventions (examples in upper semicircle) delivered within an array of
life settings (examples in lower semicircle). Intervention strategies are arrayed from most universally applicable (i.e., for general population groups not identified as having specific risk factors,
problems, or disorders) at left to narrowly focused (i.e., for youths with rarer persistent long-term conditions) at the right. Intervention settings are arrayed from least restrictive on the left to most
restrictive on the right. The upper portion of the figure is adapted from “Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research” (p. 23), by P. J. Mrazek and R. J.
16
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Haggerty, 1994, Washington, DC; National Academies Press. Copyright 1994 by National Academies
Press. Adapted with permission.
Objectives
Definition
 National Trends/Conceptualization

 Systems-Focused

Evidence-Based Models
 Program-Based

Conclusion
 Take-Home
Messages
 Questions and Answers
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General Trends

Collaborative Systems
 Systems Approach
vs Program Approach
Strengthening Families
 Cultural Competence
 Maximizing Current Resources
 Collaboration Between Families and
School

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Various Resources
MENTAL
HEALTH
EDUCATION
FIRST FIVE
JUVENILE
PROBATION
CHILD
WELFARE
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Fragmented Policy
Fragmented Practices
AfterSchool
Programs
Special
Education
Clinic
Violence &
Crime
Prevention
Juvenile
Court
Services
Pupil
Services
Community
Based
Organizations
Health
Services
SCHOOL
Drug
Prevention
Mental
Health
Services
Social
Services
Child
Protection
Services
Drug
Services
Adapted from: Health is Academic: A guide to Coordinated School Health Programs (1998).
Edited by E. Marx & S.F. Wooley with D. Northrop. New York: Teachers College Press.
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Resource Overlap
EDUCATION
EDUCATION
+
MENTAL
HEALTH
ED+MH
+CW
EDUCATION
+
CHILD
WELFARE
ED+MH
+JPD
EDUCATION+
MENTAL HEALTH+
CHILDWELFARE
+ JPD
ED+CW
+JPD
CHILD WELFARE
MENTAL HEALTH
MENTAL
HEALTH
+
JUVENILE
PROBATION
DEPT
JPD+
MH+CW
CHILD
WELFARE
+
JPD
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JUVENILE
PROBATION DEPT
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When policy focuses on schools, public services,
and communities working together, it is important
to recognize that we are talking about
three major and separate reform movements.
 School Improvement
 Public Service
 Agency Reform
And, it is especially important to
understand the implications of this!
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System Approach

Examples from other states
 New York and Illinois
 Guidelines
 Oregon
 Legislation
 Iowa and Illinois
 Positive Behavioral Interventions and Support
 Washington
 Universal School-Based “Emotional Health CheckUp”
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System Approach

Sample of Efforts Within California
 First
5 Commission
 Behavioral, Developmental, and Emotional
Screening and Treatment by Primary Care
Providers in Medi-Cal Managed Care (BEST)
 Riverside County- Youth Crime Prevention
Red Team
 Early Mental Health Initiative
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Partnering with Primary Care
PRIMARY CARE
Pediatrician
EDUCATION
PRIVATE
INSURANCE
MH
EDUCATION
+
CHILD
WELFARE
CHILD
WELFARE
CMHACY
EDUCATION+
MENTAL
HEALTH
ED+
MH+
CW
MENTAL HEALTH
ED+MH+
JPD
EDUCATION+
MENTAL
HEALTH+
CHILD
WELFARE +
ED+CW+ JPD
JPD+
JPD
MH+C
W
CHILD
WELFARE
+
JPD
MENTAL
HEALTH
+
JUVENILE
PROBATION
DEPT
JUVENILE
PROBATION
DEPT
25
Examples of Programs that Combine
Strategies Across Family, School, and
Community







Across Ages
Adolescent Transitions Project
First Step to Success
Project Northland
Promoting Alternative Thinking Strategies (PATHS)
Schools and Families Educating Children (SAFE
Child Program)
Woodrock Youth Development Project
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Objectives
Definition
 National Trends/Conceptualization

 Systems-Focused

Evidence-Based Models
 Program-Based

Conclusion
 Take-Home
Messages
 Questions and Answers
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Why Evidence-Based or
Best/Emerging Practices



Governmental organizations at the national level have
endorsed the importance of evidence-based practices
and programs (National Advisory Mental Health
Council, 2001; President’s New Freedom Commission
on Mental Health, 2003; U.S. Public Health Service,
Office of the Surgeon General, 1999; 2004).
Family advocacy groups and patient organizations
have become increasingly vocal in advocating for
interventions that produce good outcomes plus youth
and family satisfaction with the care provided.
Access and satisfaction within a system of care has
improved, but treatment outcomes need to better
improve.
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Sample Resources





There are over 800 outcome studies on prevention and health and
250 more on drug abuse prevention.
www.effectivechildtherapy.com.
The evidence-base for universal prevention indicates addressing
drug use, pregnancy, child maltreatment, and health promotion
are well documented in the literature.
www.oslc.org/spr/apa/summaries.html
http://preventionpathways.samhsa.ogv/mrepp/adv_search.cfm

Evaluation of program based approach to evaluation of
systems approaches
Web site for the National Registry of Effective Programs and
Practices (see www.mentalhealth.samhsa.gov ) shows that 91%
of those (prevention) programs (i.e., 58 of the 64 programs listed)
identify multiple ethnic groups as their target population.
http://www.cimh.org/downloads/multicultural/Final%20Summary%
20Matrix%209-15-05%20v%201%20_2_.pdf
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Program Approach
Early Childhood Programs
 Trauma
 Developmental Approaches

 Natural

Transitions
Community Engaged Programs
 Positive
Youth Development programs
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Important Features of Effective Family
Intervention Programs
(Oregon Research Institute, 2005)











Skill-building as an explicit focus, not just education, knowledge,
discussion, or support- Includes skill practice, role-playing,
videotaped models, and home practice.
Interactive and collaborative approach, rather than didactic.
Focus on social learning principles, not just parenting strategies.
Explicit education and support related to other issues, including
marital adjustment and problem solving.
Start early and capitalize on natural transitions, which are times
of opportunity and vulnerability (e.g., birth, preschool).
Build skills in effectively managing children’s behavior.
Monitor and supervised activities.
Consistent discipline.
Build positive parent-child relationships.
Self-control for parents.
Consistent parenting between parents.
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System and Program Approaches:
Accountability and Outcomes

Focus on OUTCOMES based on a logic
model and QUALITY
 Individual
 Program
 Systems

When measuring impact, school readiness
is an important indicator.
 25%
of children are not ready to enter schools
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Logic Model
Youth, Family,
and System
Conditions
Program
Components/
Service
Activities
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Outcomes
33
System and Program Approaches:
Cultural Competence

Organization/Systems Considerations
 Organizational
Cultural Competence
 Individual Cultural Competence
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System and Program Approaches:
Cultural Competence

Consumer Considerations
 Internal
complexities with ethnic demographics
 Various cultural identities
 Generalization of statistics
 Models of health and illness
 Approaches and receptivity of interventions
 Causal and contributing factors of illness
 Language
 History
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Objectives
Definition
 National Trends/Conceptualization

 Systems-Focused

Evidence-Based Models
 Program-Based

Conclusion
 Take-Home
Messages
 Questions and Answers
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Take-Home Messages
Address risk factors and protective factors
 Need for systemic and programmatic
approaches

 Implementation
of services/interventions
based on research

Accountability, Outcomes, and Quality
 Little

Hoover Commission
Know the community being served
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Objectives
Definition
 National Trends/Conceptualization

 Systems-Focused

Evidence-Based Models
 Program-Based

Conclusion
 Take-Home
Messages
 Questions and Answers
CMHACY
38
Contact Information
Eleanor Castillo: [email protected]
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Prevention and Early Intervention: A Framework