Bridging Mental Health and Education in Urban Elementary Schools: Participatory Research to Inform Intervention Development

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Increasing numbers of elementary schools have mental health professionals on site to prevent and alleviate the behavioral difficulties that interfere with learning (Brener, Weist, Adelman, Taylor, & Vernon-Smiley, 2007, Kutash, Duchnowski, & Lynn, 2006). Behavioral problems, such as inattention, impulsivity, and defiance, are common in urban high-poverty schools. Teachers express concerns about disruptive behavior (Reinke, Stormont, Herman, Puri, & Goel, 2011), and children with behavioral problems are at risk for maladjustment (Tolan & Henry, 1996). School mental health services offer the promise of support--yet this promise is inconsistently realized. Studies reveal minimal effects on children's behavioral and academic functioning (Hoagwood et al., 2007), and mental health remains isolated from the mission and structure of schools (Weist & Paternite, 2006). Recent calls have been made to align school mental health with educational goals as a means toward increasing its relevance and effect (Atkins, Hoagwood, Kutash, & Seidman, 2010; Cappella, Frazier, Atkins, Schoenwald, & Glisson, 2008).

School mental health professionals are trained in assessment, individual and group therapy, crisis and case management, and family outreach (Brener et al., 2007), all of which facilitates their direct work with children and families (Kaufman, Hughes, & Riccio, 2010). It is less common for these professionals to have the language and tools to support classroom teachers (Schaeffer et al., 2005). Yet teachers arguably have the most effect on children's adaptation in school (Heck, 2007; Nye, Konstantopoulos, & Hedges, 2004). Effective teacher-student interactions are critical to academic and social-emotional development, particularly among children experiencing multiple problems (Hamre & Pianta, 2005; Mashburn et al., 2008). Effective interactions communicate warmth and respect, positive and clear expectations, and engaging and rich opportunities for learning (Hamre & Pianta, 2010). More adequately preparing mental health professionals to help teachers interact effectively with students with behavioral difficulties--and all students--may increase the effect these professionals can have on children's development.

Toward this goal, and guided by community-based participatory methods (Gittelsohn et al., 2006; Lantz, Israel, Schulz, & Reyes, 2006), a teacher consultation and coaching program was developed for school mental health professionals to deliver as a part of their ongoing activities in urban low-income schools. The program--Bridging Education and Mental Health in Urban Schools (BRIDGE)--fits within the broader framework of education and mental health interventions (e.g., Nastasi, 2004), and draws specifically from two existing models: MyTeachingPartner (MTP; Pianta, Mashburn, Downer, Hamre, & Justice, 2008) and Links to Learning (L2L; Atkins et al., 2006; Cappella et al., 2008). Goals are to increase effective teacher-student interactions across the classroom and with children with behavioral difficulties as a means toward children's academic, social, and behavioral adjustment in underfunded schools (Cappella, Hamre, Jackson, Wagner, & Soule, 2011).

One element of the intervention development process is contextualizing the program for its settings in order to increase its relevance and feasibility. Although it is not new to engage in participatory processes to "naturalize" interventions (e.g., Gittelsohn et al., 2006; National Research Council and Institute of Medicine, 2002), it is uncommon for these processes to be the focus of published scholarship in school psychology or prevention science. Toward this end, this article documents findings from a collaborative study to inform the adaptation of BRIDGE (Phase I) and a pilot experimental trial to assess the implementation of the adapted BRIDGE program by indigenous staff in urban schools (Phase II). Aims are to increase the specificity with which we describe approaches to intervention development (Cates, 1995; Wandersman, 2003) and enhance the likelihood of building sustainable programs to support children in schools.

Education and Mental Health Foundation for BRIDGE

In underfunded schools, there is an inverse relation between the level of student mental health need and the presence of resources to address that need (Cooper, 2007). Students are referred for disruptive behaviors (e.g., aggression, impulsivity, inattention, defiance) at high rates, with more than 20% of school-age children from low-income families receiving diagnoses for mental health disorders (Howell, 2004; Kataoka, Zhang, & Wells, 2002; Tolan & Henry, 1996). Teachers indicate dissatisfaction with their ability to manage and motivate students (Guarino, Santibanez, & Daley, 2006; Reinke et al., 2011). These challenges are mirrored in observations of classrooms, which indicate low to moderate levels of effective instructional and emotional support in schools serving students from poor families (Pianta, Belsky, Houts, Morrison, & NICHD Early Child Care Research Network, 2007). Thus, data suggest that the normative experience for teachers is inadequate assistance in managing disruptive behaviors and working with challenging students. Similarly, the normative experience for students is inconsistent access to effective classrooms--in short, a lost opportunity to enhance student functioning (Hamre & Pianta, 2010).

Interestingly, many schools have auxiliary personnel who may be positioned to change these norms. Approximately 60% of school districts report partnerships with community providers who offer school-based mental health services (Kutash et al., 2006). In a recent national survey, 78% of schools reported having a school-employed counselor on site to provide services, 61% had a school psychologist, and 42% had a social worker (Brener et al., 2007). With schools hosting multiple prevention programs simultaneously--a median of 14 according to one study (Gottfredson et al., 2004)--additional part-time mental health staff may be available. Finally, education policies at state and district levels increasingly require documentation of the activities and personnel dedicated to meeting the needs of students with academic and behavioral problems (Brener et al., 2007).

Yet these activities and personnel have not reached their potential. Demonstration trials indicate most prevention programs produce small gains in student outcomes (see Foster, 2010), but when implemented widely, they are understudied, inadequately implemented, or minimally effective (Gottfredson & Gottfredson, 2002; Wilson, Lipsey, & Derzon, 2003). School-based health clinics increase access to services, but do not consistently enhance the overall functioning of children with behavioral problems (Bruns, Moore, Stephan, Pruitt, & Weist, 2005; Weist, Myers, Hastings, Ghuman, & Han, 1999). Integrated prevention and treatment in schools remains unrealized (Adelman & Taylor, 2006). Finally, mental health professionals continue to provide assessment and therapy for referred students (Brener et al., 2007). This remains so even in the face of research suggesting that children with disruptive behaviors are best served through a combination of behavioral and psychotropic interventions, consistent and supportive practices, and improvements in the quality of the contexts they traverse (Franklin, Harris, & Allen Meares, 2006).

The central motivation for the current work is the question of how to allocate school and community mental health resources in ways that will have greater effect on children--specifically, support to teachers to enhance classrooms. School psychology has a long history of research and practice in teacher consultation to guide teachers in their work with high-need students (Kratochwill, Elliott, & Callan-Stoiber, 2002; Levine & Levine, 1970; Tharinger, Pryzwansky, & Miller, 2008). Teacher professional development models recently have successfully employed external coaches to improve interactions across the classroom (Brown, Jones, LaRusso, & Aber, 2010; Raver et al., 2008). In BRIDGE, we aim to integrate teacher consultation and classroom coaching into the ongoing practice of school mental health professionals (e.g., social workers, counselors, school psychologists) toward an effective and sustainable model to support teachers to work with children with behavioral difficulties, and improve the classroom context as a whole.

Framework for BRIDGE Content and Delivery

One of the challenges facing mental health professionals in attempting to directly support teachers' classroom practice is that they often do not have a framework for understanding daily classroom life. As a result, a fundamental element of BRIDGE is the provision of a common framework for understanding classrooms, one that is grounded in the everyday interactions teachers have with students. This framework helps mental health professionals and teachers build shared language, focus on specific aspects of teaching practice known to promote positive outcomes for students, and choose concrete strategies to implement to improve classrooms. Thus, we focus explicitly on teacher-student interactions--and strategies to improve these interactions--as a primary mechanism of learning and development for children with behavioral difficulties and their classmates. With these goals in mind, we draw from two existing models for the main components of BRIDGE: Links to Learning (Atkins et al., 2006) and MyTeachingPartner (Pianta, Mashburn et al., 2008).

L2L is a mental health model that activates indigenous school and community resources, such as mental health providers, leader teachers, and parent advocates, toward the academic and behavioral functioning of children with disruptive behavior disorders (Cappella et al., 2008). The specific focus is on predictors of learning in classrooms and homes as well as concrete support to teachers to improve the classroom context for learning. Early studies of components of L2L indicate an increase in engagement in mental health services and adoption of effective strategies as compared to traditional mental health services (Atkins et al., 2008). MyTeachingPartner (MTP) is a teacher support model that pairs preschool teachers with external consultants who interact via the Web to enhance classroom interactions and child outcomes (Pianta, Mashburn et al., 2008). The consultation is rooted in the Classroom Assessment Scoring System (CLASS; Pianta, La Paro, & Hamre, 2008), an observational method that describes multiple dimensions of effective teacher-student interactions with validated links to children's social and academic development (Mashburn et al., 2008). Consultation is focused on video of actual classroom interactions and individualized to teacher needs. Within a randomized controlled trial, early education teachers who received MTP consultation increased their effective classroom interactions at higher rates than those who received no consultation (Pianta, Mashburn et al., 2008).

BRIDGE emerged from the integration of L2L and MTP, which involved multistep and collaborative decision making among members of the original program development teams (see Cappella, Hamre, Jackson et al., 2011). Prior to the Phase I and II studies (described later), components of L2L and MTP were selected for the original BRIDGE model. These included: (a) concrete observation of classroom interactions using the CLASS lens (MTP), (b) individualized teacher consultation based on classroom interactions (MTP), (c) supportive coaching to implement universal and targeted classroom strategies (L2L), and (d) intervention delivery by indigenous mental health professionals in urban poor schools (L2L).

Data-Based Process to Contextualize BRIDGE

Although the primary components of BRIDGE were derived from research and existing programs, specific decisions about content, training/supervision, and delivery emerged through a planned research process. It is not uncommon for community psychologists, public health scholars, and services researchers to contextualize programs for their settings. The goals of this process research are to engage stakeholders, enhance the relevance and feasibility of the program, and increase the likelihood of program effects (Green, 2001; Seidman, 1990; Weisz, Chu, & Polo, 2004). Similarly, implementation science highlights the need to understand the resources, structures, and relationships within implementation settings as a means toward increased fidelity and sustainability (Aarons, Hurlburt, & Horwitz, 2011; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). Guided by this scholarship, we engaged in systematic inquiry to refine BRIDGE (content and processes) for its school-community contexts (resources, barriers, structures) toward the goal of enhanced implementation, relevance, and sustainability.

This research process comprised two phases across two years: intervention adaptation (Phase I) and intervention implementation (Phase II). Specifically, Phase I involved collection and analysis of qualitative data to refine BRIDGE training/supervision and content, and to situate BRIDGE delivery within existing structures and relationships. Data were gathered to assess the systems/structures of the implementation settings, the specific components of BRIDGE, and the relationships that facilitate implementation. Phase II used a mixed method approach within a pilot experimental trial to assess the fidelity of implementation of the refined model. In the following, Phase I (Method and Results) is described first, followed by revisions that resulted from Phase I findings (Discussion). Phase II (Method, Results, and Discussion) is described second. The final section (Implications) considers this research process as a …