PRIMARY MENTAL HEALTH PROJECT

Principal Investigator: Emory Cowen

Level of Intervention: Selective

Target Population: elementary-aged children (pre-K – 4th grade) screened for behavioral, social/emotional, and learning difficulty

References: Cowen, Hightower, Pedro-Carroll, Work, Wyman, & Haffey (1996); Hightower (1997); Lorion, Caldwell, & Cowen (1976); Cowen, Gesten & Wilson (1979); Weissberg, Cowen, Lotyczewski & Gesten (1983).

Theory (Risk & Protective Factors Targeted):
PMHP is based on the premise that the traditional school-based mental health professional alone is inadequate to provide substantial assistance to the large number of children who could benefit from additional supports. PMHP addresses this problem by restructuring the role of the school mental health professional and utilizing a cadre of paraprofessional child associates to work more intensively with a larger population of students in a structured playroom environment. The program targets early elementary-age children who are exhibiting early signs of maladjustment in order to prevent future psychopathology.

Description of Intervention:
Based on composites from the initial universal screening, children are identified who seem most appropriate for PMHP services. A more extensive information gathering takes place for these children, followed by the formulation of an intervention plan. Written parental consent is required for further participation. For each identified child, the core intervention component is the development of an ongoing interactive relationship with a trained paraprofessional child associate. Child associates are carefully selected and receive an intensive 24-36 hour training followed by regular topical continuing development training. The child associate meets with the child alone or in small groups once per week for 25 to 45 minutes, for 20-25 sessions over the school year. These meetings take place in a structured playroom equipped with items designed to encourage expressive play. The expression and exploration of all emotions is encouraged, with limits placed on inappropriate behavior. Child associates exploit opportunities for teaching life skills such as taking turns, following rules, and attending to a task.

Weekly or biweekly supervisory meetings are held between the mental health professional and child associates for reviewing progress. Approximately halfway through the intervention, a more comprehensive review of each child’s progress is conducted with the entire PMHP team to assess progress to individual goals and to make mid-course corrections to the intervention plan. Each child receives an end-of-project conference, again with the entire PMHP team, including a disposition decision to terminate the child from the program based on significant progress. For most children who do not make adequate progress at the end of one year of intervention, a second year is not recommended (this is based on prior research that showed little or no effects from a second year of intervention).

Subjects:
All children are screened at the beginning of the school year by a team of child associates and mental health professionals, as well as classroom teachers. Informal observations are conducted in multiple school settings. At times child associates arrange with teachers for specific classroom observation times. Screening teams review school administrative records and, where appropriate, prior years’ screening information. Many schools utilize rating scales developed by the PMHP. One such scale, the 12-item AML-R Behavior Rating Scale assesses the frequency of acting out, moodiness, and learning problems. This scale is completed for each child by the primary grade teacher. For children in second grade and above, the self-report Child Rating Scale can also be used to measure internalizing, externalizing and social behaviors as well as interest in school.

Study 1 (Lorion, Caldwell & Cowen, 1976)
In this study a group of primary grade children who successfully completed the PMHP after one year (Terminators) was compared to a subgroup who continued the program for a second year (Non-terminators) and a no-treatment control group. The three conditions were split for separate analysis between two measures, the Teacher Referral Form (TRF), and the AML measure described above. Ns for each group were: Terminators= 45; Non-terminators =33; Controls =31. The groups were similar on demographic, socioeconomic and PMHP variables.

Research Design:
Groups appear to have been non-randomly assigned.

Outcomes:
Using the teacher-rated AML, ANOVA analysis showed significant treatment effects for seven of eight followup comparisons at both 5 and 12 months after completion of the first year of intervention. Terminators were significantly less maladjusted than Non-terminators or Controls on all seven measure. The eighth, acting-out behavior measured at 12 months post, showed a non-significant trend in the predicted direction.

On a second measure, the TRF, teachers rated children on 37 behaviorally oriented items relating to maladaptation. The measure forms summary indexes of acting-out, shy-anxious, and learning problems. ANOVAs of the eight comparisons (at 5 and 12 months post), six showed significant intervention effects with Terminators less maladjusted than Non-terminators or Controls.

Study 2 (Cowen, Gesten & Wilson, 1979)
176 subjects from 4 PMHP schools equally distributed across grades k-3 were compared to a retrospective control group of 72 subjects matched on demographic and PMHS variables.

Outcomes:
Significant intervention effects were found on two teacher-rated measures in comparisons to a matched retrospective control group. On the Classroom Adjustment Rating Scale (CARS) effects reached significance on the subscale of adjustment problem severity, but not on the other subscales of acting-out, shy-anxious, learning problems, or total maladjustment. On the Health Resources Inventory (HRI) effects reached significance on the subscales of adaptive assertiveness, frustration tolerance, following rules, and the summary competence scale, but not on the factors of good student or peer sociability.

Study 3 (Weissberg, et al., 1983)
The subjects included seven consecutive annual cohorts ranging in size from 206 to 464 that were assessed pretest and post-test without a comparison group.

Outcomes:
Intervention effects were assessed using the CARS and HRI, the Aide Status Evaluation Form (ASEF – aide-reported instrument that parallels the CARS), and the Professional Termination Report (PTR – completed by the school mental health professional at the end of the school year). Within-group pre- to post change scores were figured for 21 criterion variables (4 CARS, 6 HRI, 4 ASEF, and 7 PTR) for each of the seven cohort years plus the pooled 7-year sample using t-tests. The results showed significant improvement on 22 of 28 CARS analyses, 39 of 42 HRI analyses, 20 of 28 ASEF analyses, and all 49 PTR analyses. T-tests for the pooled seven year sample indicated that PMHP children improved significantly on all 21 adjustment variables.

Strengths & Limitations:
The PMHP seeks to prevent psychopathology by providing additional targeted support to early elementary-age children who have been identified as having social/emotional or learning difficulties. The program uses a cadre of paraprofessional support staff coordinated by a school-based mental health professional in order to maximize the number of students who receive support. Child associates develop a close, warm relationship with the child and utilize a structured playroom to encourage expressive play and to create learning opportunities. The intervention focuses on the school domain and changing both the school ecology and the individual child.

The PMHP claims to be the most extensively evaluated mental health program ever. Unfortunately, very few of the evaluations utilized well-designed control groups. In the two studies referenced above, group assignment was not random and the results were based on teacher reports that may have been biased as a result of program participation. The third study cited above used no control group, but did review 7 consecutive cohorts of intervention subjects and found consistent program effects. Despite its success with children who exhibit primarily internalizing symptoms, the PMHP has struggled to achieve the same level of effects with acting out students.

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