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 childs 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.