Twenty percent of children and adolescents have emotional and/or behavioral problems with at least mild functional impairment, and more than 10% have a problem with substance abuse, resulting in a significant impact on families, school systems, and health care entities.1,2 In one of the largest school districts in Arkansas, more than a quarter of the students reported they felt so sad or hopeless for two weeks or more that they stopped doing their usual activities.3 Growing up with such problems can interfere with scholastic achievement and social competency and, ultimately, with employability and work functioning.4 Efforts to address these problems at an early age may be especially effective in preventing or diminishing their impact throughout the course of individuals’ lives.
Creating school and community partnerships with academic health centers (AHCs) offers one strategy for initiating and sustaining broad-based change in health systems.5–7 By combining dispersed resources and attacking systemic problems on multiple levels, community stakeholders have a greater chance of ameliorating youth mental health and substance abuse problems than they would combating these problems individually.8 Such partnerships also have the capacity to blend the educational, research, and service missions of the AHC with community values and needs.9 For example, AHCs can provide state-of-the-science information on drug use, mental health, and evidence-based interventions to school personnel, who can speak eloquently of the need for specialized services, assessment methods, and consultation on other interventions that the AHC can develop as clinical foci.10 In the current climate of extraordinary need and finite resources faced by our school systems, AHCs can provide a critical link to improve the scientific knowledge and understanding of mental health conditions. Programs targeting school personnel may be especially effective at improving recognition and intervention when problems do occur because school personnel are in a position to observe the behavior and functioning of children and intervene quickly.11–13 However, many teachers have minimal background in behavioral health problems and treatment options.
In this article, we describe the development, initial evaluation, and current iteration of the Arkansas Behavioral Health Model, a unique collaboration between an AHC and K–12 school personnel across the state to address behavioral health issues in children. The model’s focus on education, research, and service provides an opportunity for AHC faculty and school personnel to work together to promote all types of health-related initiatives for school-aged youths.
The Arkansas Partners in Behavioral Health Sciences (PIBHS) model was patterned after and originally piloted within the Partners in Health Sciences (PIHS) program14 in the College of Medicine at the University of Arkansas for Medical Sciences (UAMS). The PIHS program was originally funded by internal AHC sources, and in 1997 it received a Science Educational Partnership Award (SEPA) from the National Institutes of Health (NIH). PIHS combined grassroots connections with Arkansas school personnel and a programmatic infrastructure through which medical school faculty provided core health science programs, hands-on instruction, and curricula to K–12 education personnel.14
The initial funding by internal AHC sources underscored the institutional commitment to PIHS. This financial commitment came during a time of change for UAMS and many other AHCs across the country in that they were actively expanding their community outreach programs to maximize public awareness and positive appeal through education and community-driven services. This approach directly led to the creation of PIBHS.
PIBHS evolved from two parallel streams. The original impetus came from data collected from PIHS workshop participants, who expressed the need for more training on mental health topics. With this community-driven need identified, two junior faculty members (JEK and TLK) who had directed workshops for PIHS decided to build on the PIHS model and focus their project uniquely on mental health. With a second grant funded by an NIH Science Education Partnership Award in October 2000, PIBHS was established to develop and evaluate a science-based educational program on the biology, origin, prevention, and treatment of mental illness through a partnership of researchers, clinicians, primary and secondary educators, school personnel, and students. PIBHS’s four major objectives are to
- ▪ Improve awareness of advances in the recognition, prevention, and treatment of mental disorders in K–12 teachers and students;
- ▪ reduce stigma by dispelling myths about mental illness;
- ▪ enhance access to mental health services for students and teachers; and
- ▪ increase student interest in the science of mental illness.
As indicated in Figure 1, we incorporated immediate and longer-term outcomes to evaluate these objectives across our target audiences. Through its community partnerships, PIBHS reflected the AHC’s missions for education, research, and service to benefit students, school personnel, and the community as a whole.
Treating patients is an important priority of an AHC; however, the ultimate goal should be to improve the public health of the community. Education is one method of illness prevention or early intervention when problems are identified. Thus, PIBHS aims to disseminate and make applicable the findings of cutting-edge research for school personnel, youths, and the general public to reduce the impact of emotional and behavioral problems in youth.
Six summer courses covering substance use and mental illnesses common in children and adolescents were developed in 2001 and 2002. Additional course topics were added, or existing courses were expanded based on program evaluations and ongoing needs assessments of participants. Evaluation data were also provided to AHC faculty to improve their teaching skills and, when appropriate, to contribute to the educational and service components of their dossiers for promotion and tenure purposes.
The template for a course module began with a one-day professional workshop by AHC faculty on the biological, psychological, and social aspects of mental illness, as well as an overview of interventions, resources, and possible applications for transferring scientific knowledge to the classroom. Presentations by other professionals from the community such as judges, teachers, police officers, and educational support personnel were included to reinforce the links between the program’s content, its relevance to the community at large, and the needs of school personnel. Based on participants’ responses on postcourse evaluations about the program content, the presenters, and future needs, the module was expanded into either a two- or three-day course. Importantly, reimbursement for travel, continuing education credit, free course materials, and lunches were offered to participants. The courses focused on topics including attention-deficit hyperactivity disorder and learning disabilities, alcohol use disorders, autism spectrum disorders, depression, eating disorders, tobacco use disorders, and violence and its impact (posttraumatic stress disorder). School personnel attendance at the summer courses, which involved more than 70 presenters, increased by more than 30% each year. Over 2,700 school personnel from 71 of the 75 counties in Arkansas attended more than 30,000 hours of continuing education from 2001 to 2005.
Between 2002 and 2005, the PIBHS team also developed educational components for students and the general public. These components evolved in a manner similar to that described above for school personnel. Student programs based on the module topics of depression, violence and posttraumatic stress disorder, attention deficit-hyperactivity disorder, learning disorders, healthy body image, the scientific basis of mental health, and careers in behavioral health science were developed for presentation during the fall and spring semesters of the 2001 to 2005 academic years. Designed primarily for middle school and high school students, 28 programs with 16 presenters were delivered in 90-minute distance learning classes via interactive televideo using the UAMS telecommunications network, which includes more than 50 remote sites. Schools in the Little Rock metropolitan area transported their students to UAMS to view the programs, and schools in other regions of this primarily rural state could view the programs at a local hospital or educational site with interactive televideo capacity. Total attendance was 1,250.
In addition to the student programs, the PIBHS team designed an interactive exhibit, “Mysteries of the Mind: Pathways into Hope,” in collaboration with the Arkansas Museum of Discovery. The exhibit consists of several interactive components designed to enhance visitor awareness and understanding of behavioral health issues. Features of the exhibit include an animated video that educates visitors about the biology of mental disorders; a timeline and artifacts that illustrate how models and theories of mental health and illness have changed from prehistoric to modern times; a word puzzle; and a video maze game that allows visitors to experience the effects of attention, perceptual, or learning problems on performance. After the opening of the PIBHS museum exhibit in 2002, the team also worked with museum health educators to develop a complementary educational program consisting of tools to assist teachers in grades 3 through 8 in developing a unit of study on mental health. The program focuses on the biopsychosocial model of mental health and includes lesson plans for activities to be completed before and after a visit to the museum exhibit. More than 750 students attended the museum program, with an addition 540 participating in the extended summer component. Total in-museum attendance for the past 4 years, including student groups, has exceeded 400,000.
The PIBHS team also developed the Depression Teaching Toolkit as an eight-lesson, standards-based supplemental curriculum for high school students. The development and implementation of the toolkit was a collaborative effort between a PIBHS task force and Arkansas educators, researchers, clinicians, and students. The content, now available on the program’s website (http://pibhs.uams.edu), has been referenced to national and state standards for high school biology, health, psychology, and applied social studies to maximize its applicability in a variety of high school courses, including psychology, biology, health, family and consumer sciences, sociology, and anatomy and physiology. Preliminary results of a recently completed evaluation of the toolkit in high schools in the Little Rock metropolitan area suggest that it is effective in increasing students’ knowledge of depression and mental health.
Public participation in the program’s research process
The Clinical Research Roundtable of the Institute of Medicine15 has identified several priority areas to enhance translation of research from basic sciences to clinical practice. One area of emphasis is on public participation in clinical research ensuring that the research process is responsive to their needs and concerns.16 By creating a partnership with school personnel and the community at large, PIBHS promotes an exchange of ideas, creates trust in the AHC, and exposes more individuals to the importance of the research process as a component of the overall program evaluation. Consistent with this focus, school personnel have been engaged to assist in the evaluation of PIBHS. Various methods have been implemented to assess the feasibility, acceptability, and effectiveness of PIBHS components to determine how well the program accomplishes its objectives and how the program might be improved over time.17 Focus groups and pilot testing of the museum exhibit, characters used in promotional and teaching materials, and content of the Depression Teaching Toolkit allowed for both student and teacher input during the development phase.
Although we conducted some type of formative evaluation for each program component (Figure 1), immediate and longer-term outcomes of the summer professional development courses were our primary focus. Professional development courses conducted during the summer were exposed to standard pre–post evaluations based on PIBHS goals and also on specific workshop themes. Findings from these evaluations from 2001 to 2005 indicated that the courses maintained a consistently high degree of effectiveness. The PIBHS team also conducted IRB-reviewed longitudinal follow-ups to determine whether the impact of specific programs extended throughout the academic year. For example, we evaluated participants from the PIBHS professional development course on depression and found that at the nine-month follow-up, they had maintained their perceived ability to identify and respond to a depressed or suicidal student, their awareness of community resources, and their perceived skills required to intervene in mental health crisis situations.11 A similar study after the violence workshop indicated that 61% of respondents had initiated at least one program to improve school safety and prevent violence. School personnel ratings on variables associated with school safety also improved dramatically from the postcourse evaluation to the nine-month follow-up.18 A randomized study was also conducted to assess the efficacy of the depression summer workshop (which was attended by 111 school personnel representing small and large rural, urban, and suburban high schools). At six-month follow-up, workshop attendees reported significantly higher levels of perceived knowledge of interventions to assist students who might be depressed (P < .05), ability to obtain resources for students who are depressed (P < .05) and knowledge of local state and national resources (P < .05) compared with the same attributes for 111 matched school personnel who had not attended the summer workshop. A randomized trial of the Depression Teaching Toolkit has also been recently completed, and results are pending.
We addressed human subject issues separately for each of our evaluation activities. For example, the IRB granted the overall PIBHS program exempt status as an educational program. We submitted some program components involving more extensive evaluations for full IRB review. For example, the nine-month follow-up surveys of summer workshop attendees received expedited review, and the randomized controlled trials of a summer professional development workshop and the Depression Toolkit underwent full IRB review. In general, it is important that such programs work closely with the local human subject review committees to ensure that the programs appropriately address human subject issues as a component of the evaluation process.
Through these efforts, teachers, students, and others were exposed to the research process and products. Junior faculty and residents also had an opportunity to participate in study design and data collection, analysis, and interpretation, resulting in six presentations at scientific meetings and five manuscripts that either have been published or are in development. These experiences were designed to increase their knowledge and skills in research design and implementation. This model can serve the AHC by emphasizing the importance of community-based research and attracting medical trainees who may enter this growing field.
Service is a founding principle of UAMS. Steiner and colleagues19 describe the scholarship of community engagement as the participation of academia in community service, which can be advanced by AHCs in multiple ways. The Arkansas model, as designed and implemented by PIBHS, incorporates many aspects of service. Individual service exists in the hundreds of hours of volunteer time donated by UAMS faculty to develop presentations and to teach the professional development workshops. PIBHS has also established opportunities for faculty to partner with high school students through a summer internship program and become involved in local science fairs as judges and mentors. In the internship program, students were recruited for both paid and volunteer positions, during which they broadened their knowledge of mental health, research, and program operations by helping coordinate the summer workshops for school personnel. Interns also assisted with other PIBHS projects such as developing a project Web site and contributing to and reviewing the teaching curriculum on depression. This opportunity provided students with volunteer service hours, which are necessary in an increasing number of high schools as a graduation requirement, enabled the volunteer department of UAMS to involve youths in programming, and increased staffing during the summer, which is the program’s busiest time of year. Through our networks with local and state science fair teachers and administrators and by providing funds for a cash award, we broadened student knowledge and interest in the behavioral health sciences. This has been associated with an increase of science fair submissions in the behavioral and social sciences category by 30% during the past five years. In addition, more than 2,000 volunteer hours were logged by faculty, who were more likely to be asked to participate in local school presentations, professional association meetings, media opportunities, and informal consultations to school personnel on behavioral health issues, thereby increasing their service commitment as well as the AHC’s visibility in the community.
This level of service benefits individual faculty members by providing service opportunities important for promotion and tenure, training, and connections with educational systems in the community, and it also benefits their respective departments and the AHC as a whole by portraying an institutional expectation and commitment to service. Through qualitative evaluations, we have been able to establish that this generates a tremendous measure of community goodwill for the AHC. One PIBHS teacher wrote on a postcourse evaluation: “I love coming to PIHS/PIBHS programs. It makes me proud of UAMS. I wish all our institutions were this effective.” Another reported, “These workshops enabled me as well as other teachers to receive scientific knowledge and provide additional material in our classes with a depth and understanding that was not previously attained.” For an institution that is the only university medical center in a predominantly rural state, this positive perception within the educational community is invaluable.
The Program’s Value
The Arkansas PIBHS model demonstrates that a partnership involving AHC, school personnel, and other community leaders can engage teachers and students to acquire scientific knowledge regarding mental health conditions in youths. This partnership was created through a participatory approach in which each stakeholder group informed various stages of development.20 Key to this development was the creation of culture in which evaluations occur at each phase of the program and are used in a continual quality-improvement cycle, allowing the program to remain consistent with the evolving needs of the stakeholders.
Unique to the Arkansas PIBHS model is the educational focus on mental health and behavioral sciences in collaboration with K–12 school personnel to expand and reform curricular approaches in this understudied area. We are aware of only one other similar program in the country, focusing exclusively on substance abuse. This collaborative service approach raises the public’s awareness about the science of mental health and seeks to decrease the stigmas associated with mental illness. The partnerships with individual schools and school systems are reflected in the model’s programs, toolkit curriculum, and evaluation efforts. More broadly, community service can be seen in AHC collaboration with the museum, which is a major provider of education programs, as well as through relationships that are encouraged between schools and service providers to improve access to mental health services. Finally, the model offers junior investigators ample research opportunities in the areas of education, children and adolescents, mental health programs, and policy. Importantly, evaluations are provided to faculty to improve their teaching skills and to document their community service for dossier purposes.
The development of the program has not come without challenges. The lack of involvement of parents and “buy-in” for a program that affects K–12 schools, school personnel, and students runs the risk of alienating a key constituency and an important source of potential support. In addition, although the benefit of connecting with teachers at the grassroots individual level has contributed to the model’s success, its lack of an ongoing relationship with educational administrators at the school-district and state levels could hinder broader implementation efforts. Developing and maintaining such connections is time intensive and requires ongoing attention to the changing demands and priorities placed on educational systems. For example, recent emphasis on core learning principles has necessitated a declining emphasis on supplemental topics because of increased pressure for improved academic performance and testing. Therefore, it is critical that these types of programs conform to state and national educational standards and/or benchmarks whenever possible. We also found that responses to the program have depended on characteristics of the school districts or individual schools. For example, personnel in rural schools have often been more receptive than those in urban schools because of rural schools’ lack of resources and minimal access to behavioral health expertise.
Sustainability of these types of programs is always challenging. Federal funding provided the impetus for development of PIBHS; however, the program’s potential for long-term sustainability resides in the institutional commitment to education, research, and service in this area. Whenever possible, the PIBHS team sought commitments from within the AHC and from our community partners to expand the program beyond its original scope. Although innovative funding mechanisms and dissemination tools will assure the longevity of the model, resources and priorities constantly shift in communities. Additional barriers to the program include limited time for teacher training and student education regarding behavioral health concerns outside of and within the classroom.
Several of our long-term outcomes were not quantifiably measured, which may hinder future dissemination. For example, multiple methods now exist to assess community cohesion, coalition-building, and leadership, which would have enhanced the evaluation of our program.21 For AHCs interested in this aspect of program design, we would recommend staged assessment of the partnering process, which would allow for accommodations as a program evolves as well as empirically documented accounts of the program’s accomplishments. This would ultimately require additional funding beyond the program development budget.
A Multifaceted Opportunity for AHCs
Because school attendance remains a constant in the lives of most youths, it is a natural setting for teachers and school personnel to provide scientific education about mental health and mental disorders. Further, it provides the opportunity to offer the initial link to treatment for students in need or at risk. Our model has developed innovative programs that bridge academic and scientific communities, mental health providers, and school personnel to optimize the transfer of knowledge about psychosocial and behavioral problems, empowering those who are most likely to interact with students with mental health needs. As previously mentioned, this era of extraordinary need and finite resources faced by our school systems offers AHCs a unique opportunity to provide the central link to improving the scientific knowledge and understanding of mental health conditions. Although mental health is targeted in this program, AHCs can incorporate other health conditions, scientific topics, and medical interventions into this model to provide an important service for the public. In doing so, the AHC provides unique opportunities for faculty development while realizing its mission of health leadership in the community.
This work has been supported with funding from a National Institutes of Health (NIH-NCRR) Science Education Partnership Award (SEPA) (Grant #1R25RR15976). The authors would like to thank the K–12 school personnel and students across Arkansas who participated in the Partners in Behavioral Health Sciences program between 2001 and 2005. Their support of PIBHS programs has been vital to our success. The authors would also like to thank E. Robert Burns, PhD, for providing the mentoring and guidance essential for the development of the PIBHS program, and E. Albert Reece, MD, PhD, MBA, and Greer Sullivan, MD, MSH, for their helpful comments on this manuscript. For their invaluable contributions to all aspects of this program, the authors recognize the following PIBHS faculty: Mary Lindsey, LCSW, Bruce Cohen, MS, Glen White, PhD, and Terry Miller, PhD. Finally, Shelia Romes, Penny White, and Shannon Elliott are acknowledged for their administrative support for the program.
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, where Dr. Kirchner is affiliated.
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