Co-Principal Investigators: Bruns, Eric; Berliner, Lucy; Dorsey, Shannon; Cheney, Doug; and Vander Stoep, Ann

Purpose: In this project researchers developed, documented the feasibility of, established fidelity measures for, and pilot tested a school-based mental health intervention designed for high schools, the Brief Intervention for School Clinicians (BRISC). Research indicates that youth who experience mental health problems, especially those who do not receive appropriate, timely intervention, are at risk for academic failure. School-based services can improve access to help for students in need and improve their emotional and behavioral functioning. Furthermore, school-based mental health services also seem to have the potential to enhance academic achievement.

Project Activities: In this 3-year project, the researchers first convened national and local experts to review and provide feedback on preliminary BRISC protocols. Based on this input, they conducted an initial implementation study to evaluate feasibility and inform the development of fidelity measures. In the second year, the researchers conducted a validation study in public high schools with school-based health centers using a multiple case study design. In the final year, a small-scale randomized control trial (RCT) was used to test BRISC's potential for positive impact on student social, behavioral, mental health, and academic outcomes.

Key Outcomes:

• The project team developed BRISC, a 4-session assessment, engagement, triage, and initial intervention strategy for mental health clinicians working in high schools.
• BRISC is feasible, acceptable, and appropriate to the high school context.
• In the pilot RCT, BRISC was implemented with fidelity and was feasible and acceptable to both clinicians and students. BRISC students showed greater reduction in depression and anxiety symptoms, but similar academic outcomes, to students receiving services as usual. After four sessions, the majority of BRISC students were discharged without need for continued services, suggesting it could promote efficiency.

Structured Abstract

Setting: The study took place in a large urban center in Washington State.

Sample: Participants were 21 school-based health center clinicians and 96 high school students seeking mental health services. Students were 14-19 years of age and the majority were female. Parents/guardians and teachers also provided data.

Intervention: The Brief Intervention for School Clinicians (BRISC) is tailored to the school environment and characterized by five primary elements: (1) a systematic problem-solving approach to assist mental health providers with identifying key intervention targets, testing solutions, and supporting positive student development; (2) a modularized approach to delivering specific mental health intervention components common to evidence-based practices (e.g., coping strategies, mood changing skills, cognitive restructuring, communication analysis, and problem solving); (3) a stepped care/tiered structure in which a brief empirically based intervention (BRISC) is implemented prior to more intensive, extended, or expensive treatments; (4) culturally informed treatment engagement and motivation strategies; and (5) systematic assessment and monitoring of student behaviors and emotional states including checks of symptoms, mood, academic success, completion of practice activities, and satisfaction with the treatment process.

Research Design and Methods: In Year 1 of the project, the research team convened national and local experts to review and provide feedback on preliminary BRISC protocols. This input was used to create a "beta" version of the BRISC protocol that was implemented by doctoral-level clinicians on the research team with high school students. The goals of this initial implementation were to evaluate the BRISC protocol for feasibility and inform the development of fidelity measures. In Year 2, the researchers tested the validity of the BRISC protocol in public high schools with school-based mental health clinicians randomly assigned to implement BRISC or continue with delivery of services as usual. In Year 3, the researchers conducted a randomized controlled trial (RCT) to test BRISC's potential for positive impact on student mental health and academic outcomes. Students and clinicians were interviewed throughout to obtain feedback to inform the iterative development of the intervention.

Control Condition: Students in the control conditions in the validation study and in the RCT received mental health services as typically provided through the school-based health centers in the high schools (i.e., services as usual).

Key Measures: Student social, behavioral and mental health outcomes were assessed through the use of the Behavior Assessment System for Children-2 (BASC-2), the Columbia Impairment Scale (CIS), the Clinical Global Impressions Scale (CGI), and the Revised Ways of Coping Checklist (RWCC). Academic outcomes were assessed through the Engagement in School-Teacher Rating Scale (EIS) and the participating school district's online resource for students, families, and teachers to access student attendance, discipline and academic achievement data. Treatment satisfaction was assessed with the Youth Client Satisfaction Questionnaire (YCSQ). Process measures included the Therapy Process Observational Coding System-Strategies Scale and the Therapeutic Alliance Scale for Children (TASC).

Data Analytic Strategy: The researchers used descriptive analyses to determine intervention feasibility and basic psychometric analyses to validate fidelity measures. To determine BRISC's promise for improving student outcomes, the effects of BRISC versus services as usual at post-intervention were assessed using analysis of covariance for behaviors/emotions (BASC-2), therapeutic alliance (TASC) satisfaction (YCSQ), symptom severity (CGI), school engagement (EIS), functioning (CIS), and coping (RWCC). Mixed effects regression models were used to examine attendance, homework, class participation, and disciplinary actions (level 1) clustered within students (level 2), and students clustered within clinicians (level 3). Additional covariates were included in the model including baseline youth symptom severity, therapeutic alliance (TASC), and BRISC fidelity. For all analyses, the researchers checked for potential selection bias due to attrition. Data missing at random was modeled using maximum likelihood estimation; the researchers used all student data including students providing partial data.

Related Projects: Efficacy of a Brief Intervention Strategy for School Mental Health Clinicians (R305A160111)

Products and Publications

Journal article, monograph, or newsletter

Bruns, E.J., Duong, M., Lyon, A.R., Pullman, M.D., Cook, C., and McCauley, E. (2016). Fostering SMART Partnerships to Develop Integrated Behavioral Health Services in Schools. American Journal of Orthopsychiatry, 86 (2): 156–170.

Bruns, E.J., Pullmann, M.D., Nicodimos, S., Lyon, A. R., Ludwig, K., Namkung, N., and McCauley, E. (2019). Pilot Test of an Engagement, Triage, and Brief Intervention Strategy for School Mental Health. School Mental Health 11, 148–162. https://doi.org/10.1007/s12310-018-9277-0

Lyon, A.R., Bruns, E.J., Ludwig, K., Vander Stoep, A., Pullmann, M.D., Dorsey, S., Eaton, J., Hendrix, E., and McCauley, E. (2015). The Brief Intervention for School Clinicians (BRISC): A Mixed-Methods Evaluation of Feasibility, Acceptability, and Contextual Appropriateness. School Mental Health, 7 (4): 273–286.

Lyon, A.R., Bruns, E.J., Weathers, E.S., Canavas, N., Ludwig, K., Vander Stoep, A., Cheney, D., and McCauley, E. (2014). Taking EBPs to school: Developing and Testing a Framework for Applying Common Elements of Evidence Based Practice to School Mental Health. Advances in School Mental Health Promotion, 7 (1): 42–61.

Lyon, A.R., Lau, A., McCauley, E., Vander Stoep, A., and Chorpita, B.F. (2014). A Case for Modular Design: Implications for Implementing Evidence-Based Interventions With Culturally-Diverse Youth. Professional Psychology: Research and Practice, 45 (1): 57–66.

Lyon, A.R., Ludwig, K., Romano, E., Koltracht, J., Vander Stoep, A., and McCauley, E. (2014). Using Modular Psychotherapy in School Mental Health: Provider Perspectives on Intervention-Setting fit. Journal of Clinical Child and Adolescent Psychology, 43 (6): 890–901.

Whitaker, K., Fortier, A., Bruns, E. J., Nicodimos, S., Ludwig, K., Lyon, A. R., ... & McCauley, E. (2018). How do School Mental Health Services Vary Across Contexts? Lessons Learned From Two Efforts to Implement a Research-Based Strategy. School Mental Health, 1–13.