Minding the gap: Evidence, implementation and funding gaps in mental health services delivery for school-aged children.

State and local educational agencies are grappling with growing mental health needs among school-aged children that intensified during the COVID-19 pandemic. We undertake a case study of the experiences of one state, Tennessee, to examine the landscape of mental health interventions that are being deployed and to illuminate contextual factors that can support their implementation or exacerbate state and local challenges in addressing children's fast-rising mental health needs. We begin with an examination of the knowledge base on interventions and approaches that are commonly employed in K-12 schools to address children's mental health needs, including in Tennessee, with the aim to identify notable gaps in what we understand about their implementation and impacts on student outcomes. We find a lack of rigorous research that can inform efforts to improve the implementation and effectiveness of school-based mental health interventions. We bring this insight to our case-study analysis, which shows that this lack of guidance from research is compounded by inadequate, time-limited and fluctuating public funding that hinders local efforts to establish strong, ongoing programs that provide or connect K-12 students to essential mental health services. We call for more federal funding to support state and local implementation of proven and promising interventions for addressing children's mental health needs and more rigorous evaluations to strengthen the evidence base on their implementation and impacts.

An audit test evaluation of state practices for supporting access to and promoting Covid-19 vaccinations.

A field experiment, using a paired audit testing design with testers of different racial and language profiles, was conducted to document and evaluate individual encounters in inquiring about COVID-19 vaccinations in the U.S. states. Testers communicated with state health department and major vaccination site staff about obtaining the COVID-19 vaccine and assessed the extent to which evidence-informed communication tactics for encouraging take-up were employed. The audit testers included individuals representing Latinx identities, given research showing they face greater hardships in navigating vaccine infrastructure and place less trust in public immunization efforts. Data were collected in phone and electronic communications between mid-June and mid-August of 2021. Empirical analyses confirmed that states vary considerably in how clearly officials communicate vaccination requirements and procedures, and in what they ask of individuals before providing the opportunity to receive the COVID-19 vaccine. The Spanish-speaking tester was more likely to encounter negative or racialized language-primarily implicit in nature-such as calls abruptly ended (vs. attempting to secure language support) and requests for additional identification or personal information before continuing with vaccination registration. Examples of overtly negative or racist encounters included condescending comments about Latinx testers' identification (or perceived undocumented status) and the Spanish-speaking tester's communication in Spanish. Analysis of an index of good practices constructed from the audit data revealed that very few strategies for promoting vaccinations were regularly implemented. In regression analyses, an additional point on the good practices index predicted a 0.133 percentage point increase in the percent of the population receiving the first vaccine dose, suggesting the lack of implementation of these good practices may represent a missed opportunity to increase COVID-19 vaccination rates. We identified exemplars in the communications that the federal government could disseminate to rapidly improve state practices and the accessibility of accurate information on COVID-19 vaccination opportunities.

Parents' employment and children's wellbeing.

Since modern welfare reform began in the 1980s, we have seen low-income parents leave the welfare rolls and join the workforce in large numbers. At the same time, the Earned Income Tax Credit has offered a monetary incentive for low-income parents to work. Thus, unlike some of the other two-generation mechanisms discussed in this issue of Future of Children, policies that encourage low-income parents to work are both widespread and well-entrenched in the United States. But parents' (and especially mothers') work, writes Carolyn Heinrich, is not unambiguously beneficial for their children. On the one hand, working parents can be positive role models for their children, and, of course, the income they earn can improve their children's lives in many ways. On the other hand, work can impair the developing bond between parents and young children, especially when the parents work long hours or evening and night shifts. The stress that parents bring home from their jobs can detract from their parenting skills, undermine the atmosphere in the home, and thereby introduce stress into children's lives. Unfortunately, it is low-income parents who are most likely to work in stressful, low-quality jobs that feature low pay, little autonomy, inflexible hours, and few or no benefits. And low-income children whose parents are working are more likely to be placed in inadequate child care or to go unsupervised. Two-generation approaches, Heinrich writes, could maximize the benefits and minimize the detriments of parents' work by expanding workplace flexibility, and especially by mandating enough paid leave so that mothers can breastfeed and form close bonds with their infants; by helping parents place their children in high-quality child care; and by helping low-income parents train for, find, and keep a well-paying job with benefits.

Adoption and diffusion of evidence-based addiction medications in substance abuse treatment.

OBJECTIVE: To examine the roles of facility- and state-level factors in treatment facilities' adoption and diffusion of pharmaceutical agents used in addiction treatment. DATA SOURCES: Secondary data from the National Survey of Substance Abuse Treatment Services (N-SSATS), Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Medicare and Medicaid Services, Alcohol Policy Information System, and Kaiser Family Foundation. STUDY DESIGN: We estimate ordered logit and multinomial logit models to examine the relationship of state and treatment facility characteristics to the adoption and diffusion of three pharmaceutical agents over 4 years when each was at a different stage of adoption or diffusion. DATA COLLECTION: N-SSATS data with facility codes, obtained directly from SAMHSA, were linked by state identifiers to the other publicly available, secondary data. PRINCIPAL FINDINGS: The analysis confirms the importance of awareness and exposure to the adoption behavior of others, dissemination of information about the feasibility and effectiveness of innovations, geographical clustering, and licensing and accreditation in legitimizing facilities' adoption and continued use of pharmacotherapies in addiction treatment. CONCLUSIONS: Policy and administrative levers exist to increase the availability of pharmaceutical technologies and their continued use by substance abuse treatment facilities.

Role of state policies in the adoption of naltrexone for substance abuse treatment.

OBJECTIVE: To examine state policies associated with adoption of a pharmaceutical agent-naltrexone-by substance abuse treatment facilities to treat alcohol-dependent clients. DATA SOURCES: Facility-level data from the 2003 National Survey of Substance Abuse Treatment Services, and state-level data on policy and environmental factors from publicly available sources. STUDY DESIGN: We use facility- and state-level data in a cross-sectional, multilevel model to analyze state-level policies that are associated with treatment facilities' naltrexone adoption. DATA COLLECTION/EXTRACTION METHODS: The analysis uses survey data. PRINCIPAL FINDINGS: State Medicaid policies supporting the use of generic drugs, reducing drug costs, and permitting managed care organizations to establish policies encouraging use of generics were associated with higher odds of naltrexone adoption (by up to 96 percent). State policies limiting access to pharmaceutical technologies through Medicaid preferred drug lists, restricting access to pharmacy networks, and imposing general limitations on use of Medicaid benefits for rehabilitation for substance abuse treatment were associated with reduced odds of naltrexone adoption. CONCLUSIONS: Policy levers that are available to state governments are associated with the adoption of pharmaceutical technologies such as naltrexone that could help meet widespread need for access to clinically proven and cost-effective treatments for substance abuse.

Dimensions of publicness and performance in substance abuse treatment organizations.

Changes in funding, clientele, and treatment practices of public and privately owned substance abuse treatment programs, compelled in part by increased cost containment pressures, have prompted researchers' investigations of the implications of organizational form for treatment programs. These studies primarily probe associations between ownership status, patient characteristics, and services delivered and do not empirically link organizational form or structure to treatment outcomes. Data from the National Treatment Improvement Evaluation Study (NTIES) were used to study the relationship of ownership and other dimensions of publicness identified in the public management literature to patient outcomes, controlling for patient characteristics, treatment experiences, and other program characteristics. A few effects of organizational form and structure on substance abuse treatment outcomes are statistically significant (primarily improved social functioning), although the specific contributions of measures of ownership and publicness to explaining program-level variation are generally small.

Improving the organization, management, and outcomes of substance abuse treatment programs.

OBJECTIVE: This study presents an organizing framework for empirical analyses of substance abuse treatment program effectiveness, based on relevant theories of organization and public management and the body of substance abuse treatment studies, and is applied in analyses of treatment program data. METHOD: We use descriptive analyses of data from the National Treatment Improvement Evaluation Study that were collected from 519 substance abuse treatment service delivery units and 6593 patients to identify instruments of policy and management that might either frustrate or facilitate the implementation of "best practices" in substance abuse treatment. RESULTS: The analyses show statistically significant and substantively interesting relationships among measures of organizational structure and mission, financial management (e.g., revenues per patient and revenue sources), human resources management (e.g., staffing levels, the use of case managers, etc.), and measures of service technology (e.g., the provision of supportive services, counseling intensity, etc.). CONCLUSION: Researchers should strive to measure and account for the significant interactions among structural, management, and service technology variables in substance abuse treatment programs and the impact of these variables, mediated through patient characteristics and pre-treatment histories, on treatment outcomes.