Multi-tiered, Evidence-Based Systems of Support

  • Thomas J. PowerEmail author
  • Seth D. Laracy


The most commonly used service delivery systems for pediatric behavioral health care are primary care practices and schools. Increasingly, pediatric behavioral health care is being integrated with medical care to provide more comprehensive and coordinated services for children. Unfortunately, behavioral health services offered in primary care and school are disconnected, resulting in parents being in the position of attempting to coordinate care, which may not be feasible for many families, especially those experiencing heightened levels of stress and limited resources. In this chapter, we propose a cross-system service delivery framework that links integrated services based in primary care with services based in schools. This framework is based on a multi-tier, public health model that provides a continuum of prevention and intervention services.


Pediatrics Integrated care Behavioral health Collaborative care Health care systems 



Preparation of this chapter was supported by a grant from Pfizer Independent Grants for Learning and Change.


  1. Adams, C. D., Hinojosa, S., Armstrong, K., Takagishi, J., & Dabrow, S. (2016). An innovative model of integrated behavioral health: School psychologists in pediatric primary care settings. Advances in School Mental Health Promotion, 9, 188–200.CrossRefGoogle Scholar
  2. American Academy of Pediatrics. (2002). The medical home. Pediatrics, 110, 184–186.CrossRefGoogle Scholar
  3. Asarnow, J., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics, 169, 929–937.CrossRefGoogle Scholar
  4. Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., … Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive and Behavioral Practice, 22, 5–19.CrossRefGoogle Scholar
  5. Boyle, C. A., Boulet, S., Schieve, L. A., Cohen, R. A., Blumberg, S. J., Yeargin-Allsopp, M., … Kogan, M. D. (2011). Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics, 127, 1034–1042.CrossRefGoogle Scholar
  6. Buchholz, M., & Talmi, A. (2012). What we talked about at the pediatrician’s office: Exploring differences between Health Steps and traditional pediatric primary care visits. Infant Mental Health Journal, 33, 430–436.CrossRefGoogle Scholar
  7. Casey, B. M., Andrews, N., Schindler, H., Kersh, J. E., Samper, A., & Copley, J. (2008). The development of spatial skills through interventions involving block building activities. Cognition and Instruction, 26, 269–309.CrossRefGoogle Scholar
  8. Chan, E., Fleegler, E., Weas, S., Zhang, X., Rhodes, E., Kahn, J., … Loddenkemper, T. (2016). Implementation of an internet-based patient monitoring system improves families’ perception of quality of communication and experience of care. Paper presented at the Pediatric Academic Societies Annual Meeting, Baltimore, MD.Google Scholar
  9. Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, & Medical Home Initiatives for Children with Special Needs Project Advisory Committee. (2006). Identifying infants and young children with developmental surveillance and screening. Pediatrics, 118, 405–420.CrossRefGoogle Scholar
  10. Driscoll, K. C., Wang, L., Mashburn, A. J., & Pianta, R. C. (2011). Fostering supportive teacher-child relationships: Intervention implementation in a state-funded preschool program. Early Education and Development, 22, 593–619.CrossRefGoogle Scholar
  11. Duchnowski, A. J., Kutash, K., & Friedman, R. M. (2002). Community-based interventions in a systems of care and outcomes framework. In B. J. Burns & K. Hoagwood (Eds.), Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders (pp. 16–37). New York: Oxford University Press.CrossRefGoogle Scholar
  12. Epstein, J., Langberg, J., Lichtenstein, P., Kolb, R., Altaye, M., & Simon, J. (2011). Use of an internet portal to improve community-based pediatric ADHD care: A cluster randomized trial. Pediatrics, 128, e1201–e1208.CrossRefGoogle Scholar
  13. Gilbody, S., Bower, P., Fletcher, J., Richards, D., & Sutton, A. J. (2006). Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine, 166, 2314–2321.CrossRefGoogle Scholar
  14. Ginsburg, K. R. (2007). The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics, 119, 182–191.CrossRefGoogle Scholar
  15. Guevara, J., Fuedtner, C., Romer, D., Power, T., Eiraldi, R., Nihtianova, S., … Schwarz, D. (2005). Fragmented care for inner-city minority children with attention-deficit/hyperactivity disorder. Pediatrics, 116, e512–e517.CrossRefGoogle Scholar
  16. Hamre, B. K., & Pianta, R. C. (2001). Early teacher-child relationships and the trajectory of children’s school outcomes through eighth grade. Child Development, 72, 625–638.CrossRefGoogle Scholar
  17. Hamre, B. K., Pianta, R. C., Mashburn, A. J., & Downer, J. T. (2012). Promoting young children’s social competence through the preschool PATHS curriculum and MyTeachingPartner professional development resources. Early Education and Development, 23, 809–832.CrossRefGoogle Scholar
  18. Hughes, J. N., Im, M. H., & Wehrly, S. E. (2014). Effect of peer nominations of teacher-student support at individual and classroom levels on social and academic outcomes. Journal of School Psychology, 52, 309–322.CrossRefGoogle Scholar
  19. Katon, W., Von Korff, M., Lin, E., & Simon, G. (2001). Rethinking practitioner roles in chronic illness: The specialist, primary care physician, and the practice nurse. General Hospital Psychiatry, 23, 138–144.CrossRefGoogle Scholar
  20. Kazak, A. E., Rourke, M. T., Alderfer, M. A., Pai, A., Reilly, A. F., & Meadows, A. T. (2007). Evidence-based assessment, intervention and psychosocial care in pediatric oncology: A blueprint for comprehensive services across treatment. Journal of Pediatric Psychology, 32, 1099–1110.CrossRefGoogle Scholar
  21. Kolko, D. J., Campo, J., Kilbourne, A. M., Hart, J., Sakolsky, D., & Wisniewski, S. (2014). Collaborative care outcomes for pediatric behavioral health problems: A cluster randomized trial. Pediatrics, 133, e981–e992.CrossRefGoogle Scholar
  22. Kolko, D. J., Campo, J. V., Kilbourne, A. M., & Kelleher, K. (2012). Doctor-office collaborative care for pediatric behavioral problems: A preliminary clinical trial. Archives of Pediatrics & Adolescent Medicine, 166, 224–231.CrossRefGoogle Scholar
  23. Mandell, D. M., Guevara, J. P., & Pati, S. (2007). The search for coordinated, continuous community-based care: How the parallel efforts of the Medical Home and Systems of Care can inform each other. In W. J. Fisher (Ed.), Research on community-based mental health services for children and adolescents (pp. 77–94). Amsterdam: JAI Press.Google Scholar
  24. Mautone, J. A., Marcell, E., Tresco, K. E., & Power, T. J. (2015). Assessing the quality of parent-teacher relationships for students with ADHD. Psychology in the Schools, 52, 196–207.CrossRefGoogle Scholar
  25. McDaniel, S. H., Grus, C. L., Cubic, B. A., Hunter, C. L., Kearney, L. K., Schuman, C. C., … Johnson, S. B. (2014). Competencies for psychology practice in primary care. American Psychologist, 69, 409–429.CrossRefGoogle Scholar
  26. Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., … Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity survey replication-adolescent supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980–989.CrossRefGoogle Scholar
  27. Pallini, S., Baiocco, R., Schneider, B. H., Madigan, S., & Atkinson, L. (2014). Early child-parent attachment and peer relations: A meta-analysis of recent research. Journal of Family Psychology, 28, 118–123.CrossRefGoogle Scholar
  28. Pfiffner, L. J., Rooney, M., Haack, L., Villodas, M., Delucchi, K., & McBurnett, K. (2016). A randomized controlled trial of a school-implemented school-home intervention for Attention-Deficit/Hyperactivity Disorder symptoms and impairment. Journal of the American Academy of Child & Adolescent Psychiatry, 55, 762–770.CrossRefGoogle Scholar
  29. Power, T. J., Blum, N. J., Guevara, J. P., Jones, H. A., & Leslie, L. K. (2013). Coordinating mental health care across primary care and schools: ADHD as a case example. Advances in School Mental Health Promotion, 6, 68–80.CrossRefGoogle Scholar
  30. Power, T. J., Hughes, C. L., Helwig, J. R., Nissley-Tsiopinis, J., Mautone, J. A., & Lavin, H. J. (2010). Getting to first base: Promoting engagement in family–school intervention for children with ADHD in urban, primary care practice. School Mental Health, 2, 52–61.CrossRefGoogle Scholar
  31. Power, T. J., Mautone, J. A., Marshall, S. A., Jones, H. A., Cacia, J., Tresco, K., … Blum, N. J. (2014). Feasibility and potential effectiveness of integrated services for children with ADHD in urban primary care practices. Clinical Practice in Pediatric Psychology, 2, 412–426.CrossRefGoogle Scholar
  32. Power, T. J., Michel, J., Mayne, S., Miller, J., Blum, N. J., Grundmeier, R. W., … Fiks, A. G. (2016). Coordinating systems of care using health information technology: Development of the ADHD Care Assistant. Advances in School Mental Health Promotion, 9, 201–218.CrossRefGoogle Scholar
  33. Roorda, D. L., Verschueren, K., Vancraeyveldt, C., Van Craeyvelt, S., & Copin, H. (2014). Teacher-child relationships and behavioral adjustment: Transactional links for preschool boys at risk. Journal of School Psychology, 52, 495–510.CrossRefGoogle Scholar
  34. Rosenberg, S. A., Robinson, C. C., Shaw, E. F., & Ellison, M. C. (2013). Part C early intervention for infants and toddlers: Percentage eligible versus served. Pediatrics, 131, 38–46.CrossRefGoogle Scholar
  35. Rudasill, K. M., Niehaus, K., Buhs, E., & White, J. M. (2013). Temperament in early childhood and peer interactions in third grade: The role of teacher-child relationships in early elementary grades. Journal of School Psychology, 51, 701–716.CrossRefGoogle Scholar
  36. Sanders, M. R. (2012). Development, evaluation, and multinational dissemination of the Triple P-Positive Parenting Program. Annual Review of Clinical Psychology, 8, 345–379.CrossRefGoogle Scholar
  37. Serbin, L. A., Hubert, M., Hastings, P. D., Stack, D. M., & Schwartzman, A. E. (2014). The influence of parenting on early childhood health and health care utilization. Journal of Pediatric Psychology, 39, 1161–1174.CrossRefGoogle Scholar
  38. Sheridan, S. M., Bovaird, J. A., Glover, T. A., Garbacz, S. A., Witte, A., & Kwon, K. (2012). A randomized trial examining the effects of conjoint behavioral consultation and the mediating role of the parent-teacher relationship. School Psychology Review, 41, 23–46.Google Scholar
  39. Sheridan, S. M., & Kratochwill, T. R. (2008). Conjoint behavioral consultation: Promoting family-school connections and interventions (2nd ed.). New York: Springer Science + Business Media.Google Scholar
  40. Sheridan, S. M., Warnes, E. D., Woods, K. E., Blevins, C. A., Magee, K. L., & Ellis, C. (2009). An exploratory evaluation of conjoint behavioral consultation to promote collaboration among family, school, and pediatric systems: A role for pediatric school psychologists. Journal of Educational and Psychological Consultation, 19, 106–129.CrossRefGoogle Scholar
  41. Sroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study from birth to adulthood. Attachment & Human Development, 7, 349–367.CrossRefGoogle Scholar
  42. Stroul, B. A., & Friedman, R. M. (1986). A system of care for children and youth with severe emotional disturbances. Washington, DC: Georgetown University Child Development Center.Google Scholar
  43. Sugai, G., & Horner, R. R. (2006). A promising approach for expanding and sustaining school-wide positive behavior support. School Psychology Review, 35, 245–259.Google Scholar
  44. Toomey, S. L., Finkelstein, J., & Kuhlthau, K. (2008). Does connection to primary care matter for children with attention-deficit/hyperactivity disorder? Pediatrics, 122, 368–374.CrossRefGoogle Scholar
  45. Volpe, R. J., & Fabiano, G. A. (2013). Daily behavior report cards: An evidence-based system of assessment and intervention. New York: Guilford.Google Scholar
  46. Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Failure and delay in initial treatment contact after first onset of mental disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62, 603–613.CrossRefGoogle Scholar
  47. Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: Intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33, 105–124.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of PediatricsThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Department of Child and Adolescent Psychiatry and Behavioral SciencesPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA
  3. 3.Easton Area School DistrictEastonUSA

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