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Modeling the Impact of School-Based Universal Depression Screening on Additional Service Capacity Needs: A System Dynamics Approach

  • Aaron R. Lyon
  • Melissa A. Maras
  • Christina M. Pate
  • Takeru Igusa
  • Ann Vander Stoep
Original Article

Abstract

Although it is widely known that the occurrence of depression increases over the course of adolescence, symptoms of mood disorders frequently go undetected. While schools are viable settings for conducting universal screening to systematically identify students in need of services for common health conditions, particularly those that adversely affect school performance, few school districts routinely screen their students for depression. Among the most commonly referenced barriers are concerns that the number of students identified may exceed schools’ service delivery capacities, but few studies have evaluated this concern systematically. System dynamics (SD) modeling may prove a useful approach for answering questions of this sort. The goal of the current paper is therefore to demonstrate how SD modeling can be applied to inform implementation decisions in communities. In our demonstration, we used SD modeling to estimate the additional service demand generated by universal depression screening in a typical high school. We then simulated the effects of implementing “compensatory approaches” designed to address anticipated increases in service need through (1) the allocation of additional staff time and (2) improvements in the effectiveness of mental health interventions. Results support the ability of screening to facilitate more rapid entry into services and suggest that improving the effectiveness of mental health services for students with depression via the implementation of an evidence-based treatment protocol may have a limited impact on overall recovery rates and service availability. In our example, the SD approach proved useful in informing systems’ decision-making about the adoption of a new school mental health service.

Keywords

Screening Depression Implementation System dynamics modeling School mental health 

Notes

Acknowledgments

This publication was made possible in part by funding from Grant Number K08 MH095939, awarded to the first author from the National Institute of Mental Health (NIMH). Dr. Lyon is an investigator with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (R25 MH080916) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI) and grant number U54HD070725 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), which is co-funded by the NICHD and the Office of Behavioral and Social Sciences Research (OBSSR). Dr. Pate’s work was conducted under postdoctoral fellowship support by grant number 5T32MH019545-20, awarded by the National Institute of Mental Health (NIMH) as part of a National Research Service Award Institutional Training Grant (NRSA, T32) at the Johns Hopkins Bloomberg School of Public Health.

References

  1. Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 4–23. doi: 10.1007/s10488-010-0327-7.PubMedCentralCrossRefPubMedGoogle Scholar
  2. Adelman, H. S., & Taylor, L. (2007). Systemic change for school improvement. Journal of Educational and Psychological Consultation, 17(1), 55–77. doi: 10.1207/s1532768Xjepc1701_3.CrossRefGoogle Scholar
  3. American School Counselor Association (2011). Student-to-Counselor Ratio by State 2010–2011. Retrieved from http://www.schoolcounselor.org/asca/media/asca/home/ratios10-11.pdf. Accessed 14 Jan 2015.
  4. Angold, A., Costello, E. J., Pickles, A., Winder, F., & Silver, D. (1987). The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Unpublished manuscript.Google Scholar
  5. Banh, M. K., Crane, P. K., Rhew, I., Gudmundsen, G., Stoep, A. V., Lyon, A., & McCauley, E. (2012). Measurement equivalence across racial/ethnic groups of the mood and feelings questionnaire for childhood depression. Journal of Abnormal Child Psychology, 40(3), 353–367.PubMedCentralCrossRefPubMedGoogle Scholar
  6. Becker, E. M., & Jensen-Doss, A. (2013). Computer-assisted therapies: Examination of therapist-level barriers to their use. Behavior Therapy, 44(4), 614–624.CrossRefPubMedGoogle Scholar
  7. Best, K. M., Hauser, S. T., Gralinski-Bakker, J. H., Allen, J. P., & Crowell, J. (2004). Adolescent psychiatric hospitalization and mortality, distress levels, and educational attainment: Follow up after 11 and 20 years. Archives of Pediatrics and Adolescent Medicine, 158(8), 749–752. doi: 10.1001/archpedi.158.8.749.CrossRefPubMedGoogle Scholar
  8. Bohanon, H., & Wu, M. J. (2011). Can prevention programs work together? An example of school-based mental health with prevention initiatives. Advances in School Mental Health Promotion, 4(4), 35–46.CrossRefGoogle Scholar
  9. Box, G. E., & Draper, N. R. (1987). Empirical model-building and response surfaces. New York: Wiley.Google Scholar
  10. Bradshaw, C. P., Buckley, J., & Ialongo, N. (2008). School-based service utilization among urban children with early-onset educational and mental health problems: The squeaky wheel phenomenon. School Psychology Quarterly, 23(2), 169–186. doi: 10.1037/1045-3830.23.2.169.CrossRefGoogle Scholar
  11. Brener, N. D., Weist, M., Adelman, H., Taylor, L., & Vernon‐Smiley, M. (2007). Mental health and social services: Results from the school health policies and programs study 2006. Journal of School Health, 77(8), 486–499.Google Scholar
  12. Burns, T., White, I., Byford, S., Fiander, M., Creed, F., & Fahy, T. (2002). Exposure to case management: Relationships to patient characteristics and outcome: Report from the UK 700 trial. The British Journal of Psychiatry, 181(3), 236–241.CrossRefPubMedGoogle Scholar
  13. Chartier, M., Vander Stoep, A., McCauley, E., Herting, J. R., Tracy, M., & Lymp, J. (2008). Passive versus active parental permission: Implications for the ability of school-based depression screening to reach youth at risk. Journal of School Health, 78(3), 157–164.PubMedCentralCrossRefPubMedGoogle Scholar
  14. Chorpita, B. F., Weisz, J. R., Daleiden, E. L., Schoenwald, S. K., Palinkas, L. A., Miranda, J., et al. (2013). Long-term outcomes for the Child STEPs randomized effectiveness trial: A comparison of modular and standard treatment designs with usual care. Journal of Consulting and Clinical Psychology, 81(6), 999.CrossRefPubMedGoogle Scholar
  15. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci, 4(1), 50.PubMedCentralCrossRefPubMedGoogle Scholar
  16. David-Ferdon, C., & Kaslow, N. J. (2008). Evidence-based psychosocial treatments for child and adolescent depression. Journal of Clinical Child & Adolescent Psychology, 37(1), 62–104.CrossRefGoogle Scholar
  17. De Leo, D., & Heller, T. S. (2004). Who are the kids who self-harm? An Australian self-report school survey. Medical Journal of Australia, 181(3), 140–144.PubMedGoogle Scholar
  18. Dever, B. V., Raines, T. C., & Barclay, C. M. (2012). Chasing the unicorn: Practical implementation of universal screening for behavioral and emotional risk. School Psychology Forum: Research in Practice, 6(4), 108–118.Google Scholar
  19. Dowdy, E., Ritchey, K., & Kamphaus, R. W. (2010). School-based screening: A population-based approach to inform and monitor children’s mental health needs. School Mental Health, 2(4), 166–176.PubMedCentralCrossRefPubMedGoogle Scholar
  20. Dwyer, S. B., Nicholson, J. M., & Battistutta, D. (2006). Parent and teacher identification of children at risk of developing internalizing or externalizing mental health problems: A comparison of screening methods. Prevention Science, 7(4), 343–357.CrossRefPubMedGoogle Scholar
  21. Eklund, K., & Dowdy, E. (2014). Screening for behavioral and emotional risk versus traditional school identification methods. School Mental Health, 6(1), 40–49.CrossRefGoogle Scholar
  22. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network.Google Scholar
  23. Flaspohler, P. D., Duffy, J., Wandersman, A., Stillman, L., & Maras, M. A. (2008). Unpacking prevention capacity: An intersection of research-to-practice models and community-centered models. American Journal of Community Psychology, 41(3–4), 182–196.CrossRefPubMedGoogle Scholar
  24. Flaspohler, P. D., Meehan, C., Maras, M. A., & Keller, K. E. (2012). Ready, willing, and able: Developing a support system to promote implementation of school-based prevention programs. American Journal of Community Psychology, 50(3–4), 428–444.CrossRefPubMedGoogle Scholar
  25. Fletcher, J. M. (2008). Adolescent depression: Diagnosis, treatment, and educational attainment. Health Economics, 17, 1215–1235. doi: 10.1002/hec.1319.CrossRefPubMedGoogle Scholar
  26. Forrester, J. W. (2009). Learning through system dynamics as preparation for the 21st century. Acton, MA: Creative Learning Exchange.Google Scholar
  27. Foster, S., Rollefson, M., Doksum, T., Noonan, D., Robinson, G., & Teich, J. (2005). School Mental Health Services in the United States, 2002–2003. Substance Abuse and Mental Health Services Administration. DHHS Pub. No. SMA-05-4068. Rockville, MD.Google Scholar
  28. Fox, J. K., Halpern, L. F., & Forsyth, J. P. (2008). Mental health checkups for children and adolescents: A means to identify, prevent, and minimize suffering associated with anxiety and mood disorders. Clinical Psychology: Science and Practice, 15(3), 182–211.Google Scholar
  29. Green, J. G., McLaughlin, K. A., Alegría, M., Costello, E. J., Gruber, M. J., Hoagwood, K., et al. (2013). School mental health resources and adolescent mental health service use. Journal of the American Academy of Child & Adolescent Psychiatry, 52(5), 501–510.CrossRefGoogle Scholar
  30. Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H. (1997). Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65(5), 821.CrossRefPubMedGoogle Scholar
  31. Hirsch, G. B., Levine, R., & Miller, R. L. (2007). Using system dynamics modeling to understand the impact of social change initiatives. American Journal of Community Psychology, 39(3–4), 239–253. doi: 10.1007/s10464-007-9114-3.CrossRefPubMedGoogle Scholar
  32. Homer, J. B., & Hirsch, G. B. (2006). System dynamics modeling for public health: Background and opportunities. American Journal of Public Health, 96(3), 452–458. doi: 10.2105/AJPH.2005.062059.PubMedCentralCrossRefPubMedGoogle Scholar
  33. Hovmand, P. S. (2013). Community Based System Dynamics. New York: Springer.Google Scholar
  34. Individuals with Disabilities Improvement Education Act of 2004, Pub. L 101-476, 104 Stat. 1142, codified as amended at 20 U.S.C. § 1400.Google Scholar
  35. Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among US children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), 1548–1555.CrossRefPubMedGoogle Scholar
  36. Kuo, E., Stoep, A. V., McCauley, E., & Kernic, M. A. (2009). Cost-effectiveness of a school-based emotional health screening program. Journal of School Health, 79(6), 277–285.PubMedCentralCrossRefPubMedGoogle Scholar
  37. Leischow, S. J., & Milstein, B. (2006). Systems thinking and modeling for public health practice. American Journal of Public Health, 96(3), 403.PubMedCentralCrossRefPubMedGoogle Scholar
  38. Levy, D. T., Mabry, P. L., Graham, A. L., Orleans, C. T., & Abrams, D. B. (2010). Exploring scenarios to dramatically reduce smoking prevalence: A simulation model of the three-part cessation process. American Journal of Public Health, 100(7), 1253–1259.PubMedCentralCrossRefPubMedGoogle Scholar
  39. Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1998). Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review, 18(7), 765–794.CrossRefPubMedGoogle Scholar
  40. Lyon, A. R., Ludwig, K. A., Romano, E., Koltracht, J., Vander Stoep, A., & McCauley, E. (2014). Using modular psychotherapy in school mental health: Provider perspectives on intervention-setting fit. Journal of Clinical Child & Adolescent Psychology, 43, 890–901.CrossRefGoogle Scholar
  41. Lyon, A. R., Ludwig, K. A., Vander Stoep, A., Gudmundsen, G., & McCauley, E. (2013). Patterns and predictors of mental healthcare utilization in schools and other service sectors among adolescents at risk for depression. School Mental Health, 5(3), 155–165.CrossRefGoogle Scholar
  42. Mabry, P. L., Olster, D. H., Morgan, G. D., & Abrams, D. B. (2008). Interdisciplinarity and systems science to improve population health: A view from the NIH office of behavioral and social sciences research. American Journal of Preventive Medicine, 35(2 Suppl), S211–S224. doi: 10.1016/j.amepre.2008.05.018.PubMedCentralCrossRefPubMedGoogle Scholar
  43. Maras, M., Thompson, A. M., Thornburg, K. R., Hawks, J. S., & Lewis, C. (in press). The transprofessional integration of behavior, academic, and social emotional learning. Journal of Educational & Psychological Counseling.Google Scholar
  44. McCormick, E., Thompson, K., Vander Stoep, A., & McCauley, E. (2009). The case for school-based depression screening: Evidence from established programs. Report on Emotional and Behavioral Disorders in Youth, Fall, pp. 91–99.Google Scholar
  45. Meadows, D. H. (1999). Leverage points: Places to intervene is a system. Heartland, VT: The Sustainability Institute.Google Scholar
  46. Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., et al. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980–989.PubMedCentralCrossRefPubMedGoogle Scholar
  47. Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012). The quality implementation framework: A synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50(3–4), 462–480.CrossRefPubMedGoogle Scholar
  48. Moor, S., Ann, M., Hester, M., Elisabeth, W. J., Robert, E., Robert, W., & Caroline, B. (2007). Improving the recognition of depression in adolescence: Can we teach the teachers? Journal of Adolescence, 30(1), 81–95.CrossRefPubMedGoogle Scholar
  49. Mufson, L., Dorta, K. P., Moreau, D., & Weissman, M. M. (2011). Interpersonal psychotherapy for depressed adolescents (2nd ed.). New York: Guilford.Google Scholar
  50. Mufson, L. H., Dorta, K. P., Olfson, M., Weissman, M. M., & Hoagwood, K. (2004a). Effectiveness research: Transporting interpersonal psychotherapy for depressed adolescents (IPT-A) from the lab to school-based health clinics. Clinical Child and Family Psychology Review, 7(4), 251–261.CrossRefPubMedGoogle Scholar
  51. Mufson, L., Dorta, K. P., Wickramaratne, P., Nomura, Y., Olfson, M., & Weissman, M. M. (2004b). A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Archives of General Psychiatry, 61(6), 577–584.CrossRefPubMedGoogle Scholar
  52. Mufson, L., Weissman, M. M., Moreau, D., & Garfinkel, R. (1999). Efficacy of interpersonal psychotherapy for depressed adolescents. Archives of General Psychiatry, 56(6), 573–579.CrossRefPubMedGoogle Scholar
  53. New Freedom Commission on Mental Health. (2003). Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD.Google Scholar
  54. Olmstead, T., Carroll, K. M., Canning-Ball, M., & Martino, S. (2011). Cost and cost-effectiveness of three strategies for training clinicians in motivational interviewing. Drug and Alcohol Dependence, 116(1), 195–202.PubMedCentralCrossRefPubMedGoogle Scholar
  55. Pullmann, M. D., Bruns, E. J., Daly, B. P., & Sander, M. A. (2013). Improving the evaluation and impact of mental health and other supportive school-based programmes on students’ academic outcomes. Advances in School Mental Health Promotion, 6(4), 226–230.Google Scholar
  56. Roderick, M. (2012). Drowning in data but thirsty for analysis. Teachers College Record, 114(11), 1–9.Google Scholar
  57. Romer, D., & McIntosh, M. (2005). The role of primary care physicians in detection and treatment of adolescent mental health problems. In D. L. Evans & E. B. Foa (Eds.), Treating and preventing adolescent mental health disorders: What we know and what we don’t know (p. 579). New York: Oxford.CrossRefGoogle Scholar
  58. Rosselló, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734.CrossRefPubMedGoogle Scholar
  59. Scott, M. A., Wilcox, H. C., Schonfeld, I. S., Davies, M., Hicks, R. C., Turner, J. B., & Shaffer, D. (2009). School-based screening to identify at-risk students not already known to school professionals: the Columbia suicide screen. American Journal of Public Health, 99(2), 334–339.PubMedCentralCrossRefPubMedGoogle Scholar
  60. Severson, H. H., Walker, H. M., Hope-Doolittle, J., Kratochwill, T. R., & Gresham, F. M. (2007). Proactive, early screening to detect behaviorally at-risk students: Issues, approaches, emerging innovations, and professional practices. Journal of School Psychology, 45, 193–223. doi: 10.1016/j.jsp.2006.11.003.CrossRefGoogle Scholar
  61. Shaffer, D., Gould, M. S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53(4), 339–348.CrossRefPubMedGoogle Scholar
  62. Sterman, J. D. (2000). Business dynamics: Systems thinking and modeling for a complex world. Boston, MA: McGraw-Hill.Google Scholar
  63. Sterman, J. D. (2006). Learning from evidence in a complex world. American Journal of Public Health, 96(3), 505–514.PubMedCentralCrossRefPubMedGoogle Scholar
  64. Stirman, S. W., Kimberly, J., Cook, N., Calloway, A., Castro, F., & Charns, M. (2012). The sustainability of new programs and innovations: A review of the empirical literature and recommendations for future research. Implementation Science, 7(1), 1–19.CrossRefGoogle Scholar
  65. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2008). The NSDUH Report - Major depressive episode among youths aged 12 to 17 in the United States: 2004 to 2006. Rockville, MD: Substance Abuse and Mental Health Services Administration.Google Scholar
  66. Tobias, M. I., Cavana, R. Y., & Bloomfield, A. (2010). Application of a system dynamics model to inform investment in smoking cessation services in New Zealand. American Journal of Public Health, 100(7), 1274–1281.PubMedCentralCrossRefPubMedGoogle Scholar
  67. U.S. Department of Education Office of Special Education and Rehabilitative Services. (2002). A new era: Revitalizing special education for children and their families. Washington, DC.Google Scholar
  68. U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.Google Scholar
  69. U.S. Public Health Service. (2000). Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. Department of Health and Human Services, Washington, DC. Stock No. 017-024-01659-4 ISBN No. 0-16-050637-9.Google Scholar
  70. Vander Stoep, A., McCauley, E., Thompson, K. A., Herting, J. R., Kuo, E. S., Stewart, D. G., et al. (2005). Universal emotional health screening at the middle school transition. Journal of Emotional and Behavioral Disorders, 13(4), 213–223.CrossRefGoogle Scholar
  71. Ventana Systems, Inc. (2006). Vensim PLE Software, Ventana Systems Inc. Retrieved May 30, 2014, from the website temoa: Open Educational Resources (OER) Portal at http://www.temoa.info/node/3682.
  72. Walker, B., Cheney, D., Stage, S., Blum, C., & Horner, R. H. (2005). Schoolwide screening and positive behavior supports identifying and supporting students at risk for school failure. Journal of Positive Behavior Interventions, 7(4), 194–204.CrossRefGoogle Scholar
  73. Walker, S. C., Kerns, S. E., Lyon, A. R., Bruns, E. J., & Cosgrove, T. J. (2010). Impact of school-based health center use on academic outcomes. Journal of Adolescent Health, 46(3), 251–257.CrossRefPubMedGoogle Scholar
  74. Warren, K. (2004). Why has feedback systems thinking struggled to influence strategy and policy formulation? Suggestive evidence, explanations and solutions. Systems Research and Behavioral Science, 21(4), 331–347.CrossRefGoogle Scholar
  75. Weersing, V. R., & Weisz, J. R. (2002). Community clinic treatment of depressed youth: Benchmarking usual care against CBT clinical trials. Journal of Consulting and Clinical Psychology, 70(2), 299.CrossRefPubMedGoogle Scholar
  76. Weist, M. D. (2008). Enhancing implementation quality. Advances in School Mental Health Promotion, 1(3), 2–5.CrossRefGoogle Scholar
  77. Weist, M. D., Rubin, M., Moore, E., Adelsheim, S., & Wrobel, G. (2007). Mental health screening in schools. Journal of School Health, 77(2), 53–58.CrossRefPubMedGoogle Scholar
  78. Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., et al. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69(3), 274–282.CrossRefPubMedGoogle Scholar
  79. Weisz, J. R., Jensen-Doss, A., & Hawley, K. M. (2006a). Evidence-based youth psychotherapies versus usual clinical care: A meta-analysis of direct comparisons. American Psychologist, 61(7), 671.CrossRefPubMedGoogle Scholar
  80. Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006b). Effects of psychotherapy for depression in children and adolescents: A meta-analysis. Psychological Bulletin, 132(1), 132.PubMedCentralCrossRefPubMedGoogle Scholar
  81. Wilcox-Gok, V., DE Marcotte, Farahati, F., & Borkoski, C. (2004). Early onset depression and high school dropout. In D. Marcotte & V. Wilcox-Gok (Eds.), Research in human capital and development: The economics of gender and mental illness (Vol. 15, pp. 27–51). Amsterdam: Elsevier Science.CrossRefGoogle Scholar
  82. Williams, S. B., O’Connor, E. A., Eder, M., & Whitlock, E. P. (2009). Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics, 123(4), e716–e735.CrossRefPubMedGoogle Scholar
  83. Young, J. F., Mufson, L., & Davies, M. (2006). Efficacy of Interpersonal Psychotherapy‐Adolescent Skills Training: An indicated preventive intervention for depression. Journal of Child Psychology and Psychiatry, 47(12), 1254–1262.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Aaron R. Lyon
    • 1
  • Melissa A. Maras
    • 2
  • Christina M. Pate
    • 4
  • Takeru Igusa
    • 3
  • Ann Vander Stoep
    • 1
  1. 1.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleUSA
  2. 2.University of MissouriColumbiaUSA
  3. 3.Johns Hopkins UniversityBaltimoreUSA
  4. 4.Health & Human Development ProgramWestEdLos AlamitosUSA

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