Key Themes in the National School Behavioral Health Movement cont'

1
Key Themes in the National School Behavioral
Health Movement (cont.)

• Mark D. Weist, Ph.D.
• University of Maryland
• Center for School Mental Health
• Salt Lake City 12.10.08

2
Outline

• Why School Mental Health?
• Critical Themes
• Roles
• Evidence-Based Practice

• Local examples
• State Examples
• National Community of Practice
• Resources

3
Center for School Mental Health University of
Maryland School of Medicinehttp//csmh.umaryland.
eduSupported by the Maternal and Child Health
Bureau of HRSA and numerous Maryland agencies
4
(No Transcript)
5
What is Not Working in School Mental Health (SMH)

• Turf and siloed approaches
• Single system approaches
• Same old roles
• Clinics in schools
• Co-located models
• Traditional eclectic therapies
• Schools handing off children to other systems

6
Referrals from Schools to Other Settings

• 96 referred to school-based program received
  services
• 13 referred to other community agency did
• Catron, T., Harris, V., Weiss, B.  (1998)

7
Treatment as Usual Show Rates (McKay et al.,
2005) from Kimberly Hoagwood
8
The Child and Adolescent Mental Health System is
a Non-System

• Around 1 in 5 youth will present an
  emotional/behavioral disorder (5 students in a
  classroom of 25)
• Around 1 in 10 present significant impairment,
  and 1 in 20 present extreme functional
  impairment
• Between 1/6th and 1/3rd receive any services
• Modal number of specialty mental health visits is
  2
• Major lack of systematic quality assessment and
  improvement in traditional settings

9
Psychotherapy Effects (Weisz et al., 1995),
from Kimberly Hoagwood
Children Adolescents
Adults
University
Mean Effect Sizes
Clinic settings
Weisz et al., 1995
10
Silos

• The various systems do not talk to each other,
  resulting in many children falling through the
  cracks and not receiving care, receiving
  duplication of services, or families needing to
  negotiate a confusing, fragmented array of
  services (Family Advocate, Louisiana)

11
Shame and Strain on Families

• Youth and families experience blame have
  widespread distrust of professionals have
  concerns about losing custody are often unable
  to pay for carehave to glue services together
• Kimberly Hoagwood (Congressional Briefing,
  October, 2007)

12
April 16, 2007

• Rather than falling through the cracks, Cho
  crawled into the cracks and hid there
• -Chris Flynn- director of VA Techs counseling
  center
• Shuchman, M. (2007)

13
Why Mental Health in Schools?

• Integrated approaches to reduce academic and
  non-academic barriers to learning are the most
  effective in achieving the outcomes families,
  schools and communities care about

14
School Mental Health Advantages

• ACCESS
• Promotion and Prevention
• Efficiency and Cost Effectiveness
• Ecological Approach
• Reduced Stigma

15
Impact on Academic Outcomes

• An average student enrolled in a social and
  emotional learning program ranks at least 10
  percentile points higher on achievement tests,
  has better attendance and classroom behavior,
  likes school more, has better grades, and is less
  likely to be disciplined
• Weissberg and Shriver, August, 2005 New York
  Times article based on research by Weissberg and
  Durlak (see www.casel.org)

16
Presidents New Freedom Initiative

• First presidential commission on mental health
  since 1978
• Widely disseminated document Achieving the
  Promise Transforming Mental Health Care in
  America (see www.mentalhealthcommission.gov)
• 6 goals, 19 recommendations (4.2 Improve and
  expand school mental health)
• Impact expected to last for decades

17
School Mental Health Promotion
Intensive Intervention
1-5
Targeted Individual, Group, Family Intervention
5-40
Selective Prevention
Universal Prevention Relationship
Development Systems for Positive Behavior Diverse
Stakeholder Involvement Climate Enhancement
All Students
18
A Vision for School Mental Health

• Strong stakeholder involvement and a shared
  family-school-community system agenda
• Full continuum of effective supports and services
  for all students in general and special education
• The right staff with the right training,
  supervision, coaching and support

19
Vision (cont.)

• Emphasis on quality assessment and improvement
  and evidence-based practice
• Strong focus on achieving valued outcomes
• Outcome findings feed back into program
  improvement and into policy and advocacy agendas

20
But in most communities

• The vision is not a reality as staff and programs
  are not adequately supported and often contending
  with tremendous need, and
• In an environment of low support and high needs,
  positive outcomes will most likely not be
  achieved and efforts will stall

21
Many Challenges to Overcome

• Marginalization and stigma
• Limited staff and resources
• Disciplinary silos and turf
• Bureaucracy
• A fluid environment with frequent changes in
  leadership
• Compelling need at all levels
• INERTIA

22
The Foundation of All this Work is our
Relationships with Schools, Students and Families
23
The Optimal School Mental Health Continuum?

• 10-20 Broad Environmental Improvement and Mental
  Health Promotion (CHANGE AGENT ROLE)
• 50-60 Prevention and Early Intervention
  (PREVENTION SPECIALIST ROLE)
• 20-30 Intensive Assessment and Treatment
  (THERAPIST ROLE)

24
Roles
25
WHO 2003 Psychosocial Environment (PSE) Profile

• Friendly, rewarding and supportive atmosphere
• Supports cooperation and active learning
• Forbids physical punishment and violence
• Does not tolerate bullying/harassment

• Values the development of creative activities
• Connects school and home life
• Promotes equal opportunities for participation

26
Prevention Specialist Activities

• Triage mental health (1-3 sessions without
  diagnosis)
• Work collaboratively with educators to improve
  classroom behavior
• Build a theme of mental health skills as
  promoters of student learning
• Implement skill training groups

27
Mental Health Concepts that Promote Learning

• Self-instruction (e.g., developing an internal
  dialogue)
• Problem solving (e.g., considering costs and
  benefits of actions)
• Self-control andreinforcement (e.g., work before
  play)
• Template matching (e.g., modeling actions of B
  students)

28
Variables that Affect Compliance

• Make direct requests
• Make specific requests from shorter distances in
  soft but firm voice
• Make eye contact
• Limit to two requests
• Give child 3-5 seconds to comply (without
  speaking)
• Make more start vs. stop requests
• Control negative emotions
• Reinforce compliance

29
Levels of Crisis Development

• Anxiety muttering, excessive movement, pacing,
  vacant, or withdrawn
• Staff Response Supportive
• Empathic
• Active listening
• Avoid being judgmental
• Most potentially explosive situations diffused at
  this level

30
Effective Teachers

• Flexible
• Individualize learning strategies
• Convey warmth
• Provide clear guidelines for acceptable classroom
  behavior and fair consequences for infractions
• Pianta, 1999

31
Less Effective Teachers

• More rigid in response to classroom behavior
  problems
• Interactions with disruptive children repetitive,
  inflexible and more negative as the school year
  progresses
• Nelson Roberts, 2000

32
Making Evidence-Based Practice in Schools
Achievable

• Overarching Emphasis on Quality
• Effectively Working with Families and Students
• Enhanced Modular Intervention
• On-Site Coaching and Support

33
Quality Assessment and Improvement (QAI)
Principles

• Emphasize access
• Tailor to local needs and strengths
• Emphasize quality and empirical support
• Active involvement of diverse stakeholders

• Full continuum from promotion to treatment
• Committed and energetic staff
• Developmental and cultural competence
• Coordinated in the school and connected in the
  community

34
Working Effectively with Students and Families

• Early on focus on engagement, e.g., through
  candid discussions about past experiences
• Emphasize empowerment and the potential for
  improvement
• Provide pragmatic support
• Emphasize mutual collaboration

35
Modular Intervention

• Chorpita, B.F., Daleiden, E.L. (2007). 2007
  Biennial Report Effective Psychosocial
  Intervention for Youth with Behavioral and
  Emotional Needs. Child and Mental Health
  Division, Hawaii Department of Health
• (Reviews most important treatment foci for
  Anxiety, Attention Problems, Autism, Depression,
  Disruptive Behavior Disorders, Substance Use, and
  Traumatic Stress)
• http//hawaii.gov/health/mental-health/camhd/libra
  ry/pdf/ebs/ebs012.pdf

36
Anxiety Practice Components
37
Exposure

• Direct or imagined experience with a target
  stimulus, whether performed gradually or suddenly

38
Specific Interventions to Help Students
Presenting Disruptive Behaviors

• Parent praise
• Commands/limit setting
• Tangible rewards
• Response cost
• Parent monitoring
• Time out
• Psycho-education with parent
• Problem solving

39
Giving Effective Praise

• Be honest, not overly flattering
• Be specific
• No back-handed compliments (i.e., I like the
  way you are playing quietly, why cant you do
  this while Im on the phone?)
• Give praise immediately

40
Moving Beyond Supervision toward

• Interactive and lively teaching
• Off and on-site coaching, performance assessment
  and feedback, emotional and administrative
  support
• Peer to peer support
• User friendliness
• see Dean Fixsen, Karen Blasé, National
  Implementation Research Network (NIRN)

41
Another Triangle
42
Talbot County Public Schools (Maryland)School-Bas
ed Mental Health Program
Rob Schmidt LCPC, NCC Talbot County Public
Schools Kathryn Seifert Ph.D, DABPS, DAC CEO -
Eastern Shore Psychological Services
43
Outcomes 04-05 Attendance
44
Outcomes 04-05 Suspensions
45
Expanded School Mental Health (ESMH) in Baltimore

• 29 year experience
• 1989--------4 schools
• 2007-------98 schools
• 14 provider agencies
• Recent inclusive strategic planning
• Strong cross agency collaboration and involvement
  of city leaders
• New Request for Proposals (RFP) process

46
A Real Example of Braided Funding

• Baltimore School System, 1.4 million (47)
• Mental Health System, 768,000 (25)
• Substance Abuse System, 383,000 (12)
• Health Department, 200,950 (7)
• Family League, 180,000 (6)
• Department of Labor, 105,000 (3)

47
Themes Helping ESMH in Baltimore to Move to the
Next Level

• A Strategic Plan
• One network, with a common RFP process, training,
  quality improvement and evaluation expectations
• A prominent, interdisciplinary and diverse
  Advisory Board
• Strong cross-agency collaboration and involvement
  of city leaders
• Support from national centers in Baltimore, and
  from federal, national and state organizations
  and colleagues

48
Prince Georges School Mental Health Initiative
(PGSMHI)

• Funding from the State Department of Education
• Intensive, evidence-based mental health
  intervention for students in special education in
  two schools
• Training and support to 11 schools with
  specialized programs for youth presenting
  emotional problems
• Broader training and support county wide (e.g.,
  for all school psychologists)

49
Family Needs Addressed

• Food, health insurance, medical needs, clothing,
  transportation, utilities, substance abuse
  services, mental health services, tutoring,
  mentoring, recreational programs

50
Data on Non-Public Placements

• Between September, 2006 and March, 2008, 43
  students were seen for more intensive services in
  the two schools
• All met multiple criteria for placement in
  non-public programs
• 3/43 students were placed in a non-public program

51
Data (cont.)

• Preliminary economic analyses indicate
• For 1.6 years of services (as of 3/14/08), 25
  placement years were diverted
• For a savings of between 800,000 and 1,000,000
  for Prince Georges County alone

52
Based on this Pilot Project

• Maryland has committed to ongoing funding of the
  initiative
• PG county has given an additional 500,000 per
  year to grow critical mass (based on cost savings
  from a 57 million per year annual budget)
• Maryland is rolling out a statewide initiative
• There is increasing national interest
• A large federal grant is being pursued

53
Teacher Retention

• A big issue in the U.S.
• 10 leave before the end of the 1st year
• 30 by the end of the 3rd year
• 50 by the end of the 5th year
• Exit interviews suggest a major reason for
  leaving is the lack of classroom-based support
• Bob Burke

54
Agendas

• The Prescriptive Agenda (e.g., implementing
  evidence-based services in schools, documenting
  outcomes, building advocacy, growing into more
  schools) is dependent on
• The Collaborative Agenda (i.e., building
  relationships, promoting dialogue and developing
  true collaboration and partnerships)

55
A National Community of Practice

• CSMH and IDEA Partnership (www.ideapartnership.org
  ) providing support
• 30 professional organizations and 12 states
• 10 practice groups
• Providing mutual support, opportunities for
  dialogue and collaboration
• Advancing multiscale learning systems
• Sign up at www.sharedwork.org

56
Twelve States

• Hawaii
• Illinois
• New Hampshire
• North Carolina
• Maryland
• Missouri

• New Mexico
• Ohio
• Pennsylvania
• South Carolina
• South Dakota
• Vermont

57
Ohio Mental Health Network for School Success
(http//www.omhnss.org)

• Since 2001
• Ohio Department of Mental Health
• Ohio Department of Education
• Center for School-Based Mental
• Health Programs at Miami University
• (http//www.units.muohio.edu/csbmhp)

Mission To help Ohios school districts,
community-based agencies, and families work
together to achieve improved educational and
developmental outcomes for all children
especially those at emotional or behavioral risk
and those with mental health problems
58
Effective Practice Partners (EPPs)

• Miami University
• Ohio University
• Bowling Green State University

• Case Western Reserve University
• Ohio State University
• Kent State University

Disciplines Clinical Psychology Community
Psychology Criminal Justice Public Health
Social Work Teacher Education
59
2007-2008Projects

• Communications Team
• Ongoing Regional and Statewide Networking
• Website, On-line Resources, and
• Newsletter (Network News)

60
2007-2008Projects

• Quality and Evidence Based Practice Team
• Effective Practice Registry

61
2007-2008Projects

• Systems Analysis and Change Team
• On-line School Mental Health Strategies
• Survey for School Principals

62
2007-2008Projects

• Policy Development and Advocacy Team
• Works closely with the Communications Team, Wide
  Variety of Awareness Raising Initiatives
• (e.g., information briefs)

63
2007-2008Projects

• Educator Training with Safety and
• Violence Curriculum Team
• Initial Statewide Roll Out of Training to Address
• H.B. 276 Mandate

64
Maryland School Mental Health Alliance
MSMHA
65
Twelve Practice Groups

• Learning the Language/Promoting Effective Ways
  for Interdisciplinary Collaboration
• Social, Emotional, and Mental Health in Schools
• Education An Essential Component of Systems of
  Care
• Connecting School Mental Health and Positive
  Behavior Supports
• Connecting School Mental Health with Juvenile
  Justice and Dropout Prevention

66
Twelve Practice Groups (cont.)

• Improving School Mental Health for Youth with
  Disabilities
• Family-School-Community Partnerships
• Youth Involvement and Leadership
• Child Welfare and School Mental Health
• Quality and Evidence-Based Practice
• (School Mental Health for Military Families)
• (Psychiatry and Schools)

67
Multiscale Learning Examples

• Baltimore helps NYC with RFP process for ESMH
• Maryland Department of Education helps Ohio
  Department of MH in SMH response to the pandemic
  flu
• Ohio, Maryland, and Missouri collaborate on a
  competitive grant application for Integrating MH
  and Schools

68
Meta-cognitive Analyses

• Thinking about thinking
• Helicoptering

69
(No Transcript)
70
CSMH Training Events - 2009

• 14th Annual Conference on Advancing School Mental
  Health. Minneapolis, October 19-21
• School Health Interdisciplinary Program (SHIP).
  Ellicott City, Maryland, August 3-6
• See http//csmh.umaryland.edu or call
  410-706-0980 (or 888-706-0980 toll free)

71
www.schoolmentalhealth.org

• Website developed and maintained by the CSMH with
  funding from the Baltimore City Health Department
  and State Departments of Education and Mental
  Health
• User-friendly school mental health information
  and resources for caregivers, teachers,
  clinicians, and youth

72
Other Helpful School Mental Health Websites

• UCLA Center for Mental Health in Schools
  http//smhp.psych.ucla.edu
• Center for the Advancement of Mental Health
  Practices in Schools
• http//schoolmentalhealth.missouri.edu/about.htm
• Center for School-Based Mental Health Programs
• http//www.units.muohio.edu/csbmhp/

73
INTERCAMHSInternational Alliance for Child
andAdolescent Mental Health and Schools300
Members, 35 Nations
www.intercamhs.org
74
Two Books

• Handbook of School Mental Health (2003, paperback
  2007)
• www.springer.com
• Advances in School-Based Mental Health
  Interventions (2007)
• www.civicresearchinstitute.com/sbmh.htm

75
Two New Journals

• Advances in School Mental Health Promotion
• The Clifford Beers Foundation and the University
  of Maryland
• www.schoolmentalhealth.co.uk
• School Mental Health
• www.springer.com

76
Purposeful Planning Toward a Tipping Point

• We need to prepare ourselves for the possibility
  that sometimes big changes follow from small
  events, and sometimes these changes can happen
  very quickly
• Malcolm Gladwell

77
Contact Information

• Center for School Mental Health,
  Department of Psychiatry
  University of Maryland
  737 W. Lombard Street, 4th Floor
  Baltimore, MD 21201
  PH 410-706-0980
  FX 410-706-0984
  mweist_at_psych.umaryland.edu http//csmh.umaryland.
  edu