Interconnecting Systems of PBIS and School Mental Health Mark D. Weist, Ph. D. University of South Carolina Missouri PBIS, June 12, 2014
Center for School Mental Health* University of Maryland School of Medicine http: //csmh. umaryland. edu *Supported by the Maternal and Child Health Bureau of HRSA and numerous Maryland agencies
Outline School Mental Health (SMH) Positive Behavioral Intervention and Support (PBIS) Interconnected Systems Framework for SMH/PBIS Key Themes: Readiness, Teams, Evidence-Based Practice, Funding Some Challenges National Community of Practice, State Examples Interactive Exercise Opportunities
Reality 1 Child and adolescent mental health is among the most if not the most neglected health care need in the US
Reality 2 Children, youth and families are not getting to places where mental health services are traditionally delivered
Reality 3 Schools are under-resourced to address mental health issues, and may view this as beyond their mission
“Expanded” School Mental Health Full continuum of effective mental health promotion and intervention for students in general and special education Reflecting a “shared agenda” involving school-family -community system partnerships Collaborating community professionals (not outsiders) augment the work of school-employed staff
School Mental Health (SMH) MH vs Clinics Catron, Harris & Weiss (1998) 96% offered SMH received 13% for clinics
SMH vs Clinics 2 Atkins et al. (2006) 80% enrolled in SMH vs 54% in clinics At 3 -month follow-up, 100% retained in schools, 0% in clinics
Baker-Ericzen et al. (2013) Views of families and youth toward clinics consistently negative: Highly dissatisfied, many barriers, limited support, lack of input into decision making, cumbersome and difficult bureaucracy, feeling “unheard and blamed for problems”
Advantages Improved access Improved early identification/intervention Reduced barriers to learning, and achievement of valued outcomes WHEN DONE WELL
But SMH programs and services continue to develop in an ad hoc manner, and LACK AN IMPLEMENTATION STRUCTURE
Positive Behavior Intervention and Support (www. pbis. org) In 18, 000 plus schools Decision making framework to guide selection and implementation of best practices for improving academic and behavioral functioning Data based decision making Measurable outcomes Evidence-based practices Systems to support effective implementation
Advantages Promotes effective decision making Reduces punitive approaches Improves student behavior Improves student academic performance WHEN DONE WELL
But Many schools implementing PBIS lack resources and struggle to implement effective interventions at Tiers 2 and 3
Key Rationale PBIS and SMH systems are operating separately Results in ad hoc, disorganized delivery of SMH and contributes to lack of depth in programs at Tiers 2 and 3 for PBIS By joining together synergies are unleashed and the likelihood of achieving depth and quality in programs at all three tiers is greatly enhanced
Logic Youth with challenging emotional/behavioral problems are generally treated very poorly by schools and other community agencies, and the “usual” approaches do not work
Logic, cont. • Effective academic performance promotes student mental health and effective mental health promotes student academic performance. The same integration is required in our systems
Old Approach Each school works out their own plan with Mental Health (MH) agency New Approach District has a plan for integrating MH at all buildings (based on community and school data)
Old Approach New Approach A MH counselor is housed in a school building 1 day a week to “see” students MH person participates in teams at all 3 tiers
Old Approach No data to decide on or monitor interventions New Approach MH person leads classroom, group or individual interventions based on data
Not two, but one
Interconnected Systems Framework (ISF) for SMH-PBIS Strategy for interconnection of two systems across multiple tiers Emphasizes state teams working with district teams and schools, and strong team planning and actions at each tier Two national centers (for SMH and PBIS) and a number of states involved Numerous training events and a recent monograph completed
ISF Defined A strong, committed and functional team guides the work, using data at three tiers of intervention Sub-teams having “conversations” and conducting planning at each tier Evidence-based practices and programs are integrated at each tier SYMMETRY IN PROCESSES AT STATE, DISTRICT AND BUILDING LEVELS
Chapters in the ISF Book Overview Implementation Framework School Level Systems School Level Practices Effectively Using Data District/Community Role Advancing in States Policy, Practice and People Commentaries
ISF, School Readiness Assessment 1) High status leadership and team with active administrator participation 2) School improvement priority on social/emotional/behavioral health for all students 3) Investment in prevention 4) Active data-based decision making 5) Commitment to SMH-PBIS integration 6) Stable staffing and appropriate resource allocation
ISF, Indicators of Team Functioning Strong leadership Good meeting attendance, agendas and meeting management Opportunities for all to participate Taking and maintaining of notes and the sense of history playing out Clear action planning Systematic follow-up on action planning
Team Members *School psychologist *Collaborating community mental health professional School counselor Special educator *co-leaders Assistant principal School nurse General educator Parent (Older student)
Implementing Evidence-Based Practices See - Substance Abuse and Mental Health Service Administration’s (SAMHSA) National Registry of Effective Programs and Practices (NREPP) 330 research supported programs, 126 come up with “schools” as search term
Research Supported Programs Involve Strong training Fidelity monitoring Ongoing technical assistance and coaching Administrative support Incentives Intangibles
Practice in the trenches Involves NONE of these supports
Evidence-Based “Manualized” interventions (from Sharon Stephan) Intervention/Indicated: Cognitive Behavioral Intervention for Trauma in Schools, Coping Cat, Trauma Focused CBT, Interpersonal Therapy for Adolescents (IPT-A) Prevention/Selected: Coping Power, FRIENDS for Youth/Teens, The Incredible Years, Second Step, SEFEL and DECA Strategies and Tools, Strengthening Families Coping Resources Workshops Promotion/Universal: Good Behavior Game, PATHS to PAX, Positive Behavior Interventions and Support, Social and Emotional Foundations of Early Learning (SEFEL), Olweus Bullying Prevention, Toward No Tobacco Use
“Packaging” Problem Blind commitment to parameters of manuals (e. g. , hour long sessions, too many sessions), without consideration of school realities Instead group key intervention components in “phases” and deliver flexibly See Steve Evans, Julie Owens, Ohio University
Typical Work for Clinician for Evidence. Based Prevention Group Screen students Analyze results of screen Obtain consent/assent Obtain teacher buy-in Coordinate student schedules Get them to and from groups Rotate meeting times Implement effectively Promote group cohesion Address disruptive behaviors Conduct session by session evaluation Deal with students who miss groups
Strengthening School Mental Health Services NIMH, R 01 MH 081941 -01 A 2, 2010 -14 (building from a prior R 01) 46 school mental health clinicians, 34 schools Randomly assigned to either: Personal/ Staff Wellness (PSW) Clinical Services Support (CSS)
CSS: Four Key Domains Quality Assessment and Improvement Family Engagement and Empowerment “Modular” Evidence Based Practice Implementation Support
Modular EBP for DBDs • • • Active ignoring Commands Communication Monitoring Praise • • • Problem solving Psychoeducation Tangible rewards Response cost Time-out/grounding • See Chorpita & Daleiden, 2009, and Practice. Wise
Structure for Implementation Twice monthly two-hour training Monthly or more coaching visits at school Coaching involving observing family sessions and collegially providing ideas and support CHALLENGES Expense Family no-shows
Other Conclusions Need the right clinicians For true EBP demands are intense at multiple levels TRAINING/IMPLEMENTATION SUPPORT + INCENTIVES + ACCOUNTABILITY Tension between productivity and quality
Funding -- Foundations Determining boundaries A lead group steps forward Effective convening and meeting Building expectations/standards at each tier Matching prevention/intervention strategies to the evidence-base and these standards
Foundations 2 Developing a strategy for Memorandum of Understanding (MOU) Assuring MOUs emphasize continuous quality improvement Living out a “shared agenda” Ongoing social marketing and outreach to assure key systems and stakeholders buy-in and participate
Funding mechanisms Federal and state grants and contracts (how assure investments don’t evaporate? ) Local initiatives (e. g. , Seattle tax levies for schoolbased health centers) Accessing Medicaid and other insurance BRAIDED FUNDING WITH CROSS-SYSTEM INVOLVEMENT AND TRANSPARENCY
SMH in Baltimore 1989: 4 schools 2009: 105 schools 42 Elementary schools 41 Middle/K-8 schools 22 High schools
Baltimore ESMH Funding 2009 7% 6% 12% 3% 25% 47%
Challenges
Mental Health Screening Expensive (time and cost) Which measures? Need will overwhelm existing resources Liability concerns With formal measures to do it right, need the community to rally around individual schools
Approach in Charleston (thanks to Bob Stevens)
School Related Barriers Fluidity of the school environment Teacher turnover Tenuous principal buy-in Lack of time Lack of dedicated change agents
Entrenched problematic policies and approaches Suspension Expulsion Very poor transitions Schools and people doing what they are used to doing (and being highly resistant to change)
A common pattern Crisis of the Week (COW) therapy Putting out fires Failing to achieve valued outcomes Thanks to Sharon Stephan
Roles of School-Employed MH Staff (in some instances) Course scheduling Attendance monitoring Examination monitoring Career guidance Logistics assistance See Steve Evans, Ohio University
“Optimizing” School employed staff doing rote administrative work Community mental health staff seeing same clients and delivering passive, eclectic, non evidence-based interventions
Special Education Challenges Schools and staff as gatekeepers “Social maladjustment” Highly variable labeling “Manifestation” hearings Increasing but not decreasing restrictiveness Pro-forma meetings and poor follow-up Accomodations
Students in Alternative Schools from Jason Bird and Bobby Markle Negative School Climate Stigmatized by teachers and students Negative peer interactions at both schools Little positive support from teachers and school staff upon returning from alternative school Inconsistent School Structure and Procedures Larger, more difficult classes upon return to regular school Less perceived expectations/accountability at the alternative school placements Unclear transitional procedures between schools
ISF Key Themes A true “Shared Agenda” Strong state – district – building relationships Strong teams in buildings using data and showing outcomes Teams represent interdisciplinary cadres of committed people Proactive stance toward disruptive people and organizations Making political connections and growing resources
Importance of Relationships in Change There will never be enough laws, policies, processes, documents, etc. to force change Change is best realized through the relationships we build with those people and groups that have a common interest toward solving a persistent problem or seizing an opportunity Bill East, Joanne Cashman, Natl Assoc of State Directors of Special Education
A National Community of Practice (COP); www. sharedwork. org CSMH and IDEA Partnership providing support 30 professional organizations and 16 states 12 practice groups Providing mutual support, opportunities for dialogue and collaboration
Example Practice Groups Learning the Language Quality and Evidence-Based Practice Family Involvement Youth Leadership SMH and PBIS SMH and Special Education SMH and Systems of Care Military Families
Sixteen States Hawaii Illinois New Hampshire North Carolina Maryland Minnesota* Missouri Montana* New Mexico Ohio Pennsylvania South Carolina South Dakota Utah* Vermont West Virginia
South Carolina School Behavioral Health Community Mission Statement “To promote student success by reducing barriers to learning and supporting the social, emotional, behavioral, and mental wellness of all youth and families in South Carolina”
First Annual South Carolina School Behavioral Health Conference Medallion Conference Center Columbia, S. C. Thursday, April 24, 2014
PBIS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Lexington 05 Charleston Richland 01 Dorchester 02 Jasper Greenwood 50 Oconee Greenville Lexington 02 Kershaw
SMH
PBIS and SBMH 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Lexington 05 Dorchester 02 Richland 01 Charleston Lexington 02 Greenville
PBIS/SMH in Montana
Our Vision Ontario students are flourishing, with a strong sense of belonging at school, ready skills for managing academic and social/emotional challenges, and surrounded by caring adults and communities equipped to identify and intervene early with students struggling with mental health problems A Vision for Student Mental Health and Well-Being in Ontario Schools (with thanks to Kathy Short)
Interactive Exercise: Brad Smith Elementary School
Brad Smith Elementary School K-6, 390 students 40% minority, 46% RFL 14% special education 1 -18 tchr-student ratio 2 counselors Limited PBIS, Tier 1 Ineffective referrals to CMH • Poorly functioning teams • • DISCUSSION GROUPS • 1) Bringing Community Staff into the Work • 2) Team Functioning • 3) Tier 1 Strategies • 4) Tier 2 Strategies • 5) Tier 3 Strategies • 6) Building Family/Stakeholder Inv. • 7) Coordination with the District
19 th Annual SMH Conference Pittsburgh, Pennsylvania September 18 -20, 2014 csmh. umaryland. edu
The Clifford Beers Initiative at the University of South Carolina
Background • First satellite office of the Clifford Beers Foundation o Named in recognition of Clifford Whittingham Beers • A Mind That Found Itself (Beers, 1908) • Mental hygiene movement • Emphasis on promotion of mental health • Building networks and collaborative efforts
8 th World Congress on Mental Health Promotion London, England September 23 -26, 2014 worldcongress 2014. org
Upcoming World Congresses Columbia, SC, 2015 Ontario, 2016
Contact Information Department of Psychology University of South Carolina 1512 Pendleton St. , Room 237 D Columbia, SC 29208 Ph: 803 777 8438 weist@mailbox. sc. edu
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