Comprehensive SBHC Services Addressing the Mental Health Needs of Mexican Immigrants

1. Comprehensive SBHC Services Addressing the Mental Health Needs of Mexican Immigrants Olga Acosta Price Michelle J. Lyn

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Olga Acosta Price and Michelle J. Lyn “No relationships to disclose”

3. Session Objectives • Describe the mental health needs of the immigrant/refugee population in US and the importance of utilizing school-based health centers as entry to a continuum of prevention, early intervention, and treatment services. • Discuss adaptations to mental health screening, prevention, early intervention, and treatment services to consider making when working with Mexican children and their families in particular. • Analyze strategies to develop a community collaborative, integrated school-based health center model that provides a culturally accepted continuum of prevention, early intervention, and mental health treatment services.

4. Demographics • In 2000, 31.1 million individuals in the US were foreign-born (an increase of 57% since 1990) • According to the 2000 Census, 1 of every 5 children in the US is a child of immigrants • As of July 2006, Hispanics constituted 15% of the nations total population and 23% of children under 5 • In the past 30 years, over 2 million refugees have resettled in the US, with a significant number being under 18 years old • 19% of children 5-17 speak a foreign language at home and 5% of all children have difficulty speaking English- 78% of Hispanic children 5 and older speak Spanish at home

5. Mexican Residents • 23 million of US pop are of Mexican origin- 9% of total population and 64% of Hispanic population • 53% of Mexicans 15 years old+ were married • 61% of Mexican origin were native & 31% were foreign born and did not have citizenship • 41% of Mexicans did not speak English at home • 37% of those of Mexican heritage under 18 • 30% of Mexican children under 18 lived in poverty US Census Bureau, 2004

6. General Challenges Faced • Poverty rates are much higher for children in immigrant and refugee families than children in native-born families • Parents are more likely to perform low-wage work with no benefits (lack of health insurance) or limited benefits • Pre-migration, migration, and post-migration exposure to traumatic events creates vulnerabilities • People with limited English proficiency (LEP) are less likely to seek care and receive needed services (even when economic factors and ethnicity are accounted for) • Stigma related to seeking mental health care is a barrier in many ethnic communities

7. Caring Across Communities Addressing Mental Health Needs of Diverse Children andYouth

8. Robert Wood Johnson FoundationCaring Across Communities National Program: Key Elements • 15 grantees identified and awarded up to $100,000 a year for three years (started March 2007) • Serving an immigrant or refugee-dense community • Building on the combined strengths of a community partnership • Utilizing a school base • Understanding the target community & its most pressing mental health issues • Reducing barriers to care created by language and cultural difference

9. Utilizing a School Base & SBHCs • Important resources at hand • ESL, student support services, special education, offices of multicultural services, physical health providers (i.e., nurse) • Multidisciplinary staff and collaborative structures exist • Familiarity with translation and interpretation • Understand the value of/need for community partnership • Can offer a continuum of health services (prevention, early intervention, treatment) • SBHCs were created to overcome barriers to health care access for underserved youth and families • Often less stigmatizing to receive services as part of support offered in school

10. Integrated SBHC Model • Within SBHC: • Physical health and mental health services • May include dental health, health education, case management • Within School: • SBHC staff and school staff • Parent/family involvement • Between School & Community: • Integration between school and home • Collaboration between school & community providers

11. Cultural Competence • How do we know that our constructs around mental health mean the same thing to our clients? • Do processes for obtaining informed consent need to be modified? • Are our evidence-based practices really appropriate for the families and children from other countries of origin? • What adaptations are necessary to make sure our treatment programs are effective?

12. Emerging Best PracticeKey Components • Partnership Involvement • Identification of Partners and Development of Collaboration • Supporting Meaningful Engagement • Education and Training • Cultural Competence • Stigma Reduction • Mental Health Service Delivery • Prevention • Early Intervention • Treatment

13. One Community’s Experience : Moving Toward an Integrated Model of School-Based Medical and Mental Health Services BieneSTAR: School-Connected Prevention, Early Identification, and Direct Mental Health Services A Caring Across Communities Grantee

14. Our Community Context • Durham County Total Population: 246,896 • Racial and Ethnic Composition for Durham Public Schools (32,749 students): 53.9% African-American 22.6 %White 17.1 %Hispanic 3.6%Multi-racial 2.6%Asian 0.2%Native American U.S. Census Durham Public Schools Website, www.dpsnc.net, accessed June 10, 2008

15. Our Community Context:Our Changing Demographics • Between 1990-2000, North Carolina experienced a 394% increase in the documented Latino population as compared to the national growth rate of 58%. • Most Latinos in North Carolina are of Mexican Origin (65%). • Latino preschool children age 4 or younger increased by 814% from 1990 – 2000, while Latino children 5-17 grew by 729%. North Carolina Latino Health 2003, Report of the North Carolina Institute of Medicine The New Latino South, Pew Hispanic Institute

16. Our Youth: Challenges Faced • 2007 Durham County YRBS – Mental Health • Middle School • 18.1% have thought seriously about killing themselves • 15.2% reported they had made a plan about how to kill themselves • 22% agreed or strongly agreed they felt alone in life • High School • 27.5% reported feelings of depression during last 12 mos. • 16.4% seriously considered attempting suicide • 12.8% made a plan about how they would attempt suicide • 18% said that they had attempted suicide in the past 12 months • 24% agree or strongly agree that they feel alone in their lives

17. Our Youth: Challenges Faced • 2007 Durham County YRBS – Mental Health • For Latino/Hispanic Youth • Lower grade scores • Higher levels of feelings of insecurity • Over 25% didn’t go to school in the last 30 days because they felt unsafe • 32% said that they had attempted suicide within the past 12 months.

18. Our Latino Youth and Families: Challenges Faced • Depression, grief, and traumatic grief associated with loss and change • Traumatic experiences while immigrating • Adjustments that include language, social interaction, school expectations, stigma, laws that are different from country of origin • Unfamiliar with resources and services within the community

19. The Partners • Division of Community Health, Duke • Durham Public Schools • El Centro Hispano • Center for Child and Family Health

20. Division of Community Health • Created in 1998 to build a bridge between Duke and the communities it serves • More than 40 Programs: Clinical Services, Disease Prevention and Health Promotion, and Education • multi-partnered • collaboratively planned, operated, and funded • serving at-risk, vulnerable populations who face barriers to care • built around patients, not facilities/faculty

21. El Centro Hispano • Grassroots Latino community center • Created in 1992 for newly arrived immigrants Services ↔ Education ↔ Community Organizing • Programs for children, youth, and adults • Linkages to Community Resources • Health Education, Disease Prevention & Access to Care • ESL classes • Women’s empowerment • Youth support • Family Literacy • Economic Development

22. Center for Child & Family Health • Consortium (est. 1996) • Duke University • North Carolina Central University • University of North Carolina • Child & Parent Support Services • Child maltreatment & trauma • Services • Trauma treatment, primary & secondary prevention, pediatric/MH forensic assessment • Training • Evidence based mental health, multidisciplinary collaboration & intervention, assessment, court consultation • Research • Home based prevention, service delivery, assessment & intervention with orphans & vulnerable children

23. Supporting Meaningful Engagement: Our Partnership’s Guiding Principles • Community needs and stakeholders determine the services to be developed • Programs are overseen by steering committees composed of community stakeholders/partner organizations, faculty and staff • Programs focus on populations facing health disparities • Programs are designed to be financially stable • Programs are rigorously evaluated

24. Supporting Meaningful Engagement:From Principles to Practice • Three Ways • Planning – Assessing Mental Health and Health Needs • Operating – Designing and Managing Shared Programs and Services • Advisory – Sharing Expertise to Address Specific Health Needs and to Establish New/Improved Services • Our decision-making process • Informed by practice, program evaluation/review • Everyone has an equal voice • Informal and structured opportunities for discussion tweaking

25. Supporting Meaningful Engagement:A Few Partnership Activities • Four School-Based Health Centers • Tooth Ferry Dental Van • Adolescent Centered Care, Education, and Social Support (ACCESS) • Amigas Latinas Motivando el Alma (ALMA) • Local Access to Coordinated Healthcare (LATCH)

26. Utilizing a School-Base:BieneSTAR Pilot Sites • 1. Three Elementary School-Based Health Centers in DPS Operated by the Duke’s Division of Community Health: 2. El Centro Hispano: Registration and ESL Testing for DPS Durham Public Schools, www.dpsnc.net

27. BieneSTAR Goals • Prevent and reduce exacerbation of mental health disorders of children enrolled in 3 elementary school clinics through the provision of mental health education and outreach to parents and school personnel with special emphasis on immigrant children and families. • Create sustainable mental health services, including early identification and counseling that are accessible, culturally competent, and integrated into school services with special emphasis on immigrant at-risk children enrolled in the SBHCs.

28. BieneSTAR Activities • Education and Training • Prevention • Early Intervention • Mental Health Service Delivery

29. Bilingual Licensed Clinical Social Worker from Center for Child and Family Health Bilingual, Bi-Cultural Health Educator from El Centro Hispano Who work with: SBHC Mid-level practitioners and LCSWs School Guidance Counselors and Social Workers School Classroom Faculty and Administration BieneSTAR Team

30. Prevention • Child Groups • Parent and Family Groups • Teachers, Counselors, and ESL Teachers In-Service Education • Child and Family Experiences • Identifying Needs Before They are Problems

31. Early Intervention • Mental health screening services • Educate DPS registration and ESL testing personnel at El Centro Hispano about mental health screening services and referral process • Educate DPS school personnel about mental health screening services and referral process

32. Direct Mental Health Services Group, family, or individual mental health therapy at the SBHC, El Centro Hispano, or CCFH Year One Statistics: • Number of Children Referred and Demographics • Reason for Referral • Disposition • Diagnosis • Encounters by Referral • Consultations with Teachers, Administrators, Parents, School Counselors, etc.

33. Contact Information • Olga Acosta Price, Ph.D. Co-Director, Center for Health and Health Care in Schools School of Public Health and Health Services, GWU • Email: oaprice@gwu.edu • Phone: 202-466-3396 • http://www.healthinschools.org • Michelle J. Lyn, MBA, MHA Assistant Director, Division of Community Health, Department of Community and Family Medicine, Duke University Medical Center • Email: lyn00001@mc.duke.edu • Phone: 919-681-3192 • http://communityhealth.mc.duke.edu