Interconnecting Systems of PBIS and School Mental Health

1. Interconnecting Systems of PBIS and School Mental Health Mark D. Weist, Ph.D. University of South Carolina Missouri PBIS, June 12, 2014

2. Center for School Mental Health* University of Maryland School of Medicinehttp://csmh.umaryland.edu*Supported by the Maternal and Child Health Bureau of HRSA and numerous Maryland agencies

5. 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

6. Reality 1 • Child and adolescent mental health is among the most if not the most neglected health care need in the US

7. Reality 2 • Children, youth and families are not getting to places where mental health services are traditionally delivered

8. Reality 3 • Schools are under-resourced to address mental health issues, and may view this as beyond their mission

9. “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

10. School Mental Health (SMH) MH vs Clinics • Catron, Harris & Weiss (1998) • 96% offered SMH received • 13% for clinics

11. 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

12. 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”

13. Advantages • Improved access • Improved early identification/intervention • Reduced barriers to learning, and achievement of valued outcomes • WHEN DONE WELL

14. But • SMH programs and services continue to develop in an ad hoc manner, and • LACK AN IMPLEMENTATION STRUCTURE

15. 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

16. Advantages • Promotes effective decision making • Reduces punitive approaches • Improves student behavior • Improves student academic performance • WHEN DONE WELL

17. But • Many schools implementing PBIS lack resources and struggle to implement effective interventions at Tiers 2 and 3

18. 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

19. 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

20. 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

21. Old Approach  New Approach Each school works out their own plan with Mental Health (MH) agency District has a plan for integrating MH at all buildings (based on community and school data)

22. 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

23. Old Approach  New Approach No data to decide on or monitor interventions MH person leads classroom, group or individual interventions based on data

24. Not two, but one

25. 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

26. 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

28. 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

29. 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

30. 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

31. Team Members *School psychologist *Collaborating community mental health professional School counselor Special educator *co-leaders • Assistant principal • School nurse • General educator • Parent • Parent • (Older student)

32. 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

33. Research Supported Programs Involve • Strong training • Fidelity monitoring • Ongoing technical assistance and coaching • Administrative support • Incentives • Intangibles

34. Practice in the trenches • Involves NONE of these supports

35. 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

36. “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

37. 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 Typical Work for Clinician for Evidence-Based Prevention Group

38. Strengthening School Mental Health Services • NIMH, R01MH081941-01A2, 2010-14 (building from a prior R01) • 46 school mental health clinicians, 34 schools • Randomly assigned to either: • Personal/ Staff Wellness (PSW) • Clinical Services Support (CSS)

39. CSS: Four Key Domains • Quality Assessment and Improvement • Family Engagement and Empowerment • “Modular” Evidence Based Practice • Implementation Support

40. 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 PracticeWise

41. 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

42. 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

43. 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

44. 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

45. Funding mechanisms • Federal and state grants and contracts (how assure investments don’t evaporate?) • Local initiatives (e.g., Seattle tax levies for school-based health centers) • Accessing Medicaid and other insurance • BRAIDED FUNDING WITH CROSS-SYSTEM INVOLVEMENT AND TRANSPARENCY

46. SMH in Baltimore 1989: 4 schools 2009: 105 schools 42 Elementary schools 41 Middle/K-8 schools 22 High schools

47. Baltimore ESMH Funding 2009 6% 12% 7% 3% 25% 47%

48. Challenges

49. 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

50. Approach in Charleston (thanks to Bob Stevens)