School Mental Health and Foster Care

1. School Mental Health and Foster Care Mark Weist, Ph.D.1 Nancy Lever, Ph.D.1 Michael Lindsey, PhD, MSW, MPH2 Sylvia Huntley, BA1 Dana Cunningham, Ph.D. 1University of Maryland Center for School Mental Health 2 University of Maryland School of Social Work 3Prince George’s County School Mental Health Initiative

2. Welcome • Introduction of University of Maryland Team • Participants-- role and your connection to school mental health and/or foster care

3. 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

4. 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

5. 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)

6. Treatment as Usual Show Rates (McKay et al., 2005) from Kimberly Hoagwood

7. Other Concerning Facts • Around 1 in 5 youth will present an emotional/behavioral disorder (5 students in a classroom of 25) • 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

8. 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)

9. “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 care…have to glue services together” • Kimberly Hoagwood (Congressional Briefing, October, 2007)

10. 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

11. Advantages • ACCESS • Promotion and Prevention • Efficiency and Cost Effectiveness • Systems Collaboration/ Economies of Scale • Natural/ Ecological Approach • Reduced Stigma

12. 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

13. Another Triangle

14. 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

15. 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

16. Making Empirically Supported Practice in Schools Achievable • Overarching Emphasis on Quality • Effectively Working with Families and Students • Enhanced Modular Intervention • On-Site Coaching and Support

17. 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 Quality Assessment and Improvement (QAI) Principles

18. 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

19. School Mental Health Services for Youth in Foster Care Services can include: • After school recreational and enrichment activities • School-wide mental health promotion • Classroom and small group prevention activities • Group therapy (for youth with similar emotional or behavioral concerns) • Individual therapy • Family therapy • Teacher consultation • Mental health evaluation • Assistance with mental health referrals

20. School Mental Health and Foster Care Initiative • Goal: To effectively integrate and improve school mental health services and ultimate outcomes for children, adolescents, and graduates of Maryland’s foster care system Key Objectives Include: • Develop a training curriculum and conduct training related to effective school-based outreach, support, mental health promotion and intervention for youth in foster care in Maryland Schools • Provide statewide information and technical support on effective school mental health promotion and intervention for youth in foster care through the website, www.schoolmentalhealth.org and a listserv • Funding - Maryland Mental Health Transformation Grant # 5 U79SM57459-02 from SAMHSA

21. Conceptual Framework Foster Care – School Mental Health Interface

22. Conceptual Framework A Public Mental Health Promotion Approach for Youth in Foster Care

23. Training Curriculum: School Mental Health and Foster Care: A Training Curriculum for Child Welfare Workers, Teachers, and Clinicians • Module 1: Understanding the Foster Care System • Module 2: Mental Health Needs of Children in Foster Care • Module 3: Understanding Schools and School Mental Health Services • Module 4: Prevention and Mental Health Promotion for Youth in Foster Care in Schools • Module 5: Early Identification and Intervention • Module 6: Confidentiality and Sharing Information • Module 7: Coordinated Service Delivery and Integrated Treatment Planning • Module 8: Evidence-Based Treatment for Children in Foster Care in Schools • Module 9: Family Engagement and Meaningful Involvement • Module 10: Policy and Funding

24. What is Foster Care? Foster care is one aspect of child welfare which has as its objective, the provision of short term out of home care for children removed from their family homes; at the same time, the child’s family also receives services that aim to help them reduce the risk of future neglect or abuse in preparation for the child’s return home (Child Welfare Information Getaway, 2006).

25. Permanency Planning • As part of the foster care process, permanency planning is initiated. • Permanency planning is principled to include prevention of out of home care, once a child has entered into care, the purpose of the plan is to ensure the shortest length of stay and to develop a plan for permanent home placement in concert with the family (Anderson, 1997; Pelton,1991) • The main goal of the plan is always reunification of child and family. If reunification is not attainable, then other permanency options are explored such as discharge to independent living, kinship care, or placement in a suitable adoptive family.

26. Types of Foster Care • Court-appointed foster care: Caretaking of children displaced from biological parent(s), typically by a caring adult who has met the requirements to be a foster parent by their local jurisdiction. This situation is intended to be temporary. • Kinship care: Caretaking of children who have been displaced from a biological parent(s), typically by grandparents or other relatives. Kinship care also improves stability by keeping displaced children closer to their extended families, neighborhoods and schools.

27. What Happens Once in Care? • Initial intake session and first 60 days plan • Key players and their role • Case worker, typically a master’s-level Social Worker • Case management • Clinical intervention • Permanency planning • Reunification support • Support services, typically offered by a bacherlor’s-level worker • Mentoring • Crisis intervention • Therapeutic support • Outcomes at the end of foster care: • Return home • Adoption • Discharge to independent living

28. The Situation in Maryland (Based on 2003 Statistics) • Total population: 11,521 • Age (Average: 11.4 Years) • 4% <1 year • 19% 1-5 years • 19% 6-10 years • 33% 11-15 years • 20% 16-18 years • 6% ≥ 19 years • Male: 53% Female: 47% Source: http://www.fostercaremonth.org/AboutFosterCare/StatisticsAndData/Documents/MD-Facts-FCM07.pdf

29. MD Stats: Race/Ethnicity Race/EthnicityIn out-of-home careState child population Black (non-Hispanic) 75% 32% White (non-Hispanic) 20% 56% Hispanic 2% 5% Am. Indian/Alaska Native 0% 0% Asian/Pacific Islander 0% 4% Unknown 1% N/A 2 or more races (non-Hispanic) 1% 3%

30. MD Stats: Additional Items • Length of stay • The average length of stay for children in care on September 30, 2003 was 48 months. • Reunified • Forty-one percent of the young people leaving the system in FY 2003 were reunified with their birth parents or primary caregivers. • Foster home • In 2002, there were a total of 4,440 licensed kinship and non-relative foster homes in Maryland • On September 30, 2003, 35% of youth living in out-of-home care were residing with their relatives. • Adoption • Of children with state agency involvement adopted in FY 2003, 56% were adopted by their non-relative foster parents and 40% were adopted by relatives.

31. Challenges connecting to SMH • Schools are difficult systems to navigate • Can be hard to figure out who is providing services to children and adolescents in the school and who would best serve the student • Capacity issues • Schedules – child welfare workers and families may only be available in the later day or evening • Limited or lack of understanding and appreciation about child welfare system. • Services may not be available every day (split FTE), school vacations, and in the summer

32. Schools can help children in foster care succeed by… • understanding the demands of the foster care system (e.g., court appearances during school time) • offering information about the best ways to communicate with and gather information from the school (e.g., scheduling, consent forms, and how to meet with teachers) • establishing regular communication about the child’s successes and challenges, including mental health

33. Schools can help children in foster care succeed by…(Continued) • helping to coordinate school transfers when necessary and making sure all available records transfer with the student • identifying children in foster care who are in need of special education services and ensuring that these services are provided across school placements • training school staff about the mental health issues associated with foster care and how to help youth in foster care be more successful in school

34. Resources • http://www.aacap.org/cs/root/facts_for_families/foster_care • http://www.fostercaremonth.org/AboutFosterCare/StatisticsAndData/Documents/MD-Facts-FCM07.pdf • http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report10.htm

35. Statistics Related to Mental Health for Youth in Foster Care • Youth in foster care experience even more mental health symptomatology than other high risk youth • In a recent study of children and adolescents in foster care, 54% had one or more mental health problems in the past 12 months (compared with 22% of the general population) • Remarkably, 25% had Post-Traumatic Stress Disorder within the past 12 months (twice the rate of U.S. war veterans) (Pecora et al., 2005)

36. What are the unique mental health issues that are commonly seen in youth in foster care? • Anger/Irritability • Nightmares • Distressing memories • Sleep problems • Depression and Anxiety • Avoidance • Attention problems • Problems with attachment • Delinquency • Oppositional Behavior

37. How do these issues manifest in a classroom/school setting? • Sleeping in class • Defiant or disruptive • Refusal to participate/do homework • Excessive absences/tardiness/truancy • Easily distracted/poor concentration • Irritability • Destructive behavior to self/others/objects • Change in grades/attitude • Excessive worry • Sadness/tearful • Lying • Unprovoked anger outbursts

38. Discussion • How do you respect the privacy of a youth in foster care, but still be able to identify these students so that they can be prioritized for mental health promotion, prevention, and intervention services? • How can this balance best be achieved? • What specific strategies would you recommend?

39. Strategies for Successful Identification and Consent • Education for child welfare workers about available services in schools • Improved professional development for school staff and clinicians on unique mental health issues for youth in foster care. • Provide information on counseling services/prevention services available to youth as a regular part of orientation/registration for incoming students • Inquire about the health and mental health services available in the building and how to access – Consider connecting with this person directly • Request a release of information from the school as a standard procedure when registering a child in school

40. Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Training Developed by: National Child Traumatic Stress Network LAUSD/RAND/UCLA Trauma Services Adaptation Center for Schools

41. Why a trauma program in schools?

42. Why a program for traumatized students? • More and more youth are experiencing traumatic events • Community violence • Natural and technological disasters • Terrorism • Family and interpersonal violence • Most youth with mental health needs do not seek treatment • Many internalizing disorders in children go undetected

44. Consequences of trauma exposure • Posttraumatic Stress Disorder (PTSD) • Re-experiencing • Numbing/Avoidance • Hyperarousal • Prevalence in adolescents • 4% of boys • 6% of girls • 75% of those with PTSD have additional mental health problem Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995

45. Consequences of trauma exposure • Posttraumatic Stress Disorder (PTSD) • Depression • Substance abuse • Behavioral problems • Poor school performance

46. Impact of trauma on learning • Decreased IQ and reading ability (Delaney-Black et al., 2003) • Lower grade-point average (Hurt et al., 2001) • More days of school absence (Hurt et al., 2001) • Decreased rates of high school graduation (Grogger, 1997) • Increased expulsions and suspensions (LAUSD Survey)

47. CBITS Program • 10 child group therapy sessions for trauma symptoms • 1-3 individual child sessions for exposure to trauma memory and treatment planning • Parent outreach, 2 sessions on education about trauma, parenting support • 1 teacher session including education about detecting and supporting traumatized students (1 session)

48. Goals of CBITS • Symptom Reduction • PTSD symptoms • General anxiety • Depressive symptoms • Low self-esteem • Behavioral problems • Aggressive and impulsive • Build Resilience • Peer and Parent Support

49. CBITS and other School Mental Health Programming • Sharing of implementation experiences and relevancy of CBITS and other SMH services for youth in foster care

50. Discussion • What are strategies that you think would help a school to be more trauma sensitive to its students?