Implementation of Universal Screening

1. Implementation of Universal Screening A Community / School PartnershipFond du Lac TeenScreen ProgramMarian Sheridan Matt Doll

2. Reflection Questions • What, if any, roadblocks to universal screening for behavior exist in your district/school? 1

3. Potential Roadblocks • Absence of administrative support • Lack of knowledge regarding the process • Fear of ‘labeling’ students • Apprehension regarding parental/guardian response • Concerns regarding cost/time to implement universal screening

4. Why Screen for Mental Illness and Suicide Risk? • Mental illness is treatable. • There is ample time to intervene before symptoms escalate to a full blown disorder and before a teen turns to suicide. • Screening tools that effectively and accurately identify at-risk teens are available. • Screening more accurately identifies teens with significant mental health problems than school professionals (63% vs. 37%; Scott et al., AJPH 2009). • Most mentally ill and suicidal youth aren’t already being helped. • At-risk adolescents who do not request help on the screening questionnaire are significantly more likely to report suicidal ideation in the preceding three months than those who request help (62% vs. 31%; Husky et al., Child Psychiatry Hum Dev, 2008). • No one else is asking teens about these issues, but they will give us the answers if we ask the questions. • Screening is safe and does not increase distress, depressive symptoms, or suicidal ideation (Gould et al., JAMA 2005). The National Research Council and the Institute of Medicine of the National Academies. (2009).; Anderson 2004; YRBS 2005; U.S. Census 2003

5. Challenges of Implementation • Stigma of Mental Health • Lack of knowledge • Economic (Cost of non-action, Funding) • Partnerships (sand box politics) • What will we do if we identify 1

6. Stigma • Weak to ask/get help • Weak to be affected • Negative impact on future career (military) • All or None – “I’m fine” or “I’m a Wreck” • Poor Past Experience (treatment, school) • Fear of Agents of Social Control (DSS) • Labeling 1

7. Stigma • Not in Our Community • Not in My Family • Not in My Child • 67% of 17,000 people reported at least on ACE ( Adverse Childhood Event), 87% more than one ACE (abuse, family dysfunction etc.) • If we consider; self, family, friends...100% touched by mental health 1

8. Knowledge: Five Things To Remember • Neurodevelopment Processes • Genetic predisposition exasperated by environmental influences (Nature And Nurture) • Long term negative outcomes for physical health, emotional health and society for bad things happening to children. • Long term positive outcomes when good things happen, potentially protective as well. • These issues impact us all; no social, economic or cultural group is immune

9. Knowledge: Across the Lifespan • Intrauterine Experience - Heart Disease, Obesity, Diabetes, Pollution, Mental Illness. • Adverse Childhood Experiences (ACE) - long-term changes in brain structure and function. 67% of all of us (87% < 1 ACE). 65% experience symptoms for at least a year prior to their deaths • Mortality - Individuals with an ACE score of 6 and higher had a lifespan almost 2 decades shorter than seen in those with an ACE Score of 0 but who otherwise have similar characteristics. 1

10. Knowledge: Why It Matters • Until recently, the persistent effects on neurodevelopment were “hidden” from the view. • Now that we have the knowledge, we have the responsibility to use it.65% experience symptoms for at least a year prior to their deaths • If we can think long term instead of short term, our community’s social, emotional, health and economic welfare will benefit. 1

11. Start with building a strong community / school partnership • Select Key Area Representatives • Business (Sustainability) • School (Staff, Leadership) • Clergy ( Community) • Mental Health (Public, Private) • Post Secondary schools (Interns, Research) • Other (Potential Sticking Points) 1

12. Positive Behavior Interventions & Supports:A Response to Intervention (RtI) Model Tier 1/Universal School-Wide Assessment School-Wide Prevention Systems ODRs, Attendance, Tardies, Grades, DIBELS, etc. Tier 2/Secondary Tier 3/ Tertiary Check-in/ Check-out Intervention Assessment Social/Academic Instructional Groups Daily Progress Report (DPR)(Behavior and Academic Goals) Individualized Check-In/Check-Out, Groups & Mentoring (ex. CnC) Competing Behavior Pathway, Functional Assessment Interview, Scatter Plots, etc. Brief Functional Behavioral Assessment/ Behavior Intervention Planning (FBA/BIP) Complex FBA/BIP SIMEO Tools: HSC-T, RD-T, EI-T Wraparound Illinois PBIS Network, Revised August 2009 Adapted from T. Scott, 2004

13. History of TeenScreen • TeenScreen developed in 1991 as a result of Dr. David Shaffer’s research on mental illness & suicide in youth • 90% of youth who died by suicide suffered from a treatable mental illness • 65% experience symptoms for at least a year prior to their deaths • This shattered the myth that suicide is a random and unpredictable event in youth • Found there is time to intervene with at risk youth, connect with treatment, • Potential to save lives 1

14. Why Implement TeenScreen? • One in five children has a mental or emotional problem that requires treatment • At least one in 10 may have a serious emotional disturbance that significantly impairs his or her ability to function emotionally, socially or academically • Two-thirds of children needing mental health treatment go without • Children with mental health problems are not “just being children.” Mental health problems can disrupt daily functioning at school, at home and with peers. • Suicide is the second leading cause of death for adolescents in Wisconsin. 1

15. Screening must always be voluntary • Approval to conduct screening must be obtained from appropriate leadership • All screening staff must be qualified and trained • Confidentiality must be protected • Parents of identified youth must be informed of the screening results and offered assistance with securing an appointment for further evaluation Principles of Quality Screening Programs

16. Prepare Your School to Implement a Universal Screening • Raise awareness and build school/ community support • Choose a staffing model and identify your team • Select your screening population, location, schedule and questionnaire • Develop a referral network and community resource guide

17. Establishing a Strong Foundation for Universal Screening • Administrative Support • School Board Members • Key Stakeholders • Medical Providers • Mental Health Providers • Community Agencies and Organizations

18. Purpose of Advisory Committee • Shared Agenda • Problem Solve Roll Out Issues (confidentiality) • Problem Solve Ongoing Issues (stigma) • Collect & Analyze Program Data (refusals) • Sustainability Issues 1

19. Educate and Engage School Personnel • Teachers, administrators, and school health and mental health staff can dramatically influence the success of your TeenScreen program. • Inform school personnel of your plans to implement TeenScreen and obtain their support for and commitment to your efforts. • Build working relationships with school personnel. • Present your plans at a faculty meeting and/or department meetings.

20. Seek Advice and Help from School Personnel • Ask school personnel how they think parents will react to screening and how best to reach parents and teens. • Ask for assistance with promoting the program to parents and teens and with distributing and securing the return of parent consent forms. • Help and buy-in is especially critical from the teachers whose classes will be impacted by consent distribution or screening.

21. Educate and Engage Parents • Know your community and share key facts specific to your community with parents to educate them about the need for screening. • Present information about TeenScreen at a school PTA/PTO meetings to raise awareness and build support prior to consent distribution. • Have a TeenScreen information table at parent orientations, registration days or back to school nights. • Make yourself available to answer questions or address concerns about screening . • Present information in a culturally appropriate manner and anticipate how different cultural groups will respond to screening.

22. The Screening Process

23. Screening must always be voluntary • Approval to conduct screening must be obtained from appropriate leadership • All screening staff must be qualified and trained • Confidentiality must be protected • Parents of identified youth must be informed of the screening results and offered assistance with securing an appointment for further evaluation Principles of Quality Screening Programs

24. Select Your Screening Questionnaire

25. CHS Overview 14-item, 10-minute, self-completion, paper-and-pencil survey for suicide risk Appropriate for 11-18 year-olds 6th grade reading level Trained layperson can administer and score Assesses for symptoms of depression, anxiety, substance abuse, suicide ideation and past attempts Highlights those who might be at risk and screens out those who are not Available in English and Spanish 33% positive rate

26. CHS Sample Question

27. DPS Overview 52-item, 10 minute, self-completion mental health screen Appropriate for 11-18 year-olds Computer-based with spoken questions Trained layperson can administer and score Automatic reporting of screening results English and Spanish versions available 20-33% positive rate

28. The DPS Screens For: • Social Phobia • Generalized Anxiety • Panic attacks • Obsessions and Compulsions • Depression • Suicide ideation (past month) • Suicide attempts (past year) • Alcohol Abuse/ Dependence • Marijuana Abuse/ Dependence • Other Substances Abuse/ Dependence

29. Developing a Mental Health Referral Network and Community Resource Guide • Key Points: • The Referral Network should include providers for insured and uninsured teens • Develop relationships with providers in your community who: • Evaluate and treat a variety of conditions • Agree to accept your referrals in a timely manner and do not have long wait lists • Are culturally appropriate • The Community Guide should include a variety of resources relevant to parents and their teen • Planning Questions: • Have you contacted mental health providers for your referral network? • Have you identified community resources to enhance your services and provide additional linkages and resources to at-risk teens?

30. Fond du Lac County Data 2002-present Over 6,061 students in FDL County have been screened 1,105 (18%) of these students have been identified for being at potential risk of suicide, suffering from mental health problems and received a referral for further evaluation and appropriate treatment.

31. Playing in the Sandbox of Life • Ownership; data, license, …. • Roles; screening not mental health diagnosis • Follow Up; referral options….. • Interview Questions & Forms • Best Practice Procedures • Community/Professional Education

32. Playing in the Sandbox of Life (cont) • I Don’t Want to Know – I’ll Have to Do Something • I Don’t Want you to Know – I’ll Have to Do Something • Clearly Define Follow-up Procedures • Shared Responsibility – Less Weight for All • Communication/Relationship Dividends • Systemic Improvements

33. Teen Support for Screening- What Teens Say About TeenScreen - “I feel like someone is paying attention and listening to me.” “I thought it was very helpful, and I finally feel relieved because I’m getting my problems out.” “The interview on the computer was a great way to know how we feel about stuff in our lives. I think it’s a great idea.” “I thought it was insightful because some of these things are not talked about enough.” “I think this is a good way to find out what’s going on with teens these days. Most teens are afraid to talk about their problems because they don’t want other teens to think they are different.”