School Based Mental Health

1. School Based Mental Health Kevin Junkins, MD Child and Adolescent Psychiatrist Community Care of WV

2. Objectives • Review trends in child/adolescent mental health in WV • Discuss evidence and literature regarding school based mental health • Discuss mechanisms and methods of delivering school based mental health • Discuss a current elementary school based mental health prevention strategy • Discuss Barriers to School Based Mental Health

3. Disclosures • I work for a federally qualified health center that provides school based health center services to several counties in WV • HRSA grant funding to expand and evaluate the outcomes of implementation of the PAX Good Behavior Game in rural WV

4. What is school based mental health? School-based mental health services are those delivered by school-employed and/or community-employed providers in school buildings

5. School Based Mental Health – The Need: • 90 percent of people who develop a mental disorder showing warning signs during their teen years • At least 13 percent of youth under 18 have significant mental health problems • Anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders are among the more common disorders • Great Smoky Mountain Study 27% of children have mental health impairment and 20% of children have diagnosable mental health condition • WV in midst of opioid epidemic

8. About 6000 depressed WV youth DID NOT received treatment for depression in 2011 to 2015

10. Why Should Schools Care About Mental Health: • Good mental health is critical to children’s success in school and life • Mental health problems are linked to negative outcomes • Academic problems – poor academic achievement • Behavioral problems – classroom disruption, fights • Dropping out • Delinquency • May increase need for special education services • Adds additional cost

11. Barriers to Mental Health Treatment of Children in West Virginia: • Lack of transportation • Many families will not address mental health needs if their health insurance does not offer adequate coverage • Financial constraints • Lack of access to mental health professionals • Stigmas related to mental health problems • Parent’s cannot miss work to bring to appointment • Parent/Guardian’s own psychopathology • Lack of collateral information/communication with schools/teachers

12. School Based Mental Health Overcomes Barriers: • Lack of transportation • - School buses provide transport daily • Many families will not address mental health needs if their health insurance does not offer adequate coverage • - An integrated model may allow PCP to manage conditions with consultation from behavioral health team • Financial constraints • - Less travel time, less missed work, more efficient • Lack of access to mental health professionals • - Services are brought to the patient, rather than patient brought to services

13. School Based Mental Health Overcomes Barriers: • Lack of access to mental health professionals • - Services are brought to the patient, rather than patient brought to services • Stigmas related to mental health problems • - Services provided within the safety and comfort of school, family does not present to “mental health clinic” but rather to the school based health center • - Up to 60% of students do not receive the treatment they need due to stigma and lack of access to services Of those who do get help, nearly two thirds do so only in school • - Adolescents with access to SBHCs with mental health services were 10 times more likely than students without such access to initiate a visit for a mental health or substance abuse concern (98% of such visits were at an SBHC)

14. School Based Mental Health Overcomes Barriers: • Parent’s cannot miss work to bring to appointment • Since transit not necessary, parents can phone in and participate, less missed work • Students miss less school • Parent/Guardian’s own psychopathology • - Less responsibility placed on parents to get patients to appointments • - School based mental health team can refer parent/guardian for services • Lack of collateral information/communication with schools/teachers • Ease of access to discuss behaviors/symptoms/concerns and response to intervention with principals, counselors, teachers and school psychologists • School based mental health practice makes me a more effective provider

15. Guidance for School Mental Health • Centers should be located in schools • Parents sign written consents for their children to enroll in the health center • An advisory board of community representatives, parents, youth, and family organizations participate in planning and oversight of the health center • The health center works cooperatively with school nurses, coaches, counselors, classroom teachers, and school principals and their staff to ensure that the health center is an integral part of the life of the school • Clinical services are the responsibility of a qualified health providerAmultidisciplinary team of physicians, nurse practitioners, clinical social workers, licensed counselors and other health professionals care for students • The health center provides a comprehensive range of services that specifically meet the serious health problems of young people in the community

16. Models of School Based Mental Health School-supported mental health models - Social workers, guidance counselors, and school psychologists are employed directly by the school system - Separate mental health units exist within the school system - School nurses serve as a major portal of entry for students with mental health concerns

17. Models of School Based Mental Health Community connections models • A mental health agency or individual delivers direct services in the school part-time or fulltime under contract • Mental health professionals are available within an SBHC or are invited into after-school programs • There is a formal linkage to an off-site mental health professional and/or to a managed care organization

18. Models of School Based Mental Health Comprehensive, integrated models • A comprehensive and integrated mental health program addresses prevention strategies, school environment, screening, referral, special education, and family and community issues and delivers direct mental health services. • SBHCs provide comprehensive and integrated health and mental health services within the school environment

20. Challenges to School Based Mental Health • Coordination with primary care provider • Coordination with outside agencies • Association with school • FERPA/HIPPA • School System Politics • School Personnel Buy-In • Insurance • Physical Space • Summers/Snow Days/Work Stoppages

21. How Can Pediatricians Contribute to School Based Mental Health Programs? • Advocate for schools to develop comprehensive mental health programs with an evidence based prevention component that focuses on building emotional flexibility, self-regulation and social emotional learning • Develop relationships with local schools, serve on school health advisory councils, and promote school-based mental health services • Facilitate coordination with school-based mental health professionals

22. How Can Pediatricians Contribute to School Based Mental Health Programs? • Advocate for mental health services should be included in IEPs for patients enrolled in a special education program • Advocate for financial and institutional changes that are likely to provide medical homes and families with the option of access to mental health services through school settings • Assist schools and mental health providers develop strategies and community resources that will augment school-based mental health programs • Engage in outcomes-based research to improve the design and effectiveness of school based mental health programs

23. Community Connections – Braxton A collaboration of Braxton County Schools and Community Care of WV Prevention Early Identification and Intervention Integrated Behavioral Health and Primary Care Cooperation of School Personnel and Behavioral Health Team Community Support and Engagement Support for Families

24. Community Connections – Braxton A collaboration of Braxton County Schools and Community Care of WV Prevention – PAX Good Behavior Game (GBG) Evidence BasedPrevention Intervention What is the PAX Good Behavior Game? PAX = peace in Latin

25. Prevention – PAX Good Behavior Game (GBG) • Evidence BasedPrevention Intervention • Good Behavior Game first published in 1969 • First used in 1967 in Baldwin City, Kansas • Positive Peer Pressure • Further developed, researched and refined by John’s Hopkins University and PAXIS Institute • Currently PAXIS Institute (Dr Dennis Embry) further develop the PAX Good Behavior Game

26. Community Connections – Braxton A collaboration of Braxton County Schools and Community Care of WV Prevention – PAX Good Behavior Game (GBG) Evidence BasedPrevention Intervention

27. Community Connections – Braxton A collaboration of Braxton County Schools and Community Care of WV Prevention – PAX Good Behavior Game (GBG) Evidence BasedPrevention Intervention The PAX GBG is made up of a series of “Kernels” Kernels – the smallest unit scientific behavioral influence that can stand by itself

28. Prevention - PAX Good Behavior Game Prevention – PAX Good Behavior Game (GBG) Evidence BasedPrevention Intervention The PAX GBG is made up of a series of “Kernels” Kernels – the smallest unit scientific behavioral influence that can stand by itself

29. Prevention - PAX Good Behavior Game • Children set the “Vision” for the Classroom • - Gives Children a Voice • See, Hear, Do and Feel – More or Less • Strive to be “PAX Leaders” • Decrease “spleems” or negative behaviors

30. Prevention - PAX Good Behavior Game Self-regulation- The PAX Good Behavior Game builds self-regulation - Reinforces desirable behaviors and decreases unwanted behaviors, - Kids learn to delay gratification and reduce impulsivity Increases in pro-social behavior and self-regulation - Develops and strengthens peer networks to improve relationships

31. Prevention - PAX Good Behavior Game • Students give each other positive praise notes • Parents get positive notes rather than negative notes • Teachers use harmonica’s rather than yelling or flipping lights • Avoids re-traumatization • Negative behaviors are addressed in a non-confrontational manner • Students need to cooperate as they play the Good Behavior Game • Standardized system throughout the school, no confusion • Students know expectations up front • Decreased rates of teacher burn out and depression • Good Behavior Game is played during instructional time • No loss of instructional time • Studies have shown a general increase in instructional time due to less disruptive behaviors in the classroom

32. PAX Good Behavior Game Outcomes • Increase instructional time • Increases in reading and math skills for children in poverty • Reductions in disturbing, disruptive and inattentive behaviors • Improvement of on task behaviors • Decrease in violent injuries at school • Reduction in need for later special education services • Decreased school nurse visits • Decreased risk of later attempted/completed suicide

33. Prevention - PAX Good Behavior Game PAX GBG integrates with PBIS and serves as a Tier 1 Universal Intervention, or “Behavioral Vaccination” Intervention for situations in which individual students have difficulty Tier 3 Intervention for situations in which groups of students have difficulty Tier 2 Tier 1 Universal Implementation

34. Prevention - PAX Good Behavior Game • Trauma-informed Care • Adheres to SAMHSA’s six key principles of a trauma-informed approach and model for a trauma-informed classroom • creates a nurturing environment in every school and classroom • Allows young people to develop pro-social behaviors • Provides teachers with strategies that support development and prevent the re-traumatization of children who have been exposed to trauma

35. Prevention - PAX Good Behavior Game • Social and Emotional Learning • - Promotes social and emotional learning in all students. • - Develop ability to recognize their own thoughts and feelings as well as regulate their own emotions and behaviors • Improves awareness for the needs of others • Improved ability to develop and maintain positive relationships with others

36. Once the classroom vision is decided and kernels introduced, then then classes play the Good Behavior Game

37. Unit 1: Learning PAX Key Foundations & Rationale Unit 4: Strengthening PAX More Strategies for PAX Evidence Based Kernels PAX GAME Unit 2: Launching PAX Unit 3: Living PAX 10. OK / Not Ok 9. PAX Hands-Feet 8. PAX Voices 7. Tootles 6. PAX Stix 1. PAX Vision 5. Beat the Timer 4. Wacky Prizes 3. PAX Quiet 2. PAX Leader

38. Community Connections – Braxton • A collaboration of Braxton County Schools and Community Care of WV • Early Identification and Intervention • School, SAT/504/IEP, Parent or PCP referral • GBG assists in identifying internalizers • Screening of users of School Based Health Center • Integrated Behavioral Health and Primary Care • School Based Health Centers and Behavioral Health • Outside PCP or medical home and school based mental health team • Important to close gaps in communication

39. Community Connections – Braxton • A collaboration of Braxton County Schools and Community Care of WV • Cooperation of School Personnel and Behavioral Health Team • Collateral Information • Crisis Management • Case Management • Community Support and Engagement • Civic, religious organizations, law enforcement, DHHR, Justice system, prosecuting attorney • Support for Families • GAPP, RAPP, Al Anon, Family Therapy, • Referral to services for struggling family members

40. References: Atkins MS, Hoagwood KE, Kutash K, Seidman E. Toward the integration of education and mental health in schools. Adm Policy Ment Health. 2010;37(1-2):40-7. Barrish, H., Saunders, M., & Wolf, M. (1969). Good behavior game: Effects of individual contingencies for group consequences on disruptive behavior in a classroom. Journal of Applied Behavior Analysis, 2, 119–124 Center for Mental Health in Schools. N.d. Technical Assistance Sampler on School-Based Health Centers. Los Angeles, CA: School Mental Health Project, Department of Psychology, UCLA. Committee on School Health. "School-based mental health services." Pediatrics 113.6 (2004): 1839-1845. Embry, Dennis D. "The Good Behavior Game: A best practice candidate as a universal behavioral vaccine." Clinical child and family psychology review 5.4 (2002): 273-297. Embry, Dennis D., and Anthony Biglan. "Evidence-based kernels: Fundamental units of behavioral influence." Clinical child and family psychology review 11.3 (2008): 75-113. Embry, Dennis D. "A Scientific and Research History of the PAX (Good Behavior) Game." PAXIS Institute, Clinical Child and Family Psychology Review 5 (2002): 273-297. Embry D, Fruth J, Roepcke E and Richardson C. PAX Good Behavior Game Manual, 4th Ed. PAXIS Institute. 2017. Flower, Andrea & McKenna, John & Bunuan, Rommel & Muething, Colin & Jr, Ramon. (2014). Effects of the Good Behavior Game on Challenging Behaviors in School Settings. Review of Educational Research. 84. 10.3102/0034654314536781. Fruth, Jason. "Impact of a universal prevention strategy on reading and behavioral outcomes." Reading Improvement51.3 (2014): 281-290. Greenberg MT, Domitrovich C, Bumbarger B. Preventing Mental Health Disorders in School-Age Children: A Review of the Effectiveness of Prevention Programs. University Park, PA: Prevention Research Center, Penn State University; 1999.

41. References • Kazdin AE, Holland L, Crowley M. Family experience of barriers to treatment and premature termination from child therapy. J Consult Clin Psychol. 1997;65:453–463 • Policy Leadership Cadre for Mental Health in Schools. Mental Health in Schools: Guidelines, Models, Resources, and Policy Considerations. Los Angeles, CA: University of California-Los Angeles, Center for Mental Health in Schools; 2001 • Robbins V, Armstrong B, Collins K. The Bridges Project: closing the gap between schools, families, and mental health services for all children and youth. Community Mental Health Report. July 2002:67–70 • Robert Weis, Karen J. Osborne & Emily L. Dean (2015) Effectiveness of a Universal, Interdependent Group Contingency Program on Children's Academic Achievement: A Countywide Evaluation, Journal of Applied School Psychology, 31:3, 199-218, DOI: 10.1080/15377903.2015.1025322 • SCHOOL-BASED MENTAL HEALTH SERVICES Downloaded from www.aappublications.org/news by guest on March 20, 2019 • Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: West Virginia, 2015. HHS Publication No. SMA–16–Baro–2015–WV. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.