Integrating Mental Health into PBIS: Steps for Interconnected Systems Framework

1. A10 – Integrating Mental Health into PBIS: Steps for Getting Started with the Interconnected Systems FrameworkLead Presenters: Kelly Perales, Katie Pohlman, Jennifer Jeffries-Pearsall Key Words: Mental Health, Systems Alignment, Teams

2. Maximizing Your Session Participation • When Working In Your Team • Consider 4 questions: • Where are we in our implementation? • What do I hope to learn? • What did I learn? • What will I do with what I learned?

3. Where are you in the implementation process?Adapted from Fixsen & Blase, 2005

4. Leadership Team Action Planning Worksheets: Steps • Self-Assessment: Accomplishments & Priorities • Leadership Team Action Planning Worksheet • Session Assignments & Notes: High Priorities • Team Member Note-Taking Worksheet • Action Planning: Enhancements & Improvements • Leadership Team Action Planning Worksheet

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6. Save the dates, February 20 – 23, 2019 for the… Pre-Conference Workshops FEBRUARY 20 Skill-Building Workshops FEBRUARY 23 Breakout Sessions FEBRUARY 21 - 22 Networking | Posters | Exhibits Washington, DC Grand Hyatt Washington For more information, visit: conference.apbs.org

7. Objectives • Describe the core features of an ISF • Describe the phases of implementation and the process of aligning and integrating mental health and PBIS over time • Describe how to implement the critical domains of an ISF

8. Partnerships are needed: One in 5 youth have a MH “condition” At least 50%, perhaps 80%, of those get no treatment School is “defacto” MH provider Juvenile Justice system is next level of system default Suicide is 2nd leading cause of death among young adults Factors that impact mental health occur‘round the clock’ It is challenging for educators to address the factors beyond school It is challenging for community providers to address the factors in school

9. Additional Context • 33% increase in teens reporting symptoms of depression • 46% of children in the US have experienced at least one Adverse Childhood Experience (ACE) • US has highest rate of opioid use in the world • The CDC reports “electronic aggression” as an emerging public health problem • Any type of harassment or bullying that occurs through email, a chat room, instant messaging, a website or text messaging

10. Superintendent R. RuncieBroward County Public Schools “Well, given what I’ve seen so far, I believe that we need a smarter system. We need a smarter infrastructure where various agencies, departments, school systems, they’re working in a more integrated and collaborative fashion to ensure that we can share data, we can share information, to enhance our level of effectiveness. I think folks are working as hard as they can. But we’re working in silos. Better integration in support of that, it would be helpful.” -Meet The Press, 2/18/18

11. Some Big Picture Challenges: • Low intensity, low fidelity interventions for behavior/emotional needs • Habitual use of restrictive settings (and poor outcomes) for youth with disabilities • High rate of undiagnosed MH problems (stigma, lack of knowledge, etc.) • Changing the routines of ineffective practices (systems) that are “familiar” to systems • “Referrals to a MH person” viewed as an intervention

12. Challenges • Ad hoc and weak connections of community mental health providers to schools • Need for systematic MOUs that clarify roles • Integration into school-based teams • Funding support to function at Tier 1 and 2, and to not be “co-located” at Tier 3

13. Perceived Barriers • Funding • HIPPA/FERPA • ”Working beyond your scope” • “ So you are here to take my job” • Implicit Bias and Stigma

14. Key Questions • Can we expand the effectiveness of the continuum of interventions if we include: a) a broader group of school/community mental health providers, b) youth & family voice? • How can we enhance the continuum with a greater array of EBP’s to meet the needs of more ‘clients’ with greater effectiveness ? • How can we create honest dialogue across agencies, schools, communities, families?

15. SCHOOL-WIDE POSITIVE BEHAVIOR SUPPORT FRAMEWORK: Tertiary Prevention: Specialized Individualized Systems for Students with High-Risk Behavior ~5% Secondary Prevention: Specialized Group Systems for Students with At-Risk Behavior ~15% Primary Prevention: School-/Classroom- Wide Systems for All Students, Staff, & Settings • Students • Staff • Parents/Families ~80% of Students

16. Experimental Research on SWPBIS • SWPBIS Experimentally Related to: • Reduction in problem behavior • Increased academic performance • Increased attendance • Improved perception of safety • Reduction in bullying behaviors • Improved organizational efficiency • Reduction in staff turnover • Increased perception of teacher efficacy • Improved Social Emotional competence Bradshaw, C.P., Koth, C.W., Thornton, L.A., & Leaf, P.J. (2009). Altering school climate through school-wide Positive Behavioral Interventions and Supports: Findings from a group-randomized effectiveness trial. Prevention Science, 10(2), 100-115 Bradshaw, C.P., Koth, C.W., Bevans, K.B., Ialongo, N., & Leaf, P.J. (2008). The impact of school-wide Positive Behavioral Interventions and Supports (PBIS) on the organizational health of elementary schools. School Psychology Quarterly, 23(4), 462-473. Bradshaw, C. P., Mitchell, M. M., & Leaf, P. J. (2010). Examining the effects of School-Wide Positive Behavioral Interventions and Supports on student outcomes: Results from a randomized controlled effectiveness trial in elementary schools. Journal of Positive Behavior Interventions, 12, 133-148. Bradshaw, C.P., Reinke, W. M., Brown, L. D., Bevans, K.B., & Leaf, P.J. (2008). Implementation of school-wide Positive Behavioral Interventions and Supports (PBIS) in elementary schools: Observations from a randomized trial. Education & Treatment of Children, 31, 1-26. Bradshaw, C., Waasdorp, T., Leaf. P., (2012 )Effects of School-wide positive behavioral interventions and supports on child behavior problems and adjustment. Pediatrics, 130(5) 1136-1145. Horner, R., Sugai, G., Smolkowski, K., Eber, L., Nakasato, J., Todd, A., & Esperanza, J., (2009). A randomized, wait-list controlled effectiveness trial assessing school-wide positive behavior support in elementary schools. Journal of Positive Behavior Interventions, 11, 133-145. Horner, R. H., Sugai, G., & Anderson, C. M. (2010). Examining the evidence base for school-wide positive behavior support. Focus on Exceptionality, 42(8), 1-14. Ross, S. W., Endrulat, N. R., & Horner, R. H. (2012). Adult outcomes of school-wide positive behavior support. Journal of Positive Behavioral Interventions. 14(2) 118-128. Waasdorp, T., Bradshaw, C., & Leaf , P., (2012) The Impact of Schoolwide Positive Behavioral Interventions and Supports on Bullying and Peer Rejection: A Randomized Controlled Effectiveness Trial.Archive of Pediatric Adolescent Medicine. 2012;166(2):149-156 Bradshaw, C. P., Pas, E. T., Goldweber, A., Rosenberg, M., & Leaf, P. (2012). Integrating schoolwide Positive Behavioral Interventions and Supports with tier 2 coaching to student support teams: The PBISplus Model. Advances in School Mental Health Promotion, 5(3), 177-193. doi:10.1080/1754730x.2012.707429 Freeman, J., Simonsen, B., McCoach D.B., Sugai, G., Lombardi, A., & Horner, ( submitted) Implementation Effects of School-wide Positive Behavior Interventions and Supports on Academic, Attendance, and Behavior Outcomes in High Schools.

17. PBIS Provides a Solid Foundation…. but More is Needed… Many schools implementing PBIS struggle to implement effective interventions at Tiers 2 and 3 Many systems struggle to align multiple initiatives Youth with “internalizing” issues may go undetected PBIS systems (although showing success in social climate and discipline) often do not address broader community data and mental health prevention.

18. Current National Data: Principals’ Concerns

19. National Data (cont.) • A national study completed in the journal Pediatrics (11/2016) found a 37% increase in the number of teens suffering from a major depressive episode from 2005 to 2014, but those receiving mental health counseling or treatment did not change significantly (Mojtabai, Ramin; Olfson, Mark; Han, Beth; 2016). • A 2015 report from the Child Mind Institute states that of the 74.5 million children in the United States, it is estimated that just over 17 million have or have had a psychiatric disorder. The report goes on to state that according to interviews done by professionals with a group of youth ages 13-18, “49.5% of American youth will have had a diagnosable mental illness at some point before they are 18...” and that, “22.2% of American youth will have a diagnosable mental illness with ‘serious impairment’ at some point before they are 18.”

20. Current National Statistics (National Institute of Mental Health, 2018: https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154968)

21. Where We’ve Been: • 2002-2007: Site Development with PBIS Expansion (informal and independent) • 2005: Community of Practice focus on integration of Positive Behavioral Interventions and Supports (PBIS) and School Mental Health (SMH) • 2008: ISF White Paper: formal partnership between PBIS and SMH • 2009- 2013 Monthly calls with implementation sites, national presentations (from sessions to strands) • 2009-2011 Grant Submissions • June 2012- September 2013 ISF Monograph • Monograph Advisory group • 2015: ISF Learning Community, SOC Webinar Series • 2016: Randomized Control Trial (RCT) Grant awarded • 2016: Targeted Work Group Webinars (8) • 2017: Targeted Work Group Webinars continuing, knowledge development sites across country • 2018: Continued webinars and knowledge development sites

22. Advancing Education Effectiveness: Interconnecting School Mental Health (ISF) and School-Wide Positive Behavior Support (PBIS) Editors: Susan Barrett, Lucille Eber and Mark Weist pbis.org csmh.umaryland IDEA Partnership NASDSE

23. Where We Are Headed: • 2018-19 Targeted Work Group (TWG) webinars and knowledge development sites continue • Training/TA curriculum and workbook available online • Other resources, tools, examples also available • Second volume to monograph: An Implementation Guide

24. Volume 2: An Implementation Guide • Chapter 1: Context and Structure for Volume • Chapter 2: Defining ISF: Origins, Critical Features, and Key Messages • Chapter 3: Exploration and Adoption • Chapter 4: Installing ISF at the District and Community Level • Chapter 5: Installing ISF at the Building Level • Chapter 6: Implementation at District and Building Levels • Chapter 7: Innovation, Summary, and Recommendations to the Field

25. Chapter 1: Context and Structure • Context of ISF and SMH • The why for integrated systems • Rising mental health needs • With some additional context • Technology • Opioid crisis *This context provided upfront in our session today.

26. Chapter 2: Defining ISF: Origins, Critical Features, and Key Messages • What is ISF? • Expanding on key messages • Examples of work

27. ISF Defined • Structure and process for education and mental health systems to interact in most effective and efficient way. • Guided by key stakeholders in education and mental health/community systems • Who have the authority to reallocate resources, change role and function of staff, and change policy.

28. ISF Enhances MTSS Core Features • Effective teams that include community mental health providers • Data-based decision making that include school data beyond ODRs and community data • Formal processes for the selection & implementation of evidence-based practices (EBP) across tiers with team decision making • Early access through use of comprehensive screening, which includes internalizing and externalizing needs • Rigorous progress-monitoring for both fidelity & effectiveness of all interventions regardless of who delivers • Ongoing coaching at both the systems & practices level for both school and community employed professionals

31. 1. Single System of Delivery • One committed and functional team with authority guides the work, using data at three tiers of intervention • MH/community partners participate across ALL Tiers • Evidence Based Practices/ Programs integrated at each tier • Symmetry (of process) at District and Building level • District has a plan to integrate MH at all buildings • Plan is based on community and school data • Plan to build “social emotional” capacity across staff • Training and Coaching in place for ALL staff (community and school employed) • Staff are competent and confident in identifying, intervening and/or referring

32. One SystemSchool Data  Community Data (Student and System level) Academic (Benchmark, GPA, Credit accrual etc) Discipline Attendance Climate/Perception Visits to Nurse, Social Worker, Counselor, etc Screening from one view Community Demographics Food Pantry Visits Protective and Risk Factors Calls to crisis centers, hospital visits Screening at multiple views

33. What Does it Mean to Integrate? Change in routines and procedures? (e.g. who needs to be available to participate in team meetings?) Change in how interventions are selected and monitored? (e.g. team review of data/research vs individual clinician choice?) Change in language we use? (e.g. identifying specific interventions vs generic terms such as “counseling” or “supports”?) Changes in Roles/functions of staff? (e.g. clinicians coordinating/overseeing some interventions that non-clinicians deliver?)

34. 2. Moving Beyond Access All work is focused on ensuring positive outcomes for ALL children and youth and their families. • Interventions matched to presenting problem using data, monitored for fidelity and outcome • Teams and staff are explicit about types of interventions students and youth receive (e.g. from “student receives counseling” to “student receives 4 coping skills group sessions) • Skills acquired during sessions are supported by ALL staff (e.g. staff are aware that student is working on developing coping skills and provides prompts, pre-corrects, acknowledges across school day)

35. Example • Community clinician joined Tier II team • Helped recognize that a group of students identified for support had likely experienced trauma. • Community clinician and school clinician collaborated to select an evidence-based trauma informed group. • Trauma informed group was added to school’s continuum of interventions • Community and school clinician co-facilitated the group • Students receiving intervention had improved academic and behavioral data as well as self-reporting feeling more connected to school.

36. Trauma-Informed Tier 2 Group Daily Progress Report (DPR) Sample NAME:______________________ DATE:__________________ Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors. Self-Check Use calming strategy Use your words Use safe hands Ask for help Connect with safe person Adapted from Grant Middle School STAR CLUB Adapted from Responding to Problem Behavior in Schools: The Behavior Education Program by Crone, Horner, and Hawken

37. 3. Mental Health is for ALL • Positive school climate and culture serves as protective factor. Social/emotional/behavioral health addressed with same level of attention and concern as is our children’s academic and cognitive achievement. • Social behavior skills taught and reinforced by ALL staff across ALL settings, and embedded in ALL curriculum • Behavior and social emotional examples used to explicitly teach what behaviors look like and sound like across school settings.

38. 1. Expectations 2. NATURAL CONTEXT (Locations) Invite those sitting alone to join in • Have a lunch plan and choose quiet or social lunch area • Invite friends to join me Expectations 3. Rules or Specific Behaviors • Use my breathing technique • Listen to my signals

39. 4. Installed and aligned with core features of MTSS framework. • Integrated teams representative of all stakeholders including families and students; • Apply data-based decision making; • Have a formal process for selecting and implementing evidence-based practices; • Ensure early access through comprehensive screening; • Progress monitor for both fidelity and effectiveness; • Ensure coaching.

40. Chapter 3: Exploration and Adoption • Phases of Implementation – Implementation Science • PBIS Implementer’s Blueprint

41. STAGES of IMPLEMENTATION(Fixsen, Blasé, 2005)

42. Funding Stakeholder Support Policy & Systems Alignment Workforce Capacity Executive Functions LEADERSHIP TEAMING Implementation Functions Training Coaching Evaluation & Performance Feedback Behavioral Expertise Local Implementation Demonstrations

43. Symmetry of Process

44. Exploration steps: • Establish an exploration team • Examine current partnerships • Assess impact of existing initiatives/programs • Develop a shared understanding of ISF • Determine benefit • Decide to adopt or not

45. Current Work and New Resources • Teaching Social-Emotional Competencies within a PBIS Frameworkhttps://www.pbis.org/Common/Cms/files/pbisresources/TeachingSocialEmotionalCompetenciesWithinAPBISFramework.pdf • Improving Multi-tiered Systems of Support for Students with “Internalizing” Emotional/Behavioral Problems http://www.midwestpbis.org/interconnected-systems-framework/publications • Leadership Installation Guide

46. Chapter 4: Installing ISF at District Level • What it looks and feels like to prepare systems and infrastructure to install ISF • Establish (or enhance) Leadership Team • Assess Current Status • Establish Mission • Establish Routines and Procedures for Working within a MTSS • Establish Ongoing Action Planning Process

47. Step 1: Establish a Leadership Team • Representative Stakeholders Identified • Executive leadership from both school and agency systems b) Establish Team Operating Procedures • Time to meet (at least quarterly)

48. Step 2: Assess Current Status of Mental Health & PBIS Systems • Conduct assessment of current system structures • Stakeholder Support, Funding, Policy & Systems Alignment, & Workforce Capacity • Conduct review of current initiatives & practices • Conduct staff utilization review • Review current school & community data

49. Step 3: Reach Team Consensus on a Mission Statement • Establish a common mission • Valued by all stakeholder groups • Establishes priorities to share with stakeholder groups (e.g.: teachers, students, families)

50. Step 4: Establish Procedures & Routines • Selecting and installing a universal screener • Addressing both internalizing & externalizing behavior needs • Conducted 2x per year • Selection process for evidence-based practices • Process to monitor fidelity of interventions • Process to monitor outcomes of interventions