Strengthening Partnerships for School Mental Health Services in the United States

1. Strengthening Partnerships for School Mental Health Services in theUnited States Carl E. Paternite Center for School-Based Mental Health Programs Miami University (Ohio) Mark Weist Center for School Mental Health Assistance University of Maryland Presentation at the Clifford Beers Foundation Conference: Mental Health Promotion—Going from Strength to Strength Dublin, Ireland April 21, 2005

2. The Crisis of Youth Mental Health in the U.S. • About 20% of youth, ages 9 to 17 (15 million), have diagnosable mental health disorders, (and many more are at risk or could benefit from help) • Between 9-13% of youth, ages 9-17 years, meet the federal definition of serious emotional disturbance (SED)

3. The Crisis of Youth Mental Health in the U.S. (cont.) • Less than 30% of youth with diagnoses receive any services, and these services are often inadequate • For the small percentage of youth who do receive services, most actually receive them in schools

4. Growing Focus on School Mental Health (SMH) in the U.S. • U.S. Surgeon General Reports (1999, 2000) • President’s New Freedom Commission on Mental Health Report (2003) • Mandates of “No Child Left Behind” and Individuals with Disabilities Education Act (IDEA) • Progress in localities and states • Collaborative research-practice-training networks

5. Report of President’s New Freedom Commission on Mental Healthhttp://www.mentalhealthcommission.gov “…the mental health delivery system is fragmented and in disarray…leading to unnecessary and costly disability, homelessness, school failure and incarceration”

6. New Freedom CommissionGoal 4: Early Mental Health Screening, Assessment, and Referral to Services are Common Practice 4.1 Promote the mental health of young children 4.2Improve and expand school mental health programs 4.3 and 4.4 (both focus on enhancing mental health screening)

7. New Freedom Commission Critical importance of partnership with schools in mental health care: • “While schools are primarily concerned with education, mental health is essential to learning as well as to social and emotional development. Because of this important interplay between emotional health and school success, schools must be partners in the mental health care of our children.” July, 2003, p. 58

8. Education Policies in the U.S. • 1) Achievement promotes wellbeing • 2) Wellbeing promotes achievement • School accountabilities often acknowledge 1 but fail to acknowledge 2

9. Schools: The Most Universal Natural Setting • Over 52 million youth attend 114,000 schools in the U.S. • Over 6 million adults work in schools • Combining students and staff, one-fifth of the U.S. population can be found in schools From New Freedom Commission (2003)

10. In Addition to Enhanced Access, SMH can: • Reduce stigma for help seeking • Promote generalization/maintenance of intervention gains • Enhance capacity for prevention/MH promotion • Foster clinical efficiency and productivity • Promote a natural, ecologically grounded approach to helping youth and families

11. SMH Impacts • Based on a limited knowledge base, when done well SMH programs and services are associated with: • Strong satisfaction by diverse stakeholder groups • Improvement in student emotional/behavioral functioning • Improvement in school outcomes (e.g., climate, special education referrals, reduced bullying, fewer suspensions)

12. SMH Impacts (cont’d) • When done well SMH programs and services also can play a role in: • Preventing and addressing the impacts of violence on youth • Reducing/preventing school drop-out • Enhancing student connectedness to school

13. Factors Necessary to Achieve Desired Outcomes for Youth Through SMH Programs and Services

14. Critical Themes in SMH

15. Need for Conceptual Clarity • “School mental health” is a very broad term • All schools are delivering some form of SMH • With a vague definition it is difficult to track progress and develop advocacy

16. Expanded School Mental Health • Full continuum of mental health promotion, early intervention, prevention and treatment • For youth in general and special education • Through collaborative school-community partnerships • (Emphasis on quality, evidence-based practices, ongoing evaluation)

17. Service Capacity • Schools and SMH programs typically struggle to meet the needs of students • Excessive referrals for students with serious problems and crises • Full continuum of MH promotion-prevention-treatment services is rarely provided • Schools and communities reluctant to undertake systematic MH screening for youth

18. Preventive Services andMH Promotion • In spite of best intentions, drift toward individual services for students with severe/chronic problems • Reflects fundamental bias in U.S. toward “mental health” problems presumed to reside within individuals • WHO model of health promoting schools is inverted in the U.S. • International dialogue is of great benefit to U.S. experience

19. Mental Health-Education Systems Integration • Typically, SMH programs/staff viewed by educators to be “add ons” or frills, not central to the “academic” mission • Need to move beyond cooperation to MH-Education program and systems integration, with close collaborative work based on shared values and goals

20. To Promote Integration Should Ensure: • Strong family-school-MH collaboration in SMH program planning • That SMH providers understand school culture and how to work as collaborative team players • That SMH practices are of high quality and effective • A connection between SMH programs and services and reducing barriers to learning

21. Pre-Service/In-Service Training Needs for Educators and SMH Staff • In Addition to Parents, Teachers are on the Mental Health “Front Line” • Yet, teachers/educators are very poorly trained in problem recognition and mental health promotion • Significant need to enhance teacher/educator training based on analysis of issues confronted in the classroom/school

22. Mental Health Concepts that Promote Learning • Self-instruction (e.g., developing an internal dialogue) • Problem solving (e.g., considering costs and benefits of actions) • Self-control and–reinforcement (e.g., work before play) • Template matching (e.g., modeling actions of B+ students)

23. SMH Research Base • Is fairly limited • Most of literature is on research-supported studies • Significant challenges in promoting evidence-based practices in schools that are operating without formal research support

24. Community Science Approach (Wandersman, 2003) • Promotes local accountability in community delivery processes • Engages practitioners (MH, education) in planning, implementing, evaluating, sustaining, and continuously improving services, based on locally determined needs • Process builds local capacity to improve quality of practice and achieve positive health outcomes

25. Enhancing Quality in Expanded School Mental Health • Randomized controlled study to assess impacts of systematic quality improvement on clinician behavior, satisfaction with services, and student outcomes • First experimental study of quality improvement in school mental health • Will provide guidelines for best practice and will help to standardize practice (Project # 1R01 MH71015-01A1, NIMH, 2003-2006; PI: M. Weist, University of Maryland)

26. Principles for Best Practice in Expanded School Mental Health • 1) All youth and families are able to access appropriate care regardless of their ability to pay • 2) Programs are implemented to address needs and strengthen assets for students, families, schools, and communities • 3) Programs and services focus on reducing barriers to development and learning, are student and family friendly, and are based on evidence of positive impact

27. Principles (cont.) • 4) Students, families, teachers and other important groups are actively involved in the program's development, oversight, evaluation, and continuous improvement • 5) Quality assessment and improvement activities continually guide and provide feedback to the program • 6) A continuum of care is provided, including school-wide mental health promotion, early intervention, and treatment

28. Principles (cont.) • 7) Staff hold to high ethical standards, are committed to children, adolescents, and families, and display an energetic, flexible, responsive and proactive style in delivering services • 8) Staff are respectful of, and competently address developmental, cultural, and personal differences among students, families and staff

29. Principles (cont.) • 9) Staff build and maintain strong relationships with other mental health and health providers and educators in the school, and a theme of interdisciplinary collaboration characterizes all efforts • 10) Mental health programs in the school are coordinated with related programs in other community settings

30. Importance of Family Involvement • SEARCH Institute study: • As parental involvement in schools increased, problem behaviors in students (alcohol use, violence, antisocial problems) decreased • Roehlkepartain & Benson, 1994

31. Engaging Families is a Key • In initial family contacts: • Clarify child’s need for services • Openly discuss attitudes and past experiences with the mental health system • Identify and strategize about probable obstacles • Identify concrete, practical issues that can be addressed immediately (McKay, Nudelman, & McCadam, 1996)

32. Toward Funding for a Full Continuum of Programs and Services • Maximizing all potential sources of revenue: • allocations from schools and departments of education • state and local grants and contracts • federal and foundation grants and contracts • “line item” support • innovative prevention funding • fee-for-service

33. The Significant Impacts of Federalism • State of residence determines whether youth use mental health more than race/ethnicity or income • Differences in mental health use by children across states are generally not related to differences in levels of need (e.g. AL and TX present higher rates of need but lower rates of use) • Sturm, Ringel & Andreyeva, 2003 (www.pediatrics.org)

34. Ohio Mental Health Network for School Success • Regional action networks for mental health in schools • Networks raise awareness, develop resources, offer TA, do training within and across sites • Newsletter and regular publication on progress • Genuine cost sharing across major systems • Strong partnerships with universities and development of centers of excellence

35. Actions to Advance SMH in the U.S.

36. For True Progress in SMH • Widespread acknowledgement of the marginalized status of child and school mental health resources and efforts • Recommendations from policy initiatives (e.g., Surgeon General, New Freedom Commission) broadly publicized and implemented

37. For True Progress in SMH • Nation-to-state infrastructure and plan that addresses significant local variability • Organized state-level initiatives and mechanisms for state to state collaboration with national support • Track and support effort in all localities

38. For True Progress in SMH • Debunk the view of SMH as an “add-on” or “frill” and assert the crucial links between MH and school success • Confront and resolve language issues • Promote MH system attention to educationally relevant outcomes • Build a comprehensive research agenda • Promote international dialogue

39. INTERCAMHSInternational Alliance for Child andAdolescent Mental Health and Schools www.intercamhs.org

40. CSMHA Training Events • School Health Interdisciplinary Program (SHIP). Turf Valley Country Club, Ellicott City, Maryland. August 1-4, 2005 • 10th Annual Conference on Advancing School-Based Mental Health. Cleveland Renaissance Hotel, October 26-29, 2005 • See http://csmha.umaryland.edu, or Sylvia Huntley at shuntley@psych.umaryland.edu