School Mental Health and System Transformation in Maryland : School Mental Health and System Transformation in Maryland
Mental Hygiene Administration’s Annual Conference
Transforming Mental Health Care Together
Nancy A. Lever, Ph.D.
(nlever@psych.umaryland.edu)
Mark D. Weist, Ph.D
(mweist@psych.umaryland.edu)
Center for School Mental Health Analysis and Action
Outline : Outline A Crisis in Children’s Mental Health
Expanded School Mental Health
Maryland School Mental Health Alliance
National Connections and Implications for Transforming the System of Care
Overview of Children’s MH Needs : Overview of Children’s MH Needs
Between 20% to 38% of youth in the U.S. have diagnosable mental health disorders
Between 9% to 13% of youth have serious disturbances that impact their daily functioning
Between one-sixth to one-third of youth with diagnosable disorders receive any treatment
Barriers to Traditional Mental Health Care : Barriers to Traditional Mental Health Care
Financial/Insurance
Childcare
Transportation
Mistrust/Stigma
Past Experiences
Waiting List/Intake Process
Stress
Schools: The Most Universal Natural Setting : Schools: The Most Universal Natural Setting Over 56 million youth (ages 5 to 19) attend school
Over 6 million adults work in schools
Combining students and staff, one-fifth of the U.S. population can be found in schools
Provision of Mental Health Services in Schools : Provision of Mental Health Services in Schools
While only 16% of all children receive mental health services, of those receiving care, 70-80% receive that care in the school setting.*
*Rones & Hoagwood, 2000 (http://www.healthinschools.org/cfk/mentfact.asp)
Expanded School Mental Health (ESMH) : Expanded School Mental Health (ESMH) Full continuum of mental health services for children and adolescents in both regular and special education
Assessment
Treatment
Case Management
Mental Health Promotion
Prevention
Crisis Management
Consultation
Expanded School Mental Health : Expanded School Mental Health Family-school-community partnerships
Commitment to a full continuum of care (mental health education, promotion, assessment, prevention, early intervention, treatment)
Collaboration and partnerships with school staff and families
Commitment to quality assessment and improvement and empirically supported practice
School Mental Health Program (SMHP) : School Mental Health Program (SMHP) Established in 1989 in four Baltimore City Public Schools
Gradually expanded to 29 schools
Primarily serving South, Southwest, Northwest, and West Baltimore
Staff includes social workers, psychologists, psychiatrists, masters level clinicians, licensed professional counselors, and trainees
Slide10 : Family and community violence
Academic and/or attendance problems
Bereavement and loss
Depression and anxiety
Abuse and neglect
Substance abuse
Problems in peer relationships
Family conflict
Bullying and the bullied
School refusal
Common Presenting Problems
ESMH Advantages : ESMH Advantages
Access to youth
Clinical efficiency and productivity
Outreach to youth with internalizing disturbances
Enhanced capacity for prevention
Enhanced ability to promote generalization
Reduced stigma
Broadened roles for clinicians
Challenges and Opportunities : Challenges and Opportunities Significant emotional/behavioral problems in youth
Involving families in care
High number of referrals
Isolation from other ESMH staff
Confidentiality and privacy
Stigma
Program sustainability and limited resources
What Makes a Successful ESMH Clinician? : What Makes a Successful ESMH Clinician? Flexibility
Creativity
Visibility
Accountability
Cultural Sensitivity
Energy
A Team Player
Respectful of individuals and the school
Good Clinical Skills
Cost Effectiveness and ESMH : Cost Effectiveness and ESMH
Reduced “no-shows”
Shared costs and resources
One study concluded that school-based services cost about a half to a quarter of what similar services would cost in the private sector (Nabors, Leff, & Metrick, 2001)
ESMH Outcomes : ESMH Outcomes When Programs are Done Well, we can see
Improved grades, attendance, and behavior in students. Decreased discipline referrals.
Decreased inappropriate referrals to special education
Decreased high intensity use of mental health services
Improved school climate
Improved awareness of mental health issues
Outcomes continued : Outcomes continued
Service utilization is enhanced in disadvantaged communities
Services are viewed positively by clients
Services are viewed as being as at least as effective as clinic based services
Catron, Harris, & Weiss, 1998
96 % Follow through with SBMH services
13 % Follow through with CMHC
Maryland Seed Grant : Maryland Seed Grant Funded by the IDEA Partnership
Further strengthen collaboration between families, schools, state mental health, and education agencies
Develop a shared mental health agenda
Seed Grant (cont.) : Seed Grant (cont.) Partners include
Center for School Mental Health Analysis and Action
The Department of Health and Mental Hygiene Administration
Maryland Coalition of Families for Children’s Mental Health
Maryland State Department of Education
Mental Health Association of Maryland
Working strategically in the state to improve collaboration between general education, special education, mental health and families.
Unprecedented State and National Resources and Initiatives in MD : Unprecedented State and National Resources and Initiatives in MD UM, Quality R01
UM, CSMHA
JHU, Center for EBP
JHU, Center for Viol Pr
MSDE, School MH Sys Int.
DHMH/GOC/MDOD Transformation
MSDE, PBIS
MHA, ESMH
GOC, Innovations Inst.
MSDE, MHA, WkFrce
IDEA Seed Grant
Others?
Slide20 : Maryland School Mental Health Alliance School Mental Health Integration Grant
History : History Commitment from key local, state, and national partners to collaborate and form an Alliance to advance school-mental health system integration in Maryland
Strong support for children’s mental health and school mental health in the state
A strong PBIS structure within the state and an interest in enhancing mental health support and resources for red and yellow zone youth
Notified of award in September 2005
1 of 20 funded projects (84 total applicants)
Maryland School Mental Health Alliance (MSMHA) : Maryland School Mental Health Alliance (MSMHA) Maryland State Department of Education
Center for School Mental Health Analysis and Action - University of Maryland
Center for Prevention and Early Intervention - Johns Hopkins University
Governor’s Office for Children
Maryland Assembly on School-Based Health Care
Maryland Coalition of Families for Children’s Mental Health
Maryland Department of Juvenile Services
Mental Hygiene Administration Department of Health and Mental Hygiene
Mental Health Association of Maryland
Primary Grant Objectives : Primary Grant Objectives 1. To further build a systematic state initiative for school mental health (SMH)
2. To improve outcomes related to red and yellow zone youth in PBIS schools through:
Helping school staff to better identify and refer students who could benefit from mental health services
Enhancing mechanisms for effective communication between schools and the mental health system to help better integrate quality mental health care for students
Developing training and resources to assist school staff with creating environments that support academic, social, and emotional learning for children with more intensive mental health needs
Key Structural Components : Key Structural Components 1 Management Team
1 Advisory Board
4 Counties (Anne Arundel, Harford, St. Mary’s, Washington)
4 County Integration Teams
12 PBIS Schools (3/County) and Demonstration Teams
County Integration Teams : County Integration Teams Responsible for pursing improved school-mental health system integration in their county through:
Active communication
Needs assessment
Resource sharing
Problem solving
Demonstration Project : Demonstration Project Presents an opportunity for three schools in each of the five counties to do a very strong assessment of school mental health programming
Each team will focus on
1) improving linkages to the public mental health system
2) evidence based practice for one to two disorders
3) enhancing practices related to two indicators associated with best practice in school mental health
Family Participation and Leadership : Family Participation and Leadership Families as equal partners at all levels of the project, (planning, implementation, evaluation, management, and continuous improvement)
Training, oversight, and resource development facilitated by the Maryland Coalition of Families for Children’s Mental Health
Major goal to empower family members to become effective advocates for children’s mental health and improve their linkages to and true collaboration with schools
Benefits of This Project : Benefits of This Project Further build a systematic initiative for SMH in MD
Enhanced focus on helping red and yellow zone youth
Meaningful family partnerships and training and resources for families
Improved linkages between families, schools and mental health systems
Training for PBIS coaches/leaders on helping school staff and families understand mental health issues in youth and promote mental health for red and yellow zone youth
Improved outcomes for students (we hope)
Maryland School Mental Health Alliance : Maryland School Mental Health Alliance For More Information About the MSMHA and to Access Resources Developed for the Project,
Visit Our Website: http://www.msmha.org
Slide30 :
National Connections
Growing Focus on School Mental Health (SMH) in the U.S. : 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-policy networks
New Freedom Commission Goal 4: Early Mental Health Screening, Assessment, and Referral to Services are Common Practice : New Freedom Commission Goal 4: Early Mental Health Screening, Assessment, and Referral to Services are Common Practice
4.1 Promote the mental health of young children
4.2 Improve and expand school mental health programs
4.3 and 4.4 (both focus on enhancing mental health screening)
“Enhancing Quality in Expanded School Mental Health” : “Enhancing Quality in Expanded School Mental Health” Three year, three state (Delaware, Maryland, Texas) study seeking to implement and evaluate a framework for systematic quality assessment and improvement in school mental health
Funded by the National Institute of Mental Health (2003-2006)
Principles for Best Practice in Expanded School Mental Health : 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
Principles (cont.) : 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
Principles (cont.) : 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
Principles (cont.) : 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
Four Critical Themes in School Mental Health Intervention : Four Critical Themes in School Mental Health Intervention
Establish and maintain strong relationships, especially with families
Reduce, help to buffer stress and risk
Enhance protective and resilience factors
Train in evidence-based skills
Addressable Stress/Risk Factors : Addressable Stress/Risk Factors Family Level
Abuse and neglect
Criminal behavior
Substance abuse
Family isolation
Overcrowding
Emotional/behavioral problems in family members
Morbidity and mortality in family members
Addressable Protective Factors : Addressable Protective Factors Family level
Support and nurturance
Rituals and routines
Self-control displayed and modeled by family members
Healthy behaviors by family members
Slide41 : Top Evidence-Based Practices
Parent praise
Cognitive coping
Parent psycho-education
Modeling
Problem solving
Skill building/behavioral rehearsal
Maintenance/relapse prevention
Tangible rewards
Slide42 : See. Bruce Chorpita, and Evidence Based Services Committee (2004). Biennial report: Summary of effective interventions for youth with behavioral and emotional needs. Hawaii Department of Health, Child and Adolescent Mental Health Division.
Center for School Mental Health Analysis and Action : Center for School Mental Health Analysis and Action
CSMHA : CSMHA
Established in 1995 with a grant from the Health Resources and Services Administration (HRSA)
Renewed 5-year funding in 2000 from HRSA, with co-funding from the Substance Abuse and Mental Service Administration (SAMHSA)
Renewed 5-year funding in 2005 from HRSA and SAMHSA with a focus on policy analysis and dissemination
http://csmha.umaryland.edu,
csmha@psych.umaryland.edu, (410) 706-0980
CSMHA Annual Conferences on Advancing School Mental Health : CSMHA Annual Conferences on Advancing School Mental Health Baltimore, 1996
New Orleans, 1997
Virginia Beach, 1998
Denver, 1999
Atlanta, 2000
Portland, 2001* Philadelphia, 2002
Portland, 2003
Dallas, 2004
Cleveland, 2005
Baltimore, 2006
*the 2001 conference was cancelled related to the events of September 11
School Health Interdisciplinary Program (SHIP) : School Health Interdisciplinary Program (SHIP) Organized by the CSMHA with leadership of MSDE, MHA and most child serving systems in MD
Many other state collaborators
Intensive, interdisciplinary training reflecting the coordinated school health model
Held every summer in Maryland since 2002
Slide47 : THE IDEA PARTNERSHIP
www.ideainfo.org
www.ideapartnership.org
Building a Community of Practice on School Mental Health : Building a Community of Practice on School Mental Health CSMHA and IDEA Partnership (www.ideapartnership.org) providing support
60 professional organizations and at least 10 states
10 practice groups
Providing mutual support, opportunities for dialogue and collaboration
Advancing multi-scale learning systems
What is a Community of Practice? : What is a Community of Practice? Communities of Practice include people who care passionately about an issue and agree to come together routinely to improve the state of practice
Communities form practice groups that explore pieces of an issue and bring it back to the whole community
Together, the community and its practice groups can bridge training, practice, research and policy
What is a Community of Practice? : What is a Community of Practice?
Based on relationships and natural bonds
Supportive and convening functions enable a collective intelligence
Share learnings at all levels to escalate progress
Create new knowledge grounded in ‘doing’ the work
Reflect a “pull” versus a “push”
First Community Building Forum Dallas, TX October, 2004 : First Community Building Forum Dallas, TX October, 2004
Over 80 diverse participants
Identified shared interests
Planned communication and meeting strategies
Planned for inclusive involvement
Identified 8 priority theme areas which became practice groups
Second National Community Building Forum Cleveland, OH October, 2005 : Second National Community Building Forum Cleveland, OH October, 2005
110 Diverse and Enthusiastic Participants!
THEMES:
Build strong communications
Support the development of the Practice Groups
Raise their profile
Maintain strong and intentional connections with the broader community
Cleveland Community Building Forum, cont. : Cleveland Community Building Forum, cont. Practice group facilitators will be key
Give practice groups control over the development of the annual conference
Use technology to promote relationship development and action in the practice groups
Shared Agenda States : Shared Agenda States The First States
OH, OR, SC, MO, TX,* OR*
*In restructuring at the state level, but connected
The New States
HI, NH, MD, NM, NC
The Newest State
PA
Slide55 : Mission
To help Ohio’s school districts, community-based agencies,
and families work together to achieve improved educational
and developmental outcomes for all children — especially
those at emotional or behavioral risk and those with
mental health problems. Since 2001
Ohio Department of Mental Health
Ohio Department of Education
Center for School-Based Mental
Health Programs at Miami University
(http://www.units.muohio.edu/csbmhp) Ohio Mental Health Network
for School Success
Slide56 : The Ohio Mental Health Network for School Success Overarching Agenda
Build and sustain a “community of practice” to create and foster demand for expanded, effective school mental health programs and services
Create and foster demand at all levels—local, regional, state, and national, and federal
Legislative Forum On Mental Health and School Success Creating A Shared Agenda In Ohio October 9, 2003 : Legislative Forum On Mental Health and School Success Creating A Shared Agenda In Ohio October 9, 2003
Slide58 : An Immediate Legislative Outcome
Senate Bill 2
Section 3319.61(E)
(effective June 9, 2004)
“The standards for educator professional development developed under division (A) (3) of this section shall include standards that address the crucial link between academic achievement and mental health issues.”
10 Practice Groups : 10 Practice Groups Mental Health-Education Integration
Developing a Common Language
Connecting Education and Systems of Care
Connecting SMH and Positive Behavior Support
Improving SMH for Youth with Disabilities
10 Practice Groups (cont.) : 10 Practice Groups (cont.) SMH, Juvenile Justice and Dropout Prevention
Family Partnerships
Youth Involvement and Leadership
Faith-Community Partnerships
Quality and Evidence-Based Practice
Practice Groups will : Practice Groups will Communicate and collaborate through www.sharedwork.org, email and phone conferences
Shape the development of and convene at the annual Community Building Forum
Share ideas and action strategies with the larger Community
New Communication Vehicle www.sharedwork.org : New Communication Vehicle www.sharedwork.org
Website for communication and shared work
Space for the national community
Space for practice group work
Space for each state to build its own community
Listserv for public communication, community announcements, summaries of practice group work, request for comment, etc
Mental Health –Education Training and Workforce : Mental Health –Education Training and Workforce KEY THEMES
Mental Health Education Integration Consortium (MHEDIC) : Mental Health Education Integration Consortium (MHEDIC) Working to improve interdisciplinary training and collaboration between educators and mental health staff
Making recommendations to address limitations in training for both groups
Mental health training for educators should be based on “backward analysis” of needs presenting in classrooms
Contributed report to the Annapolis Coalition (www.annapoliscoalition.org) on SMH workforce issues
Significant Workforce Issues : Significant Workforce Issues Not enough mental health staff in most schools
And those there
are often not trained in cognitive-behavioral therapy or evidence-based practices (EBP)
may actively resist EBP
Workforce 2 : Workforce 2 Graduate mental health program accreditation is not connected to EBP
Many people who are not trained to work in schools are working in them
There is notable blurring in functioning across disciplines
Supervision is generally extremely poor
No real interdisciplinary training models yet the work is inherently interdisciplinary
Workforce 3 : Workforce 3 Most teachers have limited if any training in mental health, and
Stress over classroom behavioral issues is one of the major reasons for leaving the profession early
Are we approaching a Tipping Point? : Are we approaching a Tipping Point? “We need to prepare ourselves for the possibility that sometimes big changes follow from small events, and sometimes these changes can happen very quickly”
Malcolm Gladwell
For a School Behavioral Health Social Epidemic : For a School Behavioral Health Social Epidemic We need:
Connectors (those with wide social circles)
Mavens (smart people)
Salesmen (charismatic negotiators)
and Others!