Module 6 School Mental Health and Foster Care: A Public Health Perspective.

Module 6Module 6

School Mental Health and Foster School Mental Health and Foster Care: A Public Health PerspectiveCare: A Public Health Perspective

Test Your KnowledgeTest Your Knowledge

All children in foster care can benefit from All children in foster care can benefit from receiving mental health promotion, prevention receiving mental health promotion, prevention and/or treatment services.and/or treatment services. (T/F) (T/F)

If I think a child in foster care is having If I think a child in foster care is having emotional difficulties, I should wait a few emotional difficulties, I should wait a few months to refer the child for mental health months to refer the child for mental health services because he/she probably just needs services because he/she probably just needs time to adjust. time to adjust. (T/F)(T/F)

Schools readily have a list of students in their Schools readily have a list of students in their building who are currently in the foster care building who are currently in the foster care system that is available for mental health system that is available for mental health providers. providers. (T/F)(T/F)

Individuals who work with children in foster Individuals who work with children in foster care should be of the same racial, ethnic, and care should be of the same racial, ethnic, and cultural background to ensure that they are cultural background to ensure that they are culturally competent to work with the children. culturally competent to work with the children. (T/F)(T/F)

Lesson ObjectivesLesson Objectives

Participants will be able to:Participants will be able to: Be knowledgeable about the 3-tiered public health Be knowledgeable about the 3-tiered public health

model and be able to determine which level of model and be able to determine which level of mental health service the child or adolescent mental health service the child or adolescent needs. needs.

Be familiar with how to refer children and Be familiar with how to refer children and adolescents in foster care for mental health adolescents in foster care for mental health services in schools. services in schools.

Be familiar with strategies for implementing Be familiar with strategies for implementing programs and evidenced-based treatments for programs and evidenced-based treatments for children and adolescents in foster care.children and adolescents in foster care.

Be knowledgeable about cultural competency and Be knowledgeable about cultural competency and the importance of being culturally sensitive in the importance of being culturally sensitive in working with children from different backgrounds. working with children from different backgrounds.

Brainstorming ActivityBrainstorming Activity

Discuss and make a list of the Discuss and make a list of the unique mental health needs of unique mental health needs of children in foster care.children in foster care.

Symptoms of Mental Symptoms of Mental Health ProblemsHealth Problems Many symptoms of mental health problems may Many symptoms of mental health problems may

be misidentified (e.g., laziness, lack of interest, be misidentified (e.g., laziness, lack of interest, delinquency). delinquency).

These maladaptive coping skills may have These maladaptive coping skills may have developed in order for children to handle more developed in order for children to handle more serious underlying mental health problems. serious underlying mental health problems.

For example:For example:– Depression manifest in the classroom as sleeping in Depression manifest in the classroom as sleeping in

class, refusal to participate, not turning in homework class, refusal to participate, not turning in homework assignments and failing class assignments and failing class

– Signs of anxiety may include failing grades, frequent Signs of anxiety may include failing grades, frequent absences and excessive worry about grades and absences and excessive worry about grades and performance performance

– School avoidance and difficulty concentrating may be School avoidance and difficulty concentrating may be signs of unresolved trauma.signs of unresolved trauma.

Do All Youth in Foster Care Do All Youth in Foster Care Need Mental Health Services?Need Mental Health Services?

The public mental health tertiary model provides us with The public mental health tertiary model provides us with direction for what types of services children will need. direction for what types of services children will need.

– 80-90% of children need 80-90% of children need universal services. universal services. These These prevention services are meant to be proactive. The goal is prevention services are meant to be proactive. The goal is to promote mental health and positive well-being. E.g., to promote mental health and positive well-being. E.g., Positive Behavior Intervention Supports (PBIS). Positive Behavior Intervention Supports (PBIS).

– 5-10% of children need 5-10% of children need secondary services. secondary services. These services These services are provided to children who are at-risk for mental health are provided to children who are at-risk for mental health difficulties. The goal is to provide services to these children difficulties. The goal is to provide services to these children before they deteriorate and require more intensive services. before they deteriorate and require more intensive services. E.g., small groups such as elementary social skills group, E.g., small groups such as elementary social skills group, middle school transitions group, self-esteem building group, middle school transitions group, self-esteem building group, etc. etc.

– 1-5% of children need 1-5% of children need tertiary services. tertiary services. These services are These services are provided to children who meet criteria for a mental health provided to children who meet criteria for a mental health disorder and/or require more intensive services. E.g., disorder and/or require more intensive services. E.g., Individual therapyIndividual therapy

1-5% 1-5%

5-10% 5-10%

80-90% 80-90%

Tertiary Interventions•Individual Students•Assessment-based•High Intensity

Tertiary Interventions•Individual Students•Assessment-based•Intense, durable procedures

Secondary Interventions•Some students (at-risk)•High efficiency•Rapid response•Small Group Interventions• Some Individualizing

Secondary Interventions•Some students (at-risk)•High efficiency•Rapid response• Small Group Interventions• Some Individualizing

Universal Interventions•All students•Preventive, proactive

Universal Interventions•All settings, all students•Preventive, proactive

School-Wide Systems for Student SuccessSchool-Wide Systems for Student SuccessA Response to Intervention ModelA Response to Intervention Model

Academic Systems Behavioral Systems

OSEP Technical Assistance Center on Positive Behavioral Supports and Interventions

Universal ServicesUniversal Services

All children benefit! All children benefit! These services benefit These services benefit youth at risk for youth at risk for

developing mental health disorders may be developing mental health disorders may be especially helpful for youth in foster care. especially helpful for youth in foster care.

For children in foster care, they should For children in foster care, they should receive at minimum universal services receive at minimum universal services and/or secondary services. and/or secondary services.

The best option is to provide children with The best option is to provide children with universal (prevention) services before their universal (prevention) services before their emotional and behavioral functioning emotional and behavioral functioning deteriorates. deteriorates.

Evidence Based Practices from a Evidence Based Practices from a Public Mental Health Public Mental Health PerspectivePerspective

Universal prevention programsUniversal prevention programs– Programs that improve school climate and Programs that improve school climate and

behavioral outcomes at systems levels. behavioral outcomes at systems levels. – One example is Positive Behavior One example is Positive Behavior

Intervention Supports (PBIS)Intervention Supports (PBIS)– Juvenile Justice/Special Education (JJ/SE) Juvenile Justice/Special Education (JJ/SE)

Shared Agenda that establishes a trauma Shared Agenda that establishes a trauma sensitive school culture. E.g., Helping sensitive school culture. E.g., Helping Traumatized Children Learn, Turnaround Traumatized Children Learn, Turnaround for Children, the Sanctuary Model of for Children, the Sanctuary Model of Organizational Change for Children’s Organizational Change for Children’s Residential Treatment. Residential Treatment.

– Extracurricular activities (art, music, Extracurricular activities (art, music, sports, drama, chess)sports, drama, chess)

Evidence Based Practices from a Evidence Based Practices from a Public Mental Health Perspective Public Mental Health Perspective (cont.)(cont.)

Secondary programsSecondary programs– Cognitive Behavioral Intervention for Cognitive Behavioral Intervention for

Trauma in Schools (CBITS)Trauma in Schools (CBITS)– Support groups focused on school Support groups focused on school

connectedness, self esteem, connectedness, self esteem, improving academic performance, improving academic performance, and/or social skills. and/or social skills.

Evidence Based Practices from a Evidence Based Practices from a Public Mental Health Perspective Public Mental Health Perspective (cont.)(cont.)

Tertiary programs Tertiary programs – Therapeutic foster care Therapeutic foster care – Intensive case management and Intensive case management and

wraparound serviceswraparound services– Multisystemic therapy (MST)Multisystemic therapy (MST)

List of Evidence Based List of Evidence Based ProgramsPrograms http://csmh.umaryland.edu/resourhttp://csmh.umaryland.edu/resour

ces.html/Summary%20of%20Recces.html/Summary%20of%20Recognized%20Evidence%20Based%ognized%20Evidence%20Based%20Programs6.14.08.doc20Programs6.14.08.doc

How to Promote Positive How to Promote Positive Mental Health for Youth at Mental Health for Youth at SchoolSchool Inquire about the names of the mental Inquire about the names of the mental

health staff at school and other non-health staff at school and other non-school hired counselors through other school hired counselors through other agencies. agencies.

Create a resource list for the schools in Create a resource list for the schools in your region and update the list as new your region and update the list as new staff is hired. staff is hired. – Make it standard practice to provide the Make it standard practice to provide the

resource list of mental health staff to resource list of mental health staff to foster care parents when a child enrolls in foster care parents when a child enrolls in a new school. a new school.


Brainstorm some ideas for some Brainstorm some ideas for some best practices to overcome the best practices to overcome the barriers around early identification barriers around early identification and intervention for school mental and intervention for school mental health services. Focus your ideas health services. Focus your ideas on how to better reach out to on how to better reach out to youth in foster care in schools and youth in foster care in schools and more effectively make referrals more effectively make referrals and obtain consent for services. and obtain consent for services.

How Do I make a Referral How Do I make a Referral For Mental Health For Mental Health Services?Services?

No firm guidelines currently exist. No firm guidelines currently exist. Best practice currently suggests that parents Best practice currently suggests that parents

and guardians for children in foster care as and guardians for children in foster care as well as teachers and school staff should be well as teachers and school staff should be mindful of the mental health warning signs at mindful of the mental health warning signs at home and at school and make appropriate home and at school and make appropriate referrals if any concerns persist. referrals if any concerns persist.

Foster parents and guardians enrolling Foster parents and guardians enrolling children in schools should take the time to children in schools should take the time to connect to school mental health professionals connect to school mental health professionals if they believe that services would be helpful if they believe that services would be helpful for their student, especially in the school for their student, especially in the school setting.setting.

Ask to make a referral for mental health Ask to make a referral for mental health services early! services early!

More About the Referral More About the Referral Process…Process…

Help students in foster care learn how Help students in foster care learn how to advocate for their needs.to advocate for their needs.

The process for making a school The process for making a school mental health referral varies across mental health referral varies across jurisdictions and even across schools. jurisdictions and even across schools.

Referral procedures also differ based Referral procedures also differ based on whether the referral is to a school on whether the referral is to a school employed staff or to a school-based employed staff or to a school-based community provider. Many community provider. Many community programs have their own community programs have their own referral forms that can be distributed referral forms that can be distributed to teachers, parents and guardians. to teachers, parents and guardians.

Obtaining Consent for Obtaining Consent for ServicesServices

Obtaining consent for children in foster care to Obtaining consent for children in foster care to receive mental health services in school can receive mental health services in school can be a challenging process! be a challenging process!

Be aware of who has the legal authority to Be aware of who has the legal authority to provide consent for the child to receive provide consent for the child to receive services. services.

School-based clinicians typically require School-based clinicians typically require consent for services. consent for services.

It is very important for schools to have the It is very important for schools to have the most up-to-date contact information in order most up-to-date contact information in order to contact parents and guardians as needed to contact parents and guardians as needed – Hint: Child welfare caseworkers are often the best Hint: Child welfare caseworkers are often the best

source for the most up to date information for each source for the most up to date information for each child on their caseload.child on their caseload.

Strategies to Ensure a Strategies to Ensure a Successful ReferralSuccessful Referral– Request a release of information from Request a release of information from

child welfare caseworkers as a standard child welfare caseworkers as a standard procedure when registering a child in procedure when registering a child in school. school.

– Provide information to Provide information to parents/guardians on available school-parents/guardians on available school-based counseling services/prevention based counseling services/prevention services as a regular part of the services as a regular part of the standard school registration process for standard school registration process for all incoming students.all incoming students.

– Empower families/guardians to find out Empower families/guardians to find out more information about the mental more information about the mental health services at school. health services at school.

More Strategies to Ensure More Strategies to Ensure a Successful Referrala Successful Referral– Encourage families/guardians to Encourage families/guardians to

always provide up to date contact always provide up to date contact information for students.information for students.

– Clinicians should share information on Clinicians should share information on warning signs of mental health warning signs of mental health concerns and information on when and concerns and information on when and how to refer students for mental how to refer students for mental health services.health services.


Provide the group with the various statements Provide the group with the various statements below and have groups discuss the competency below and have groups discuss the competency around these statements.around these statements.– You don’t know what its like to be poor.You don’t know what its like to be poor.– You’re the wrong color to help these kidsYou’re the wrong color to help these kids– Male therapists shouldn’t work with girls who have Male therapists shouldn’t work with girls who have

been sexually abused.been sexually abused.– How can a woman understand a male student’s How can a woman understand a male student’s

problems?problems?– I never feel that young professionals can be trusted.I never feel that young professionals can be trusted.– Social Workers (nurses/MD’s psychologists/teachers) Social Workers (nurses/MD’s psychologists/teachers)

don’t have the right training to help these kids.don’t have the right training to help these kids.– If you haven’t had alcohol or other drug problems, you If you haven’t had alcohol or other drug problems, you

can’t help students with such problems.can’t help students with such problems.– If you don’t have teenagers at home, you can’t really If you don’t have teenagers at home, you can’t really

understand them.understand them.

Treat people as if they Treat people as if they were what they ought to were what they ought to

be, be, and you help them and you help them

become what they are become what they are capable of being. capable of being.

-Goethe-Goethe

Diversity of Youth in Diversity of Youth in Foster CareFoster Care Children and adolescents in foster care Children and adolescents in foster care

are from all different races, ethnicities, are from all different races, ethnicities, and cultures. and cultures.

Differences can result in problems for Differences can result in problems for students, parents, and staff. Although students, parents, and staff. Although such problems are not easily resolved, such problems are not easily resolved, they are solvable as long as everyone they are solvable as long as everyone works in the best interests of the works in the best interests of the students, and the differences are not students, and the differences are not allowed to become barriers to relating allowed to become barriers to relating with others. with others.

Developing Cultural Developing Cultural CompetencyCompetency Enhance your competence with respect to Enhance your competence with respect to

the group and its intragroup differences.the group and its intragroup differences. Developing such competence is a dynamic, Developing such competence is a dynamic,

on going-process- not a goal or outcome. on going-process- not a goal or outcome. Diversity training is widely viewed as Diversity training is widely viewed as

important, but is not effective in isolation. important, but is not effective in isolation. Hiring staff from the same back ground as a Hiring staff from the same back ground as a

target population does not necessarily target population does not necessarily ensure the provision of appropriate services. ensure the provision of appropriate services.

Establishing a process for enhancing a Establishing a process for enhancing a program’s competence with respect to group program’s competence with respect to group and intragroup differences is an opportunity and intragroup differences is an opportunity for positive organizational and individual for positive organizational and individual growth.growth.

Retest Your KnowledgeRetest Your Knowledge

1) All children in foster care can 1) All children in foster care can benefit from receiving mental benefit from receiving mental health promotion, prevention health promotion, prevention and/or treatment services. (True) and/or treatment services. (True)

Explanation: Based on the public Explanation: Based on the public mental health perspective, all mental health perspective, all children and adolescents can children and adolescents can benefit from universal prevention benefit from universal prevention services. services.


2) If I think a child in foster care is having 2) If I think a child in foster care is having emotional difficulties, I should wait a few emotional difficulties, I should wait a few months to refer the child for mental health months to refer the child for mental health services because he/she probably just needs services because he/she probably just needs time to adjust. (False) time to adjust. (False)

ExplanationExplanation: Many children, including those in : Many children, including those in foster care, are not referred for mental health foster care, are not referred for mental health services until they are displaying clinically services until they are displaying clinically significant levels of problem behavior. The best significant levels of problem behavior. The best option is to provide children with universal option is to provide children with universal (prevention) services before their emotional (prevention) services before their emotional and behavioral functioning deteriorates.and behavioral functioning deteriorates.


3) Schools readily have a list of students in 3) Schools readily have a list of students in their building who are currently in the their building who are currently in the foster care system that is available for foster care system that is available for mental health providers. (False)mental health providers. (False)

ExplanationExplanation: Due to privacy laws, schools do not possess : Due to privacy laws, schools do not possess a list of students who are in the foster care system. a list of students who are in the foster care system. To work around this issue, best practice currently To work around this issue, best practice currently suggests that parents and guardians as well as suggests that parents and guardians as well as teachers and school staff should be mindful of the teachers and school staff should be mindful of the mental health warning signs at home and at school mental health warning signs at home and at school and make appropriate referrals if any concerns and make appropriate referrals if any concerns persist. Foster parents, guardians, and/or social persist. Foster parents, guardians, and/or social workers enrolling children in schools should take the workers enrolling children in schools should take the time to connect to school mental health time to connect to school mental health professionals if they believe that prevention, early professionals if they believe that prevention, early intervention or treatment services might be helpful intervention or treatment services might be helpful for the student.for the student.


4) Individuals who work with children in foster care 4) Individuals who work with children in foster care should be of the same racial, ethnic, and should be of the same racial, ethnic, and cultural background to ensure that they are cultural background to ensure that they are culturally competent to work with the children. culturally competent to work with the children. (False)(False)

ExplanationExplanation: Hiring staff from the same background : Hiring staff from the same background as a target population does not necessarily as a target population does not necessarily ensure the provision of appropriate services, ensure the provision of appropriate services, especially if those staff do not fully appreciate especially if those staff do not fully appreciate or respect group and intragroup differences. or respect group and intragroup differences. Establishing a process for enhancing an Establishing a process for enhancing an individual or program’s cultural competence is individual or program’s cultural competence is the best strategy to ensure competent and the best strategy to ensure competent and respectful care.respectful care.

Practical ResourcesPractical Resources

School Mental Health.org: School Mental Health.org: www.schoolmentalhealth.orgwww.schoolmentalhealth.org

Baltimore City Public Schools School Baltimore City Public Schools School Mental Health Directory: Mental Health Directory:

Can be accessed at Can be accessed at www.schoolmentalhealth.orgwww.schoolmentalhealth.org (see (see directory section on left hand side)directory section on left hand side)

Practical ResourcesPractical Resources

Moving toward a Comprehensive System Moving toward a Comprehensive System of Learning Supports: Mapping & of Learning Supports: Mapping & Analyzing Learning Supports Analyzing Learning Supports http://smhp.psych.ucla.edu/summit2002/thttp://smhp.psych.ucla.edu/summit2002/tool%20mapping%20current%20status.pdool%20mapping%20current%20status.pdff

AcknowledgementsAcknowledgements

Funding for this project was supported by: Funding for this project was supported by: Maryland Mental Health Transformation Maryland Mental Health Transformation

Grant # 5 U79SM57459-02 from SAMHSA Grant # 5 U79SM57459-02 from SAMHSA

The Center for School Mental Health is The Center for School Mental Health is supported in full by Project #U45 MC 00174 supported in full by Project #U45 MC 00174 from the Office of Adolescent Health, from the Office of Adolescent Health, Maternal, and Child Health Bureau (Title V, Maternal, and Child Health Bureau (Title V, Social Security Act), Health Resources and Social Security Act), Health Resources and Services Administration, Department of Services Administration, Department of Health and Human Services.Health and Human Services.