Transforming Child and Adolescent Mental Health Mark D. Weist, Ph.D. Department of Psychology, University of South Carolina Appalachian State University,

Transforming Child and Transforming Child and Adolescent Mental HealthAdolescent Mental Health

Mark D. Weist, Ph.D.Mark D. Weist, Ph.D.

Department of Psychology, Department of Psychology,

University of South Carolina University of South Carolina

Appalachian State University, 4.19.13Appalachian State University, 4.19.13

Thanks toThanks to

Vittoria AnelloVittoria Anello Jason BirdJason Bird Lori ChappelleLori Chappelle Kendra DeLoachKendra DeLoach Melissa DvorskyMelissa Dvorsky Melissa GeorgeMelissa George Lucille EberLucille Eber Johnathan FowlerJohnathan Fowler Nancy LeverNancy Lever Bobby MarkleBobby Markle

Heather McDanielHeather McDaniel Kurt MichaelKurt Michael Elaine MillerElaine Miller Samantha PaggeotSamantha Paggeot Sharon StephanSharon Stephan Kathy ShortKathy Short Joni SplettJoni Splett Leslie TaylorLeslie Taylor John TerryJohn Terry Rachel WilliamsonRachel Williamson Eric YoungstromEric Youngstrom

Center for School Mental Health* Center for School Mental Health* University of Maryland School of MedicineUniversity of Maryland School of Medicine

http://csmh.umaryland.edu*Supported by the Maternal and Child Health Bureau of *Supported by the Maternal and Child Health Bureau of

HRSA and numerous Maryland agenciesHRSA and numerous Maryland agencies

Outline Outline

RealitiesRealities Expanded school mental healthExpanded school mental health Achieving evidence-based practiceAchieving evidence-based practice Interconnection with PBISInterconnection with PBIS Other collaborative projectsOther collaborative projects Progress, …but many challengesProgress, …but many challenges A National Community of PracticeA National Community of Practice

Reality 1Reality 1

Child and adolescent mental health is Child and adolescent mental health is among the most if not the most neglected among the most if not the most neglected health care need in the UShealth care need in the US

Reality 2Reality 2

Children, youth and families are not Children, youth and families are not getting to places where mental health getting to places where mental health services are traditionally deliveredservices are traditionally delivered

Reality 3Reality 3

Schools are under-resourced to address Schools are under-resourced to address mental health issues, and may view this as mental health issues, and may view this as beyond their missionbeyond their mission

““Expanded” School Mental HealthExpanded” School Mental Health

Full continuum of effective mental health Full continuum of effective mental health promotion and intervention for students in promotion and intervention for students in general and special educationgeneral and special education

Reflecting a “shared agenda” involving Reflecting a “shared agenda” involving school-family-community system school-family-community system partnershipspartnerships

Collaborating community professionals Collaborating community professionals (not (not outsidersoutsiders) ) augmentaugment the work of the work of school-employed staffschool-employed staff

A Vision for Student Mental Health and Well-A Vision for Student Mental Health and Well-Being in Ontario SchoolsBeing in Ontario Schools

Ontario students are Ontario students are flourishing, flourishing,

with a strong sense of with a strong sense of belonging at school,belonging at school,

ready skills for ready skills for managing academic managing academic and social/emotional and social/emotional

challenges, challenges,

and surrounded by and surrounded by caring adults and caring adults and

communities equipped communities equipped to identify and intervene to identify and intervene

early with students early with students struggling with mental struggling with mental

health problemshealth problems

(from Kathy Short)(from Kathy Short)

A Vision

Research Supported ProgramsResearch Supported Programs

Substance Abuse and Mental Health Substance Abuse and Mental Health Service Administration’s National Registry Service Administration’s National Registry of Effective Programs and Practicesof Effective Programs and Practices

www.nrepp.samhsa.com Roughly 56 of 170 research supported Roughly 56 of 170 research supported

interventions can be implemented in interventions can be implemented in schoolsschools

Research Supported Programs Research Supported Programs InvolveInvolve

Strong trainingStrong training Fidelity monitoringFidelity monitoring Ongoing technical assistance and Ongoing technical assistance and

coachingcoaching Administrative supportAdministrative support IncentivesIncentives IntangiblesIntangibles

Practice in the trenchesPractice in the trenches

Involves NONE of these supportsInvolves NONE of these supports

http://www.jhsph.edu/prevention/

Johns Hopkins Center for

Prevention & Early Intervention Leads: Nick Ialongo, Phil Leaf,

Catherine Bradshaw

Barriers to Evidence-Based Programs in Schools

Clinician School Setting Funding/Resources

Clinician Related Barriers

Limited prior training on evidence-based practices

Resistance Role constraints Need for administrative support Need for ongoing coaching and technical

assistance

Typical Work for Clinician for Evidence-Based Prevention Group

Screen students Analyze results of

screen Obtain

consent/assent Obtain teacher buy-in Coordinate student

schedules Get them to and from

groups

Rotate meeting times Implement effectively Promote group

cohesion Address disruptive

behaviors Conduct session by

session evaluation Deal with students

who miss groups

School Related Barriers

Fluidity of the school environment Teacher turnover Tenuous principal buy-in Lack of time Lack of dedicated change agents

Evidence-Based Evidence-Based “Manualized” interventions “Manualized” interventions (from Sharon Stephan)(from Sharon Stephan)

Intervention/Indicated: Cognitive Behavioral Intervention for Trauma in Schools, Coping Cat, Trauma Focused CBT, Interpersonal Therapy for Adolescents (IPT-A)

Prevention/Selected:

Coping Power, FRIENDS for Youth/Teens, The Incredible Years, Second Step, SEFEL and DECA Strategies and Tools, Strengthening Families Coping Resources Workshops

Promotion/Universal:Good Behavior Game, PATHS to PAX, Positive Behavior Interventions and Support, Social and Emotional Foundations of Early Learning (SEFEL), Olweus Bullying Prevention, Toward No Tobacco Use

““Packaging” ProblemPackaging” Problem

Blind commitment to parameters of Blind commitment to parameters of manuals (e.g., hour long sessions, too manuals (e.g., hour long sessions, too many sessions), without consideration of many sessions), without consideration of school realitiesschool realities

Instead group key intervention Instead group key intervention components in “phases” and deliver components in “phases” and deliver flexiblyflexibly See Steve Evans, Julie Owens, Ohio See Steve Evans, Julie Owens, Ohio

UniversityUniversity

Strengthening School Strengthening School Mental Health ServicesMental Health Services

Study OverviewStudy Overview

NIMH, R01MH081941-01A2, 2010-14 NIMH, R01MH081941-01A2, 2010-14 (building from a prior R01)(building from a prior R01)

46 school mental health clinicians, 34 46 school mental health clinicians, 34 schoolsschools

Randomly assigned to either:Randomly assigned to either: Personal/ Staff Wellness (PSW)Personal/ Staff Wellness (PSW) Clinical Services Support (CSS)Clinical Services Support (CSS)

CSS: Four Key DomainsCSS: Four Key Domains

Quality Assessment and ImprovementQuality Assessment and Improvement Family Engagement and EmpowermentFamily Engagement and Empowerment ““Modular” Evidence Based PracticeModular” Evidence Based Practice Implementation Support Implementation Support

Quality Assessment and Improvement Quality Assessment and Improvement (QAI) Principles (QAI) Principles

Emphasize accessEmphasize access Tailor to local needs Tailor to local needs

and strengthsand strengths Emphasize quality Emphasize quality

and empirical supportand empirical support Active involvement of Active involvement of

diverse stakeholdersdiverse stakeholders

Full continuum from Full continuum from promotion to promotion to treatmenttreatment

Committed and Committed and energetic staffenergetic staff

Developmental and Developmental and cultural competencecultural competence

Coordinated in the Coordinated in the school and connected school and connected in the communityin the community

Working Effectively with Working Effectively with Students and FamiliesStudents and Families

EngagementEngagement SupportSupport CollaborationCollaboration Empowerment Empowerment

see the work of Kimberly Hoagwood and Mary see the work of Kimberly Hoagwood and Mary McKayMcKay

Modular Evidence-Based Practice Modular Evidence-Based Practice (EBP)(EBP)

SEE: Chorpita, B.F., & Daleiden, E.L. (2009). Biennial Report: Effective Psychosocial Intervention for Youth with Behavioral and Emotional Needs. Child and Mental Health Division, Hawaii Department of Health

• 10 skills for disruptive behavior problems:o Active Ignoringo Commandso Communication Skillso Monitoring behavioro Praiseo Problem Solvingo Psychoeducationo Response costo Tangible rewardso Time out/ Grounding

Implementation SupportImplementation Support

Interactive and lively teachingInteractive and lively teaching Off and on-site coaching, performance Off and on-site coaching, performance

assessment and feedback, emotional and assessment and feedback, emotional and administrative supportadministrative support

Peer to peer support Peer to peer support User friendlinessUser friendliness

see Dean Fixsen, Karen Blasé, National see Dean Fixsen, Karen Blasé, National Implementation Research Network (NIRN)Implementation Research Network (NIRN)

A A “Transformative” “Transformative” Impact?Impact?

Largest and most prominent SMH program in Largest and most prominent SMH program in SCSC

In a network of SMH in all jurisdictionsIn a network of SMH in all jurisdictions Strong interest in the study across all relevant Strong interest in the study across all relevant

sectorssectors Pursuing integrated QAI – Wellness strategy Pursuing integrated QAI – Wellness strategy

nownow Given positive findings, the study approach is Given positive findings, the study approach is

set up for rapid replication in SC and beyondset up for rapid replication in SC and beyond

ButBut

SMH programs and services continue to SMH programs and services continue to develop in an ad hoc manner, anddevelop in an ad hoc manner, and

LACK AN IMPLEMENTATION LACK AN IMPLEMENTATION STRUCTURESTRUCTURE

Positive Behavior Intervention Positive Behavior Intervention and Support (www.pbis.org)and Support (www.pbis.org)

In 17,000 plus schoolsIn 17,000 plus schools Decision making framework to guide Decision making framework to guide

selection and implementation of best selection and implementation of best practices for improving academic and practices for improving academic and behavioral functioningbehavioral functioning Data based decision makingData based decision making Measurable outcomesMeasurable outcomes Evidence-based practicesEvidence-based practices Systems to support effective implementationSystems to support effective implementation

Tiered Support in Systems of CareTiered Support in Systems of Care

Universal Evidence-BasedMental Health Promotion, Social-Emotional Learning

Targeted Evidence-

Based Prevention

E-B ClinicalIntervention

Evidence-Based Clinical Intervention

Targeted Evidence-

Based Prevention

Universal E-B Mental Health

Promotion

Community

School Districts

Interconnected Systems Interconnected Systems Framework (ISF) for SMH-PBISFramework (ISF) for SMH-PBIS

Strategy for interconnection of two systems Strategy for interconnection of two systems across multiple tiersacross multiple tiers

Emphasizes state teams working with Emphasizes state teams working with district teams and schools, and strong team district teams and schools, and strong team planning and actions at each tierplanning and actions at each tier

Two national centers (for SMH and PBIS) Two national centers (for SMH and PBIS) and a number of states involvedand a number of states involved

Numerous training events and a monograph Numerous training events and a monograph in progressin progress

ISF DefinedISF Defined

A strong, committed and functional team A strong, committed and functional team guides the work, using data at three tiers of guides the work, using data at three tiers of interventionintervention

Sub-teams having “conversations” and Sub-teams having “conversations” and conducting planning at each tierconducting planning at each tier

Evidence-based practices and programs are Evidence-based practices and programs are integrated at each tierintegrated at each tier

SYMMETRY IN PROCESSES AT STATE, SYMMETRY IN PROCESSES AT STATE, DISTRICT AND BUILDING LEVELSDISTRICT AND BUILDING LEVELS

ISF cont.ISF cont.

Key stakeholders from education and Key stakeholders from education and mental health are involved and these mental health are involved and these people have the people have the authorityauthority to reallocate to reallocate resources, change roles and functioning of resources, change roles and functioning of staff, and change policystaff, and change policy

There is a priority on strong There is a priority on strong interdisciplinary, cross-system interdisciplinary, cross-system collaborationcollaboration

Old Approach Old Approach New ApproachNew Approach

Each school Each school works out their works out their own plan with own plan with Mental Health Mental Health (MH) agency(MH) agency

District has a plan District has a plan for integrating MH for integrating MH at all buildings at all buildings (based on (based on community and community and school data)school data)

Old Approach Old Approach New ApproachNew Approach

A MH counselor A MH counselor is housed in a is housed in a school building school building 1 day a week to 1 day a week to “see” students“see” students

MH person MH person participates in participates in teams at all 3 teams at all 3 tierstiers

Old Approach Old Approach New ApproachNew Approach

No data to No data to decide on or decide on or monitor monitor interventionsinterventions

MH person leads MH person leads classroom, group classroom, group or individual or individual interventions interventions based on databased on data

ISF, School Readiness ISF, School Readiness AssessmentAssessment

1) High status leadership and team with active 1) High status leadership and team with active administrator participationadministrator participation

2) School improvement priority on 2) School improvement priority on social/emotional/behavioral health for all studentssocial/emotional/behavioral health for all students

3) Investment in prevention3) Investment in prevention 4) Active data-based decision making4) Active data-based decision making 5) Commitment to SMH-PBIS integration5) Commitment to SMH-PBIS integration 6) Stable staffing and appropriate resource 6) Stable staffing and appropriate resource

allocationallocation

ISF, Indicators of Team FunctioningISF, Indicators of Team Functioning

Strong leadership Strong leadership Good meeting attendance, agendas and Good meeting attendance, agendas and

meeting managementmeeting management Opportunities for all to participateOpportunities for all to participate Taking and maintaining of notes and the Taking and maintaining of notes and the

sense of history playing outsense of history playing out Clear action planningClear action planning Systematic follow-up on action planningSystematic follow-up on action planning

Team MembersTeam Members

*School psychologist*School psychologist *Collaborating *Collaborating

community mental community mental health professionalhealth professional

School counselorSchool counselor Special educatorSpecial educator

*co-leaders*co-leaders

Assistant principalAssistant principal School nurseSchool nurse General educatorGeneral educator ParentParent ParentParent (Older student) (Older student)

Interdisciplinary, evidence-based intervention Interdisciplinary, evidence-based intervention for youth with mood disorders in schoolsfor youth with mood disorders in schools

USC, ASU and UNCUSC, ASU and UNC More than 20 student participants and More than 20 student participants and

promising datapromising data Likely big grant application by this fall Likely big grant application by this fall

Student Emotional and Educational Student Emotional and Educational Development (SEED)Development (SEED)

SEED TeamSEED Team

CLIMBCLIMB

Changing Lifestyles to Improve Mind Changing Lifestyles to Improve Mind and Body and Body (Melissa George et al.)(Melissa George et al.)

10 middle school participants, 6 sessions 10 middle school participants, 6 sessions integrated into work of SMH clinicians integrated into work of SMH clinicians (enhanced exercise and/or reduced (enhanced exercise and/or reduced screen time, increased fruit and vegetable screen time, increased fruit and vegetable intake and/or reduced junk food)intake and/or reduced junk food)

Strong feasibility and acceptability and Strong feasibility and acceptability and preliminary evidence of impactpreliminary evidence of impact

Progress, but…. many other Progress, but…. many other challenges challenges

SuspensionSuspension

ExpulsionExpulsion

Very poor transitionsVery poor transitions

Schools and people doing what they are Schools and people doing what they are used to doing (and being highly resistant used to doing (and being highly resistant to change)to change)

Roles of School-Employed MH Roles of School-Employed MH Staff (in some instances)Staff (in some instances)

Course schedulingCourse scheduling Attendance monitoringAttendance monitoring Examination monitoringExamination monitoring Career guidanceCareer guidance Logistics assistanceLogistics assistance

See Steve Evans, Ohio UniversitySee Steve Evans, Ohio University

Significant Accountability IssuesSignificant Accountability Issues

““Optimizing” Optimizing” School staff doing rote administrative workSchool staff doing rote administrative work Community mental health staff seeing same Community mental health staff seeing same

clients and delivering passive, eclectic, non clients and delivering passive, eclectic, non evidence-based interventionsevidence-based interventions

Special Education Challenges Special Education Challenges

Schools and staff as gatekeepersSchools and staff as gatekeepers ““Social maladjustment”Social maladjustment” Highly variable labelingHighly variable labeling ““Manifestation” hearingsManifestation” hearings Increasing but not decreasing restrictivenessIncreasing but not decreasing restrictiveness Pro-forma meetings and poor follow-upPro-forma meetings and poor follow-up AccomodationsAccomodations

A National Community of Practice A National Community of Practice (COP); www.sharedwork.org(COP); www.sharedwork.org

CSMH and IDEA Partnership (CSMH and IDEA Partnership (www.ideapartnership.org) providing ) providing supportsupport

30 professional organizations and 16 30 professional organizations and 16 statesstates

12 practice groups12 practice groups Providing mutual support, opportunities for Providing mutual support, opportunities for

dialogue and collaborationdialogue and collaboration

Example Practice Groups Example Practice Groups

Learning the LanguageLearning the Language Quality and Evidence-Based PracticeQuality and Evidence-Based Practice Family InvolvementFamily Involvement Youth LeadershipYouth Leadership SMH and PBISSMH and PBIS SMH and Special EducationSMH and Special Education SMH and Systems of CareSMH and Systems of Care Military FamiliesMilitary Families

Sixteen StatesSixteen States

HawaiiHawaii IllinoisIllinois New HampshireNew Hampshire North CarolinaNorth Carolina MarylandMaryland Minnesota*Minnesota* MissouriMissouri Montana*Montana*

New MexicoNew Mexico OhioOhio PennsylvaniaPennsylvania South CarolinaSouth Carolina South DakotaSouth Dakota Utah*Utah* VermontVermont West VirginiaWest Virginia

MissionTo help Ohio’s school districts, community-based agencies,and families work together to achieve improved educationaland developmental outcomes for all children — especially

those at emotional or behavioral risk and those withmental 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 Networkfor School Success (http://www.omhnss.org)

Montana’s Integrated School Montana’s Integrated School Mental Health InitiativeMental Health Initiative

American Foundation for Suicide Prevention, South Carolina Appalachian State University Clemson University Eastern Carolina University Medical University of South Carolina North Carolina Department of Public Instruction South Carolina Department of Education South Carolina Department of Mental Health University of North Carolina at Chapel Hill University of North Carolina at Greensboro University of North Carolina at Pembroke University of South Carolina Wake Forest University

Advances in School Mental Health Advances in School Mental Health PromotionPromotion

New to Routledge for 2012!

Published on behalf of The Clifford Beers Foundation

Published in collaboration with the University of Maryland School of Medicine

Editor in Chief – Mark WeistConsulting Editor – Michael Murray Deputy Editor – Sharon Stephan

1818thth Annual SMH Conference Annual SMH ConferenceCrystal City, Arlington, VirginiaCrystal City, Arlington, Virginia

October 3-5, 2013October 3-5, 2013

Contact InformationContact Information

Department of Psychology Department of Psychology University of South Carolina University of South Carolina 1512 Pendleton St., Room 237D 1512 Pendleton St., Room 237D

Columbia, SC 29208Columbia, SC 29208

Ph: 803 777 8438 Ph: 803 777 8438 [email protected]