The Interconnected Systems Framework: School Mental Health within a Multi-Tiered System
of Behavioral Supports in Schools
The Wisconsin PBIS Conference August 20-21, 2013
Lucille Eber, IL PBIS NetworkNational PBIS TA Center
acknowledgements
Susan Barrett, Sheppard-Pratt Health systems, Baltimore MDKelly Peralis, Community Care Behavioral Health, Pittsburg, PA
Mark Wiest, University of South CarolinaJill Johnson, IL PBIS Network
PBIS: Equity in Education
Making Education Work for All
School Mental Health Strand: • Integrating SMH & PBIS: Examples at All 3 Tiers• Integrating SMH & PBIS: Using Data• Integrating SMH & PBIS: Selecting Evidence-based Practices• Interconnected Systems Framework Monograph: Lessons from
the Field• Implementing an Interconnected System Framework in an
Urban School System • Integrating SMH & PBIS at the State Level• The Changing Role of School-based Clinicians
2013 National PBIS Leadership Forum | October 10-11, 2013 | Donald E. Stephens Convention Center | Rosemont, Illinois
Content:
• Describe the features of an Interconnected Systems Framework (ISF) for Integrating Mental Health in Schools
• Describe efforts and resources from blended efforts of National Centers to promote a broader continuum of evidence-based practices to support the mental health of all students
• Describe emerging examples of ISF
BIG Ideas…
• How Multi-tiered Systems of Support (MTSS) can enhance mental health in schools
• Installing SMH through MTSS in Schools• The Interconnected Systems Framework (ISF)
SMH +MTSS=ISF
History-Rationale
• Sparse availability of MH providers in schools• Labels and ‘places’ confused with
interventions• Separate delivery systems (Sp.Ed., Mental
health, etc)• Minimal accountability for outcomes for most
vulnerable populations
Why Partnership Are Needed
• One in 5 youth have a MH “condition”
• About 70% of those get no treatment
• School is “defacto” MH provider
• JJ system is next level of system default
• Suicide is 4th leading cause of death among young adults
SMH and PBISCommon Purpose
• Schools supporting/promoting MH of ALL students
• Prevention, early access, interventions commensurate with level of need (vs label)
• School personnel feel confident and competent in identifying and intervening with accuracy and effectiveness
Logic
– Youth with MH needs require multifaceted education/behavior and mental health supports
– The usual systems have not routinely provided a comprehensive, blended system of support.
– Supports need to be provided in a clustered and integrated structure,
– Academic/behavior and mental health supports need to be efficiently blended
Promotion and Prevention
Simple and complex supports require integrated systems with foundation of a school-wide system
• Schools and community serve as protective factor• problem-solving teams with
school/family/youth/community voice• use of data for decision-making (screening/ selection
and monitoring/outcomes)• layers supports from the foundational/universal to the
more complex
Tier 3/Tertiary Interventions 1-5%•Individual students•Assessment-based•High intensity
1-5% Tier 3/Tertiary Interventions• Individual students• Assessment-based• Intense, durable procedures
Tier 2/Secondary Interventions 5-15%•Some students (at-risk)•High efficiency•Rapid response•Small group interventions• Some individualizing
5-15% Tier 2/Secondary Interventions• Some students (at-risk)• High efficiency• Rapid response• Small group interventions• Some individualizing
Tier 1/Universal Interventions 80-90%•All students•Preventive, proactive
80-90% Tier 1/Universal Interventions• All settings, all students• Preventive, proactive
School-Wide Systems for Student Success: A Response to Intervention (RtI) Model
Academic Systems Behavioral Systems
Illinois PBIS Network, Revised May 15, 2008. Adapted from “What is school-wide PBS?” OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports. Accessed at http://pbis.org/schoolwide.htm
Primary Prevention:School-/Classroom-Wide Systems for
All Students,Staff, & Settings
Secondary Prevention:Specialized Group
Systems for Students with At-Risk Behavior
Tertiary Prevention:Specialized
IndividualizedSystems for Students
with High-Risk Behavior
~80% of Students
~15%
~5%
SCHOOL-WIDE POSITIVE BEHAVIOR
SUPPORT:
What is meant by “layering”
interventions?
Positive Behavior Intervention and Support (www.pbis.org)
• Decision making framework to guide selection and implementation of best practices for improving academic /behavioral functioning
• Data-based, measurable outcomes, evidence-based practices, systems to support effective implementation
Core Features of a Response to Intervention (RtI) Approach
• Investment in prevention, screening and early intervention for students not at “benchmark”
• Multi-tiered intervention approach
• Use of progress monitoring and problem-solving process at all 3-tiers
Core Features of a Response to Intervention (RtI) Approach
• Research-based practices and active use of data for decision-making at all 3-tiers
• Use of progress monitoring and problem-solving process at all 3-tiers
3-Tiered System of Support
Necessary Conversations (Teams)
Check-In Check-Out
Skills Groups
Group w. individual
feature
Complex
FBA/BIP
Problem Solving Team Meeting
Tertiary Systems Team Meeting
Brief
FBA/BIP
Brief FBA/BIP
Wraparound
Secondary Systems Team
Meeting
Plans schoolwide &
classroom supports
Uses process data; determines overall
intervention effectiveness
Standing team; uses FBA/BIP process for one student at a time
Uses process data; determines overall
intervention effectiveness
Rev. 11.19.2012
UniversalTeam
Meeting
Universal Support
Illinois PBIS Network
Tier 1/Universal School-Wide Assessment
School-Wide Prevention Systems
SIMEO Tools: HSC-T, RD-T, EI-T
Check-in Check-out (CICO)
Group Intervention with Individualized Feature (e.g., Check and Connect - CnC and Mentoring)
Brief Functional Behavior Assessment/Behavior Intervention Planning (FBA/BIP)
Complex or Multiple-domain FBA/BIP
Wraparound
ODRs, Attendance, Tardies, Grades, DIBELS, etc.
Daily Progress Report (DPR) (Behavior and Academic Goals)
Competing Behavior Pathway, Functional Assessment Interview, Scatter Plots, etc.
Social/Academic Instructional Groups (SAIG)
Positive Behavior Interventions & Supports:A Response to Intervention (RtI) Model
Illinois PBIS Network, Revised October 2009Adapted from T. Scott, 2004
Tier 2/Secondary
Tier 3/Tertiary
Inte
rven
tio
nAssessm
en
t
Individual Student Information System (ISIS)
Definition of school mental health •Involves partnership between schools and community health/mental health organizations, as guided by families and youth
•Builds on existing school programs, services, and strategies
•Focuses on all students, both general and special education
•Involves a full array of programs, services, and strategies- mental health education and promotion through intensive intervention
(Weist & Paternite, 2006)
“Expanded” School Mental Health
• Full continuum of effective mental health promotion and intervention for ALL students
• Reflecting a “shared agenda” involving school-family-community partnerships
• Collaborating community professionals (augment the work of school-employed staff
The Context
• Over 18,000 schools engaged in implementation of SWPBIS (MTSS ) prevention based system
• Current focus on capacity to scale-up • MTSS as platform to install effective
interventions for youth w/or at-risk of EBD
The Context (cont.)
• Emphasis now on scaling with expansion and connection to other systems – i.e. academic, juvenile justice, mental health, child welfare,
systems of care
• Emphasis on deliberate actions that foster connections w/families & community
Development of ISF
• 2002-2007: Site Development with PBIS Expansion (informal and independent)
• 2005 CoP focus on integration of PBIS and 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
Interconnected Systems Framework paper (Barrett, Eber and Weist , revised 2009)
Developed through a collaboration of theNational SMH and National PBIS Centers
www.pbis.orgwww.pbis.org http://csmh.umaryland.edu
• Define the common goals of SMH and PBIS
• Discuss the advantages of interconnection
• Identify successful local efforts to implement collaborative strategies and cross-initiative efforts
• Define the research, policy, and implementation agendas to take us to the next action level
ISF Monograph DevelopmentJune 2012 – September 2013
ISF Defined– ISF provides structure and process for education and mental
health systems to interact in most effective and efficient way. – ISF is guided by key stakeholders in education and mental health
system who have the authority to reallocate resources, change role and function of staff, and change policy.
– ISF applies strong interdisciplinary, cross-system collaboration.
ISF Defined– ISF uses the tiered prevention logic as the overall
organizer to develop an action plan.– ISF involves cross system problem solving teams that
use data to decide which evidence based practices to implement.
ISF Defined (cont)
– ISF involves ongoing progress monitoring for both fidelity and impact.
– ISF emphasizes active involvement by youth, families, and other school and community stakeholders.
Interconnected Systems Framework
Tier I: Universal/Prevention for AllCoordinated Systems, Data, Practices for Promoting Healthy Social and Emotional Development for ALL Students
· School Improvement team gives priority to social and emotional health
· Mental Health skill development for students, staff/, families and communities
· Social Emotional Learning curricula for all· Safe & caring learning environments · Partnerships : school, home & community· Decision making framework guides use of
and best practices that consider unique strengths and challenges of each school community
MH/PBIS: An Expanded Tier One• Universal screening for social, emotional, and behavioral at-risk
indicators• Universal screening for families who may request assistance for
their children• Teaching social skills with evidence-based curricula to all students• Teaching appropriate emotional regulation and expression to all
students• Teaching behavioral expectations to all students• Mental health professionals are part of the Tier 1 systems team,
providing input and progress monitoring data• Opportunity to review community data and expand Tier 1
intervention options based on data
Interconnected Systems Framework
Tier 2: Early Intervention for Some
Coordinated Systems for Early Detection, Identification, and Response to Mental Health Concerns
· Systems Planning Team coordinates referral process, decision rules and progress monitors
· Array of services available· Communication system: staff, families and
community · Early identification of students at risk for
mental health concerns due to specific risk factors
· Skill-building at the individual and groups level as well as support groups
· Staff and Family training to support skill development across settings
MH/PBIS: An Expanded Tier Two• Mental health/community professionals part of secondary
systems and problem solving teams• Working smarter matrix completed to ensure key resources are
both efficient and effective (i.e., initiatives are aligned and combined such as “bully prevention”, “discipline”, “character education”, “RtI behavior”, etc.)
• Groups co-facilitated by school staff and community partner (example – guidance counselor and community provider clinician)
• Opportunity to expand the continuum of interventions based on data (i.e. trauma informed interventions)
• Out-reach to families for support/interventions
Interconnected Systems FrameworkTier 3: Intensive Interventions for FewIndividual Student and Family Supports
· Systems Planning team coordinates decision rules/referrals and progress monitors
· Individual team developed to support each student
· Individual plans have array of interventions/services
· Plans can range from one to multiple life domains
· System in place for each team to monitor student progress
MH/PBIS: An Expanded Tier Three
• Mental health professional(s) part of tertiary systems team
• FBA/BIP and/or person-Centered Wraparound plans completed together with school staff and mental health provider for one concise plan, rather than each completing paperwork to be filed
• Quicker access to community-based supports for students and families
Traditional Preferred
• Each school works out their own plan with Mental Health (MH) agency;
• District has a plan for integrating MH at all buildings (based on community data as well as school data);
Traditional Preferred
• A MH counselor is housed in a school building 1 day a week to “see” students;
• MH person participates in teams at all 3 tiers;
Traditional Preferred
• No data to decide on or monitor interventions;
• MH person leads group or individual interventions based on data;
Structure for Developing an ISF: Community Partners
Roles in Teams
• A District/Community leadership that includes families, develops, supports and monitors a plan that includes:
• Community partners participate in all three levels of systems teaming in the building: Universal, Secondary, and Tertiary
Structure for Developing an ISF: Community Partners Roles in Teams (cont.)
• Team of SFC partners review data and design interventions that are evidence-based and can be progress monitored
• MH providers from both school & community develop, facilitate, coordinate and monitor all interventions through one structure
3-Tiered System of Support Necessary Conversations
CICO
SAIG
Group w. individual
feature
Complex
FBA/BIP
Problem Solving Team
Tertiary Systems Team
Brief
FBA/BIP
Brief FBA/BIP
WRAP
Secondary Systems Team
Plans SW & Class-wide supports
Uses Process data; determines overall
intervention effectiveness
Standing team with family; uses FBA/BIP process for one youth
at a time
Uses Process data; determines overall
intervention effectiveness
Sept. 1, 2009
UniversalTeam
Universal Support
Family and community Family and
community
Family and community
Community
SPARCS – IL HS
• 5 students participated in group– 1 student internalizer– 1 student participated last year as well
• Time 1 = Seven weeks before starting SPARCSTime 2 = First seven weeks on interventionTime 3 = Second seven weeks on intervention (with a total of 14 weeks of group)
ODRs Over Time
ODR Time 1 ODR Time 2 ODR Time 30
2
4
6
8
10
12
14
16
Total Number ODR All Participants
Total Number ODR
Time Period
ODR
Tot
al
13%↑
80%↓
ODRs by Student
Student 1 Student 2 Student 3 Student 4 Student 50
1
2
3
4
5
6
7
8
9
ODRs Over Time
Time 1 - 7 weeks before SPARCSTime 2 - First 7 weeks SPARCSTime 3 - Second 7 weeks SPARCS
Students
Num
ber o
f ODR
s
OSS Data
ISS Time 1 ISS Time 2 ISS Time 3 OSS Time 1 OSS Time 2 OSS Time 30
0.5
1
1.5
2
2.5
3
3.5
4
4.5
ISS/OSS Days Out
Student 1Student 2Student 3Student 4Student 5
Time Period
Num
ber o
f Day
s Out
Grades
A B C D F0
2
4
6
8
10
12
14
Overall Grade Distribution Over Time Periods for All Students
Time 1Time 2Time 3
Grades
Num
ber
TRAC-Nom Data
• Increased (Moving in Right Direction) • Life satisfaction .67 Significance Level
• Anxiety/depression symptoms .34
• Drug use .46
• Time spent living outside of the home (e.g. in jail, an emergency room, or
psychiatric hospital) .37
• Decreased (Moving in Wrong Direction)• Unexcused Absences .42
• Support Systems
Youth Outcomes Questionaire
• On the Youth Outcome Questionnaire (self report) it measures six subscales: Somatic; Social Isolation; Aggression; Conduct/Delinquency; Hyperactivity/Distraction; Depression/Anxiety– Students reported a decrease in symptoms/problems on all six
scales from pre to post– The largest reported improvement was on Aggression, second
was Hyperactivity/Depression and third was Depression/Anxiety– Out of the 5 students that completed the group, we had 2
parents that completed both the pre and post YOQ and both reported a reduction in symptoms/problems in their child…one score dropped from 40 to 18 and the other from 22 to 15
PA example
Accountable Clinical Home
• Accountable TO the family and FOR the care• Accessible, coordinated, and integrated care• Comprehensive service approach • Increased accountability and communication• Single point of contact for behavioral health• School is “launching pad” for services delivered in all
settings• Youth continue on the team with varying intensity of
service
SBBH Service Components
CLINICAL INTERVENTIONS
CASE MANAGEMENT
CRISIS INTERVENTION
CASE CONSULTATION AND TRAININGfor educational staff
District and Community Leadership Team
• Quarterly meetings• Stakeholder representation – System of Care• Implementer’s blueprint• Systems, data and practices• Scaling and sustainability
Time Line
School Year Activity
2008-09 •Community Care engaged district through ICSP regarding SBBH Team
2009-10 •SBBH Team begins work within district – September 2009•District and Community Leadership Team is established, district commitment signed, tertiary demonstration project begins – spring 2010
2010-11 •Tier One SWPBIS is fully implemented with kickoff at the start of the school year•Tier Two training begins in the spring of 2011 with some implementation
2011-12 •All three tiers are being implemented at both elementary schools•Montrose Junior High receives Tier One training in fall, with “soft” kickoff in January 2012•Discussion of SBBH Team model expanding into Junior and Senior High
1-5% 1-5%
5-10% 5-10%
80-90% 80-90%
Tertiary, Tier 3, Individual
Child Outcomes SurveyStrengths and Difficulties Q.Teacher feedbackAcademic data
Tertiary, Tier 3, Individual
•Guidance counselors see individual students•SBBH Team
Secondary, Tier 2 Group/Individual
Data from Tier One teamProgress monitoringData decision rules
Secondary, Tier 2 Group/Individual
•Guidance counselors run Targeted groups•IST•CICO•mentoring
Universal, Tier 1 Whole School ODRs, teacher nominations,Card system, MMS,
(lessons learned)
Universal, Tier 1, Whole school
•Guidance counselors teach “I Can Problem Solve” lessons•Treehab D and A awareness•Bully prevention/Character Ed•Peer Mediation
Montrose Elementary SchoolsK-6th Grade
Data Practices
Scranton School District
Year One2009-10
Year Two2010-11
Year Three2011-12
Year Four2012-13
Year Five2013-14
Year Six2014-15
District and Community Leadership Team established. District commits to implementing SWPBIS with fidelity across the district.
SBBH Teams begin implementation at Frances Willard Elementary, George Bancroft Elementary, and Scranton High. A Tier Three support.
Frances Willard Elementary, George Bancroft Elementary, and Scranton High all receive training to implement Tier One SWPBIS.
Frances Willard Elementary, George Bancroft Elementary, and Scranton High all implement Tier One SWPBIS.
Frances Willard Elementary reaches implementation fidelity.
Frances Willard Elementary receives training for implementation of Tier Two and begins implementation.
Frances Willard Elementary implements three tiers of Interconnected Systems Framework.
Isaac Tripp Elementary, McNichols Plaza Elementary, and South Scranton Intermediate all receive training to implement Tier One SWPBIS.
Isaac Tripp Elementary, McNichols Plaza Elementary, and South Scranton Intermediate all implement Tier One SWPBIS.
George Bancroft Elementary and Scranton High receive training for implementation of Tier Two and begin implementation
Scranton High receives training and begins implementation of RENEW.
SBBH Teams begin implementation at Northeast Intermediate, John F. Kennedy Elementary, McNichols Plaza Elementary, and John G. Whittier Elementary.
John F. Kennedy Elementary, John G. Whittier Elementary, and Northeast Intermediate all receive training to implement Tier One SWPBIS.
John F. Kennedy Elementary, John G. Whittier Elementary, and Northeast Intermediate all implement Tier One SWPBIS.
Tier 3/Tertiary Interventions 1-5%1-5% Tier 3/Tertiary Interventions
•SBBH Team•Outpatient therapy•SB Partial•Guidance – individual support•SAVES/school aged mothers
Tier 2/Secondary Interventions 5-15%5-15% Tier 2/Secondary Interventions
•SAP•Guidance – groups•Community Partners – groups•Resource Officer
Tier 1/Universal Interventions80-90%
80-90% Tier 1/Universal Interventions•SWPBIS•Drug and Alcohol Prevention
School-Wide Systems for Student Success:A Response to Intervention (RtI) Model:
Resources
Illinois PBIS Network, Revised May 15, 2008. Adapted from “What is school-wide PBS?” OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports. Accessed at http://pbis.org/school-wide.htm
Needs
Scranton High School
Key features• Systems
– District and building teaming models – Facilitation, technical assistance, coaching– Stakeholder participation and buy-in
• Practices– Mental health and school staff work in an integrated way to support
students across tiers– Using assessment and screening in order to determine which EBPs to
use, progress monitor– One plan for both education and mental health
• Data– Shared decision rules– Used for decision making with all stakeholders at the table – school, mental health,
other child serving systems, family
OutcomesChange in Family Functioning
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Change at 3 mos Change at 6 mos Change at 9 mos
Not Implementing Low Fidelity High Fidelity
Impr
ovin
g
OutcomesChange in Child Functioning
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Change at 3 mos Change at 6 mos Change at 9 mos
Not Implementing Low Fidelity High Fidelity
Impr
ovin
g
The Smith Family
• Jason was referred to the SBBH Team in November. He is a seven-year-old first grader who was having difficulty coming to school and being separated from his mother.
• When he was four, Jason and his family were in a car accident in a rural area. The members of the family were taken to different hospitals and Jason did not know where his mom was or if she was okay.
• Every day, since the first day of school, Jason’s mom would bring him into the school and the school staff would literally have to peel Jason off of his mother and hold him so she could leave.
The Smith Family cont.
• Once referred to the team, they were immediately able to work with Jason and his family to create strategies to help him separate more smoothly.
• Jason found the SBBH Team office/room a safe place to be. His mother also spent time there to help create a nice transition area.
• After the Holiday break, Jason began riding the bus for the fist time, accompanied by one of the BHWs from the team.
• Soon, Jason was able to ride the bus on his own, increasing his confidence and allowing him some relief from his anxiety.
Lessons Learned
• Return on investment• Funding efficiency• Scaling and sustaining SBBH Teams – size• Community “politics”
For More Information:
• www.sharedwork.org• www.pbis.org