1. Transforming Child and Adolescent Mental Health Mark D. Weist, Ph.D. Department of Psychology, University of South Carolina Appalachian State University, 4.19.13

2. Thanks to  Vittoria Anello  Jason Bird  Lori Chappelle  Kendra DeLoach  Melissa Dvorsky  Melissa George  Lucille Eber  Johnathan Fowler  Nancy Lever  Bobby Markle  Heather McDaniel  Kurt Michael  Elaine Miller  Samantha Paggeot  Sharon Stephan  Kathy Short  Joni Splett  Leslie Taylor  John Terry  Rachel Williamson  Eric Youngstrom

3. Center for School Mental Health* University of Maryland School of Medicine http://csmh.umaryland.edu *Supported by the Maternal and Child Health Bureau of HRSA and numerous Maryland agencies http://csmh.umaryland.edu

6. Outline  Realities  Expanded school mental health  Achieving evidence-based practice  Interconnection with PBIS  Other collaborative projects  Progress, …but many challenges  A National Community of Practice

7. Reality 1  Child and adolescent mental health is among the most if not the most neglected health care need in the US

8. Reality 2  Children, youth and families are not getting to places where mental health services are traditionally delivered

9. Reality 3  Schools are under-resourced to address mental health issues, and may view this as beyond their mission

10. “Expanded” School Mental Health  Full continuum of effective mental health promotion and intervention for students in general and special education  Reflecting a “shared agenda” involving school-family-community system partnerships  Collaborating community professionals (not outsiders) augment the work of school-employed staff

11. A Vision for Student Mental Health and Well- Being in Ontario Schools Ontario students are flourishing, with a strong sense of belonging at school, ready skills for managing academic and social/emotional challenges, ready skills for managing academic and social/emotional challenges, and surrounded by caring adults and communities equipped to identify and intervene early with students struggling with mental health problems (from Kathy Short) A Vision

12. Research Supported Programs  Substance Abuse and Mental Health Service Administration’s National Registry of Effective Programs and Practices  www.nrepp.samhsa.com www.nrepp.samhsa.com  Roughly 56 of 170 research supported interventions can be implemented in schools

13. Research Supported Programs Involve  Strong training  Fidelity monitoring  Ongoing technical assistance and coaching  Administrative support  Incentives  Intangibles

14. Practice in the trenches  Involves NONE of these supports

15. http://www.jhsph.edu/prevention/ Johns Hopkins Center for Prevention & Early Intervention Leads: Nick Ialongo, Phil Leaf, Catherine Bradshaw

16. Barriers to Evidence-Based Programs in Schools   Clinician   School Setting   Funding/Resources

17. Clinician Related Barriers   Limited prior training on evidence-based practices   Resistance   Role constraints   Need for administrative support   Need for ongoing coaching and technical assistance

18. 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

19. School Related Barriers   Fluidity of the school environment   Teacher turnover   Tenuous principal buy-in   Lack of time   Lack of dedicated change agents

20. Evidence-Based “Manualized” interventions (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

21. “Packaging” Problem  Blind commitment to parameters of manuals (e.g., hour long sessions, too many sessions), without consideration of school realities  Instead group key intervention components in “phases” and deliver flexibly See Steve Evans, Julie Owens, Ohio University See Steve Evans, Julie Owens, Ohio University

22. Strengthening School Mental Health Services

23. Study Overview  NIMH, R01MH081941-01A2, 2010-14 (building from a prior R01)  46 school mental health clinicians, 34 schools  Randomly assigned to either:  Personal/ Staff Wellness (PSW)  Clinical Services Support (CSS)

24. CSS: Four Key Domains  Quality Assessment and Improvement  Family Engagement and Empowerment  “Modular” Evidence Based Practice  Implementation Support

25. Quality Assessment and Improvement (QAI) Principles  Emphasize access  Tailor to local needs and strengths  Emphasize quality and empirical support  Active involvement of diverse stakeholders  Full continuum from promotion to treatment  Committed and energetic staff  Developmental and cultural competence  Coordinated in the school and connected in the community

26. Working Effectively with Students and Families  Engagement  Support  Collaboration  Empowerment see the work of Kimberly Hoagwood and Mary McKay see the work of Kimberly Hoagwood and Mary McKay

27. Modular Evidence-Based Practice (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 Ignoring o Commands o Communication Skills o Monitoring behavior o Praise o Problem Solving o Psychoeducation o Response cost o Tangible rewards o Time out/ Grounding

28. Implementation Support  Interactive and lively teaching  Off and on-site coaching, performance assessment and feedback, emotional and administrative support  Peer to peer support  User friendliness see Dean Fixsen, Karen Blasé, National Implementation Research Network (NIRN) see Dean Fixsen, Karen Blasé, National Implementation Research Network (NIRN)

29. A “Transformative” Impact?  Largest and most prominent SMH program in SC  In a network of SMH in all jurisdictions  Strong interest in the study across all relevant sectors  Pursuing integrated QAI – Wellness strategy now  Given positive findings, the study approach is set up for rapid replication in SC and beyond

30. But  SMH programs and services continue to develop in an ad hoc manner, and  LACK AN IMPLEMENTATION STRUCTURE

31. Positive Behavior Intervention and Support (www.pbis.org)  In 17,000 plus schools  Decision making framework to guide selection and implementation of best practices for improving academic and behavioral functioning Data based decision making Data based decision making Measurable outcomes Measurable outcomes Evidence-based practices Evidence-based practices Systems to support effective implementation Systems to support effective implementation

32. Tiered Support in Systems of Care Universal Evidence-Based Mental Health Promotion, Social- Emotional Learning Targeted Evidence-Based Prevention E-B Clinical Intervention Evidence-Based Clinical Intervention Targeted Evidence-Based Prevention Universal E-B Mental Health Promotion Community School Districts

33. Interconnected Systems Framework (ISF) for SMH-PBIS  Strategy for interconnection of two systems across multiple tiers  Emphasizes state teams working with district teams and schools, and strong team planning and actions at each tier  Two national centers (for SMH and PBIS) and a number of states involved  Numerous training events and a monograph in progress

34. ISF Defined A strong, committed and functional team guides the work, using data at three tiers of intervention A strong, committed and functional team guides the work, using data at three tiers of intervention Sub-teams having “conversations” and conducting planning at each tier Sub-teams having “conversations” and conducting planning at each tier Evidence-based practices and programs are integrated at each tier Evidence-based practices and programs are integrated at each tier SYMMETRY IN PROCESSES AT STATE, DISTRICT AND BUILDING LEVELS SYMMETRY IN PROCESSES AT STATE, DISTRICT AND BUILDING LEVELS

35. ISF cont. Key stakeholders from education and mental health are involved and these people have the authority to reallocate resources, change roles and functioning of staff, and change policy Key stakeholders from education and mental health are involved and these people have the authority to reallocate resources, change roles and functioning of staff, and change policy There is a priority on strong interdisciplinary, cross-system collaboration There is a priority on strong interdisciplinary, cross-system collaboration

36. Old Approach  New Approach  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 and school data)

37. Old Approach  New Approach  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

38. Old Approach  New Approach  No data to decide on or monitor interventions  MH person leads classroom, group or individual interventions based on data

39. ISF, School Readiness Assessment  1) High status leadership and team with active administrator participation  2) School improvement priority on social/emotional/behavioral health for all students  3) Investment in prevention  4) Active data-based decision making  5) Commitment to SMH-PBIS integration  6) Stable staffing and appropriate resource allocation

40. ISF, Indicators of Team Functioning  Strong leadership  Good meeting attendance, agendas and meeting management  Opportunities for all to participate  Taking and maintaining of notes and the sense of history playing out  Clear action planning  Systematic follow-up on action planning

41. Team Members  *School psychologist  *Collaborating community mental health professional  School counselor  Special educator *co-leaders  Assistant principal  School nurse  General educator  Parent  (Older student)

42.  Interdisciplinary, evidence-based intervention for youth with mood disorders in schools  USC, ASU and UNC  More than 20 student participants and promising data  Likely big grant application by this fall Student Emotional and Educational Development (SEED)

43.  Appalachian State University Kurt Michael Kurt Michael J.P. Jameson J.P. Jameson Abby Albright Abby Albright Theresa Egan Theresa Egan Alex Kirk Alex Kirk Cameron Massey Cameron Massey Rafaella Sale Rafaella Sale  University of North Carolina at Chapel Hill Eric Youngstrom Eric Youngstrom  University of South Carolina Mark Weist Mark Weist Aidyn Iachini Aidyn Iachini Mary Ellen Warren Mary Ellen Warren Melissa George Melissa George Joni Splett Joni Splett Leslie Taylor Leslie Taylor Support: Heather McDaniel, Bryn Schiele, Elaine Miller Support: Heather McDaniel, Bryn Schiele, Elaine Miller Trainees in Psychiatry, Social Work, School and Clinical-Community Psychology Trainees in Psychiatry, Social Work, School and Clinical-Community Psychology SEED Team

44. CLIMB  Changing Lifestyles to Improve Mind and Body (Melissa George et al.)  10 middle school participants, 6 sessions integrated into work of SMH clinicians (enhanced exercise and/or reduced screen time, increased fruit and vegetable intake and/or reduced junk food)  Strong feasibility and acceptability and preliminary evidence of impact

45. Progress, but…. many other challenges  Suspension  Expulsion  Very poor transitions  Schools and people doing what they are used to doing (and being highly resistant to change)

46. Roles of School-Employed MH Staff (in some instances)  Course scheduling  Attendance monitoring  Examination monitoring  Career guidance  Logistics assistance See Steve Evans, Ohio University See Steve Evans, Ohio University

47. Significant Accountability Issues  “Optimizing” School staff doing rote administrative work School staff doing rote administrative work Community mental health staff seeing same clients and delivering passive, eclectic, non evidence-based interventions Community mental health staff seeing same clients and delivering passive, eclectic, non evidence-based interventions

48. Special Education Challenges  Schools and staff as gatekeepers  “Social maladjustment”  Highly variable labeling  “Manifestation” hearings  Increasing but not decreasing restrictiveness  Pro-forma meetings and poor follow-up  Accomodations

49. A National Community of Practice (COP); www.sharedwork.org  CSMH and IDEA Partnership (www.ideapartnership.org) providing support www.ideapartnership.org  30 professional organizations and 16 states  12 practice groups  Providing mutual support, opportunities for dialogue and collaboration

50. Example Practice Groups  Learning the Language  Quality and Evidence-Based Practice  Family Involvement  Youth Leadership  SMH and PBIS  SMH and Special Education  SMH and Systems of Care  Military Families

51. Sixteen States  Hawaii  Illinois  New Hampshire  North Carolina  Maryland  Minnesota*  Missouri  Montana*  New Mexico  Ohio  Pennsylvania  South Carolina  South Dakota  Utah*  Vermont  West Virginia

52. 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 (http://www.omhnss.org)

53. Montana’s Integrated School Mental Health Initiative

55.   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

58. Advances in School Mental Health Promotion 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 Weist Consulting Editor – Michael Murray Deputy Editor – Sharon Stephan

59. 18 th Annual SMH Conference Crystal City, Arlington, Virginia October 3-5, 2013

60. Contact Information  Department of Psychology University of South Carolina 1512 Pendleton St., Room 237D  Columbia, SC 29208 Ph: 803 777 8438 weist@mailbox.sc.edu Ph: 803 777 8438 weist@mailbox.sc.edu weist@mailbox.sc.edu