Best Practices in Expanded School Mental Health Carl E. Paternite, Ph.D. Center for School-Based Mental…

Best Practices in ExpandedSchool Mental Health

Carl E. Paternite, Ph.D.Center for School-Based Mental Health Programs

Department of PsychologyMiami University (Ohio)

http://www.units.muohio.edu/csbmhp

Workshop for the Center for Children and FamiliesCincinnati, OHMay 14th, 2004

Center for School-Based Mental Health Programs, Miami University

Mental Health Needs of Youth and Available Services

About 20% of children/adolescents (15 million), ages 9-17, have diagnosable mental health disorders (and many more are at risk or could benefit from help).

Less than one-third of youth with diagnosable disorders receive any service, and, of those who do, less than half receive adequate treatment (even fewer at risk receive help).

For the small percentage of youth who do receive service, most actually receive it within a school setting.

These realities raise questions about the mental health field’s over-reliance on clinic-based treatment, and have reinforced the importance of alternative models for mental health service — especially expanded school-based programs.

Report of President’s New Freedom Commission on Mental Health

http://www.mentalhealthcommission.gov

“…the mental health delivery system is fragmented and in disarray…leading to unnecessary and costly disability, homelessness, school failure and incarceration.”

Unmet needs and barriers to care include (amongothers):• Fragmentation and gaps in care for children.• Lack of national priority for mental health and suicide

prevention. July,

2003

Report of President’s New Freedom Commission on Mental Health: Six Goals

for a Transformed System• Americans understand that mental health is essential to

overall health.• Mental health care is consumer and family driven.• Disparities in mental health services are eliminated.• Early mental health screening, assessment, and referral

to services are common practice.• Excellent mental health care is delivered and research is

accelerated.• Technology is used to access mental health care and

information.July, 2003

Four Recommendations Supporting Goal 4: Early Mental Health Screening, Assessment,

and Referral to Services are Common Practice

1. Promote the mental health of young children.

2. Improve and expand school mental health programs.

3. Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.

4. Screen for mental disorders in primary health care, across the lifespan, and connect to treatment and supports.

July, 2003


Expanded School-Based Mental Health Programs

National movement to place effective mental health programs in schools, serving youth in general and special ed.

To promote the academic, behavioral, social, emotional, and contextual/systems well-being of youth, and to reduce “mental health” barriers to school success.

Programs incorporate primary prevention and mental health promotion, secondary prevention, and intensive intervention,joining staff and resources from education and other community systems.

Intent is to contribute to building capacity for a comprehensive, multifaceted, and integrated system of support and care.

University of Maryland

Center for School Mental Health Assistance

Mark Weist

(http://csmha.umaryland.edu)

ESBMH

UCLA

Center for Mental Health Assistance

Howard Adelman & Linda Taylor

(http://smhp.psych.ucla.edu)

“Barriers to Learning”

Two Important Goals: Achievement and Wellbeing

1) Achievement promotes wellbeing 2) Wellbeing promotes achievement

School philosophy often acknowledges 1 but fails to acknowledge 2

Mark Weist (CSMHA)

Non-academic barriers to learning exert a powerful negative influence

• Environmental– Poor nutrition– Family stress– Family conflict– Peer influences– Exposure to violence– Abuse, Neglect– Poor school

environment

• Personal– Attentional difficulties– Behavioral problems– Depression– Anxiety– Social problems– Trauma reactions

Mark Weist (CSMHA)

School Effectiveness in Promoting Achievement and the NCLB Mandate

• Least effective: Limited focus on academic and nonacademic barriers

• More effective: Focus on academic barriers

• Most effective: Integrated Focus on academic and nonacademic barriers

Mark Weist (CSMHA)


Potential of Schools as Key Points of Engagement

Opportunities to engage youth where they are.

Unique opportunities for intensive, multifaceted approaches and are essential contexts for prevention and research activity.


Schools: The Most Universal Natural Setting

• Over 52 million youth attend 114,000 schools• Over 6 million adults work in schools• Combining students and staff, one-fifth of the

U.S. population can be found in schools

From New Freedom Commission (2003)


Center for School-Based Mental Health Programs (at Miami University)

Overarching Goals Build collaborative mental health—schools—families relationships to address the mental health needs of children and adolescents through multifaceted programming.

Promote mental health and school success for youth through:

Primary prevention and mental health education

Early direct intervention for identified at-risk children and adolescents, and treatment for those with severe/ chronic mental health problems Action research, training, and consultation

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.

Mission

The Ohio Mental Health Network forSchool Success

Action Agenda Create awareness about the gap between children’s mental health

needs and “treatment” resources, and encourage improved and expanded services (including new anti-stigma campaign).

Partner with regional action networks to enhance within-region implementation of the action agenda, actively soliciting student and family input. Also, contribute to statewide efforts (e.g., training institutes, workshops, research, etc.).

Conduct surveys of mental health agencies, families, and school districts to better define the mental health needs of children and to gather information about promising practices.


Action Agenda (continued)

Provide training and technical assistance to mental health agencies and school districts, to support adoption of evidence-based and promising practices, including improvement and expansion of school-based mental health services.

Develop a guide for education and mental health professionals and families, for the development of productive partnerships.


Action Agenda (continued)

Assist in identification of sources of financial support for school-based mental health initiatives.

Assist university-based professional preparation programs in psychology, social work, public health, and education, in developing inter-professional strategies and practices for addressing the mental health needs of school-age children.

Policymaker Partnership (PMP) at the National Association of State Directors of Special Education (NASDSE) and the National Association of State Mental Health Program Directors (NASMHPD)

Concept Paper:Mental Health, Schools and Families Working

Together for All Children and Youth:Toward A Shared Agenda (2002)

www.nasmhpd.org/publications.cfmwww.nasdse.org/sharedagenda.pdf

Ohio’s Mental Health, Schools, and Families Shared Agenda Initiative

http://www.units.muohio.edu/csbmhp/sharedagenda.html

Phase 1—Statewide forum for leaders of mental health, education, and family policymaking organizations and child-serving systems(March 3, 2003)

Phase 2—Six regional forums for policy implementers and consumer stakeholders (April-May, 2003)

Phase 3—Legislative forum involving key leadership of relevant house and senate committees (October 9, 2003)

Phase 4—Ongoing policy/funding advocacy and technical assistance to promote attention to the crucial links between mental health and school success

Phase 4 Steps for Ohio’s Shared Agenda Initiative

1.ODMH and ODE jointly formed an ad hoc workgroup to address action steps related to the Shared Agenda Recommendations The workgroup met three times between November (2003) and March

(2004)

A final report with recommended goals and objectives will be released in late Spring 2004


2. Ohio is one of eight states selected to participate in a SAMHSA-funded 3-year Elimination of Barriers Initiative (EBI) to identify effective approaches in addressing the stigma and discrimination associated with mental illness. Ohio is focusing on the school population.

Contact strategies: Youth speaker bureau

Educator inservice modules


3. Expansion of Ohio’s Positive Behavior Support Initiative will continue.

4. Ongoing work of the Ohio Mental Health Network for School Success will continue through implementation of the action agenda and through special targeted efforts.

Phase 4: An Immediate Legislative Outcome

Senate Bill 2Section 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.”


Creating and Maintaining Ongoing, Empowering Dialogue

with Educators Multi-level, formal and informal dialogue with policy makers,

formulators, enforcers, and implementers. Programs for school board members and administrators. Newsletter for teachers. Website resources. Extensive “contact time” with educators in their school buildings. “Joining” the school community. Key opinion leaders.


Assessing and Responding To Educator-Identified Needs and

Concerns

Careful, detailed, local needs assessments from the perspective of educators, and a commitment to be responsive to identified needs.

Results used in advocacy efforts and as guideposts for ongoing work.


Teacher Consultants

Teacher consultants develop and implement special projects related to school-based mental health enhancement.

Teacher consultants serve as liaisons to the schools in efforts to promote school-based mental health programming.

Teacher consultants serve as informal advisers/mentors to school staff on matters related to social-emotional adjustment and learning

needs of children and school/climate issues.


Incentives For Teacher Consultants

Leadership opportunity

Training opportunity

Academic credit

Stipends (“supplemental contracts”)

Empowerment

Demystification


Educators as Key Members of the Mental Health Team

Schools should not be held responsible for meeting every need of every student.

However, schools must meet the challenge when the need directly affects learning and school success. (Carnegie Council Task Force on Education of Young Adolescents, 1989)

There is clear and compelling evidence that there are strong positive associations between mental health and school success.


“Children whose emotional, behavioral, or social difficulties are not addressed have a diminished capacity to learn and benefit from the school environment. In addition, children who develop disruptive behavior patterns can have a negative influence on the social and academic environment for other children.” (Rones & Hoagwood, 2000, p.236)

Contemporary school reform—and the associated high-stakes testing (including federal legislation signed in 2002)—has not incorporated the Carnegie Council imperative. That is, recent reform has not adequately incorporated a focus on addressing barriers to development, learning, and teaching.

Educators as Key Members of the Mental

Health Team


An Exercise:

How much time does a typical classroom teacher spend addressing the

emotional,behavioral, and/or social difficulties of students(minutes per hour)?

Educators as Key Members of the Mental

Health Team

Context Examples

Senior high school with 880 students reported over 5,100 office discipline referrals in one academic year.

What does this mean?

• 5100 referrals @ 10 minutes each =– 51,000 minutes or– 850 hours or

– 141 6 hour days!

Context Examples

Middle school principal reports he must teach classes when teachers are absent, because substitute teachers refuse to work in a school that is unsafe and lacks discipline.

Context Examples

Middle school counselor spends nearly 15% of day “counseling” staff who feel helpless & defenseless in their classrooms because of lack of discipline & support.

Problem Behaviors

Insubordination, noncompliance, defiance, late to class, nonattendance, truancy, fighting, aggression, inappropriate language, social withdrawal, excessive crying, stealing, vandalism, property destruction, tobacco, drugs, alcohol, unresponsive, not following directions, inappropriate use of school materials, weapons, harassment, unprepared to learn, parking lot violation, irresponsible, trespassing, disrespectful, disrupting teaching, uncooperative, violent behavior, disruptive, verbal abuse, physical abuse, dress code, other, etc., etc., etc.

• Exist in every school• Vary in intensity• Are associated w/

variety of contributing variables

• Are concern in every community


Prioritizing Promotion of Healthy Development and Problem Prevention

School-based models should capitalize on schools’ unique opportunities to provide mental health-promoting activities.

For example, recommended strategies for drop-out and violence prevention, including those for which the central role of educators is evident, can be promoted actively within an expanded school-based mental health program.


Prioritizing Promotion of Healthy Development and Problem Prevention

For drop-out prevention, these include: Early intervention. Mentoring and tutoring. Service learning. Conflict resolution and violence prevention

curricula and training for students/staff. Alternative schooling.


Some of What We Know About Youth ViolenceFrom the Surgeon General (2001), U.S. Secret Service (2000),

CDC (2002), Mulvey & Cauffman (2001)

Violence is a serious public health problem.

Violence is most often expressive/interpersonal, rather than primarily instrumental or psychopathological.

About 30 to 40 percent of male and 15 to 30 percent of female youth report having committed a serious violent offense by age 17.

About 10 to15 percent of high school seniors report that they have committed an assault with injury in the past year — a rate that has been rising since 1980.

By self-report, about 30 percent of high school seniors have committed a violent act in the past year — hit instructor or supervisor; serious fight at school or work; in group fight; assault with injury; used weapon (knife/gun/club) to get something from a person.

Violent acts are committed much more frequently by male than by female youth. (see Miedzian, 1991)


Some of What We Know About Youth Violence (continued)

43% of male and 24% of female high school students report that they had been in a physical fight during the past school year. (CDC, 2002)

No differences are evident by race for self-report of violent behavior.

At school, highest victimization rates are among male students.

Violent behavior seldom results from a single cause.

School continues to be one of the safest places for our nation’s children.

Serious acts of violence (e.g., shootings) at school are very rare.

Targeted violence at school is not a new phenomenon.

Most school shooters had a history of gun use and had access to them.

In over 2/3 of school shooting cases, having been bullied played a role in the attack.


A QUESTION:

WHAT ARE THE CAUSES OF VIOLENCE, OTHER PROBLEM BEHAVIOR,

AND DISCIPLINE PROBLEMS?


“For every complex problem there is a simple solution that is wrong.” H.L. Mencken

Model: Influences on Violent versusNon-Violent Behavior

(From Shapiro, 1999, Applewood Centers, Inc., Cleveland, OH)


Some of What We Know AboutYouth Violence Prevention

From the Surgeon General (2001), U.S. Secret Service (2000),CDC (2002), Mulvey & Cauffman (2001)

Promoting healthy relationships and environments is more effective for reducing school violence than instituting punitive penalties.

The best predictor of adolescent well-being is a feeling of connection to school. Students who feel close to others, fairly treated, and vested in school are less likely to engage in risky behaviors.

A critical component of any effective school violence program is a school environment in which ongoing activities and problems of students are discussed, rather than tallied. Such an environment promotes ongoing risk management, which depends on the support and involvement of those closest to the indicators of trouble — peers and teachers.

Violence Prevention:What Doesn’t Work

From the Surgeon General (2001) and others

Scare tactics. (e.g., Scared Straight)

Deterrence programs — shock incarceration, boot camps.

Efforts focusing exclusively on providing education/information about drugs/violence and resistance. (DARE)

Efforts focusing solely on self-esteem enhancement.

Vocational counseling.

Residential treatment.

Traditional casework and clinic-based counseling.

Deutsch (1993) — Educating for a peaceful world

Four Key Components Including:

Cooperative Learning.

Conflict Resolution Training.

Use of Constructive Controversy in Teaching Subject Matters.

Mediation in the Schools.

Promoting Nonviolence: AnExample of a Heuristic

School-Based Framework

Prioritizing Promotion of Healthy Development and Violence Prevention:

Best and Promising Practices

Including:Structured social skill development programs.Mentoring. (see Big Brothers/Sisters; Garbarino, 1999)Employment.Programs that foster school engagement, participation, and bonding.Promotion of developmental assets. (see Search Institute)A variety of approaches that engage parents and families. (e.g., parent training, MST, functional FT)Early childhood home visitation programs.Multi-faceted programs that combine several of the above.For good examples see “Blueprint Programs.”


Developmental Assets and Violence(1997 data, www.search-institute.org)

Approximately 100,000 6th-12th graders.Definition of violence—three or more acts of fighting, hitting, injuring a person, carrying a weapon, or threatening physical harm in the past 12 months.

61% of youth with fewer than 11 of 40 developmental assets were violent.

6% of youth with 31 or more of 40 developmental assets were violent.

Positive Behavior Support(see www.pbis.org)

• PBS is a broad range of systemic & individualized strategies for achieving important social & learning outcomes while preventing problem behavior with all students.

Specialized Individual Interventions(Individual StudentSystem)

Continuum of Effective BehaviorSupport

Specialized GroupInterventions(At-Risk System)

Universal Interventions (School-Wide SystemClassroom System)

Studentswithout SeriousProblemBehaviors (80 -90%)

Students At-Risk for Problem Behavior(5-15%)

Students withChronic/IntenseProblem Behavior(1 - 7%)

Primary Prevention

Secondary Prevention

Tertiary Prevention

All Students in School

Terminology

• Positive Behavior….– Includes all skills that increase success in home, school and

community settings.

• Supports….– Methods to teach, strengthen, and expand positive

behaviors.– System change.

Discipline Defined

• “The steps or actions, teachers, administrators, parents, and students follow to enhance student academic and social behavior success.”

• “Effective discipline is described as teaching students self-control.”

Reactive Vs. Proactive

• Traditional approaches. (including aversive interventions) – Address problem behaviors reactively– Crisis driven

• PBS emphasizes proactive interventions.

Goals

1. Improved quality of life for all relevant stakeholders. (the individual, family members, teachers, friends, employers, etc.)

2. Problem behaviors become irrelevant, inefficient, and ineffective and are replaced by efficient and effective alternatives.

Components of School-Wide Systems

• Common philosophy.• Positively stated rules. (3 or 4)• Behavior expectations defined by context.• Teaching behavior expectations in context.• Reinforcement of expectations.• Discouragement of violations.• Monitor and evaluate effects.

Two Distinct Discipline Models

• Obedience Model

• Responsibility Model

From Johnston (2003)

Obedience• MAIN GOAL:

– Student follows orders

• PRINCIPLE:– Do what the teacher wants

• INTERVENTION: PUNISHMENT– External locus of control– Done to the student

• STUDENT LEARNS:– Don’t get caught– It’s not my responsibility


Responsibility

•MAIN GOAL: To teach students to make good choices

•PRINCIPLE:Learn from the outcomes of decisions

•INTERVENTION: CONSEQUENCESInternal locus of controlNatural or logicalDone by the student

•STUDENT LEARNS:I have more than one alternativeI have power to chooseI cause my own outcomes


Teacher Behaviors That Contribute to Discipline

Problems• Sitting at the desk most of the time, not moving or

mingling with the students• Using a low, unenthusiastic or uniteresting voice tone• Becoming easily sidetracked by one student’s irrelevant

question



Problems

• Ignoring students’ interests and tying instruction solely to the textbook

• Repeating student’s answers too frequently• Leaving concepts before they have been clarified and/or expecting

independent work before understanding has been checked• Not being prepared and leaving “down time” for students to fill



Problems

• Poorly worded questions that cloud discussion or understanding• Having questions/answers be directed solely between teacher and

student• Neglecting to tie content or learning to prior knowledge of students• Using too much time to teach the lesson and not focusing on what is

being learned


Teacher Behaviors That Contribute to Reduction of Discipline Problems

• Remove conditions that trigger & maintain undesirable practices

• Increase conditions that trigger & maintain desirable practices

• Remove aversives that inhibit desirable practices• Establish environments & routines that support

continuum of PBS


Specialized Individual Interventions(Individual StudentSystem)

Continuum of Effective BehaviorSupport

Specialized GroupInterventions(At-Risk System)

Universal Interventions (School-Wide SystemClassroom System)

Studentswithout SeriousProblemBehaviors (80 -90%)

Students At-Risk for Problem Behavior(5-15%)

Students withChronic/IntenseProblem Behavior(1 - 7%)

Primary Prevention

Secondary Prevention

Tertiary Prevention

All Students in School

Positive Adolescent Choices Training (PACT)Developed by

Betty R. Yung & W. Rodney Hammond

Components

I. Violence-Risk Education

II. Anger Management

III. Social Skills

Promoting Nonviolence: An Example of a Promising Secondary

Violence Prevention Program

Violence Risk Education: Increase awareness of circumstances, risk

factors, and consequences of violence.

Anger Management: Understand and normalize feelings of anger,

recognize anger triggers, and manage anger constructively.

PACT Components I and II

Givin’ It: Expressing criticism, disappointment, anger, or

displeasure calmly and ventilating strongemotions constructively.

Takin’ It: Listening, understanding, and reacting

appropriately to others’ criticism and anger.

Workin’ It Out: Listening, identifying problems and potential

solutions, proposing alternatives whendisagreements persist, and learning to

compromise.

PACT Components III: Social Skills

Best Practices in Expanded School Mental Health

Instructional Objectives: Increase participant awareness of the model and best practices of

expanded school mental health

Increase participant awareness of the importance of educators in school-based mental health programming.

Increase participant knowledge of effective approaches to enhance educator – mental health professional collaboration.

Increase knowledge of ways to infuse "mental health education" and problem prevention into the school milieu.

QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

Mental Health and School Success WebsitesNational:

National Association of State Directors of Special Education(www.nasdse.org)

Center for School Mental Health Assistanc (CSMHA, http://csmha.umaryland.edu)

Center for Mental Health in Schools(http://smhp.psych.ucla.edu)

Ohio:Center for School-Based Mental Health Programs

(http://www.units.muohio.edu/csbmhp)

Center for Learning Excellence, Alternative Education and Mental Health Projects(http://altedmh.osu.edu/omhn/omhn.htm)

Ohio’s Shared Agenda Initiative(http://www.units.muohio.edu/csbmhp/sharedagenda.html)

Several PowerPoint presentations pertinent to today’s presentation are available on the CSBMHP website

http://www.units.muohio.edu/csbmhp

Documents

Best Practices in Expanded School Mental Health Carl E. Paternite, Ph.D. Center for School-Based Mental…