advancing school mental health in northwest ohio mark d. weist university of maryland school of...
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Advancing School Mental Advancing School Mental Health in Northwest OhioHealth in Northwest Ohio
Mark D. WeistMark D. Weist
University of Maryland University of Maryland
School of MedicineSchool of Medicine
The Crisis of Youth Mental HealthThe Crisis of Youth Mental Health
3-5% severe impairment3-5% severe impairment
12-22% diagnosable disorders12-22% diagnosable disorders
20-100% at risk or could otherwise benefit20-100% at risk or could otherwise benefit
< 33% with serious problems receive care< 33% with serious problems receive care
% at risk who receive care ???????% at risk who receive care ???????
% who receive effective care ???????% who receive effective care ???????
Quotes from the U.S. Surgeon General’s Quotes from the U.S. Surgeon General’s Conference on Children’s MH (9/2000)Conference on Children’s MH (9/2000)
““A terrifying gap between what we know and A terrifying gap between what we know and what we do”what we do”
““The system has an emergency room, crisis The system has an emergency room, crisis mentality” (Steven Hyman)mentality” (Steven Hyman)
““The burden of suffering for children’s mental The burden of suffering for children’s mental health problems is unmatched” (Dan Offord)health problems is unmatched” (Dan Offord)
Surgeon General’s Conference IISurgeon General’s Conference II
““Children are wallowing in systems”Children are wallowing in systems”
““I received curt, callous and substandard care I received curt, callous and substandard care until the provider learned of my educational until the provider learned of my educational status” (Senora Simpson)status” (Senora Simpson)
““Referrals from primary care sites result in Referrals from primary care sites result in wait times of 3 to 4 months, with 60% never wait times of 3 to 4 months, with 60% never receiving care” (Kelly Kelleher)receiving care” (Kelly Kelleher)
Schools: The Most Schools: The Most Universal Natural SettingUniversal Natural Setting
Over 52 million youth attend 114,000 schoolsOver 52 million youth attend 114,000 schools
Over 6 million adults work in schoolsOver 6 million adults work in schools
Combining students and staff, one-fifth of the Combining students and staff, one-fifth of the U.S. population can be found in schoolsU.S. population can be found in schools
Expanded School Mental Health (ESMH)Expanded School Mental Health (ESMH)
ESMH programs join staff and resources from ESMH programs join staff and resources from education and other community systems education and other community systems to develop a full array of mental health to develop a full array of mental health promotion and intervention programs and promotion and intervention programs and services services for youth in general and special educationfor youth in general and special education(Weist, 1997)(Weist, 1997)
Positive Outcomes of ESMH Positive Outcomes of ESMH Programs are Being ShownPrograms are Being Shown
Outreach to under-served youthOutreach to under-served youth
Productivity of staffProductivity of staff
Cost-effectivenessCost-effectiveness
Improved satisfactionImproved satisfaction
Improved student outcomesImproved student outcomes
Improved school- and system- level outcomesImproved school- and system- level outcomes
But the movement toward ESMH is still in But the movement toward ESMH is still in the early phasesthe early phases
ESMH estimated to be in less than 10% of the ESMH estimated to be in less than 10% of the nation’s 114,000 schoolsnation’s 114,000 schools
A concerning trend toward clinics in schoolsA concerning trend toward clinics in schools
Funding remains limited and illness-focusedFunding remains limited and illness-focused
Evaluation
Stable
Funding
EmpiricallySupportedTreatments
Building Programson Assets
QualityAssurance
Bridging Scienceand Practice
IntegratingPrevention
Developing andMaintainingCommunitySupport
Training Issues
AdolescentIssues
ProgramDevelopment
UniqueLegal/Ethical
StakeholderInvolvement
CulturalSensitivity
Violence Related
Crisis Intervention
FamilyInvolvement
ESMH
Need Assessment/Resource Mapping
Major Categories of Work to Advance Major Categories of Work to Advance Mental Health in SchoolsMental Health in Schools
Raising awareness of unmet youth mental Raising awareness of unmet youth mental health needs and building advocacyhealth needs and building advocacy
Involving youth, families and other Involving youth, families and other stakeholdersstakeholders
Influencing policy and growing a diverse array Influencing policy and growing a diverse array of funding mechanismsof funding mechanisms
Applying new resources strategicallyApplying new resources strategically
Major Categories of Work IIMajor Categories of Work II
Enhancing methods of early identification and Enhancing methods of early identification and screeningscreening
Broadening and improving training at all Broadening and improving training at all levels and for diverse disciplineslevels and for diverse disciplines
Strengthening quality assessment and Strengthening quality assessment and improvement approachesimprovement approaches
Major Categories of Work IIIMajor Categories of Work III
Coordinating services in schools and making Coordinating services in schools and making progress toward true systems of careprogress toward true systems of care
Addressing areas of special needAddressing areas of special need
Emphasizing prevention and broad efforts to Emphasizing prevention and broad efforts to promote youth mental healthpromote youth mental health
Supporting, using, and building the evidence Supporting, using, and building the evidence base (Weist, Evans & Lever, 2003)base (Weist, Evans & Lever, 2003)
Media IssuesMedia Issues
Journalistic media pay very little attention to child Journalistic media pay very little attention to child and adolescent mental healthand adolescent mental health
Entertainment media present mental illness in a Entertainment media present mental illness in a “stereotypic and blatantly negative” light. Mentally “stereotypic and blatantly negative” light. Mentally ill are presented as “objects of amusement, derision ill are presented as “objects of amusement, derision or fear” (Granello & Pauley, 2002)or fear” (Granello & Pauley, 2002)
Many Relevant Training Many Relevant Training DimensionsDimensions
TURF is promotedTURF is promoted– training is usually discipline specifictraining is usually discipline specific– meetings are often discipline specificmeetings are often discipline specific– organizations often focus on advancing the organizations often focus on advancing the
disciplinediscipline
Training Dimensions 2Training Dimensions 2
Formal training programs do not reflect Formal training programs do not reflect realities occurring in the fieldrealities occurring in the field– disciplines are blending togetherdisciplines are blending together– subjective, passive approaches are less toleratedsubjective, passive approaches are less tolerated
Training Dimensions 3Training Dimensions 3
True interdisciplinary training for staff from True interdisciplinary training for staff from different disciplines and from different different disciplines and from different educational backgrounds does not often occureducational backgrounds does not often occur
Training of people who can play a huge role in Training of people who can play a huge role in improving systems of mental health promotion improving systems of mental health promotion is neglected (e.g., teachers, nurses, primary is neglected (e.g., teachers, nurses, primary care providers, family advocates)care providers, family advocates)
MEDICMEDIC
The Mental Health Education Integration The Mental Health Education Integration Consortium is seeking to:Consortium is seeking to:– improve pre-service, in-service and graduate improve pre-service, in-service and graduate
education for school-based professionals education for school-based professionals including: teachers, school administrators, student including: teachers, school administrators, student support staffsupport staff
Toward a True System of CareToward a True System of Care
Work in schools is well coordinatedWork in schools is well coordinated
School-based programs are connected to School-based programs are connected to outpatient centers, hospitals, residential outpatient centers, hospitals, residential treatment centers…treatment centers…
Systems (education, mental health, juvenile Systems (education, mental health, juvenile justice, child welfare, substance abuse…) are justice, child welfare, substance abuse…) are working well togetherworking well together
Major Approaches to Mental Major Approaches to Mental Health in SchoolsHealth in Schools
1. Enabling Framework 1. Enabling Framework
2. Other Education-Based 2. Other Education-Based
3. School-Based Health Centers3. School-Based Health Centers
4. Community Mental Health Center Outreach4. Community Mental Health Center Outreach
5. Private Practitioner Outreach5. Private Practitioner Outreach
6. Communities in Schools6. Communities in Schools
7. Research supported 7. Research supported (i.e., with all the associated (i.e., with all the associated resources of funded studies) resources of funded studies)
Effectiveness and SchoolEffectiveness and School Mental Health Mental Health
Status and presenting issues are much different Status and presenting issues are much different for approaches 1-6 (non research supported) for approaches 1-6 (non research supported) than for approach 7 (research supported)than for approach 7 (research supported)
Research Supported Programs and Research Supported Programs and Interventions in SchoolsInterventions in Schools
Key reviews underscoring effectiveness in Key reviews underscoring effectiveness in multiple domainsmultiple domains– emotional and social development (Durlak & emotional and social development (Durlak &
Wells, 1998; Rones & Hoagwood, 2000)Wells, 1998; Rones & Hoagwood, 2000)– youth development (Catalano et al., 1998)youth development (Catalano et al., 1998)– violence prevention (Elliot, 1998)violence prevention (Elliot, 1998)– drug prevention (Tobler et al., 2000)drug prevention (Tobler et al., 2000)– prevention of mental disorders (Greenberg, prevention of mental disorders (Greenberg,
Domitrovich & Bumbarger, 2001)Domitrovich & Bumbarger, 2001)
Characteristics of Effective ProgramsCharacteristics of Effective Programs (Greenberg, Domitrovich, & Bumbarger, 2001)(Greenberg, Domitrovich, & Bumbarger, 2001)
Theoretically based and developmentally Theoretically based and developmentally appropriate appropriate
Multiyear in duration and address a range of Multiyear in duration and address a range of risk and protective factors vs. unitary problem risk and protective factors vs. unitary problem behaviorsbehaviors
Target multiple domains (e.g., school, family) Target multiple domains (e.g., school, family) with an emphasis on changing environments as with an emphasis on changing environments as well as individualswell as individuals
Collaborative for Academic, Social and Collaborative for Academic, Social and
Emotional Learning (CASEL) ReviewEmotional Learning (CASEL) Review Key Competencies Trained in Universal SEL Key Competencies Trained in Universal SEL Programs in Schools:Programs in Schools:– Knowledge of self Knowledge of self – Caring for othersCaring for others– Responsible decision makingResponsible decision making– Social effectiveness (communication, building Social effectiveness (communication, building
relationships, negotiation, refusal, help seeking) relationships, negotiation, refusal, help seeking) (Payton et al., 2000) (Payton et al., 2000)
Social Skills Training in SchoolsSocial Skills Training in Schools(Quinn et al., 1999)(Quinn et al., 1999)
Meta-analysis of 35 studies with students with Meta-analysis of 35 studies with students with emotional/behavioral problems (EBP)emotional/behavioral problems (EBP)
““Results suggest that social skill interventions, Results suggest that social skill interventions, when used alone in small group settings, are when used alone in small group settings, are not very effective in increasing the social not very effective in increasing the social competence of students with EBP…Social competence of students with EBP…Social skill training may be more effective if skill training may be more effective if integrated across the school curriculum, on the integrated across the school curriculum, on the playground, and at home.”playground, and at home.”
Three Key Dimensions in Three Key Dimensions in Implementation Implementation (Graczyk et al., 2003)(Graczyk et al., 2003)
Characteristics of the interventionCharacteristics of the intervention– (program content, structure, timing, dosage; (program content, structure, timing, dosage;
quality of service delivery)quality of service delivery)
Training and technical supportTraining and technical support– (training and supervision models, implementer (training and supervision models, implementer
qualities)qualities)
Environmental conditionsEnvironmental conditions– (classroom, school, district, community factors)(classroom, school, district, community factors)
Moving Toward Evidence-Based Practice Moving Toward Evidence-Based Practice in the School Mental Health Movementin the School Mental Health Movement
Need to address realities:Need to address realities:– Approaches 1-6 are characterized by significant Approaches 1-6 are characterized by significant
variability in all dimensions variability in all dimensions – Effectiveness literature for school mental health Effectiveness literature for school mental health
programs and staffprograms and staff is very limited is very limited– Research and practice in the field remains largely Research and practice in the field remains largely
separatedseparated– In programs and in schools there is very little In programs and in schools there is very little
support for evidence-based practicesupport for evidence-based practice
Using the Evidence Base in Using the Evidence Base in ContextContext
Building Blocks for the Promotion of Mental Health in Schools
Awareness raising, advocacy, coalition building, policy change, enhanced funding
Adequate capacity
Staff and program qualities, school and community buy-in and involvement
Training, TA, ongoing support for the use of evidence-based programs and interventions
Effective programs and interventions
Positive Outcomesfor students, schools and communities
A Critical Need to Advance the A Critical Need to Advance the Quality AgendaQuality Agenda
Programs are doing very littlePrograms are doing very little
Research literature is limitedResearch literature is limited
What exists is painful, boring or bothWhat exists is painful, boring or both
Enhancing Quality in Expanded Enhancing Quality in Expanded School Mental HealthSchool Mental Health
Randomized controlled study to assess impacts Randomized controlled study to assess impacts of systematic quality improvement on clinician of systematic quality improvement on clinician behavior, satisfaction with services, and behavior, satisfaction with services, and student outcomesstudent outcomes
First experimental study of quality First experimental study of quality improvement in school mental healthimprovement in school mental health
Will provide guidelines for best practice and Will provide guidelines for best practice and will help to standardize practicewill help to standardize practice
Example Quality Principle and Example Quality Principle and IndicatorsIndicators
Principle # 3Principle # 3– Programs are implemented to address needs and Programs are implemented to address needs and
strengthen assets for students, families, schools strengthen assets for students, families, schools and communitiesand communities
Example IndicatorsExample Indicators– Have you conducted assessments on common risk Have you conducted assessments on common risk
and stress factors faced by students?and stress factors faced by students?– Are you developing programs to help students Are you developing programs to help students
contend with common risk/stress factors?contend with common risk/stress factors?
A Four-Pronged Approach to Evidence-A Four-Pronged Approach to Evidence-Based Practice in School Mental HealthBased Practice in School Mental Health
Decrease stress/risk factorsDecrease stress/risk factors
Increase protective factorsIncrease protective factors
Train in validated skillsTrain in validated skills
Implement manualized interventionsImplement manualized interventions– (see Schaeffer, 2002; Weist, 2003)(see Schaeffer, 2002; Weist, 2003)
Examples of Modifiable Examples of Modifiable Stress/Risk FactorsStress/Risk Factors
IndividualIndividual– low commitment to school, early school failure, low commitment to school, early school failure,
association with acting out peersassociation with acting out peers
FamilyFamily– marital discord, poor family managementmarital discord, poor family management
CommunityCommunity– poor housing, community disorganization poor housing, community disorganization
(Hawkins et al., 1992; Mrazek & Haggerty, 1994)(Hawkins et al., 1992; Mrazek & Haggerty, 1994)
Examples of Modifiable Protective FactorsExamples of Modifiable Protective Factors
Individual Individual – social competence, internal locus of control, social competence, internal locus of control,
reading for pleasurereading for pleasure
FamilyFamily– routines and rituals, parenting skills, parental routines and rituals, parenting skills, parental
responsivenessresponsiveness
CommunityCommunity– good schools, positive relationships with other good schools, positive relationships with other
adults adults (Hawkins et al., 1992; Mrazek & Haggerty, 1994)(Hawkins et al., 1992; Mrazek & Haggerty, 1994)
Validated SkillsValidated Skills
Relaxation trainingRelaxation training
Problem solvingProblem solving
Cognitive restructuringCognitive restructuring
Self-control trainingSelf-control training
Anger management trainingAnger management training
Social competence and resistance trainingSocial competence and resistance training– (see Christophersen & Mortweet, 2001)(see Christophersen & Mortweet, 2001)
Promoting the Use of Promoting the Use of Manualized InterventionsManualized Interventions
Choose a program that matches the needs of Choose a program that matches the needs of the school and can be implementedthe school and can be implemented
Promote and maintain school and staff buy-inPromote and maintain school and staff buy-in
Ensure environmental receptiveness, adequate Ensure environmental receptiveness, adequate infrastructure, and training and technical infrastructure, and training and technical assistanceassistance
Examples of Universal InterventionsExamples of Universal Interventions(from Schaeffer, 2002)(from Schaeffer, 2002)
Promotion of Social and Emotional Promotion of Social and Emotional CompetenceCompetence– I Can Problem Solve (Spivak & Shure)I Can Problem Solve (Spivak & Shure)– Promoting Alternative Thinking Strategies Promoting Alternative Thinking Strategies
(Greenberg)(Greenberg)– Skillstreaming (Goldstein)Skillstreaming (Goldstein)
High Risk BehaviorsHigh Risk Behaviors– Life Skills Training (Botvin)Life Skills Training (Botvin)– Project ALERT (Ellickson)Project ALERT (Ellickson)
Examples of Selected InterventionsExamples of Selected Interventions(from Schaeffer, 2002)(from Schaeffer, 2002)
DepressionDepression– Adolescent Coping with Stress Course (Lewinsohn)Adolescent Coping with Stress Course (Lewinsohn)– Penn Optimism Program (Reivich)Penn Optimism Program (Reivich)
AnxietyAnxiety– Friends (Bartlett)Friends (Bartlett)
Aggressive BehaviorAggressive Behavior– Coping Power (Lochman)Coping Power (Lochman)– Reconnecting Youth (Herting & Eggert)Reconnecting Youth (Herting & Eggert)
Examples of Indicated InterventionsExamples of Indicated Interventions(from Schaeffer, 2002)(from Schaeffer, 2002)
AnxietyAnxiety– Coping Cat (Kendall)Coping Cat (Kendall)
DepressionDepression– Adolescent Coping with Depression Course Adolescent Coping with Depression Course
(Lewinsohn)(Lewinsohn)
ADHDADHD– CBT for Impulsive Children (Kendall & Braswell)CBT for Impulsive Children (Kendall & Braswell)
Oppositional and Conduct DisordersOppositional and Conduct Disorders– Defiant Children (Barkley)Defiant Children (Barkley)
The Optimal School Mental Health The Optimal School Mental Health Continuum?Continuum?
10-20% Broad Environmental Improvement 10-20% Broad Environmental Improvement and Mental Health Promotionand Mental Health Promotion
50-60% Prevention and Early Intervention50-60% Prevention and Early Intervention
20-30% Intensive Assessment and Treatment20-30% Intensive Assessment and Treatment
Youth Mental Health Services Youth Mental Health Services in Most Communitiesin Most Communities
Primary Secondary Tertiary
Education - - - - - - - -
M. Health - - - - - - - -
Pub. Health
The VisionThe Vision
Primary Secondary Tertiary
Education -------------- -------------- --------------
M. Health --- -------------- --------------
Pub. Health --------------
Deciding on Roles in a SchoolDeciding on Roles in a School(no stereotyping intended)(no stereotyping intended)
Primary Secondary Tertiary
Sch. Psy. XOXOXO XXXXXX XX
Sch. SW. XOXOXO XXXXXX
Sch. Co. XOX0 OOO
Com. St. XO OOOOOO OOOOOOREG.ED=O SPEC.ED=X
To Move Toward This Continuum To Move Toward This Continuum We Need To Address The We Need To Address The
Over-Reliance On Fee-For-ServiceOver-Reliance On Fee-For-Service
Need to diagnoseNeed to diagnose
Significant bureaucracySignificant bureaucracy
Limits on productivityLimits on productivity
Contingencies to hold on to youth and families Contingencies to hold on to youth and families who show up and can paywho show up and can pay
Toward Funding for a Full Continuum of Toward Funding for a Full Continuum of Programs and ServicesPrograms and Services
Maximizing all potential sources of revenue:Maximizing all potential sources of revenue:– allocations from schools and departments of allocations from schools and departments of
educationeducation– state and local grants and contractsstate and local grants and contracts– federal and foundation grants and contractsfederal and foundation grants and contracts– innovative prevention fundinginnovative prevention funding– fee-for-servicefee-for-service
Under-Explored Funding Under-Explored Funding ApproachesApproaches
Early Periodic Screening Diagnosis and Early Periodic Screening Diagnosis and Treatment (EPSDT)Treatment (EPSDT)
Transitional Assistance for Needy Families Transitional Assistance for Needy Families (TANF)(TANF)
Safe and Drug Free Schools fundsSafe and Drug Free Schools funds
ESMH Funding in BaltimoreESMH Funding in Baltimore
Significant expansion of the Medicaid in Significant expansion of the Medicaid in Schools billing office of the City School Schools billing office of the City School SystemSystem
Protecting $1.6 million in revenue for Protecting $1.6 million in revenue for contracting with community providerscontracting with community providers
Other contracting mechanismsOther contracting mechanisms
Billing by community providersBilling by community providers
““Community Support and Prevention”Community Support and Prevention”
The Baltimore Experience:The Baltimore Experience:Key IngredientsKey Ingredients
Strong leadershipStrong leadership
A commitment to children A commitment to children
Vigorous nonacceptance of Vigorous nonacceptance of Same Old Same OldSame Old Same Old
History in school healthHistory in school health
Funding experience and perseveranceFunding experience and perseverance
Interdisciplinary networksInterdisciplinary networks
Political will and activismPolitical will and activism
Centers for Mental Health in Centers for Mental Health in SchoolsSchools
Supported by the Office of Adolescent Health, Supported by the Office of Adolescent Health, Maternal and Child Health Bureau, Health Resources Maternal and Child Health Bureau, Health Resources and Services Administration; and Services Administration;
With co-funding from the Center for Mental Health With co-funding from the Center for Mental Health Services, Substance Abuse and Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health Services Administration, U.S. Department of Health and Human Services. and Human Services.
UCLA Center for Mental UCLA Center for Mental Health in SchoolsHealth in Schools
Directed by Howard Adelman and Linda Directed by Howard Adelman and Linda TaylorTaylor
Phone: 310-825-3634Phone: 310-825-3634
Enews: [email protected]: [email protected]
web: http://smhp.psych.ucla.eduweb: http://smhp.psych.ucla.edu
University of MarylandUniversity of MarylandCenter for School Mental Health AssistanceCenter for School Mental Health Assistance
Provide technical assistance and consultationProvide technical assistance and consultation
Provide national training and educationProvide national training and education
Disseminate and develop knowledgeDisseminate and develop knowledge
Promote communication and networkingPromote communication and networking– phone: 410-706-0980 (888-706-0980 toll free)phone: 410-706-0980 (888-706-0980 toll free)
– email: [email protected]: [email protected]
– web: http://csmha.umaryland.eduweb: http://csmha.umaryland.edu
ReferencesReferences
Catalano, R.F., Berglund, M.L., Ryan, J., Lonczak, H.C., & Hawkins, J.D. Catalano, R.F., Berglund, M.L., Ryan, J., Lonczak, H.C., & Hawkins, J.D. (1998). Positive youth development in the United States: Research findings (1998). Positive youth development in the United States: Research findings on evaluations of positive youth development programs (NICHD on evaluations of positive youth development programs (NICHD publication). Washington, DC: U.S. Department of Health and Human publication). Washington, DC: U.S. Department of Health and Human Services.Services.
Christophersen, E.R., & Mortweet, S. (2001). Treatments that work with Christophersen, E.R., & Mortweet, S. (2001). Treatments that work with children. Washington, DC: American Psychological Association. children. Washington, DC: American Psychological Association.
Durlak, J.A., & Wells, A.M. (1998). Evaluation of indicated prevention Durlak, J.A., & Wells, A.M. (1998). Evaluation of indicated prevention (secondary prevention) mental health programs for children and (secondary prevention) mental health programs for children and adolescents. American Journal of Community Psychology, 26, 775-802.adolescents. American Journal of Community Psychology, 26, 775-802.
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References 2References 2
Greenberg, M.T., Domitrovich, C., & Bumbarger, B. (2001). Preventing Greenberg, M.T., Domitrovich, C., & Bumbarger, B. (2001). Preventing mental disorder in school-aged children: Current state of the field. mental disorder in school-aged children: Current state of the field. Prevention & Treatment, 4, 1-64. Prevention & Treatment, 4, 1-64.
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Hawkins, J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and protective Hawkins, J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64-105.Bulletin, 112, 64-105.
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Weist, M.D. (1997). Expanded school mental health services: A national Weist, M.D. (1997). Expanded school mental health services: A national movement in progress. In T. Ollendick, & R. Prinz (Eds.), Advances in movement in progress. In T. Ollendick, & R. Prinz (Eds.), Advances in Clinical Child Psychology, Volume 19 (pp. 319-352).Clinical Child Psychology, Volume 19 (pp. 319-352).
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Weist, M.D., Evans, S.W., & Lever, N. (2003). Advancing mental health Weist, M.D., Evans, S.W., & Lever, N. (2003). Advancing mental health practice and research in schools. In M. Weist, S. Evans, N. Lever (Eds.), practice and research in schools. In M. Weist, S. Evans, N. Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp. Handbook of school mental health: Advancing practice and research (pp. 1-8). New York: Kluwer Academic/Plenum Publishers. 1-8). New York: Kluwer Academic/Plenum Publishers.