what is - pbis · what is “school based ... acute bronchitis

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What is What is “School Based Mental Health?” “School Based Mental Health?”

and What do we know?and What do we know?

Krista Kutash, Professor Emeritus, USFDenver, Colorado March 2012 1

Topics of DiscussionTopics of Discussion

• How many children?

• What does treatment cost?

• How are we doing?

• What do we know about services and treatment?

• Trends and challenges

in the field

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Seriousness of the ProblemSeriousness of the Problem

Prevalence of Serious Emotional Disturbance (SED)

Population Proportions (9 to 17 year‐olds)

5‐9% Youth with SED & extreme functional impairment

9‐13% Youth with SED, h b l

5‐9%

3

20%

9‐13%

with substantial functional impairment

20% Youth with any diagnosable disorder

5 Most Costly Children’s Health Conditions 5 Most Costly Children’s Health Conditions (MEPS, 2009: (MEPS, 2009: noninstitutionalizednoninstitutionalized children)children)

C di i Child T t d C tConditions Children Treated Cost

Mental Disorders 4.6M $8.9B

Asthma 13 M $8.0B

Trauma‐related Disorders 7 M $6.1B

4

Acute Bronchitis 12.8 M $3.1B

Infectious Diseases 4.5M $2.9B

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What do we know and What do we know and What have we learned?What have we learned?

Children and youth who have Serious EmotionalChildren and youth who have Serious Emotional Disturbances have deficits in multiple domains (social, emotional and behavior) and are often served in multiple systems simultaneously (MH, Education, JJ and Child Welfare).

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Typical Mental Health Services to Children Typical Mental Health Services to Children in Child Welfare are Often Ineffective in Child Welfare are Often Ineffective

McCrae, JS, Guo, S & Barth, RP. (2010). Changes in maltreated children's emotional‐behavioral problems following typically provided mental health services. American Journal of Orthopsychiatry. 80(3):350.

• For those children involved h h ld lf d

Borderline or Clinical Behavioral Health bl h ld h ld with child welfare and receiving

MHS, this study was not able to show a positive relationship between MHS and changes in children’s behavior across time.

• The study should not be understood to indicate that all MHS for children involved with CWS i ff ti th it25%

50%75%100%

Problems among Children Receiving Child Welfare Services, with and without Mental Health Services

CWS are ineffective; rather, it indicates that children do not predictably receive services that are sufficient to help them overcome their behavioral difficulties.

From: Clare Anderson, ACYF 6

0%25%

Did not receive mental health services

Received mental mealth services

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Serious Youth Offender Study: Serious Youth Offender Study: Substance Abuse And ReoffendingSubstance Abuse And Reoffending

(Schubert , (Schubert , MulveyMulvey, & , & GlasheenGlasheen, 2011) , 2011)

• N= 1 354 felony youth offenders Phoenix• N= 1,354 felony youth offenders, Phoenix and Philadelphia

• 8 year study (21,000 interviews)

• Mental health disorder alone does not affect time in gainful activity (school/work) d ff diand re‐offending

• Substance use disorder significantly contributes to re‐arrest over 6 years and less time in gainful activity

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Serious Youth Offender Study: Serious Youth Offender Study: Substance Abuse And ReoffendingSubstance Abuse And Reoffending

((MulveyMulvey, 2011) , 2011)

• No benefit from longer lengths of institutional o be e t o o ge e gt s o st tut o astay to rate of re‐arrest

• “The good news, however, is that treatment appears to reduce both substance use and offending, at least in the short term. Youth whose treatment lasted for at least 90 days ose ea e as ed o a eas 90 daysand included significant family involvement showed significant reductions in alcohol use, marijuana use, and offending over the following 6 months.“ E. Mulvey, March 2011

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What do we mean by Trauma? What do we mean by Trauma?

• Event(s) Exposure to violence, victimization including sexual physical abuse severe neglect lossincluding sexual, physical abuse, severe neglect, loss, domestic violence, witnessing of violence, disasters

• Experience Intense fear of/ threat to physical or psychological safety and integrity, helplessness; intense emotional pain and distress

• Effects Stress that overwhelms capacity to cope and manifests in physical, psychological, and neuro‐physiological responses

Gene Griffin, PhD, 2012, 3E’s

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Trauma and Youth Trauma and Youth • Among U.S. Youth:

• 60% exposed to violence within past year

• 8% report lifetime prevalence of sexual assault

• 17% report physical assault

• 39% report witnessing violence

• Survey of adolescents in SU treatment > 70% had history of trauma exposure (Suarez, 2008)

• Childhood traumas potentially explain 32% of psychiatric disorders in adulthood

Archives of General Psychiatry, Feb 2010, NCRS‐R Study

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NLTS and NLTS2 OverviewNLTS and NLTS2 Overview

NLTS NLTS2

Focuses on Youth and young adults Youth and young adultsFocuses on Youth and young adults Youth and young adults

Study began 1987 2001

Age at start of study 13 to 21 13 to 16

Disability categories All disability categories All disability categories

Longitudinal7 years 10+ years

Longitudinal2 waves of data over 4 years 5 waves of data over 9 years

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High school academic outcomes of High school academic outcomes of students with EBD (1987 and 2003)students with EBD (1987 and 2003)

• The percentage earning “mostly As and Bs”• The percentage earning mostly As and Bs increased from 21% to 47%.**

• The high school completion rate increased from 39% to 56%.*

• The percentage suspended for 1 or 2 days increased from 2% to 11%** and averageincreased from 2% to 11% and average days absent in a 4‐week period increased from 1.9 to 3.1.**

* p < .05; ** p < .01. SOURCE: U.S. Department of Education, Office of Special Education Programs, National Longitudinal Transition Study (NLTS), Wave 1 parent interviews, 1987; U.S. Department of Education, Institute of Education Sciences, National Center for Special Education Research, National Longitudinal Transition Study‐2 (NLTS2), Wave 2 parent interviews and youth interviews/surveys, 2003.

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Postsecondary school enrollment Postsecondary school enrollment (1990 and 2005) (1990 and 2005)

18%Any post

Young adults with EBD attended Percentage‐point difference

+17**

21%

21%

35%

7%

10%

Vocational, business, technical

school

2‐year/community college

secondary school +17**

+11

+17***

13

6%1%4‐year college

1990 2005

** p < .01; *** p < .001. SOURCES: U.S. Department of Education, Office of Special Education Programs, National Longitudinal Transition Study (NLTS), Wave 2 parent interviews 1990; U.S. Department of Education, Institute of Education Sciences, National Center for Special Education Research, National Longitudinal Transition Study‐2 (NLTS2), Wave 3 parent interviews and youth interviews/surveys, 2005.

+5

Community participation Community participation (1990 and 2005) (1990 and 2005)

23%14%Belonged to a

community

Young adults with EBD Percentage‐point difference

+9

69%

65%

24%

23%

50%

59%

11%

Were registered to vote

Had a driver's license

Participated in volunteer or …

community …

+13

+6

+19**

14

61%36%Were ever

arrested

1990 2005

** p < .01; *** p < .001. SOURCES: U.S. Department of Education, Office of Special Education Programs, National Longitudinal Transition Study (NLTS), Wave 2 parent interviews 1990; U.S. Department of Education, Institute of Education Sciences, National Center for Special Education Research, National Longitudinal Transition Study‐2 (NLTS2), Wave 3 parent interviews and youth interviews/surveys, 2005.

+25***

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What are the evidenceWhat are the evidence‐‐based based mental health treatments? mental health treatments?

• 140 new randomized clinical trials since• 140 new randomized clinical trials since 2002 (almost doubled the total number of RCTs).

• Chorpita and Colleagues (2011) reviewed 435 studies on mental health treatments.

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What worksWhat works? Evidence? Evidence‐‐based based treatments for disruptive treatments for disruptive behaviorbehavior

23 different treatment h ith tapproaches with some support

Approaches with most support:

•Multisystemic Therapy (MST) / Cognitive Behavior Therapy

•Parent Management Training•Parent Management Training

• Social Skills & Assertiveness Training, Anger Control

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What works? EvidenceWhat works? Evidence‐‐based treatments based treatments for Attention and Hyperactivity:for Attention and Hyperactivity:

• Self Verbalization Skills• Self Verbalization Skills

• Behavior Therapy plus medication

• Parent Management Training

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Overall Overall

• Evidence‐based MH treatments are made up of an array of approaches that made up of an array of approaches that • Build skills in student

• Build skills in parents

• Build a relationship between student and an adult who reinforces new skills acquired by students and can work with parents.

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C t fCenter for School Mental Health

University of Maryland

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National Registry of EvidenceNational Registry of Evidence‐‐Based Practices Based Practices

• “NREPP is a searchable online registry of more than 220 interventions supporting mental health promotion, pp g p ,substance abuse prevention, and mental health and substance abuse treatment (for youth and adults). We connect members of the public to intervention developers so they can learn how to implement these

approaches in their communities.”•http://www.nrepp.samhsa.gov/http://www.nrepp.samhsa.gov/•See list of Programs from NREPP in School‐based Mental Health

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Institute for Educational SciencesInstitute for Educational Sciences

Wh t W k• What Works Clearinghouse

• Behavior Guide

• Research Reports on Interventions– First Steps to SuccessFirst Steps to Success

– Check and Connect

– Incredible Years

• Funding of Studies– CBITS

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Trends in the fieldTrends in the field

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Entry Multiple Entry PointsCommon Assessment Elements

Crisis Services

Is this child in crisis?

OutpatientAssessmentD thi hild

No

Yes


Crisis Services



No

Yes

Yes

NoCase Manager Selected

Case Manager with family, identifies key people to participate in team meeting

Yes

Crisisstabilized,

refer for otherservices

Assessment& Treatment

Is problem solved?

Does this childrequire a complex

intervention? No

Yes



Yes

Crisisstabilized,



Is problem solved?


intervention? No

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No orPartially

ExitSystem

Develop & implement modified plan

Convening of team meeting, including family,members of natural support system and representatives of relevant

programs and systems, to develop individualized plan

Was the plan successful? Yes

Opportunity to implement evidence based intervention

No orPartially

ExitSystem







Crisis Services



No

Yes


Crisis Services



No

Yes

Yes



Yes

Crisisstabilized,



Is problem solved?


intervention? No

Yes



Yes

Crisisstabilized,



Is problem solved?


intervention? No

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No orPartially

ExitSystem






No orPartially

ExitSystem






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•• 1/3 of school districts 1/3 of school districts report that they exclusively use school‐ or district‐based staff to provide mental h lth i

How many schools have MH How many schools have MH resources? resources?

(Foster et al., 2005)(Foster et al., 2005)

health services

•• 1/4 of school districts 1/4 of school districts onlyonly use outside agencies for the provision of mental health services

•• 2% of school districts 2% of school districts reported they operated their own mental health unit or clinic

59% f h l59% f h l t i i l b d

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•• 59% of schools 59% of schools report using curriculum‐based programs to enhance social and emotional functioning and reduce barriers to learning

•• 78% provide 78% provide school‐wide strategies to promote safe, drug free schools

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Tested four models of SchoolTested four models of School‐‐based Mental based Mental Health that served with youth who have SED Health that served with youth who have SED

and educated in Special Ed classroomsand educated in Special Ed classrooms

• Pull‐out 2 – Contracted with MH counselor from• Pull out 2 Contracted with MH counselor from Community Agency

• Pull‐Out 1 – Hired as School employees MH counselors

• Integrated 1 – PBS and Wraparound Process

I t t d 2 MH/ED l ithi l• Integrated 2 – MH/ED classrooms within regular schools operated by intermediate unit.

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Effect sizes Effect sizes for emotional for emotional functioning, functional impairment, & functioning, functional impairment, & achievement.achievement.

0 6

0.8

‐0.2

0

0.2

0.4

0.6

Integrated 1Integrated 2

Effect Size

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‐0.4

0.2 Integrated 2Pull‐Out 1

Pull‐Out 2

Emotional Functioning Functional Impairment Reading Math

Program

Kutash, K., Duchnowski, A.J., Green, A.L. (2011). School-based mental health programs for students who have emotional disturbances: Academic and social-emotional outcomes. School Mental Health. 3,191-208.

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Wraparound Wraparound

• National Wraparound Initiative• National Wraparound Initiative

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Wraparound… An Wraparound… An ArtArt

Values Based Wraparound Process

Wraparound… An Art Wraparound… An Art andand ScienceScience

Family‐Centered, Flexible, Strengths‐Based

ANDEvidence Based InterventionsScience of Behavior ChangeScience of Behavior Change

Effective Clinical and Academic Interventions [(e.g., Medication, CBT) e.g., DI]

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Model for Schools Model for Schools ED MH Families

• Consultation on

Universal• Primary role is building school‐wide support

identifying target behaviors

• Provide mental health promotion

• Be aware of and support school programs

Selective/ Targeted

• Conduct FBA• Facilitate team meetings

• Monitor progress

• Enhance assessment with psychological evaluation

• Provide evidence‐based interventions

• Provide information• Identify strengths in home setting

• Provide information,

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Intensive/ Indicated

• Conduct FBA• Report on progress• Facilitate team meeting

• Monitor progress

• Psychological assessment• Evidence‐based intervention

o de o a o ,• Express opinions about needed intervention

• Support intervention at home

• Be engaged

• Figure 4 in Blue Book

Common Vision

Families (FAM)Mental Health (MH)Education (ED)

IntensiveStudents in

Special Ed due to Emotional Disturbances

ED – FBA / PBS

UniversalAll Students

ED – PBS

MH - Screening

FAM

SelectiveAt-Risk Students

ED – FBA / PBS

MH – Assessment

FAMFigure 4 in Blue Book MH – Assessment

FAMEDMH

Cognitive Behavior Therapy and other EBPs

FAMED MH

EBP’s (PATHS)

FAMEDMH

MHED

ED

Group Interventions

Team Monitors

RtI

3636

EDFAMMH

Team Monitors Progress

MHFAM

Team Monitors ProgressImplemented

in organizationsthat support and facilitatecollaborative, integrated

systems of services.Integrated Partnership

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Model of Implementation ComplexityModel of Implementation Complexity

FIT

Does the

CLIMATE

Willing to

IMPLEMENTATION EFFECTIVENESS

INNOVATION EFFECTIVENESSDoes the

innovation fit within your

organization

Complement or Compete?

Willing to remove

obstacles?

Are there rewards?

Leadership support?

Can you implement the innovation with

accuracy and fidelity?

Impact of innovation, commit

ment, and satisfaction

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Clarity of Goals?

VOLITIONVOLITION

Is there capacity and Is there capacity and willingness to implement?willingness to implement?

FIDELITY BELIEFSFIDELITY BELIEFS

Favorable attitudes toward Favorable attitudes toward practice Complexity of innovatipractice Complexity of innovationon

“The earmark of a quality program or organization is that it has the capacity to get & use information for continuous improvement and accountability. No program, no matter what it does, is a good p g , , gprogram unless it is getting and using data of a variety of sorts, from a variety of places, and in an ongoing way to see if there are ways it can do better.”

– Weiss, 2002

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Refocus School‐Based Mental Health Services Focus On the Core Foundation of Schools:To Promote LearningTo Promote Learninggg

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School Based Mental Health School Based Mental Health

Krista Kutash, Professor Emeritus, USFDenver, Colorado March 2012 40

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Other Resources

For more information contact:

Krista Kutash, [email protected]

Atkins, M., Hoagwood, K., Kutash, K., & Seidman, E. (2010). Toward the Integration of Education and Mental Health in Schools. Administration and Policy in Mental Health Services Research, 37, 40‐47

Cappella, E., Frazier, S. L., Atkins, M. S., Schoenwald, S. K., & Glisson, C. (2008). Enhancing Schools’ Capacity to Support Children in Poverty: An Ecological Model of School‐Based Mental Health Services. Adm Policy M H l h 35 395 409Ment Health, 35, 395‐409.

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School-Based Mental Health: An Empirical Guide for Decision-Makers

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Krista Kutash, Ph.D., Albert J. Duchnowski, Ph.D., Nancy Lynn, M.S.P.H.

This monograph provides a discussion of barriers to school-based services with the intention of improving service effectiveness and capacity. Reviews the history of mental health services supplied in schools, implementation of serviced, and provides an overview of the evidence base for school-based interventions. Includes: recommendations for evidence-based mental health services in schools.

Download a free copy at: http://rtckids.fmhi.usf.edu/rtcpubs/study04/Or purchase a printed copy for $5.95 at https://fmhi.pro-copy.com/

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Kutash, K., Duchnowski, A.J., Green, A.L. (2011). School-based mental health programs for students who have emotional disturbances: Academic and social-emotional outcomes. School Mental

l h 3( ) 191 208Health, 3(4), 191-208.

Kutash, K., Duchnowski, A.J., Green, A.L., & Ferron, J. (2011). Supporting parents who have youth with emotional disturbances through a parent-to-parent support program: A proof of concept study using random assignment. Administration and Policy in Mental Health and Mental Health Services Research, 38, 412-427

Kutash, K., Cross, B., Madias, A., Duchnowski, A., & Green, A. (2012) Description of a Fidelity Implementation System: An Example

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(2012). Description of a Fidelity Implementation System: An Example from a Community-based Children’s Mental Health Program. Journal of Child and Family Studies.

To download and print – free:

http://ies.ed.gov/ncee/wwc/publications/practiceguides

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