Comprehensive Children’s Schools and Communities€¦ · Comprehensive children’s mental health services in schools and communities : a public health problem-solving model / Robyn

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Comprehensive Children’sMental Health Services inSchools and Communities

Robyn S. Hess � Rick Jay Short � Cynthia E. Hazel

��

A Public Health Problem-Solving Model

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Library of Congress Cataloging-in-Publication Data

Hess, Robyn.

Comprehensive children’s mental health services in schools and communities : a

public health problem-solving model / Robyn S. Hess, Rick Jay Short & Cynthia E.

Hazel.

p. cm.

Summary: “In this text, the authors propose a public health model for

comprehensive children’s mental health services that encompasses, rather than

replaces, the traditional model in school psychology”-- Provided by publisher.

Includes bibliographical references and index.

ISBN 978-0-415-80448-6 (hardback) -- ISBN 978-0-415-80449-3 (paperback)

1. Child mental health services. I. Short, Rick Jay. II. Hazel, Cynthia E. III. Title.

RJ499.H55 2012

618.92’89--dc23 2011038066

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vii

Contents

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ixList of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiSeries Editors’ Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

SECTION I Reconceptualizing Our Work

Chapter 1 Intersection of Public Health, Children’s Mental Health, and School Psychology . . . . . . . . 3

Chapter 2 The Continuum of Services Within a Public Health Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 3 Building Capacity Through Collaboration and Coalition Building . . . . . . . . . . . . . . . . . . . . 43

SECTION II Public Health Problem-Solving Model

Chapter 4 Problem Identification Through Applied Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Chapter 5 Problem Analysis of Risk Factors and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 6 Defining Risk and Protective Factors in Child–Environment Interactions . . . . . . . . . . . . 79

Chapter 7 Ecological Plan Implementation. . . . . . . . . . . . . 89

Chapter 8 Monitoring and Evaluating Outcomes . . . . . . . 101



viii Contents

SECTION III From Concept to Action

Chapter 9 Case Study in Public Health Problem-Solving 113

Chapter 10 Changing Role of School Psychologists . . . . . . 129

Chapter 11 Sustaining Change in the Public Health Problem-Solving Model. . . . . . . . . . . . . . . . . . . 147

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

CD Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189



3

One

Intersection of Public Health, Children’s Mental Health, and School Psychology

Imagine a pediatric health care system where nobody receives treatment until their physical state is so bad that they are incapacitated. No checkups, no diagnosis or

treatment of minor symptoms, no visits to the doctor’s office. Symptoms that might indicate a more serious condition are ignored, covered up with a bandage, or dismissed as grow-ing pains or laziness or immaturity. When illnesses are finally diagnosed, they have become so severe and disruptive that patients must be removed from their normal environment and placed in hospitals for intensive care—but only after diabe-tes has been diagnosed or a life-threatening asthma attack has occurred. In this system, insurance companies and caregivers are not concerned about routine wellness checks to monitor growth, there are no vaccines, and families are not informed that these things could be related to problems later on. No edu-cation about healthy diet and exercise is provided, and there are no walking trails, fun runs, or nutrition programs. Instead, the only approach is to treat those individuals who demon-strate such advanced and chronic levels of disease that their lives, and those of their families, are disrupted.

In many ways, this scenario describes our present approach to addressing children’s mental health needs. Every day, chil-dren come to school unable to focus on academics because of family and peer conflict, environmental stressors, and increas-ing rates of mental health problems. According to a report from the U.S. Department of Health and Human Services (1999), about 20% of children will experience some sort of



4 Comprehensive Children's Mental Health Services

mental health problem in a given year. Of the children who will receive mental health services, the majority will receive them within the school setting (Burns et al., 1995). As in our example described above, most of these problems will have a significant effect on children’s quality of life and educational outcomes but won’t be recognized or treated until they become so problematic that they disrupt lives. Children who ultimately exhibit severe educational, behavioral, or emotional difficul-ties typically receive no formal recognition or help until their problems have forced them into failure.

There is a growing recognition that we cannot provide effective support services by waiting until each child, one child at a time, succumbs to the weight of educational and mental health problems and fails. This recognition has led to the consideration of alternative methods of service delivery. In fact, one of the pervasive themes of the 2001 Conference on the Future of School Psychology was the need for compre-hensive, integrated services that promote positive outcomes and prevent problems (Cummings et al., 2004; Dawson et al., 2004). We cannot deal with significant problems of childhood and adolescence by waiting for them to become so severe that lives are disrupted and expensive specialized services are required. We must consider ways in which our schools can foster the adaptive functioning and social-emotional growth of all children. We must develop effective systems for recog-nizing and dealing with early signs of developing problems as they occur in schools and communities before they result in failure and disruption. To do so, we must think about our roles differently and consider how we can create the broadest level of service delivery through our own services and through our collaboration with others (Sheridan & Gutkin, 2000). Systemic approaches such as primary prevention programs and school-community linkages help to ensure that services are provided to all students.

RECONCEPTUALIZING SCHOOL-BASED MENTAL HEALTH SERVICES

Accomplishing this goal will probably require a significant reconceptualization of school psychological services as they relate to children’s mental health (Sheridan & Gutkin, 2000). In this book, we propose a reconceptualization of services from the deficit-centric, late-intervention orientation associated



5Public Health, Children’s Mental Health, and School Psychology

with the traditional clinical model to a more systemic, compre-hensive perspective that comprises the public health model. Mainstream school psychology presently reflects a variant of the traditional clinical model, wherein services typically are delivered to individual children who have been identified as having a problem. By definition, the problem resides within the child; treatment focuses on changing the child’s charac-teristics to resolve the problem. Although efficient in directing services toward those who need them, this model is reactive and weakness oriented. It fails to recognize and address envi-ronmental and systemic contributors to problem behaviors and generally initiates interventions late in the development of these problems.

One approach that holds promise for meeting this difficult goal incorporates a systemic, preventive approach while provid-ing resources to address a broad range of mental health needs. Nastasi (2004) and others have advocated for conceptualizing school mental health from a public health model, specifically, a model in which mental health is considered to be an issue of health and services are directed toward populations rather than individuals. The U.S. Department of Health and Human Services (1999) supports an approach that emphasizes screening of the general population, provides prevention and mental health pro-motion, increases access to services for all, attends to environ-mental resources, and evaluates services. A public health model promotes the idea of a continuum of services available to meet the broadest needs, with an emphasis on prevention.

DEFINING PUBLIC HEALTH

When people think of public health, they often consider poli-cies related to clean air and water, or perhaps they envision a dramatic public service announcement or a local campaign encouraging children to wear bike helmets. These examples are part of the services of public health. There is no agreed-upon definition of public health; however, in the document titled The Future of Public Health (Institute of Medicine, 1988), public health is defined as “what society does collectively to assure the conditions for people to be healthy” (p. 1). Public health can also be viewed as a social movement. For example, Dan E. Beauchamp (1976), a professor and philosopher on pub-lic health, wrote that “public health should be a way of doing justice, a way of asserting the value and priority of all human life” (p. 8).




These broad statements capture one of the key ideas of public health. The focus is on the population rather than the person. When the emphasis is placed on meeting the needs of many rather than a few, change must occur in the envi-ronment. Further, a public health model focuses on preven-tion and promotion of positive outcomes. To best understand where there is a need from a public health-based approach, population-based assessments are carried out. These assess-ments not only help to pinpoint in which areas intervention is most needed, but they also help to identify the determi-nants of health. According to Miles, Esperitu, Horen, Sebian, & Waetzig (2010), “determinants are malleable factors that are part of the social, economic, physical, or geographical envi-ronment, can be influenced by policies and programs, and contribute to the good and poor health of a population in order to determine which factors, if modified, would lead to positive outcomes” (p. 40).

A public health model also refers to a process for address-ing health-related needs within a community. As noted above, assessment is key and is considered a core function in this process. The second core function is policy development. In a school setting, this second component might include both policy development and intervention/prevention implementa-tion. For example, if school leaders decide that a healthy life-style program is to be included as part of the broader academic curriculum, that reflects policy development. The program-ming delivered in each setting (e.g., physical education classes, nutrition awareness programs) is considered the intervention.

The final core function, assurance, refers to the idea that whatever is put in place, the policy and/or the intervention, is actually carried out. This general process should seem famil-iar; both problem-solving and public health models include efforts to define an issue or a problem, to create an interven-tion, and to ensure that it has been implemented with fidelity.

Within a public health model, there are also a number of steps within each of these broad core functions or actions that provide further guidance on the process for addressing an issue. These steps are referred to as the Ten Essential Services and define each of these functions in an operationalized man-ner (Miles et al., 2010). Table 1.1 provides the essential services associated with each core function.

From a public health perspective, prevention planning is accomplished through information and empowerment, the training of caregivers and service providers, coordination of




services, and policy and advocacy actions. However, there are other available frameworks that allow us to focus even more broadly in our systemic change efforts. These other frameworks are similar to a public health model in that they outline levels and strategies for building a coalition, empowering stakehold-ers, and advocating and impacting public policy. Even though these models have been developed and implemented in differ-ent contexts (e.g., schools, community), each of them covers similar concepts. We refer interested readers to the works of Cohen and Swift (1999), Dowrick (1998), and Nastasi (2004).

CD Activity 1.1 invites readers to consider their practices and perspectives on children’s mental health as related to their own settings.

CURRENT APPROACHES TO ADDRESSING CHILDREN’S MENTAL HEALTH IN THE SCHOOLS

To accompany our new approach, we need to define what we mean by children’s mental health. Historically, we have not had a clear vision for what constitutes mental health and instead have defined it as the absence of disorder (Doll & Yoon, 2010). In this work, we have adopted the definition provided in the Surgeon General’s Report (U.S. Department of Health and Human Services, 1999) that “child mental health is charac-terized by achievement of expected developmental cognitive,

PR

ACTICE IN ACTIONTable 1.1 Core Functions and Essential Services of Public Health

Core Function: Assessment 1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community.

Core Function: Policy Development 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts.

Core Function: Assurance 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health

care when otherwise unavailable. 8. Assure a competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based

health services. 10. Research for new insights and innovative solutions to health problems.




emotional, and social milestones as well as secure attach-ments, satisfying social relationships, and effective coping skills” (p. 123). This definition conforms to the comprehensive precepts of diagnosis, prevention, and treatment underlying the broad field of developmental psychopathology (Cichetti, 2010; Drabick & Kendall, 2010; Ialongo et al., 2006).

Within the field of school psychology, we have witnessed a similar shift toward positive approaches rather than sim-ply addressing what is wrong with an individual. As early as the late 1950s, efforts to attend to the positive aspects of human experience within adult populations were begin-ning. However, it has only been in the past 20 years that concepts such as wellness (Cowen, 1991), primary preven-tion (Coie et al., 1993), developmental assets (Scales & Leffert, 1999), and positive youth development (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004) have focused on children and adolescents. With the publication of a special issue on positive psychology in American Psychologist (Seligman & Csikszentmihalyi, 2000), the shift toward ideas of prevention, promotion, and optimizing life experiences have grown expo-nentially. Although there are subtle differences between pri-mary prevention, wellness, and positive psychology (Cowen & Kilmer, 2002), each of these movements delivers a consistent message: It is no longer sufficient to use a medical model to understand children’s mental health.

A public health model, which emphasizes prevention, pro-motion of positive outcomes, population-based assessment and interventions, and comprehensive services, may provide a better paradigm for children’s mental health services in the schools. The public health model defines issues and clini-cal problems as being multi-determined and existing along a developmental spectrum. Effective public health interven-tions rely on careful diagnosis of system problems and focus treatment on important individual, family, school, and com-munity targets. Rather than replacing the traditional clini-cal model, the public health model broadens the scope and definition of children’s mental health services to include a full continuum of service provision.

APPLYING A PUBLIC HEALTH MODEL TO THE PRACTICE OF SCHOOL PSYCHOLOGY

Although the language used to define these services is different than what is familiar to school psychology practice, it is easy




to see the areas of overlap. Public health conceptualizations of school-based practice are evident in School Psychology: A Blueprint for Training and Practice III [Blueprint III] (Ysseldyke et al., 2006). As in previous versions, the latest document out-lines a set of competency domains that underlie school psy-chology; it also adds several new domains, including “Systems Thinking” and “Wellness, Mental Health, & Development of Life Competencies,” which clearly reflect movement toward population-based conceptualizations of practice. Further, Blueprint III was organized to reflect a continuum of services, ranging from universal delivery (assessment of and interven-tion with populations to improve functioning or prevent prob-lems) to intensive services (assessment of and intervention with individuals or small groups that exhibit clear problems).

Indeed, Ysseldyke and his colleagues (2006) proposed that the dual goals of school psychologists were to (1) improve competencies for all children, and (2) build and maintain the capacities of systems to meet the needs of all children, suggest-ing that traditional problem-based individual services should be superseded by systemic, population-based conceptualiza-tions of training and practice. In support of this conclusion, the authors stated, “If the goals of school psychology are to improve competencies for children and build and maintain systems capacity, then the logical next question is: What is the mechanism by which these goals can be attained?” (Ysseldyke et al., 2008, p. 44). Blueprint III depicts a service delivery sys-tem characterized by variably intensive interventions depend-ing on the severity of student need. Without a doubt, school psychology is evolving from its clinical roots to a broader, more comprehensive specialty, as shown in Figure 1.1.

This blueprint helped to create the foundation for the new revision in the standards for school psychology practice and training. In their revision of practice standards, the National Association of School Psychologists (NASP; 2010) outlined 10 competency domains, which serve as a foundation for how school psychologists should organize and evaluate their prac-tice. The competency domains are organized into three broad dimensions of practice and training: Practices that Permeate All Aspects of Service Delivery; Direct and Indirect Services for Children, Families, and Schools (further divided into Student-Level Services and System-Level Services); and Foundations of School Psychological Service Delivery. Competency domains in the NASP standards are presented in Table 1.2.




NASP has also provided a graphic representation of these components (see Figure 1.2) that illustrates their relationship in practice. In this model, two aspects of service delivery—data-based decision-making and consultation and collabora-tion—are key to the delivery of services. There is a continual feedback loop in which the outcomes of services drive addi-tional decision-making and collaborative efforts. Underlying all aspects of these professional services are competencies related to meeting the needs of diverse populations, conduct-ing ongoing research and program evaluation, and function-ing in a legal and ethical manner (NASP, 2010).

Many of these competencies align with the Essential Services presented as part of the public health model. For example, one of the 10 competency domains outlined by NASP is data-based decision-making, which is similar to two of the Essential Services which describe monitoring health status and diagnosing problems as the first two services (see Table 1.1). In the traditional school psychology model focus-ing on services to individuals and small groups, data-based decision-making typically refers to individual assessment and diagnosis. In the public health model, however, a school

Delivery System OutcomesDomains of Competence

Intensive

Targeted

Universal

Continuous Improvement

Build Capacity

of Systems

Improved

Competencies

for All Students

Enhancing the

Development of

Cognitive and

Academic Skills

Data-Based

Decision Making

& Accountablity

Enhancing the

Development of

Wellness, Social

Skills, Mental

Health, and Life

Competencies

Systems-Based

Service Delivery

Professional, Legal, Ethical, and Social

Responsibility

Technological Applications

Diversity Awareness and Sensitive

Service Delivery

Interpersonal and Collaborative Skills

Psychological

and Educational

Principles

Application of

Science and

Scientific Method

Fo

un

dat

ion

al

Co

mp

eten

cies

Fu

nct

ion

al

Co

mp

eten

cies

Training and Practice in School Psychology

Contextual Issues and Challenges

Figure 1.1 Blueprint for training and practice model. (Copyright 2010 by the National Association of School Psychologists, Bethesda, MD. Reprinted with permission of the pub-lisher. www.nasponline.org)


http://www.nasponline.org



psychologist might exhibit competency within the same domain by performing a needs assessment within the school to determine areas of strength and concern, and subsequently help to develop school-wide programming to address identi-fied needs. The target of these efforts would focus on assess-ment and diagnosis of the school or community population rather than on individual students or small groups of students. Similar parallels can be drawn for consultation, home–school linkages, and program evaluation, as well as other dimensions of competence in school psychology. A comparative table (Table 10.1) is provided in Chapter 10.

The new practice model, titled the Model for Comprehensive and Integrated School Psychological Services (NASP, 2010), provides a framework for service delivery. One of the goals of this model, also called the NASP Practice Model, is to support more consistent practice between school psychology practitio-ners across different states, districts, and schools. For schools that adopt this model, the document advocates for a lower rec-ommended ratio of school psychologists per students than pre-viously. The new ratio, 1:500–700, is thought to provide school psychologists the opportunity to become more involved at dif-ferent levels of service delivery. We believe that this model aligns well with a public health model, and by integrating the two approaches, school psychologists will be able to better meet the needs of students, families, schools, and communi-ties through comprehensive, preventive programming that is developed and implemented in collaboration with others.

CONCLUSION

Reconceptualizing school psychology services through a pub-lic health lens is aligned with the NASP competence domains and training and practice guidelines. It is also in keeping with students’ needs and what the public wants for our stu-dents: comprehensive mental health supports that assist all students in meeting their academic potential. In the subse-quent chapters of this book, we present in detail the compo-nents of the public health model applied to the practice of psychology in the school, relate those components to com-prehensive children’s mental health services, and provide practical examples of school psychological services within the model. Finally, we address new roles for school psycholo-gists, focusing on prevention and promotion, that will likely accrue to our identification with the public health model.




Table 1.2 NASP Competency Domains (NASP, 2010)

Practices That Permeate All Aspects of Service Delivery

Data-Based Decision-Making and AccountabilitySchool psychologists have knowledge of varied models and methods of assessment and data collection methods for identifying strengths and needs, developing effective services and programs, and measuring progress and outcomes. As part of a systematic and comprehensive process of effective decision-making and problem-solving that permeates all aspects of service delivery, school psychologists demonstrate skills to use psychologi-cal and educational assessment, data collection strategies, and technology resources, and apply results to design, implement, and evaluate response to services and programs.

Consultation and CollaborationSchool psychologists have knowledge of varied models and strategies of consultation, collaboration, and communication applicable to individuals, families, groups, and systems, and methods to promote effective implementation of services. As part of a systematic and comprehensive process of effective decision-making and problem-solving that permeates all aspects of service delivery, school psychologists demonstrate skills to consult, collaborate, and communicate effectively with others.

Direct and Indirect Services for Children, Families, and Schools

Student-Level Services

Interventions and Instructional Support to Develop Academic SkillsSchool psychologists have knowledge of biological, cultural, and social influences on academic skills; human learning, cognitive, and developmental processes; and evidence-based curricula and instructional strategies. School psychologists, in collaboration with others, demonstrate skills to use assessment and data collection methods and to implement and evaluate services that support cognitive and academic skills.

Interventions and Mental Health Services to Develop Social and Life SkillsSchool psychologists have knowledge of biological, cultural, developmental, and social influences on behavior and mental health, behavioral and emotional impacts on learning and life skills, and evidence-based strategies to promote social–emotional functioning and mental health. School psychologists, in collaboration with others, demonstrate skills to use assessment and data-collection methods and to implement and evaluate services that support socialization, learning, and mental health.

Systems-Level Services

School-Wide Practices to Promote LearningSchool psychologists have knowledge of school and systems structure, organization, and theory; general and special education; technology resources; and evidence-based school practices that promote learning and mental health. School psychologists, in collaboration with others, demonstrate skills to develop and implement practices and strategies to create and maintain effective and supportive learning environments for children and others.




Table 1.2 (continued) NASP Competency Domains (NASP, 2010)

Preventive and Responsive ServicesSchool psychologists have knowledge of principles and research related to resilience and risk factors in learning and mental health, services in schools and communities to support multi-tiered prevention, and evidence-based strategies for effective crisis response. School psychologists, in collaboration with others, demonstrate skills to promote services that enhance learning, mental health, safety, and physical well-being through protective and adaptive factors and to implement effective crisis preparation, response, and recovery.

Family-School Collaboration ServicesSchool psychologists have knowledge of principles and research related to family systems, strengths, needs, and culture; evidence-based strategies to support family influences on children’s learning and mental health; and strategies to develop collaboration between families and schools. School psychologists, in collaboration with others, demonstrate skills to design, implement, and evaluate services that respond to culture and context and facilitate family and school partnerships and interactions with community agencies for enhancement of academic and social–behavioral outcomes for children.

Foundations of School Psychological Service Delivery

Diversity in Development and LearningSchool psychologists have knowledge of individual differences, abilities, disabilities, and other diverse characteristics; principles and research related to diversity factors for children, families, and schools, including factors related to culture, context, and individual and role differences; and evidence-based strategies to enhance services and address potential influences related to diversity. School psychologists demonstrate skills to provide effective professional services that promote effective functioning for indivi duals, families, and schools with diverse characteristics, cultures, and backgrounds and across multiple contexts, with recognition that an understanding and respect for diversity in development and learning and advocacy for social justice are foundations for all aspects of service delivery.

Research and Program EvaluationSchool psychologists have knowledge of research design, statistics, measurement, varied data collection and analysis techniques, and program evaluation sufficient for under standing research and interpreting data in applied settings. School psychologists demonstrate skills to evaluate and apply research as a foundation for service delivery and, in collaboration with others, use various techniques and technology resources for data collection, measurement, and analysis to support effective practices at the individual, group, and/or systems levels.

Continued




Professional Services

by School Psychologists

Practices That Permeate AllAspects of Service Delivery

Data-Based Decision Makingand Accountability

Consultation and Collaboration

Direct and Indirect Services for Children,Families, and Schools

Student-Level Services Systems-Level Services

Interventions andInstructional Support toDevelop Academic Skills

School-Wide Practicesto Promote Learning

Preventive andResponsive ServicesInterventions an Mental

Health Services toDevelop Social and Life

Skills

Family-SchoolCollaboration Services

Foundations of School Psychologists’ Service Delivery

Diversity in Developmentand Learning

Research and Program EvaluationLegal, Ethical, and

Professional Practice

Figure 1.2 Model of comprehensive and integrated school psychological services. (Copyright 2010 by the National Association of School Psychologists, Bethesda, MD. Reprinted with permission of the publisher. www.nasponline.org)

Table 1.2 (continued) NASP Competency Domains (NASP, 2010)

Legal, Ethical, and Professional PracticeSchool psychologists have knowledge of the history and foundations of school psychology; multiple service models and methods; ethical, legal, and professional standards; and other factors related to professional identity and effective practice as school psychologists. School psychologists demonstrate skills to provide services consistent with ethical, legal, and professional standards; engage in responsive ethical and professional decision-making; collaborate with other professionals; and apply professional work characteristics needed for effective practice as school psychologists, including respect for human diversity and social justice, commun ication skills, effective interpersonal skills, responsibility, adaptability, initiative, dependability, and technology skills.

Source: Copyright 2010 by the National Association of School Psychologists, Bethesda, MD. Reprinted with permission of the publisher. www.nasponline.org





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Comprehensive Children’s Schools and Communities€¦ · Comprehensive children’s mental health services in schools and communities : a public health problem-solving model / Robyn