Strengthening Partnerships for School Strengthening Partnerships for School Mental Health Services in theMental Health Services in the

United StatesUnited States

Carl E. PaterniteCarl E. PaterniteCenter for School-Based Mental Health ProgramsCenter for School-Based Mental Health Programs

Miami University (Ohio)Miami University (Ohio)

Mark WeistMark WeistCenter for School Mental Health AssistanceCenter for School Mental Health Assistance

University of Maryland University of Maryland

Presentation at the Clifford Beers Foundation Conference:Presentation at the Clifford Beers Foundation Conference:Mental Health Promotion—Going from Strength to StrengthMental Health Promotion—Going from Strength to Strength

Dublin, IrelandDublin, IrelandApril 21, 2005April 21, 2005

The Crisis of Youth Mental Health The Crisis of Youth Mental Health in the U.S.in the U.S.

About 20% of youth, ages 9 to 17 (15 About 20% of youth, ages 9 to 17 (15 million), have diagnosable mental health million), have diagnosable mental health disorders, (and disorders, (and manymany more are at risk or more are at risk or could benefit from help)could benefit from help)

Between 9-13% of youth, ages 9-17 years, Between 9-13% of youth, ages 9-17 years, meet the federal definition of serious meet the federal definition of serious emotional disturbance (SED)emotional disturbance (SED)

The Crisis of Youth Mental Health The Crisis of Youth Mental Health in the U.S. (cont.)in the U.S. (cont.)

Less than 30% of youth with diagnoses Less than 30% of youth with diagnoses receive any services, and these services are receive any services, and these services are often inadequateoften inadequateFor the small percentage of youth who do For the small percentage of youth who do receive services, most actually receive them receive services, most actually receive them in schoolsin schools

Growing Focus on School Mental Growing Focus on School Mental Health (SMH) in the U.S.Health (SMH) in the U.S.

U.S. Surgeon General Reports (1999, 2000)U.S. Surgeon General Reports (1999, 2000)

President’s New Freedom Commission on Mental President’s New Freedom Commission on Mental Health Report (2003)Health Report (2003)

Mandates of “No Child Left Behind” and Individuals Mandates of “No Child Left Behind” and Individuals with Disabilities Education Act (IDEA)with Disabilities Education Act (IDEA)

Progress in localities and statesProgress in localities and states

Collaborative research-practice-training networksCollaborative research-practice-training networks

Report of President’s New Freedom Report of President’s New Freedom Commission on Mental HealthCommission on Mental Health

http://www.mentalhealthcommission.govhttp://www.mentalhealthcommission.gov

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

New Freedom CommissionNew Freedom Commission

Goal 4: Early Mental Health Screening, Assessment, Goal 4: Early Mental Health Screening, Assessment, and Referral to Services are Common Practiceand Referral to Services are Common Practice

4.1 Promote the mental health of young children

4.24.2 Improve and expand school mental health programsImprove and expand school mental health programs

4.3 and 4.4 (both focus on enhancing mental health screening)

New Freedom CommissionNew Freedom Commission

Critical importance of partnership with schoolsin mental health care:

“While schools are primarily concerned with education, mental health is essential to learning as well as to social and emotional development. Because of this important interplay between emotional health and school success, schools must be partners in the mental health care of our children.”

July, 2003, p. 58July, 2003, p. 58

Education Policies in the U.SEducation Policies in the U.S..

1) Achievement promotes wellbeing1) Achievement promotes wellbeing 2) Wellbeing promotes achievement2) Wellbeing promotes achievement

School accountabilities often acknowledge 1 butSchool accountabilities often acknowledge 1 but

fail to acknowledge 2fail to acknowledge 2

Schools: The Most Schools: The Most Universal Natural SettingUniversal Natural Setting

Over 52 million youth attend 114,000 Over 52 million youth attend 114,000 schools in the U.S.schools in the U.S.Over 6 million adults work in schoolsOver 6 million adults work in schoolsCombining students and staff, one-fifth of Combining students and staff, one-fifth of the U.S. population can be found in the U.S. population can be found in schoolsschools

From New Freedom Commission (2003)From New Freedom Commission (2003)

In Addition to Enhanced In Addition to Enhanced Access, SMH can:Access, SMH can:

Reduce stigma for help seekingReduce stigma for help seeking

Promote generalization/maintenance of Promote generalization/maintenance of intervention gainsintervention gains

Enhance capacity for prevention/MH promotionEnhance capacity for prevention/MH promotion

Foster clinical efficiency and productivityFoster clinical efficiency and productivity

Promote a natural, ecologically grounded Promote a natural, ecologically grounded approach to helping youth and familiesapproach to helping youth and families

SMH ImpactsSMH ImpactsBased on a limited knowledge base, Based on a limited knowledge base, when when done welldone well SMH programs and services are SMH programs and services are associated with:associated with:– Strong satisfaction by diverse stakeholder Strong satisfaction by diverse stakeholder

groupsgroups– Improvement in student emotional/behavioral Improvement in student emotional/behavioral

functioningfunctioning– Improvement in school outcomes (e.g., Improvement in school outcomes (e.g.,

climate, special education referrals, reduced climate, special education referrals, reduced bullying, fewer suspensions)bullying, fewer suspensions)

SMH Impacts (cont’d)SMH Impacts (cont’d)

When done well SMH programs and When done well SMH programs and services also can play a role in:services also can play a role in:

– Preventing and addressing the impacts of Preventing and addressing the impacts of violence on youthviolence on youth

– Reducing/preventing school drop-outReducing/preventing school drop-out

– Enhancing student connectedness to schoolEnhancing student connectedness to school

Factors Necessary to Achieve Desired Factors Necessary to Achieve Desired Outcomes for Youth Through SMH Outcomes for Youth Through SMH

Programs and ServicesPrograms and Services

Effective mental health promotion, problem preventionand intervention

Outstanding staff and program qualitiesOngoing training, technical assistance & support

School and community buy-in and investment

Awareness raising, public policy advocacy and improvement,coalition building, systems-level change, and resource commitment

Critical Themes in SMHCritical Themes in SMH

Need for Conceptual ClarityNeed for Conceptual Clarity

““School mental health” is a very broad School mental health” is a very broad termtermAll schools are delivering some form of All schools are delivering some form of SMHSMHWith a vague definition it is difficult to track With a vague definition it is difficult to track progress and develop advocacyprogress and develop advocacy

Expanded School Mental HealthExpanded School Mental Health

Full continuum of mental health promotion, Full continuum of mental health promotion, early intervention, prevention and early intervention, prevention and treatmenttreatment

For youth in general and special educationFor youth in general and special education

Through collaborative school-community Through collaborative school-community partnershipspartnerships

(Emphasis on quality, evidence-based (Emphasis on quality, evidence-based practices, ongoing evaluation)practices, ongoing evaluation)

Service Capacity Service Capacity

Schools and SMH programs typically struggle to meet Schools and SMH programs typically struggle to meet the needs of studentsthe needs of students

Excessive referrals for students with serious problems Excessive referrals for students with serious problems and crisesand crises

Full continuum of MH promotion-prevention-treatment Full continuum of MH promotion-prevention-treatment services is services is rarelyrarely provided provided

Schools and communities reluctant to undertake Schools and communities reluctant to undertake systematic MH screening for youthsystematic MH screening for youth

Preventive Services andPreventive Services andMH PromotionMH Promotion

In spite of best intentions, drift toward individual In spite of best intentions, drift toward individual services for students with severe/chronic services for students with severe/chronic problemsproblems

Reflects fundamental bias in U.S. toward Reflects fundamental bias in U.S. toward “mental health” problems presumed to reside “mental health” problems presumed to reside within individualswithin individuals

WHO model of health promoting schools is WHO model of health promoting schools is inverted in the U.S.inverted in the U.S.

International dialogue is of International dialogue is of great benefitgreat benefit to U.S. to U.S. experienceexperience

Mental Health-Education Mental Health-Education Systems IntegrationSystems Integration

Typically, SMH programs/staff viewed by Typically, SMH programs/staff viewed by educators to be “add ons” or frills, not educators to be “add ons” or frills, not central to the “academic” missioncentral to the “academic” mission

Need to move beyond cooperation to MH-Need to move beyond cooperation to MH-Education program and systems Education program and systems integration, with close collaborative work integration, with close collaborative work based on shared values and goalsbased on shared values and goals

To Promote Integration To Promote Integration Should Ensure:Should Ensure:

Strong family-school-MH collaboration in SMH Strong family-school-MH collaboration in SMH program planningprogram planning

That SMH providers understand school culture and That SMH providers understand school culture and how to work as collaborative team playershow to work as collaborative team players

That SMH practices are of high quality and effectiveThat SMH practices are of high quality and effective

A connection between SMH programs and services A connection between SMH programs and services and reducing barriers to learning and reducing barriers to learning

Pre-Service/In-Service Training Pre-Service/In-Service Training Needs for Educators and SMH StaffNeeds for Educators and SMH Staff

In Addition to Parents, Teachers are on the In Addition to Parents, Teachers are on the Mental Health “Front Line”Mental Health “Front Line”

Yet, teachers/educators are very poorly trained Yet, teachers/educators are very poorly trained in problem recognition and mental health in problem recognition and mental health promotionpromotion

Significant need to enhance teacher/educator Significant need to enhance teacher/educator training based on analysis of issues confronted training based on analysis of issues confronted in the classroom/schoolin the classroom/school

Mental Health Concepts that Mental Health Concepts that Promote LearningPromote Learning

Self-instruction (e.g., developing an Self-instruction (e.g., developing an internal dialogue)internal dialogue)Problem solving (e.g., considering costs Problem solving (e.g., considering costs and benefits of actions)and benefits of actions)Self-control and–reinforcement (e.g., work Self-control and–reinforcement (e.g., work before play)before play)Template matching (e.g., modeling actions Template matching (e.g., modeling actions of B+ students)of B+ students)

SMH Research Base SMH Research Base

Is fairly limitedIs fairly limited

Most of literature is on research-supported Most of literature is on research-supported studiesstudies

Significant challenges in promoting Significant challenges in promoting evidence-based practices in schools that evidence-based practices in schools that are operating without formal research are operating without formal research support support

Community Science Approach Community Science Approach (Wandersman, 2003)(Wandersman, 2003)

Promotes local accountability in community Promotes local accountability in community delivery delivery processesprocesses

Engages practitioners (MH, education) in Engages practitioners (MH, education) in planning, implementing, evaluating, sustaining, planning, implementing, evaluating, sustaining, and continuously improving services, based on and continuously improving services, based on locally determined needslocally determined needs

Process builds local capacity to improve quality Process builds local capacity to improve quality of practice and achieve positive health outcomesof practice and achieve positive health outcomes

Enhancing Quality in Expanded Enhancing Quality in Expanded School Mental HealthSchool Mental Health

Randomized controlled study to assess Randomized controlled study to assess impacts of systematic quality improvement impacts of systematic quality improvement on clinician behavior, satisfaction with on clinician behavior, satisfaction with services, and student outcomesservices, and student outcomesFirst experimental study of quality First experimental study of quality improvement in school mental healthimprovement in school mental healthWill provide guidelines for best practice Will provide guidelines for best practice and will help to standardize practiceand will help to standardize practice

(Project # 1R01 MH71015-01A1, NIMH, 2003-2006; PI: M. Weist, (Project # 1R01 MH71015-01A1, NIMH, 2003-2006; PI: M. Weist, University of Maryland)University of Maryland)

Principles for Best Practice in Principles for Best Practice in Expanded School Mental HealthExpanded School Mental Health1) All youth and families are able to access 1) All youth and families are able to access appropriate care regardless of their ability to appropriate care regardless of their ability to paypay

2) Programs are implemented to address 2) Programs are implemented to address needs and strengthen assets for students, needs and strengthen assets for students, families, schools, and communitiesfamilies, schools, and communities

3) Programs and services focus on reducing 3) Programs and services focus on reducing barriers to development and learning, are barriers to development and learning, are student and family friendly, and are based on student and family friendly, and are based on evidence of positive impactevidence of positive impact

Principles (cont.)Principles (cont.)

4) Students, families, teachers and other 4) Students, families, teachers and other important groups are actively involved in the important groups are actively involved in the program's development, oversight, program's development, oversight, evaluation, and continuous improvementevaluation, and continuous improvement 5) Quality assessment and improvement 5) Quality assessment and improvement activities continually guide and provide activities continually guide and provide feedback to the programfeedback to the program 6) A continuum of care is provided, including 6) A continuum of care is provided, including school-wide mental health promotion, early school-wide mental health promotion, early intervention, and treatmentintervention, and treatment

Principles (cont.)Principles (cont.)

7) Staff hold to high ethical standards, are 7) Staff hold to high ethical standards, are committed to children, adolescents, and committed to children, adolescents, and families, and display an energetic, flexible, families, and display an energetic, flexible, responsive and proactive style in responsive and proactive style in delivering services delivering services 8) Staff are respectful of, and competently 8) Staff are respectful of, and competently address developmental, cultural, and address developmental, cultural, and personal differences among students, personal differences among students, families and staff families and staff

Principles (cont.)Principles (cont.)

9) Staff build and maintain strong 9) Staff build and maintain strong relationships with other mental health and relationships with other mental health and health providers and educators in the health providers and educators in the school, and a theme of interdisciplinary school, and a theme of interdisciplinary collaboration characterizes all efforts collaboration characterizes all efforts

10) Mental health programs in the school 10) Mental health programs in the school are coordinated with related programs in are coordinated with related programs in other community settings other community settings

Importance of Family Importance of Family InvolvementInvolvement

SEARCH Institute study:SEARCH Institute study:– As parental involvement in schools increased, As parental involvement in schools increased,

problem behaviors in students (alcohol use, problem behaviors in students (alcohol use, violence, antisocial problems) decreasedviolence, antisocial problems) decreased

– Roehlkepartain & Benson, 1994Roehlkepartain & Benson, 1994

Engaging Families is a KeyEngaging Families is a Key

In initial family contacts:In initial family contacts:– Clarify child’s need for servicesClarify child’s need for services– Openly discuss attitudes and past Openly discuss attitudes and past

experiences with the mental health systemexperiences with the mental health system– Identify and strategize about probable Identify and strategize about probable

obstaclesobstacles– Identify concrete, practical issues that can be Identify concrete, practical issues that can be

addressed immediately (McKay, Nudelman, & addressed immediately (McKay, Nudelman, & McCadam, 1996)McCadam, 1996)

Toward Funding for a Full Continuum Toward Funding for a Full Continuum of Programs and Servicesof Programs and Services

Maximizing all potential sources of Maximizing all potential sources of revenue: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– ““line item” supportline item” support– innovative prevention fundinginnovative prevention funding– fee-for-servicefee-for-service

The Significant Impacts of The Significant Impacts of FederalismFederalism

State of residence determines whether youth State of residence determines whether youth use mental health more than race/ethnicity or use mental health more than race/ethnicity or incomeincome

Differences in mental health use by children Differences in mental health use by children across states are generally not related to across states are generally not related to differences in levels of need (e.g. AL and TX differences in levels of need (e.g. AL and TX present higher rates of need but lower rates of present higher rates of need but lower rates of use)use)– Sturm, Ringel & Andreyeva, 2003 Sturm, Ringel & Andreyeva, 2003

(www.pediatrics.org)(www.pediatrics.org)

Ohio Mental Health Network for Ohio Mental Health Network for School SuccessSchool Success

Regional action networks for mental health in Regional action networks for mental health in schoolsschools

Networks raise awareness, develop resources, Networks raise awareness, develop resources, offer TA, do training within and across sitesoffer TA, do training within and across sites

Newsletter and regular publication on progress Newsletter and regular publication on progress

Genuine cost sharing across major systemsGenuine cost sharing across major systems

Strong partnerships with universities and Strong partnerships with universities and development of centers of excellencedevelopment of centers of excellence

Actions to Advance SMH in the U.S.Actions to Advance SMH in the U.S.

For True Progress in SMHFor True Progress in SMH

Widespread acknowledgement of the Widespread acknowledgement of the marginalized status of child and school marginalized status of child and school mental health resources and effortsmental health resources and efforts

Recommendations from policy initiatives Recommendations from policy initiatives (e.g., Surgeon General, New Freedom (e.g., Surgeon General, New Freedom Commission) broadly publicized and Commission) broadly publicized and implementedimplemented

For True Progress in SMHFor True Progress in SMH

Nation-to-state infrastructure and plan that Nation-to-state infrastructure and plan that addresses significant local variabilityaddresses significant local variability

Organized state-level initiatives and Organized state-level initiatives and mechanisms for state to state collaboration mechanisms for state to state collaboration with national supportwith national support

Track and support effort in all localitiesTrack and support effort in all localities

For True Progress in SMHFor True Progress in SMH

Debunk the view of SMH as an “add-on” or Debunk the view of SMH as an “add-on” or “frill” and assert the crucial links between “frill” and assert the crucial links between MH and school successMH and school success

Confront and resolve language issuesConfront and resolve language issues

Promote MH system attention to Promote MH system attention to educationally relevant outcomeseducationally relevant outcomes

Build a comprehensive research agendaBuild a comprehensive research agenda

Promote international dialoguePromote international dialogue

INTERCAMHSINTERCAMHSInternational Alliance for Child andInternational Alliance for Child and

Adolescent Mental Health and SchoolsAdolescent Mental Health and Schools

www.intercamhs.org

CSMHA Training EventsCSMHA Training Events

School Health Interdisciplinary Program School Health Interdisciplinary Program (SHIP). Turf Valley Country Club, Ellicott (SHIP). Turf Valley Country Club, Ellicott City, Maryland. August 1-4, 2005City, Maryland. August 1-4, 2005

1010thth Annual Conference on Advancing Annual Conference on Advancing School-Based Mental Health. Cleveland School-Based Mental Health. Cleveland Renaissance Hotel, October 26-29, 2005Renaissance Hotel, October 26-29, 2005

See See http://csmha.umaryland.eduhttp://csmha.umaryland.edu, or Sylvia , or Sylvia Huntley at Huntley at shuntley@psych.umaryland.edushuntley@psych.umaryland.edu