The Interconnected Systems Framework: School Mental Health within a Multi-Tiered System

of Behavioral Supports in Schools

The Wisconsin PBIS Conference August 20-21, 2013

Lucille Eber, IL PBIS NetworkNational PBIS TA Center

acknowledgements

Susan Barrett, Sheppard-Pratt Health systems, Baltimore MDKelly Peralis, Community Care Behavioral Health, Pittsburg, PA

Mark Wiest, University of South CarolinaJill Johnson, IL PBIS Network

PBIS: Equity in Education

Making Education Work for All

School Mental Health Strand: • Integrating SMH & PBIS: Examples at All 3 Tiers• Integrating SMH & PBIS: Using Data• Integrating SMH & PBIS: Selecting Evidence-based Practices• Interconnected Systems Framework Monograph: Lessons from

the Field• Implementing an Interconnected System Framework in an

Urban School System • Integrating SMH & PBIS at the State Level• The Changing Role of School-based Clinicians

2013 National PBIS Leadership Forum | October 10-11, 2013 | Donald E. Stephens Convention Center | Rosemont, Illinois

Content:

• Describe the features of an Interconnected Systems Framework (ISF) for Integrating Mental Health in Schools

• Describe efforts and resources from blended efforts of National Centers to promote a broader continuum of evidence-based practices to support the mental health of all students

• Describe emerging examples of ISF

BIG Ideas…

• How Multi-tiered Systems of Support (MTSS) can enhance mental health in schools

• Installing SMH through MTSS in Schools• The Interconnected Systems Framework (ISF)

SMH +MTSS=ISF

History-Rationale

• Sparse availability of MH providers in schools• Labels and ‘places’ confused with

interventions• Separate delivery systems (Sp.Ed., Mental

health, etc)• Minimal accountability for outcomes for most

vulnerable populations

Why Partnership Are Needed

• One in 5 youth have a MH “condition”

• About 70% of those get no treatment

• School is “defacto” MH provider

• JJ system is next level of system default

• Suicide is 4th leading cause of death among young adults

SMH and PBISCommon Purpose

• Schools supporting/promoting MH of ALL students

• Prevention, early access, interventions commensurate with level of need (vs label)

• School personnel feel confident and competent in identifying and intervening with accuracy and effectiveness

Logic

– Youth with MH needs require multifaceted education/behavior and mental health supports

– The usual systems have not routinely provided a comprehensive, blended system of support.

– Supports need to be provided in a clustered and integrated structure,

– Academic/behavior and mental health supports need to be efficiently blended

Promotion and Prevention

Simple and complex supports require integrated systems with foundation of a school-wide system

• Schools and community serve as protective factor• problem-solving teams with

school/family/youth/community voice• use of data for decision-making (screening/ selection

and monitoring/outcomes)• layers supports from the foundational/universal to the

more complex

Tier 3/Tertiary Interventions 1-5%•Individual students•Assessment-based•High intensity

1-5% Tier 3/Tertiary Interventions• Individual students• Assessment-based• Intense, durable procedures

Tier 2/Secondary Interventions 5-15%•Some students (at-risk)•High efficiency•Rapid response•Small group interventions• Some individualizing

5-15% Tier 2/Secondary Interventions• Some students (at-risk)• High efficiency• Rapid response• Small group interventions• Some individualizing

Tier 1/Universal Interventions 80-90%•All students•Preventive, proactive

80-90% Tier 1/Universal Interventions• All settings, all students• Preventive, proactive

School-Wide Systems for Student Success: A Response to Intervention (RtI) Model

Academic Systems Behavioral Systems

Illinois PBIS Network, Revised May 15, 2008. Adapted from “What is school-wide PBS?” OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports. Accessed at http://pbis.org/schoolwide.htm

Primary Prevention:School-/Classroom-Wide Systems for

All Students,Staff, & Settings

Secondary Prevention:Specialized Group

Systems for Students with At-Risk Behavior

Tertiary Prevention:Specialized

IndividualizedSystems for Students

with High-Risk Behavior

~80% of Students

~15%

~5%

SCHOOL-WIDE POSITIVE BEHAVIOR

SUPPORT:

What is meant by “layering”

interventions?

Positive Behavior Intervention and Support (www.pbis.org)

• Decision making framework to guide selection and implementation of best practices for improving academic /behavioral functioning

• Data-based, measurable outcomes, evidence-based practices, systems to support effective implementation

Core Features of a Response to Intervention (RtI) Approach

• Investment in prevention, screening and early intervention for students not at “benchmark”

• Multi-tiered intervention approach

• Use of progress monitoring and problem-solving process at all 3-tiers

Core Features of a Response to Intervention (RtI) Approach

• Research-based practices and active use of data for decision-making at all 3-tiers

• Use of progress monitoring and problem-solving process at all 3-tiers

3-Tiered System of Support

Necessary Conversations (Teams)

Check-In Check-Out

Skills Groups

Group w. individual

feature

Complex

FBA/BIP

Problem Solving Team Meeting

Tertiary Systems Team Meeting

Brief

FBA/BIP

Brief FBA/BIP

Wraparound

Secondary Systems Team

Meeting

Plans schoolwide &

classroom supports

Uses process data; determines overall

intervention effectiveness

Standing team; uses FBA/BIP process for one student at a time

Uses process data; determines overall

intervention effectiveness

Rev. 11.19.2012

UniversalTeam

Meeting

Universal Support

Illinois PBIS Network

Tier 1/Universal School-Wide Assessment

School-Wide Prevention Systems

SIMEO Tools: HSC-T, RD-T, EI-T

Check-in Check-out (CICO)

Group Intervention with Individualized Feature (e.g., Check and Connect - CnC and Mentoring)

Brief Functional Behavior Assessment/Behavior Intervention Planning (FBA/BIP)

Complex or Multiple-domain FBA/BIP

Wraparound

ODRs, Attendance, Tardies, Grades, DIBELS, etc.

Daily Progress Report (DPR) (Behavior and Academic Goals)

Competing Behavior Pathway, Functional Assessment Interview, Scatter Plots, etc.

Social/Academic Instructional Groups (SAIG)

Positive Behavior Interventions & Supports:A Response to Intervention (RtI) Model

Illinois PBIS Network, Revised October 2009Adapted from T. Scott, 2004

Tier 2/Secondary

Tier 3/Tertiary

Inte

rven

tio

nAssessm

en

t

Individual Student Information System (ISIS)

Definition of school mental health •Involves partnership between schools and community health/mental health organizations, as guided by families and youth

•Builds on existing school programs, services, and strategies

•Focuses on all students, both general and special education

•Involves a full array of programs, services, and strategies- mental health education and promotion through intensive intervention

(Weist & Paternite, 2006)

“Expanded” School Mental Health

• Full continuum of effective mental health promotion and intervention for ALL students

• Reflecting a “shared agenda” involving school-family-community partnerships

• Collaborating community professionals (augment the work of school-employed staff

The Context

• Over 18,000 schools engaged in implementation of SWPBIS (MTSS ) prevention based system

• Current focus on capacity to scale-up • MTSS as platform to install effective

interventions for youth w/or at-risk of EBD

The Context (cont.)

• Emphasis now on scaling with expansion and connection to other systems – i.e. academic, juvenile justice, mental health, child welfare,

systems of care

• Emphasis on deliberate actions that foster connections w/families & community

Development of ISF

• 2002-2007: Site Development with PBIS Expansion (informal and independent)

• 2005 CoP focus on integration of PBIS and SMH• 2008: ISF White Paper: formal partnership between

PBIS and SMH• 2009- 2013 Monthly calls with implementation sites,

national presentations (from sessions to strands)• 2009-2011 Grant Submissions• June 2012- September 2013 ISF Monograph• Monograph Advisory group

Interconnected Systems Framework paper (Barrett, Eber and Weist , revised 2009)

Developed through a collaboration of theNational SMH and National PBIS Centers

www.pbis.orgwww.pbis.org http://csmh.umaryland.edu

• Define the common goals of SMH and PBIS

• Discuss the advantages of interconnection

• Identify successful local efforts to implement collaborative strategies and cross-initiative efforts

• Define the research, policy, and implementation agendas to take us to the next action level

ISF Monograph DevelopmentJune 2012 – September 2013

ISF Defined– ISF provides structure and process for education and mental

health systems to interact in most effective and efficient way. – ISF is guided by key stakeholders in education and mental health

system who have the authority to reallocate resources, change role and function of staff, and change policy.

– ISF applies strong interdisciplinary, cross-system collaboration.

ISF Defined– ISF uses the tiered prevention logic as the overall

organizer to develop an action plan.– ISF involves cross system problem solving teams that

use data to decide which evidence based practices to implement.

ISF Defined (cont)

– ISF involves ongoing progress monitoring for both fidelity and impact.

– ISF emphasizes active involvement by youth, families, and other school and community stakeholders.

Interconnected Systems Framework

Tier I: Universal/Prevention for AllCoordinated Systems, Data, Practices for Promoting Healthy Social and Emotional Development for ALL Students

· School Improvement team gives priority to social and emotional health

· Mental Health skill development for students, staff/, families and communities

· Social Emotional Learning curricula for all· Safe & caring learning environments · Partnerships : school, home & community· Decision making framework guides use of

and best practices that consider unique strengths and challenges of each school community

MH/PBIS: An Expanded Tier One• Universal screening for social, emotional, and behavioral at-risk

indicators• Universal screening for families who may request assistance for

their children• Teaching social skills with evidence-based curricula to all students• Teaching appropriate emotional regulation and expression to all

students• Teaching behavioral expectations to all students• Mental health professionals are part of the Tier 1 systems team,

providing input and progress monitoring data• Opportunity to review community data and expand Tier 1

intervention options based on data

Interconnected Systems Framework

Tier 2: Early Intervention for Some

Coordinated Systems for Early Detection, Identification, and Response to Mental Health Concerns

· Systems Planning Team coordinates referral process, decision rules and progress monitors

· Array of services available· Communication system: staff, families and

community · Early identification of students at risk for

mental health concerns due to specific risk factors

· Skill-building at the individual and groups level as well as support groups

· Staff and Family training to support skill development across settings

MH/PBIS: An Expanded Tier Two• Mental health/community professionals part of secondary

systems and problem solving teams• Working smarter matrix completed to ensure key resources are

both efficient and effective (i.e., initiatives are aligned and combined such as “bully prevention”, “discipline”, “character education”, “RtI behavior”, etc.)

• Groups co-facilitated by school staff and community partner (example – guidance counselor and community provider clinician)

• Opportunity to expand the continuum of interventions based on data (i.e. trauma informed interventions)

• Out-reach to families for support/interventions

Interconnected Systems FrameworkTier 3: Intensive Interventions for FewIndividual Student and Family Supports

· Systems Planning team coordinates decision rules/referrals and progress monitors

· Individual team developed to support each student

· Individual plans have array of interventions/services

· Plans can range from one to multiple life domains

· System in place for each team to monitor student progress

MH/PBIS: An Expanded Tier Three

• Mental health professional(s) part of tertiary systems team

• FBA/BIP and/or person-Centered Wraparound plans completed together with school staff and mental health provider for one concise plan, rather than each completing paperwork to be filed

• Quicker access to community-based supports for students and families

Traditional Preferred

• Each school works out their own plan with Mental Health (MH) agency;

• District has a plan for integrating MH at all buildings (based on community data as well as school data);

Traditional Preferred

• A MH counselor is housed in a school building 1 day a week to “see” students;

• MH person participates in teams at all 3 tiers;

Traditional Preferred

• No data to decide on or monitor interventions;

• MH person leads group or individual interventions based on data;

Structure for Developing an ISF: Community Partners

Roles in Teams

• A District/Community leadership that includes families, develops, supports and monitors a plan that includes:

• Community partners participate in all three levels of systems teaming in the building: Universal, Secondary, and Tertiary

Structure for Developing an ISF: Community Partners Roles in Teams (cont.)

• Team of SFC partners review data and design interventions that are evidence-based and can be progress monitored

• MH providers from both school & community develop, facilitate, coordinate and monitor all interventions through one structure

3-Tiered System of Support Necessary Conversations

CICO

SAIG

Group w. individual

feature

Complex

FBA/BIP

Problem Solving Team

Tertiary Systems Team

Brief

FBA/BIP

Brief FBA/BIP

WRAP

Secondary Systems Team

Plans SW & Class-wide supports

Uses Process data; determines overall

intervention effectiveness

Standing team with family; uses FBA/BIP process for one youth

at a time

Uses Process data; determines overall

intervention effectiveness

Sept. 1, 2009

UniversalTeam

Universal Support

Family and community Family and

community

Family and community

Community

SPARCS – IL HS

• 5 students participated in group– 1 student internalizer– 1 student participated last year as well

• Time 1 = Seven weeks before starting SPARCSTime 2 = First seven weeks on interventionTime 3 = Second seven weeks on intervention (with a total of 14 weeks of group)

ODRs Over Time

ODR Time 1 ODR Time 2 ODR Time 30

2

4

6

8

10

12

14

16

Total Number ODR All Participants

Total Number ODR

Time Period

ODR

Tot

al

13%↑

80%↓

ODRs by Student

Student 1 Student 2 Student 3 Student 4 Student 50

1

2

3

4

5

6

7

8

9

ODRs Over Time

Time 1 - 7 weeks before SPARCSTime 2 - First 7 weeks SPARCSTime 3 - Second 7 weeks SPARCS

Students

Num

ber o

f ODR

s

OSS Data

ISS Time 1 ISS Time 2 ISS Time 3 OSS Time 1 OSS Time 2 OSS Time 30

0.5

1

1.5

2

2.5

3

3.5

4

4.5

ISS/OSS Days Out

Student 1Student 2Student 3Student 4Student 5

Time Period

Num

ber o

f Day

s Out

Grades

A B C D F0

2

4

6

8

10

12

14

Overall Grade Distribution Over Time Periods for All Students

Time 1Time 2Time 3

Grades

Num

ber

TRAC-Nom Data

• Increased (Moving in Right Direction) • Life satisfaction .67 Significance Level

• Anxiety/depression symptoms .34

• Drug use .46

• Time spent living outside of the home (e.g. in jail, an emergency room, or

psychiatric hospital) .37

• Decreased (Moving in Wrong Direction)• Unexcused Absences .42

• Support Systems

Youth Outcomes Questionaire

• On the Youth Outcome Questionnaire (self report) it measures six subscales: Somatic; Social Isolation; Aggression; Conduct/Delinquency; Hyperactivity/Distraction; Depression/Anxiety– Students reported a decrease in symptoms/problems on all six

scales from pre to post– The largest reported improvement was on Aggression, second

was Hyperactivity/Depression and third was Depression/Anxiety– Out of the 5 students that completed the group, we had 2

parents that completed both the pre and post YOQ and both reported a reduction in symptoms/problems in their child…one score dropped from 40 to 18 and the other from 22 to 15

PA example

Accountable Clinical Home

• Accountable TO the family and FOR the care• Accessible, coordinated, and integrated care• Comprehensive service approach • Increased accountability and communication• Single point of contact for behavioral health• School is “launching pad” for services delivered in all

settings• Youth continue on the team with varying intensity of

service

SBBH Service Components

CLINICAL INTERVENTIONS

CASE MANAGEMENT

CRISIS INTERVENTION

CASE CONSULTATION AND TRAININGfor educational staff

District and Community Leadership Team

• Quarterly meetings• Stakeholder representation – System of Care• Implementer’s blueprint• Systems, data and practices• Scaling and sustainability

Time Line

School Year Activity

2008-09 •Community Care engaged district through ICSP regarding SBBH Team

2009-10 •SBBH Team begins work within district – September 2009•District and Community Leadership Team is established, district commitment signed, tertiary demonstration project begins – spring 2010

2010-11 •Tier One SWPBIS is fully implemented with kickoff at the start of the school year•Tier Two training begins in the spring of 2011 with some implementation

2011-12 •All three tiers are being implemented at both elementary schools•Montrose Junior High receives Tier One training in fall, with “soft” kickoff in January 2012•Discussion of SBBH Team model expanding into Junior and Senior High

1-5% 1-5%

5-10% 5-10%

80-90% 80-90%

Tertiary, Tier 3, Individual

Child Outcomes SurveyStrengths and Difficulties Q.Teacher feedbackAcademic data

Tertiary, Tier 3, Individual

•Guidance counselors see individual students•SBBH Team

Secondary, Tier 2 Group/Individual

Data from Tier One teamProgress monitoringData decision rules

Secondary, Tier 2 Group/Individual

•Guidance counselors run Targeted groups•IST•CICO•mentoring

Universal, Tier 1 Whole School ODRs, teacher nominations,Card system, MMS,

(lessons learned)

Universal, Tier 1, Whole school

•Guidance counselors teach “I Can Problem Solve” lessons•Treehab D and A awareness•Bully prevention/Character Ed•Peer Mediation

Montrose Elementary SchoolsK-6th Grade

Data Practices

Scranton School District

Year One2009-10

Year Two2010-11

Year Three2011-12

Year Four2012-13

Year Five2013-14

Year Six2014-15

District and Community Leadership Team established. District commits to implementing SWPBIS with fidelity across the district.

SBBH Teams begin implementation at Frances Willard Elementary, George Bancroft Elementary, and Scranton High. A Tier Three support.

Frances Willard Elementary, George Bancroft Elementary, and Scranton High all receive training to implement Tier One SWPBIS.

Frances Willard Elementary, George Bancroft Elementary, and Scranton High all implement Tier One SWPBIS.

Frances Willard Elementary reaches implementation fidelity.

Frances Willard Elementary receives training for implementation of Tier Two and begins implementation.

Frances Willard Elementary implements three tiers of Interconnected Systems Framework.

Isaac Tripp Elementary, McNichols Plaza Elementary, and South Scranton Intermediate all receive training to implement Tier One SWPBIS.

Isaac Tripp Elementary, McNichols Plaza Elementary, and South Scranton Intermediate all implement Tier One SWPBIS.

George Bancroft Elementary and Scranton High receive training for implementation of Tier Two and begin implementation

Scranton High receives training and begins implementation of RENEW.

SBBH Teams begin implementation at Northeast Intermediate, John F. Kennedy Elementary, McNichols Plaza Elementary, and John G. Whittier Elementary.

John F. Kennedy Elementary, John G. Whittier Elementary, and Northeast Intermediate all receive training to implement Tier One SWPBIS.

John F. Kennedy Elementary, John G. Whittier Elementary, and Northeast Intermediate all implement Tier One SWPBIS.

Tier 3/Tertiary Interventions 1-5%1-5% Tier 3/Tertiary Interventions

•SBBH Team•Outpatient therapy•SB Partial•Guidance – individual support•SAVES/school aged mothers

Tier 2/Secondary Interventions 5-15%5-15% Tier 2/Secondary Interventions

•SAP•Guidance – groups•Community Partners – groups•Resource Officer

Tier 1/Universal Interventions80-90%

80-90% Tier 1/Universal Interventions•SWPBIS•Drug and Alcohol Prevention

School-Wide Systems for Student Success:A Response to Intervention (RtI) Model:

Resources

Illinois PBIS Network, Revised May 15, 2008. Adapted from “What is school-wide PBS?” OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports. Accessed at http://pbis.org/school-wide.htm

Needs

Scranton High School

Key features• Systems

– District and building teaming models – Facilitation, technical assistance, coaching– Stakeholder participation and buy-in

• Practices– Mental health and school staff work in an integrated way to support

students across tiers– Using assessment and screening in order to determine which EBPs to

use, progress monitor– One plan for both education and mental health

• Data– Shared decision rules– Used for decision making with all stakeholders at the table – school, mental health,

other child serving systems, family

OutcomesChange in Family Functioning

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Change at 3 mos Change at 6 mos Change at 9 mos

Not Implementing Low Fidelity High Fidelity

Impr

ovin

g

OutcomesChange in Child Functioning

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Change at 3 mos Change at 6 mos Change at 9 mos

Not Implementing Low Fidelity High Fidelity

Impr

ovin

g

The Smith Family

• Jason was referred to the SBBH Team in November. He is a seven-year-old first grader who was having difficulty coming to school and being separated from his mother.

• When he was four, Jason and his family were in a car accident in a rural area. The members of the family were taken to different hospitals and Jason did not know where his mom was or if she was okay.

• Every day, since the first day of school, Jason’s mom would bring him into the school and the school staff would literally have to peel Jason off of his mother and hold him so she could leave.

The Smith Family cont.

• Once referred to the team, they were immediately able to work with Jason and his family to create strategies to help him separate more smoothly.

• Jason found the SBBH Team office/room a safe place to be. His mother also spent time there to help create a nice transition area.

• After the Holiday break, Jason began riding the bus for the fist time, accompanied by one of the BHWs from the team.

• Soon, Jason was able to ride the bus on his own, increasing his confidence and allowing him some relief from his anxiety.

Lessons Learned

• Return on investment• Funding efficiency• Scaling and sustaining SBBH Teams – size• Community “politics”

For More Information:

• www.sharedwork.org• www.pbis.org