School Mental Health Perspectives
from Baltimore and Beyond
Mark D. Weist
Center for School Mental Health Analysis
and Action, University of Maryland
October, 2005
Outline
The Baltimore Experience
Needs of Youth and Reasons for School
Mental Health
A Public Mental Health Promotion Approach
Empowering Educators
An Emerging Advocacy Agenda
Baltimore
A city of around 600,000 growing again
Significant sociodemographic challenges
Collaborative relations between committed child
system leaders
Vigorous non-acceptance of Same Old Same Old
History in school health
Funding experience and perseverance
Interdisciplinary networks
Political will and activism
School Mental Health Program
Established in 1989 in 4 schools
Currently operating in 30 schools
Annual budget of around $1.1 million
($800,000 contracts; $300,000 fee-for-service)
Interdisciplinary group of about 30 staff
SMHP – 10 Program Qualities
We build from the access advantage
We strive to be viewed as from the school
Families, youth and other stakeholders guide the
program
A proactive, energetic approach is taken
A full range of services is provided
10 Program Qualities (cont.)
Continuous quality improvement is emphasized
We help to build school-community partnerships
We’re careful about diagnoses, and focus on strengths
and environmental interventions
We are truly interdisciplinary
We strive for services to be developmentally and
culturally relevant and based on evidence of positive
impact
Center for School Mental Health
Analysis and Action
CSMHA
Established in 1995 with a grant from the
Health Resources and Services Administration
(HRSA)
Renewed 5-year funding in 2000 from HRSA,
with co-funding from the Substance Abuse and
Mental Service Administration (SAMHSA)
Renewed 5-year funding in 2005 from HRSA
and SAMHSA with a focus on policy analysis
and dissemination
Needs of Youth and Reasons for
School Mental Health
The Crisis of Youth Mental Health in
the U.S.
About 20% of youth, ages 9 to 17 (15 million),
have diagnosable mental health disorders, (and
many more are at risk or could benefit from help)
Between 9-13% of youth, ages 9-17 years, meet
the federal definition of serious emotional
disturbance (SED)
The Crisis of Youth Mental Health in
the U.S. (cont.)
Less than 30% of youth with diagnoses receive
any services, and these services are often
inadequate
For the small percentage of youth who do receive
services, most actually receive them in schools
Growing Focus on School Mental
Health (SMH) in the U.S.
U.S. Surgeon General Reports (1999, 2000)
President’s New Freedom Commission on Mental Health
Report (2003)
Mandates of “No Child Left Behind” and Individuals
with Disabilities Education Act (IDEA)
Progress in localities and states
Collaborative research-practice-training networks
President’s New Freedom Initiative
First presidential commission on mental health
since 1978
Widely disseminated document: Achieving the
Promise: Transforming Mental Health Care in
America (see www.mentalhealthcommission.gov)
6 goals, 19 recommendations
Impact expected to last for “decades”
President’s New Freedom
Commission (cont.)
Goal 4: Early Mental Health Screening, Assessment and
Referral to Services are Common Practice
4.1 Promote the mental health of young children
4.2 Improve and expand school mental health
programs
4.3 Screen for co-occurring mental and substance abuse
disorders and link with integrated treatment
strategies
4.4 Screen for mental disorders across the lifespan and
connect to treatment supports
In Addition to Enhanced Access,
SMH can:
Reduce stigma for help seeking
Promote generalization/maintenance of intervention
gains
Enhance capacity for prevention/MH promotion
Foster clinical efficiency and productivity
Promote a natural, ecologically grounded approach to
helping youth and families
SMH Impacts
Based on a limited knowledge base, when
done well SMH programs and services are
associated with:
– Strong satisfaction by diverse stakeholder groups
– Improvement in student emotional/behavioral
functioning
– Improvement in school outcomes (e.g., climate,
special education referrals, reduced bullying, fewer
suspensions)
Expanded School Mental Health
(ESMH):
Programs join families, schools, mental health
and other community systems
To develop a full array of effective programs
and services that improve the school
environment, reduce barriers to learning, and
provide prevention, early intervention and
treatment
for youth in general and special education
Critical Challenges for the Field
ESMH still in a relatively small percentage of
schools
Efforts remain marginalized and undersupported (STIGMA)
Interdisciplinary and intersystem turf and
tension
Considerable variability in experience
Limited community ownership of the
programs
A Central Challenge
School mental health is a tenuously supported field
with efforts in most communities scattered at best
Scattered, unsupported services do not lead to the
achievement of critical outcomes
We need to build support for effective services to
enable the documentation of enhanced outcomes,
which will in turn fuel advocacy efforts and bring
needed resources into the field
A Time of Great Opportunity
Two plus decades of experience in ESMH
Growing federal awareness and support
Many communities showing strong leadership
Development of organized national and state
networks
Increasing international discussion and
attention (see www.intercamhs.org)
A Public Mental Health
Promotion Approach
Factors Necessary to Achieve Desired
Outcomes for Youth Through ESMH Programs
and Services (Weist, Paternite & Adelsheim, 2005)
Effective mental health promotion, problem prevention
and intervention
Outstanding staff and program qualities
Ongoing 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
“Enhancing Quality in Expanded
School Mental Health”
Three year, three state (Delaware, Maryland,
Texas) study seeking to implement and
evaluate a framework for systematic quality
assessment and improvement in school mental
health
Funded by the National Institute of Mental
Health (2003-2006)
Principles for Best Practice in
Expanded School Mental Health
1) All youth and families are able to access
appropriate care regardless of their ability to pay
2) Programs are implemented to address needs
and strengthen assets for students, families,
schools, and communities
3) Programs and services focus on reducing
barriers to development and learning, are student
and family friendly, and are based on evidence of
positive impact
Principles (cont.)
4) Students, families, teachers and other important
groups are actively involved in the program's
development, oversight, evaluation, and
continuous improvement
5) Quality assessment and improvement activities
continually guide and provide feedback to the
program
6) A continuum of care is provided, including
school-wide mental health promotion, early
intervention, and treatment
Principles (cont.)
7) Staff hold to high ethical standards, are
committed to children, adolescents, and
families, and display an energetic, flexible,
responsive and proactive style in delivering
services
8) Staff are respectful of, and competently
address developmental, cultural, and
personal differences among students,
families and staff
Principles (cont.)
9) Staff build and maintain strong
relationships with other mental health and
health providers and educators in the
school, and a theme of interdisciplinary
collaboration characterizes all efforts
10) Mental health programs in the school
are coordinated with related programs in
other community settings
Integrated Systems to Support the
Development of All Children
Systems of Prevention and Promotion
All Students (universal)
Systems of Early Intervention
Students At-Risk (selected)
Systems of Treatment
Students with Problems
(indicated)
School, Family, and Community Partnerships
From: Zins (in progress).
Importance of Family Partnerships
SEARCH Institute study:
– As parental involvement in schools increased,
problem behaviors in students (alcohol use,
violence, antisocial problems) decreased
– Roehlkepartain & Benson, 1994
Barriers to Family Partnerships
Service availability
Stigma
Fear of being blamed
Feeling unwelcome in the school
Fear of violated confidentiality
Perceived lack of mutuality
Traditional Approach
“In the past, families were seen primarily as
contributing to the mental health problems of
their children, and their ONLY ROLE was in
treatment to alter their structure and/or
functioning” (Osher, 2001)
Best Approach
“The model of therapist as expert is replaced
by a shared-learner framework in which both
parties (family member and clinician)
contribute knowledge and insight” (Axelrod et
al., 2003)
Key Processes in Working with
Families
Engagement
Empowerment
Support
Collaboration
Engagement
In initial family contacts:
– Clarify child’s need for services
– Openly discuss attitudes and past experiences with the
mental health system
– Identify and strategize about probable obstacles
– Identify concrete, practical issues that can be addressed
immediately
– Establish communications systems to promote continuity
and stability in services (see McKay, Nudelman, &
McCadam, 1996)
Empowerment
Reduce perceived barriers to successful outcomes
Develop realistic and optimistic goals for treatment
Provide or provide access to relevant information
Ensure collaborative decision making and parental
choice
Encourage involvement in relevant organizations and
in advocacy
Support
Connect families to needed resources
Together consider sources of support within
the family, neighborhood and community, and
at state and national levels
Be encouraging and optimistic in all
interactions
Collaboration
Involve family members as equal partners in
understanding problems and in developing and
implementing interventions to address targeted
problems
On an ongoing basis request feedback from families
about how you are doing, how the program is doing,
and how the community is doing in responding to the
needs of children, asking for their recommendations
An Excellent Overview Article:
Hoagwood, K.E. (2005). Family-based services in children’s mental health: A
research review and synthesis. Journal of Child Psychology and
Psychiatry, 46(7), 690-713.
Deciding on Roles in a School
(no stereotyping intended)
Sch. Psy.
Sch. SW.
Sch. Co.
Com. St.
Primary
Secondary
XOXOXO XXXXXX
XOXOXO
XOX0
OOO
XO
OOOOOO
GEN.ED=O
SPEC.ED=X
Tertiary
XX
XXXXXX
OOOOOO
The Optimal School Mental Health
Continuum?
10-20% Broad Environmental Improvement
and Mental Health Promotion (CHANGE
AGENT ROLE)
50-60% Prevention and Early Intervention
(PREVENTION SPECIALIST ROLE)
20-30% Intensive Assessment and Treatment
(THERAPIST ROLE)
Change Agent Activities
Promote positive relationships in the school
Participate on school planning teams
Assist in mapping and coordinating various
programs and services
Assist in bringing resources into the school
Help to improve the environment
Strategies for Environmental
Improvement
Assess the school climate; problem solve with
peers and families and students on strategies
for improvement
Use the Assets framework to promote staffstudent engagement and positive relationships
Assist in ensuring school safety
Assist in bringing in resources (e.g., mentoring
programs, community members as hall
leaders)
WHO 2003: Psychosocial
Environment (PSE) Profile
Friendly, rewarding and
supportive atmosphere
Supports cooperation
and active learning
Forbids physical
punishment and
violence
Does not tolerate
bullying/harassment
Values the development
of creative activities
Connects school and
home life
Promotes equal
opportunities for
participation
Prevention Specialist Activities
“Triage” mental health (1-3 sessions without
diagnosis)
Working collaboratively with educators to
improve classroom behavior
Building a theme of mental health skills as
promoters of student learning
Implementing skill training groups
The Effective Therapist
Feels well trained, supervised and supported
Feels integrated into the school(s)
Is able to establish and maintain strong
relationships with other staff and with students
and families
Interacts with families and students as
collaborators, building on their strengths
Is able to conduct an assessment in a way that
is therapeutic
The Effective Therapist (cont.)
Is able to match delivered services to students
and families in a way that optimally matches
their presenting needs and goals
Develops and implements interventions from
the science base
Works closely with a range of people
important to the student
The Effective Therapist (cont.)
Is continually evaluating whether the current
plan and services are effective, and is making
adjustments when indicated
Understands and makes explicit differences in
role functioning (e.g., as therapist vs. mentor)
Closes cases when problems are mostly
resolved in a way that is collegial and allows
for some ongoing contact
Three Critical Themes in Intervention
Reduce, help to buffer stress and risk
Enhance protective and resilience factors
Train in evidence-based skills
Addressable Stress/Risk Factors
Family Level
–
–
–
–
–
–
–
Abuse and neglect
Criminal behavior
Substance abuse
Family isolation
Overcrowding
Emotional/behavioral problems in family members
Morbidity and mortality in family members
Addressable Protective Factors
Family level
– Support and nurturance
– Rituals and routines
– Self-control displayed and modeled by family
members
– Healthy behaviors by family members
Top Evidence-Based Practices
•
•
•
•
•
•
•
•
Parent praise
Cognitive coping
Parent psycho-education
Modeling
Problem solving
Skill building/behavioral rehearsal
Maintenance/relapse prevention
Tangible rewards
See. Bruce Chorpita, and Evidence Based Services Committee
(2004). Biennial report: Summary of effective interventions
for youth with behavioral and emotional needs. Hawaii
Department of Health, Child and Adolescent Mental Health
Division.
Having Goals
School
Helping Others
On time
Pay attention
Health
Do work
Exercise
study
Nutrition
Sleep
Athletics
Birth
Positive Friends
Thinking Skills
Support from Positive Adults
Great wife, kids,
job, house, car
Age 25
Faith/Church
A thousand possible future
lives depending on the daily
choices you make
Age 15
Roaming the halls Wrong friends
Skipping school
Not doing school
work
Violent media
Exposure to violence
Alcohol and drug use
Being in the wrong places
Life Trajectories
Age 25
Jail, sickness,
addiction, death
Empowering Educators
Teachers are the “De Facto” providers
of mental health to youth in the U.S.
This fact needs acknowledgement in local,
state, and national policy
There is a significant need to empower
teachers to fulfill this critical role
Mental Health Education Integration
Consortium (MHEDIC)
Working to improve interdisciplinary training
and collaboration between educators and
mental health staff
Making recommendations to address
limitations in training for both groups
Mental health training for educators should be
based on “backward analysis” of needs
presenting in classrooms
MHEDIC (cont.)
Key mental health skills for teachers:
– Identifying emotional/behavioral problems within
students
– Referring students with emotional/behavioral
problems for assistance
– Promoting positive classroom behavior
– Using mental health concepts to promote learning
Mental Health Concepts that Promote
Learning
Self-instruction (e.g., developing an internal
dialogue)
Problem solving (e.g., considering costs and
benefits of actions)
Self-control and–reinforcement (e.g., work
before play)
Template matching (e.g., modeling actions of
B+ students)
Ten Variables that Affect Compliance
Make direct requests
Make specific requests from shorter distances in soft
but firm voice
Make eye contact
Limit to two requests
Give child 3-5 seconds to comply (without speaking)
Make more start vs. stop requests
Control negative emotions
Reinforce compliance
Levels of Crisis Development
Anxiety: muttering, excessive movement, pacing,
vacant, or withdrawn
Staff Response: Supportive
– Empathic
– Active listening
– Avoid being judgmental
Most potentially explosive situations diffused at
this level
An Emerging Advocacy Agenda
The Need for Advocacy Training
Most people in most child serving systems
have little or no training in effective advocacy
Advocacy Involves:
Bringing diverse people together around a
common theme
Understanding the lay of the land in terms of
the problem and existing efforts to address it
Developing an idea that works better
Increasing support for the idea and refining it
Facilitating the translation of the idea into
policy and practice change with necessary
resource/system enhancements
Barriers to Support of ESMH
Concerns about:
–
–
–
–
confidentiality/ privacy
competition for resources
effectiveness
appropriateness
Myths about School Mental Health
“Manipulating children’s minds”
Teaching “new age” concepts
Compromising family values
Providing services without parental approval and
parental consent
Stigma is Huge
Being called “crazy” is about the worst thing
you could be called
Stigma accounts for significant utilization
problems
Knowledge removes stigma
Addressing Stigma
MESSAGES
Mental health is a positive concept, conveying
positive thoughts, feelings and actions that
contribute to success in life
Mental health problems are universal. We all
have at some point in our lives
Seeking mental health assistance is a sign of
strength
Addressing Stigma (cont.)
ACTIONS
Conduct education for students, families and
staff, conveying messages of previous slide
Appropriately self-disclose
Respect family and student privacy and
confidentiality
Empower some students and families to show
their support for the school’s mental health
efforts
Toward Funding for a Full Continuum of
Programs and Services
Maximizing all potential sources of revenue:
– allocations from schools and departments of
education
– state and local grants and contracts
– federal and foundation grants and contracts
– “line item” support
– innovative prevention funding
– fee-for-service
The Critical Challenge of Federalism
State of residence determines whether youth use
mental health more than race/ethnicity or income
Differences in mental health use by children across
states are generally not related to differences in levels
of need (e.g. AL and TX present higher rates of need
but lower rates of use)
– Sturm, Ringel & Andreyeva, 2003 (www.pediatrics.org)
Mission
To help Ohio’s school districts, community-based
agencies, and families work together to achieve improved
educational and developmental outcomes for all children
— especially those at emotional or behavioral risk and
those with mental health problems.
2nd Community Building Forum and 10th
Annual Conference on Advancing School
Mental Health
Federal funders, HRSA, SAMHSA, OSEP
Major Partners: IDEA Partnership, NASDSE,
CSMHA, Ohio Mental Health Network for School
Success
Cleveland Ohio, October 26 (Forum) – 29, 2005
Come to Cleveland, the City that Rocks!!
See http://csmha.umaryland.edu or contact Christina
at chuntley@psych.umaryland.edu
INTERCAMHS
International Alliance for Child and
Adolescent Mental Health and Schools
www.intercamhs.org
UCLA Center for Mental
Health in Schools
Directed by Howard Adelman and Linda
Taylor
Phone: 310-825-3634
Enews: listserv@listserv.ucla.edu
web: http://smhp.psych.ucla.edu