Linking School Behavioral
Health within a MultiTiered System of Support
JoAnne M. Malloy, Ph.D.
Institute on Disability at the University of New Hampshire
The Annual Bradley Kidder School Law Conference
October 7, 2015
Agenda

The need – social/emotional development

Define behavioral health and school behavioral health

A Framework and Model for Effective Action: Multi-Tiered
Systems of Support

Developing community partnerships within a Multi-Tiered
Model

Examples
Acknowledgements





Lucille Eber, Director, Illinois Midwest PBIS Network
Mary Steady, Director, Office of Student Wellness, NH DOE
Nancy Lever & Sharon Stephan Co-Directors, National
Center on School Mental Health, University of Maryland
George Sugai, OSEP Center on Positive Behavioral
Interventions & Supports
Howard Muscott, Eric Mann, NH Center for Effective
Behavioral Interventions and Supports at SERESC
What are we talking about?

Mental health is “a state of well-being in which the
individual realizes his or her own abilities, can cope with
the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to his or her
community.”
(World Health Organization, 2001)

Mental illness is defined as “collectively all diagnosable
mental disorders” or “health conditions that are
characterized by alterations in thinking, mood, or
behavior (or some combination thereof) associated with
distress and/or impaired functioning.”
(U. S. Department of Health and Human Services, 1999)
In a given
classroom of 25
students….
1 in 10 will
experience
a mental
health
problem of
severe
impairment
1 in 5 will
experience
a mental
health
problem of
mild
impairment
Less than half of those who need it will get services
Mental Health Needs of Youth

School is the “defacto” Mental Health provider

Juvenile Justice system is next level of system default

1-2% identified by schools as Emotional Behavioral
Disabilities

Those identified have poor outcomes

Suicide is 4th leading cause of death among youth
6
School Climate &
Discipline
School Violence & Mental
Health
Disproportionality &
School-Prison Pipeline
Recommendations in Justice/Education
Letter
I. Climate and Prevention
(A) Safe, inclusive, and positive school climates that provide students with
supports such as evidence-based tiered supports and social and emotional learning.
(B) Training and professional development for all school personnel
(C) Appropriate use of law enforcement
II. Clear, Appropriate, and Consistent Expectations and Consequences
(A) Nondiscriminatory, fair, and age-appropriate discipline policies
(B) Communicating with and engaging school communities
(C) Emphasizing positive interventions over student removal
The U.S. Department of Education and the U.S. Department of Justice Departments
“guidance to assist public elementary and secondary schools in meeting their
obligations under Federal law to administer student discipline without discriminating
on the basis of race, color, or national origin” 2014
You see the need in your schools


Increasingly diverse student population

Language, SES,

Academic ability (range)

Social behaviors

Stressors at home / community
To meet the range of needs, teachers need to:

Employ a range of instructional strategies

Teach classroom routines to support higher level thinking skills

Encourage student behaviors

Pointed toward self-management
Who’s in our prisons and jails…

Youth with disabilities (21%)

African American and Hispanic youth in disproportionate
numbers
Youth and young adults who have been exposed to trauma (30%60%)


PTSD prevalence in the juvenile justice population range
between 30 and 50%

High rates of physical or sexual abuse victims among the jj
population
Average reading level of incarcerated youth and adults is 4th
grade

(Arroyo, 2001; Garland et al., 2001; Martin, Martin, Dell, Davis, & Guerrieri, 2008;
Teplin et al., 2002; Wasserman, et al., 2002; Cauffman, et al., 1998).
But… What can you do?
 You’re
concerned about safety
concerned about your staff
 You’re concerned about the students who
are doing just fine
 You have principals calling you every day
asking for help…
 Other concerns….
 You’re
You have to be responsive….and… you can be
proactive
We now know how to prevent the development of
or ameliorate the severity of mental disorders in
youth
The Adverse Childhood Experiences (ACE) Study
Vincent J. Felitti, M.D.
Robert F. Anda, M.D.
• The largest study of its kind ever done to examine
the health and social effects of adverse childhood
experiences over the lifespan (18,000 participants)
Categories of Adverse
Childhood Experiences
Category
Prevalence (%)
Abuse, by Category
Psychological (by parents)
Physical (by parents)
Sexual (anyone)
11%
11%
22%
Household Dysfunction, by Category
Substance Abuse
Mental Illness
Mother Treated Violently
Imprisoned Household Member
26%
19%
13%
3%
Adverse Childhood Experiences Score
Number of categories adverse childhood
experiences
are summed …
ACE score Prevalence
0
48%
1
25%
2
13%
3
7%
4 or more
7%
• More than half have at least one ACE
• If one ACE is present, the ACE Score is likely to
range from 2.4 to 4
Adverse Childhood Experiences are highly
correlated with the ten most common causes of
death in the United States.
Top 10 Risk Factors:
 Smoking
 severe
(cardio-vascular disease, pulmonary disease, cancer)
obesity (diabetes and related diseases)
 physical
inactivity,
 depression,
 suicide
attempt,
 alcoholism,
 illicit
drug use,
 injected
drug use,
 50+
sexual partners and unwanted pregnancies, and,
 STD
(sexually transmitted disease)
Impact of Trauma on Development
Impairment of:
 Attachment
 Biological
 Affect
Impacts
Regulation
 Dissociation
 Behavioral
Regulation
 Cognition
 Self-Concept
 Family
Context
Science of Early Brain and Child Development
(Shonkoff, 2002)
Cognitive, emotional and social capacities are
inextricably intertwined and learning,
behavioral, physical, and mental health are
interrelated over the life course
 Toxic stress in early years can damage
developing brain architecture and lead to
learning and behavioral problems and
susceptibility to physical and mental illnesses
 Brain plasticity and the ability to change
behavior decrease over time

What are the impacts of trauma on
children?
•
Emotional development
•
Social development
•
Cognitive development
•
Physical development
Development in these areas are affected by actual
changes in the brain, neurochemistry, and fear
response systems
All human behavior is an attempt to…

Meet one or more basic needs (Mastery, Belonging,

Regulate stress & deal with uncomfortable emotions
Draw attention to self
Avoid unpleasant, uninteresting, too difficult, or too easy
activities
Gain control over ones environment
Gain access to enjoyable activities
Obtain justice/revenge





Independence, & Generosity)
There is a clear link between maltreatment
and the development of emotional and
behavioral disorders:
Cerezo-Jimenez, M. A., & Frias, D., 1994; Cook, A., Spinazzola, J., Ford,
J., Lanktree, C., Blaustein, M., Cloitre, M., DeRosa, R., Hubbard, R.,
Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & van der Kolk, B., 2005;
De Bellis, M. D., 2005; Ethier LS, Lemelin JP, & Lacharité C., 2004;
Herman, J. L., 1992; Hildyard, K. L., & Wolfe, D. A., 2002; Kim, J., &
Cicchetti, D., 2003; Saigh, P. A., Yasik, A. E., Oberfield, R. A.,
Halamandaris, P. V., & McHugh, M., 2002; Schore, 2001; Toth, S. L.,
Manly, J. T., & Cicchetti, D., 1992; Widom, C. S., 1999; Zinzow, H.J.,
Ruggiero, K.G., Hanson, R. F., Smith, D. W., B. E. Saunders, B. E. &
Kilpatrick, D. G., 2009
There is a clear link between maltreatment
and poor school performance
Cicchetti, Toth, & Hennessy, 1993;
Ethier, Lemelin, & Lacharit´e, 2004;
Reyome, 1993;
Eckenrode, Laird, & Doris, 1993;
Kendall-Tackett., & Eckenrode, 1996;
Leiter, & Johnsen, 1997;
Nelson, Benner, Lane, & Smith, 2011;
Shonk, & Cicchetti, 2001
Developmental Trauma Disorder
(van der Kolk, 2005)
“many problems of traumatized children can be
understood as efforts to minimize objective threat
and to regulate their emotional distress” (p.403)
These
are survival responses to disordered or
dangerous environments
“{the child’s} maladaptive behaviors tend to inspire
revulsion and rejection…and is likely to lead to
labeling and stigmatizing children for behaviors that
are meant to ensure survival.” (p. 404)
Kelsey- Conflict
 Neurological
basis for the behavior: Fight
or Flight
Families and caring adults are a big part
of the solution
Protective Factors include:
 Sense
of safety and consistency
 Psychological
 Nurturing
 How
support, non-blaming and non-stigmatizing responses
from loved ones, parental health,
the family and culture interpret traumatic event
 Availability
 Helpers,
of and power of resources
support, aid agencies
SS/HS Framework: Guiding Principles

Cultural and linguistic competency

Developmental appropriateness

Evidence-based interventions

Resource leveraging

Service for vulnerable and at-risk populations

Sustainability

Youth guided

Family-driven
(SAMHSA SS/HS RFP, 2013, p.17)
Few
Some
The Mul(-­‐Tiered
Framework: A Con(nuum
of Evidence-­‐Based
Supports and
Interven(ons
All
PBIS (aka SWPBS, MTSS-B, MTBF, RtI-B…)
Framework
Continuum
Academically
All
A Systematic, Research-Based
Framework
CORE FEATURES
MTSS/PBIS
What works for all students….

More positive than negative contacts

Predictable, consistent, & equitable treatment

Challenging academic success

Adults modeling expected behavior

Recognition & acknowledgement

Opportunity to learn

Safe learning environment

Academic & social engagement
Pyramid of
Interventions
Matched to the
Needs of the
Children/Youth
Level III: Intensive, Individual
Interventions
•GEDO
•PLP
•SDA Diploma
•MSP
•RENEW
•Complex FBA/BSP
C ommunity Agency Referrals
•Community Partners
•HUB
•North Star
Level II: Targeted Interventions
• CICO
•Social Skills Groups
•Simple FBA
•Anger Management
Groups
•Mediation
•Adult Ed Classes
•Credit Recovery
•Truancy
Interventions
•Drug and Alcohol
Counseling
• Alt Study
Level 1: Universal Interventions and Supports
• Differentiated Instruction
•Parent Contact
•Student /Teacher Conference
• Parent/teacher Conference
•Guidance Support
•ELO’s
•Extracurricular Activities
• B ehavior matrix
•RQQP
•VLACs
•After School Support
•Freshman Experience/Academic
Skills
* Created by Somersworth High School & NH RESPONDS Facilitator
Positive Behavior Intervention & Support
(www.pbis.org)
Currently in about 20,000 schools nationwide
 Decision
making framework to guide selection and implementation of
best practices for improving academic and behavioral functioning
 Data based decision making
 Measurable outcomes
 Evidence-based practices
 Systems to support effective implementation
2014
RCT & Group Design PBIS Studies
Bradshaw, C.P., Koth, C. W., Thornton, L. A., & Leaf, P. J. (2009). Altering school climate through school-wide
Positive Behavioral Interventions and Supports: Findings from a group-randomized effectiveness
trial. Prevention Science, 10(2), 100-115
• R ed
uced m
ajor dis
• Imp
ciplina
rove
ryeffects
infrofacSchool-Wide
Bradshaw, C. P., Mitchell, M.
M.,m
&e
Leaf, P. J. (2010). Examining the
Positive Behavioral
nt inoutcomes:
ticontrolled
Interventions
Supports on student
Results from a randomized
conandce
on effectiveness trial in
aggre
elementary schools. Journal
Interventions,
ntratiofoPositive Behavior
ssive b12, 133-148. s
n
,
e
p
m
ro
Bradshaw, C. P., Pas,oE.
A., Rosenberg,
S., & Leaf, P.e
J.h
(2012).
school-wide
avioIntegrating
socM.iatier
tiT.,interventions
nGoldweber,
r,
a
positive behavioralo
and supports with
2bcoaching
to student
support
teams: The PBISplus
l
l
re
e
h
guHealth
model. Advances in School Mental
latiPromotion
• Imp
on 5, 177-193.avior, &
rovW.em
Bradshaw, C. P., Reinke,
M., Brown, L. D., Bevans, K. B., & Leaf, P. J. (2008). Implementation of school-wide
Positive Behavioral Interventions
and Supports (PBIS) in elementary schools: Observations from a
en& ts
in
randomized
trial. Education
Treatment
of
Children,
31, 1-26.
a
• Enh
ca d e m
anceT.dE. & Leaf, P. J. (2012).
Bradshaw, C. P., Waasdorp,
Effectsic
of School-Wide
achievPositive Behavioral Interventions and
percep
Supports
on child behavior
130(5), 1136-1145.
ement
hea
lth & T.sE., &problems. Pediatrics,
tiC.oP.n(inopress).
Goldweber, A., Waasdorp,
link between forms of bullying
f orgExamining
afeBradshaw,
ty
anizatheschool
behaviors and perceptions of safety
and belonging among
secondary
Journal of School
• Psychology.
tionstudents.
R educ
al
tions inK., Eber, L., Nakasato, J., Todd, A., & Esperanza,
Horner, R.,
G., Smolkowski,
J., (2009). A randomized,
beSugai,
tetrial
acassessing
hcontrolled
wait-list
effectiveness
school-wide positive behavior support in elementary
avioofr Positive
h
e
r
re
schools. Journal
Behavior
Interventions,
11,
133-145.
& pee
ported
r M. (2010).
• Im
bully
jectiExamining
Horner,
R. H.,
Sugai, G., & Anderson, C. re
the evidence
base for school-wide positive behavior
pro
ing
o
support.
Focus
veondExceptionality,
sch o 42(8), 1-14. n
l clim
Waasdorp, T. E., Bradshaw, C. P.,o
& Leaf,
P. J. (2012). The impact of School-wide Positive Behavioral
ate and peer rejection: A randomized controlled effectiveness
Interventions and Supports (SWPBIS) on bullying
Bradshaw, C. P., Koth, C. W., Bevans, K. B., Ialongo, N., & Leaf, P. J. (2008). The impact of school-wide Positive
Behavioral Interventions and Supports (PBIS) on the organizational health of elementary schools. School
Psychology Quarterly, 23(4), 462-473.
trial. Archives of Pediatrics and Adolescent Medicine, 116(2), 149-156
PBIS is a foundation…but more is
needed…

Many schools implementing PBIS struggle to
implement effective interventions at Tiers 2 and
3.

Youth with “internalizing” issues may go
undetected.

PBIS systems (although showing success in social
climate and discipline) often do not address
broader community data and mental health
prevention.
School Behavioral Health
School Behavioral Health involves a partnership between
schools and community behavioral health organizations as
guided by families and youth. Community partners
essentially build on existing school programs, services,
and strategies with the intent of focusing on all students,
both those, for example, who are in general education,
as well as those receiving special education services. And
when we talk about community-partnered school
behavioral health, we really are talking about a full array
of programs, services, and strategies, all the way from
behavioral health education and promotion to more
intensive intervention.
(Stephan, 2015)
Advancing
Education
Effectiveness:
Interconnecting
School Mental
Health and
School-Wide
Positive Behavior
Support
Editors: Susan Barrett,
Lucille Eber and Mark Weist
hAps://www.pbis.org/common/cms/files/Current%20Topics/Final-­‐Monograph.pdf
Barriers to accessing traditional
mental health care

Financial/Insurance
Childcare
Transportation
Mistrust/Stigma
Past Experiences
Waiting List/Intake
Process
Stress

What do you think?






ISF Defined



Tiered prevention logic.
Cross system problem solving teams.
Use of data to decide which evidence
based practices to implement.
Progress monitoring for both fidelity and
impact.
 Active involvement by youth, families,
and other school and community
stakeholders.

Behavioral Health community partners are
embedded throughout the system (all
Tiers)
Why?
To expand and increase accessibility to
interventions and data sources used to
guide system design.
Partners will help evaluate the practices
that expand access and options.
The NIRN: “Stop chasing shiny objects”
Implementation
Research:
A Synthesis of the
Literature
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005).
Implementation Research: A Synthesis of the Literature. Tampa, FL: University
of South Florida, Louis de la Parte Florida Mental Health Institute, The National
Implementation Research Network (FMHI Publication #231).
© Dean Fixsen, Karen Blase, Robert Horner, George Sugai, 2008
42
What can we do? What works?
Safe Schools/Healthy Students Model:
5 Interrelated Elements:
Element 1: Promoting Early Childhood Social Emotional
Learning and Development
Element
2: Promoting Mental, Emotional, and Behavioral
Health
Element 3: Connecting Families, Schools, and Communities
Element
4: Preventing and Reducing Alcohol, Tobacco, and
Other Drug Use
Element
5: Creating Safe and Violence-Free Schools
Form a District Community Team

Ensure representation:

School administrators, specialists, family members and
family organizations, community behavioral health
providers, law enforcement, juvenile justice, child welfare,
community mental health, cultural brokers, early childhood
experts and providers, youth leaders.

Look at your data and make it public: attendance,
suspensions, dropouts, office referrals, surveys of staff,
students, and families, assess your existing resources and
interventions. Disaggregate your data by subgroups.

Define success in measurable terms.

“Is what we are doing working?”
Assess your intervention systems in
every building- USE DATA! BE HONEST!

Is there a rational multi-tiered system or continuum in place? Is it
clear to everyone in your buildings what the system is?

Do you have an easy-to-use and accessible data system in place?

Are there teams that focus on the levels of intervention?

What are we doing for all students? Is it working?

Who are the students who are not succeeding and what are their
needs? Internalizing behaviors? Externalizing behaviors?

What interventions are available to meet their needs? Are they
evidence-based or best practice? YOU ARE A CONSUMER OF
PRACTICES…
Make sure your crisis management systems
are in place….

Is there a robust and specific crisis plan in place in every
one of your buildings and do staff know exactly what to
do?

Send your staff to Youth Mental Health First Aid training.
Trainings are organized by the NH DOE Office of Student
Wellness.
Youth Mental Health First Aid is designed to teach parents,
family members, caregivers, teachers, school staff, peers,
neighbors, health and human services workers, and other
caring citizens how to help an adolescent (age 12-18) who
is experiencing a mental health or addictions challenge or
is in crisis.
http://www.mentalhealthfirstaid.org
EXAMPLE: Memoranda of Understanding Between
Community Mental Health Centers and School Districts
within the SS/HS Framework

Designed to create collaborative relationships between communitybased clinicians and school staff

Features of the MOUs:
 Clinicians are supported by the district to sit on Tier 1, Tier2, and Tertiary
Implementation Teams* (community mental health reimbursement is clientspecific)
 Clinicians are supported by the district to help plan and provide school-wide
and small group (Tier 2) evidence-based interventions such as….

Education for faculty of trauma-informed care.

Co-lead Coping Cat groups with school staff.

Develop functional behavioral support plans for non-mental health eligible students.

Design a facilitated referral process and promote student screening and
assessments.
Concord School District MOU with Riverbend
Community Mental Health Center
KEY COMPONENTS OF THE CONCORD SCHOOL DISCTRICT SAFE SCHOOLS/HEALTHY
STUDENTS CONTRACT WITH RIVERBEND COMMUNITY MENTAL HEALTH CENTER
Riverbend Community Mental Health will:
 Provide
clinical and administrative supervision to Riverbend staff who provide
services in the Concord School District
 Bill
for services on a monthly basis
Clinician activities will include:
 Participation
in school-based teams
 Facilitation
school-based psycho-educational groups to promote social, emotional
and mental health.
 Provision
of consultation, mental health education and prevention information to
school personnel.
Concord School District MOU with Riverbend
Community Mental Health Center (cont.)
Clinicians will:
 Provide
appropriate feedback to assist school staff in the implementation of
behavior plans and service planning.
 Facilitate
parent education activities.
 Serve
as a liaison with Riverbend Community Mental Health Center and
facilitate communication and referrals (Facilitated Referral Process)
 Adhere
to relevant school related confidentiality regulations and district
policies
 Exercise
clinical/ethical judgment regarding sharing information with school
personnel
 Complete
a Monthly Activity Summary for data collection purposes
Concord School District MOU with Riverbend
Community Mental Health Center (cont.)
The District will:
 Provide
and administrative contact at each school
 Provide
Clinicians with adequate workspace, internet access and access to a
telephone Assist Clinicians in collection of data
 Collaborate
with Clinicians to assess effectiveness of services
 Support
the purpose, mission and work of the Clinicians and Riverbend
Community Health Center
Evidence-based Practices
“Evidence-based interventions: Using a continuum of integrated policies,
strategies, activities, and services whose effectiveness has been proven or
informed by research… EBPs must be selected from the following sources”*:
 http://www.nrepp.samhsa.gov/
U.S. Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration, “National Registry of Evidence-based Programs
and Practices” (NREPP)
 http://www.colorado.edu/cspv/blueprints
University of Colorado, Center for the Study and Prevention of Violence,
“Blueprints for Violence Prevention”21
 http://www.dsgonline.com/mpg2.5/mpg_index.htm
U.S. Department of Justice, Office of Juvenile Justice and Delinquency
Prevention, “Model Programs Guide”
 http://www.whatworks.ed.gov
U.S. Department of Education, “What Works Clearinghouse”
*(Safe Schools/Healthy Students RFP, June 2013).
Resources
Partnerships in NH that have been created to promote the
social/emotional wellness and mental health for all children
and youth:
Office
of Student Wellness
http://www.nhstudentwellness.org/
The
NH Children’s Behavioral Health Collaborative:
nh4youth.org
NH
MTSS Training a Technical Assistance Collaborative:
UNH/IOD, CEBIS at SERESC and Strafford Learning Center
Resources







UNH PBIS webpage
http://www.iod.unh.edu/Projects/pbis/PBIS_detail/pbis_descr
iption.aspx
OSEP Center for PBIS: www.pbis.org
Who Cares About Kelsey and other videos:
www.whocaresaboutkelsey.com
NAMI-NH, PIC, Granite State Federation of Families for
Children’s Mental Health
NH Office of Refugees and Minority Affairs:
http://www.dhhs.nh.gov/omh/
National Center for School Mental Health:
csmh.umaryland.edu
Safe Schools/Healthy Students at the Substance Abuse and
Mental Health Services Administration:
http://www.samhsa.gov/safe-schools-healthy-students
Thank You!
JoAnne Malloy, Clinical Assistant Professor
Institute on Disability
University of New Hampshire
56 Old Suncook Rd.
Concord, NH 03301
(603)228-2084
Joanne.malloy@unh.edu
9/22/15
54