“Mental Health Screening in Schools Telemedicine, Wellness, Intervention, Triage and Referral The (TWITR) Project” Billy U. Philips, Jr., PhD, MPH Hall Professor, Family and Community Medicine and Public Health Executive Vice President for Rural and Community Health Texas Tech University Health Sciences Center Cole Johnson, JD Managing Director Contracts, Reporting and Data Management F. Marie Hall Institute for Rural and Community Health Next Generation 9-1-1 Telemedicine Medical Services Pilot Project Billy U. Philips, Jr., PhD, MPH Executive Vice President and Director F. Marie Hall Institute for Rural and Community Health & Cole Johnson, JD Managing Director Contracts, Reporting and Data Management F. Marie Hall Institute for Rural and Community Health Criminal Justice Division, Office of the Governor of the State of Texas Grant# 2731701-3.

TTUHSC Telemedicine Network Telemedicine Wellness, Intervention, Triage & Referral “The TWITR Project” The primary purpose is to provide screening, assessment, and referral services to students who are judged to be immediate threats to do harm to themselves or others. Provides school-based screening, assessment, and referral services to students that are typically struggling with behavioral and mental health issues. Currently active in 10 West Texas ISDs. Uses Telemedicine technology to link remote rural schools that are without sufficient counselors, psychiatrists, and other mental health service providers. Provides mental health recognition and training services to educators and school resource officers to promote greater recognition and prompt referral. Outcome data has demonstrated a reduction in truancy (17%), reduction in student discipline referrals (25%), and increase in student overall GPA (3.6%).

Location of Schools We have focused TWITR on relatively small, rural school districts that lack adequate mental health resources and have proximity to Lubbock. The TWITR project services expand out as far a 50 miles outside of Lubbock. TWITR personnel offer presentations twice a year to each school district that is contracted by TTUHSC. When caseloads permit, TWITR will refer to crisis centers, local practitioners, faith-based and civic organizations.

TWITR Referral Process The primary purpose of TWITR is to screen troubled youth (especially those at high risk of being imminently harmful to themselves and others) and get them to mental health care as quickly as possible. This requires training all school staff to recognize the signs of behavioral health problems and refer children needing immediate care. Evidenced based screening is done by Licensed Professional Counselors. If a child exceeds norms they are seen immediately via Telemedicine by a Psychiatrist at TTUHSC and emergency measures are taken if needed. Parents often are the bigger problem of getting the child treated. A multidisciplinary team plan the long-term care and follow-up on patient outcomes. LPC

The TWITR Process: Assessment TWITR Project staff will make contact with the referral school administration when they arrive at the school. The Telepsychiatry staff will follow the school districts procedures for signing in and out of the building. During this visit the TWITR Project staff can request student records [current grades, truancy reports, discipline referrals, and any other pertinent information] to assist in understanding the student’s academic /social history and to monitor changes in student’s behavior throughout the school year. TWITR Project staff will then complete the initial student evaluation, administer required TWITR Project assessments to the student, and other applicable parties [parent/guardian, teacher/counselor]. TWITR project staff will also obtain guardian/ parent signatures on required psychiatry forms.

Assessments Assessments 1) Child Mania Rating Scale 2) Children’s Loneliness Questionnaire (CLQ) 3) CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) 4) Hopelessness Scale for Children (HSC) 5) Mood and Feelings Questionnaire (Parent & Child Instrument) 6) Screen for Child Anxiety Related Disorders (SCARED) (Parent & Child Instrument) 7) National Stressful Event Survey Short Scale (NESSS) (Child Instrument) 8) Vanderbilt ADHD Assessment Scales (Parent instrument) 9) Structured Assessment of Violence Risk in Youth (SAVRY) (Clinician) 1) Child Mania Rating Scale (Parent and Child) a. Mood Disorders & Psychosis 2) Children’s Loneliness Questionnaire (CLQ) Child a. Loneliness 3) CRAFFT (Child) a. Substance Abuse 4) Hopelessness Scale for Children (HSC) Child a. Hopelessness 5) Mood and Feelings Questionnaire (Parent & Child Instrument) a. Mood Disorders 6) Screen for Child Anxiety Related Disorders (SCARED) (Parent & Child Instrument) a. Generalized Anxiety Disorder b. Social Anxiety c. Panic Disorder d. Separation Anxiety e. Significant School Avoidance 7) National Stressful Event Survey Short Scale (PTSD) (Child) a. Post-Traumatic Stress Disorder 8) Vanderbilt ADHD Assessment Scales (Parent and Teacher) a. Inattentive & Hyperactive [ADHD] b. Oppositional Defiant Disorder [ODD] c. Conduct Disorder [CD] d. Depression e. Anxiety 9) Structured Assessment of Violence Risk in Youth (SAVRY)(LPC) a. Violence

TWITR Outcomes Number of School Staff Trained = ~1640 Number of students impacted = ~41,807 Number of referrals = 414 Number triaged = 215 (all by telemedicine) Number removed from school = 25 Number in-school supervision = 44 Other outcomes = reduction in truancy (17%), reduction in student discipline referrals (25%), increase in student overall GPA (3.6%) These are the outcomes of record for ‘13-17 school years of TWITR. The key figure here are the 25 students that were removed from schools. About half were homicidal and the remainder were actively suicidal. While we cannot share much detail three stories illustrate the seriousness of these young people. Following triage subject was detained by the school resource officer, held on a mental health warrant, searches found – a note, a map, names, a date certain, and interviews verified the intent to purchase the ammunition and handgun. The timeframe – detained on Thursday, Gun sale on Saturday, Plan was for Monday morning. Subject is in alternate JJS facility. Following triage subject was ordered to inpatient emergency care by psychiatrists, EMS failed to transport, school personnel found subject moments before suicide in gym locker room. Subject was hospitalized, stabilized, and is in long-term residential treatment facility. Following triage subject was arrested by school resource officer for patterned sexual abuse of other minor siblings and perhaps other children. Children were placed in foster care, case is ongoing. Subject is in alternate school facility under local law enforcement supervision. 2014-2015 : Following triage crisis team was called to assess subject for suicidal intent. Subject left school grounds and was quickly located and detained by the school resource officer. Subject was placed in an alternate JJS facility. 2014-2015: Following triage subject was arrested for violating probation. Subject was sexually abusing younger siblings, stole laptop and wrote pornographic emails to teachers at school. CPS was contacted by TWITR staff for further investigation into the sexual abuse. Student was removed from home and placed in Juvenile Detention facility 2014-2015: Following triage subject assaulted his mother and stepfather. Subject was placed in another city with grandmother. 2015-2016: Student displayed knife in a threatening manner on school grounds to other students. Student also had fetish for foster mothers underwear. Underwear was found under students mattress by family members. Student was referred, assessed, and treated by tele-psychiatry. Student was placed in DAEP. 2015-2016: Student was referred to for assessment for suicidal ideation and cutting. Numerous CPS cases were opened on mother. Mother was a chronic drug user and failed to come to tele-psychiatry appointments. 2016-2017: Student was referred to TWITR project after making “terroristic threat” to kill another student. Student was arrested and released to parent. Student was assessed and treated by tele-psychiatry. Student was returned to classroom after treatment by psychiatry. 2017-2018: Student posted a map of the school and threatened to “blow up” the school on a post to social media. Student was being bullied by classmates. Student was arrested and placed in JJAEP. Student was later assessed and treated by tele-psychiatry. Student placed in DAEP for the remainder of the school year pending resolution of “terroristic threat” charges. 2017-2018 Following triage CPS was notified due to subject report on physical, and sexual abuse, and medical neglect. A law Enforcement referral was made by CPS due to the nature of the allegation. 2017-2018: Following Triage Subject was hospitalized due to Imminent harm to self, after stabilization, subject returned to school and completed the TWITR project 2017-2018 Following Triage Subject was deemed high risk for committing an act of violence. The School Resource Officer was notified and student was seen in person for psychiatric care. The subject struggled to maintain psychiatry appointments, however, did complete the TWITR project, continues to be followed by psychiatry and completed the rest of the year off campus. 2017-2018 Following Triage Subject was deemed high risk for committing an act of violence with clear intent and psychotic symptoms, and no means at the time. The subject was seen in person for psychiatric care. Subject successfully completed TWITR and is followed closely for the remainder of the year.

Follow Up Study (N=118) Itinerate students – 88 (75%) Family criminal history – 53 (45%) Student lives with Mom – 66 (56%) Student lives with Dad – 17 (14%) Student lives with other family – 19 (16%) Of 47 pairs studied Youth report significantly more social anxiety compared to parents. 98 (83%) report hopelessness, 65 (55%) report anxiety 53 (45%) report loneliness School avoidance (highest risk groups 56 (47%) females; 35 (30%) Hispanic) These are the results of a limited follow-up study which gives some insights into the trajectory of these troubled students. This is a familiar pattern from what we have heard in media reports from nearly all the mass shooting events dating to Columbine, Co. These are iterant youth, lonely – hopeless – anxious. They males tend to act out and the females tend to act in – thus more acts of violence toward others for males and more acts of violence toward self for females. Our studies of the profiles are pending publication and will enlighten the literature more in the near future.

TTUHSC Telemedicine Network Why Telemedicine for TWITR? Provides easier access to mental health services not available in rural areas. Convenient for parents to make appointment(s) at school rather than traveling. Reduces the amount of time student(s) is(are) out of class. Often more comfortable for students to discuss issues online rather than face-to-face. Quick and easy set-up of equipment. Provides opportunity for simultaneous appointments. Provides attending physician the opportunity to provide services to more patients within a given amount of time. Cut the wait time from 6 weeks to 3 days (sooner in emergent events)