Mental Health Integration Susan Barrett, Lucille Eber Ron Sudano, Kelly Perales

March 2009 National Academy of Sciences Preventing Mental, Emotional, Behavioral Disorders Among Young People (MEB) Progress and Possibilities Almost one in five young people have one or more MEB disorders at any given time. Among adults, half of all MEB disorders were first diagnosed by age 14 and three-fourths by age 24 The financial costs in terms of treatment ser- vices and lost productivity are estimated at $247 billion annually.

The Research should not just focus on … prevention of MEB disorders but also a focus on wellness-the promotion of mental health

MH is developmental Failure to reach developmental milestones can be one of the first signs of an MEB disorder- as well as one of the key to the interventions that can redirect the negative patterns that contribute to disorder-

MH is Developmental IndividualFamilySchool/Community Self regulation Communication and learning; cumulative mastery of school subjects, appropriate behavior at school Making friends and getting along with peers Healthy physical development and habits Intellectual development life, school, and vocational skills; cultural knowledge and competence Psychological and emotional competence—e.g. self esteem and mastery, responsibility, morality and values, social development Self sufficiency and identity exploration, independent decision-making, future orientation Healthy physical environment Nurturing relationship with caregiver adequate socioeconomic resources Parental education and cognitive stimulation Extended family support and positive parenting Physical and psychological safety Appropriate structure and limits Opportunities to belong Opportunities for skill building Positive social norms Balance of autonomy and relatedness to family  Availability of high quality child care Nurturance and support for early learning Access to supplemental services Regulatory systems that support high quality care School environment that supports positive development, e.g. high teacher/academic expectations, effective classroom management; partnerships between school and family Positive social norms Opportunities for skill building Opportunities for exploration in work and school Connectedness to adults outside the family

Recommendations for Researchers 1.Research and interventions on the prevention of MEB disorders should focus on interventions that occur before the onset of disorder but should be broadened to include promotion of mental, emotional, and behavioral health. 2. Researchers should broaden the range of outcomes included in evaluations of prevention programs and policies to include relevant MEB disorders and related problems, as well as common positive outcomes, such as accomplishment of age-appropriate developmental tasks (e.g., school, social, and work outcomes). They should also adequately explore and report on potential iatrogenic effects. 3. Researchers should include analysis of the costs and cost-effectiveness (and whenever possible cost- benefit) of interventions in evaluations of effectiveness studies (in contrast with efficacy trials). 4. Researchers and community organizations should form partnerships to develop evaluations of (1) adaptation of existing interventions in response to community-specific cultural characteristics; (2) preventive interventions designed based on research principles in response to community concerns; and (3) preventive interventions that have been developed in the community, have demonstrated feasibility of implementation and acceptability in that community, but lack experimental evidence of effectiveness.

© Dean Fixsen, Karen Blase, Robert Horner, George Sugai, 2008 Problem Innovative practices do not fare well in old organizational structures and systems Organizational and system changes are essential to successful use of innovations – Expect it – Plan for it

STUDENTS in one school RtI Special Education SEL Fragmented StructuresFragmented Practices Student Assistance Teams Student Assistance Teams Social Work Services Family Coordinators Pre-referral Interventions After School Programs School-based Mental Health Services Student Support Leaders How does a school decide how to support different students?

SCHOOL Violence & Crime Prevention Drug Services Juvenile Court Services Social Services Child Protection Services Special Education Pupil Services Health Services Mental Health Services Drug Prevention Community Based Organizations Clinic After- School Programs Adapted from: Health is Academic: A guide to Coordinated School Health Programs (1998). Edited by E. Marx & S.F. Wooley with D. Northrop. New York: Teachers College Press. Fragmented PolicyFragmented Practices

Tier I: Universal/Prevention for All Coordinated Systems, Data, Practices for Promoting Healthy Social and Emotional Development for ALL Students School Improvement team gives priority to social and emotional health Systems Planning Team to coordinate universal supports and universal screening Mental Health skill development for students, staff, families and communities Social Emotional Learning curricula for all students Safe & caring learning environments Partnerships between school, home and the community Decision making framework used to guide and implement best practices that consider unique strengths and challenges of each school community Tier 2: Early Intervention for Some Coordinated Systems for Early Detection, Identification, and Response to Mental Health Concerns Systems Planning Team identified to coordinate referral process, decision rules and progress monitor impact of intervention Array of targeted interventions available Communication system for staff, families and community Early identification of students who may be 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 Tier 3: Intensive Interventions for Few Individual Student and Family Supports Systems Planning team coordinates decision rules/referrals for this level of service and progress monitors Individual team developed to support each student Individual plans may have array of interventions/services Plans can range from one to multiple life domains System in place for each team to monitor student progress Adapted from the ICMHP Interconnected Systems Model for School Mental Health, which was originally adapted from Minnesota Children’s Mental Health Task Force, Minnesota Framework for a Coordinated System to Promote Mental Health in Minnesota; center for Mental Health in Schools, Interconnected Systems for Meeting the Needs of All Youngsters. Interconnected Systems Framework for School Mental Health

Supervisor SW/Psych Building Principal Rep. Service Providers Local Area Network Co-Convenor Homeless Coordinator Mental Health/ 708 Board Curriculum/ Prof. Dev RtI Coordinator Family Groups Police Juvenile Justice Special Education Director Supt/ Asst. Supt Core District and Community Leadership Team

Building Level Model Community/ Family Mental Health Rep. SW, School Psych Guidance Principal Special Education Teachers Grade Level Teachers Building Leadership Team

3-Tiered System of Support Necessary Conversations (Teams) CICO SAIG Group w. individual feature Complex FBA/BIP Universal Support Problem Solving Team Tertiary Systems Team Brief FBA/ BIP Brief FBA/BIP Universal Team WRAP Secondary Systems Team Plans SW & Class-wide supports Uses Process data; determines overall intervention effectiveness Standing team; uses FBA/BIP process for one youth at a time Uses Process data; determines overall intervention effectiveness

Old Approach  New Approach Each school works out their own plan with Mental Health (MH) agency; A MH counselor is housed in a school building 1 day a week to “see” students; No data to decide on or monitor interventions; “Hoping” that interventions are working; but not sure. District has a plan for integrating MH at all buildings (based on community data as well as school data); MH person participates in teams at all 3 tiers; MH person leads small groups based on data; MH person co-facilitates FBA/BIP or wrap individual teams for students.

Leadership Team Active Coordination Funding Visibility Political Support TrainingCoachingEvaluation Local School/District Teams/Demonstrations Behavioral Expertise Policy

Implementation Stages Exploration Installation Initial Implementation Full Implementation Innovation Sustainability Implementation occurs in stages: Fixsen, Naoom, Blase, Friedman, & Wallace, – 4 Years