1. Psychotherapy and residential placement as related services

2. What do serious diagnosable mental health disorders look like?

3. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition

4. Mental Disorders Definition considerations: – Mental disorders and physical disorders are not distinct. – No consistent operational definition that covers all situations. – Classification of disorders that people have— not people. – A current manifestation of a behavioral, psychological, or biological dysfunction.

5. Mental Disorders “…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom”.

6. Principal DSM-IV Diagnoses Pervasive Developmental Disorders (Except Autistic Disorder) Attention Deficit Disorder Disruptive Behavior Disorders Schizophrenia Psychotic Disorders Mood Disorders Anxiety Disorders Dissociative Disorders Impulse Control Disorder Adjustment Disorder Personality Disorders

7. Excluded DSM-IV Diagnoses Mental Retardation Learning Disorders Motor Skills Disorder Communication Disorder Autistic Disorder Tic Disorder Delirium, Dementia Substance-Related Disorder Sleep Disorder Antisocial Personality Disorder Relational problems

8. Clinically significant impairment or distress is the common requirement of all mental disorder diagnoses

9. Clinical Significance Common criterion for all mental disorders – “…causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”. (DSM-IV, p.7)

11. Medical Necessity Definition Considerations: – A term of convenience that describes the qualification criteria for: Medi-Cal or insurance funding. – The term is not used to distinguish between: Mental disorders and general medical conditions – Mental disorders can be related to physical or biological factors. – General medical conditions can be related to behavioral or psychosocial factors or processes.

12. Diagnosis of a qualifying condition Mental Disorder Impairment in major area of life functioning, or Probability of significant deterioration, or Probability of developmental delay Clinical Significance Significantly diminish the impairment, or Prevent deterioration of a major life function, or Allow appropriate developmental progression Amenable to Intervention Not responsive to physical healthcare treatment Physical Healthcare Exclusion CCR 9 1830.205

14. Educational Necessity Definition Considerations: – Mental Health disorder must adversely impact educational performance. Educational performance is a broader concept than academic performance – Mental disorder must have an impact on the ability of the child to function in the school environment by impeding: Access to education, or Ability to accomplish IEP goals – Mental health treatment is available to any child with a disability if it is necessary for the child to benefit from their special education.

15. Diagnosis of a condition that meets medical necessity Mental Disorder Impedes access to education, or Impedes the ability to accomplish IEP goals (including therapy plan goals) Educational Significance Provide access to education in the LRE Enable progress in educational performance Amenable to Intervention Not responsive to physical healthcare treatment alone (medication) Physical Healthcare Exclusion

16. What is the incidence level of mental health disorders among children?

17. An estimated 9% to 13% of American children and adolescents between the ages of nine to 17 have serious diagnosable emotional or behavioral health disorders resulting in substantial to extreme impairment. (Friedman, 2002) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

18. Of those children with serious diagnosable emotional or behavioral disorders, less than 4% are identified as ED eligible for special education services. (Dataquest, CDE, 2009)

19. Over 15% of all students with disabilities (6-21) are taking psychotropic medications. About 1/3 of all adolescent students with disabilities have been suspended or expelled. (USDOE, 2005) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

20. Of children with disabilities with serious emotional or behavioral disorders, only about 1 in 5 received mental health services under AB3632. (Dataquest, CDE, 2009; LAO, 2010)

21. Students with ED reported higher use of: – alcohol (54%) – illegal drug use (36%) – marijuana use (33%) – smoking (53%) than all other disability categories. (NLTS2, 2008) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

22. More than 50% of students with ED drop out of grades 9-12, the highest rate among all disability categories. (U.S. Department of Education, 2002; 2006) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

23. At 2 years post high school, – 58% of youth with ED have been arrested at least once, and – 42% are on probation or parole. (NLTS2, 2005). Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

25. Campbell (1995) estimated that approximately 10-15% of all typically developing preschool children have chronic mild to moderate levels of behavior problems. Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

26. Children who are poor are much more likely to develop behavior problems with prevalence rates that approach 30% (Qi & Kaiser, 2003). Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

27. Children who are identified as hard to manage at ages 3 and 4 have a high probability (50:50) of continuing to have difficulties into adolescence (Campbell & Ewing, 1990; Campbell, 1997; Egeland et al., 1990). Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

28. The correlation between preschool-age aggression and aggression at age 10 is higher than that for IQ. (Kazdin, 1995) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

29. Early appearing aggressive behaviors are the best predictor of juvenile gang membership and violence. (Reid, 1993) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

30. When aggressive and antisocial behavior has persisted to age 9, further intervention has a poor chance of success. (Dodge, 1993) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

31. Student must be identified as a student with an emotional disturbance in order to qualify for mental health services.

32. Mental health treatment is available to any child with a disability if it is necessary to benefit from special education.

33. Mental Health Treatment by Disability

36. How do mental health disorders develop?

37. Environmental Factors Fear, anxiety and trauma affect the developing brain.

38. Environmental Factors Prenatal Substance Exposure Postnatal Exposure to Toxic Stress

39. Family Factors Harsh Parenting Stressful Family Life Events Low Social Support Family Instability Maternal Depression Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

40. Depression Hurts Children of mothers who were depressed in their infancy are more likely to be delayed. Children of depressed mothers are at increased risk for: – Language delays – Internalizing behavior problems – Depression, and mood disorders in adolescence Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

41. Early Predictors Temperamental Difficulties Early Aggression Language Difficulties Noncompliance Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

43. Young Children with Challenging Behavior Are rejected by peers Receive less positive feedback Do worse in school Are less likely to be successful in kindergarten Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

44. Preschool children are three times more likely to be “expelled” than children in grades K-12 (Gilliam, 2005) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

45. Faculty in higher education early childhood programs report that their graduates are least likely to be prepared to work with children with persistently challenging behavior (Hemmeter, Santos, & Ostrosky, 2004). Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

46. Of the young children who need mental health services, it has been estimated that fewer than 10% receive services for these difficulties. (Kataoka, Zhang, & Wells, 2002) Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

47. In a Typical Kindergarten Class in California 6 children will manifest significant problem behaviors. Only 1 in every 2 classes will receive help. 4 children will continue to exhibit aggressive behaviors at age 10 with little chance for successful intervention

48. There are evidence-based practices that are effective in changing this developmental trajectory…the problem is not what to do, but rests in ensuring access to intervention and support (Kazdin & Whitley, 2006). Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

49. What do evidence-based mental health treatment look like?

50. Student must be identified as a student with a disability in order to benefit from mental health services.

51. Schools can choose to provide mental health services to any child with significant mental health disorders.

52. Whether schools choose to or not, they are still providing treatment.

57. Mental Health Treatment Individual Group Targeted Case Management Collateral Therapeutic Behavioral Services (TBS) Rehabilitation Day Rehab/Day Treatment

58. Mental Health Treatment Psychotherapy – Cognitive-Behavioral Therapy (CBT) “Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.” National Association of Cognitive-Behavioral Therapists (http://www.nacbt.org)

59. Mental Health Treatment Psychotherapy (Cont.) – Interpersonal Therapy – Exposure Therapy – Behavior Therapy – Parent/Child Interaction Therapy – Theraplay Choosing the Right Treatment: What Families Need to Know About Evidence-Based Practices (2007) (http://www.nami.org/Template.cfm?Section=child_and_teen_support&template=/ContentMa nagement/ContentDisplay.cfm&ContentID=47656)http://www.nami.org/Template.cfm?Section=child_and_teen_support&template=/ContentMa nagement/ContentDisplay.cfm&ContentID=47656

60. Who can provide these services?

61. Who Can Provide Mental Health Treatment? The answer is related to two factors: – Who is qualified? Training Experience – Who Pays?

62. Who Can Provide Mental Health Treatment? Psychological assessments: – Licensed Psychologist – Credentialed School Psychologist – Licensed Educational Psychologist

63. Who Can Provide Mental Health Treatment? Psychosocial status assessments: – Licensed Clinical Social Worker – Licensed Marriage, Family Therapist – Credentialed School Social Worker – Credentialed School Counselor

64. Who Can Provide Mental Health Treatment? Individual and Group Therapy: – Licensed Physician/Psychiatrist – Licensed Psychologist – Credentialed School Psychologist – Licensed Educational Psychologist – Credentialed School Social Worker – Licensed Clinical Social Worker – Licensed Marriage, Family Therapist

65. How do you pay for it?

66. Prevalence Rates LAO stated that about 20,000 students with disabilities received AB3632 services. – 12 in 400 (3%) – 1 in 400 requires residential placement (.27%)

67. Prevalence of MH Services As a Proportion of Pupil Count

68. Mental Health Funding Millions 408 Million 417 Million Funding Sources

69. Mental Health Funding Millions 5.04 Million 100,000 ADA, 10,000 students with disabilities, $5.364 million

71. Mental Health Funding Millions 5.60 Million 100,000 ADA, 10,000 students with disabilities, $5.364 million

72. Mental Health Funding Millions 696 Million 417 Million

73. EPSDT Medi-Cal Funding $2.61 @ minute: $156.6 @ hour

74. LEA Medi-Cal Funding $44.46 @ hour

75. Funding Options MH Funding Only – Outpatient $7,900 – Residential R/B $96,800 Provider – Schools

76. Funding Options MH Funding plus LEA Medi-Cal – Outpatient $7,900 Non Medi-Cal $8790 Medi-Cal – Residential R/B $96,800 Provider – Schools

77. Funding Options MH Funding plus EPSDT Medi-Cal – Outpatient $7,900 Non Medi-Cal $11,030 Medi-Cal eligible – Residential R/B $96,800 Provider – Schools in partnership with: Community-based MH organization County Department of Mental Health

79. “The good of it is that you climb mountains.” -John Dewey