1. THE SCHOOL MENTAL HEALTH IMPERATIVE Mark Weist Ph. D. Steven Adelsheim, M.D. March 3, 2003

3. “Could someone help me with these? I’m late for math class.”

5. Prevalence of Childhood Mental Health Problems ä About 20% of children and adolescents (15 million), ages 9 to 17, have diagnosable mental health disorders ä Between 9-13% of children, ages 9-17 years, meet the definition of serious emotional disturbance (SED) that limits their ability to function in the family, school, and community ä An estimated 70% of those identified are not getting the mental health treatment they need

7. Proven, Successful Treatments Exist for Most Disorders Treatment success rates: ä 80% for major depression ä 65% for bipolar disorder ä 60% for schizophrenia ä 45% for heart disease

8. Mental Health and Disability ä Mental illness is the leading cause of disability (25%) in Western Europe,Canada, and U.S. ä Global Burden of Disease study predicts that major depression will become the second leading cause of disability in the world by the year 2010 ä By 2020, childhood neuropsychiatric disorders will rise by over 50% internationally to become one of the 5 most common causes of morbidity, mortality, disability

9. The Cost of Mental Illness in the United States In addition to the overwhelming human suffering: ä $63 billion in lost productivity due to work absence, SSI ä $12 billion in lost productivity due to premature death ä $6 billion incurred costs to incarcerate the 250,000 inmates with serious mental illness ä 1997 estimated total U.S. cost of mental illnesses was $148 billion.

10. Surgeon General’s Suicide Data - 1997 ä Rate for ages* 10-14 - 1.6 /100,000 * 15-19 - 9.7 /100,000 * 20-24 - 14.5 /100,000 ä For young people 15-24, suicide is third leading cause of death ä In 1996, more youth and young adults died from suicide than cancer, heart disease, AIDS, stroke, pneumonia, & birth defects COMBINED

11. CAUSE# OF DEATHS Accidents6573 Homicide1861 Suicide1574 Cancer/Leukemia759 Heart Disease372 Congenital Anomalies213 Lung Disease151 Stroke60 Diabetes40 Blood Poisoning36 HIV36 NCHS 2001, preliminary 1631 Leading Causes of Death in 15-19 Year Olds in the United States in 2000 — U N I T E D S T A T E S, 2000 —

12. 1999 Surgeon-General’s Report on Children’s Mental Health “There is no mental health equivalent to the federal government’s commitment to childhood immunization”

13. Interim Report of President’s New Freedom Commission on Mental Health “Our Nation’s failure to prioritize mental health is a national tragedy. So many lives are at stake, so many families and communities struggle to stay afloat.” October 29,2002

14. STIGMA and Children’s Mental Health ä 1999 study said 71% thought mental illness caused by emotional weakness, 65% from bad parenting, 35% from immoral or sinful behavior (Hinckley, 1999) ä 66% of people with diagnosable MH problems do not see treatment, especially true for rural areas and adolescents ä Lack of public willingness to pay for treatment

15. Issues in Appropriate Assessment for Mental Health Problems ä Less than 50% of adolescents with significant treatable mental health disorders are correctly identified as having problems by school counselors ä Pediatricians correctly identify 35% of those with diagnosable mental disorders ä Parents are only generally able to identify acting out problems

16. An Attitudinal Shift Towards Children’s Mental Health Programs ä Public Health perspective similar to that for immunizations, sexually transmitted diseases ä Put children’s services on equal financial footing as adult programs if we really believe in prevention and early identification ä Equal focus for children’s services at federal, state, and local systems ä University training systems prioritize children services

17. Anytown, USA ä People don’t know about or care about youth mental health issues or view them with stigma ä Limited evaluation/consultative services in the schools for youth in special education ä Limited treatment services for youth who act out in community centers and private offices

18. Anytown 2 ä Significant, unaddressed mental health needs in child welfare and juvenile justice ä Child serving agencies operating with significant bureaucracy and passivity ä There is no system of care ä Quality improvement and evaluation are limited if non existent

19. Promiseland, USA ä The public recognizes the critical importance of youth mental health and is ENGAGED ä Policymakers are responsive and resources are growing progressively ä Major child serving systems are joining with families, youth and other stakeholders to plan and continuously improve systems of education, youth development and care

20. Promiseland 2 ä The full continuum of mental health promotion and intervention is being implemented in schools through family-school-community partnerships ä There is a major emphasis on quality improvement, evaluation, and building and using the evidence base ä Positive outcomes for youth, families, schools, and communities are being demonstrated

21. Why is School Mental Health so Critical to this Vision? ä Because there is probably no approach with as much promise to change paradigms and move the country from an illness care to health promoting perspective: ä Focus on youth -- our future ä Schools, the most universal natural setting ä Connecting to a central mission of society

22. Major Approaches to Mental Health in Schools ä Enabling Framework (Adelman and Taylor) ä Other Education-Based ä School-Based Health Centers ä Community Mental Health Center Outreach ä Private Practitioner Outreach ä Communities in Schools

23. Expanded School Mental Health (ESMH) ä ESMH programs join staff and resources from education and other community systems ä to develop a full array of mental health promotion and intervention programs and services ä for youth in general and special education

24. Positive Outcomes of ESMH Programs are Being Shown ä Outreach to under-served youth ä Productivity of staff ä Cost-effectiveness ä Improved satisfaction ä Improved student outcomes ä Improved school- and system- level outcomes

25. Progressive Growth of ESMH Also Being Propelled By: ä Increasing recognition of mutual benefits to schools and other community systems ä Prominent federal developments (Surgeon General’s reports, Safe Schools/Healthy Students, No Child Left Behind) ä Increasing training and technical assistance ä Bridging of research and practice ä Growing international dialogue

26. But the movement toward ESMH is still in the early phases ä ESMH estimated to be in less than 10% of the nation’s 114,000 schools ä A concerning trend toward clinics in schools ä Funding remains limited and illness-focused

27. Major Categories of Work to Advance Mental Health in Schools ä Raising awareness of unmet youth mental health needs and building advocacy ä Involving youth, families and other stakeholders ä Influencing policy and growing a diverse array of funding mechanisms ä Applying new resources strategically

28. Major Categories of Work II ä Enhancing methods of early identification and screening ä Broadening and improving training at all levels and for diverse disciplines ä Strengthening quality assessment and improvement approaches

29. Major Categories of Work III ä Coordinating services in schools and making progress toward true systems of care ä Addressing areas of special need ä Emphasizing prevention and broad efforts to promote youth mental health ä Supporting, using, and building the evidence base

30. Impacts of September 11 ä Increasing recognition that mental health issues and problems are universal ä Underscoring significant capacity problems in mental health systems

32. Impacts of September 11, cont. ä Increasing support for expanded school mental health ä Propelling advocacy, coalition building, and the breaking down of entrenched boundaries and bureaucratic obstacles

33. Media Issues ä Journalistic media pay very little attention to child and adolescent mental health ä Entertainment media present mental illness in a “stereotypic and blatantly negative” light. Mentally ill are presented as “objects of amusement, derision or fear” (Granello & Pauley, 2002)

34. Toward Interdisciplinary Work Guided by Stakeholders ä Close collaborative relations among and between: ä professionals of different disciplines ä non- and para-professionals ä the stakeholders (e.g., youth, families, community leaders) ä “being in the trenches, shoulder to shoulder with the teachers, students and families, trying to make a difference”

35. The Optimal School Mental Health Continuum? ä 10-20% Broad Environmental Improvement and Mental Health Promotion ä 50-60% Prevention and Early Intervention ä 20-30% Intensive Assessment and Treatment

36. To Move Toward This Continuum We Need To Address The Over-Reliance On Fee-For-Service ä Need to diagnose ä Significant bureaucracy ä Limits on productivity ä Contingencies to hold on to youth and families who show up and can pay

37. Toward Funding for a Full Continuum of Programs and Services ä Maximizing all potential sources of revenue: ä allocations from schools and departments of education ä state and local grants and contracts ä federal and foundation grants and contracts ä innovative prevention funding ä fee-for-service

38. Under-Explored Funding Approaches ä Early Periodic Screening Diagnosis and Treatment (EPSDT) ä Transitional Assistance for Needy Families (TANF) ä Safe and Drug Free Schools funds

39. Youth Mental Health Services in Most Communities

40. The Vision

41. Deciding on Roles in a School (no stereotyping intended)

42. Using the Evidence Base ä A major feature of school-based mental health from the beginning ä Perhaps the most dominant issue in child and adolescent mental health research ä We can lead the way in school mental health ä Significant work and opportunities ahead

43. Using the Evidence Base in Context

44. Lessons from Dialogue with Other Countries ä US focus is primarily on illness in individuals ä Tremendous variability in US experience can be a real barrier to communication and to progress

45. The Australian MindMatters Program ä Mapping and managing mental health resources in schools ä School-wide training ä resilience ä bullying and harassment ä grief and loss ä understanding mental illness

46. International Network for Child and Adolescent Mental Health and Schools ä Planning meetings in Virginia Beach (98), Denver (99), Atlanta (00), Paris (01) and London (02) ä Network established in November, 2002 ä Over 100 members from over 20 countries ä First meeting October 22, 2003, Portland Oregon

48. New Mexico Facts ( We Still Have a Lot of Work to Do ) ä Greatest Percentage of Children Living in Poverty ä Greatest Percentage of Teens Not in School/Working ä 2nd Highest Teen Dropout Rate ä 2nd Highest Teen Death Rate Due to Accident, Suicide, Homicide ä 6th Highest Teen Suicide Rate ä 3rd Worst Health Statistics of All States

49. State of New Mexico Others School Health Unit Special Education Division State Board of Education State Department of Education Governor’s Office Department of Health Others Children, Youth and Families Department Public Health Division Office of School Health Prevention And Intervention Human Services Department Juvenile Justice Division Child Protective Services Income Support Division Cimarron Salud Behavioral Health Division Others Lovelace Salud Presbyterian Salud Medical Assistance Division

50. New Mexico School Behavioral Health Partnership ä Office of School Health $300,000 ä Behavioral Health Division $400,000 ä CYFD-Prev. & Interv. $320,000 ä Dept of Ed.-Spec.Ed.$165,000 ä Dept. of Ed.-School Health$350,000 ä Fed. M H Block Grant $140,000 ä HSD-Med. Asst. Div. $84,000

51. NM DOH Office of School Health

52. Continuum of Care for School Mental Health Programs ä Awareness and training ä Three levels of prevention, including universal, selective and indicated ä Screening and assessment ä Early identification and early intervention ä Three levels of treatment, including community- based, transitional, and high-end

53. Early Identification and Treatment of Mental Health Issues is Prevention! ä Research on brain changes in PTSD and brain cell neurogenesis ä Results from NYC Schools PTSD survey (Hoven) ä ADHD – Pharmacotherapy reduces risk for later ASUD (Biederman, 1999) ä Bipolar disorders – early identification in younger children reduces risk of ASUD 8X (Wilens,1999) ä Opposition Defiant/Conduct Disorders – early treatment of child, parent, family all decrease later ASUD risk (Riggs)

54. Interdepartmental School Behavioral Health Partnership ä School Behavioral Health Training Institute ä Youth Mental Health Awareness Initiative- “Childhood Revealed” ä Dropout Prevention Project ä School Behavioral Health Screening Program ä School-Based Mental Health Center Program Development ä SBHC Mental Health Exemplary Pilot Sites

55. School Mental Health Partnerships with Families ä Opportunities to collaborate with providers on-site about education needs of child ä Improved coordination of interventions around whole child and family ä Access is easier with fewer transportation issues ä More comfortable community setting ä Stigma issues may be minimized

56. School-Community Collaboration in School Mental Health Programs ä Collaboration and coordination between school and providers is critical ä Roles of all on-site providers, including school health professionals must be clear ä Communication and confidentiality issues must be directed addressed and established ä Resource coordination efforts must be determined by organized team within school (SAT, resource team, etc.)

57. School Behavioral Health Training Institute ä Train-the–Trainers model of adult education ä Training 180 teachers and school health professionals from 14 districts this year ä Training in aspects of school behavioral health and classroom intervention ä On-site workshops with staff support

58. Childhood Revealed New Mexico 2001 ä Art exhibit as centerpiece for youth mental health awareness expansion statewide ä Linkages to school districts for in-service training and classroom programs (0ver 5000 youth so far this year) ä Community education programs for expanded awareness ä Media, government, and business support all to help to decrease stigma ä “Marketer of the Year 2001” by American Marketing Association- New Mexico Chapter

59. Dropout Prevention Initiative “PASS” ä Case management model for high risk youth and their families ä Focus on wraparound supports for those identified of being at risk to dropout ä Statewide training and RFP development 2002 fiscal year ä Focus on implementation at 3 pilot sites statewide for fiscal years 2003-4 ä Target 9th grade students making transition to high school

60. New Mexico Screening and Early Identification Models ä Early identification and intervention as prevention ä Public health screenings vs. selective screenings in SBHCs ä Piloting computer-based models for early identification and suicide prevention ä Expanded interest by schools to utilize screening tools on larger scale

61. New Mexico SBHC Mental Health Program Development ä Expanded funding for mental health and substance abuse services 17 SBHC programs ä One cluster wide Medicaid Managed Care School Behavioral Health Pilot Program ä Standards and protocols for MH/SA services in schools ä Four “Exemplary” School Mental Health Sites looking at mental health and educational outcomes

62. New Mexico Medicaid Managed Care SBHC Pilot Projects ä Pilot with Center for Health Care Strategies ä Reimbursement through Medicaid for mental health and substance abuse services ä 5 Medicaid Managed Care SBHC pilots ä Developing depression, ADHD and substance abuse protocols for MH/SA services in schools ä “Enhanced Mental Health Services” code for some sites

63. Find Students With Mental Health Issues Early and Treat Them! ä Prevent later special education referrals ä Reduce primary care and urgent care over utilization ä Decrease high risk behaviors including violence and substance abuse ä Improve educational outcomes ä Decrease the accidents, suicides, and homicides that are the public health mortalities for our children

64. Advocacy Role in School and Child Mental Health ä Legislation on school mental health and early behavioral assessment ä Collaboration and support for parent advocacy organizations ä Raise awareness about mental health needs of our state’s children ä Increase parental awareness about the educational rights of our children ä Expand funding for school behavioral health to improve access ä Expand awareness of relationship between mental health issues and other youth risk factors

66. " It is not the malicious acts that will do us in... but the appalling silence and indifference of good people." Martin Luther King, Jr.

68. Centers for Mental Health in Schools ä Supported by the Office of Adolescent Health, Maternal and Child Health Bureau, Health Resources and Services Administration; ä With co-funding from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

69. UCLA Center for Mental Health in Schools ä Directed by Howard Adelman and Linda Taylor ä Phone: 310-825-3634 ä Enews: listserv@listserv.ucla.edu ä web: http://smhp.psych.ucla.edu

70. University of Maryland Center for School Mental Health Assistance ä Provide technical assistance and consultation ä Provide national training and education ä Disseminate and develop knowledge ä Promote communication and networking ä phone: 410-706-0980 (888-706-0980 toll free) ä email: csmha@psych.umaryland.edu ä web: http://csmha.umaryland.edu

71. New Mexico School Mental Health Initiative ä Statewide efforts to link families, communities, schools and behavioral health programs ä Phone: 505-841-5879 ä Fax: 505-841-5885 ä Email: stevea@doh.state.nm.usstevea@doh.state.nm.us ä Website: http://www.nmsmhi.org