Transcript MONTANA-IZING PBIS…

Mark D. Weist, Ph.D.
University of South Carolina
Missouri PBIS, June 12, 2014
Center for School Mental Health*
University of Maryland School of Medicine
http://csmh.umaryland.edu
*Supported by the Maternal and Child Health Bureau of HRSA and
numerous Maryland agencies
Outline
 School Mental Health (SMH)
 Positive Behavioral Intervention and Support (PBIS)
 Interconnected Systems Framework for SMH/PBIS
 Key Themes: Readiness, Teams, Evidence-Based
Practice, Funding
 Some Challenges
 National Community of Practice, State Examples
 Interactive Exercise
 Opportunities
Reality 1
 Child and adolescent mental health is among the most
if not the most neglected health care need in the US
Reality 2
 Children, youth and families are not getting to places
where mental health services are traditionally
delivered
Reality 3
 Schools are under-resourced to address mental health
issues, and may view this as beyond their mission
“Expanded” School Mental Health
 Full continuum of effective mental health promotion
and intervention for students in general and special
education
 Reflecting a “shared agenda” involving schoolfamily-community system partnerships
 Collaborating community professionals (not outsiders)
augment the work of school-employed staff
School Mental Health
(SMH) MH vs Clinics
 Catron, Harris & Weiss (1998)
 96% offered SMH received
 13% for clinics
SMH vs Clinics 2
 Atkins et al. (2006)
 80% enrolled in SMH vs 54% in clinics
 At 3-month follow-up, 100% retained in schools, 0% in
clinics
Baker-Ericzen et al. (2013)
 Views of families and youth toward clinics consistently
negative:
 Highly dissatisfied, many barriers, limited support,
lack of input into decision making, cumbersome and
difficult bureaucracy, feeling “unheard and blamed for
problems”
Advantages
 Improved access
 Improved early identification/intervention
 Reduced barriers to learning, and achievement of
valued outcomes
 WHEN DONE WELL
But
 SMH programs and services continue to develop in an
ad hoc manner, and
 LACK AN IMPLEMENTATION STRUCTURE
Positive Behavior Intervention and
Support (www.pbis.org)
 In 18,000 plus schools
 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
Advantages
 Promotes effective decision making
 Reduces punitive approaches
 Improves student behavior
 Improves student academic performance
 WHEN DONE WELL
But
 Many schools implementing PBIS lack resources and
struggle to implement effective interventions at Tiers 2
and 3
Key Rationale
 PBIS and SMH systems are operating separately
 Results in ad hoc, disorganized delivery of SMH and
contributes to lack of depth in programs at Tiers 2 and
3 for PBIS
 By joining together synergies are unleashed and the
likelihood of achieving depth and quality in programs
at all three tiers is greatly enhanced
Logic
Youth with challenging
emotional/behavioral problems are
generally treated very poorly by schools
and other community agencies, and the
“usual” approaches do not work
Logic, cont.
• Effective academic performance promotes
student mental health and effective mental
health promotes student academic
performance. The same integration is
required in our systems
Old Approach 
 Each school
works out their
own plan with
Mental Health
(MH) agency
New Approach
 District has a plan
for integrating
MH at all buildings
(based on
community and
school data)
Old Approach 
 A MH counselor
is housed in a
school building 1
day a week to
“see” students
New Approach
 MH person
participates in
teams at all 3 tiers
Old Approach 
 No data to
decide on or
monitor
interventions
New Approach
 MH person leads
classroom, group
or individual
interventions
based on data
Not two, but one
Interconnected Systems Framework (ISF) for
SMH-PBIS
 Strategy for interconnection of two systems across
multiple tiers
 Emphasizes state teams working with district
teams and schools, and strong team planning and
actions at each tier
 Two national centers (for SMH and PBIS) and a
number of states involved
 Numerous training events and a recent monograph
completed
ISF Defined
 A strong, committed and functional team
guides the work, using data at three tiers of
intervention
 Sub-teams having “conversations” and
conducting planning at each tier
 Evidence-based practices and programs are
integrated at each tier
 SYMMETRY IN PROCESSES AT STATE,
DISTRICT AND BUILDING LEVELS
Chapters in the ISF Book
 Overview
 District/Community
 Implementation
Role
 Advancing in States
 Policy, Practice and
People
 Commentaries
Framework
 School Level Systems
 School Level Practices
 Effectively Using Data
ISF, School Readiness
Assessment
 1) High status leadership and team with active
administrator participation
 2) School improvement priority on
social/emotional/behavioral health for all students
 3) Investment in prevention
 4) Active data-based decision making
 5) Commitment to SMH-PBIS integration
 6) Stable staffing and appropriate resource
allocation
ISF, Indicators of Team Functioning
 Strong leadership
 Good meeting attendance, agendas and meeting
management
 Opportunities for all to participate
 Taking and maintaining of notes and the sense of
history playing out
 Clear action planning
 Systematic follow-up on action planning
Team Members
 *School psychologist
 Assistant principal
 *Collaborating
 School nurse
community mental
health professional
 School counselor
 Special educator
 General educator
 *co-leaders
 Parent
 Parent
 (Older student)
Implementing Evidence-Based
Practices
 See - Substance Abuse and Mental Health Service
Administration’s (SAMHSA) National Registry of
Effective Programs and Practices (NREPP)
 330 research supported programs, 126 come up with
“schools” as search term
Research Supported Programs Involve
 Strong training
 Fidelity monitoring
 Ongoing technical assistance and coaching
 Administrative support
 Incentives
 Intangibles
Practice in the trenches
 Involves NONE of these supports
Evidence-Based “Manualized”
interventions (from Sharon Stephan)
Intervention/Indicated:
Cognitive Behavioral Intervention for Trauma in
Schools, Coping Cat, Trauma Focused CBT,
Interpersonal Therapy for Adolescents (IPT-A)
Prevention/Selected:
Coping Power, FRIENDS for Youth/Teens, The
Incredible Years, Second Step, SEFEL and
DECA Strategies and Tools, Strengthening
Families Coping Resources Workshops
Promotion/Universal:
Good Behavior Game, PATHS to PAX,
Positive Behavior Interventions and Support,
Social and Emotional Foundations of Early
Learning (SEFEL), Olweus Bullying
Prevention, Toward No Tobacco Use
“Packaging” Problem
 Blind commitment to parameters of manuals (e.g.,
hour long sessions, too many sessions), without
consideration of school realities
 Instead group key intervention components in
“phases” and deliver flexibly
 See Steve Evans, Julie Owens, Ohio University
Typical Work for Clinician for EvidenceBased Prevention Group





Screen students
Analyze results of screen
Obtain consent/assent
Obtain teacher buy-in
Coordinate student
schedules
 Get them to and from
groups




Rotate meeting times
Implement effectively
Promote group cohesion
Address disruptive
behaviors
 Conduct session by
session evaluation
 Deal with students who
miss groups
Strengthening School Mental Health
Services
 NIMH, R01MH081941-01A2, 2010-14 (building from a
prior R01)
 46 school mental health clinicians, 34 schools
 Randomly assigned to either:
 Personal/ Staff Wellness (PSW)
 Clinical Services Support (CSS)
CSS: Four Key Domains
 Quality Assessment and Improvement
 Family Engagement and Empowerment
 “Modular” Evidence Based Practice
 Implementation Support
Modular EBP for DBDs
•
•
•
•
•
Active ignoring
Commands
Communication
Monitoring
Praise
•
•
•
•
•
Problem solving
Psychoeducation
Tangible rewards
Response cost
Time-out/grounding
• See Chorpita &
Daleiden, 2009, and
PracticeWise
Structure for Implementation
 Twice monthly two-hour training
 Monthly or more coaching visits at school
 Coaching involving observing family sessions and
collegially providing ideas and support
 CHALLENGES
 Expense
 Family no-shows
Other Conclusions
 Need the right clinicians
 For true EBP demands are intense at multiple levels
 TRAINING/IMPLEMENTATION SUPPORT +
INCENTIVES + ACCOUNTABILITY
 Tension between productivity and quality
Funding -- Foundations
 Determining boundaries
 A lead group steps forward
 Effective convening and meeting
 Building expectations/standards at each tier
 Matching prevention/intervention strategies to the
evidence-base and these standards
Foundations 2
 Developing a strategy for Memorandum of
Understanding (MOU)
 Assuring MOUs emphasize continuous quality
improvement
 Living out a “shared agenda”
 Ongoing social marketing and outreach to assure key
systems and stakeholders buy-in and participate
Funding mechanisms
 Federal and state grants and contracts (how assure
investments don’t evaporate?)
 Local initiatives (e.g., Seattle tax levies for schoolbased health centers)
 Accessing Medicaid and other insurance
 BRAIDED FUNDING WITH CROSS-SYSTEM
INVOLVEMENT AND TRANSPARENCY
SMH in Baltimore
 1989: 4 schools
 2009: 105 schools
 42 Elementary schools
 41 Middle/K-8 schools
 22 High schools
Baltimore ESMH Funding 2009
Baltimore City
Health
Department,
$235,950
Family League of
Baltimore, Inc.,
$177,000
7%
Baltimore Mental
Health Systems,
Inc., $768,000
6%
Baltimore
Substance Abuse
Systems, Inc.,
$383,000
12%
3%
Department of
Labor Grant,
$105,000
25%
47%
Baltimore City
Public School
System,
$1,450,000
Challenges
Mental Health Screening
 Expensive (time and cost)
 Which measures?
 Need will overwhelm existing resources
 Liability concerns
 With formal measures to do it right, need the
community to rally around individual schools
Approach in Charleston (thanks to Bob Stevens)
School Related Barriers
 Fluidity of the school environment
 Teacher turnover
 Tenuous principal buy-in
 Lack of time
 Lack of dedicated change agents
Entrenched problematic policies and
approaches
 Suspension
 Expulsion
 Very poor transitions
 Schools and people doing what they are used to
doing (and being highly resistant to change)
A common pattern
 Crisis of the Week (COW)
therapy
 Putting out fires
 Failing to achieve valued
outcomes
 Thanks to Sharon Stephan
Roles of School-Employed MH
Staff (in some instances)
 Course scheduling
 Attendance monitoring
 Examination monitoring
 Career guidance
 Logistics assistance
 See Steve Evans, Ohio University
“Optimizing”
 School employed staff doing rote administrative work
 Community mental health staff seeing same clients
and delivering passive, eclectic, non evidence-based
interventions
Special Education Challenges
 Schools and staff as gatekeepers
 “Social maladjustment”
 Highly variable labeling
 “Manifestation” hearings
 Increasing but not decreasing restrictiveness
 Pro-forma meetings and poor follow-up
 Accomodations
Students in Alternative Schools
from Jason Bird and Bobby Markle
Negative School Climate 


Stigmatized by teachers and students
Negative peer interactions at both schools
Little positive support from teachers and school staff upon
returning from alternative school
Inconsistent School Structure and Procedures 


Larger, more difficult classes upon return to regular school
Less perceived expectations/accountability at the alternative
school placements
Unclear transitional procedures between schools
ISF Key Themes
 A true “Shared Agenda”
 Strong state – district – building relationships
 Strong teams in buildings using data and showing
outcomes
 Teams represent interdisciplinary cadres of
committed people
 Proactive stance toward disruptive people and
organizations
 Making political connections and growing
resources
Importance of Relationships in Change
There will never be enough laws, policies, processes,
documents, etc. to force change
Change is best realized through the relationships we build
with those people and groups that have a common interest
toward solving a persistent problem or seizing an
opportunity
Bill East, Joanne Cashman, Natl Assoc of State Directors of Special Education
A National Community of Practice
(COP); www.sharedwork.org
 CSMH and IDEA Partnership providing support
 30 professional organizations and 16 states
 12 practice groups
 Providing mutual support, opportunities for dialogue
and collaboration
Example Practice Groups
 Learning the Language
 Quality and Evidence-Based Practice
 Family Involvement
 Youth Leadership
 SMH and PBIS
 SMH and Special Education
 SMH and Systems of Care
 Military Families
Sixteen States
 Hawaii
 New Mexico
 Illinois
 Ohio
 New Hampshire
 Pennsylvania
 North Carolina
 South Carolina
 Maryland
 South Dakota
 Minnesota*
 Utah*
 Missouri
 Vermont
 Montana*
 West Virginia
South Carolina School Behavioral
Health Community
 Mission Statement
“To promote student success by reducing barriers to
learning and supporting the social, emotional,
behavioral, and mental wellness of all youth and
families in South Carolina”
First Annual
South Carolina
School Behavioral
Health Conference
Medallion Conference Center
Columbia, S.C.
Thursday, April 24, 2014
100%
PBIS
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Lexington 05 Charleston Richland 01 Dorchester
02
Jasper
Greenwood
50
Oconee
Greenville Lexington 02 Kershaw
SMH
45%
PBIS and
SBMH
40%
35%
30%
25%
20%
15%
10%
5%
0%
Lexington 05
Dorchester 02
Richland 01
Charleston
Lexington 02
Greenville
PBIS/SMH in Montana
Our Vision
Ontario students are
flourishing,
with a strong sense of
belonging at school,
ready skills for
managing academic and
social/emotional
challenges,
and surrounded by
caring adults and
communities equipped
to identify and
intervene early with
students struggling
with mental health
problems
A Vision for Student Mental Health and Well-Being in
Ontario Schools (with thanks to Kathy Short)
Interactive Exercise:
Brad Smith Elementary School
Brad Smith Elementary School
K-6, 390 students
40% minority, 46% RFL
14% special education
1-18 tchr-student ratio
2 counselors
Limited PBIS, Tier 1
Ineffective referrals to
CMH
• Poorly functioning
teams
•
•
•
•
•
•
•
• DISCUSSION GROUPS
• 1) Bringing Community
Staff into the Work
• 2) Team Functioning
• 3) Tier 1 Strategies
• 4) Tier 2 Strategies
• 5) Tier 3 Strategies
• 6) Building
Family/Stakeholder Inv.
• 7) Coordination with
the District
19th Annual SMH Conference
Pittsburgh, Pennsylvania
September 18-20, 2014
csmh.umaryland.edu
The Clifford
Beers Initiative
at the University of South Carolina
Background
• First satellite office of the Clifford Beers Foundation
o Named in recognition of Clifford Whittingham Beers
• A Mind That Found Itself (Beers, 1908)
• Mental hygiene movement
• Emphasis on promotion of mental health
• Building networks and collaborative efforts
8th World Congress on Mental Health Promotion
London, England
September 23-26, 2014
worldcongress2014.org
Upcoming World Congresses
Columbia, SC, 2015
Ontario, 2016
Contact Information
Department of Psychology
University of South Carolina
1512 Pendleton St., Room 237D
Columbia, SC 29208
Ph: 803 777 8438
[email protected]