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4/15/2012
What is “School Based Mental Health?” and What do we know?
Krista Kutash, Professor Emeritus, USF
Denver, Colorado March 2012
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Topics of Discussion
•
•
•
•
How many children?
What does treatment cost?
How are we doing?
What do we know about services and treatment?
• Trends and challenges
in the field
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Seriousness of the Problem
Prevalence of Serious Emotional Disturbance (SED)
Population Proportions (9 to 17 year‐olds)
5‐9%
Youth with SED & extreme functional impairment
5‐9%
9‐13% Youth with SED, with substantial h b
l
functional impairment
20%
9‐13%
Youth with any diagnosable disorder
20%
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5 Most Costly Children’s Health Conditions (MEPS, 2009: noninstitutionalized
(MEPS, 2009: noninstitutionalized children)
C di i
Conditions Child
T t d
Children Treated C t
Cost
Mental Disorders
4.6M $8.9B Asthma
13 M $8.0B Trauma‐related Disorders 7 M $6.1B Acute Bronchitis 12.8 M $3.1B Infectious Diseases 4.5M
$2.9B 4
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What do we know and What have we learned?
Children and youth who have Serious Emotional
Children and youth who have Serious Emotional Disturbances have deficits in multiple domains (social, emotional and behavior) and are often served in multiple systems simultaneously (MH, Education, JJ and Child Welfare). 5
Typical Mental Health Services to Children in Child Welfare are Often Ineffective McCrae, JS, Guo, S & Barth, RP. (2010). Changes in maltreated children's emotional‐behavioral problems following typically provided mental health services. American Journal of Orthopsychiatry. 80(3):350. Borderline or Clinical Behavioral Health •
bl
h ld
h ld
Problems among Children Receiving Child Welfare Services, with and without Mental Health Services 100%
75%
50%
25%
0%
•
Did not receive mental health services
Received mental mealth services
For those children involved h h ld lf
d
with child welfare and receiving MHS, this study was not able to show a positive relationship between MHS and changes in children’s behavior across time. The study should not be understood to indicate that all MHS for children involved with CWS are ineffective; rather, it CWS
i ff ti
th it
indicates that children do not predictably receive services that are sufficient to help them overcome their behavioral difficulties. From: Clare Anderson, ACYF 6
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Serious Youth Offender Study: Substance Abuse And Reoffending
(Schubert , Mulvey
(Schubert , Mulvey, & , & Glasheen
Glasheen, 2011) , 2011) 1 354 felony youth offenders Phoenix
• N=
N= 1,354 felony youth offenders, Phoenix and Philadelphia • 8 year study (21,000 interviews) • Mental health disorder alone does not affect time in gainful activity (school/work) and re‐offending d
ff di
• Substance use disorder significantly contributes to re‐arrest over 6 years and less time in gainful activity 7
Serious Youth Offender Study: Substance Abuse And Reoffending
(Mulvey
Mulvey, 2011) , 2011) • No benefit from longer lengths of institutional o be e t o o ge e gt s o st tut o a
stay to rate of re‐arrest • “The good news, however, is that treatment appears to reduce both substance use and offending, at least in the short term. Youth ose ea e as ed o a eas 90 days
whose treatment lasted for at least 90 days and included significant family involvement showed significant reductions in alcohol use, marijuana use, and offending over the following 6 months.“ E. Mulvey, March 2011
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What do we mean by Trauma? • Event(s) Exposure to violence, victimization including sexual physical abuse severe neglect loss
including sexual, physical abuse, severe neglect, loss, domestic violence, witnessing of violence, disasters • Experience Intense fear of/ threat to physical or psychological safety and integrity, helplessness; intense emotional pain and distress • Effects Stress that overwhelms capacity to cope and manifests in physical, psychological, and neuro‐
physiological responses
Gene Griffin, PhD, 2012, 3E’s 9
Trauma and Youth •
•
•
•
•
•
Among U.S. Youth: 60% exposed to violence within past year 8% report lifetime prevalence of sexual assault 17% report physical assault 39% report witnessing violence Survey of adolescents in SU treatment > 70% had history of trauma exposure (Suarez, 2008)
• Childhood traumas potentially explain 32% of psychiatric disorders in adulthood Archives of General Psychiatry, Feb 2010, NCRS‐R Study 10
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NLTS and NLTS2 Overview
NLTS
NLTS2
Focuses on
Focuses on
Youth and young adults
Youth and young adults
Youth and young adults
Youth and young adults
Study began
1987
2001
Age at start of study
13 to 21
13 to 16
Disability categories
All disability categories
All disability categories
7 years
2 waves of data over 4 years
10+ years
5 waves of data over 9 years
Longitudinal
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High school academic outcomes of students with EBD (1987 and 2003)
percentage earning “mostly
As and Bs” • The
The percentage earning mostly As and Bs
increased from 21% to 47%.**
• The high school completion rate increased from 39% to 56%.* • The percentage suspended for 1 or 2 days increased from 2% to 11%
increased from 2% to 11%** and average and average
days absent in a 4‐week period increased from 1.9 to 3.1.**
* p < .05; ** p < .01. SOURCE: U.S. Department of Education, Office of Special Education Programs, National Longitudinal Transition Study (NLTS), Wave 1 parent interviews, 1987; U.S. Department of Education, Institute of Education Sciences, National Center for Special Education Research, National Longitudinal Transition Study‐2 (NLTS2), Wave 2 parent interviews and youth interviews/surveys, 2003. 12
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Postsecondary school enrollment (1990 and 2005) Young adults with EBD attended
Percentage‐point difference Any post 18%
+17**
+17** 35%
secondary school
2‐year/community college
10%
21%
Vocational, busine
ss, technical school
7%
4‐year college
1%
6%
1990
21%
+11 +17*** +5 2005
** p < .01; *** p < .001. SOURCES: U.S. Department of Education, Office of Special Education Programs, National Longitudinal Transition Study (NLTS), Wave 2 parent interviews 1990; U.S. Department of Education, Institute of Education Sciences, National Center for Special Education Research, National Longitudinal Transition Study‐2 (NLTS2), Wave 3 parent interviews and youth interviews/surveys, 2005. 13
Community participation (1990 and 2005) Young adults with EBD
Belonged to a 14%
23%
community…
community Participated in volunteer or …
Percentage‐point difference +9
11%
24%
+13 Had a driver's license
59%
65%
+6
Were registered to vote
50%
69%
+19** Were ever arrested
1990
36%
61%
+25*** 2005
** p < .01; *** p < .001. SOURCES: U.S. Department of Education, Office of Special Education Programs, National Longitudinal Transition Study (NLTS), Wave 2 parent interviews 1990; U.S. Department of Education, Institute of Education Sciences, National Center for Special Education Research, National Longitudinal Transition Study‐2 (NLTS2), Wave 3 parent interviews and youth interviews/surveys, 2005. 14
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What are the evidence‐
What are the evidence‐based mental health treatments? new randomized clinical trials since
• 140
140 new randomized clinical trials since 2002 (almost doubled the total number of RCTs).
• Chorpita and Colleagues (2011) reviewed 435 studies on mental health treatments.
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What works? Evidence‐‐based What works? Evidence
treatments for disruptive behavior
treatments for disruptive behavior
™ 23 different treatment h
ith
t
approaches with some support
™ Approaches with most support: • Multisystemic Therapy (MST) / Cognitive Behavior Therapy • Parent Management Training
Parent Management Training
• Social Skills & Assertiveness Training, Anger Control
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What works? Evidence
What works? Evidence‐‐based treatments for Attention and Hyperactivity:
Self Verbalization Skills
• Self Verbalization Skills • Behavior Therapy plus medication
• Parent Management Training 17
Overall • Evidence‐based MH treatments are made up of an array of approaches that • Build skills in student
• Build skills in parents
• Build a relationship between student and an adult who reinforces new skills acquired by students and can work with parents. 18
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C t for
f
Center
School
Mental
Health
University
of Maryland
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National Registry of Evidence
National Registry of Evidence‐‐
Based Practices • “NREPP is a searchable online registry of more than 220 interventions supporting mental health promotion, pp
g
p
,
substance abuse prevention, and mental health and substance abuse treatment (for youth and adults). We connect members of the public to intervention developers so they can learn how to implement these approaches in their communities.”
http://www.nrepp.samhsa.gov/
•http://www.nrepp.samhsa.gov/
•See list of Programs from NREPP in School‐based Mental Health
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Institute for Educational Sciences
Wh t W k
• What Works Clearinghouse • Behavior Guide • Research Reports on Interventions
– First Steps to Success
First Steps to Success
– Check and Connect
– Incredible Years • Funding of Studies
– CBITS
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Trends in the field
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Entry
Yes
Crisis Services
Crisis
stabilized,
refer for other
services
Multiple Entry Points
Common Assessment Elements
Is this child
in crisis?
No
D
thi child
hild
Does
this
require a complex
intervention?
Outpatient
Assessment
& Treatment
No
Is problem solved?
Yes
Yes
No
Case Manager Selected
Case Manager with family, identifies key people
to participate in team meeting
Convening of team meeting, including family,
members of natural support system and representatives of relevant
programs and systems, to develop individualized plan
No or
Partially
Was the plan successful?
Yes
Exit
System
Develop & implement modified plan
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Opportunity to implement evidence based intervention
Entry
Yes
Crisis Services
Crisis
stabilized,
refer for other
services
Multiple Entry Points
Common Assessment Elements
Is this child
in crisis?
No
D
Does
this
thi child
hild
require a complex
intervention?
Outpatient
Assessment
& Treatment
No
Yes
Case Manager Selected
Is problem solved?
No
Yes
Case Manager with family, identifies key people
to participate in team meeting
Convening of team meeting, including family,
members of natural support system and representatives of relevant
programs and systems, to develop individualized plan
No or
Partially
Was the plan successful?
Develop & implement modified plan
Opportunity to implement evidence based intervention
Yes
Exit
System
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How many schools have MH resources? (Foster et al., 2005)
• 1/3 of school districts 1/3 of school districts report that they exclusively use school‐ or district‐based staff to provide mental h lth
i
health services
• 1/4 of school districts 1/4 of school districts only
only use outside agencies for the provision of mental health services
• 2% of school districts 2% of school districts reported they operated their own mental health unit or clinic
• 59% of schools 59% of schools report using curriculum‐based 59% f h l
t i
i l
b d
programs to enhance social and emotional functioning and reduce barriers to learning
• 78% provide 78% provide school‐wide strategies to promote safe, drug free schools
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Tested four models of School
Tested four models of School‐‐based Mental Health that served with youth who have SED and educated in Special Ed classrooms
2 – Contracted with MH counselor from Contracted with MH counselor from
• Pull‐out
Pull out 2 Community Agency
• Pull‐Out 1 – Hired as School employees MH counselors • Integrated 1 – PBS and Wraparound Process • Integrated 2 –
I t
t d 2 MH/ED classrooms within regular MH/ED l
ithi
l
schools operated by intermediate unit.
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Effect sizes for emotional functioning, functional impairment, & achievement.
0.8
06
0.6
0.4
Effect Size
0.2
0
0.2
‐0.2
Integrated 1
‐0.4
Emotional Functioning
Integrated 2
Integrated 2
Pull‐Out 1
Pull‐Out 2
Program
Functional Impairment
Reading
Math
Kutash, K., Duchnowski, A.J., Green, A.L. (2011). School-based mental health programs for students who
have emotional disturbances: Academic and social-emotional outcomes. School Mental Health. 3,191-208.
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Wraparound National Wraparound Initiative
• National Wraparound Initiative 33
Wraparound… An Art
Wraparound… An Wraparound… An Art and
Wraparound… An Art Art and Science
Values Based Wraparound Process
Family‐Centered, Flexible, Strengths‐Based
AND
Evidence Based Interventions
Science of Behavior Change
Science of Behavior Change
Effective Clinical and Academic Interventions [(e.g., Medication, CBT) e.g., DI]
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Model for Schools ED
MH
•
•
Universal
Selective/ Targeted
•
•
•
Primary role is building school‐
wide support
•
Conduct FBA
Facilitate team meetings
Monitor progress
•
•
Consultation on identifying target behaviors
Provide mental health promotion
Enhance assessment with psychological evaluation
Provide evidence‐based interventions
Families
•
Be aware of and support school programs
•
Provide information
Identify strengths in home setting
•
•
•
Intensive/ Indicated
•
•
•
Conduct FBA
Report on progress
Facilitate team meeting
Monitor progress
•
•
•
Psychological assessment
Evidence‐based intervention
•
•
o de o a o ,
Provide information, Express opinions about needed intervention Support intervention at home Be engaged
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Common
Vision
Families
(FAM)
Mental Health (MH)
Education
(ED)
Universal
Selective
Intensive
All Students
At-Risk Students
Students in
Special Ed due
to Emotional
Disturbances
ED – PBS
ED – FBA / PBS
MH - Screening
MH – Assessment
• Figure 4 in Blue Book Figure
4 in Blue
Book
FAM EBP’s
FAM
ED
MH
Implemented
in organizations
that support and facilitate
collaborative, integrated
systems of services.
(PATHS)
ED – FBA / PBS
ED
MH
RtI
MH – Assessment
MH
ED
Group
Interventions
FAM Cognitive Behavior
ED Therapy and other
MH EBPs
ED
MH
FAM
Team Monitors
Progress
ED Team
FAM Monitors
MH Progress
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Integrated Partnership
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Model of Implementation Complexity
FIT
CLIMATE
Does the
innovation fit
within your
organization
Willing to
remove
obstacles?
Are there
rewards?
Complement
or Compete?
IMPLEMENTATION
EFFECTIVENESS
INNOVATION
EFFECTIVENESS
Can you implement
the innovation with
accuracy and
fidelity?
Impact of
innovation, commit
ment, and
satisfaction
Leadership
support?
Clarity of Goals?
VOLITION
FIDELITY BELIEFS
Is there capacity and
willingness to implement?
Favorable attitudes toward
practice Complexity of innovation
innovation
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“The earmark of a quality program or organization is that it has the capacity to get & use information for continuous improvement and accountability. No program, no matter what it does, is a good p g
,
,
g
program unless it is getting and using data of a variety of sorts, from a variety of places, and in an ongoing way to see if there are ways it can do better.”
– Weiss, 2002
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Refocus School‐Based Mental Health Services Focus On the Core Foundation of Schools:
To Promote Learningg
39
School Based Mental Health Krista Kutash, Professor Emeritus, USF
Denver, Colorado March 2012
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4/15/2012
For more information contact:
Krista Kutash, Ph.D.
[email protected]
Other Resources
Atkins, M., Hoagwood, K., Kutash, K., & Seidman, E. (2010). Toward the Integration of Education and Mental Health in Schools. Administration and Policy in Mental Health Services Research, 37, 40‐47
Cappella, E., Frazier, S. L., Atkins, M. S., Schoenwald, S. K., & Glisson, C. (2008). Enhancing Schools’ Capacity to Support Children in Poverty: An Ecological Model of School‐Based Mental Health Services. Adm Policy Ment
Health, 35, 395‐409.
M
H l h 35 395 409
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School-Based Mental Health: An Empirical Guide
for Decision-Makers
Krista Kutash, Ph.D., Albert J. Duchnowski, Ph.D., Nancy Lynn, M.S.P.H.
This monograph provides a discussion of barriers to school-based services with the intention of improving
service effectiveness and capacity. Reviews the history of mental health services supplied in
schools, implementation of serviced, and provides an overview of the evidence base for school-based
interventions. Includes: recommendations for evidence-based mental health services in schools.
Download a free copy at: http://rtckids.fmhi.usf.edu/rtcpubs/study04/
Or purchase a printed copy for $5.95 at https://fmhi.pro-copy.com/
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4/15/2012
Kutash, K., Duchnowski, A.J., Green, A.L. (2011). School-based
mental health programs for students who have emotional disturbances:
Academic and social-emotional outcomes. School Mental
l h 3(4),
3( ) 191
208
Health,
191-208.
Kutash, K., Duchnowski, A.J., Green, A.L., & Ferron, J. (2011).
Supporting parents who have youth with emotional disturbances
through a parent-to-parent support program: A proof of concept study
using random assignment. Administration and Policy in Mental Health
and Mental Health Services Research, 38, 412-427
Kutash, K., Cross, B., Madias, A., Duchnowski, A., & Green, A.
(2012). Description of a Fidelity Implementation System: An Example
(2012)
from a Community-based Children’s Mental Health Program. Journal
of Child and Family Studies.
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To download and print – free:
http://ies.ed.gov/ncee/wwc/pu
blications/practiceguides
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