1 Supporting Students’ Mental Health: A Response to Intervention Approach Wisconsin Department of...

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Supporting Students’ Mental Health:

A Response to Intervention Approach

Wisconsin Department of Public Instruction

September 2011

Today’s presentation Why should our school/district address mental

health? How are students affected by mental illness? Is mental illness a “mental” illness or a

“physical” illness? What about stigma? Mental health & illness on a continuum Risk & protective factors Educational & medical diagnoses

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Today’s presentation Warning signs & symptoms Using RtI to support students’ mental health

Tier 1 – Universal Tier 2 – Selective Tier 3 - Targeted

Starting to plan changes What are we doing now to support students’ mental

health? How can we build on current efforts? What else

can we do?

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Mental health is directly related to a school’s missionCalifornia Healthy Kids Survey Schools in this study with more depressed

students made less progress in raising test scores

The results were evident in both low- & high-performing schools

California Healthy Kids Survey & STAR data files

www.wested.org/chks/pdf/p1_stuartreport_ch_final.pdf

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Impacts on Student in School Attentiveness Concentration Opportunities to rehearse & demonstrate

Mastery is difficult without any of the components of attention, concentration, self-appraisal, or rehearsal

Self-appraisal Set of attitudes & expectations about one’s

own abilityAdapted from SAMHSA Eliminating Barriers, 2005

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Example of Impacts on Learning: Anxiety Attention can be disrupted by a sense of

impending doom Concentration is difficult to maintain during

intense anxiety, or is impacted by irritability, restlessness, or feeling out of control

Self-appraisal/expectations of poor outcomes or a sense of inability to bring about good results

Adapted from SAMHSA Eliminating Barriers, 2005

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Example of Impacts on Learning: Anxiety Behavior includes “freezing” during exams,

asking for help when unnecessary, talking about worries, making “what if” statements or exaggerated/irrational fears; can be overly prepared; can be upset or even frantic when worries escalate

Rehearsal can be disrupted by worries about performance

Mastery is difficult when feeling acute anxiety; cannot retrieve or demonstrate previously learned information

Adapted from SAMHSA Eliminating Barriers, 2005

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National Profile of Adolescent Mental Health Half of lifetime (chronic) mental illness started by

age 14 20% of adolescents experienced significant

symptoms of emotional distress 10% had moderate to severe symptoms with

significant impairment Most common disorders were depression,

anxiety, ADHD, & substance abuse

Knopf, D. et al (2008) The Mental Health of Adolescents: A National Profile, 2008. San Francisco, CA: National Adolescent Health Information Center.

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2009 WI Youth Risk Behavior Survey 20.8% of high school students reported

symptoms of depression in past 12 months 13.2% seriously considered suicide 11.0% made a plan about how to attempt

suicide in the past 12 months 1.7% made suicide attempt that required

medical treatmentWhat does that mean for us & our students?

Let’s do the math ….

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Mental illness or physical illness? Mental illnesses impact on the brain

Brain chemistry - interferes with thinking, mood, & behavior

Affects both brain structure & function Can be misinterpreted as negative

personality traits, low motivation, bad decision-making, etc.

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PET scan of lower serotonin function in a patient with major depression (right), compared to a healthy volunteer

Columbia Kreitchman PET Center

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http://www.cumc.columbia.edu/dept/radiology/pet/pdf/pet_healthpoints_winter06.pdf

Healthy brain:

plenty of seretonin transport

Brain of person with depression: inadequate seretonin transport

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What about us? Would we talk about our own personal experiences with mental illness here? Maybe …

A few would feel comfortable, but it’s unlikely

Some might feel comfortable talking about this with close friends or family they trust

Compare that to other health conditions It’s all about stigma

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People with mental illness have accomplished great things Can you name famous people who

have lived with some kind of mental illness?

Abraham Lincoln is described as having “melancholy” (depression)

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Starry Night by Vincent van Gogh

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Lionel Aldridge experienced schizophrenia

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Buzz Aldrin lived with Bipolar Disorder

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Ernest Hemingway had depression

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Winston Churchill lived with depression

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Thelonius Monk experienced a number of mental illnesses

Stigma & Myths

Stigma causes Lack of awareness of a problem Reluctance to seek treatment Ignorance of how to seek services

Myths create stigma, while understanding removes ignorance & barriers

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Stigma & Children Children may internalize stigmatizing

messages as part of their self-image

Teachers who are aware stigma may be less likely to allow it into their classrooms

Hinshaw, S. P. (2005). The stigmatization of mental illness in children and parents: developmental issues, family concerns, and research needs. Journal of Child Psychology and Psychiatry, 46, 714-734.

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Do’s & Don’ts to Reduce Stigma Do use respectful, person-first language

“He has schizophrenia” not “He’s schizophrenic” “The student with OCD” not “The OCD student”

Do emphasize abilities, not limitations Do talk about stigmatizing messages Don’t use terms like crazy, Wacko, Nut Case,

Psycho, Schizo, EMO What terms are your students using?

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Is this just a high school issue?Are we seeing …

students with mental health challenges at younger ages?

with more severe issues?

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Mental Health Mental Illness Continuum

It’s not an “either-or” situation Students may have symptoms & behaviors

without having a diagnosable disorder Students may have a diagnosable disorder

that is managed well, so there are minimal symptoms & behaviors

Both symptoms & disorders can have a serious impact on a child’s overall health

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One end of the continuum: Health

Mentally healthy people usually … Have friends Regulate their emotions Cope with normal stressors Live in supportive environments with others

who care about them Focus on goals & achieve them

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The other end of the continuum: Illness

People with mental illness often … Lack friends or are involved with maladaptive

peers Lack capacity & strategies for regulating

emotions Have few effective ways of coping with

stresses Have serious work or academic difficulties

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Mental Illness & Health is an Interplay between Risk &

Protective Factors Biological predispositions

Genes, temperament, prenatal care Social & environmental effects - most risk

here Trauma, violence, poverty, loss, access,

racism Difficult interpersonal relationships

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Mental Illness & Health is an Interplay between Risk &

Protective Factors Cultural influences & attitudes Practices & beliefs about behaviors & mental

illness itself Stigma can compound the effects of disorder

Family influences Parental modeling & treatment Family violence & conflict

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Interplay between Risk & Protective Factors Protective factors from the research

include1. Loving, effective parenting (limits, bed times, etc.)

2. Adequate family income & housing

3. Positive peer group

4. Bonding to & engagement in school

5. Social & emotional knowledge & skills

Which of these protective factors can a school impact?

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Bonding to & engagement in school School connectedness is the extent to

which students feel accepted, valued, respected, & included in the school

Connectedness has been found to correlate (-) strongly with concurrent mental health symptoms, particularly for depression

Shochet, I.M., Dadds, M.R., Ham, D., Montague, R. (2006). "School connectedness is an underemphasized parameter in adolescent mental health: Results of a community prediction study." Journal of Clinical Child and Adolescent Psychology, 35,170-9.

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Interplay between Risk & Protective Factors

Risk factors increase the likelihood that a given individual will develop a disorder, but risk factors are not “destiny”

Each additional risk factor increases the negative influence of the others

Protective factors reduce likelihood, but are not “all powerful”

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Educational & Medical Categorization Systems School-Based Systems

Focus on school functioning & behaviors IDEA, Section 504 of Rehabilitation Act

Mental Health Diagnoses Diagnostic & Statistical Manual of Mental

Disorders (DSM) Diagnostic categories based on combinations of

symptoms Severity, Frequency, Duration

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Diagnostic Categories in DSM & Most Commonly Used

with Children Internalizing Problems Mood Disorders Anxiety Disorders

Externalizing Problems Conduct & Oppositional Defiant Disorders AD/HD, ADD

Other Disorders Eating Disorders Trauma-related disorders Schizophrenia Autism Spectrum

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All teens have ups & downs, but a student who is… so sad & cries frequently (mood problem) … for the last 4 weeks (duration) … that she won’t get out of bed (severity) … most mornings & is late for school

(frequency) … & is failing 3 classes (impairment) …

...meets the clinical criteria for depression, & needs help in school & at home

Warning Signs & Symptoms See handout Being Alert to Mental Health

Problems Contacts in our school/district/community for

more information _____________________________ _____________________________ _____________________________

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Three Levels of Prevention

1. Structure the school setting to serve as a protective factor for all children to reduce new occurrences of mental health problems

2. Identify & intervene with children at-risk for mental health problems to reverse, halt, or at least slow the progression of the disorder

3. Provide intensive supports for students with severe & pervasive needs to slow the progression of the disorder & provide the student & significant others with adaptive coping skills

Tier 3/Targeted Interventions 1-5%•Wrap-around services•Intensive case management•IEPs/504 plans•Parent training & support

1-5% Tier 3/Targeted Interventions•Individual students•Assessment-based

•Intense, durable procedures

Tier 2/Selective Interventions 5-15%•BCT process•Screening•Monitoring •Community referrals•Parent education•Classroom supports•504 plans/IEPs

5-15% Tier 2/Selective Interventions•Some students (at-risk)

•High efficiency•Early detection

•Rapid response•Small group interventions

•Some individualizing

Tier 1/Universal Interventions 80-90%•School climate•School policies•Curriculum/instruction•Modeling•CSCM

80-90% Tier 1/Universal Interventions•All settings, all students

•Preventive, proactive

Using PBIS to meet the mental health needs of students

Illinois PBIS Network, Revised May 15, 2008. Adapted from “What is school-

wide PBS?” OSEP Technical Assistance Center on Positive Behavioral

Interventions and Supports. Accessed at http://pbis.org/school-wide.htm

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Tier 1 – Universal Strategies There is a school-wide commitment to the

social-emotional needs of all students Adults model appropriate & respectful

behavior & language Focus is on building resilience rather than

punishing deficiencies Prevention is evidence-based & evaluated

for effects

Universal Strategies Welcoming school climate for students &

families School policies & procedures that prohibit

discrimination & bullying that are consistently enforced by all

Respectful behavior modeled by adults Comprehensive School Counseling Model Proactive discipline system (e.g., PBIS) Classroom instruction on mental health & illness

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What Teachers Can Do Create rules that recognize positive behaviors Learn & inquire about students’ personal lives Help children feel useful & helpful Have students set behavioral & academic goals Foster communication with parents Use varied instructional methods

www.casel.org

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What Teachers & Pupil Services Can Do Provide instruction in social-emotional skills:

Self Awareness Social Awareness Self Management Relationship Skills Responsible Decision Making

Provide instruction in health promotion & problem prevention - www.casel.org

Respect students’ & families’ privacy




Tier 2/Selective Interventions 5-15%•BCT process•Screening•Monitoring•Community referrals•Parent education•Classroom supports•504 plans/IEPs












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Tier 2 - Selective Level

General education students who are showing some symptoms or signs are the target

Signs may be obvious, such as emotional outbursts or disruptive behavior

Signs may be subtle & less easy to notice, such as withdrawal or sadness

Teachers & pupil services should partner to support students’ mental health

Selective Strategies Building Consultation Team (BCT) process -

classroom supports to improve behavior management & student learning & support

Share information about mental health & illness with parents

Screen students’ presenting with symptoms & challenges

Monitor students’ progress (e.g., Check In – Check Out)

Refer students in need for mental health assessments in community

504 plans & IEPs

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Assessing Barriers to Learning A problem-solving approach examines

possible barriers in the: Student Environment Curriculum Instruction

Purpose of assessment is to better understand & address barriers

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Assessing Barriers to LearningMay be within the student

Mental health problems Physical health problems Intellectual deficits Behavioral skills deficits Academic skills deficits Low motivation

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Assessing Barriers to LearningMay be within the environment

Classroom management issues Peer relationship issues Overcrowded conditions Conditions that provoke anxiety or distractibility Missing or poor organizational supports Missing or poor targeted reinforcers Lack of functional understanding of problem

behavior

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Assessing Barriers to LearningMay be within the curriculum or instruction

Curriculum not matched to skill level Curriculum is of low interest Insufficient practice is available Instruction not matched to student learning

needs Pace Feedback Error correction

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Assessing Barriers to LearningWhat are the functions of the problem

behaviors? Avoid or escape from anxiety? Attract or avoid attention? Avoid or escape from aversive task/location? Confirm low self-esteem/depressive

symptoms? Attract/maintain stimulation?

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Addressing Barriers to LearningSelective prevention activities may include

one or more of: Consultation for building- &/or classroom-level

positive behavioral supports Direct service skills training in individual or

small group format Facilitation of community or home-based

services

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Addressing Barriers to Learning

Positive Behavioral Supports Linked to the function of the problem

How can Andy avoid anxiety without withdrawing from classroom activities?

Reinforcing more desirable behaviors Reducing undesired behavior

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Positive Behavioral Supports Key is MORE desirable, not ideal behavior How can the environment be altered to

increase the likelihood of the more desirable behavior?

Support can be at the antecedent level or the consequence level

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Antecedent Positive Behavioral Supports Routine organization to reduce anxiety Classroom rules & procedures Chunking academic assignments Desk placement Timely reminders Welcoming, friendly tone of voice & body

language

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Addressing Barriers to LearningConsequent Positive Behavioral Supports

Positive reinforcement of more desired behavior

Response cost for undesired behavior (loss of points or preferred activity)

Group contingency programs (Good Behavior Game, classroom-wide reinforcement)

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Direct Skills Training Teach the desired behavior or skill Small group or individual Use evidence-supported interventions by

trained pupil services personnel Results are better when you collaborate with

other stakeholders (teachers, parents)

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Direct Skills Training Anxiety reduction techniques Depression management techniques Anger management techniques Impulse control techniques Social skills training




Tier 2/Selective Interventions 5-15%•BCT process•Screening•Monitoring •Community referrals•Parent education•Classroom supports•504 plans/IEPs












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Tier 3 – Targeted Prevention Strategies

Programming is strength-based, rather than merely symptom-suppressing

Schools actively collaborate with family & community persons of influence & concern

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Targeted Level: Who is Served? Students with diagnosable mental

disorders May receive IEP services for students

with EBD May also be in general education, if

symptoms are adequately managed Generally require systemic levels of

support

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Targeted Prevention Programs Intensity & frequency of the efforts may

surpass those of secondary level Group size may be smaller or individual

interventions may be necessary Goals are to increase the student’s …

coping skills & ability to profit from school curriculum

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Targeted Prevention Programs Targeted activities are assessment driven Functional Behavioral Assessment (FBA) is

a critical tool All behavior, even problem behavior, is

purposeful Problem behavior serves a function for the

student FBA helps identify likely functions of the behaviorhttp://cecp.air.org/fba/default.asp

Parent Training & Support

Parents need information & support to parent Tier 3 child effectively

Intervention focused on specific student Information & resources are targeted to

family needs & situation School can provide information & support to

parents or refer out to community-based treatment provider

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Intensive Case Management Check & Connect Contingency plans built into IEPs & 504 Plans Regular communication with family Regular communication with other systems

(e.g., mental health) High quality transition services School-based monitoring of treatment in

cooperation with physicians & mental health professionals

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Collaborative wrap-around system Brings family, community agencies, &

school personnel together to coordinate services to child & family

Wrap-around is a planning process Used to build consensus within a team

of professionals, family members, & natural support providers

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Supporting Students’ Mental Health1. How do we put together an effective team to

oversee and manage this effort?

2. How do we conduct an inexpensive yet helpful needs assessment of our school?

3. How do we go about analyzing the assessment data into a useful form to guide planning?

4. How do we determine which programs or procedures to use in our school?

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Supporting Students’ Mental Health5. How do we ensure that the prevention

programs are implemented so that they do the most good for the time & money spent on them? How do we build on current RtI efforts?

6. Is there a practical & simple way that we can evaluate the success of the program and have some accountability data?

7. How do we make certain that the effort is sustained after a year of hard work?

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Meeting the mental health needs of students is everybody’s job.

Painting over the problem doesn’t solve it.

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