School Mental Health and Foster Care

Mark Weist, Ph.D.1

Nancy Lever, Ph.D.1

Michael Lindsey, PhD, MSW, MPH2

Sylvia Huntley, BA1

Dana Cunningham, Ph.D.

1University of Maryland Center for School Mental Health2 University of Maryland School of Social Work

3Prince George’s County School Mental Health Initiative

Welcome

Introduction of University of Maryland Team

Participants-- role and your connection to school mental health and/or foster care

Center for School Mental Health* University of Maryland School of Medicinehttp://csmh.umaryland.edu*Supported by the Maternal and Child Health Bureau of HRSA and numerous Maryland agencies

What is Not Working in School Mental Health (SMH)

“Turf” and “siloed” approachesSingle system approachesSame old rolesClinics in schoolsCo-located modelsTraditional eclectic therapiesSchools handing off children to other

systems

Referrals from Schools to Other Settings

96% referred to school-based program received services

13% referred to other community agency did

Catron, T., Harris, V., & Weiss, B.  (1998)

72%

49%

26%

9%0%

10%20%30%40%50%60%70%80%90%

100%

Number of Sessions

Pe

rce

nt

of

Yo

uth

Re

ma

inin

g in

Se

rvic

es

Treatment as Usual Show Rates (McKay et al., 2005) from Kimberly Hoagwood

Other Concerning Facts

Around 1 in 5 youth will present an emotional/behavioral disorder (5 students in a classroom of 25)

Between 1/6th and 1/3rd receive any servicesModal number of specialty mental health visits

is 2Major lack of systematic quality assessment

and improvement in traditional settings

Silos

“The various systems do not talk to each other, resulting in many children falling through the cracks and not receiving care, receiving duplication of services, or families needing to negotiate a confusing, fragmented array of services” (Family Advocate, Louisiana)

“Shame” and “Strain” on Families

“Youth and families experience blame; have widespread distrust of professionals; have concerns about losing custody; are often unable to pay for care…have to glue services together” Kimberly Hoagwood (Congressional Briefing, October,

2007)

Why Mental Health in Schools?

Integrated approaches to reduce academic and non-academic barriers to learning are the most effective in achieving the outcomes families, schools and communities care about

Advantages

ACCESSPromotion and PreventionEfficiency and Cost EffectivenessSystems Collaboration/ Economies of

ScaleNatural/ Ecological ApproachReduced Stigma

School Mental Health Promotion

Selective Prevention

All Students

5-40%

1-5%

Universal PreventionRelationship Development

Systems for Positive BehaviorDiverse Stakeholder Involvement

Climate Enhancement

Targeted Individual, Group, Family Intervention

Intensive Intervention

Another Triangle

Desired Outcomes Effective mental health promotion and intervention

Outstanding staff and program qualitiesOngoing training, technical assistance & support

School and community buy-in and investment

Resources Awareness raising, advocacy, policy improvement

But in most communities…

The vision is not a reality as staff and programs are not adequately supported and often contending with tremendous need, and

In an environment of low support and high needs, positive outcomes will most likely not be achieved and efforts will stall

Many Challenges to Overcome…

Marginalization and stigmaLimited staff and resourcesDisciplinary silos and turfBureaucracy A fluid environment with frequent changes

in leadershipCompelling need at all levelsINERTIA

Making Empirically Supported Practice in Schools Achievable

Overarching Emphasis on QualityEffectively Working with Families and

StudentsEnhanced Modular InterventionOn-Site Coaching and Support

Quality Assessment and Improvement (QAI) Principles

Emphasize access Tailor to local needs

and strengths Emphasize quality

and empirical support Active involvement of

diverse stakeholders

Full continuum from promotion to treatment

Committed and energetic staff

Developmental and cultural competence

Coordinated in the school and connected in the community

Working Effectively with Students and Families

Early on focus on engagement, e.g., through candid discussions about past experiences

Emphasize empowerment and the potential for improvement

Provide pragmatic supportEmphasize mutual collaboration

School Mental Health Services for Youth in Foster Care Services can include:

After school recreational and enrichment activities School-wide mental health promotion Classroom and small group prevention activities Group therapy (for youth with similar emotional or

behavioral concerns) Individual therapy Family therapy Teacher consultation Mental health evaluation Assistance with mental health referrals

School Mental Health and Foster Care Initiative Goal: To effectively integrate and improve school mental health

services and ultimate outcomes for children, adolescents, and graduates of Maryland’s foster care system

Key Objectives Include: Develop a training curriculum and conduct training related to

effective school-based outreach, support, mental health promotion and intervention for youth in foster care in Maryland Schools

Provide statewide information and technical support on effective school mental health promotion and intervention for youth in foster care through the website, www.schoolmentalhealth.org and a listserv

Funding - Maryland Mental Health Transformation Grant # 5 U79SM57459-02 from SAMHSA

Conceptual Framework  Foster Care – School Mental Health Interface

Conceptual Framework

 A Public Mental Health Promotion Approach for Youth in Foster Care

Training Curriculum: School Mental Health and Foster Care: A Training Curriculum for Child Welfare Workers, Teachers, and Clinicians

  Module 1: Understanding the Foster Care System Module 2: Mental Health Needs of Children in Foster Care Module 3: Understanding Schools and School Mental Health

Services Module 4: Prevention and Mental Health Promotion for Youth

in Foster Care in Schools Module 5: Early Identification and Intervention Module 6: Confidentiality and Sharing Information Module 7: Coordinated Service Delivery and Integrated

Treatment Planning Module 8: Evidence-Based Treatment for Children in Foster

Care in Schools Module 9: Family Engagement and Meaningful Involvement Module 10: Policy and Funding

What is Foster Care?

Foster care is one aspect of child welfare which has as its objective, the provision of short term out of home care for children removed from their family homes; at the same time, the child’s family also receives services that aim to help them reduce the risk of future neglect or abuse in preparation for the child’s return home (Child Welfare Information Getaway, 2006).

Permanency Planning

As part of the foster care process, permanency planning is initiated.

Permanency planning is principled to include prevention of out of home care, once a child has entered into care, the purpose of the plan is to ensure the shortest length of stay and to develop a plan for permanent home placement in concert with the family (Anderson, 1997; Pelton,1991)

The main goal of the plan is always reunification of child and family. If reunification is not attainable, then other permanency options are explored such as discharge to independent living, kinship care, or placement in a suitable adoptive family.

Types of Foster Care

Court-appointed foster care: Caretaking of children displaced from biological parent(s), typically by a caring adult who has met the requirements to be a foster parent by their local jurisdiction. This situation is intended to be temporary.

Kinship care: Caretaking of children who have been displaced from a biological parent(s), typically by grandparents or other relatives. Kinship care also improves stability by keeping displaced children closer to their extended families, neighborhoods and schools.

What Happens Once in Care? Initial intake session and first 60 days plan

Key players and their role Case worker, typically a master’s-level Social Worker

Case management Clinical intervention Permanency planning Reunification support

Support services, typically offered by a bacherlor’s-level worker Mentoring Crisis intervention Therapeutic support

Outcomes at the end of foster care: Return home Adoption Discharge to independent living

The Situation in Maryland (Based on 2003 Statistics)

Total population: 11,521

Age (Average: 11.4 Years) 4% <1 year 19% 1-5 years 19% 6-10 years 33% 11-15 years 20% 16-18 years 6% ≥ 19 years

Male: 53% Female: 47%

Source: http://www.fostercaremonth.org/AboutFosterCare/StatisticsAndData/Documents/MD-Facts-FCM07.pdf 

MD Stats: Race/Ethnicity

Race/Ethnicity In out-of-home care State child population

Black (non-Hispanic) 75% 32%

White (non-Hispanic) 20% 56%

Hispanic 2% 5%

Am. Indian/Alaska

Native 0% 0%

Asian/Pacific Islander 0% 4%

Unknown 1% N/A

2 or more races

(non-Hispanic) 1% 3%

MD Stats: Additional Items Length of stay

The average length of stay for children in care on September 30, 2003 was 48 months.

Reunified Forty-one percent of the young people leaving the system in FY 2003

were reunified with their birth parents or primary caregivers.

Foster home In 2002, there were a total of 4,440 licensed kinship and non-relative

foster homes in Maryland On September 30, 2003, 35% of youth living in out-of-home care

were residing with their relatives.

Adoption Of children with state agency involvement adopted in FY 2003, 56%

were adopted by their non-relative foster parents and 40% were adopted by relatives.

Challenges connecting to SMH

Schools are difficult systems to navigate Can be hard to figure out who is providing

services to children and adolescents in the school and who would best serve the student

Capacity issues Schedules – child welfare workers and families

may only be available in the later day or evening Limited or lack of understanding and

appreciation about child welfare system. Services may not be available every day (split

FTE), school vacations, and in the summer

Schools can help children in foster care succeed by…

understanding the demands of the foster care system (e.g., court appearances during school time)

offering information about the best ways to communicate with and gather information from the school (e.g., scheduling, consent forms, and how to meet with teachers)

establishing regular communication about the child’s successes and challenges, including mental health

Schools can help children in foster care succeed by…(Continued) helping to coordinate school transfers when

necessary and making sure all available records transfer with the student

identifying children in foster care who are in need of special education services and ensuring that these services are provided across school placements

training school staff about the mental health issues associated with foster care and how to help youth in foster care be more successful in school

Resources

http://www.aacap.org/cs/root/facts_for_families/foster_care

http://www.fostercaremonth.org/AboutFosterCare/StatisticsAndData/Documents/MD-Facts-FCM07.pdf

http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report10.htm

Statistics Related to Mental Health for Youth in Foster Care Youth in foster care experience even more

mental health symptomatology than other high risk youth

In a recent study of children and adolescents in foster care, 54% had one or more mental health problems in the past 12 months (compared with 22% of the general population)

Remarkably, 25% had Post-Traumatic Stress Disorder within the past 12 months (twice the rate of U.S. war veterans) (Pecora et al., 2005)

What are the unique mental health issues that are commonly seen in youth in foster care?

Anger/Irritability• Nightmares• Distressing memories• Sleep problems• Depression and Anxiety• Avoidance• Attention problems• Problems with attachment• Delinquency• Oppositional Behavior

How do these issues manifest in a classroom/school setting?

Sleeping in class Defiant or disruptive Refusal to participate/do homework Excessive absences/tardiness/truancy Easily distracted/poor concentration Irritability Destructive behavior to self/others/objects Change in grades/attitude Excessive worry Sadness/tearful Lying Unprovoked anger outbursts

Discussion

How do you respect the privacy of a youth in foster care, but still be able to identify these students so that they can be prioritized for mental health promotion, prevention, and intervention services?

How can this balance best be achieved?

What specific strategies would you recommend?

Strategies for Successful Identification and Consent Education for child welfare workers about available

services in schools Improved professional development for school staff and

clinicians on unique mental health issues for youth in foster care.

Provide information on counseling services/prevention services available to youth as a regular part of orientation/registration for incoming students

Inquire about the health and mental health services available in the building and how to access – Consider connecting with this person directly

Request a release of information from the school as a standard procedure when registering a child in school

Cognitive Behavioral Intervention

for Trauma in Schools (CBITS)

Training Developed by:National Child Traumatic Stress Network

LAUSD/RAND/UCLA Trauma Services Adaptation Center for Schools

Why a trauma program in schools?

Why a program for traumatized students?

More and more youth are experiencing traumatic events Community violence Natural and technological disasters Terrorism Family and interpersonal violence

Most youth with mental health needs do not seek treatment

Many internalizing disorders in children go undetected

National Survey of Adolescents Prevalence of Violence History

(N=1,245) Kilpatrick et. al., 1995

Assault + Witness (23%)

No Violence (27%)

Witness Only (48%)

Direct Assault Only

(2%)

Consequences of trauma exposure

Posttraumatic Stress Disorder (PTSD) Re-experiencing Numbing/Avoidance Hyperarousal Prevalence in adolescents

4% of boys 6% of girls 75% of those with PTSD have additional

mental health problem

Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995

Consequences of trauma exposure

Posttraumatic Stress Disorder (PTSD)

Depression

Substance abuse

Behavioral problems

Poor school performance

Impact of trauma on learning

Decreased IQ and reading ability (Delaney-Black et al., 2003)

Lower grade-point average (Hurt et al., 2001)

More days of school absence (Hurt et al., 2001)

Decreased rates of high school graduation (Grogger, 1997)

Increased expulsions and suspensions (LAUSD Survey)

CBITS Program

10 child group therapy sessions for trauma symptoms

1-3 individual child sessions for exposure to trauma memory and treatment planning

Parent outreach, 2 sessions on education about trauma, parenting support

1 teacher session including education about detecting and supporting traumatized students (1 session)

Goals of CBITS

Symptom Reduction PTSD symptoms General anxiety Depressive symptoms Low self-esteem Behavioral problems Aggressive and impulsive

Build ResiliencePeer and Parent

Support

CBITS and other School Mental Health Programming

Sharing of implementation experiences and relevancy of CBITS and other SMH services for youth in foster care

Discussion

What are strategies that you think would help a school to be more trauma sensitive to its students?

Fostering Community Connections and Collaboration with Schools

It takes a village to help each student to be successful Who are needed partners to help youth in foster

care to be successful in schools? How can we improve coordination and

collaboration? How can we learn about each others systems

to enhance a coordinated mental health model of care?

Developing a Directory of Health and Mental Health Services in BCPSS Schools

Goals To share information about who provides

mental health related services in schools Increase awareness of services available at

each school Promote ease of connecting with schools and

school staff

Large Group Discussion

How can the initiative better outreach to youth and parents/guardians to enhance their involvement in advancing mental health in schools for youth in foster care?

www.schoolmentalhealth.org

Website developed and maintained by the CSMH with initial funding from the Baltimore City Health Department

User-friendly mental health related information and resources for caregivers, teachers, clinicians, and youth

Section on School mental health for youth in foster care

Conclusions

School mental health services and programming can help reduce barriers to learning and promote success for youth in foster care

Building effective partnerships and communication among schools, families, mental health providers, and child welfare staff is a priority

Educators, clinicians and child welfare staff would benefit from enhanced training related to school mental health and foster care

Youth in foster care need to be a priority population in schools

A National Community of Practice

CSMH and IDEA Partnership (www.ideapartnership.org) supporting

30 professional organizations and 12 states, 10 practice groups

Providing mutual support, opportunities for dialogue and collaboration

Advancing multiscale learning systemsSign up at www.sharedwork.org

10 Practice Groups

Social, Emotional, and Mental Health in Schools

Developing a Common LanguageConnecting Education and Systems of

CareConnecting SMH and Positive Behavior

SupportImproving SMH for Youth with Disabilities

10 Practice Groups (cont.)

Connecting School Mental Health with Juvenile Justice and Dropout Prevention

Family PartnershipsYouth Involvement and LeadershipSMH – Child Welfare ConnectionsQuality and Evidence-Based Practice

13th Annual Conference

13th Annual Conference on Advancing School Mental Health. Phoenix, Arizona. September 25-27, 2008

See http://csmh.umaryland.edu or call 410-706-0980 (or 888-706-0980 toll free)

www.schoolmentalhealth.org

Website developed and maintained by the CSMH with initial funding from the Baltimore City Health Department

User-friendly mental health related information and resources for caregivers, teachers, clinicians, and youth

Two New Journals

Advances in School Mental Health Promotion The Clifford Beers Foundation and the

University of Maryland www.schoolmentalhealth.co.uk

School Mental Health www.springer.com

Question and Answers

Contact Information

mweist@psych.umaryland.edunlever@psych.umaryland.eduMLINDSEY@ssw.umaryland.edushuntley@psych.umaryland.eduDana.Cunningham@pgcps.org