Transforming Mental Health Care: A Focus on the Schools

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Transforming Mental Health Care A Focus on the
Schools

• Larke Nahme Huang, Ph.D.
• American Institutes for Research
• 9th Annual Conference on
• Advancing School-Based Mental Health
• Dallas, Texas
• October 8, 2004

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Presidents New Freedom Commission on Mental
Health

• The Mission
• Conduct a comprehensive study of the U.S.
  mental health service delivery system and
  recommend improvements to the President.

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Presidents New Freedom Commission on Mental
Health

• Charge
• The Commission shallrecommend
  improvements to enable adults with serious mental
  illnesses and children with severe emotional
  disturbances to live, work, learn, and
  participate fully in their communities.

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About the Commission

• 15 Commissioners
• Public, private payers, providers, consumers,
  family members, policy makers, researchers
• 7 Federal Ex officio members
• Labor, Education, Veterans Affairs, HUD
• CMS, SAMHSA, NIMH,
• Monthly meetings
• Site Visits,Testimony and Town Hall meetings
• Research Review/Consultants
• Website Responses content analysis
• 15 Subcommittees

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15 Working Subcommittees

• Housing and Homelessness
• Medicare/Medicaid
• Mental Health Interface with General Medicine
• Older Adults
• Rights and Engagement
• Rural Issues
• Suicide Prevention
• Analysis of Federal Funding Streams

• Acute Care
• Children and Families
• Consumer Issues
• Co-occurring Disorders
• Criminal Justice
• Cultural Competence
• Employment Income Support
• Evidence-based Practice Medication Issues

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Presidents New Freedom Commission on Mental
Health

• Interim Report, October 2002
• The mental health delivery system is fragmented
  and in disarray not from lack of commitment and
  skill of those who deliver care, but from
  underlying structural, financing, and
  organizational problems The systems failings
  lead to unnecessary and costly disability,
  homelessness, school failure, and incarceration.

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Selected Findings A Public Health Crisis in
Mental Health

• 20 adults/children have a mental health problem
• ½ have a serious emotional disorder
• 20 million suffer from serious disabling mental
  illness
• Suicide 30,000 a year 80/day
• 40 had contact with primary care provider
  within the last month
• Adolescents 15-19y/o 3rd leading cause of
  death 17-19 think about killing themselves
  5-8 make attempt only 1/3 get treatment
• YET,
• Only half of individuals with serious mental
  illness get treatment, services or supports

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Scope of MH Needs of Youth

• By the year 2020, childhood neuropsychiatric
  disorders will rise by over 50 internationally
  to become one of the five most common causes of
  morbidity, mortality, and disability among
  children no other illnesses damage so many
  children so seriously.
• World Health Organization, 2002

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Presenting Problems of Youth Admitted to MH
Services 1997
50
46
44
41
24
20
16
16
13
11
Abuse or neglect victim
Suicide threat or attempt
Depressed or anxious mood
Aggression
School coping
Alcohol or drug use
Family problems
Skill deficits
Delinquent behavior
Social withdrawal
Update, www.ihhcpar.rutgers.edu, 2002
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Selected Findings for Children

• Of children with serious emotional/behavioral
  disorders 50 drop-out of high school (compared
  to 30 of students with other disabilities) (Dept
  of Education)
• Youth entering Juvenile Justice 66-75 have
  serious emotional problems (Coalition on Juvenile
  Justice Teplin)
• 500,000 children in foster care estimates up to
  85 have emotional/behavioral and/or substance
  abuse problem 44 lt 5 yrs old (The AFCARS
  Report  Preliminary FY 2001 Estimates as of
  March 2003.  Washington, D.C., DHHS, 2003.  (
  latest federal statistics  on foster care
  supplied by the states for the Adoption and
  Foster Care Analysis and Reporting System Zero
  to Three)
• 1/3 children in mental health system have a
  co-occurring disorder (age 11 age 17-18 SA)

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Disparities for Children of Diverse Racial and
Ethnic Groups

• Black and Latino kids identified/referred at same
  rates as general population, but less likely to
  receive specialty mental health or meds
  (Kelleher, 2000)
• Minority children tend to receive mental health
  services through juvenile justice and child
  welfare systems more often than through schools
  or mental health setting (Alegria, 2000)
• African American and Latino children have highest
  rates of unmet need (Sturm, 2000)
• Asian American and Latino female teens have
  highest rates of depression (Commonwealth Fund,
  1997)
• In child welfare, minority youth have poorer
  outcomes, fewer services, less likely to have
  plans for family contact and more likely to be in
  out-of-home placements (Courtney et al, 1996).

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Rural Disparities

• Rates of mental disorders are similar between
  rural and urban youth, although limited sampling
  in rural America
• Exception Rural adolescents have higher rate of
  suicide than urban counterparts
• Significantly higher rate among Native American
  youth
• Child poverty higher in rural areas children of
  color at-risk with 46 African American, 43
  Native American and 41 Hispanic rural children
  in poverty

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Presidents New Freedom Commission on Mental
Health Final Report

• Achieving the Promise
• Transforming Mental Health Care in America
• We envision a future when everyone with a
  mental illness will recover, a future when mental
  illness can be prevented or cured, a future when
  mental illnesses are detected early, and a future
  when everyone with a mental illness at any stage
  of life has access to effective treatment and
  supports-essentials for living, working,
  learning, and participating fully in the
  community.

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Principles Underlying Transformation

• Services and treatments that
• Are consumer and family-driven, not focused
  primarily on the demands of bureaucracies
• Provide real and meaningful choice of treatments,
  services and supports and providers
• Engage consumers, families, youth

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Principles Underlying Transformation

• Care is focused on
• Promoting consumers and familys ability to
  manage lifes challenges successfully
• Facilitating recovery
• Building resilience, not just managing symptoms

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Presidents New Freedom Commission on Mental
Health

• Goals of a Transformed System
• 1 Americans Understand that Mental Health is
  Essential to Overall Health
• 2 Mental Health Care is Consumer and Family
  Driven
• 3 Disparities in Mental Health Care are
  Eliminated
• 4 Early Mental Health Screening, Assessment, and
• Referral to Services are Common Practice
• 5 Excellent Mental Health Care is Delivered and
• Research is Accelerated
• 6 Technology is Used to Access Mental Health Care
• and Information

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Transforming Concepts Recovery and Resiliency

• Consumers and families told the Commission that
  having hope and the opportunity to regain control
  of their lives was vital to their recovery.
  Indeed, emerging research has validated that hope
  and self-determination are important factors
  contributing to recovery
• Metro Youth, Chicago
  compelling testimony and survey data presented
  importance of youth voice.
•   Presidents New Freedom Commission

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Transforming ConceptConsumer Family-Driven

• the effectiveness of services, no matter what
  they are, may hinge less on the particular type
  of service than on how, when, and why families or
  caregivers are engaged in the delivery of careit
  is becoming increasingly clear that family
  engagement is a key component not only of
  participation in care, but also in the effective
  implementation of it
•   (Burns, Hoagwood, Mrazek, 1999)
• Not all the studies show that the improvements
  resulted from the intervention specifically.
  Family engagement may play a stronger role in
  outcomes than the actual intervention program
• (Thomlison, 2003)
• Direct implications for schools have the
  interventions, have the technology, but how do we
  ENGAGE students?

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So, what?

• How is the NFC relevant to what you do?
• How can you use the report?

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Is there a childrens goal?

• What will it take to transform mental health care
  for children and families?
• There is no single childrens goal or
  recommendation.
• Childrens issues embedded throughout.

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Recommendations with Implications for Children
and Families

• 1.1- National anti-stigma campaign, and
• national strategy for suicide prevention
• 2.1- Individualized plans of care
• 2.2 -Consumers and families fully involved
• in orienting system toward recovery
• 2.3 -Align federal programs to improve
• access and accountability
• 2.4 -Comprehensive State Mental Health
• Plan
• 2.5 -Protect and enhance rights of people
• with mental illnesses

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Recommendations with Implications for Children
and Families

• 3.1- Improve access to quality, culturally
  competent care
• 4.1- Promote mental health of young children
• 4.2- Improve and expand school mental health
  programs
• 4.3- Screen for co-occurring disorders, and link
  with integrated treatment
• 4.4- Screen in primary care, and connect to
  treatment and supports

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Recommendations with Implications for Children
and Families

• 5.2- Advance evidence-based practice using
  dissemination demonstration projects
• 5.3- Improve and expand workforce providing
  evidence-based services and supports
• 5.4- Develop knowledge base in four understudied
  areas (trauma, medications, disparities, acute)
• 6.2- Integrated electronic health record, and
  online personal health information
  systems/resources

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Is there a school-related goal?

• The fundamental policy problem related to mental
  health in schools is that
• existing student support services and school
  health programs do not have high status in the
  educational hierarchy
• schools and districts treat such activity, in
  policy and practice, as desirable but not a
  primary consideration
• the programs and staff are marginalized
• interventions are referred to asauxiliary
• Student support personnel almost never a
  prominent part of a schools organizational
  structuredeemed dispensable as budgets tighten.
• Adelman Taylor, Submitted to the NFC

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Goal 4/Rec 4.2 - Improve and Expand School Mental
Health Programs

• Work with parents, local providers, local
  agencies to support screening, assessment and
  early intervention
• Ensure that mental health services are part of
  school health centers
• Ensure that these services are federally funded
  as health, mental health and education programs
• Implement empirically supported prevention, early
  intervention approaches at the school district,
  local school, classroom, and individual student
  levels
• Create State-level structure for school-based
  mental health services to provide state
  leadership and collaboration among education,
  general health, and mental health

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Key Learnings

• Mental health consumers/ youth/families are not
  in the mental health system de facto systems
• Stigma key barrier to changing practice
• Gap between what we know works and what we
  practice.
• Places that have changed their systems better
  outcomes and cost savings

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Mental health consumers/youth/families are not in
the mental health system de facto systems -
schools

• Over 52 million children in 100,000 schools in
  U.S. 6 million adults working in the schools
  1/5 of U.S. population
• Children receive more MH services through schools
  than any other public system
• Student support services/school health programs
  need greater focus in health and education policy
  initiatives
• Must serve ALL children.. so they can learn in
  schools.

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Stigma prevents accessing mental health

• Schools are accessible, familiar to families
• Stigma and school-comfort level variable among
  diverse groups
• Generally, stigma, non-compliance,
  inaccessibility lesser in schools
• Youth report painful stigma in classroom-
  prefer jj involvement, SA disorder rather than MH
  disorder
• Schools- pivot point to families, community
  stakeholders

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Gap between what we know works and what we
practice.

• School MH programs decrease absence and
  discipline referrals, improve test scores
  (Jennings et al., 2000).
• School connectedness related to academic,
  behavioral and social success in schools (Blum
  Hibbey, 2004).
• School-based wraparound decrease out-of-school
  out-of-home placements (Eber et al., 1996).
• Positive behavioral interventions and supports
  (PBIS- Horner Carr, 1997 Sugai et al.2000)
• Promotion and Prevention Interventions

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Children and Families Issue PaperBackground
Report

• Comprehensive overview of childrens issues
  resources and rationale
• 9 Policy Areas, 26 Recommendations and 120
  Implementation Options
• Broad stakeholder Input

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Children and Family Issue Paper 9 Policy Areas

• Cross Agency Responsibility, Coordination and
  Financing to Reduce Fragmentation
• Family Youth Partnerships and Support
• Access to Care and Reducing Disparities
• Broaden Array of Services and Supports
• Develop Apply Knowledge
• Build Workforce
• Prevent Disorders
• Communication Strategy and Stigma
• Accountability and Quality Improvement

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Built on

• Surgeon Generals Reports Mental Health Mental
  Health Culture, Race Ethnicity
• Surgeon Generals National Action Agenda for
  Children
• National Academy of Sciences From Neurons to
  Neighborhoods
• New Freedom Commission on Excellence in Special
  Education
• Reviews of Evidence-base Practices in Prevention
  and Treatment
• Etc.

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Stakeholder Input Key Experts

• American Psychological Association
• AACAP
• CWLA
• NASP
• Federation of Families for Childrens Mental
  Health
• State Family Organizations
• NMHA
• NAMI
• CHADD
• Professional Guilds/Associations
• NASMHPD
• State Childrens MH Directors
• National Racial/Ethnic Associations
• Child Policy Centers
• Natl Assoc. State Directors of Special Education
• Policymaking Partnership

• Families Youth
• National Assembly on School-based Health Care
• University Child Study Centers
• Bazelon Center for MH Law
• Amer. Acad. Pediatrics
• Gains Center (JJ)
• Natl Council on Disability
• Natl Assoc Psychiatric Health Systems
• Calif. Institute of Mental Health
• Early Childhood Programs
• Community Agencies
• NASADAD
• School Mental Health Projects
• Coalition for Juvenile Justice
• Natl Council for Community Behavioral HealthCare

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School-related Recommendations in CF Background
Issue Paper

• Policy option IV.4.3 Promote Mental Health in
  the Education System
• Multi-level, tiered approach
• Collaboration at Federal, State, local level
• Workforce

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(1) Strengthen mental health services in schools
and the role of schools in promoting social and
emotional well-being

• ED DHHS Collaborate to Strengthen and
  Develop/Implement Plan
• Identify strategies to promote the social and
  emotional well-being of children in schools
• Identify children who need specialized services
• Encourage partnerships with families
• Provide or link children with needed services and
  supports
• TA on service options, payment mechanisms,
  outcomes

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(2) Expand Prevention and Early Intervention
Approaches and Positive Behavioral Supports in
Schools

• ED and SAMHSA work together to expand existing
  efforts and develop prevention/early intervention
  approach to social and emotional well being of
  children in schools. Include interventions at
• School system/district level
• School building level
• Classroom level
• Individual level with students with special needs

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(3) Ensure that Mental Health Services are
Provided as Part of School Health Centers

• DHHS ensure that mental health services are
  provided through school health centers and
  allocate funding for this as part of Federally
  funded mental health and education programs.
  This will increase access to care.

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(4) Train teachers and school personnel to
recognize signs of emotional problems in children
and to make appropriate referrals for assessment
and services

• Pre-service and professional development and
  staff training for teachers and school personnel
  to increase ability to recognize early warning
  signs and take appropriate action
• Referrals for assessment/services
• Classroom accommodations
• Partnering with families
• Maximize established funding streams (IDEA,No
  Child Left Behind)

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(5) Ensure Special Education and Related Services
for Children with Emotional Disturbances under
IDEA

• ED work with States to more effectively implement
  IDEA
• Services coordination should be considered
  related services and included in IEPs for
  children with emotional disturbances under Part B
  of IDEA.

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(6) Create a State-level Infrastructure for
School-based Mental Health Services

• Ensure clear, coordinated State agenda for school
  health and mental health services
• Collaboration between Education and Mental Health
• Pool funding for school-based mental health
  services
• Link with States comprehensive plan for
  childrens mental health (Goal 2, NFC)

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(7) Create Specific Funding Streams for School
Mental Health Services

• To support provision of mental health and
  substance abuse services, designate small
  percentage of funds from selected programs
• Safe and Drug Free Schools
• No Child Left Behind
• Safe Schools/Healthy Students
• Title V
• School-based Health Center Grants

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(8) Create a Collaborative Grant Program to
Support Effective School-Based Mental Health
Approaches

• SAMHSA and ED grants to States, other units of
  government, and private nonprofit organizations
  to schools in providing
• Screening and assessment
• Early intervention, crisis interventions, and
  mental health services to children with or
  at-risk of emotional/behavioral disorders

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(9) Study the Role of School Culture in Promoting
Social and Emotional Well-being

• ED, SAMHSA, NIMH study and identify
  evidence-based interventions for promoting both
  academic success and social and emotional
  well-being through strengthening school culture.
• Information on these interventions to be
  disseminated and technical assistance provided to
  increase uptake

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(10) Develop a Comprehensive Strategy for
School-based Response to Trauma

• DHHS, Federal Homeland Security ED
• Train/prepare teachers and other school personnel
• Develop linkages with trained mental health
  providers for trauma response
• Include school-based mental health interventions
  in Federal, State and community disaster and
  emergency response plans
• Consider needs of children beyond initial crisis
  to identify/refer/treat PTSD and other mental
  health problems following trauma

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Policy Option IV.5 Achieve Cultural Competence

• Develop federal leadership to focus on
  disproportionate numbers of youth of color with
  MH problems in JJ, foster care and special
  education.
• Strengthen capacity of schools to be key link to
  comprehensive, seamless system of school- and
  community-based identification, assessment and
  treatment services.
• Involve SAMHSA, CMS, Office of SpEd and
  Rehabilitation Services (0SERS), State agencies

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Thrust of Recommendations

• Build a continuum of mental health services in
  schools promotion, prevention, early
  identification, and treatment

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Federal LevelSAMHSA Child and Families Action
Plan FY 05

• New Initiatives
• State MH Transformation Grants to include
  children and families (offered)
• Prototype grants to fund State adolescent SA
  treatment coordinators to build
  infrastructure/capacity for services integration
• Enhance TA Efforts
• Develop toolkit on SA and MH screening for use in
  multiple settings with multiple age groups,
  strategies and incentives for linking to care
• Develop prototype of individualized plan of care
  for children and their families

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Federal LevelSAMHSA Child and Families Action
Plan

• Align Federal Programs
• Collaborate with Dept of Education to expand
  school-based mental health programs
• Collaborate with ASPE, ACF,CMS and Depts. of
  Education and Justice on eliminating practice of
  parents giving up custody for treatment
• Track and Report Child/Family focus across
  relevant grants

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Leverage NFC Report for State-Level Reform

• MH/School Leadership participate in State Mental
  Health Plans (use experience, outcome and cost
  data).
• Major reform efforts in New Mexico (legislation
  May 2004 Purchasing Collab.17 agencies),
  Illinois(Ch MH Partnership), South Carolina
  drawing on NFC
• Different strategies focus on specific goal
  areas or general concept of transformation and
  recovery (www.nasmhpd.org for state
  implementation activities)

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Leverage NFC Report for Local Reform

• Educate public officials about NFC report and its
  alignment with mental health in school efforts
• Use NFC recommendations to fuel innovation, e.g.,
  Westchester County implement recommendation in
  Goal 4 screening for mental health in Latino
  primary care clinics
• Use NFC financing discussion to map behavioral
  health financing and expenditures across
  child-serving systems to identify opportunities
  for improved integration and efficiency
• Social marketing of NFC to gain political will

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Using the Report Strategically

• Alignment of NFC principles with underlying
  principles in school-based mental health
• Leverage NFC report for local reform
• Leverage NFC report and local State data for
  State level reform
• NFC report and background papers for advocacy,
  promoting transformation

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Websites to Access (Pending) Report

• www.samhsa.gov.
• www.mentalhealthcommission.gov
• www.tapartnership.org