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Transforming Mental Health Care: A Focus on the Schools


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Title: Transforming Mental Health Care: A Focus on the Schools

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

Presidents New Freedom Commission on Mental
  • The Mission
  • Conduct a comprehensive study of the U.S.
    mental health service delivery system and
    recommend improvements to the President.

Presidents New Freedom Commission on Mental
  • 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.

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
  • Monthly meetings
  • Site Visits,Testimony and Town Hall meetings
  • Research Review/Consultants
  • Website Responses content analysis
  • 15 Subcommittees

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

Presidents New Freedom Commission on Mental
  • 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.

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
  • 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

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

Presenting Problems of Youth Admitted to MH
Services 1997
Abuse or neglect victim
Suicide threat or attempt
Depressed or anxious mood
School coping
Alcohol or drug use
Family problems
Skill deficits
Delinquent behavior
Social withdrawal
Update,, 2002
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)

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,
  • 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).

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
  • 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

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

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

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

Presidents New Freedom Commission on Mental
  • Goals of a Transformed System
  • 1 Americans Understand that Mental Health is
    Essential to Overall Health
  • 2 Mental Health Care is Consumer and Family
  • 3 Disparities in Mental Health Care are
  • 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

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

Transforming Concept Consumer 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?

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

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
  • Childrens issues embedded throughout.

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

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
  • 4.3- Screen for co-occurring disorders, and link
    with integrated treatment
  • 4.4- Screen in primary care, and connect to
    treatment and supports

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

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

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
  • Create State-level structure for school-based
    mental health services to provide state
    leadership and collaboration among education,
    general health, and mental health

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
  • Places that have changed their systems better
    outcomes and cost savings

Mental health consumers/youth/families are not in
the mental health system de facto systems -
  • 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
  • Must serve ALL children.. so they can learn in

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
  • Schools- pivot point to families, community

Gap between what we know works and what we
  • 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

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

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

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

Stakeholder Input Key Experts
  • American Psychological Association
  • CWLA
  • NASP
  • Federation of Families for Childrens Mental
  • State Family Organizations
  • NMHA
  • NAMI
  • Professional Guilds/Associations
  • 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
  • School Mental Health Projects
  • Coalition for Juvenile Justice
  • Natl Council for Community Behavioral HealthCare

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

(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
  • TA on service options, payment mechanisms,

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

(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.

(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)

(5) Ensure Special Education and Related Services
for Children with Emotional Disturbances under
  • ED work with States to more effectively implement
  • Services coordination should be considered
    related services and included in IEPs for
    children with emotional disturbances under Part B
    of IDEA.

(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
  • Link with States comprehensive plan for
    childrens mental health (Goal 2, NFC)

(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

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

(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

(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

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
  • 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

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

Federal Level SAMHSA 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

Federal Level SAMHSA Child and Families Action
  • 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

Leverage NFC Report for State-Level Reform
  • MH/School Leadership participate in State Mental
    Health Plans (use experience, outcome and cost
  • 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 ( for state
    implementation activities)

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

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

Websites to Access (Pending) Report