MULTITIERED SYSTEMS OF SUPPORT FOR BEHAVIORAL HEALTH WELLNESS

MULTI-TIERED SYSTEMS OF SUPPORT FOR BEHAVIORAL HEALTH &WELLNESS (MTSS-B) AND SCHOOL MENTAL HEALTH JUNE 2, 2020 JOANNE MALLOY, PHD, MSW UNIVERSITY OF NEW HAMPSHIRE

Agenda • Big Ideas Behind School MH • Big Ideas Behind MTSS-B • Using the MTSS-B Framework to Align Initiatives • Getting Started

Acknowledgements

THE BIG IDEAS About MH in Schools

We pathologize students…. . >mental health is defined, de facto, as the absence of problems >there is a lack of emphasis on promoting positive social and emotional development for all.

Additional Context • 33% increase in teens reporting symptoms of depression • 46% of children in the US have experienced at least one Adverse Childhood Experience (ACE) • US has highest rate of opioid use in the world • The CDC reports “electronic aggression” as an emerging public health problem – Any type of harassment or bullying that occurs through email, a chat room, instant messaging, a website or text messaging

Bright Futures in Practice: Mental Health (National Center for Education in Maternal and Child Health): “Mentally healthy children and adolescents develop the ability to experience a range of emotions (including joy, connectedness, sadness, and anger) in appropriate and constructive ways: possess positive self-esteem and a respect for others; and harbor a deep sense of security and trust in themselves and the world. Mentally healthy children and adolescents are able to function in developmentally appropriate ways in the contexts of self, family, peers, school, and community. Building on a foundation of personal interaction and support, mentally healthy children and adolescents develop the ability to initiate and maintain meaningful relationships (love) and learn to function productively in the world (work). ” UCLA

Mental Health in Schools: It’s Needs to be About Much More Than Therapy and Counseling It’s about…. . • Building a system for teaching social/emotional skills to all students • Building a community-based response • Supporting families • Mental health providers working in collaboration with educators • Creating a safe, supportive environment that fosters student mental health • Creating policies that promote student health and wellness • Responding to the needs of students who are struggling UCLA

Understanding the Different Causes of Problems: Consider the Implications for Intervention LOCUS OF PRIMARY INSTIGATING CAUSE* Problems caused by factors in the equally by | | environment and person Environment (E) Problems caused by factors in the Person (P) | (e. g. , LD, ADHD, other disorders) UCLA

THE BIG IDEAS BEHIND MTSS-B

Outcomes of MTSS-B Substantially Reduce: • Problem behavior, suspensions, office discipline referrals, and punitive/exclusionary discipline practices • Time teachers spend managing problem behavior Substantially Improve: • Student’s Social skills • School culture and climate • Consistency of responses to students with concerning behaviors • Academic engagement

Experimental Research on SWPBIS Bradshaw, C. P. , Koth, C. W. , Thornton, L. A. , & Leaf, P. J. (2009). Altering school climate through school-wide Positive Behavioral Interventions and Supports: Findings from a group-randomized effectiveness trial. Prevention Science, 10(2), 100 -115 Bradshaw, C. P. , Koth, C. W. , Bevans, K. B. , Ialongo, N. , & Leaf, P. J. (2008). The impact of school-wide Positive Behavioral Interventions and Supports (PBIS) on the organizational health of elementary schools. School Psychology Quarterly, 23(4), 462 -473. SWPBIS E xperimenta lly Related to: Bradshaw, C. P. , Mitchell, M. M. , & Leaf, P. J. (2010). Examining the effects of School-Wide Positive Behavioral Interventions and Supports on student outcomes: Results from a randomized controlled effectiveness trial in elementary schools. Journal of Positive Behavior Interventions, 12, 133 -148. 1. Reducti on in prob lem behav 2. I n c r e ior a Bradshaw, C. P. , Reinke, W. M. , Brown, L. D. , Bevans, K. B. , & Leaf, P. J. (2008). Implementation of school-wide Positive sed acade m Behavioral Interventions and Supports (PBIS) in elementary schools: Observations from a randomized ic perform 3. Increas trial. Education & Treatment of Children, 31, 1 -26. ance ed attenda nce 4. Improve Bradshaw, C. , Waasdorp, T. , Leaf. P. , (2012 )Effects of School-wide positive behavioral interventions and supports on child d perceptio behavior problems and adjustment. Pediatrics, 130(5) 1136 -1145. n of safety 5. Reducti on in bully Horner, R. , Sugai, G. , Smolkowski, K. , Eber, L. , Nakasato, J. , Todd, A. , & Esperanza, J. , (2009). A randomized, wait-list ing behav controlled effectiveness trial assessing school-wide positive behavior support in elementary schools. Journal of 6. I m p r iors oved organ Positive Behavior Interventions, 11, 133 -145. izational e 7. Reducti fficiency Horner, R. H. , Sugai, G. , & Anderson, C. M. (2010). Examining the evidence base for school-wide positive behavior support. on in staff Focus on Exceptionality, 42(8), 1 -14. turnover 8. Increas Ross, S. W. , Endrulat, N. R. , & Horner, R. H. (2012). Adult outcomes of school-wide positive behavior support. ed percept Journal of Positive Behavioral Interventions. 14(2) 118 -128. ion of teac 9. Improve Waasdorp, T. , Bradshaw, C. , & Leaf , P. , (2012) The Impact of Schoolwide Positive Behavioral Interventions and her efficac d Social E Supports on Bullying and Peer Rejection: A Randomized Controlled Effectiveness Trial. Archive of y motional c Pediatric Adolescent Medicine. 2012; 166(2): 149 -156 ompetenc Bradshaw, C. P. , Pas, E. T. , Goldweber, A. , Rosenberg, M. , & Leaf, P. (2012). Integrating schoolwide Positive Behavioral e Interventions and Supports with tier 2 coaching to student support teams: The PBISplus Model. Advances in School Mental Health Promotion, 5(3), 177 -193. doi: 10. 1080/1754730 x. 2012. 707429 Freeman, J. , Simonsen, B. , Mc. Coach D. B. , Sugai, G. , Lombardi, A. , & Horner, ( submitted) Implementation Effects of School-wide Positive Behavior Interventions and Supports on Academic, Attendance, and Behavior Outcomes in High Schools.

PBIS Provides a Solid Foundation…. but More is Needed… • Many schools implementing PBIS struggle to implement effective interventions at Tiers 2 and 3 • Many systems struggle to align multiple initiatives • Youth with “internalizing” issues may go undetected • PBIS systems (although showing success in social climate and discipline) often do not address broader community data and mental health prevention.

Core Values of MTSS-B: Build positive, respect-filled, and caring relationships Focus on intentional development of systems, data, and practices for prevention and early intervention All students can learn and be successful

MTSS is A framework for enhancing adoption & implementation of Continuum of evidence-based interventions to achieve Academically & behaviorally important outcomes for All students

Everyone Works Together!

Greatest Impact: Improved Relationships

Typical School Day 17% 33% 20% 30% Direct Instruction Seatwork Transitions Discipline & Other Non-Instructional Activities Reinke, Herman & Stormont, 2013; Walberg, 1988

Positive Behavior Support is Embedded in MTSS-B “Our chief concern is not with problem behavior, and certainly not with problem people, but rather with problem contexts” (Carr, p. 3). Interventions are focused on the contexts that create problem behaviors, based on the belief that behavior is driven by basic principles: -To avoid -To gain -or, to communicate

Starting Point… Starting Point • We can’t “make” students learn or behave • We can create environments to increase the likelihood students learn and behave • Environments that increase the likelihood are guided by a core curriculum and implemented with consistency and fidelity

The science of how we learn

Shifting from a Negative to a Positive School Climate Negative Student Behavior Coercive Cycle Negative School Behavior Positive Reinforcement Cycle Positive Student Behavior

Effective Positive Classroom Environments “The goal of effective classroom management is not creating “perfect” children, but providing the perfect environment for enhancing their growth, using research-based strategies that guide students toward increasingly responsible and motivated behavior. ” (Sprick, Knight, Reinke & Mc. Kale, 2006, p. 185)

Positive Behavior Support Maximize Structure & for the Classroom Predictabilit y Continuum of Strategies to Respond Post & Teach Expectation s Prevention Continuum of Strategies to Acknowledg e Actively Engage Students

Examples of Positive Feedback Specific positive behaviors should be verbally acknowledged. Less attention and emphasis should be placed on corrective feedback for minor behaviors. “You did a nice job most of the period being respectful today. You followed directions, you used kind words – I appreciate that!” “There was some loud calling out during reading that didn’t stop right away when I asked. That disrupted the lesson. “Next period, I’d like you to be more respectful by raising your hand when you want to talk. I know you can do that. ”

https: //www. youtube. com/watch? v=Vxyxyw. Shew. I&t=117 s Every Opportunity

The MTSS-B Framework: Systems, Data and Practices

MTSS-B Core Features Team Implementation & Coordination Universal & Comprehensive Screening Content Expertise and Fluency Continuum of Evidence-based Interventions Implementation Fidelity 2/21/2021 Continuous Progress Monitoring MTSS-B Cultural & Contextual Relevance Data Based Decision Making 30

Continuum of School-Wide Instructional & Positive Behavior Support Primary Prevention: School-/Classroom. Wide Systems for All Students, Staff, & Settings ~5% ~15% School-wide strategies for addressing trauma, building resilience, and teaching social emotional learning ~80% of Students Tertiary Prevention: Specialized, Individualized Systems for Students with High-Risk Behavior Secondary Prevention: Specialized Group Systems for Students with At-Risk Behavior

Alignment of Multi-Tiered Systems & Mental Health • • Moving from a co-located school mental health model to an integrated model where all S/E/B interventions are designed, delivered, and monitored through one set of teams at each school. Community and school-based clinicians actively participate with other school staff in multi-tiered teams, reviewing data and ensuring effective system structures at the school level.

Example Wrap. Around Intensive Academic Support Intensive Social Skills Teaching Comprehensive FBA/BSP Parent Training & Collaboration Community Agencies Involvement Tier III: FEW Intensive, Individualized Intervention Individualized CICO Social Skill Groups Behavioral Contracting Self-monitoring Differential Reinforcement Increased Classroom Support & Practice: Focus on environment changes and teaching skills Brief FBA Tier II: SOME Classroom & Small Group Strategies CICO Parent Training & Collaboration Intervention Advisory activities, Freshman orientation, =Fostering Relationships, Circles, Class/Morning meetings, Continuum for Discouraging Concerning Behaviors , Family Contact Prevention Effective Classroom Management Strategies: defining, teaching & prompting expectations; clear procedures and routines, provide a variety of OTR, active supervision Teaching pro-social skills; /SEL; Acknowledging expectations, ; Family engagement; Physiology for learning Tier 1: ALL Students Preventative & Proactive Approaches

Effective Support Requires Attention to: Systems, Data, and Practices OUTCOME S Supporting Adults/Staff System s Data Practice s Supporting Students and Families Supporting Decision Making

Team Members • Actively participate in MTSS-B meetings • Attend MTSS-B trainings • Spread the message of MTSS-B to other staff – be a “cheerleader” • Have a quick response for “What is MTSSB? ” • Offer suggestions and ideas to the team (no ideas are too big or too small) • Ask questions and keep learning

Who Are the Coaches/Behavior Experts? Internal Coach • A school-based person who works onsite • Is familiar with the school-wide process • Facilitates team throughout the process (insures critical elements are in place) • Attends all trainings/meetings with their school-based teams • Receives extended and ongoing training from MTSS-B Network • Is the main contact person for the schoolbased team • Reports to the External Coach • Employed outside the schools • Assists team/internal coach throughout the process • Provides trainings to the school-based teams • Attends trainings/meetings with their school-based teams • Conducts fidelity assessments with the team and guides them in action planning activities • Is the main contact person for the internal coach • Reports to the District/State/Project Coordinator

Family and Youth Engagement within a MTSS-B Framework DATA Students and family members use their benchmarking data to choose and adjust practices Family member reviews child’s data to improve outcomes and adjust practices Parents see Schoolwide, community wide data and give input into action planning ACTIVITIES Family members are active participants In the development of their child’s Individualized plans and teams. Family members are active partners in the implementation of their child’s intervention. Parents participate in the development of the schoolwide social expectations, skill-building and norms.

Examples of MTSS-B Engagement with Families Tier 3: Intensive, Individual Interventions ØFamily Liaison-matched with family, needs matched with community resources Ø Individual Skill Building Sessions- 1 -5% Tier 2: Targeted Group Interventions ØSupport Groups (Military Families, Newcomer Group) ØSkill Building Sessions (Academic and Behavior) 5 -10% Tier 1: Universal Interventions ØSelf Assessments: Family Engagement Checklist, Surveys ØSkill Building Series Guest Speaker (Topics Vary- Survey Families) ØNewsletter, Resource Library , “Shout Outs”- Mickey Mouse PB 80 -90% ØVolunteer Opportunities (DOGS- Dads of Great Students) ØTeacher Conferences- Goal Setting, Family Vision, Strengths Discovery ØFamily Fun Nights throughout the year ØSchool Handbook (Description, Teaching Matrix – promote common language between school and home)

Tier 1 Example: Rundlett Middle School Parent & PTO Volunteer § Joined Universal (PRIDE) team in February 2014 as a two-year PTO/Parent Volunteer § Had a daughter starting 8 th Grade at RMS this year and a son starting RMS in September 2015 § PRIDE sub-committee started working on the Student Handbook Revision Initiative in March 2014

District Organizational Design for MTSSB Stakeholder Engageme nt Funding and Alignment Policy Workforce Capacity Executive Functions LEADERSHIP TEAMING Implementation Functions Training Coaching School Implementation Evaluation

The MTSS-B Framework: Aligning Initiatives

Partnerships are needed: • • One in 5 youth have a MH “condition” At least 50%, perhaps 80%, of those get no treatment School is “defacto” MH provider Juvenile Justice system is next level of system default Suicide is 2 nd leading cause of death among young adults Factors that impact mental health occur ‘round the clock’ It is challenging for educators to address the factors beyond school It is challenging for community providers to address the factors in school

Big Picture Challenges: • We use low intensity, low fidelity interventions for behavior/emotional needs • Habitual use of restrictive settings (and poor outcomes) for youth with disabilities • High rate of undiagnosed MH problems (stigma, lack of knowledge, etc. ) • Changing the routines of ineffective practices (systems) that are “familiar” to systems • “Referrals to a MH person” viewed as an intervention

Advancing Education Effectiveness: Interconnecting School Mental Health (ISF) and School-Wide Positive Behavior Support (PBIS) Editors: Susan Barrett, Lucille Eber, & Mark Weist pbis. org csmh. umaryland IDEA Partnership NASDSE

Traditional An Interconnected Systems Framework MH counselor “sees” student at appointments MH person on teams at all tiers. Interventions are defined (core features, dosage, frequency, outcomes) Clinicians only do “mental health” MH is everyone’s job. Clinicians contribute to integrated plan Case management notes Fidelity AND outcome data determined before delivery; data monitored continuously by teams

The Role of the School-Based Clinician at All Three Tiers Shift from using ”therapist” or “counselor” to clinician Coaching/Facilitation Coaching/Coordinatio n Coaching/Consultatio n

1. Single System of Delivery One set of teams • Community and School MH staff serve on leadership team and make decisions as a TEAM • Symmetry of Process • State • County • District • School • A seamless system for accessing interventions • Both school and community- based supports What Does it Look Like? Invest in one set of school “behavioral health” teams organized around tiers. Flexibility of funding to allow community employed staff to serve on teams and assist serving ALL students. Role and function of staff are explicitly stated in MOU. ALL Requests for Assistance managed within one set of teams. ALL school and community employed staff take part in teaching Social/Emotional/Behavioral (SEB) necessary to navigate social situations, school, family and work environments.

2. Access is NOT Enough Success is defined by student impact • Interventions are evidenced based and matched to presenting problem using data • Interventions are progress monitored for fidelity and impact • Teams are explicit about intervention description (what, when, how long) • Skills taught in Tier 2/3 interventions are assessed across all tiers by ALL Staff across ALL settings linked to Tier 1 Social Emotional Behavioral (SEB) instruction What Does it Look Like? The District and School team includes community providers, families, students and persons who have authority to make structural changes within their organizations. Teams works collaboratively with leaders to continuously assess student needs, implement programs, and eliminate, adjust, replace programs at all tiers to increase their impact on students. Ineffective programs or practices are eliminated.

3. Mental Health is FOR ALL From Few to ALL • Integrate SEB competencies into PBIS Matrix • Vast majority of students will benefit from safe, predictable, positive nurturing environment, mentoring and academic support. • • Universal Screening to identify ALL possible MH/Behavioral needs (externalizers and internalizers) Need MH experts to triage and identify students with positive screen to determine next steps. However, not all interventions require clinical expertise What Does it Look Like? ALL staff are trained and supported through PD plan/coaching process. MOU defines roles of all staff working in schools. Clinicians role includes support of systems and support of ALL adults as well as delivery of some interventions with students. Teachers provide social emotional behavior (SEB) instruction along with academic content. District Leadership prioritizes Staff Wellness

4. Use MTSS Framework Need implementation science to guide the work • All S-E-B* instruction and interventions are decided upon and monitored through team process across tiers. • Data-based decision making is used by teams at all tiers with type of data matched to specifics and complexity of interventions. • A formal process for selecting and implementing evidence-based practices is established. • Comprehensive screening allows for early access to interventions. • Progress monitoring for both fidelity and effectiveness; • Ongoing professional development and coaching to ensure fluency and to guide refinement of implementation. *Social–emotional-behavioral (S-EB) What Does it Look Like? All initiatives/programs are aligned and installed with core features of MTSS The continuum of evidencebased interventions are linked across tiers, with dosage and specificity of interventions increasing from lowest to highest tiers. Skills taught in Tier 2/3 interventions are supported by ALL Staff across ALL settings linked to Tier 1 S-E-B* instruction

What is SEL? • Social and Emotional Learning (SEL) is a process for building competency in: • • • Competencies adapted from “ 5 CASEL Competencies” https: //casel. org/ Self-Awareness Self-Regulation Social Awareness Relationship Skills Thoughtful Decision-Making • SEL Skills: • A set of essential skills for life and learning that demonstrate competency in SEL

The Blend: Strategic Multi-Tiered Supports to Build Social-Emotional and Behavioral Skills

How the MTSS-B Framework Aligns Initiatives: EX: Continuum of Supports in Trauma-Sensitive Schools Tier 3: Tertiary Interventions Individualized Interventions and Family- Driven Supports Intensity of need and response Specific trauma interventions Tier 2: Secondary Interventions e. g. Anxiety Skill Building groups For some students exposed/at-risk Group interventions Mindfulness groups School-wide strategies for addressing trauma and building resilience. Tier 1: Universal Interventions For all students Preventive, proactive

Systems Work for School-Based Teams Multidisciplinary Tier 1 Team Coordinates and monitors support for all students, all staff, and all settings Focuses on prevention and early identification of student needs across the school/community Monitors data to identify when and how to adjust system to meet the needs of whole school/community Develops decision rules for when a student receives additional interventions Reviews aggregate data from both school and community Multidisciplinary Tier 2 Systems Multidisciplinary Tier 3 Systems Team Coordinates and monitors interventions for groups of students needing support beyond Tier 1 Ensures data-based selection of evidence-based practices for small groups of students Monitors and ensures timely access for students identified through data and/or request for assistance from student, family, or staff Reviews how many interventions are in place, how many students are supported through each intervention, and how many of those students are responding Coordinates and monitors interventions for all students receiving individual interventions Ensures data-based selection of evidence-based practices for individual students Monitors the number of students receiving individual interventions Evaluates the number of students are responding to individual intervention Considers needs for additional staff PD and coaching as needed per aggregate data review of effectiveness

Mindfulness exercises give Concord students something to think about Led by Margreta Doerfler, a clinical social worker from Riverbend Community Mental Health, fourth-graders learn about mindfulness in class at Broken Ground School in Concord on Tuesday, May 16, 2017. (ELIZABETH FRANTZ / Monitor staff) http: //www. concordmonitor. com/mindfulness-in-concord-elementary-schools-9654266

Alignment Example School Counseling School Social Work Nurse/MH Integration System Supports Second Step Curriculum MTSS Core Curriculum Academic, Attendance and Discipline Universal Screening & Outcomes Data Systems Community Schools/CIS Compassionate Schools/Trauma Informed Mindful Schools Evidence-based Practices

Getting Started to Implement MTSS-B

STAGES of IMPLEMENTATION (Fixsen, Blasé, 2005) Exploration/ Adoption • Should we do this? Installation • Put resources and systems in place Initial Implementation • Initial pilots and assess results Full Implementation • The practice was successful, adopt system- wide Innovation • Adopt variations of the practice and assess results Sustainability • Make this the way of doing business

Getting Started in MTSS-B 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Establish an effective and representative leadership team Develop core values Identify positive school wide expectations Develop procedures for teaching class-wide expectations Develop continuum for reinforcing expected behavior Develop continuum for discouraging concerning behavior Develop data-based procedures for monitoring Develop systems to support staff Build routines to ensure on-going implementation

Questions?

PBIS. org Implementation Blueprints

Resources • Positive Behavioral Interventions and Supports website: http: //www. pbis. org/ • Association for Positive Behavior Support: www. apbs. org • UNH IOD MTSS-B: https: //iod. unh. edu/projects/multi-tieredsystem-support-mtss • NH Center for Effective Behavioral Interventions and Supports (CEBIS): https: //www. seresc. net/nh-cebis • National Center for School Mental Health: http: //csmh. umaryland. edu/index. html • NH Office of Student Wellness, Department of Education: www. NHStudent. Wellness. org

Resources (cont. ) • Missouri Schoolwide Positive Behavior Support website: http: //pbismissouri. org/educators/effective-class-practice • Trauma and Learning Policy Initiative at Harvard University: https: //traumasensitiveschools. org/ • The National Child Traumatic Stress Network: https: //www. nctsn. org/resources/creating-supporting-andsustaining-trauma-informed-schools-system-framework • Collaborative for Academic, Social, and Emotional Learning: https: //casel. org/ • UCLA Center for Mental Health in Schools m http: //smhp. psych. ucla. edu/materials/resources. ht

Thank you Jo. Anne Malloy UNH Institute on Disability Phone: (603) 228 -2084 X 41 Email: joanne. malloy@unh. edu Fax: (603) 228 -3270 https: //iod. unh. edu/projects/multi-tiered-system-support-mtss Like us on Facebook: https: //facebook. com/IOD. RENEW Follow us on Twitter https: //twitter/RENEW_IOD