The Interconnected Systems Framework School Mental Health within

The Interconnected Systems Framework: School Mental Health within a Multi-Tiered System of Behavioral Supports in Schools The Wisconsin PBIS Conference August 20 -21, 2013 Lucille Eber, IL PBIS Network National PBIS TA Center

acknowledgements Susan Barrett, Sheppard-Pratt Health systems, Baltimore MD Kelly Peralis, Community Care Behavioral Health, Pittsburg, PA Mark Wiest, University of South Carolina Jill Johnson, IL PBIS Network

2013 National PBIS Leadership Forum | PBIS: Equity in Education October 10 -11, 2013 | Donald E. Stephens Convention Center Making Education Work for All | Rosemont, Illinois School Mental Health Strand: Integrating SMH & PBIS: Examples at All 3 Tiers Integrating SMH & PBIS: Using Data Integrating SMH & PBIS: Selecting Evidence-based Practices Interconnected Systems Framework Monograph: Lessons from the Field • Implementing an Interconnected System Framework in an Urban School System • Integrating SMH & PBIS at the State Level • The Changing Role of School-based Clinicians • •

Content: • Describe the features of an Interconnected Systems Framework (ISF) for Integrating Mental Health in Schools • Describe efforts and resources from blended efforts of National Centers to promote a broader continuum of evidence-based practices to support the mental health of all students • Describe emerging examples of ISF

BIG Ideas… • How Multi-tiered Systems of Support (MTSS) can enhance mental health in schools • Installing SMH through MTSS in Schools • The Interconnected Systems Framework (ISF) SMH +MTSS=ISF

History-Rationale • Sparse availability of MH providers in schools • Labels and ‘places’ confused with interventions • Separate delivery systems (Sp. Ed. , Mental health, etc) • Minimal accountability for outcomes for most vulnerable populations

Why Partnership Are Needed • • • One in 5 youth have a MH “condition” About 70% of those get no treatment School is “defacto” MH provider JJ system is next level of system default Suicide is 4 th leading cause of death among young adults

SMH and PBIS Common Purpose • Schools supporting/promoting MH of ALL students • Prevention, early access, interventions commensurate with level of need (vs label) • School personnel feel confident and competent in identifying and intervening with accuracy and effectiveness

Logic – Youth with MH needs require multifaceted education/behavior and mental health supports – The usual systems have not routinely provided a comprehensive, blended system of support. – Supports need to be provided in a clustered and integrated structure, – Academic/behavior and mental health supports need to be efficiently blended

Promotion and Prevention Simple and complex supports require integrated systems with foundation of a school-wide system • Schools and community serve as protective factor • problem-solving teams with school/family/youth/community voice • use of data for decision-making (screening/ selection and monitoring/outcomes) • layers supports from the foundational/universal to the more complex

School-Wide Systems for Student Success: A Response to Intervention (Rt. I) Model Academic Systems Tier 3/Tertiary Interventions 1 -5% Behavioral Systems 1 -5% Interventions • Individual students • Assessment-based • Intense, durable procedures • Individual students • Assessment-based • High intensity Tier 2/Secondary Interventions 5 -15% • Some students (at-risk) • High efficiency • Rapid response • Small group interventions • Some individualizing Tier 1/Universal Interventions 8090% • All students • Preventive, proactive 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/schoolwide. htm Tier 3/Tertiary 5 -15% Tier 2/Secondary Interventions 80 -90% Interventions • Some students (atrisk) • High efficiency • Rapid response • Small group interventions Tier 1/Universal • Some individualizing • All settings, all students • Preventive, proactive

SCHOOL-WIDE POSITIVE BEHAVIOR SUPPORT: What is meant by “layering” interventions? ~5% ~15% Primary Prevention: School-/Classroom. Wide Systems for All Students, Staff, & Settings ~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

Positive Behavior Intervention and Support (www. pbis. org) • Decision making framework to guide selection and implementation of best practices for improving academic /behavioral functioning • Data-based, measurable outcomes, evidencebased practices, systems to support effective implementation

Core Features of a Response to Intervention (Rt. I) Approach • Investment in prevention, screening and early intervention for students not at “benchmark” • Multi-tiered intervention approach • Use of progress monitoring and problemsolving process at all 3 -tiers

Core Features of a Response to Intervention (Rt. I) Approach • Research-based practices and active use of data for decision-making at all 3 -tiers • Use of progress monitoring and problemsolving process at all 3 -tiers

3 -Tiered System of Support Necessary Conversations (Teams) Universal Team Meeting Plans schoolwide & classroom supports Universal Support Secondary Systems Team Meeting Uses process data; determines overall intervention effectiveness Problem Solving Team Meeting Tertiary Systems Team Meeting Standing team; uses FBA/BIP process for one student at a time Uses process data; determines overall intervention effectiveness Check-In Check-Out Skills Group w. individual feature Brief FBA/BIP Complex FBA/BIP Wraparound Brief FBA/BIP Rev. 11. 19. 2012 Illinois PBIS Network

Positive Behavior Interventions & Supports: A Response to Intervention (Rt. I) Model Tier 1/Universal School-Wide Assessment School-Wide Prevention Systems Competing Behavior Pathway, Functional Assessment Interview, Scatter Plots, etc. nt ve er Int nt me (Behavior and Academic Goals) ss se Daily Progress Report (DPR) ion Tier 2/ Secondary As ODRs, Attendance, Tardies, Grades, DIBELS, etc. Tier 3/ Tertiary Individual Student Information System (ISIS) SIMEO Tools: HSC-T, RD-T, EI-T Check-in Check -out (CICO) Social/Academic Instructional Groups (SAIG) Group Intervention with Individualized Feature (e. g. , Check and Connect - Cn. C and Mentoring) Brief Functional Behavior Assessment/ Behavior Intervention Planning (FBA/BIP) Complex or Multiple-domain FBA/BIP Wraparound Illinois PBIS Network, Revised October 2009 Adapted from T. Scott, 2004

Definition of school mental health • Involves partnership between schools and community health/mental health organizations, as guided by families and youth • Builds on existing school programs, services, and strategies • Focuses on all students, both general and special education • Involves a full array of programs, services, and strategies- mental health education and promotion through intensive intervention (Weist & Paternite, 2006)

“Expanded” School Mental Health • Full continuum of effective mental health promotion and intervention for ALL students • Reflecting a “shared agenda” involving school-family-community partnerships • Collaborating community professionals (augment the work of school-employed staff

The Context • Over 18, 000 schools engaged in implementation of SWPBIS (MTSS ) prevention based system • Current focus on capacity to scale-up • MTSS as platform to install effective interventions for youth w/or at-risk of EBD

The Context (cont. ) • Emphasis now on scaling with expansion and connection to other systems – i. e. academic, juvenile justice, mental health, child welfare, systems of care • Emphasis on deliberate actions that foster connections w/families & community

Development of ISF • 2002 -2007: Site Development with PBIS Expansion (informal and independent) • 2005 Co. P focus on integration of PBIS and SMH • 2008: ISF White Paper: formal partnership between PBIS and SMH • 2009 - 2013 Monthly calls with implementation sites, national presentations (from sessions to strands) • 2009 -2011 Grant Submissions • June 2012 - September 2013 ISF Monograph • Monograph Advisory group

Interconnected Systems Framework paper (Barrett, Eber and Weist , revised 2009) Developed through a collaboration of the National SMH and National PBIS Centers www. pbis. org http: //csmh. umaryland. edu

ISF Monograph Development June 2012 – September 2013 • Define the common goals of SMH and PBIS • Discuss the advantages of interconnection • Identify successful local efforts to implement collaborative strategies and cross-initiative efforts • Define the research, policy, and implementation agendas to take us to the next action level

ISF Defined – ISF provides structure and process for education and mental health systems to interact in most effective and efficient way. – ISF is guided by key stakeholders in education and mental health system who have the authority to reallocate resources, change role and function of staff, and change policy. – ISF applies strong interdisciplinary, cross-system collaboration.

ISF Defined – ISF uses the tiered prevention logic as the overall organizer to develop an action plan. – ISF involves cross system problem solving teams that use data to decide which evidence based practices to implement.

ISF Defined (cont) – ISF involves ongoing progress monitoring for both fidelity and impact. – ISF emphasizes active involvement by youth, families, and other school and community stakeholders.

Interconnected Systems Framework Tier I: Universal/Prevention for All Coordinated Systems, Data, Practices for Promoting Healthy Social and Emotional Development for ALL Students · School Improvement team gives priority to social and emotional health · Mental Health skill development for students, staff/, families and communities · Social Emotional Learning curricula for all · Safe & caring learning environments · Partnerships : school, home & community · Decision making framework guides use of and best practices that consider unique strengths and challenges of each school community

MH/PBIS: An Expanded Tier One • Universal screening for social, emotional, and behavioral atrisk indicators • Universal screening for families who may request assistance for their children • Teaching social skills with evidence-based curricula to all students • Teaching appropriate emotional regulation and expression to all students • Teaching behavioral expectations to all students • Mental health professionals are part of the Tier 1 systems team, providing input and progress monitoring data • Opportunity to review community data and expand Tier 1 intervention options based on data

Interconnected Systems Framework Tier 2: Early Intervention for Some Coordinated Systems for Early Detection, Identification, and Response to Mental Health Concerns · Systems Planning Team coordinates referral process, decision rules and progress monitors · Array of services available · Communication system: staff, families and community · Early identification of students at risk for mental health concerns due to specific risk factors · Skill-building at the individual and groups level as well as support groups · Staff and Family training to support skill development across settings

MH/PBIS: An Expanded Tier Two • Mental health/community professionals part of secondary systems and problem solving teams • Working smarter matrix completed to ensure key resources are both efficient and effective (i. e. , initiatives are aligned and combined such as “bully prevention”, “discipline”, “character education”, “Rt. I behavior”, etc. ) • Groups co-facilitated by school staff and community partner (example – guidance counselor and community provider clinician) • Opportunity to expand the continuum of interventions based on data (i. e. trauma informed interventions) • Out-reach to families for support/interventions

Interconnected Systems Framework Tier 3: Intensive Interventions for Few Individual Student and Family Supports · Systems Planning team coordinates decision rules/referrals and progress monitors · Individual team developed to support each student · Individual plans have array of interventions/services · Plans can range from one to multiple life domains · System in place for each team to monitor student progress

MH/PBIS: An Expanded Tier Three • Mental health professional(s) part of tertiary systems team • FBA/BIP and/or person-Centered Wraparound plans completed together with school staff and mental health provider for one concise plan, rather than each completing paperwork to be filed • Quicker access to community-based supports for students and families

Traditional • Each school works out their own plan with Mental Health (MH) agency; Preferred • District has a plan for integrating MH at all buildings (based on community data as well as school data);

Traditional • A MH counselor is housed in a school building 1 day a week to “see” students; Preferred • MH person participates in teams at all 3 tiers;

Traditional Preferred • No data to decide • MH person leads on or monitor group or individual interventions; interventions based on data;

Structure for Developing an ISF: Community Partners Roles in Teams • A District/Community leadership that includes families, develops, supports and monitors a plan that includes: • Community partners participate in all three levels of systems teaming in the building: Universal, Secondary, and Tertiary

Structure for Developing an ISF: Community Partners Roles in Teams (cont. ) • Team of SFC partners review data and design interventions that are evidence-based and can be progress monitored • MH providers from both school & community develop, facilitate, coordinate and monitor all interventions through one structure

Family and community Universal Team Plans SW & Class-wide supports Universal Support 3 -Tiered System of Support Necessary Conversations Family and community Community Secondary Systems Team Problem Solving Team Uses Process data; determines overall intervention effectiveness Standing team with family; uses FBA/BIP process for one youth at a time Tertiary Systems Team Uses Process data; determines overall intervention effectiveness CICO SAIG Group w. individual feature Brief FBA/BIP Sept. 1, 2009 Family and community Brief FBA/ BIP Complex FBA/BIP WRAP

SPARCS – IL HS • 5 students participated in group – 1 student internalizer – 1 student participated last year as well • Time 1 = Seven weeks before starting SPARCS Time 2 = First seven weeks on intervention Time 3 = Second seven weeks on intervention (with a total of 14 weeks of group)

ODRs Over Time

ODRs by Student 9 ODRs Over Time 8 7 Number of ODRs 6 5 Time 1 - 7 weeks before SPARCS Time 2 - First 7 weeks SPARCS 4 Time 3 - Second 7 weeks SPARCS 3 2 1 0 Student 1 Student 2 Student 3 Students Student 4 Student 5

OSS Data 4, 5 ISS/OSS Days Out 4 3, 5 Number of Days Out 3 Student 1 2, 5 Student 2 Student 3 2 Student 4 1, 5 Student 5 1 0, 5 0 ISS Time 1 ISS Time 2 ISS Time 3 Time Period OSS Time 1 OSS Time 2 OSS Time 3

Grades 14 Overall Grade Distribution Over Time Periods for All Students 12 Number 10 8 Time 1 Time 2 6 Time 3 4 2 0 A B C Grades D F

TRAC-Nom Data • Increased (Moving in Right Direction) • • Life satisfaction. 67 Significance Level Anxiety/depression symptoms. 34 Drug use. 46 Time spent living outside of the home (e. g. in jail, an emergency room, or psychiatric hospital). 37 • Decreased (Moving in Wrong Direction) • Unexcused Absences • Support Systems . 42

Youth Outcomes Questionaire • On the Youth Outcome Questionnaire (self report) it measures six subscales: Somatic; Social Isolation; Aggression; Conduct/Delinquency; Hyperactivity/Distraction; Depression/Anxiety – Students reported a decrease in symptoms/problems on all six scales from pre to post – The largest reported improvement was on Aggression, second was Hyperactivity/Depression and third was Depression/Anxiety – Out of the 5 students that completed the group, we had 2 parents that completed both the pre and post YOQ and both reported a reduction in symptoms/problems in their child…one score dropped from 40 to 18 and the other from 22 to 15

PA example

Accountable Clinical Home Accountable TO the family and FOR the care Accessible, coordinated, and integrated care Comprehensive service approach Increased accountability and communication Single point of contact for behavioral health School is “launching pad” for services delivered in all settings • Youth continue on the team with varying intensity of service • • •

SBBH Service Components CLINICAL INTERVENTIONS CRISIS INTERVENTION CASE MANAGEMENT CASE CONSULTATION AND TRAINING for educational staff

District and Community Leadership Team • • • Quarterly meetings Stakeholder representation – System of Care Implementer’s blueprint Systems, data and practices Scaling and sustainability

Time Line School Year Activity 2008 -09 • Community Care engaged district through ICSP regarding SBBH Team 2009 -10 • SBBH Team begins work within district – September 2009 • District and Community Leadership Team is established, district commitment signed, tertiary demonstration project begins – spring 2010 -11 • Tier One SWPBIS is fully implemented with kickoff at the start of the school year • Tier Two training begins in the spring of 2011 with some implementation 2011 -12 • All three tiers are being implemented at both elementary schools • Montrose Junior High receives Tier One training in fall, with “soft” kickoff in January 2012 • Discussion of SBBH Team model expanding into Junior and Senior High

Montrose Elementary Schools K-6 th Grade Data Practices Tertiary, Tier 3, Individual Child Outcomes Survey Strengths and Difficulties Q. Teacher feedback Academic data 1 -5% 5 -10% Tertiary, Tier 3, Individual • Guidance counselors see individual students • SBBH Team Secondary, Tier 2 Group/Individual Data from Tier One team Progress monitoring Data decision rules 80 -90% • Guidance counselors run Targeted groups • IST • CICO • mentoring Universal, Tier 1 Whole School Universal, Tier 1, Whole school ODRs, teacher nominations, Card system, MMS, • Guidance counselors teach “I Can Problem Solve” lessons • Treehab D and A awareness • Bully prevention/Character Ed • Peer Mediation (lessons learned)

Scranton School District Year One 2009 -10 Year Two 2010 -11 Year Three 2011 -12 Year Four 2012 -13 Year Five 2013 -14 Year Six 2014 -15 District and Community Leadership Team established. District commits to implementing SWPBIS with fidelity across the district. SBBH Teams begin implementation at Frances Willard Elementary, George Bancroft Elementary, and Scranton High. A Tier Three support. Frances Willard Elementary, George Bancroft Elementary, and Scranton High all receive training to implement Tier One SWPBIS. Frances Willard Elementary, George Bancroft Elementary, and Scranton High all implement Tier One SWPBIS. Frances Willard Elementary reaches implementation fidelity. Frances Willard Elementary receives training for implementation of Tier Two and begins implementation. Frances Willard Elementary implements three tiers of Interconnected Systems Framework. Isaac Tripp Elementary, Mc. Nichols Plaza Elementary, and South Scranton Intermediate all receive training to implement Tier One SWPBIS. Isaac Tripp Elementary, Mc. Nichols Plaza Elementary, and South Scranton Intermediate all implement Tier One SWPBIS. George Bancroft Elementary and Scranton High receive training for implementation of Tier Two and begin implementation Scranton High receives training and begins implementation of RENEW. SBBH Teams begin implementation at Northeast Intermediate, John F. Kennedy Elementary, Mc. Nichols Plaza Elementary, and John G. Whittier Elementary. John F. Kennedy Elementary, John G. Whittier Elementary, and Northeast Intermediate all receive training to implement Tier One SWPBIS. John F. Kennedy Elementary, John G. Whittier Elementary, and Northeast Intermediate all implement Tier One SWPBIS.

Scranton High School

Key features • Systems – District and building teaming models – Facilitation, technical assistance, coaching – Stakeholder participation and buy-in • Practices – Mental health and school staff work in an integrated way to support students across tiers – Using assessment and screening in order to determine which EBPs to use, progress monitor – One plan for both education and mental health • Data – Shared decision rules – Used for decision making with all stakeholders at the table – school, mental health, other child serving systems, family

Outcomes Change in Family Functioning

Outcomes Change in Child Functioning

The Smith Family • Jason was referred to the SBBH Team in November. He is a seven-year-old first grader who was having difficulty coming to school and being separated from his mother. • When he was four, Jason and his family were in a car accident in a rural area. The members of the family were taken to different hospitals and Jason did not know where his mom was or if she was okay. • Every day, since the first day of school, Jason’s mom would bring him into the school and the school staff would literally have to peel Jason off of his mother and hold him so she could leave.

The Smith Family cont. • Once referred to the team, they were immediately able to work with Jason and his family to create strategies to help him separate more smoothly. • Jason found the SBBH Team office/room a safe place to be. His mother also spent time there to help create a nice transition area. • After the Holiday break, Jason began riding the bus for the fist time, accompanied by one of the BHWs from the team. • Soon, Jason was able to ride the bus on his own, increasing his confidence and allowing him some relief from his anxiety.

Lessons Learned • • Return on investment Funding efficiency Scaling and sustaining SBBH Teams – size Community “politics”

For More Information: • www. sharedwork. org • www. pbis. org