On August 25, 2016, I presented an overview of the expanded school mental health movement to participants at the Annual Children's Services State of the Art Conference in New Bern, NC. Below is a summary of that discussion, including links to the various resources mentioned.
Due to healthcare barriers (e.g., lack of insurance, lack of community-based providers), schools are the de facto mental health system for most children and adolescents. In fact, of all mental health services provided to children and adolescents, an estimated 70-80% are delivered in the school setting (Farmer et al., 2003; Lyon, McCauley, & Vander Stoep, 2011). Unfortunately, the quality of those services is concerning due to a profound research-practice gap. Despite ample evidence to support their effectiveness, research-supported treatments are rarely provided as intended in schools.
Part of the research-practice gap is attributable to the manner in which evidence-based practices (EBPs) are designed and tested. Typically, interventions are designed and tested in isolation without regard for available funding, the capacity of likely service providers, or local policies. In other words, EBPs are packaged without a clear recipient in mind (Fixsen et al., 2013). Community-based psychologists generally have the flexibility to adapt their practices -- scheduling sessions for convenience, choosing to specialize in specific therapies, etc. -- but school-based practitioners do not. Referrals in schools represent the entire spectrum of mental health concerns, so school-based practitioners must be generalists. School-based practitioners also have little control over resources and scheduling in their settings, so it is not uncommon for practitioners to have their sessions cut short by class schedules. Moreover, school-based practitioners have competing professional responsibilities, particularly when administrators and teaches fail to see the value of mental health services.
So when designing a school mental health system, there are three basic components that must be considered: (1) strong school-community partnerships; (2) high quality practices; and (3) sustainability (cf. School-based Health Alliance, n.d.). The last element, sustainability, is perhaps the most complicated, and unfortunately it was beyond the scope of the presentation (and this blog post). Several models of third-party billing and grant funding have been attempted, but sustainability is a challenge even in the best-case scenario. For this reason I focus here on strengthening community partnerships and practice elements. Readers interested in funding issues are encouraged to explore the business model resources here (although not specific to school mental health, these resources can be helpful).
Partnering with Schools
Given the challenges faced by school-based practitioners, any effective school mental health system will require strong community partnerships. This is critical when students fail to respond to the universal and indicated intervention attempts commonly used in schools (i.e., Tier 1 and Tier 2). Traditionally cases that do not respond to school-based prevention efforts are referred to special education, but not all referrals qualify. If, for example, an adolescent is clinically depressed but performs satisfactorily in her classes, the likelihood of being found eligible for special education is low. As a result, many serious mental health needs can "fall through the cracks" of the special education system. Thus, to ensure adoption and buy-in of expanded services, it is critical to assemble a team of professionals who recognize the critical role mental health plays in academic performance. Such efforts may require initial discussions with school superintendents and administrators about mental health issues, and how unwanted school outcomes (e.g., low test scores, office disciplinary referrals, suspensions/expulsions, dropout rates) are related to those needs. Too often community partners make the mistake of emphasizing clinical outcomes (e.g., session counts, client satisfaction) that are simply not compelling to administrators whose job it is to focus on broad performance indicators.
Early in the process of collaboration it is also critical to conduct a needs assessment. As part of this effort, it is important to map the various school mental health providers and their roles. To ensure a good partnership, it is vital that these providers avoid overlapping their efforts, such that community partners augment existing services rather than supplant them. To document these efforts, it is also recommended that community partners develop a "memorandum of understanding" where their role within the collaboration is delineated, including the services they will be responsible for providing. The goal is to avoid any potential 'turf wars' that might be triggered by unnecessary redundancies and misunderstandings (Weist et al., 2011).
Once service provision is coordinated, it is critical that the school mental health team then meet on a regular basis (e.g., monthly) to discuss implementation needs. There is a tendency in schools for such meetings to become perfunctory, so efforts must be made to prioritize these meetings and the agenda. Leaders might keep minutes and send those to the team members to maintain a running list of topics, for example (Weist et al., 2011).
In eastern North Carolina, there are unique concerns that school mental health teams will encounter. For example, many of the counties in our area meet the NC Department of Commerce designation of "Tier 1" economic distress, which indicates the most severe levels of poverty and unemployment. There are also much higher caseloads among school-based practitioners. By our estimates in the counties surrounding Pitt, the caseload for the average school counselor is 1:367, which is well above the recommended ceiling of 1:250 by the American School Counselor Association. Many counties in Eastern North Carolina have also been identified as health provider shortage areas by the US Department of Health and Human Services. Taken together, these indicators suggest that mental health professionals working in our schools will be confronted by many challenges. In fact, while I was preparing this presentation, the local news reported on teacher turnover rates in our area, highlighting one school that my lab has collaborated with. Clearly, school mental health initiatives can seem secondary when 60% of teachers leave a school in a single year.
High Quality Practice
The other challenge in the school mental health movement relates to the quality of the services that are ultimately provided to students. Although services might be "provided," it is not always clear what those services are or whether those services are consistent with the research base. As mentioned above, most school-based practices are substandard. To improve the situation, several researchers have examined ways to modify existing EBPs to make them more applicable to school settings. One such effort has been the "modular therapy" efforts of Bruce Chorpita and John Weisz. Modular therapies are derived from the elements common to multiple EBPs, with each session designed to function alone. The result is that clinicians can arrange sessions based on clinical judgment, while ensuring that all aspects are rooted in the research literature. For example, among the effective treatments for oppositional behavior, most include parent training sessions targeting parental praise, time out, and tangible rewards (token reward systems). Thus, a modular approach would emphasize these elements above elements that have not been extensively tested (e.g., self-reward, self-praise). Research suggests that modular therapies outperform treatment-as-usual and traditional treatment manual approaches when few constraints are placed on clinical referrals (Weisz et al., 2012; Chorpita et al., 2013).
In recent years, researchers in North and South Carolina have applied modular therapies in school mental health. Although early, modular therapies appear to be well-suited to to the fluid schedule and limited resources of schools, and the results are encouraging (Michael et al., 2016; Weist et al., 2009; Weist et al., 2014). I believe that community-based practitioners interested in collaborating with schools would be wise to review this literature and this approach to clinical work, given the unique challenges of the school setting. Clinicians who could offer modular treatments for students who need individualized interventions would greatly improve and expand the services that are generally available in our region.
The MATCH-ADTC manual for modular therapies is available here.
The website for the Carolina Network, a regional research group testing modular therapies, is here.
School-based practitioners who are interested in potential collaborations can contact me here.
Chorpita, B.F., & Daleiden, E.L. (2009). Mapping evidence-based treatments for children and adolescents: Application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology, 77, 566-579.
Chorpita, B.F., Weisz, J.R., Daleiden, E.L., Schoenwald, S.K., Palinkas, L.A., Miranda, J…Research Network on Youth Mental Health. (2013). Long-term outcomes for the Child STEPs Randomized Effectiveness Trial: A comparison of modular and standard treatment designs with usual care. Journal of Consulting and Clinical Psychology, 81, 999-1009.
Weist, M., Lever, N., Stephan, S., Youngstrom, E., Moore, E., Harrison, B., … Stiegler, K. (2009). Formative evaluation of a framework for high quality, evidence-based services in school mental health. School Mental Health, 1, 196-211.
Weist, M.D., Mellin, E.A., Chambers, K.L., Lever, N.A., Haber, D., & Blaber, C. (2012). Challenges to collaboration in school mental health and strategies for overcoming them. Journal of School Health, 82, 97-105.
Weist, M.D., Youngstrom, E.A., Stephan, S., Lever, N., Fowler, J., Taylor, L., McDaniel, H., Chappelle, L., Paggeot, S., & Hoagwood, K. (2014). Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health. Journal of Clinical Child & Adolescent Psychology, 43, 244-255. doi: 10.1080/15374416.2013.833097
Weisz, J.R., Chorpita, B.F., Palinkas, L.A., Schoenwald, S.K., Miranda, J., Bearman, S.K.,…Research Network on Youth Mental Health. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69, 274-282.