Supporting Students’ Mental Health: A Response to Intervention Approach

1. Supporting Students’ Mental Health: A Response to Intervention Approach Wisconsin Department of Public Instruction September 2011

2. Today’s presentation • Why should our school/district address mental health? • How are students affected by mental illness? • Is mental illness a “mental” illness or a “physical” illness? • What about stigma? • Mental health & illness on a continuum • Risk & protective factors • Educational & medical diagnoses

3. Today’s presentation • Warning signs & symptoms • Using RtI to support students’ mental health • Tier 1 – Universal • Tier 2 – Selective • Tier 3 - Targeted • Starting to plan changes • What are we doing now to support students’ mental health? • How can we build on current efforts? What else can we do?

4. Mental health is directly related to a school’s mission California Healthy Kids Survey • Schools in this study with more depressed students made less progress in raising test scores • The results were evident in both low- & high-performing schools California Healthy Kids Survey & STAR data files www.wested.org/chks/pdf/p1_stuartreport_ch_final.pdf

5. Impacts on Student in School • Attentiveness • Concentration • Opportunities to rehearse & demonstrate • Mastery is difficult without any of the components of attention, concentration, self-appraisal, or rehearsal • Self-appraisal • Set of attitudes & expectations about one’s own ability Adapted from SAMHSA Eliminating Barriers, 2005

6. Example of Impacts on Learning: Anxiety • Attention can be disrupted by a sense of impending doom • Concentrationis difficult to maintain during intense anxiety, or is impacted by irritability, restlessness, or feeling out of control • Self-appraisal/expectations of poor outcomes or a sense of inability to bring about good results Adapted from SAMHSA Eliminating Barriers, 2005

7. Example of Impacts on Learning: Anxiety • Behaviorincludes “freezing” during exams, asking for help when unnecessary, talking about worries, making “what if” statements or exaggerated/irrational fears; can be overly prepared; can be upset or even frantic when worries escalate • Rehearsal can be disrupted by worries about performance • Mastery is difficult when feeling acute anxiety; cannot retrieve or demonstrate previously learned information Adapted from SAMHSA Eliminating Barriers, 2005

8. National Profile of Adolescent Mental Health • Half of lifetime (chronic) mental illness started by age 14 • 20% of adolescents experienced significant symptoms of emotional distress • 10% had moderate to severe symptoms with significant impairment • Most common disorders were depression, anxiety, ADHD, & substance abuse Knopf, D. et al (2008) The Mental Health of Adolescents: A National Profile, 2008. San Francisco, CA: National Adolescent Health Information Center.

9. 2009 WI Youth Risk Behavior Survey • 20.8% of high school students reported symptoms of depression in past 12 months • 13.2% seriously considered suicide • 11.0% made a plan about how to attempt suicide in the past 12 months • 1.7% made suicide attempt that required medical treatment What does that mean for us & our students? Let’s do the math ….

10. Mental illness or physical illness? • Mental illnesses impact on the brain • Brain chemistry - interferes with thinking, mood, & behavior • Affects both brain structure & function • Can be misinterpreted as negative personality traits, low motivation, bad decision-making, etc.

11. PET scan of lower serotonin function in a patient with major depression (right), compared to a healthy volunteer Columbia Kreitchman PET Center

12. Healthy brain: plenty of seretonin transport Brain of person with depression: inadequate seretonin transport http://www.cumc.columbia.edu/dept/radiology/pet/pdf/pet_healthpoints_winter06.pdf

13. What about us? Would we talk about our own personal experiences with mental illness here? • Maybe … • A few would feel comfortable, but it’s unlikely • Some might feel comfortable talking about this with close friends or family they trust • Compare that to other health conditions • It’s all about stigma

14. People with mental illness have accomplished great things • Can you name famous people who have lived with some kind of mental illness?

15. Abraham Lincoln is described as having “melancholy” (depression)

16. Starry Night by Vincent van Gogh

17. Lionel Aldridge experienced schizophrenia

18. Buzz Aldrin lived with Bipolar Disorder

19. Ernest Hemingway had depression

20. Winston Churchill lived with depression

21. Thelonius Monk experienced a number of mental illnesses

22. Stigma & Myths • Stigma causes • Lack of awareness of a problem • Reluctance to seek treatment • Ignorance of how to seek services • Myths create stigma, while understanding removes ignorance & barriers

23. Stigma & Children • Children may internalize stigmatizing messages as part of their self-image • Teachers who are aware stigma may be less likely to allow it into their classrooms Hinshaw, S. P. (2005). The stigmatization of mental illness in children and parents: developmental issues, family concerns, and research needs. Journal of Child Psychology and Psychiatry, 46, 714-734.

24. Do’s & Don’ts to Reduce Stigma • Do use respectful, person-first language • “He has schizophrenia” not “He’s schizophrenic” • “The student with OCD” not “The OCD student” • Do emphasize abilities, not limitations • Do talk about stigmatizing messages • Don’t use terms like crazy, Wacko, Nut Case, Psycho, Schizo, EMO • What terms are your students using?

25. Is this just a high school issue? Are we seeing … • students with mental health challenges at younger ages? • with more severe issues?

26. Mental Health   Mental Illness Continuum • It’s not an “either-or” situation • Students may have symptoms & behaviors without having a diagnosable disorder • Students may have a diagnosable disorder that is managed well, so there are minimal symptoms & behaviors • Both symptoms & disorders can have a serious impact on a child’s overall health

27. One end of the continuum: Health Mentally healthy people usually … • Have friends • Regulate their emotions • Cope with normal stressors • Live in supportive environments with others who care about them • Focus on goals & achieve them

28. The other end of the continuum: Illness People with mental illness often … • Lack friends or are involved with maladaptive peers • Lack capacity & strategies for regulating emotions • Have few effective ways of coping with stresses • Have serious work or academic difficulties

29. Mental Illness & Health is an Interplay between Risk & Protective Factors • Biological predispositions • Genes, temperament, prenatal care • Social & environmental effects - most risk here • Trauma, violence, poverty, loss, access, racism • Difficult interpersonal relationships

30. Mental Illness & Health is an Interplay between Risk & Protective Factors • Cultural influences & attitudes • Practices & beliefs about behaviors & mental illness itself • Stigma can compound the effects of disorder • Family influences • Parental modeling & treatment • Family violence & conflict

31. Interplay between Risk & Protective Factors • Protective factors from the research include • Loving, effective parenting (limits, bed times, etc.) • Adequate family income & housing • Positive peer group • Bonding to & engagement in school • Social & emotional knowledge & skills • Which of these protective factors can a school impact?

32. Bonding to & engagement in school • School connectedness is the extent to which students feel accepted, valued, respected, & included in the school • Connectedness has been found to correlate (-) strongly with concurrent mental health symptoms, particularly for depression Shochet, I.M., Dadds, M.R., Ham, D., Montague, R. (2006). "School connectedness is an underemphasized parameter in adolescent mental health: Results of a community prediction study." Journal of Clinical Child and Adolescent Psychology, 35,170-9.

33. Interplay between Risk & Protective Factors • Risk factors increase the likelihood that a given individual will develop a disorder, but risk factors are not “destiny” • Each additional risk factor increases the negative influence of the others • Protective factors reduce likelihood, but are not “all powerful”

34. Educational & Medical Categorization Systems • School-Based Systems • Focus on school functioning & behaviors • IDEA, Section 504 of Rehabilitation Act • Mental Health Diagnoses • Diagnostic & Statistical Manual of Mental Disorders (DSM) • Diagnostic categories based on combinations of symptoms • Severity, Frequency, Duration

35. Diagnostic Categories in DSM & Most Commonly Used with Children • Internalizing Problems • Mood Disorders • Anxiety Disorders • Externalizing Problems • Conduct & Oppositional Defiant Disorders • AD/HD, ADD • Other Disorders • Eating Disorders • Trauma-related disorders • Schizophrenia • Autism Spectrum

36. All teens have ups & downs, but a student who is… • so sad & cries frequently (mood problem) … • for the last 4 weeks (duration) … • that she won’t get out of bed (severity) … • most mornings & is late for school (frequency) … • & is failing 3 classes (impairment) … ...meets the clinical criteria for depression, & needs help in school & at home

37. Warning Signs & Symptoms • See handout Being Alert to Mental Health Problems • Contacts in our school/district/community for more information • _____________________________ • _____________________________ • _____________________________

38. Three Levels of Prevention • Structure the school setting to serve as a protective factor for all children to reduce new occurrences of mental health problems • Identify & intervene with children at-risk for mental health problems to reverse, halt, or at least slow the progression of the disorder • Provide intensive supports for students with severe & pervasive needs to slow the progression of the disorder & provide the student & significant others with adaptive coping skills

39. Using PBIS to meet the mental health needs of students • Tier 3/Targeted Interventions 1-5% • Wrap-around services • Intensive case management • IEPs/504 plans • Parent training & support • 1-5% Tier 3/Targeted Interventions • Individual students • Assessment-based • Intense, durable procedures • Tier 2/Selective Interventions 5-15% • BCT process • Screening • Monitoring • Community referrals • Parent education • Classroom supports • 504 plans/IEPs • 5-15% Tier 2/Selective Interventions • Some students (at-risk) • High efficiency • Early detection • Rapid response • Small group interventions • Some individualizing • Tier 1/Universal Interventions 80-90% • School climate • School policies • Curriculum/instruction • Modeling • CSCM • 80-90% Tier 1/Universal Interventions • All settings, 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/school-wide.htm

40. Tier 1 – Universal Strategies • There is a school-wide commitment to the social-emotional needs of all students • Adults model appropriate & respectful behavior & language • Focus is on building resilience rather than punishing deficiencies • Prevention is evidence-based & evaluated for effects

41. Universal Strategies • Welcoming school climate for students & families • School policies & procedures that prohibit discrimination & bullying that are consistently enforced by all • Respectful behavior modeled by adults • Comprehensive School Counseling Model • Proactive discipline system (e.g., PBIS) • Classroom instruction on mental health & illness

42. What Teachers Can Do • Create rules that recognize positive behaviors • Learn & inquire about students’ personal lives • Help children feel useful & helpful • Have students set behavioral & academic goals • Foster communication with parents • Use varied instructional methods www.casel.org

43. What Teachers & Pupil Services Can Do • Provide instruction in social-emotional skills: • Self Awareness • Social Awareness • Self Management • Relationship Skills • Responsible Decision Making • Provide instruction in health promotion & problem prevention - www.casel.org • Respect students’ & families’ privacy

44. Using PBIS to meet the mental health needs of students • Tier 3/Targeted Interventions 1-5% • Wrap-around services • Intensive case management • IEPs/504 plans • Parent training & support • 1-5% Tier 3/Targeted Interventions • Individual students • Assessment-based • Intense, durable procedures • Tier 2/Selective Interventions 5-15% • BCT process • Screening • Monitoring • Community referrals • Parent education • Classroom supports • 504 plans/IEPs • 5-15% Tier 2/Selective Interventions • Some students (at-risk) • High efficiency • Early detection • Rapid response • Small group interventions • Some individualizing • Tier 1/Universal Interventions 80-90% • School climate • School policies • Curriculum/instruction • Modeling • CSCM • 80-90% Tier 1/Universal Interventions • All settings, 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/school-wide.htm

45. Tier 2 - Selective Level • General education students who are showing some symptoms or signs are the target • Signs may be obvious, such as emotional outbursts or disruptive behavior • Signs may be subtle & less easy to notice, such as withdrawal or sadness • Teachers & pupil services should partner to support students’ mental health

46. Selective Strategies • Building Consultation Team (BCT) process - classroom supports to improve behavior management & student learning & support • Share information about mental health & illness with parents • Screen students’ presenting with symptoms & challenges • Monitor students’ progress (e.g., Check In – Check Out) • Refer students in need for mental health assessments in community • 504 plans & IEPs

47. Assessing Barriers to Learning • A problem-solving approach examines possible barriers in the: • Student • Environment • Curriculum • Instruction • Purpose of assessment is to better understand & address barriers

48. Assessing Barriers to Learning May be within the student • Mental health problems • Physical health problems • Intellectual deficits • Behavioral skills deficits • Academic skills deficits • Low motivation

49. Assessing Barriers to Learning May be within the environment • Classroom management issues • Peer relationship issues • Overcrowded conditions • Conditions that provoke anxiety or distractibility • Missing or poor organizational supports • Missing or poor targeted reinforcers • Lack of functional understanding of problem behavior

50. Assessing Barriers to Learning May be within the curriculum or instruction • Curriculum not matched to skill level • Curriculum is of low interest • Insufficient practice is available • Instruction not matched to student learning needs • Pace • Feedback • Error correction