Advancing Comprehensive School Mental Health Systems Guidance From the Field

September 2019 2 • Advancing Comprehensive School Mental Health Systems Positive mental health allows children to think clearly, develop socially and learn new skills. Additionally, good friends and encouraging words from caring adults are important for helping children develop self-confidence, high self-esteem and a healthy emotional outlook on life.

Each day in the United States, millions of children and adolescents go to school with mental health concerns that threaten their well-being and educational performance.

Comprehensive school mental health systems provide an array of supports and services that promote positive school climate, social and emotional learning, and mental health and well-being, while reducing the prevalence and severity of mental illness.

Advancing Comprehensive School Mental Health Systems • 3 Contents

5 Preface 6 Acknowledgments 10 Executive Summary 13 Introduction 14 Why Address Mental Health in Schools 16 A Public Health Approach to School Mental Health 18 The Value of School Mental Health 20 Core Features of a Comprehensive School Mental Health System 28 Opportunities, Challenges and Recommended Strategies 34 Local Spotlights 38 State Spotlights 41 Moving Forward

Report Development Timeline

September 7, 2017 May 17, 2018 June 15, 2018

National convening: Expert panel on National convening: National convening: school mental health School mental health in School mental health rural communities state summit

4 • Advancing Comprehensive School Mental Health Systems Preface

This report offers collective insight and guidance to local communities and states to advance comprehensive school mental health systems. Contents were informed by exam- ination of national best practices and performance standards, local and state exemplars, and recommendations provided by federal/national, state, local and private leaders.

In 2017 and 2018, the U.S. Department of Health stakeholder engagement at all levels) needed and Human Services, Substance Abuse and Mental to scale up school mental health Health Services Administration (SAMHSA) and Health • Consensus on critical areas of focus for shared Resources and Services Administration (HRSA), in work over the next five years partnership with the Bainum Family Foundation, hosted three national convenings of experts to Outcomes of the discussions from the meetings advance the widescale adoption of high-quality, com- were shared and augmented with input from prehensive school mental health systems in the United the broader field via local, state and national meetings States. The meetings were designed to document: and conferences, including sessions at the Annual • K ey milestones and the current state of the Advancing School Mental Conferences in 2017 and 2018. school mental health field Additionally, in 2018, the National Training Institutes • A shared vision of scaling up quality compre- provided an important forum for multiple school mental hensive school mental health across the nation health sessions and discussions to 1) further engage • Opportunities and challenges to improve quality local, state and national partners involved in advancing and foster the wide-scale adoption of compre- comprehensive systems of care, and 2) create momen- hensive school mental health systems tum toward wide-scale advancement of comprehen- • The conditions (resources, strategies and sive school mental health systems across the nation.

July−December 2018 August 2018−May 2019 June 2019 and beyond Gathered additional feedback at Developed and produced report other local, state and national Engage partners and stakeholders meetings and conferences to champion and scale up comprehensive school mental health systems nationally

Advancing Comprehensive School Mental Health Systems • 5 Acknowledgments

Special appreciation to members of the School Mental Health Work Group, whose commitment and partnership helped make this possible.

Federal Agencies Child Health and Development Institute U.S. Department of Health and Human Services, of Connecticut, Inc. Health Resources and Services Administration Jeana Bracey, Jason Lang and Jeffrey Vanderploeg Aite Aigbe, Trina Anglin and Bethany Miller National Association of State Directors U.S. Department of Health and Human of Special Education Services, Substance Abuse and Mental Health Joanne Cashman and Mariola Rosser Services Administration Andrea Alexander, Ingrid Donato, Larke Huang, National Center for School Mental Health, Justine Larson, Joyce Sebian and Wendie Veloz University of Maryland School of Medicine Jill Bohnenkamp, Elizabeth Connors, Sharon Hoover, Organizations Nancy Lever, Kathryn Moffa, Chandni Patel and Mills Bainum Family Foundation Smith-Millman Noel Bravo and Nisha Sachdev School-Based Health Alliance Center for Health and Health Care in Schools, John Schlitt Milken Institute School of Public Health at The George Washington University Olga Acosta Price and Linda Sheriff

Content from this document may be used directly or adapted. Users are encouraged to acknowledge this document as a source using the following suggested citation:

Hoover, S., Lever, N., Sachdev, N., Bravo, N., Schlitt, J., Acosta Price, O., Sheriff, L. & Cashman, J. (2019). Advancing Comprehensive School Mental Health: Guidance From the Field. Baltimore, MD: National Center for School Mental Health. University of Maryland School of Medicine.

www.schoolmentalhealth.org/AdvancingCSMHS

We dedicate this guidance monograph to the memory of Andrea Alexander, a dear friend and colleague who spent her career working to advance school mental health at local, state and national levels. Andrea was a significant partner in the national School Mental Health Work Group, and her untimely death only fueled the group to persevere with its goals. Andrea’s energy, passion and commitment to improving systems of care for youth contributed signifi- cantly to the advancement of school mental health and to the quality of life for countless chil- dren and families. May her light shine bright through the work carried forth by school mental health champions across the nation.

6 • Advancing Comprehensive School Mental Health Systems Advancing Comprehensive School Mental Health Systems • 7 Acknowledgements

The following individuals participated in the school mental health convenings and contributed to the content of this guidance document. They shared their knowledge and helped inform best practice and policy strategies pertinent to the advancement of comprehensive school mental health systems at local, state and national levels.

Federal Departments/Agencies States U.S. Department of Education Connecticut Department of Children and Families, Office of Elementary and Secondary Education, Tim Marshall Norris Dickard, Paul Kesner and Kimberly Lights District of Columbia Department of Behavioral Office of Special Education and Rehabilitative Health, Charnetta Scott Services Programs, Rene Bradley Maryland State Department of Education, U.S. Department of Health and Human Services Reginald Burke Office of Intergovernmental and External New Hampshire Department of Education, Affairs/Center for Faith and Opportunity Mary Steady Initiatives, Ben O’Dell North Carolina Office of the Secretary/Office of the Assistant Department of Health and Human Services, Secretary for Planning and Evaluation, Terri Grant Joel Dubenitz and Pamala Trivedi Department of Public Instruction, Lauren Holahan Centers for Disease Control and Prevention, Pennsylvania Department of Human Services, Holly Hunt and Zanie Leroy Sherry Peters and Shannon Fagan Centers for Medicare and Medicaid Services, Tennessee Liz Clark, Karen Matsuoka and Deirdra Stockmann Department of Education, Sara Smith Health Resources and Services Administration, Department of Mental Health and Substance Aite Aigbe, Trina Anglin, Alfred Delena, William Abuse Services, Keri Virgo England, Dawn Levinson, Lorah Ludwig, Carlos Vermont Department of Public Health and Mental Mena and Alex Ross Health, Laurin Kasehagen (CDC Epidemiologist Substance Abuse and Mental Health Services assigned to Vermont) Administration, Tanvi Ajmera, Andrea Alexander, West Virginia Department of Health and Human Gary Blau, Ingrid Donato, Lora Fleetwood, Larke Resources, Jackie Payne Huang, Eric Lulow, Joyce Sebian, Elizabeth Wisconsin Department of Public Instruction, Sweet, Wendie Veloz, Melodye Watson and Monica Wrightman Ekaterina Zoubak U.S. Department of the Interior School Districts/Schools Bureau of Indian Education, Teresia Paul Adams-Friendship Area School District (WI), U.S. Department of Justice Crystal Holmes Office of Justice Programs/Office of Juvenile Anne Arundel County Public Schools (MD), Justice and Delinquency Prevention, Ginny Dolan Kathryn Barry and Kathy Mitchell Ashland School District (WI), Greta Blancarte

8 • Advancing Comprehensive School Mental Health Systems Baltimore County Public Schools (MD), Lisa Selby National Association of School Psychologists, Chapel Hill-Carrboro City Schools (NC), Kerry Sherrill John Kelly District of Columbia Prep Charter School (DC), National Association of State Directors of Special R aymond Weeden Education, Joanne Cashman and Mariola Rosser District of Columbia Public Schools (DC), National Association of State Mental Health Deitra Bryant-Mallory Program Directors, Aaron Walker Hennepin County/Minneapolis Public Schools National Association of State Mental Health (MN), Mark Sander Program Directors, Pennsylvania Representative, McDowell County Schools (WV), Perry Blankenship Shannon Fagan Methuen Public Schools (MA), John Crocker National Center for School Mental Health, Monument Academy Public Charter School (DC), University of Maryland School of Medicine, Tiffany Emily Bloomfield Beason, Yourdanos Bekele, Jill Bohnenkamp, New York Office of School Health, Scott Bloom Rachel Bolan, Dan Camacho, Elizabeth Connors, Somerset County Public Schools (MD), Dana Cunningham, Sharon Hoover, Vinetra King, Tracey Cottman Nancy Lever, Stephanie Moore, Brittany Parham, Kris Scardamalia and Rachel Siegal Other Organizations National Conference on State Legislatures, American Institutes for Research, Karen Francis, Tahra J ohnson and Margaret Wile Beth Freeman and Frank Rider National Federation of Families for Children’s American Public Health Association, Kelly Nelson  Mental Health, Lynda Gargan Basset Healthcare Network, Chris Kjolhede National Governors Association, Akeiisa Coleman Breaking the Cycle, Sadia Coleman  and Sandra Wilkniss Center for Health and Healthcare in Schools, National Rural Health Association, Lolita Jadotte George Washington University, Olga Acosta Price, Please Pass the Love, Jennifer Ulie-Wells Rachel Sadlon, Linda Sheriff and Eme Udoh RAND Corporation, Brad Stein Communities for Just Schools Fund, Jaime Koppel School-Based Health Alliance, John Schlitt Connecticut Association of School Based Health School Social Work Association of America, Centers, Jesse White-Fresé  Libby Nealis Dignity in Schools Campaign, Zakiya Sankara-Jabar Family-Run Executive Directors Leadership Universities Association, Jane Walker Appalachian State University, Kurt Michael Flint Hills Special Education Cooperative, Allison Georgetown University Center for Child and Anderson-Harder Human Development, Neal Horen Management and Training Innovations, Beth Stroul Johns Hopkins Bloomberg School of Public Medstar Georgetown, Jeff Bostic Health, Catherine Bradshaw Midwest PBIS Network, Kelly Perales University of Maryland School of Social Work, Montgomery County Federation of Families for Shannon Robshaw Children’s Mental Health, Robyn Horsey University of South Carolina, Mark Weist National Association for Rural Mental Health, Paul Mackie Foundations National Association of School Nurses, Bainum Family Foundation, Noel Bravo, Rozita Susan Hoffman Green and Nisha Sachdev

Advancing Comprehensive School Mental Health Systems • 9 Executive Summary

Effective comprehensive school mental health systems contribute to improved student and school outcomes, including greater academic success, reduced exclusionary discipline practices, improved school climate and safety, and enhanced student social and emotional behavioral functioning.

Schools are a natural setting for collaboration across district and school professionals, including admin- partners to promote student well-being and to support istrators, educators and specialized instructional early identification and intervention for students support personnel (e.g., school psychologists, school with mental health concerns. Comprehensive school social workers, school counselors, school nurses and mental health systems provide a full array of supports other school health professionals), in strategic collab- and services that promote positive school climate, oration with students, families, and community health social and emotional learning, and mental health and and mental health partners. These systems also well-being, while reducing the prevalence and severity assess and address the social, political and environ- of mental illness. Comprehensive school mental mental structures — public policies and social norms health systems are built on a strong foundation of included — that influence mental health outcomes.

10 • Advancing Comprehensive School Mental Health Systems “Schools are a natural setting for collaboration across partners to promote student well-being and to support early identification and intervention for students with mental health concerns.”

The core features of a comprehensive school mental • Use of screening and referral as a strategy for health system include: early identification and treatment • A full complement of school and district pro- • Us e of evidence-based and emerging best fessionals, including specialized instructional practices to ensure quality in the services and support personnel, who are well-trained to supports provided to students support the mental health needs of students in • Use of data to monitor student needs and progress, the school setting assess quality of implementation, and evaluate the • Collaboration and teaming among students, fam- effectiveness of supports and services ilies, schools, community partners, policymakers, • Diverse and leveraged funding and continu- funders and providers to address the academic, ous monitoring of new funding opportunities social, emotional and behavioral needs of all from federal/national, state and local sources students as well as the predictable problems of to support a sustainable comprehensive school practice in crossing systems and roles mental health system • A thorough and continuous needs assessment of • Leaders who lead by convening and who work school and student needs and strengths, coupled effectively on both the technical and human sides with resource mapping of school and community to enable change in policy, practice and people assets, to inform decision-making about needed supports and services There are numerous exemplary models in locali- • A full array of tiered, evidence-based processes, ties across the United States that have inspired this policies and practices, called a multi-tiered guidance, several of which are featured here as a road system of support (MTSS), that promotes mental map for states and communities that seek to achieve health and reduces the prevalence and severity of wide-scale adoption of comprehensive school mental mental illness health systems.

Advancing Comprehensive School Mental Health Systems • 11 Mental health is defined as the social, emotional and behavioral well-being of students. Mental health services are broadly defined as any activities, services and supports that address social, emotional and behavioral well-being of students, including substance use.

12 • Advancing Comprehensive School Mental Health Systems Introduction

The well-being of school-aged children from kindergarten to 12th grade is a top priority for every community in our nation. Successful achievement of this goal is driven not only by a quality education, but also by healthy social and emotional development — the necessary foundation for children to learn, grow and thrive.

Every child’s development is affected by several Building comprehensive school mental health systems factors. Child outcomes are driven not only by a is one critical strategy to promote positive outcomes quality education and physical health, but also by for our nation’s children. As such, there is a growing social and emotional development, including home movement across the United States to establish and and neighborhood environment, peer groups, and strengthen these systems. At local, state and national the support they receive in school. The effects of levels, policymakers, practitioners and other community these factors on the developing brain begin at a members are looking for opportunities to learn about, very early age and continue through adolescence fund, implement and evaluate improvements for com- and into adulthood. Decades of research demon- prehensive school mental health systems. strate that supportive and safe environments rich in developmental opportunities provide children Comprehensive school mental health systems what they need to be successful academically, provide an array of supports and services that promote socially and emotionally. positive school climate, social and emotional learn- ing, and mental health and well-being, while reducing Despite our best efforts to provide for the youngest the prevalence and severity of mental illness. These members of our communities, many children systems are built on a strong foundation of district and struggle to achieve healthy social and emotional school professionals, including administrators, educa- development. They may be challenged with mental tors and specialized instructional support personnel health concerns that can disrupt their learning, their (e.g., school psychologists, school social workers, families and their peer relationships — and that school counselors, school nurses and other school can lead to immediate and enduring detrimental health professionals), all in strategic partnership with effects. To address these challenges, states and students and families, as well as community health and communities are implementing innovative policies mental health partners. These systems also assess and high-quality programs and strategies that and address the social and environmental factors that have improved the development and well-being impact mental health, including public policies and of and long-term outcomes for children. social norms that shape mental health outcomes.

Advancing Comprehensive School Mental Health Systems • 13 Why Address Mental Health in Schools

Policymakers, researchers and practitioners increasingly understand the inextricable link between mental health and learning, and the roles of home, school and community environments in mental health outcomes. Universal mental-health promotion activities in schools include an emphasis on positive school climate, social and emotional competencies, and reinforcement of prosocial behaviors. Universal approaches to promoting mental health in schools are increasingly being implemented by educators and student support staff across the United States and globally.

The past decade has documented the beneficial impact the United States, millions of children and adoles- of mental health and evidence-based prevention cents go to school with mental health concerns that programming on both long-term psychosocial out- threaten their well-being and educational perfor- comes and academic performance.1, 2, 3 In 2009, the mance.4 In a given year, 13%–20% of children meet Institute of Medicine report, “Preventing Mental, criteria for a mental disorder and approximately 5% of Emotional, and Behavioral Disorders Among Young adolescents meet criteria for a substance use People: Progress and Possibilities,” recognized the disorder, while only 12% of these youth receive any positive longitudinal impact of school-based social, services to address the mental health and/or sub- emotional and behavioral interventions. This further stance use concerns.5, 6 For many young people, bolstered public interest in integrating universal especially those of color and those who live in mental health supports into schools.1 In addition, disadvantaged communities, their social and environ- efforts to shape school policies and practices that mental contexts set them up for poor health and influence mental health outcomes, such as reducing education outcomes. Youth living in impoverished exclusionary discipline (disciplinary action that communities have higher rates of depression and removes or excludes a student from his or her usual substance use and are at the highest risk of not educational setting) and installing trauma-informed having regular health maintenance visits.7 Further, systems, have increasing empirical support. adverse childhood experiences (ACEs) have been correlated with short- and long-term physical and Beyond advancing social and emotional development mental health consequences, chronic absenteeism, and mental health promotion, educators, student school failure, and school dropout.8, 9, 10 In the longer support staff and other school-based staff play an term, youth exposed to ACEs are less likely to integral role in the identification and support of graduate from high school and more likely to be students with mental health problems. Each day in underemployed and financially unstable.11

14 • Advancing Comprehensive School Mental Health Systems Missing 10% or more school days 13%-20% is an early warning Percentage of U.S. children sign of academic risk who meet criteria for a and school dropout. mental disorder each year Mental, behavioral, 5% social and emotional Percentage of U.S. health issues are a adolescents who meet leading contributor criteria for a substance to chronic absenteeism abuse disorder each year Youth are 12% 6 times Percentage of these youth more likely to complete who receive any services evidence-based to address the mental treatment when offered health and/or substance in schools than in other abuse concerns community settings12

Advancing Comprehensive School Mental Health Systems • 15 A Public Health Approach to School Mental Health

On the strength of the compelling evidence alone, schools have an imperative to attend not just to the academic success of students, but to their social, emotional and behav- ioral development as well.13 Schools are a natural and logical setting in which to employ a public health framework that focuses on promoting student well-being and healthy behaviors and preventing mental health problems before they occur. But schools cannot do it alone.

16 • Advancing Comprehensive School Mental Health Systems Many schools already operate from a preventive, A public health approach to school mental multi-tiered approach to academic performance, health recognizes the primacy of the environ- often referred to as MTSS, that employs universal ment in which children live, learn and play. screening, early identification and intervention to Healthy, well-adjusted young people thrive when address academic concerns. This same approach they live among healthy families, schools and can be applied to mental health by implementing communities. This approach rests on the seminal policies and interventions that promote mental health, work of Urie Bronfenbrenner, a renowned develop- prevent problem behaviors and address environmen- mental psychologist at Cornell University who tal factors that put students at risk for various mental articulated an “ecological systems” model (see health problems, while also offering early identifica- Figure 1) that helps practitioners and researchers tion and treatment for students already displaying better understand how environment has a crucial signs of mental health problems. In partnership with impact on children’s healthy development.15 The communities, schools can offer a seamless contin- model stipulates that there is constant interplay uum of supports to a large population of students between individuals and their environments. It with and without mental health difficulties. also highlights that interventions aimed solely at individual behavior change are important but Today, children and adolescents are more likely to insufficient; interpersonal/environmental/social receive needed mental health care in their school changes are needed to sustain improvements over than in any other setting. Of children and adolescents time. Building off Bronfenbrenner’s work and who receive mental health services, 70%–80% receive based in the public health approach, the Whole them in school.14 Schools offer a more accessible, School, Whole Community, Whole Child (WSCC) less stigmatizing environment than traditional model calls for schools to partner with communi- community-based mental health settings do. In ties and families to ensure that all students are addition, many school professionals, including healthy, engaged, safe, supported and chal- school psychologists, social workers, counselors, lenged.16 The WSCC model aims to improve nurses and other health professionals, have special- educational attainment and healthy development ized training to address student mental health for students, and it recognizes mental health as a concerns. While schools are an important setting in critical component for addressing the needs of the which to deliver mental health services, there are whole child. Developing comprehensive school differences in training, experience and role definition mental health systems as part of the model is that continue to challenge effective integration. essential for supporting all students.

Figure 1. Ecological Systems Model

Macrosystem (e.g., society, culture)

Exosystem (e.g., media, services, neighbors) CHILD/ YOUTH Mesosystem (e.g., interaction of extended levels of microsystems)

Microsystem (e.g., family, peers, school)

Advancing Comprehensive School Mental Health Systems • 17 The Value of School Mental Health

There is growing data to show the impact and value of providing mental health supports and services in schools. Comprehensive school mental health systems address the full array of these services and supports, including mental health promotion, prevention, early identification and treatment. Key findings are featured below and in Figure 2.

Positive Impact on Psychosocial and Positive School Climate and Safety Academic Outcomes Creating a positive school climate is a prior- Comprehensive school mental health systems are ity for school-based staff. As defined by the associated with improved student academic and National Center for Safe and Supportive Learning psychosocial outcomes. Students who participate in Environments (2019), “a positive school climate social and emotional learning programs demonstrate is the product of a school’s attention to fostering improvements not only in self- and social aware- safety; promoting a supportive academic, disci- ness, decision-making and relationship skills, but plinary, and physical environment; and encouraging also in academics, including standardized testing.2 and maintaining respectful, trusting, and caring Comprehensive school mental health systems can relationships throughout the school community.”27 positively impact students who face physical and There is abundant evidence that schools with mental health issues that impair their well-being and positive school climate and integrated social and academic performance.17 Impoverished youth and emotional learning are more likely than compari- youth of color are at a higher risk for these negative son schools to achieve higher standards of school outcomes.18, 19 Of the many youth experiencing mental safety, including less bullying, less student isolation, illness, few seek and receive adequate treatment.20 more positive peer and teacher-student relation- Comprehensive school mental health systems ships, and less weapon threat and use in schools.28 improve access to all students, including traditionally Although the vast majority of students with mental underserved youth, and positively impact student illness are not violent (and are more likely than outcomes — for example, with improved academic their peers to be victims of violence), systems for performance,21 fewer special education referrals, early identification and mental health treatment for decreased need for restrictive placements,22 fewer students with mental health challenges can protect disciplinary actions,23, 24 increased student engage- students who are vulnerable to being disconnected, ment and feelings of connectedness to school,25 and isolated, self-harming, retaliating and aggressive, all higher graduation rates.26 of which are predictive of future violence.29

18 • Advancing Comprehensive School Mental Health Systems Early Identification and Intervention mental health services in schools.36, 37, 38 These Schools can identify mental health problems and services can be offered using direct school-based intervene early. School staff spend a large part of the services, co-located school-based health centers and day with students and can apply their professional services, and school-linked community-based care, skills and experience to identify potential mental health and through tele-mental health provided by school- or concerns.30 Additionally, periodic universal screening community-hired staff. Further, schools can reduce for mental health problems can help schools identify stigma and normalize mental illness and treatment students in need of services before they develop a by providing training and education to teachers and diagnosable mental health problem.31 Given the high parents on mental health literacy and help-seeking. prevalence and recurrence of mental health disorders, it is important to identify problems early and connect Youth, Family, School and Peer Engagement students to services and supports. Early identification and Partnership and treatment are associated with positive outcomes Youth, family, educators and peers are critical stake- for both students and society, including saving money holders in children’s mental health and well-being.39, 40, 41 by reducing the need for more costly and intensive Meaningful engagement of youth and families in psychological services.32, 33 Screening also offers school-based mental health care requires that services the opportunity to assess the social determinants of are high-quality, easily accessible and individualized mental health, including adverse early life experiences, to their needs. Because the school setting is familiar food and housing insecurity, and income inequality. and convenient to parents and caregivers and does not require the caregiver to take the student out of Access to Care school for appointments, access to care is higher Stigma can directly impact help-seeking behaviors and in schools when compared with more traditional openness to mental health treatment for both students community-based settings. School-based settings and caregivers. Only a fraction of children, adolescents provide mental health professionals easy access and families who experience mental health concerns to educators, who report both increased abilities to access outpatient care in traditional, community respond appropriately to students in psychological dis- mental health settings, and of those who access care, tress and better relationships with students. Educators about 40%–60% drop out of treatment early.34, 35 These observe less peer victimization in their classrooms rates speak to the barriers that keep many students after receiving training about identifying and addressing and their families from accessing mental health student mental health needs.42 In addition, schools services and reflect on the health disparities within provide the unique advantage of being able to engage populations of color and other demographic groups prosocial and influential peers in school mental health that impact their overall health and success in school. activities by inviting them to be peer mentors, advo- Many of these barriers can be avoided by providing cates and/or therapy group members.

Figure 2. The Value of Comprehensive School Mental Health Systems: Positive Outcomes

Better academic outcomes

Access to care

Early identification and intervention

Positive school climate and safety

Youth, family, educator and peer engagement

A continuum of services

Better psychosocial outcomes

Advancing Comprehensive School Mental Health Systems • 19 Core Features of a Comprehensive School Mental Health System

There are several core features of a comprehensive school mental health system. Each feature is highlighted in this section and in Figure 3.

1. Well-Trained Educators and Specialized so.Equipping educators with social and emotional Instructional Support Personnel skills and mental health literacy will prepare them A comprehensive school mental health system is to best support student mental health and create a built on the foundation of a full complement of school healthier workforce. In addition, specialized instruc- and district professionals, including specialized tional support teams (e.g., school counselors, social instructional support personnel who are well-trained workers and school psychologists, and other qualified to support the mental health needs of students in professional personnel, such as school nurses and the school setting. Administrators and educators are occupational therapists) must be adequately staffed often on the front lines of promoting student mental to provide assessment, diagnosis, counseling, edu- health and addressing mental health concerns and cational, therapeutic and other necessary services to must be adequately trained and supported to do support student needs.

20 • Advancing Comprehensive School Mental Health Systems Figure 3. Core Features of a Comprehensive School Mental Health System

Well-Trained Educators and Mental Health Specialized Screening Instructional Support Personnel

Family-School- Evidence-Based Community and Emerging Collaboration Best Practices and Teaming

Needs Assessment and Resource Data Mapping

Multi-Tiered System Funding of Support

2. Family-School-Community Collaboration of the school setting. Using a collaborative team and Teaming approach requires shared funding streams, data To promote student mental health, school-employed collection processes and data-sharing mechanisms, mental health staff, school administrators, com- which can be complicated to navigate. Community munity partners, policymakers, funders, provid- partners can augment services within the school ers, students and families must be committed to building and can link students to other services working together to address the interconnected and supports in the community. In addition, they academic, social, emotional and behavioral needs can champion what schools are doing to support of all students. Collaborative partnerships guided mental health with key leadership, such as boards by school-employed staff working closely with of education and policymakers. communities and families help improve student outcomes and impact academic, social, emo- Successful and sustainable school mental health tional and behavioral needs. Further, coordinating systems do more than co-locate services within resources and strategies leads to efficient, effec- the school building; they seek to integrate part- tive and sustainable workflows in the busy context ners seamlessly so that the diverse complement

Advancing Comprehensive School Mental Health Systems • 21 Core Features of a Comprehensive School Mental Health System

Figure 4. An Example of Complementary Roles and Resources of Community Partners and School Districts in Comprehensive School Mental Health Systems 43

COMMUNITY PARTNERS SCHOOL DISTRICTS

TIER 3 Indicated Services 3 and Supports 3

TIER 2 2 Selective Services 2 and Supports

TIER 1 1 Universal Services 1 and Supports

of mental health supports and services are tightly system needs and helps staff determine priorities. coordinated to meet the student body's needs A school mental health needs assessment, which efficiently and effectively. Working directly with could include student mental health and school community partners broadens the availability of climate surveys, informs decisions about school potential supports that can be available to stu- mental health planning, implementation and quality dents and families, enhancing access to mental improvement. Resource mapping offers schools health care. The roles and responsibilities of school and districts a comprehensive view of school and and community partners will differ based on unique community mental health services and resources resources and needs. One example of this balance available to students and families.45 Having a sys- is illustrated in Figure 4. tematic process that helps individuals better under- stand specific details about the types of services Conceptually, the roles of school and commu- offered, and how and when they can be accessed, nity personnel fit together to form an integrated can improve student follow-through with services system that is responsive to student needs. Yet we and coordination of care. Resource mapping offers know that in practice the individuals in these roles a map of how needs are being addressed, and work in environments shaped by multiple systems, can visually display many factors, including the where practices emerge in response to context and location of service, the type of service, and how roles must be adapted. This dynamic environment students and families can access the services that demands a set of core principles to ground the are available to them. Together, needs assessment work and collaboration of all partners.44 and resource mapping highlight strengths and gaps in the school mental health system and can 3. Needs Assessment and Resource Mapping inform prioritization of goals and action planning. Conducting a needs assessment offers a sys- When conducting needs assessment and resource tematic process for identifying programmatic and mapping, collaborative teams that understand and

22 • Advancing Comprehensive School Mental Health Systems with Tier 1 focusing on promoting mental health and A needs assessment may preventing occurrences of problems, Tier 2 focusing include the following activities on preventing risk factors or early-onset problems from progressing, and Tier 3 focusing on individual conducted by the school mental student interventions that address more serious con- health team in partnership with cerns and prevent the worsening of symptoms that educators, youth, families and can impact daily functioning.46 Professional develop- community partners. ment and support for a healthy school workforce as well as family-school-community partnerships are • Determine appropriate data (e.g., foundational elements that support these three tiers. school-level data, survey data, informal inquiries with teachers and parents, Matching the range of academic, behavioral and review of office referrals, provider social needs within a school involves the layering of feedback on caseload characteristics) interventions from universal approaches to targeted and identify priority areas of focus that programming for students with mild impairment and, are based on student needs. for some students, adding on individualized interven- • A ssess common risk and stress factors tions linked to the lower-tiered structures. faced by students (e.g., exposure to crime, violence, illicit substance abuse). The MTSS approach ensures that all students can • Evaluate whether the school mental access the service array, including students in both health team has staffing capacity general and special education, and that all students and services in place to help students will have exposure to universal mental health sup- contend with common risk and ports. The number of tiers in an MTSS can vary, stress factors. though many districts employ a three-tiered model. • Assess the frequency, quality and (See Figure 5.) content of professional development for school staff. Mental health promotion services and supports • A ssess school efforts to refer students to (Tier 1) are mental health-promoting activities, community-based behavioral health including the strengthening or reinforcement of services and track access to and utiliza- positive social, emotional and behavioral skills tion of these services. designed to support the well-being of all students, regardless of whether they are at risk for mental health problems. These activities might include represent the community, including school person- efforts to support positive school climate and staff nel, community staff, and families and students, well-being. They can be implemented schoolwide, should be utilized. at the grade level and/or at the classroom level.

4. Multi-Tiered System of Support Examples include schoolwide curricular lessons Many schools deliver instructional or behavioral and grade-level or classroom presentations for intervention to students in varying intensities, also all students, regardless of whether they are at risk known as a multi-tiered system of support (MTSS), for mental health problems. to address the academic needs of the larger student body, including (but not limited to) students with iden- Early intervention services and supports (Tier 2) tified disabilities. Based on a public health framework, to address mental health concerns are provided for prevention is an underlying principle at all three tiers, students who have been identified through needs

Advancing Comprehensive School Mental Health Systems • 23 Core Features of a Comprehensive School Mental Health System

Figure 5: Multi-Tiered System of Support

TIER 3 + Targeted interventions for students with serious concerns that impact daily functioning

TIER 2 + Supports and early intervention for students identified through needs assessments as being at risk for mental health concerns

TIER 1 + Promotion of positive social, emotional, and behavioral skills and overall wellness for all students

Foundational Elements

+ Professional development and support for a healthy school workforce + Family-school-community partnerships

assessments, screening, referral or other school Examples include individual, group or family therapy teaming processes as experiencing mild distress or for students who have been identified, and often diag- functional impairment, or being at risk for a given nosed, with social, emotional and/or behavioral needs. problem or concern. When problems are identified early and supports put in place, positive youth devel- 5. Mental Health Screening opment is promoted and problems can be elimi- Early identification and intervention lead to better nated or reduced. outcomes for students. Given the high prevalence and recurrence of mental health disorders, it is Examples include small-group interventions important to identify problems early and connect for students identified with similar needs (e.g., students to needed services and supports. Mental students with asthma), brief individualized health screening, including assessment of the interventions (e.g., motivational interviewing, social determinants of mental health, is a founda- problem-solving), mentoring, and/or low-intensity tional component of a comprehensive approach to classroom-based supports such as a daily report behavioral health problem-prevention, early iden- card or daily teacher check-in. tification and intervention services. Screening can be conducted using a systematic tool or process Treatment services and supports (Tier 3) to with an entire population (e.g., a school’s student address mental health concerns are provided for body) or a group of students (e.g., a classroom or students who need individualized interventions for grade level). Screening should be conducted only the significant distress and functional impairment when there is a system in place to promptly review they are experiencing. screening data once it is collected and then make

24 • Advancing Comprehensive School Mental Health Systems necessary referrals for further assessment, ser- improvement are needed to promote effective vices and supports. implementation. The Hexagon Tool, developed by the National Implementation Research Network, 6. Evidence-Based and Emerging Best Practices offers EBP implementation guidance to schools Using research-based interventions and best prac- and districts.47 tices within an MTSS increases the likelihood that youth will have access to effective interventions 7. Data matched to their strengths and needs. School dis- Data outcomes, data systems and data-driven tricts can learn more about evidence-based inter- decision-making are all critical components to sup- ventions by accessing databases such as the What porting a comprehensive school mental health system. Works Clearinghouse (WWC), https://ies.ed.gov/ ncee/wwc/. WWC is an investment of the Institute Outcomes. Comprehensive school mental health of Education Sciences within the U.S. Department systems must document the provision and impact of of Education, and is designed to provide educators service and supports. Data may include student-level the information they need about programs, practices outcomes such as numbers of students referred and and policies to make evidence-based decisions. receiving mental health supports, as well as docu- Evidence-based approaches that promote mental mented improvement for students served. School-level health and reduce mental illness are not solely outcomes, such as school climate, teacher retention directed at students; for example, strategies that and discipline practices, may also prove useful in focus on social and environmental determinants documenting the impact of universal mental health of mental health, school climate, or staff wellness programming. Tracking and monitoring these out- each have a positive influence on student mental comes at the school and district levels can improve health. MTSS also allows for the installation of understanding of the system and of student needs, practices to support specific target populations. gaps and service utilization patterns. School mental For example, trauma-informed schools are increas- health systems routinely face barriers to systematically ingly adopting MTSS as a foundational framework tracking individual student data, including: for interventions across the continuum of mental • Lack of staffing capacity health supports. • Lack of technological options/infrastructure • Lack of knowledge, training and time to create a In addition to ensuring that a practice has been data collection system tested through a scientifically rigorous process, • Limited data sharing across systems (e.g., it is important that the practice is based on popu- between school and community providers) lation strengths and needs, is culturally relevant, and can be implemented given current workforce Data systems. Use of existing student information capacity, cost and organizational infrastructure. The systems and partnerships with experts in data collec- National Center for Healthy Safe Children (https:// tion (e.g., through university partnerships) can facilitate healthysafechildren.org/) provides a step-by-step the collection of information to document services and guide and a series of online learning modules outcomes. Examples of data indicators that reflect for selecting and implementing evidence-based school mental health outcomes are given in Table 1. practices (EBPs) in schools. After selection of an EBP and initial staff training has been carried Data-driven decision-making. A critical compo- out, ongoing supervision/coaching, organizational nent of school mental health systems is the use of support, data collection and continuous quality comprehensive data for data-driven decision-making

Advancing Comprehensive School Mental Health Systems • 25 Core Features of a Comprehensive School Mental Health System

Table 1: Examples of Data Indicators Useful to a Comprehensive School Mental Health System

Student Psychosocial System Functioning Student Academic Functioning Functioning • School climate • Grades • Social and emotional wellness • Trauma-responsive policies • Benchmark assessments • Mental illness (e.g., anxiety, and practices • State testing depression, trauma) • School staff retention • Attendance • Interpersonal relationships • School staff well-being • Expulsion and suspension • Food and housing security • Discipline practices (including • School connectedness • Risk behaviors disproportionate rates • Engagement with learning of suspension and expulsion) • Family engagement

(DDDM) to inform school mental health planning and delivery. DDDM can inform decisions related to appropriate student supports and can be used Assessing Core Features of to monitor progress and outcomes across multiple Comprehensive School Mental tiers. Data can facilitate information sharing across Health Systems team members, achieve common understanding of target concern(s), and inform decisions about which As part of the National Quality Initiative on strategies to try to test and how to adjust interven- School Health Services, the National Center tions as needed. for School Mental Health (NCSMH) (www. schoolmentalhealth.org) led a rigorous, 8. Funding stakeholder-driven process that resulted in Building and sustaining comprehensive school the first National School Mental Health Qual- mental health systems requires innovative strat- ity Performance Measures.48 These stan- egies to leverage and apply various financial and dards reflect best-practice strategies for nonfinancial resources in a school or district. systematically developing, improving and Best-practice considerations include using sustaining comprehensive school mental diverse sources, combining categorical and health systems. District and school assess- block grant funds from across multiple agencies ments and resources to support the core to achieve shared outcomes, leveraging funding features of comprehensive school mental and Medicaid reimbursement by developing rela- health systems can be found at the School tionships with other agencies, matching funding to Health Assessment and Performance service delivery across multiple tiers, and moni- Evaluation (SHAPE) System site (www. toring policy and new funding opportunities (e.g., theshapesystem.com), a free, private, web- education, behavioral health, health, climate/ based portal that offers school districts and safety, juvenile justice) at local, state and national/ schools a virtual work space to document and federal levels. track the advances they are making in their school mental health systems. In our experience, diversification of funding is the bedrock of sustainable programs and services.

26 • Advancing Comprehensive School Mental Health Systems “ Given the high prevalence and recurrence of mental health disorders, it is important to identify problems early and connect students to needed services and supports.”

Successful systems draw from a wide array of revenue from third-party payers (State Children’s sources, including (but not limited to) legislative Health Insurance Programs, Medicaid and com- earmarks and federal block and project grants mercial insurance) and private individual donors (e.g., Healthy Schools, Healthy Communities and private foundations (e.g., Bainum Family Program; Project AWARE State Education Agency Foundation, Annie E. Casey Foundation and Robert Grants; The Promoting Student Resilience Program; Wood Johnson Foundation). Additionally, the and the Title XX Social Services Block Grant), Center for Health and Health Care in Schools devel- state or county funding (e.g., budget line items, oped a guide to federal education programs that local taxes, and funding to implement special can fund K-12 universal prevention and social and programs and health initiatives), fee-for-service emotional learning activities.49

To attain best practices in funding your comprehensive school mental health system:

• C reate multiple and diverse funding and resources to support a full continuum of services. • M aximize leveraging and sharing of funding and resources to attract an array of funders. • Increase reliance on more permanent versus short-term funding. • H ave adequate funding for services and supports at each tier. • U se best-practice strategies to retain staff. • U tilize and maximize third-party fee-for-service mechanisms to support services. • De-implemen t programs that are not achieving desired outcomes, and reallocate resources to evidence-based and effective programs. • E valuate and document outcomes, including the impact on academic and classroom functioning. • U se outcome findings to inform school, district and state-level policies that impact funding and resource allocation.

Source: National Center for School Mental Health, 2018

Advancing Comprehensive School Mental Health Systems • 27 Opportunities, Challenges and Recommended Strategies

During convenings of national, state and local school mental health leaders and stakeholders, participants were asked to identify the top challenges to, and opportunities and strategies for, advancing comprehensive school mental health systems. Stakeholders identified the following common themes, as captured in this section and in Table 2.

Opportunities partners is essential to the planning, implementation Given the growing awareness and commitment to and sustainability of comprehensive school mental school mental health, there is tremendous potential health systems. to increase access to quality mental health care and to promote student well-being and prevent With new models emerging for partnerships across and mitigate mental health challenges before they youth-serving systems and community partners, become more serious and costly. Furthermore, there is an opportunity to work across sectors to there is consensus among stakeholders that it is strengthen the system. Lastly, new policies being necessary to engage caregivers, family members, implemented, such as Every Student Succeeds Act, students, the school and other community members create opportunities for advancing innovative and in a meaningful way. Buy-in of these and other key locally responsive ideas and services.

28 • Advancing Comprehensive School Mental Health Systems Challenges strategies, including evidence-based policy and pro- An overarching challenge facing the advancement grams, are available to promote mental health and to of comprehensive school mental health systems is prevent mental health challenges. the gap between public perceptions and scientific knowledge. Mental health is not well understood Comprehensive school mental health systems have and is often viewed as something that we cannot an essential role in reaching young people to foster influence. For example, public discussion of mental healthy social and emotional development and health frequently frames it as an individual illness well-being. In addition, mental health issues and and does not consider its social and public health supports often carry stigma, which limits buy-in of aspects. A major challenge is to change the dialogue providing and receiving services from staff, parents so that mental health and mental illness can be and students. viewed through two lenses — an individual’s disease and a public health framework — which allows the Furthermore, the multiple systems involved in use of a full spectrum of strategies that include school mental health (e.g., education, health, mental health promotion, as well as prevention, early behavioral health) operate in a disconnected or intervention and treatment of mental illness. Public fragmented way. Siloed systems do not allow for health strategies are applied at the individual, school, integration of services and supports or for leverag- community, state and national levels. Rather than ing of resources. School and other staff need training waiting for problems to surface prior to interven- and support to be ready to implement best practices tions, prevention science shows that public health and evidence-based interventions with fidelity.

Table 2: Overall Summary of Opportunities, Challenges and Strategies (Expert Panels, 2017 and 2018)

• There is growing awareness and commitment to school mental health among stakeholders. Opportunities • New models are emerging for partnerships across youth-serving systems. • New policies are being implemented to advance innovative and locally responsive ideas and services.

• A gap exists between public perceptions and scientific knowledge of mental health. • Multiple systems involved in school mental health (e.g., education, health, behavioral health) operate in a disconnected or fragmented way. • School and other staff need training and support to be ready to implement Challenges best practices and evidence-based interventions with fidelity. • Insurance coverage and other financing for multi-tiered systems of support are limited. • The stigma of mental health issues and supports limits buy-in from staff, parents and students. • Unequal access to health care limits equal access to mental health supports.

• Develop and disseminate evidence-based resources, tools and practices. • Improve school mental health infrastructure support. • Use a whole-child approach with aligned academic and social, emotional and Strategies behavioral goals. • Connect mental health to other academic outcomes. • Share and braid financial and other resources from multiple sources.

Advancing Comprehensive School Mental Health Systems • 29 Opportunities, Challenges and Recommended Strategies

“ At the federal/national level, it is important to engage in cross-agency collaboration with clearly identified actions, outcomes and accountability.”

Extra effort also is required to implement new sup- mental health systems. With this data in hand, stake- ports with fidelity to the model. As is understood holders are well-positioned to move forward using the in the field of implementation science, the “how” most effective strategies to meet their community, of implementation is critical to the success of any state or national/federal goals around advancing model. Additionally, there is a growing understand- quality comprehensive school mental health systems ing of the importance of school connectedness. that will benefit our schools, students and families. According to the Centers for Disease Control and Prevention, school connectedness — the belief held Participants at the State School Mental Health by students that adults and peers in the school Summit (June 2018) identified strategies for care about their learning as well as about them advancing school mental health systems. They as individuals — is an important protective factor. were organized into the following categories: Research has shown that young people who feel Communication/Dissemination, Financing, Policy/ connected to their school are less likely to engage Legislation and Technical Assistance/Workforce in many risk behaviors, including early sexual initi- Development. These strategies can be adapted for ation; alcohol, tobacco and other drug use; and vio- use at the local, state and national/federal levels. lence and gang involvement.50 Understanding these factors can help decrease the fact that student disci- Prioritization of Strategies at Local, State and pline is often punitive instead of restorative. Another Federal/National Levels challenge identified is that insurance coverage and Furthering the development of multilevel strategies, other financing for multi-tiered systems of support participants also identified and prioritized local, state are limited. This is one of the factors that add to the and federal/national strategies critical to advancing unequal access to health care and limit equal access school mental health. (See Table 4.) to mental health supports. Local Strategies Recommended Strategies At the local level it is important to engage the wider Strategies were identified by local, state, federal/ community and diverse stakeholders to gain buy-in national leaders at various convenings. (See Table for the value and need for implementing a compre- 3.) The stakeholders discussed opportunities and hensive school mental health system. Furthermore, it challenges and identified considerations to capitalize is necessary for the partners to designate time and on those opportunities and mitigate the challenges. resources to build, enhance and sustain compre- Some are more linked to state, local or federal/ hensive school mental health systems. This process national partners, and some are cross-cutting and involves building capacity for ongoing processes for can be adapted for any level. Those interested in engaging in data collection, reporting, dissemination advancement of these or other strategies need to and continuous quality improvement to promote and assess the unique opportunities and readiness within advance school mental health activities that achieve their school, community, state or organization for positive student outcomes, school climate and other buy-in and for advancement of comprehensive school school-level outcomes.

30 • Advancing Comprehensive School Mental Health Systems Table 3: Strategies for Advancing School Mental Health Systems (Expert Panels, 2017 and 2018)

• Educate policymakers on the importance of school mental health and its relevance for academic success, economic growth, substance abuse prevention/ treatment and other community priorities. Communication/ • Use social marketing to promote messages that have been shown by research Dissemination to improve child and youth well-being (similar to efforts used for tobacco, teen pregnancy and healthy eating). • Be creative in messaging. • Ensure youth and family voices are included in messaging.

• Align planning and funding by Medicaid, private insurance and managed care organizations at the state level to support school mental health. • Build relationships and communities of practice to influence awareness, funding and advocacy. Financing • Document the return on investment. • Link school mental health with state Every Student Succeeds Act plans. • Use other federal education (e.g., Title I, Title IV) funds to support school mental health.

• Convene state departments of education and mental health staff with commu- nity representatives, families, students and professional associations to enhance communication and opportunities to collaborate. • Improve understanding across state systems about their efforts and funding. • Build agreement among stakeholder groups in a structural process to determine Policy/ priority issues and strategies in school mental health. Find an issue that is Legislation manageable and specific to receive immediate focus. • Have data and success stories ready for state legislators. • Improve awareness and support for the importance of staff and teacher wellness and conditions for teaching that promote mental health. • Ensure advocacy messaging unifies the voices and agendas of key stakeholders around a shared vision and priorities that will mobilize broad support for this work.

• Integrate families and youth in partnership to provide leadership and feed- back loops. • Reassess practices and modify approaches in a continuous improvement pro- cess, and include youth and others in this process. Technical • Strengthen the coordination of technical assistance networks to support states Assistance/ and local stakeholders, and link this network to other national networks. Workforce • Ensure curriculum changes at the pre-service level to teach undergraduate and Development postgraduate students in education, health and behavioral health professions about high-quality and sustainable school mental health systems. • Identify and advance sustainable funding mechanisms. • Ensure there is adequate technical assistance to support states in developing a multi-tiered approach to school mental health.

Advancing Comprehensive School Mental Health Systems • 31 Opportunities, Challenges and Recommended Strategies

State Strategies school mental health. Convening a coordinated At the state level, it is important to provide training school mental health “council” with substructures and implementation opportunities and supports. that include designated stakeholder representa- Examples of strategies include 1) hosting an annual tives to establish and monitor school mental health state school mental health conference that raises activities can help advance the field. awareness and provides tools and resources for districts in building capacity for implementation Federal/National Strategies of quality comprehensive school mental health At the federal/national level, it is important to engage systems, 2) developing and disseminating a school in cross-agency collaboration with clearly identified mental health website, 3) providing technical assis- actions, outcomes and accountability related to tance to schools on developing and implementing comprehensive school mental health systems. One effective school mental health systems in schools example would be to establish jointly issued funding and districts, and 4) implementing cross-system opportunities with synchronized requirements across provider training on key topics, including evi- agencies, including expansion of school mental dence-based program selection and implementa- health initiatives. In addition, it is important to fund tion, and state-specific funding guidance. national and state school mental health technical assistance and infrastructure supports. Promoting Stakeholders at the state level should promote awareness of strategies among regions and states cross-sector engagement, goal-setting and can help achieve high-quality, sustainable school decision-making to advance a coordinated school mental health systems. Funding for national and mental health vision and best-practice strategies regional centers to execute research and innovation — for example, linking school safety and student that advance school mental health strategies can well-being within the umbrella of comprehensive help strengthen the opportunities in the field.

Table 4: Summary of Recommended Strategies by Level (Expert Panels, 2017 and 2018)

• Gain community buy-in on the value of school mental health. • Designate time and resources to build, enhance and sustain comprehensive Local school mental health systems. • Engage in data collection, reporting, dissemination and continuous quality improvement.

• Develop statewide training and implementation support. State • Promote cross-sector engagement, goal-setting and decision-making. • Convene a coordinated school mental health “council.”

• Establish jointly issued funding opportunities. • Fund national and state school mental health technical assistance and infrastructure supports. Federal/ • Promote awareness of strategies among regions and states. National • Engage in cross-agency collaboration. • Fund national and regional centers to execute research and innovation.

32 • Advancing Comprehensive School Mental Health Systems Advancing Comprehensive School Mental Health Systems • 33 Local Spotlights

Numerous local schools and communities have demonstrated significant progress in the advancement of school mental health systems in recent years. This progress is seen through the numbers of schools and communities that are connecting with the SHAPE System discussed previously. Highlights of their efforts, and links to reports and resources related to those efforts, are offered as a road map for other states and communities seeking to advance comprehensive school mental health systems. Featured here are highlights from local districts representing diverse geographic areas: the District of Columbia Public Schools (DCPS); Adams-Friendship Middle School in Adams, Wisconsin; Seneca Family of Agencies and Education for Change Public Schools (Seneca/EFC), California; and Chapel Hill-Carrboro City Schools (CHCCS), North Carolina.

District of Columbia Public Schools (DCPS) incremental, collaborative, innovative methods to DCPS has taken on high-quality school mental produce durable quality improvements across the health in a large, urban school district that employs entire district and is reflected in its School Mental 266 school social workers and psychologists to Health Quality Assessment, a quality indicator within serve more than 48,000 students across 113 public the SHAPE System, which shows substantial growth schools. Through collaborative conversations and nearing “Mastery” in Resource Mapping, Teaming districtwide data collection from their front-line and data-driven decision-making (DDDM) since school mental health providers, DCPS developed a January 2017. Workload Analysis that includes recommendations for school administrators and teams to optimize social work and psychology service delivery time in To learn more about how your school or the school building. Most recently, DCPS worked on district can access the School Mental Health advancing its social and emotional learning cur- Quality Assessment and achieve Gold Level ricula in classrooms by collecting data on current SHAPE Recognition like DCPS did, visit task-sharing practices among educators and mental www.theshapesystem.com. health providers. DCPS has mastered the art of

34 • Advancing Comprehensive School Mental Health Systems Adams-Friendship Middle School in Adams, Wisconsin Seneca Family of Agencies and Education for Change Adams-Friendship Middle School received recent Public Schools (Seneca/EFC) accolades for its school mental health services from The partnership between Seneca Family of Agencies leadership at the U.S. Department of Health and and Education for Change Public Schools (Seneca/EFC) Human Services (HHS) following a tour of the school. is innovating ways to bring the science of mental health During the site visit, HHS representatives listened to screening and DDDM to actual school mental health teachers, administrators, mental health professionals, practice in Oakland, California. This school mental law enforcement, students and parents talk about pro- health system significantly increased its screening grams and services at Adams-Friendship that support data collection effort by assigning care coordinators positive school climate, health and safety in their to this task and providing feedback to school staff and school. HHS acknowledged the state of Wisconsin for administrators about student strengths and needs, taking the lead on integrating mental health services resulting in more than 2,000 students screened during into schools and for its Wisconsin School Mental the 2018-19 school year. Seneca/EFC also surveyed Health Framework, noting that HHS is interested in clinician-reported barriers and successes to using extending “sophisticated, comprehensive services” like screening data and is currently training and sup- Wisconsin’s into more schools and communities, espe- porting clinicians’ ability to integrate this data into cially rural communities such as Adams. Read more decision-making and collaborative service planning about efforts in Adams, Wisconsin, at https://madison. with the school team. Mental health screening and com/opinion/column/alex-azar-put-mental-health-ser- DDDM are two key domains of school mental health vices-in-schools/article_b99cf4f1-d77e-5788-8091- quality that in practice can be challenging to imple- 862adbd52ff6.html. ment. Seneca/EFC is a pioneer in these domains by

Advancing Comprehensive School Mental Health Systems • 35 Local Spotlights

access to school mental health services. Its team “Its team has has outlined a vision for co-locating community mental health providers in every school. The district outlined a vision first developed a request for proposals, and then used decision analysis to prioritize its list of require- for co-locating ments for community mental health providers and to support its decisions to work initially with three pro- community mental vider organizations. This district-led school mental health team worked collaboratively to set a high bar for co-located services in its school buildings. For health providers in example, the district specified the importance of the following examples of qualifiers for community every school.” mental health providers to partner with the district: teacher consultation, prevention and early interven- supporting clinicians’ use of data and using clinician tion activities, and strengths-based services that feedback to inform system improvements. prioritize family involvement. CHCCS also has Gold Level SHAPE Recognition and routinely monitors Chapel Hill-Carrboro City Schools (CHCCS) the quality and sustainability of its comprehensive CHCCS has taken an intentional and proactive school mental health system on a regular basis approach to ensure students in its district have throughout the year.

36 • Advancing Comprehensive School Mental Health Systems Advancing Comprehensive School Mental Health Systems • 37 State Spotlights

States clearly have an important role in advancing comprehensive school mental health systems and are important partners with local districts seeking to implement school mental health systems. Federal grants such as the Project AWARE State grants and Safe Schools/Healthy Students State grants funded by DHHS/SAMHSA and School Climate grants from the U.S. Department of Education have been significant in leveraging state and local partnerships and achieving transformational results for school mental health. Below are highlights from three states, among many, that have demonstrated signifi- cant progress in the advancement of comprehensive school mental health systems in recent years. Their efforts offer a road map for other states and communities seeking to advance comprehensive school mental health systems.

Figure 6. North Carolina School Mental North Carolina Health Initiative’s Statewide Support The North Carolina School Mental Health Initiative (NC SMHI) is a statewide partnership of families, Piedmont- Triad Region students, public school representatives, community-

Northwest North Central based mental health clinicians, North Carolina state Region Region department officials, advocates, university faculty, justice system representatives and others. The Research & Evaluation NC SMHI mission is to develop recommendations CommunicationVisability & for and support implementation of policy and/or legislative changes to ensure that public school Western Northeast Region Region students in North Carolina have equitable access to Professional Learning a full continuum of high-quality and well-coordinated mental health services. The partnership has studied

Continuum statewide perceptions of and access to mental Southwest Southeast Region Region health services for children and youth, drafted state board of education policy, prepared legislative Sandhills reports, influenced continuous improvement of the Region statewide implementation of MTSS, and supported Source: North Carolina School Mental Health Initiative 38 • Advancing Comprehensive School Mental Health Systems Figure 7. Wisconsin School Mental Health Framework

1. Strong Universal ImplemenationImplementation 6. Positive School Culture & Climate 2. Integrated Leadership Teams 7. Staff Mental Health Attitudes, Competencies & Wellness 3. Youth-Family-School-Community Collaboration at all Levels 8. Systemic Professional Development & Implementation Source: Wisconsin 4. Culturally Responsive Evidence Based Practices 9. Confidentiality & Mental Health Promotion Policies 5. Data-Based Continuous Improvement 10. Continuum of Supports School Mental Health Initiative

Introduction 7 the development of an awarded SAMHSA AWARE to receive school mental health professional devel- grant proposal. Overarching recommendations opment, technical assistance and coaching. Teaming for policy and/or legislative action stemming from efforts through a state management team and com- NC SMHI findings include 1) creating a continuum munity management teams have helped advance of school mental health supports and services, 2) strategic school mental health advancement. Central making it sustainable and 3) engaging stakeholders. to Wisconsin school mental health system advance- More information on the NC SMHI and its findings ment was the adoption of a School Mental Health and recommendations can be found in the North Framework in the state. The School Mental Health Carolina School Mental Health Initiative final report. Framework defines and outlines key elements to For more information about school mental health in implement comprehensive school mental health North Carolina, visit http://bit.ly/NCSMHI2019. systems in districts and schools across Wisconsin. The framework offers the foundational elements to Wisconsin build and sustain school mental health systems. The The Wisconsin Department of Public Instruction’s framework is designed to integrate mental health school mental health initiative has benefited from and wellness supports into a multi-tiered system of three large-scale federal grants: Safe Schools/ support. Using the tenets of this framework, districts Healthy Students (SAMHSA), Project AWARE and schools can build and sustain a comprehensive (SAMHSA) and School Climate Transformation school mental health system. For more informa- (Department of Education’s Office of Safe and tion about school mental health in Wisconsin, visit Healthy Students). Braided funding from these proj- https://dpi.wi.gov/sspw/mental-health or www. ects allowed for more than 100 schools in the state schoolmentalhealthwisconsin.org/.

Advancing Comprehensive School Mental Health Systems • 39 State Spotlights

Massachusetts in Massachusetts. Member districts voluntarily The Massachusetts School Mental Health participate based on their recognition of the sig- Consortium (MASMHC) offers a compelling nificant mental health and substance use needs example of how school districts within a state can of students, and work with the MASMHC through work together to advance professional develop- shared learning, collaboration and consultation. ment and best practices and policies in school Member districts attend monthly MASMHC mental health. It advances school mental health meetings, complete needs assessments, partici- quality and sustainability to 1) increase awareness pate in professional development, develop action of mental health problems, 2) promote mental plans to advance school mental health in their well-being through education and prevention own community, and share best practices and pol- activities, and 3) increase access to and utiliza- icies. For more information about school mental tion of evidence-based mental health services health in Massachusetts, visit www.methuen.k12. and supports. The MASMHC comprises school ma.us/departments/special-education/guidance/ districts committed to improving school mental massachusetts-school-mental-health- health services and supports available to students consortium-masmhc.

40 • Advancing Comprehensive School Mental Health Systems Moving Forward

There is a growing national recognition of the need to elevate and address the mental health of students and other young people. Comprehensive school mental health systems can become the “new way of doing business.” How can we made this a reality on a large-scale basis?

Participants in the set of three school mental health to carry out the agenda. Several states and com- gatherings convened during 2017 and 2018 identi- munities have established School Mental Health fied several key areas of focus for shared learning Communities of Practice or coalitions to enhance to build momentum for advancing high-quality communication and shared learning to further goals comprehensive school mental health systems at that support school mental health. Development of the state and local levels. These areas include: a compelling vision and shared agenda challenges us to build new leadership skills. Approaches such • Funding and sustainability as Leading by Convening (www.ideapartnership. • Training and building internal staff capacity org/building-connections/the-partnership-way.html) • Coordination/collaboration across family- guide us to achieve changes in practice and foster school-community partners adaptive leadership. We must learn to convene across • Resource support and technical assistance disciplines, roles and agencies. Progress in practice • Trauma-informed care demands that we share leadership and learn together. • Engagement of youth, families and other key Drawing on science, practitioner wisdom, and the lived partners in school mental health experience of families and youth, we will more fully • P olicies to support comprehensive school address the promise and the challenge of comprehen- mental health systems sive school mental health systems. When state and • Screening and early identification of youth risk local champions are positioned to strategically build and protective factors and advance school mental health policy, funding and • Supportive discipline and restorative practices programming can expedite wide-scale school mental health adoption. These champions, in partnership with The advancement and sustainment of school mental schools and communities as well as the youth and health systems across the United States requires families they serve, can work together to build com- the cross-stakeholder development of a compelling prehensive school mental health systems that address vision and shared agenda ― one that can inspire local our shared goals for safe and supportive schools that action ― and a strategic action plan and infrastructure promote student well-being and success.

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