Individuals in a number of child-serving settings, including the education, welfare, and juvenile justice systems, work with children who have behavioral health needs. As discussed in this session of the workshop, training for health care providers who interact with these systems and their
workforces can improve coordination across sectors and lead to better outcomes for children and families.
In a classroom of 25 students, on average 1 in 10 will experience a behavioral health problem causing severe impairment, 1 in 5 will experience a behavioral health problem causing mild impairment, and less than half of those who need services will receive them (Merikangas et al., 2010; National Research Council and Institute of Medicine, 2009b). “There’s a tremendous opportunity to address children’s mental health needs—in particular, in schools—that are simply unmet at this time,” said Elizabeth Connors, a clinical psychologist and assistant professor at the University of Maryland School of Medicine and a faculty member at the Center for School Mental Health. Furthermore, of those children who do receive services, 70 to 80 percent receive them in school settings (Rones and Hoagwood, 2000). “Our schools are becoming the de facto mental health system for our children,” said Connors.
Comprehensive school mental health systems—at the school, district, or state level—are guided by youth and families, and based on a strategic partnership among schools, community health organizations, and behavioral health organizations. The partners generally build on existing school programs, services, and strategies, and they focus on all students in both general and special education, she explained. By providing a full array of evidence-based services and strategies, school mental health systems can offer behavioral health promotion, targeted prevention, and intensive support to meet the strengths and needs of all students (Lever et al., 2015).
In the approximately 100,000 public schools in the United States, behavioral health services are provided by the school and district staff only (32%), outside contract only (28%), and a combination of school and district staff and outside contracts (40%) (Foster et al., 2005). These providers may include school psychologists, school social workers, and mental health providers employed in the community. In addition, students have other forms of support in schools, including teachers, school nurses, and parents (see Box 6-1). An important question for everyone involved with children’s behavioral health, said Connors, is, “Who else might be on your mental health team, and how can you build a multidisciplinary team of providers who support student mental health?”
Information about who provides mental health services in schools, what kind of services are provided, and to what extent those services are evidence-based is being updated through a National School Mental Health Census. The Center for School Mental Health is conducting this census with federal funds from the Health Resources and Services Administration.
(School or district teams can be counted in the National School Mental Health Census (available at https://theshapesystem.com/ [September 2017]). The free, web-based platform also houses the first National Standardized Performance Measures for School Mental Health Quality and Sustainability (Connors et al., 2016). These data should make it possible to leverage pockets of excellence in school behavioral health systems across the country
to inform improvements and investments in what schools need the most to support student behavioral health.
According to implementation research, one-time training opportunities or workshops are necessary but insufficient for lasting practice changes, Connors reported. Instead, ongoing opportunities to return to materials, rehearse new skills, and receive coaching and consultation are associated with improving the competency of mental and behavioral health providers. However, ongoing implementation supports can be difficult to find and costly, especially for the public education system, so various implementation strategies, including technology-based options, are increasingly used.
The Center for School Mental Health is pursuing several strategies to support professionals in school-based behavioral health. The first is self-paced online training for individual clinicians (available at http://www.mdbehavioralhealth.com [September 2017]). Second, web-based strategic planning and quality improvement platforms (such as https://theshapesystem.com [September 2017]) can enhance outcomes through such team-based self-assessment of quality and sustainability, paired with customized reports and resources. Finally, learning communities and collaboratives, such as the Collaborative Improvement and Innovation Network of the School Health Services National Quality Initiative, allow for cross-team sharing of ideas and knowledge to inform rapid quality improvement cycles.
The goals of the child welfare system are to provide children with safety, security, and well-being, said David Kolko, professor of psychiatry, psychology, pediatrics, and clinical and translational science at the University of Pittsburgh School of Medicine. Achieving all three of these goals requires addressing the effects of trauma, behavioral health problems, and family adversity, he said.
Summarizing research findings from a variety of studies, Kolko observed that two-thirds of behavioral health providers will complete training; the training of supervisors is critical; turnover among staff is continual; and some techniques, even some that have been demonstrated to be effective with children, tend to be avoided. Regarding treatment, he reported that two-thirds of those trained will deliver an evidence-based treatment, the quality of these treatments is generally adequate, delivering evidence-based treatments in community settings is much more effective clinically than routine care, and the sustainability of such care is a major challenge.
Kolko noted that screening and assessment tools are now helping to inform treatment. However, challenges remain, including the scope of their use, limited psychometrics, the proven utility of these tools, and their costs. Kolko suggested the need for more thought to develop a core set of
efficient and valid tools that the community can and will use to assess behavioral health problems. He also urged training for child welfare workers to identify behavioral health problems and refer children for evidence-based treatment.
Kolko estimated the number of available evidence-based practices at 10 to 15. They are being used on a national and sometimes international basis, and many have been adapted to the needs of particular populations. However, they have mixed fidelity in some settings, and the turnover of providers adds to this challenge. They also can be harder to deliver than other practices, which requires different and more intensive approaches to training and consultation. With the child welfare system in particular, providers need to know about such issues as existing regulations, the expectations made of families, and what it is like to be in placement.
Kolko also looked at trauma-informed care and systems. Clinicians, nurses, and others are working on teams in such systems. But the definition of trauma-based care is still unclear, coordinating across systems can be difficult, reimbursement remains an issue, and not much outcome evidence exists on whether a trauma-informed care model helps. Overcoming these issues requires interprofessional training, an expanded capacity of health care settings to address trauma, and linking the physicians of record with other providers, which “do not happen very much in the real world,” said Kolko.
Kolko recommended further study of the systems used for training, whether learning collaboratives, a training-the-trainers approach, or online methods. He also recommended incentivizing quality—for example, by using value-based models or pay for performance. Lastly, he emphasized measuring reach and outcomes. Providers may know something about the people they serve, but they may know very little about the extent to which they are reaching a broader population in need of services.
Integrating care across systems can be a difficult problem, he said. “We’re still trying to figure out how to organize care within a system,” he noted. “But what we have to figure out is how to integrate the care from child welfare, education, behavioral health, and the medical home. This is really the area in which we have to do a lot of work.”
José Szapocznik, professor of public health sciences, architecture, psychology and educational research, and counseling psychology at the University of Miami, spoke briefly about the juvenile justice system. A program in Florida run by a for-profit company called Evidence Based Associates led to youth being recommended for multisystemic family therapy, functional family therapy, and brief strategic family therapy. These interventions led
to significant improvements in recidivism, whether re-arrest or placement in a more restricted setting. When comparing the redirection cases with the residential cases, the savings were $27,000 to $31,000 per child per year, Szapocznik noted, and with redirection of about 5,000 cases, the savings represented by the program were an estimated $124 million. Importantly, looking at recidivism, which is the Florida Department of Juvenile Justice’s outcome of choice, evidence-based family interventions saved funds to the state and also achieved better recidivism outcomes than residential treatment.
“The message is that we should be looking at cities, counties, and states as places for interventions, because in the current environment it’s going to be very difficult to be able to affect these programs from a federal level,” Szapocznik said.
No career path exists for people who want to work in residential treatment settings with children who have severe emotional behavioral disorders, noted Christopher Bellonci, a child, adolescent, and adult psychiatrist, associate professor of psychiatry at Tufts University School of Medicine, and member of the American Academy of Children and Adolescent Psychiatry’s workgroup responsible for writing the practice standards for child psychiatry. Moreover, he said, few data are available on the outcomes of a service that consumes a significant portion of behavioral health funding.
Therapeutic residential care involves the planful use of a purposefully constructed, multidimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs. It occurs in partnership with their families and in collaboration with a full spectrum of community-based formal and informal helping resources. Levers to achieve excellence in such environments include governments, national organizations, foundations, accreditation entities, private agency–university partnerships, youth engagement specialists, parents, and faith-based programs and partnerships. For example, the Building Bridges Initiative supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) is working to identify and promote practices and policies that will create strong and closely coordinated partnerships and collaborations among families, youth, community- and residentially based treatment and service providers, advocates, and policy makers to ensure that comprehensive behavioral health services and supports are available to improve the lives of young people and their families. In particular, the initiative is committed to identifying needed technical assistance, training, and support for providers, policy makers, families, and youth.
The Association of Children’s Residential Centers has written a series of white papers about needed reforms in residential treatment.1 In addition, Casey Family Programs and the Annie E. Casey Foundation and Jim Casey Youth Opportunities held a consensus conference on best practices for behavioral health in child welfare in which 32 behavioral health practice guidelines covering behavioral health screening, assessment and treatment, parent support, and youth empowerment were developed. These philanthropic organizations also have supported a practice pathway tool for transition-age youth and a research brief on elements of effective practice for children and youth served by therapeutic residential care.
Accreditation entities, including the Council on Accreditation, the Joint Commission, and the Commission on Accreditation of Rehabilitation Facilities, have established standards for therapeutic residential care facilities. These standards have helped establish best practices within residential treatment, including improved standards of care around seclusion or restraint.
Most residential programs do not have funding or resources to do their own outcomes research, but partnerships with a university can turn therapeutic residential care facilities into laboratories of innovation, Bellonci observed. For example, an evidence-based best practice model developed by the University of Kansas has become a core practice of the Boys Town residential programs.
Though not necessarily based in residential treatment programs, SAMHSA has undertaken a community initiative that emphasizes the key role faith-based organizations play in the delivery of substance use prevention, addiction treatment, and behavioral health services, particularly to underserved communities and culturally diverse populations. In addition, the Office of Juvenile Justice and Delinquency Prevention supports the Accessing Resources for Community and Faith-based Organizations (ARC) initiative, which has an overlapping mission.
Bellonci spoke for many at the workshop when he pointed to the moral dimensions of the issue of behavioral health. “We’re talking about rates of 1 in 5 children developing a behavioral disorder in their lifetime,” he said. “This impacts all of us, and I think it’s critically important that we leverage those stories to effect the kind of change that we want to see in our society. We are a resource-rich country. It doesn’t have to be this way. . . . Moral outrage may be our greatest lever if we choose to use it.”
Research has shown that prevention and intervention approaches can work, Bellonci said. Workforce shortages persist, he continued, not because
people do not want to work in those jobs but because the jobs do not pay enough to attract workers.
As an action plan, Bellonci suggested development of a legally binding document similar to an individualized education plan for children’s behavioral health disorders. When children display a behavioral health disorder, they would undergo standardized assessments similar to what happens when a learning disorder is identified. The assessment would determine their treatment needs, which would drive a treatment or service plan with measurable goals. A service plan would identify who will do what, a case manager would monitor the service plan, an annual review would be done of the response, and assessment would be repeated every 3 years.