LOCATING STUDENTS WHO COULD BENEFIT FROM INTERVENTION

Definition and Standards of Practice

Definition

Locating students who could benefit from mental health intervention is a process involving SBHC and school staff that utilizes both aggregate and individual screening methods.*

Standard of Practice

  1. The SBHC policy of locating students who could benefit from mental health intervention should involve screening for problems and not pathology. Students with risk factors, or early signs of behavioral or emotional difficulties, may not meet criteria for a diagnosis of psychiatric pathology.
  2. Locating students who could benefit from mental health services requires collaborative effort and should be the purview of all SBHC staff. While the mental health professional on the SBHC team may serve as advisor and consultant, SBHC and school staff members should be actively involved – separately and in collaboration – in screening for and recognizing students in need of services. Relationships with and presentations to community service organizations, the PTA, etc., also are helpful.

Prerequisites

  1. Relationships with key school personnel to facilitate the flow of information regarding students who may be at risk. Such personnel include, but are not limited to, the School-Based Support Team, Committee on Special Education, Pupil Personnel/Child Study Team, School LeadershipTeam, attendance officer, dean, social worker, guidance counselor, and school nurse. Especially important at all grade levels is the school principal.
  2. Access to information from school records including, but not limited to, suspensions, attendance, academic probation.
  3. Appropriate screening tools and any required scoring materials.

Strategies and Tools

  1. Establish ongoing communication and appropriate involvement with school committees and personnel.
  2. Attend meetings of school committees or task forces devoted to mental health/social service or special education issues.
  3. Make periodic presentations to school committees, school faculty as a whole or by specialization (school administrators/deans, physical education teachers, security personnel, lunchroom aides, etc.) about the mission and functions of the SBHC.
  4. Establish relationships with and make periodic presentations to families, parent organizations and community services.
  5. Utilize such mechanisms as “teacher or peer nomination” forms to gather information on students with potential risk factors and mental health needs.

Target Populations (condition, age, etc.)

Conditions differ by grade level. At the elementary level, note students with:

    • Behavioral problems (disruptive, acting out)
    • Academic problems
    • Symptoms of :
      -Depression
      -Anxiety
      -AbuseAt the secondary level, note students with:
    • Symptoms of depression or anxiety
    • Major traumatic events/suicidal ideation or behavior
    • A history of
    • Involvement with court system
    • Abuse
    • Poor academic performance
    • Issues of sexuality/pregnancy or parentingAt both levels, note students who are:
    • Undergoing transitions (new grade, new to school, recent immigrant)
    • Truant or have been suspended
    • Demonstrating marked social withdrawal or isolation
    • Excessively absent in general or due to an acute or chronic medical illness

Additional issues or concerns: An important caution is warranted. Both pragmatic and ethical constraints require that careful consideration of the outcome of such outreach efforts be carefully considered. If the number of students identified as requiring services exceeds the capacity of the SBHC to provide those services, either adequate referral measures must be in place, or the scope of the screening mechanisms should be reconsidered.

Note also the obstacles to early identification efforts: language and cultural barriers, lack of knowledge of SBHCs, staff and student turnover, and lack of support from the school principal and PTA president.

*Aggregate level screening refers to broad-based efforts to locate students in one of the following groups:

  • the school-wide population
  • the body of students enrolled in the SBHC
  • high-risk populations

*Individual level screening is the responsibility of the mental health provider on the SBHC team. Working collaboratively within the team, and between the team and school personnel, the mental health provider offers consultation and education to promote

  • sensitivity and awareness regarding emotional and behavioral problems in students presenting with medical or other complaints
  • increased awareness of mental health risk factors and early signs of mental health problems.

 

ASSESSMENT & EVALUATION

Definition and Standards of Practice

Definition

The first contact a student has with the SBHC should include medical as well as mental health screening. This will determine whether “wait-and-see” and “supportive/holding” activities, followed by periodic team re-evaluation, or a full mental health intake is required.

A mental health intake/diagnostic evaluation should be done by the mental health worker, following the guidelines of a diagnostic evaluation using DSM-4 criteria.

Standards of Practice

Mental health treatment requires careful treatment planning which is predicated on thorough diagnostic evaluation resulting in a clear understanding of problems, symptoms, choice(s) of treatment and treatment goals.

Prerequisites

    • Time for interdisciplinary case conferences (minimum bimonthly recommended) and discussion of initial client assessment, mental health diagnostic evaluation, and follow-up and periodic status review as needed.
    • Standardized assessment and evaluation forms.
    • Standards for completing assessments and specific chart forms prior to a diagnostic evaluation.
    • Appropriate use of DSM-4 terminology and diagnostic procedures.
    • DSM-4-based diagnostic evaluation when psychiatric illness is suspected (either on-site or at an appropriate mental health facility.) Strategies and Tools
    • The initial screening/assessment should include questions regarding mental health issues that determine if a mental health problem may be present. This can take the form of a simple intake form (name, address, “why are you here?”) or a fuller questionnaire filled out by the student or provider. The assessment procedure must be uniform and organized.
    • The mental health intake/evaluation should have a structured questionnaire, which identifies the presence of a mental illness based on the DSM-4. This may take the form of a psychosocial assessment and a mental status exam.
    • Combine “core” SBHC and specialist staff as needed for effective, periodic case conferences. Similarly, use opportunities for presentation of SBHC cases at sponsoring or host agency’s case conferences.
    • A mechanism is recommended.for evaluation of the family, which may include completion of a family map or genogram.
    • Standardized evaluation tools such as the Connors or Beck can be used where appropriate.
      Target Populations (condition, age, etc.)
    • Assessment, which includes screening for mental health problems, should be done on all students who enter the SBHC for any reason.
    • A complete intake is used with those students who demonstrate mental health problems.

Additional issues or concerns: Lack of time may create a tendency to neglect case conferencing. Addressing this ever-present obstacle is necessary if the benefits of periodic case review is to be realized. Similarly, ongoing communication, collaboration and support among staff are essential, given the likelihood that youth, especially at the secondary level, may approach SBHC staff with whom they are most comfortable (irrespective of assigned staff/clinician).

TREATMENT – INDIVIDUAL, GROUP, FAMILY

Definition and Standards of Practice

Definition:

Treatment is the use of a systematic response to an articulated mental health problem in which there is an attempt to:

    • define the mental health problem
    • create a well-defined treatment plan which is regularly revised
    • apply accepted tools of clinical practice
    • regularly assess, revise and re-evaluate the planThere is a distinction between treatment and outreach or alliance-building. Although the latter is essential for community-based mental health work and may create a milieu for treatment, it is not treatment per se.

      Standards of Practice:

    • Mental health treatment services should not be confined to long-term, individual, insight-oriented therapy as this is not the most effective, efficient or appropriate treatment methodology for many child and adolescent problems.
    • Treatment modality (e.g., individual, family, group, psychopharmacology etc.) and content should be determined by the needs of the individual student/client, and drawn from evidence-based practice.
    • “It is recommended that physical and mental health providers have a shared vision regarding reaching students in need and a willingness to collaborate on specific cases.” (Weist, Mark D. et. al., (2001), Addressing Mental Health Issues within School-Based Health Centers , p. 5. Such a vision necessitates flexibility in roles and boundaries. In such a system, the treatment of emotional and behavioral issues should not be the sole purview of a particular provider but of the SBHC staff as a whole.
    • Since the termination of the therapeutic relationship is especially difficult for children and youth, therapists must work to minimize the impact of transitions, anticipate them occurring and provide appropriate planning and support.
      Prerequisites
    • Policies regarding the total number of cases permitted in one provider’s active caseload as well as the total number of cases in supportive management.
    • Policy regarding the triage of cases which assures that every case is assigned to treatment with:
      a. a specific plan.
      b. a specified time period after which progress is reviewed.
    • an articulated decision-tree for re-assigning a case to an alternate level of care, i.e., individual, group or family treatment, supportive maintenance or outside referral.
      Strategies and Tools
    • Utilize accepted short-term, goal-directed, and outcome-based models of treatment, including groups for individuals who share a common problem, multiple family group work, and brief family counseling, as appropriate.
    • Support other essential relationships with a positive impact on the student/client’s life.
    • Utilize informal means of maintaining connection with student/clients through such mechanisms as Drop-In Centers, discussion groups and flexible scheduling of appointments. Collaborate in these efforts with school guidance and mental health staff as well as peer educators, adult mentors, and community services.
    • Utilize reviews of standard, evidence-based treatment practices for child and adolescent mental health found in the publications of such professional organizations as the American Psychological Association, the National Association of Social Workers, the National Association of School Nurses, the National Assembly on School-Based Health Care, and the Academy of Child and Adolescent Psychiatry.
    • Employ published treatment protocols or practice parameters, such as:
      McDermott, John F. Jr. et al., (October, 1997). 1997 Supplement to the Journal of the American Academy of Child and Adolescent Psychiatry, Practice Parameters. Vol. 36, No. 10. Pp. 1S-202S.
      Dulcan, Mina K. (December, 1999). 1999 Supplement to the Journal of the American Academy of Child and Adolescent Psychiatry, Practice Parameters. Vol. 38, No. 12. pp. 82S.
    • Utilize materials developed by the two national centers on school mental health: the UCLA School Mental Health Project/Center for Mental Health in Schools and the University of Maryland Center for School Mental Health Assistance.

Target Populations (condition, age, etc.)

Students exhibiting:

    • Aggressive behavior
    • School refusal
    • Depression
    • Anxiety
    • PTSD
    • Separation anxiety
    • Conversion disorder
    • Parent-child conflict
    • Disruptive Behavior Disorders
    • AD/HD
    • ODD
    • Conduct Disorder
    • Symptoms of grief or lossFamilies in need of support, through after-school hours presentations and discussions; developing the school as a family-oriented community center, referral to outside counseling. NB Judy, I can’t get the family piece above to list the three items after “families in need of support” by numbers, as per the 8 items under students. Can you??


      SERVICE COORDINATION

      Definition and Standards of Practice

      Definition

      The term service coordination expresses the facilitation and advocacy roles of the mental health provider. It encompasses coordination of care with the educational and service community in the school building as well as service referral, coordination and systems negotiation with outside service providers.

      Standards of Practice

    • A thorough referral involves contacting the prospective service provider, assuring that a connection is made and service or treatment occurs, and establishing ongoing feedback mechanisms.
    • Referrals must be appropriate to both the student and provider/agency. They should be ethnically sensitive, feasible, relevant to the needs of the student and family, and within the expertise of the referral agency.

Prerequisites

      1. Established referral policy and lines of responsibility for follow-up. This should include a feedback system to the referring agent.
      2. Referral networks in place and regularly reviewed.
      3. Knowledge of social services and government benefits, including education, income and health care resources and benefits.
      4. Access to published and on-line directories of community agencies and services, as well as the time to establish the reliability of such information.

Strategies and Tools

      1. Relationships with/membership on Pupil Personnel and other relevant school committees.
      2. Directories of services and programs.
      3. Liaisons with service delivery agencies.
      4. Working alliances with other health care/social service providers within the school.
      5. Visits and presentations to and from community agencies.

Target Populations (condition, age, etc.)

      1. Victims of child abuse
      2. Children with chronic illness
      3. Children with chronic mental health or behavior disorders
      4. Any child referred after intake/evaluation
      5. Pregnant or parenting teenagers
      6. Children with legal problems

 

Additional concerns: Although provision of treatment for substance use is beyond the purview of SBHCs, the contribution of this issue to health, educational, and mental health problems has been well documented. Identification of referral routes and advocacy for appropriate care is recommended.


PREVENTION/EARLY INTERVENTION

Definition and Standards of Practice

Prevention/early intervention refers to interventions, programs and strategies offered to benefit students showing early, little or no signs of distress, with the aim of decreasing the likelihood that symptoms or problems will occur or worsen in the future. Prevention may target individuals or systems affecting the lives of students, including school personnel, family members, other adults and the community-at-large.


Standards of Practice

 

      1. Since prevention efforts can greatly decrease the costs and burden of providing palliative care, significant mental health provider time should be devoted to these activities.
      2. Prevention programs and strategies should be utilized if there is evidence of effectiveness or if their effectiveness is being tested.
      3. Prevention activities should be responsive to the needs and resources of the school and larger community, and should be re-evaluated periodically.


Prerequisites

      1. Knowledge of prevention strategies.
      2. Access to information from the school and community regarding student risk factors.
      3. Collaboration and communication between school and SBHC staff on prevention priorities and efforts.
      4. Access to materials providing information and “how-to’s” on evidence-based prevention strategies. Some prevention programs may require training or certification in specific skills.
      5. Opportunity to provide professional development programs to school personnel.
      6. Attention to appropriate orientation, coordination and supervision of staff and volunteers involved in prevention activities.


Strategies and Tools

      1. Effective and accepted prevention activities generally are most effective when undertaken in collaboration with other school or community personnel.
      2. Since working with school staff may be optimal, consider development of a core leadership group or utilization of an existing school committee or task force that includes both SBHC and school staff to plan and track prevention activities.
      3. Think about ways to extend your reach. For example, it may be useful to develop volunteers (or to collaborate with existing organizations willing to provide volunteer personnel, such as colleges, religious institutions, voluntary associations) to help plan or implement a particular prevention activity. Similarly, it is economical to disseminate such information as mental health warning signs or indicators of ADHD to large and influential constituencies, such as school faculty, family members, etc.
      4. Utilize “train-the-trainer” or “turn-key” models of staff development in which the mental health provider offers concentrated, time-limited training and consultation to enable selected school (or other) personnel to replicate and carry out identified prevention activities.

Target Populations (condition, age, etc.)

    1. Broad-based prevention efforts may be applied to the entire school population. This is practical only for interventions that are time-limited and focused. For example, all students may participate in a Healthy Minds/Healthy Bodies Week or in such short-term activities as social skills training.
    2. Programs that are on-going or require greater staff effort should start by focusing on appropriate target populations. For example, conflict resolution or anger management programs may be provided for those students in specific grades experiencing the most difficulty with aggression. Similarly, students with a history of court involvement, suspension, or family stress may be identified for early identification/prevention efforts.