school mental health services for the 21st century ......report l school mental health services for...

School Mental Health Services

for the 21st Century:

Lessons from the District of Columbia School

Mental Health Program

Olga Acosta Price, PhD Julia Graham Lear, PhD

Center for Health and Health Care in Schools l www.healthinschools.org

Report l December 2008

The Center forHealth and Health Care in SchoolsGeorge Washington University

2121 K Street, NW, Suite 250Washington, DC 20037202-466-3396 fax: 202-466-3467www.healthinschools.org

Report l School Mental Health Services for the 21st Century: Lessons from the District of Columbia School Mental Health Program

AuthorsOlga Acosta Price, P.h.D.Co-DirectorCenter for Health and Health Care in SchoolsAssociate Research ProfessorPrevention & Community HealthSchool of Public Health and Health ServicesGeorge Washington University

Jula Graham Lear, P.h.D.DirectorCenter for Health and Health Care in SchoolsResearch ProfessorPrevention & Community HealthSchool of Public Health and Health ServicesGeorge Washington University

DesignTheresa Chapman, Center for Health and Health Care in Schools

Copyright©2008This publication is protected by copyright and may not be reprinted without written permission from the Center for Health and Health Care in Schools. Send permission requests to [email protected].

“Funded through the Safe Schools/Healthy Students Program, a partnership of the U.S. Departments of Education, Health and Human Services, and Justice.” Under the Elementary and Secondary Education Act of 1965 (ESEA), as amended, Title IV, Part A, Subpart 2, Sec. 4121; 20 U.S.C. 7131 Grant PR/Number #Q184L050335.

Report l School Mental Health Services for the 21st Century

iCenter for Health and Health Care in Schools l www.healthinschools.org

School Mental Health Services for the 21st Century: Lessons from the District of Columbia School Mental Health Program

EXECUTIVESUMMARY iii

SECTIONI:INTRODUCTION 1Report Goal 1Methodolgy 1

SECTIONII:BACKGROUND 3Critical health statistics in the District of Columbia 3Recent developments in school mental health 6The DMH school mental health conceptual model 6The SSC school mental health conceptual framework 7What the researchers and experts say about children’s mental health needs and schools 9What we can learn from other states & localities 11School mental health in the District of Columbia: Opportunities and challenges 13

Recommendations for DMH 17

SECTIONIII:FINDINGSANDOBSERVATIONS 18Organizational management 18

What the research and the experts say about organizing school mental health programs 18What we can learn from other states & localities 19Making it happen: strengthening and improving systems operations 19Recommendations for DMH 24

Program development and evidence-based practices 25Overview of what the research and the experts say 26What we can learn from other states & localities 28Recommendations for DMH 30

Training/professional development 30Overview of what the research and the experts say 31What we can learn from other states & localities 32Recommendations for DMH 33

Financing school mental health: Some initial thoughts 34Current funding arrangements for the DC school mental health program 34Future sources of funding 35Overview of what the experts say 37What we can learn from other states & localities 38Recommendations for DMH 40

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Contents


iiCenter for Health and Health Care in Schools l www.healthinschools.org

Program evaluation and outcomes research 41Current approaches to evaluating school mental health services

in the District of Columbia 41What we can learn from other states & localities 48Recommendations for DMH 49

CONCLUSION 49

REFERENCES 55

APPENDICES. 62Appendix A: Interviewees for DMH school mental health report 62Appendix B: List of supplemental reports available upon request 66

Appendix C: District of Columbia schools with school mental health professionals 67 Appendix D: Comparison of Staff Requirements, Cost, and Productivity Between D.C. and Other Cities 70 Appendix E: Examples of state mental health laws that address a continuum of children’s mental health care and the role of schools 72

Appendix F: List of school health programs and initiatives in DC 73 Appendix G: A guide for mapping school-based mental health activities 74

Appendix H: Table of Organization for the D.C. Department of Mental Health Officeof ProgramsandPrevention&EarlyInterventionPrograms 75 Appendix I: Template for the development of standards for school mental health programs in D.C. 77 Appendix J: List of Evidenced-Based Programs or Data Driven Practices or Programs for use in the School Mental Health Program for SY 2007-2008 86 Appendix K: Sources that have reviewed evidence-based or promising programs for use in schools 88 Appendix L: Sources of Federal funding for school-based mental health care 90 Appendix M: Proposed plan to implement a citywide school mental health evaluation program 91

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Contentscontinued


iiiCenter for Health and Health Care in Schools l www.healthinschools.org

EXECUTIVE SUMMARYOverview

InJanuary2007,TheCenterforHealthandHealthCareinSchoolsattheGeorgeWashingtonUniversitySchoolof PublicHealthandHealthServiceswascommissionedtoassessoperationsof schoolmentalhealthprogramsinWashington,D.C. andrecommendfuturedirections inpractices,policiesandsystemsdevelopment.While thisguidance isdirectedprimarilyat theDistrictof ColumbiaDepartmentof MentalHealth,thegoalof thisreportistoofferguidanceforallpublicandprivateorganizationsandindividualsthatshareacommitmenttoeffectivementalhealthprogramsforchildrenintheDistrictof Columbia.

Thisreportisbasedona16-monthexaminationof school-connectedmentalhealthprogramshereintheDistrictof Columbiaandincities,countiesandstatesaroundthenation.Inthecourseof thestudy,theauthorsconductedanin-depthexaminationof schoolmentalhealthprogramsinDC,reviewedrelevantliterature,andinterviewed100localandnationalexpertsinchildren’smentalhealthandschoolmentalhealth.

Policymakers,programdirectors,educatorsandmentalhealthprofessionals increasinglyviewschool-connectedmentalhealthasessential toeffectiveschoolsandwell-functioningmentalhealthsystemsof care.LastyearthisperspectivewasevidentintheDistrictof ColumbiawhentheInteragencyCollaborationandServicesIntegrationCommission(ICSIC) includedschoolmentalhealthaspartof theDistrictof ColumbiaPublicEducationReformAmendmentActof 2007.

Theoverarchinggoalof thisreportistodocumentthecriticalcomponentsof effectiveschoolmental health programs utilizing the best current thinking and practice so that programsdevelopedwiththisguidanceinmindcanwithstandthepolitical,economic,andsocialpressuresthat frequently erodebest-practicemodels. To this end, the report recommends anumberof roles, functions, and activities for the DC Department of Mental Health within five areas: organizationalmanagement,programdevelopmentandevidence-basedpractices, trainingandprofessional development, financing, and program evaluation and outcomes research.

Key Findings

There is significant support for school mental health in the District of Columbia.Over the courseof this study, school systemandmentalhealthpolicymakers andprogramleadershavestatedtheirbelief thatschool-connectedmentalhealthprogrammingisessentialtoeffectiveschoolsandtoeffectivechildmentalhealthsystemsof care.Thedepthof thissupportisevidencedbytheestablishmentof theInteragencyCollaborationandServicesIntegrationCommission(ICSIC),withintheDistrictof ColumbiaPublicEducationReformAmendmentActof 2007. TitleVof thisActstatesthatICSICwilladdresstheneedsof at-riskchildren“throughacomprehensiveintegratedservicedeliverysystem.”TheActthenoutlinesanumberof issuesthattheschool-basedstrategiesshouldaddress.Thelegislationindicateshowimportantschool-basedprofessionalsareincoordinatingintegratedmentalhealthandsocialserviceswithinaneducationalsetting.


ivCenter for Health and Health Care in Schools l www.healthinschools.org

EXECUTIVE SUMMARY: continued

Despite growing support, school mental health services remain fragmented and need an overarching principle or framework to facilitate services integration and coordination. The most significant observation emerging from this study is that District government agencies, public school officials, and state leaders have not articulated a unified conceptual framework to guidetheestablishmentof anintegratedapproachtoimprovingschoolperformanceandreducinghealthandmentalhealthriskfactorsamongDistrictstudents.AlthoughtheICSICprovidesasoundorganizational structure to examine programmatic, political, and fiscal issues related to providing services, there is no single model of care that guides this group. For example: A number of different,andsometimescompeting,pressurepoints(e.g..NoChildLeftBehindlegislation,theBlackman-Joneslawsuit,Dixonconsentdecree,andthenewpublicschoolauthority)havedriventheimplementationof multipleschoolhealthandmentalhealthinitiativesthroughoutthecity.Althoughwellintentionedandindividuallybasedonstrongevidence,theseinitiativesarenotcoordinatedanddo not reflect a single vision for school-based health and mental health programs in the District of Columbia.Redundancyandfragmentationof servicesisevident.

Looking to the future, the mental health experts consulted recommend a public health model as the best framework for organizing school-connected programs, policies and practices.Thepublichealthapproachtomentalhealthischaracterizedbyconcernforthehealthof anentirepopulation,extendingbeyonddiagnosisandtreatmentforindividualstoincludingpopulation-basedapproachesthatpromotewell-being,facilitateaccesstotreatment,ensuredeliveryof qualitycare,andidentifyindividualsinneedbeforetreatmentisnecessary.DMHhasdrawnheavilyfromthismodelintheestablishmentof theSchoolMentalHealthProgram(SMHP)butadoptionof thisframeworkhasnotreachedthehighestlevelsof Districtgovernment.Havinganumbrellaframeworkthatdistinguishesmultiple levelsof carewillyieldacitywideplanwithnumerousprogrammaticactivitiesthatwouldbeintegrated,complimentary,andtogethercreatesupportiveschoolexperiencesfordisadvantagedyouth.

The “DC School Mental Health Model” should involve a continuum of services and programs delivered by a variety of school and community mental health professionals and educators. Determining who is best able to help students calls for a critical assessment of services andprogramstobeprovided,theskillsneeded,thecapacitiesof schoolandcommunityproviders,andthe identification of best practice models suitable to District of Columbia school students and their families.Intheend,theorganizationanddeliveryof schoolmentalhealthprogramsrequiresahighdegreeof interdependencebetweentheeducationandmentalhealthagencies.Thedegreetowhichprevention,earlyintervention,andtreatmentservicesaredeliveredwillbeafunctionof theskills,supports,andstaff availablefrombotheducationandmentalhealth.

Expanding school-based mental health programs across the City will require investment in infrastructure development as well as program development. The District¹s public mental health agency is ideally positioned to lead the formation of a unified masterplanforschool-basedmentalhealthservices–servicesthatcanprovideprevention,earlyintervention,andtreatmentcareforallDistrictstudentsinneed.Formentalhealthprogramstotakeroot,DMHmustalsoinvestinaninfrastructurethatsupportshighqualitycare,transparent

andconsistentcommunications insideandoutsideof theagency,sounddecision-makingabouttheallocation of resources, and professional capacity-building sufficient to sustain the programmatic growthenvisioned.The use of evidence-based practices and programs and data-driven decision-making is essential to establishing and maintaining a high quality, continually improving school mental health program. Twoof themost importantdecisionstheDCSchoolMentalHealthProgramcanmaketoensurequality services and effective delivery of care are: (1) to adopt evidence-based mental health practices (EBP),and(2)tocommittousingdata-drivendecision-making.ConcerningEBP,expertscautionthat,becausetheevidencebaseisalwayschangingduetoon-goingresearch,acitywideschoolmentalhealthprogram needs to adapt to the latest empirical evidence about effectiveness and efficacy. Experts also notethatacitywideschoolmentalhealthprogrammodelalsoneedstobeabletoadapttochangingdemographicsorenvironmentalriskfactors.Concerningdata-drivendecision-making,thecitymustinvestinaninformationsystemthatenablesprogramandpoliticalleadershiptomonitorandevaluateschoolmentalhealthprogramsandservicesacrossthecity.Theinformationsystemmusthavethecapacitytocollectmentalhealth,substanceuse,violence-related,andacademicdatafromthemultipleagencies involved in each school-based program. Compatible and flexible information systems will significantly improve the program’s potential to create and sustain fundamental change.

A unified DC School Mental Health Model will only be achieved with district-wide cooperation and community involvement.Whilesupportforapublichealthapproachtoschoolmentalhealthprogramshasgrownwithintheeducationandmentalhealthcommunities,clarityaroundwhoisresponsibleforthedelivery,funding,training,andevaluationof interventionswithineachcomponentof a school-basedmentalhealthapproachremainstobedetermined.Decisionsaboutwhatthe“DCSchoolMentalHealthModel”lookslikecanonlybemadebythoseresponsibleforschool-connectedservices.Mentalhealth,education,health, parents, and elected officials all need to be at the table.

The future of mental health services provided in District of Columbia schools-will be decided by the city’s political leadership, in consultation with community members, mental health and education professionals, and consistent with insights from research and informed by other state and community experiences.Tosecurethedesiredend,decisionsmustbeinformedbywhattheresearchteachesaboutthestructuresandresourcesthatmustbeinplacetosupportwhateverstrategiesareselected.TheDistrictof Columbiagovernmentandthepublicschoolsystemshavebeenremarkable intheirsupportof school-basedservicesandprograms.Ourhopeisthatdecision-makerswillrecognizethemanycommunity,family,anduniversityresourcesthatexistandcanbebroughttobeartobuilduponthemanysuccessesalreadyexperienced.

EXECUTIVE SUMMARY: continued


vCenter for Health and Health Care in Schools l www.healthinschools.org


1Center for Health and Health Care in Schools l www.healthinschools.org

SECTIONI:INTRODUCTION

TheCenterforHealthandHealthCare inSchoolswasasked by the Student Support Center (formerly theCenter forStudentSupportServices) to recommendaplanforsustainingandexpandingschool-basedmentalhealthservicesinWashington,D.C.

Early in this decade the city recognized that existingresources in the District of Columbia Public Schools(DCPS) were insufficient to meet the mental health needs of itsyoungpeople.BuildingonaninitialfederalgranttotheCenterforStudentSupportServices(CSSS)toprovidementalhealthassistanceinanumberof charterschools,theDCDepartmentof MentalHealth(DMH)committedtosustainingtheoriginalgrant-supportedschool-basedmentalhealthservicesincharterschoolsandexpandingtheservicesintoDCPSbuildings.Thisexpansionbecameknown as the DC School Mental Health Program.Currently,thecityhastwoprincipalschoolmentalhealthproviders: the Student Support Center (SSC; formerly known as CSSS) and the DC Department of MentalHealth.Ingeneral,theexpansionof schoolmentalhealthservices is supported by the schools and elected officials, particularlyCouncilmembersDavidCataniaandTommyWells who chair the Council’s Health Committee andHumanServicesCommitteerespectively.MayorAdrianFentyalsoannouncedthatexpandingschool-basedmentalhealthservices intheDistrict isoneof hismajorgoalsfor2008(Neibauer,January26,2008). Intheschools,parents, family members, and community leaders havealsowelcomedtheadditionalhelpforstudents–leadingotherschoolstoseekthisserviceaswell.

Asinterestinschoolmentalhealthhasgrown,questionshavebeenraisedabouthowbesttodesignandmanagethispromisingnewsetof services. Amongthesequestionsare: What should be the role for the Department of MentalHealth?ShoulditbeadirectserviceproviderasisnowthecaseorshouldDMHprimarilydevelopprogramstandards, implement training, and provide oversight?What emphasis should be placed on prevention, earlyintervention,andtreatmentactivities?Whatdoweknowabout best practice in staffing requirements and training, andhowhaveother cities and statesorganizedmentalhealthservices inschools? What lessonsdotheyhaveforusintermsof theimplementationof evidence-basedpractice? And while program financing was not a primary

objective of this study, current funding arrangementsthatrelyprimarilyonlocaldollarsintheDCbudgethavecreatedurgentconcernaboutwhetherthisisthebestuseof localdollars. Thisreportaddresses thesequestionswiththeintentof presentingtheinformationessentialtosupportdecision-makingaboutthecontinuedexpansionof theSchoolMentalHealthProgram.

Report goalThegoalof thisreportistoprovideasetof recommen-dationsaboutthemosteffectivestrategiesforexpandingschool-basedmentalhealthservicesinWashington,DCthatcanwithstandpolitical,economic,andsocialchanges.Althoughnationallythereareavarietyof schoolmentalhealthprogrammodelsandarrangements,thisreportfo-cusesonstrategies thatcanstrengthentherelationshipbetween community mental health organizations andschools/schooldistricts inthedeliveryof school-basedmentalhealthcare.

The report covers the following topics critical to thedevelopmentandmaintenanceof schoolmentalhealthservices and programs:

OrganizationalmanagementProgramdevelopmentandevidence-basedpracticesTraining/professionaldevelopmentFinancingProgramevaluationandoutcomesresearch

MethodologyThe report and its recommendations are based on ananalysisof localschool-basedservicesandprograms,anenvironmentalscanof bestpracticesacrossthecountry,and assessment of peer-reviewed research in the five areas indicatedabove.TherecommendationsaremeanttoprovideguidancetotheDepartmentof MentalHealth,theDCPublicSchoolSystemandpubliccharterschools,the State Superintendent of Education, communitymentalhealthproviders,andtheMayorandcitycouncilmembersas thecityproceeds tomakedecisionsaboutprogrammaintenance,sustainability,andexpansion.Multiplemethodswereusedtogatherinformationforthisreport. These include:

Face-to-faceinterviewswith38localkeystakeholders,elected officials, and city administrators involved in

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theprovisionof school-basedservicesinWashington,D.C.Theseindividualsrepresentedthementalhealth,health,education,orsocialservicesectors.

Face-to-face or phone interviews with nationalexperts in the fields of children’s mental health or school mental health. These interviews sought tolearnaboutbestpractices inprogramdevelopment,administration,evaluation,andqualityimprovement.Twentynationalexpertswereinterviewed.

Face-to-faceorphoneinterviewswithrepresentativesfromstateorcountymentalhealthagenciesoutsidetheDistrictof Columbiatodiscusscurrentpolicies,programs, management, and financing of school-based mentalhealthcareintheirstateorlocality.Forty-twostate/countyrepresentativeswereinterviewed.

Focus groups with two groups of school-basedclinicians, one from the DC DMH School MentalHealth Program (8 participants) and the otherfrom the Center for Student Support Services (15participants).

Participation in five national meetings addressing the critical issues emerging in the field of school mental health, including:

A System of Care for Children’s MentalHealthconferencehostedbytheResearchandTrainingCenterforChildren’sMentalHealth(March,2007)

NationalSchool-BasedHealthCareconventionhostedbytheNationalAssemblyonSchool-BasedHealthCare(June,2007&June,2008)

Advancing School Mental Health AnnualMeetingsponsoredbytheCenterforSchoolMentalHealth(October,2007&September,2008)

Documents reviewed included: Descriptive materials about local initiativesinhealthandeducation,aswellascity-widestrategiesaimedat improvingthewell-beingof theDistrict’schildren.

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InformationaboutservicesprovidedbytheDC Department of Mental Health SchoolMental Health Program and the StudentSupportCenter,includingevaluationstudies,grantproposals,andannualreports.Materialsincludedreports,protocols,regulations,andpolicies.

Descriptive materials related to theorganizational structure, evaluation, staffing, training, financing, and program and policy developmentof school-basedmentalhealthprogramsinotherstates,countiesandcitiesaroundtheUnitedStates.

Research papers, scientific reports, andguidelines for best practices and evidence-basedprogramsinschoolmentalhealth.

AppendixAlistsindividualsinterviewedforthisreport.Reports reviewed are listed in Appendix B. Researchpapers specifically cited within this report are included in thereferencesection.

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SECTIONII:BACKGROUND

Twohundredandthirty-fourpublicschoolsandpubliccharterschoolsserve72,378D.C.school-agechildren.Of these children, 82% are African-American andabout 11% are Hispanic (DC Public Schools MasterEducationPlan,2006).TheDistrictof ColumbiaPublicSchools(DCPS),thecity’slargestlocaleducationagency(LEA),operates162 schools in151different locations(morethanoneschoolmayoccupyabuilding). Publiccharter schools numbered 72 during the 2006-2007school year and are operated by private non-profit boards under the jurisdiction of the Public Charter SchoolBoard. DCPSenrollmentwas52,645 last schoolyear(down4.8% from theprevious school year),while thepubliccharterschoolstudentenrollmenttotaled19,733during thesameperiod. StudentmobilityamongD.C.studentsishigh,withlessthan90%of studentsremainingin the same school within a school year, and somemovingseveral timesbeforeyear’send(TheBrookingsInstitution,2008).

Allpublicschools(bothDCPSandpubliccharterschools)receive aUniformPerStudentFunding allocation—aresourcethatconstitutesmostof theiroperatingbudget.

The amount allocated to each local education agency(LEA) by the state agency is based on a formula thatcoversschool-basedinstructionandpupilsupportaswellasnon-instructionalservices(suchasfacilitiesorsecurity),administration and other overhead. According to theMasterEducationPlanforDC,theDCPSschoolsystemandcharterschoolsreceived$7,600perstudentinFiscalYear(FY)2007(D.C.PublicSchoolsMasterEducationPlan,2006).

Critical health statistics in the District of Columbia

TheneedforarobustschoolmentalhealthprogramintheDistrictof Columbiaisevidentinthedatathatcharacterizethephysicalandmentalhealthissuesaffectingchildrenandyouthinthecommunity.Childrenandfamiliesinurbanareas are agenerallyunderservedgroup (Atkins, et al.,2006),andunfortunatelyasindicatedinTable1,childrenintheDistrictof Columbiaareatevengreaterriskforpoorerhealthand lifeoutcomesthanchildren inotherpartsof theUnitedStates(AnnieE.CaseyFoundation,2008).

Table 1. Child Health/Economic Statistics Comparing D.C. to the National Average

HealthIndicator* 2001 2002 2003 2004 2005

Infant mortality rate (deaths per 1,000 live births)

DCUS

10.66.8

11.37.0

10.56.9

12.06.8

14.16.9

Rate of teen death by accident, homi-cide, or suicide (ages 15-19) (deaths per 100,000)

DCUS

14967

16868

15166

18866

17365

Child death rate (ages 1-14) (deaths per 100,000)

DCUS

3322

2321

2721

3620

2420

2002 2003 2004 2005 2006

Percent of children living with parents who do not have full time jobs

DCUS

49%33%

54%33%

52%33%

49%34%

46%33%

2003 2004 2005 2006 2007

Percent of families with children headed by single parent

DCUS

63%31%

68%31%

65%32%

62%32%

60%32%

Percent of children in poverty DCUS

36%18%

34%18%

32%19%

33%18%

23%18%

Percent of teens who drop out of HS (ages 16-19)

DCUS

6%8%

10%8%

8%7%

7%7%

8%7%

Source: Annie E. Casey Foundation, 2008* The most recent published data differs by health indicator



ChildpovertyplaysacriticalroleinpoorchildphysicalandmentalhealthoutcomesandthechildpovertyrateishigherintheDistrictof Columbiathaninmostmajorcities(D.C.FiscalPolicyInstitute,2006).Theconsequencesof severepovertyaretangible.Thepoorestof D.C.neighborhoodshaveaviolentcrimeratesixtimeshigherthanintheleastimpoverished areas, and just under half of all confirmed casesof childabuseandneglectcomefromthepoorestfifth of District neighborhoods (D.C. Action for Children, 2007).

AsdocumentedinarecentRANDreportpreparedfortheExecutive Office of the Mayor, the physical and mental healthproblemsconfrontingchildrenintheDistrictof Columbiaareextensive(Lurie,Gresenz,Blanchard,Ruder,

Parentalassessmentofchildren’shealth

Poor/fair health (%)

Requires more medical care than other children (%)

Chronic conditions

Current asthma (any severity) %

Moderate or severe asthma (%)

At risk of being overweight (%)

Overweight among 6 – 12 yrs (%)

Mental & cognitive health Behavioral health issue needing treatment (%)

Learning disability diagnosis (%)

Serious emotional disturbance (%) (2000)

Alcohol or illicit drug abuse or dependence among 12 – 17 (%)

4.1 6.3 9.1 0.6 1.9 4.4 3.1 4.4 4.5

12.1 12.4 11.7 8.2 12.9 15.2 9.6 14.1 11.3

11.9 7.6 5.0 3.9 9.1 14.9 12.6 17.9 12.1

4.3 3.7 1.6 0.6 5.2 5.6 3.8 5.3 4.4

16.8 20.4 11.5 7.7 19.2 16.5 16.4 19.4 15.6

36.3 35.4 25.5 10.8 30.4 36.5 49.7 36.4 44.2

10.5 10.6 8.0 8.0 7.1 14.7 11.7 12.0 7.9

12.9 12.1 12.0 11.1 10.1 13.6 15.6 13.3 13.5

7.9 8.1 7.6 6.4 7.5 7.9 8.1 8.1 8.4

6.0 6.1 -- 8.5 5.6 5.5 5.9 5.4 5.7

DC Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8

Table 2. Health Status Among Children in District of Columbia

Source: Lurie, Gresenz, Blanchard, Ruder, & Chandra, 2008 Working paper: Assessing Health and Health Care in the District of Columbia, RAND, p. 16.

&Chandra, 2008). For example, basedon 2003data,District-wide,36.3%of childrenbetweenages6and12wereoverweight,11.9%hadasthma,12.9%hadalearningdisabilitydiagnosis,10.5%hadabehavioralhealth issueneedingtreatment,andnearly8%hadaseriousemotionaldisturbance.Themagnitudeof theseproblemscanvarysubstantiallyamongthecity’seightwardsasevidencedinTable2.

Another window on the health care needs of DistrictchildrenisprovidedbyDCPS.Theschoolsystemreportsthatroughly18%of studentsrequirespecialeducationservices, with 46% of this population having learningdisabilities,18%emotionaldisabilitiesand13%mentalretardation(D.C.PublicSchoolsMasterEducationPlan,



2006).ThedataonacademicoutcomesforstudentsinDCpublic andpublic charter schools isdisheartening.Astudyof DCpublicschoolstudentsfoundthat43%of students graduate from high school within five years, 29%enrollinpostsecondaryeducationalprogramswithin18monthsof graduatingfromhighschool,andof thisgroup,only9%willearnapostsecondarydegreewithinfive years of enrolling in college. The statistics are even worse foryouth living inWards7and8,and formalestudentsinD.C.(Kernan-Schloss&Potapchuk,2006).

Finally,resultsfromthe2007YouthRiskBehaviorSurvey(YRBS)conductedbytheCentersforDiseaseControlandPrevention(CDC)alsounderscorethehighlevelof riskaffectingDistrictyouth(seeTable3).SeveralriskfactorsindicateyouthinD.C.areatgreaterriskthanacomparablesampleof youthnationwide. AlmostthreetimesmorestudentsinD.C.reportedtheydidnotgotoschoolbecausetheyfeltunsafeandabouttwiceasmanyD.C.highschoolstudentsattemptedsuicidethanwasreportednationally.Furthermore,almost60%of studentssaidtheyhadbeenorhadafamilymemberorfriendshotorwounded.Theconsequencesof witnessingviolencearewelldocumentedandextensive(Schuler&Nair,2001).

Table 3. Risk Behaviors Among D.C. Senior High School Students Compared to Students Nationwide

Findingsfromthe2007YRBSindicatethatgay,lesbian,bisexual, and transgendered and questioning youth(GLBTQyouth)inDCschoolsareespeciallyvulnerableand in critical need for mental health programs andservices. Specifically, 31% of gay, lesbian, bisexual (GLB) youthseriouslyconsideredattemptingsuicideinthepast12 months compared to 14% of heterosexual youth,while33%of GLByouthactuallyattemptedsuicideatleast once in the past 12 months compared to 9% of heterosexual youth (CDC, 2007; refer to http://www.k12.dc.us/offices/oss/hivaids/pdfs/GLBT_fact_sheet.pdf foradditionalinformation).

Beginningin2001,asdescribedinthefollowingsectionsof this report, the District of Columbia began toaddressthelong-timegapbetweentheneedforchildren’smental health care and available services. Led by anew non-profit entity, the Center for Student Support Services(CSSS),thecitygovernment–actingthroughtheDepartmentof MentalHealth(DMH)–begantoaddresstheneedformentalhealthservicesforchildrenandyouth.CSSS(nowknownastheStudentSupportCenter-SCC),inpartnershipwithDMHandthepubliccharterschools,launchedaschool-basedmentalhealth2007initiativethatinauguratedanewerainservicesforyoungpeopleand

Health-RiskBehavior 2007Percent of students who did not go to school because they felt unsafe at school or on their way home from school on one or more of the past 30 days

DCUS

14.4%5.5%

Percent of students who have been threatened or injured with a weapon such as a gun, knife or club on school property one of more times during the past 12 months

DCUS

11%8%

Percent of students who were injured in a physical fight and had to be treated by a doctor or nurse one or more times in the past 12 months

DCUS

10%4%

Had sexual intercourse with four or more persons during their life DCUS

21.5%14.9%

Percent of students who had seriously considered attempting suicide during 12 months preceding survey

DCUS

14.9%14.5%

Percent of students who actually attempted suicide one or more times in the past 12 months

DCUS

12.2%6.9%

Percent of students who had been or had a family member or friend shot/wounded (2003 data)

DCUS

59.9%N/A

Source: CDC Youth Risk Behavior Survey, 2007



theirfamilies.Thegoalof theseserviceswastoreduceriskandimproveoutcomesforchildrenintheDistrictof Columbia.

Recent developments in school mental health

Over the past 15 years, the District of Columbia hasestablished a recordof providing school-basedmentalhealthservicestochildren,youth,andfamiliesthroughapartnershipbetweenthepublicschoolsandtheCommissiononMentalHealthServices,thepredecessororganizationtotheDepartmentof MentalHealth(DMH).Buildingonitssponsorshipof communitymentalhealthcentersinthesoutheast,northeast,andnorthwestquadrantsof thecity,theCommissiononMentalHealthServicesbeganprovidingavarietyof school-basedservices(individual,family, group therapy, and consultation) on an ad-hocbasistoasmallnumberof publicschoolsacrossthecityinthemid-1990s.

In1999,acoalitionof seventeenpubliccharterschoolswas awarded a federally-funded Safe Schools/HealthyStudentsInitiative(SS/HS)grantwhosepurposewastoimplementacomprehensiveviolencepreventioninitiative.TheschoolssubcontractedwiththeCenterforStudentSupport Services (CSSS) to manage this effort. Thecharter school coalition and CSSS then subcontractedwith DMH to develop a school-based mental healthpromotion and intervention service in sixteen of theseventeen charter schools. With prevalence estimatessuggestingthatover7%of youthintheDistrictstruggledwithseriousmentalhealthproblemsbutlessthan1%of thepopulationof childrenandyouthwerebeingserved,communityadvocatescomplainedthatthepublicmentalhealthsystemwasignoringchildren(Jones,2001).Asaresult,thisnewSchoolMentalHealthProgram(SMHP)quickly won support among community members andtheirelectedleaders.Giventhenumerousenvironmental,social,andpersonalriskfactorsfacingyoungresidents--poverty,crime,schoolfailure,andhighlevelsof individualdepressionandtrauma--expandingmentalhealthsupportforchildrenbecameatoppriorityforfamilies,communityleaders,andgovernmentagencies.

WhenthefederalSafeSchools/HealthyStudentsgrantended in 2002, DMH agreed to allocate some of itsappropriated dollars to support the ten public charter

schools that continued tooffermentalhealth services.(Sixcharterschoolsdroppedoutof theprogrameitherduetoschoolclosureoradecisionnottosustaintheirmentalhealthservices.)DMHthenspreadservicesto16moreD.C.publicschools.These16, referred toas theSpingarnCluster(schoolsingeographicproximitytoeachotherandthatfeedintoSpingarnHighSchool),becamethe first step in a progressive expansion of the program. Since2002,DMHhasaddedthirtymoreschoolstotheSchoolMentalHealthProgramby allocating increasedfundsfromtheagency’sbudget.(Refertopg.35Table8fordetails.)

In the 2005-2006 school year, another federal SS/HSgrantwasawardedto18newD.C.publiccharterschoolsandagain theCSSSwas subcontractedby the charterstomanagethepreventionandearlyinterventionservicesprovidedthroughthatgrant.Takentogether,duringthe2007-2008 school year, 63public schools inD.C.hadsupplementalemotionalandbehavioralsupportserviceson-siteandmanagedbyoneof twooutsidementalhealthorganizations (DMHorCSSS). SeeAppendixCforalistingof D.C.PublicSchoolsandD.C.PublicCharterSchoolswithSchoolMentalHealthProgramstaff offeringserviceson-site.

The DMH school mental health conceptual model

“This model is the best thing in terms of accessibility for kids, obtaining information on relevant mental health issues quickly from multiple sources and for reducing stigma, and it is a major test of clinical expertise and skills for clinicians in terms of how well they can address children’s mental health issues.”JacquelynDuval-Harvey,Director,EastBaltimoreMentalHealthPartnership,personalcommunication,January11,2008.

TheconceptualmodelfortheDMHSchoolMentalHealthProgramisbasedonanunderstandingthatbyfosteringresilienceandreducingemotionalandbehavioralbarriersto learningforallstudents, theProgramwillmaximizestudents’ potential to become successful learners andresponsiblecitizens.TheProgram’spathwaytothisgoalis implementingaprogramthatpreventsmental illnessand promotes emotional, behavioral, and social healthamongstudentsandtheirfamilies.



The DMH School Mental Health Program (SMHP)is modeled after the expanded school mental healthframeworkthataimstosupplementmentalhealthservicestraditionallyofferedinschools(Weist,1997).TheSMHPemploys licensed or license-eligible social workers,psychologists, or mental health specialists to providepreventionandinterventionservicestostudentswiththeaimof preventingthenegativeoutcomeslikelytoresultfromexposuretomultipleriskfactors.Earlyinterventionand treatment services are available to all studentsassessedasneedingthem.Theseservices,however,arenotintendedtomeettheservicerequirementsof studentswith Individualized Education Programs (IEPs). Thefocusof theSMHPhasbeenonpreventionandearlyintervention andonpreventingunnecessary entry intothe special education system by addressing emotionaland behavioral problems before they significantly impact learning.

Former school district administrators voiced theirpreferenceforschoolemployeestoprovidetherequiredservicesforstudentswithspecialneedsinordertomaintaingreatercontroloverthedeliveryof thoseservices.Legalconcernsandanabsenceof practiceguidelinesforDCschool-basedprovidersunderscoredtheneedtomaintainschool-hired mental health professionals as the mainprovidersof caretostudentswithIEPs.DMHprogramadministrators, therefore, decided thatuntil claritywasachievedaroundeducationandmentalhealthregulations(i.e.,HIPAA,FERPA,andtheMentalHealthInformationAct), and public financing for school-based services was achieved, it was inadvisable for school mental healthprofessionalstobethemainprovidersof careforspecialneedsstudents.

Until recently, one full-time school mental healthprofessionalwas assigned toone school toprovide anarrayof servicesandsupports to thestudentsand theschool community. Beginning in the fall of 2008, theDMHSMHPassigned10clinicianstotwoschoolseachinordertoaddresspressurestoexpandandtoreachmorestudentsandtheirfamilies.

Based on lessons from successful programs in otherregions, the DMH SMHP designed a set of servicesconsisting of three levels of care; primary, secondary, and tertiarypreventionservices.

Primary Prevention (also known as Universal Prevention Services) Preventionservicesavailabletotheentirestudentbody,theschoolstaff,orparents/guardians(dependingonthetargetaudienceforaparticular intervention)aredeliveredtopreventthedevelopmentof seriousmentalhealthproblemsand topromotepositivedevelopmentamongchildrenandyouth.Programexamplesincludedstaff professionaldevelopment,mentalhealtheducationalworkshops for parents/guardians, school staff, orstudents,andevidence-basedorpromisingschool-wideorclassroom-basedsubstanceabuseandviolencepreventionprograms.

Secondary Prevention (also known as Selective Prevention Services) Students identified at elevated risk for developing amentalhealthproblemareofferedoneof anumberof early intervention services. These interventionscould include involvement in support groups, focusedskillstraininggroups,dropoutpreventionprograms,andtraining or consultation for families and teachers whowork with identified children.

Tertiary Prevention (also known as Indicated Prevention Services) Studentswithmoreintenseorchronicproblemswhoneedmoretargetedsupportareofferedanumberof brief treatmentservices.Theaimistominimizetheimpactof theproblemandhelprestorethechildoradolescenttoahigherlevelof functioning.Examplesof theseclinicalservices included individualandfamilycounseling,andtherapeuticgroups(i.e.,grief andlossgroups).Studentswhoneedmore intensive servicesmaybe referred forcommunity-basedservicesoutsidetheschooldependingontheirneedformorespecializedcare.

The SSC school mental health conceptual framework

WhiletheStudentSupportCenter(SSC),formerlyknownastheCenterforStudentSupportServices,andtheDMHhavebeencloselylinkedpartnersinthedevelopmentof theSchoolMentalHealthProgram,SSCschoolmentalhealthserviceshaveevolvedinaslightlydifferentdirection.Theemphasisof theSSCoverallprogramisonenhancingtheschool’scapacity tosuccessfully implementschool-wide behavioral health promotion strategies through



manualizedinterventionsandtosupportdisciplinepolicyimprovement, to identify all students inneedof moretargetedmentalhealthsupport,andtoprovidestudentsandtheirfamilieswithschoolbasedshort-termtreatmentservices(upto21weeks).Referralsarelimitedtothosestudents who need extensive services not available atschool.

Primary Prevention: TheSSCmodelexpectsandsupportstheschoolstaff totakeprimaryresponsibilityforimplementationof universalevidence-basedpreventioncurriculumtocreatea “healthy” school culture. SSC’s team of educators/coaches provide hands-on expert coaching on theimplementationof PositiveBehavioralSupport(PBS),andtrainsallteachersfrompre-schoolthroughmiddleschooltoconductschool-widetrainingsinaviolencepreventioncurriculumcalledSecondStep.Earlychildhoodprogramsaresupportedtoprovideuniversalscreeningandtousefindings for the development of individualized plans.

Early Intervention: Ateamof threePreventionEducatorsconductmanualized universal and targeted evidence-basedpreventionprogramsaugmentingthecliniciansandschoolsupport staff in delivering evidence based preventioncurriculum in the schools for students and parents.Theyfacilitatethe implementationof parenteducation

workshops(i.e.,GuidingGoodChoices)andconductpreandposttests.

Early Intervention and Treatment: Mental health clinicians, a multi-disciplinaryteamof doctoralandmasters-levelclinicians,areplacedfull time in the larger schools and half time in smallcharter schools. They provide clinical services, bothearlyinterventionandtreatment,tochildrenandfamiliesreferredthroughtheStudentSupportTeams.OngoingtrainingandsupportisprovidedwithCognitiveBehavioralTherapy(CBT)asthemajormodeof supportforolderchildren. Theorganizationalsohasaspecialtypracticewithpre-schoolchildrenusingchildcenteredplaytherapyasthepredominanttherapyemployed.Cliniciansreceivemonthlysupervision.Aweb-basedcaserecordingsystemprovidessupervisorswiththeabilitytomonitorclinicalwork,caseplansandanypre-postdatathatiscollected.

SSC’semphasisontreatmentispartiallydrivenbyitsconcernaboutsustainability.Itsfundingispredominantlythroughfederal grants, with a 20% subsidy from participatingschools(see“Financing”sectionformoreinformation).TheorganizationhassoughttosustainservicesthroughMedicaid.However,currentDCMedicaidreimbursementpolicieshavebeencomplexandcostlyforschool-basedpractitionersandadministratorstoutilize.SSC,althoughcertified as a Core Service Agency as required by city

Washington, DC (DMH SMHP) Baltimore, MDi Long Island, NYii South Carolinaiii Charlotte, NCiv Montgomery County, MDv Arkansasvi

UniversalSelectiveIndicatedLocationPreventionPreventionPreventionTreatment1Other2

25% 25% 30% 20%7% 20% 40% 33% 40% 40% 20%30% 70%35% 55% 70% 30%30% 70%

Table 4. Continuum of School Mental Health Services by Location

Note: In many cases, programs did not differentiate levels of prevention programming offered through their SMHP.1Treatment services are defined as services that are eligible for reimbursement by insurance plans (Medicaid or other private insurer) and where a diagnosis is provided.2 Other refers to quality improvement activities, school meetings, and training of mental health staff.

Source:i Baltimore Mental Health Systems, Inc. FY08 Appendix “A” Contract Deliverables & Provider Progress Report, pg 5ii Rose Starr, Director of Planning, Alliance for School Mental Health, North Shore-Long Island Jewish Health System, Interview (October 9, 2007).iii South Carolina Department of Mental Health School Based Mental Health Programs Annual Report Summary FY 2004-2005, page 1iv Joanne Sobolewski, Manager of SBMH Program, Carolina’s Health Care, Interview (December 18, 2007)v Monica Martin, Manager/DHHS Representative, Linkages to Learning, Interview (December 19, 2007) vi Arkansas Department of Education, Special Education Unit. (2005). School-Based Mental Health Network: Policy and Procedures Manual, page 7-8 and 29.



regulations,reportsthatithasfoundthecostof billingforMedicaid insured services financially prohibitive.

A comparison of mental health services offered inschools located inseveralcitiesandcounties intheUSshowgreatvariability(Table4).However,allprogramsmaintain some level of preventive intervention andprovide somereimbursable treatment services.Table5reports thenumberof community-hiredmentalhealthstaff employedandthenumberof schoolsinvolvedintheprograms.AppendixDoffersanadditionalcomparisonof theDCschoolmentalhealthprogramsandothercitiesas it relates to staffing requirements, cost per clinician, and productivityrequirements.

What the researchers and experts say about children’s mental health needs and schools

Therisingtideof unmetchildren’smentalhealthneeds,documented extensively by the Surgeon General’sMental Health report in 1999, has continued to drawthe attentionof researchers andpolicymakers (Atkins,et al., 2006; Cooper, 2008; Foster, et al., 2005; Kutash, Duchnowski, & Lynn, 2006; Tableman, 2004; Weist & Paternite, 2006). Authors of the CDC School HealthPolicies andProgramsStudy (SHPPS)2006 argue thatstronger collaboration between school-hired mentalhealth professionals and community mental healthproviders could begin to address the insufficient number

Washington, DC DMH/SMHP 48 48Washington, DC SSC 16 21 (this represents school campuses not LEAs)Baltimore, MD UMD/SMHP 20 25Baltimore, MD JHU/SMHP 14 18Rockville, MD Linkages to Learning 28 35Charlotte, NC Behavioral Randolf SMHP 28 42New York Cityvii SBMHP -- 135South Carolinaviii SC Dept of Mental Health 282 457

Location ProgramHealthStaff*MentalHealthStaffNumberofMentalNumberofSchoolswith

Table 5. Number of Clinicians and Schools by School Mental Health Program (SY 2007-2008)

* We could not confirm whether all mental health staff in this column were clinical providers or if this number included other staff (supervisors, managers, etc.). In addition, information provided indicated number of staff and not total FTEs, which would differ if clinicians did not work full time.

of mentalhealthandsocialserviceprovidersemployedbyschools tomeet students’ emotional andbehavioralneeds(Brener,etal.,2007).Over40%of statechildren’smentalhealthauthoritiesreportavarietyof mentalhealthinitiatives in their schools (Cooper, 2008). TheCDCsurveyedall50statesandtheDistrictof Columbiaaboutpoliciesandpracticesatthestate,schooldistrictandlocalschool levels and theauthors found that98%of stateeducationagencies,76%of schooldistricts,and72%of localschoolscollaboratedwithacorrespondingmentalhealthagencyintheircommunity,butthenature,extent,andlengthof theseassociationsremainuninvestigated.AlthoughBrenerandhercolleaguescallforgreatereffortstobuild‘systematicstateagendas,’therearefewexamplesavailable to help define the essential components of a solidpartnershipbetweeneducationandmentalhealthsystems.(SeeAppendixEforalistof statechildmentalhealthlawsthataddressamentalhealthcontinuumandtheroleof schools).

TheNewFreedomCommission,establishedbyPresidentBush,alsoencouragedtheexpansionof schoolmentalhealthprogramsnationwideasakeystrategytoincreaseaccesstomentalhealthcareforchildren(President’sNewFreedomCommissionReport,2003).AccordingtotheCommission,school-basedprogramsshouldprovideon-sitepreventive interventions, screeningandother earlydetectionmethods,earlyinterventionsupports,assessment,andtreatment,withlinkstocommunity-basedservices.A

Source: vii New York City School-Based Mental Health Program, New York City Department of Education, viewed 02/01/2008 at: http://schools.nyc.gov/Offices/DYD/Health/SBHC/MentalHealth.htmviii South Carolina Department of Mental Health School Based Mental Health Programs Outcome Report FY 2006-2007, page 1



SAMHSAstudyof asampledrawnfrom83,000publicschools and their associated school districts, reportedthatalmosthalf theschooldistrictssampledhadformalarrangementswithcommunitymentalhealthproviders,60%of districtsreportedanincreaseinreferralstotheseprovidersoverthelastyear,andone-thirdstatedthattheavailabilityof outsideprovidershaddecreased (Foster,et al., 2005). Furthermore, two-thirds of the schooldistrictsindicatedthattheneedformentalhealthserviceshad increasedamong their students,butone thirdhadtocontendwithadecreaseinfundingformentalhealthservicesprovidedinschools. Thediscrepancybetweenneedandavailablefundingrequiresthatpublicagenciesand communities consider alternative models of care,creativepartnershipapproaches,andthecarefulallocationof limitedresources.

Experts in the school mental health field caution that a nationally-accepted definition of school mental health does not yet exist (Cooper, 2008), and that it is tooearly todeemonemodelas ‘bestpractice’. Yet,manyrespectedexpertsagreeonusingapublichealthmodelasanorganizingframeworkforschool-basedmentalhealthinterventions(M.Weist,K.Hoagwood,C.Paternite,K.Kutash,A.Duchnowski,L.Eber,&M.Atkins,personalcommunication, varying dates; SAMHSA, 2007).

The public health approach to mental health extendsbeyond diagnosis and treatment for those who needcare,toincludesystematicpopulation-basedapproachestofacilitatingaccesstotreatment,ensuringthedeliveryof quality care, identifying individuals in need beforetreatment is necessary, and preventing the onset of symptoms all together. Through a population-basedapproach, strategies are used to define the problem, identifyriskandprotectivefactors,develop, implementandevaluateinterventions,andbringthemodelstoscalewiththeaimof improvingtheemotional,behavioral,andsocialhealthof theschool-agedpopulation.Anumberof conceptualapproachesof schoolmentalhealthbasedonthepublichealthpreventionmodelhaveevolvedovertime(Kutash,Duchnowski,&Lynn,2006),withthemosteffectivemodelsbeinglocallydevelopedandadoptedbyschools and communities to fit their unique configurations (K.Kutash,personalcommunication,January7,2008).

Weisz, Sandler, Durlak & Anton (2005) propose aninclusivemodelof carethatlinkspreventionstrategieswith

mentalhealthtreatmentapproachesthatcaneffectivelybeofferedinschoolsandhelpsorganizethevarietyof mentalhealthinterventionsprovidedon-sitebyanumberof qualified providers. Weisz and his colleagues include ‘health promotion/positive development strategies’ atoneendof thespectrum,withuniversal,selective,andindicatedpreventionstrategiesatthecoreof theirmodel,andtreatmentstrategies(time-limitedtherapy,enhancedtherapy,andcontinuingcare)representingtheoppositeendof thespectrumtoaddressyouthwithhighsymptomlevelsordiagnosablementalillnesses.Thearrayof servicesoutlinedrepresentsafullcontinuumof outpatientservicesmostlikelytoeffectivelymeettheneedsof mostschool-agedchildrenattendingourpublicschools.

InlinewiththepublichealthframeworkandtheenhancedmodeldevelopedbyWeiszetal.(2005),WeistandMurrayoffer a definition of school mental health as “a full continuumof mental healthpromotionprograms andservices in schools, includingenhancingenvironments,broadly training and promoting social and emotionallearningandlifeskills,preventingemotionalandbehavioralproblems,identifyingandinterveningintheseproblemsearly on, and providing intervention for establishedproblems”(Weist&Murray2007,pg.3).

Criticsof applyingthepublichealthapproachtoschoolmental health programs argue that community mentalheath services are rarely integrated within the fabricof schools and that mental health administrators andproviderseasilyoverlookthefactthatthemainmissionof schoolsistohelpchildrenlearn.Newerparadigmsareemergingthatacknowledgesomeof thesetruthsandhelpreframeschool-basedmentalhealthservices,particularlythoseofferedinpoor,urbanschools,byusinganecologicalmodel informed by public health and organizationaltheories(Cappella,etal., inpress). Amajoraspectof thismodel,thoughttofacilitatebetterschool-communityintegration, is a uniform focus on educational goalsandmentalhealthpractices thatdirectly impact schoolsuccess.

ConsistentwiththelatestSAMHSAreporttoCongresson the advancements known regarding prevention(SAMHSA,2007),theDCschoolmentalhealthprogramshave maintained a strong emphasis on mental healthpromotionandmentalillnessprevention.TheD.C.schoolsystemhasalsoinvestedinbuildinganinfrastructurefor



the early identification and treatment of students over the past five years. A State Incentive Grant (SIG) awarded to theDistrictanumberof yearsagohelpedprovidetrainingand support to local school staff on theutilizationof Student Support Teams (SST), early identification and interventionprocessess, and in the implementationof practices consistent with Positive Behavior Supports.Someof theSIGgrantactivitiesincludedanoverhaulof SSTpolicies,proceduresandtrainingprocessesaswellastheimplementationof othereffectiveschoolpractices.

PositiveBehaviorSupports(PBS),nationallyrecognizedasasystem-wideapproachtopreventingandimprovingproblem behaviors in classrooms and schools, utilizesthe public health model to promote safe and healthyschoolenvironments. PBSaims to improveoutcomesfor all students and is comprisedof abroad rangeof individualizedstrategies,effectivepractices,interventions,andsystemschangestrategiesthathavebeendemonstratedtobeeffective.Nationaldisseminationof thisapproachisunderway with the U.S. Department of Education Office of SpecialEducationProgramsleadingthecharge(RefertoAppendixBforSchool-widePositiveBehaviorSupport,Implementers’BlueprintandSelf-Assessment,2004).Thesuccessfulcollaborationof communitymentalhealthandpublicschoolsystemsintheimplementationof PBISisnoted in other cities (i.e., Chicago, IL; Atkins, Graczyk, Frazier,&Abdul-Adil,2003).

What we can learn from other states & localities

Informationgatheredforthisreportfoundthatanumberof state public mental health agencies are engagedin developing partnerships with education agenciesandwithpromoting apublichealthmodel to serve asa framework for school-based mental health services(e.g.,Maryland,Illinois,NewYork,Pennsylvania,Ohio,Texas,Michigan,andSouthCarolina).These initiativesare summarized below. Because the City of Baltimorehasbeenparticularlyactiveincreatingschool-connectedmental health programs, this summary of relevantprogramsbeginswiththatuniquecity.

Baltimore City.BaltimoreCityhasanumberof well-establishedschoolmentalhealthprogramssponsoredby theUniversityof Maryland,Baltimoreor JohnsHopkins University. Dr. Joshua Sharfstein, the

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Commissioner of Health in Baltimore, requestedareviewof thecity’sservicemodelandstatedthata “comprehensive and integrated model is clearlythe ideal for any expanded school mental healthprogram”(BaltimoreCityHealthDepartment,2006,p.12). This ideal model would include universalprevention (designed todevelop thesocial, coping,andproblem-solvingskillsof allstudents),selectiveprevention(designedtoidentifystudentsatelevatedrisk of developing mental health problems andprovidethemwithearlyandfocusedinterventions),indicated prevention (designed to provide supportand intervention for students with establishedemotional and behavioral difficulties who do not meet DSM-IV diagnostic criteria) and treatmentservices(therapeuticinterventionsforstudentswithemotional and behavioral difficulties who do meet DSM-IV diagnostic criteria). The result of theCommissioner’s review was a revised Request ForProposalswhoseintentwastoreducethenumberof providersinschools,createonepointof accountability(BaltimoreMentalHealthSystems,Inc. -- theCoreServiceAgencyforBaltimore),andstandardize theschoolmentalhealthprogramsavailablethroughouttheir public schools (Baltimore City HealthDepartment,2006).

Whenanidealmodelof servicesdidnotprovefeasible,Commissioner Sharfstein suggested that a plan bedevelopedunderwhichallBaltimoreschoolswouldreceiveatleastoneof threetiersof intervention(BaltimoreCityHealth Department, 2006):

Tier1-BaselineServicesConsistingof TechnicalAssistanceandTraining

Establishahelp lineforphoneconsultationtoschoolstaffMinimalon-siteconsultationforcrisis

interventionOnlineandhardcopyeducationalmaterialsResource mapping to identify communitysupportsandresourcesTrainingonclassroommanagementIdentification of students in need of mental healthsupportAssistancewithdevelopingreferral

proceduresIdentification of school needs (gaps and resources)

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Tier2-ExpandedServicesforExistingSMHPsEnsureadoptionof universalstandardsContinue evaluation of program efficacyEngageinprofessionaldevelopmentactivitiestoenhanceevidence-basedskills

Tier3-ModelProgramsFullyimplementbestpracticemodel

programsinasmallernumberof schools

New Orleans, Louisiana.Inresponsetothetraumaticevents related to Hurricane Katrina, local socialservice agencies, schools, and national expertsjoined forces to pilot an intermediate and long-term school mental health consultation model forchildren exposed to trauma. The project, calledProject Fleur-de-lisTM, employs three traumainterventions--Classroom-BasedIntervention(CBI),Cognitive Behavioral Intervention for Trauma inSchools (CBITS), and Trauma Focused- CognitiveBehavioral Therapy (TF-CBT). Two interventionpathwaysweredevelopedthatreliedonusingexistingresources and a collaborative peer consultationprocess where community mental health providersoffer consultation to existing school mental healthstaff (i.e., school counselors)on challenging issuespresentedbystudents(Walker,2007).Thecosttofundthecore team is approximately$500,000butwhenfullyfunctionaltheteamshouldbeabletomanagethementalhealthneedsof studentsin60schools.

Illinois. The Illinois Children’s Mental Health Actof 2003ledthewayinpresentingamodelforhowschool districts could strengthen their capacity toidentifyandmeetthementalhealthneedsof studentsinnaturalsettings(schools),withanemphasisonearlyintervention.ThislegislationlaidthefoundationfortheStateDepartmentof Educationtoimplementagrant program, the School Mental Health Supportprogram, and to spend $850,000 to develop thecapacity of schools to provide mental healthsupports for students. Grants under this initiativeencourageschooldistrictstoformalizepartnershipswithcommunitymentalhealthproviderstoprovideschool-based and/or school-linked services by aqualified mental health professional. Funded services include screening and assessment, individual andgroup counseling, skill-building activities, familysupport, teacher consultation, school-wide mental

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healthprevention,targetedgroupearlyintervention,andcrisisintervention.(IllinoisViolencePreventionAuthority,2007).

Ohio. The Ohio Community Collaboration ModelforSchoolImprovement(OCCMSI)isacommunity-centeredmodel,sponsoredbytheOhioDepartmentof Education in collaboration with the Collegeof Social Work at The Ohio State University andthe Department of Psychology and Center forSchool-Based Mental Health at Miami University,that assists schools in expanding their traditionalschool improvement processes, which primarilyfocus on academics, to include efforts to addressnon-academic barriers to learning. This initiativehas already demonstrated early success in buildingcollaborative leadershipstructures tohelp integrateschool-andcommunity-basedresourcesandservices(DawnAnderson-Butcher,personalcommunication,January18,2008).

New Mexico. The state Department of Health,Office of School Health in New Mexico funded a project where five Masters-level clinicians, School MentalHealthAdvocates,provideconsultationandtrainingof educators,healthprofessionals,parents,and other community members in specific regions aroundthestate.Theseindividualsarechargedwithcreating regional networks of schools and mentalhealth providers to expand understanding andlocalcapacityforschool-connectedprevention,earlyintervention, and treatment services for students.Trainingopportunitiesweredevelopedusingpooledresources from the Interdepartmental SchoolBehavioral Health Partnership, a state-level,interdepartmentalcollaborativedevelopedtoexpandschool mental health programs for New Mexico’schildren.Thislevelof infrastructurewasonethestatecouldmanageandmaintain,andthathasdemonstratedsuccessacross thestate (SteveAdelsheim,personalcommunication,February19,2008).

Arkansas.TheArkansasDepartmentof Education,SpecialEducationUnithascreatedtheSchool-BasedMentalHealthNetworkmadeupof programsthatfosteraccesstoafullarrayof mentalhealthserviceswithin Arkansas public schools. This unit withintheDepartmentof Educationmonitorscomplianceamongmembers(schooldistrictsandmentalhealth

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providers) to specific standards and guidelines, and delineatesaprocessforapplicationtotheNetwork.(Refer to Appendix B for the full title of thecorrespondingpoliciesandproceduresmanual).

Texas. The Children’s Hospital Association of Texas (CHAT) commissioned an assessment of children’smentalhealthinTexas(thereportislistedin Appendix B). Among its findings: the authors encourage further development of preventionand early intervention services for mental health,additionalsupport forcommunity-basedcare (suchasservicesprovidedinschools),aswellasagreaternumberof integratedmentalhealth and substanceabuseprogramsforyouth.Inaddition,theauthorswarn about thedetrimental resultsof poor systemcapacityandcoordination,aswellasof thelimitationsof publicandprivate insuranceplanstoadequatelyaddress the mental health needs of the state’sresidents.

School mental health in the District of Columbia: Opportunities and challenges

“I do expect there to be additional resources made available to school-based mental health services. ... This has been the subject of a lot of discussionbetweentheExecutive,theCityAdministrator’soffice,the Department of Mental Health and of course this Committee. Iexpecttheretobeareallystatisticallysignificantincreaseinschoolmental health funds. ... What we have is a very good program that could be made better. This remains a priority of the Mayor, the Chancellor and this Committee.”DavidCatania,Councilmember, Districtof ColumbiaCityCouncil,Chairman,CommitteeonHealth,PublicHearingApril17,2008.

The 2007 swearing-in of Mayor Adrian Fenty andestablishmentof hisnewadministration,togetherwiththeformation of the Office of the State Superintendent of Education(OSSE)andtheappointmentof aChancellorto preside over the DC Public School system are themost significant environmental changes impacting the expansion and sustainability of school mental healthprogramsinD.C.Withnewleadershipinthecityhavecomeadjustmentstocitywidepriorities,revisedgoalsforDistrictagencies,andnewstructuresforaccountability.ThebiggestchallengethispresentstoDMHif itmovesto become a public mental health authority providing

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oversightbutnotdirectserviceforaschool-basedmentalprogramisthatsomerelationships,alliances,andsupportsare no longer present. Thus, during the first year of the Fenty administration, DMH and SCC have moved toinformthenewleadershipabouttheirmissionandgoals.And while gaining the ear of a new administration ischallenging,thealignmentof theDMHSchoolMentalHealthProgramwithothers in theadministrationwhosupportpreventionandearly interventionservicesandsupportsfortheDistrict’syoungpeopleandtheirfamiliescreateson-goingpossibilitiesforProgramgrowth.

Relevant DC Agencies, Initiatives, and Activities That Could Broaden Support for SMH

Office of the Mayor, Deputy Mayor for Education (DME)

TitleVof PublicEducationReformAmendmentActof 2007 (http://www.dccouncil.washington.dc.us/images/00001/20070423153411.pdf)

This piece of legislation established theInteragency Collaboration and ServicesIntegrationCommission(ICSIC)chargedwith“developing a pilot school-based programinvolving school-based clinicians, cliniciantraining,aservices integrationdatabase,andprogramevaluation”andwithimplementingevidence-basedpracticesinschools.

ICSICwillsetprioritygoalsaroundimprovingthe welfare of children in D.C., coordinateinteragency youth initiatives connected toeducation, and develop innovative earlyinterventionprogramsinschools.Onesuchpilot,aroundtheassessmentandcounselingservices provided by ICSIC school-basedclinicians (DC START), is in the earlyimplementationphasebuthasthepotentialtoexistsimultaneoustoboththeDMHSMHPandSCCSMHP.

Citywide goals that drive activities withinICSICare1)ChildrenareReadyforSchool,2) Children and Youth Succeed in School,3) Children and Youth are Healthy andPracticeHealthyBehaviors,4)ChildrenandYouth Engage in Meaningful Activities, 5)

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ChildrenandYouthLive inHealthy,Stable,and Supportive Families, and 6) All YouthMakeaSuccessfulTransitionintoAdulthood.Although programs and services offeredthrough DMH may impact developmentsacross all six goals, DMH has been mostactivelyengagedinaddressingGoal#3.

CapStat review is a performance-basedaccountability process that identifiesopportunities for D.C. government to runmore efficiently and ensure high quality care to itsresidents. D.C.agencydirectorsmustparticipate in these reviews and evaluatetheirperformanceonanumberof goalsandpriorities for children’s health establishedby the Mayor and monitored through theICSIC.

Office of the State Superintendent of Education (OSSE)

Special Education Reform.TherecentagreementreachedintheBlackman/JonesclassactionlawsuitagainsttheDistrictof Columbia requiresDCPSandOSSEtoimplementanumberof reformsthatwouldimpactthecoordinationanddeliveryof servicesforstudentsidentified with disabilities. Most relevant to DMH, theagreementmandatesthatthedefendants“improvethedeliveryof mentalhealth services to students”and that the resulting plan has been developed incollaborationwithDMH(amongotheragencies).

Truancy policy. D.C.Boardof EducationpublishedaResolutiononEnhancing theTruancyPolicy forthe District of Columbia Public Schools (2005)that includedrecommendationsontheuseof earlyinterventionwithstudentsandparentsandindicatedthataggressiveinterventionsforthechildandfamilyshouldbeimplemented.Currently,atruancytaskforce,chairedbytheDeputyMayorof EducationandtheChief Judgeof theFamilyCourtmeetsmonthlyandhasbeenpilotinganearly interventionmodelcalledthe “Byer Model” in which a Judge visits schoolsweeklytomeetwithtruantmiddleschoolyouthandtheirfamilies.DMHhasplayedanactiveroleintheprogramfromits inception.Tothedegreethatthistask force will oversee demonstration projects and

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inform policies and best practices around truancyprevention,DMHshouldremainanactivecontributortothisinitiative.

DC Public Schools“We must make sure that DCPS and DMH realize the extent of thebenefitsthatcanbederivedbyhavingaSMHPproviderintheirschool. Principals who have had successful SMHP programs in their schools need to share the best practices with their colleagues, school communities and other appropriate administrators throughout the District government. We need to make sure the principal knows that there is an investment in time and resources required at the front end but that it is worth it in the end.”PeterParham,formerChief of Staff,DCPublicSchools,personal communication,February23,2007.

The District of Columbia Public Schools MasterEducationPlan(2006)isintendedtodriveallaspectsof instructionbyestablishingdirectionforcurriculumandcoordinatingallelementsthatimpactlearning.

OnegoaloutlinedinthePlanstatesthateveryschool will have a Student Support Team(SST), considered a national best practice.These school-based committees/teams arecentraltoaschool’searlyinterventionprocessandhelp identify students earlywhowouldbenefit from academic and/or behavioral interventions.AccordingtothePlan,teams,madeupof educationandhealthprofessionals,will participate in monthly professionaldevelopmentsessionsonidentifyingresearch-basedinterventionsandcreatinginterventionplansforstudents.TheStateIncentiveGrantpreviouslyawardedtoDCPSboostedeffortsto train school administrators and staff onbestpracticeprinciplesforSST.Theongoingfunding source for this additional level of trainingandthemanagementof SSTsacrossDCPSisnotclear.DMHstaff haveofferedexpertisetoDCPSbyhelpingtoidentifyandimplement evidence-based interventions,assistingwith the trainingofferedtoschoolleadersandstaff,andmostimportantly,beinganactivememberof theSSTinschoolsthathaveaSMHPprovider.

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Asecondgoalof thePlancallsforestablishingpolicies and protocols that invite parentsintotheschoolsandclassroomsasrespectedparticipantsintheirchildren’seducation.DMHSMHPcouldplayacentralroleindevelopingmaterials or conducting workshops to helpcreatewelcoming environments forparentsandfamilies.

DC Health Learning Standards developedby OSSE have been drafted and provideguidance about the content of healtheducation to be provided in the publicschools. The goals of these standards areto teach students the knowledge and skillstheyneedtoreducehealthrisksandincreasepositive health behaviors to ultimatelyenhancetheiracademicachievement.Therearesixstrandsoutlinedinthestandards,allof whichhaveanemotionalhealthcomponent.School mental health providers assigned toschoolscanfacilitatethe implementationof thesestandardsthroughoutallgradelevelsincollaborationwithschool-hiredpupilsupportorhealtheducationstaff.

The Office of Youth Engagement within DCPSprovidesdirectandindirectsupportsto students, families, and schools. This office isresponsibleforthosefunctionsthataddresshealth,wellness,studentsafety,schoolclimate,student discipline, residency verificationand academic supports for hospitalized,homebound and homeless students. Thisoffice is responsible for implementing the federally-fundedPeaceableSchoolsInitiative,supportedbytheTitleIV,SafeandDrug-FreeSchoolsandCommunitiesAct,andaims tobuildandsustainsafe,drug-free,disciplined,and peaceable learning environments inwhichallstudentscanachievehighacademicstandards.OSSEisresponsibleforthefederalTitleIVstatefunctions,whiletheLEATitleIVfunctions remain the authority of the Office of YouthEngagementwithinDCPS. LEATitleIVfundingisbeingallocatedtosupportthe Peaceable Schools Summer Institute,

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peermediationprogramsintheschools,andintensivetruancyinterventionsandsupportsprovided through attendance interventioncenters.

DCPublicSchoolswaspreviously awardedaStateIncentiveGrant(SIG). Onepartof thatSIGinvolvededucatingstaff within47selectedschoolsinPositiveBehaviorSupports(PBS).InschoolswheretherewasaSMHPprovider,he/shewasanactivememberof thePBISlocalschoolteam.Theunderstandingis that OSSE now has authority over thisinitiative, but there has been little mentionpubliclyof thecontinuedcommitmenttothismulti-yearproject.

Whilethepubliccharterschoolshaveaccessto expertise on evidence-based practicesandmentalhealthservicesfromtheStudentSupportCenter(SSC)throughseveralfederalgrantstheyhavebeenawarded,SSCisanotforprofit service agency that lacks the authority todirectplanningforthecharters.ThatrolefallstotheCharterBoardandOSSE.

Department of HealthDistrictof Columbia’sStateHealthPlan

Under Focus Area 18: Mental Health and MentalDisorders(pg.79),theDOHliststheexpansion of prevention-oriented servicesforchildreninpublicschoolsasanobjectiveandtargetsa20%increaseinthenumberof childrenservedthroughSMHPs.Giventhisagency’s interest inseeinganincrease inthenumber of children served through schoolmental health programs, an exploration of theirinvestmentinexpansioniswarranted.

School Nursing Contract with Children’s NationalMedicalCenter(CNMC)

The DOH subcontracts with CNMC tomanage the school nursing program forD.C. By lawallpublicschools inDCmusthave at least a part-time (20 hours/week)nurseavailabletostudents. Consistentwiththe SAMSHA survey (Foster, et al., 2005)schoolnurses inD.C. indicate that theyare

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often the first professional in a school to meet with students experiencing anemotionalorbehavioral problem. Attempts have beenmade,andshouldcontinue,tosupportschoolnurses’abilitytoidentifyandscreenstudentswithmentalhealthconcerns. DMHshouldexplore the possibility of institutionalizingtraining, consultation, and education to theSchoolNurseProgramasawaytoenhancethe skills and competencesof these schoolhealthprofessionals.

AddictionRecoveryandPreventionAdministration(APRA)

APRAisresponsibleforthepreventionandtreatmentof substanceabuseintheDistrictof Columbiaandprovidesoversight,ensuresaccess, sets standards and monitors thequality of services delivered. APRA’sprevention programs and services areadministered through the Office of Prevention andYouthServices(OPYS).OPYSgenerallyutilizesabroadrangeof provenpreventionstrategies (using universal, selective, andindicatedpreventionmeasures),anumberof whichareprovidedinafter-schoolandfamilycenteredenvironments. Twentypreventionprogram grants are disbursed by APRA tocommunity-basedorganizations thatdeliverscienceandevidence-basedAlcoholTobaccoandOtherDrug(ATOD)preventionprogrammodels. Little has been done to integrategoals,objectives,orfundsforDMHSMHPsandAPRA/OPYS.DMHshouldexploreanypossibility forclosercollaborationwith thisagency.

CommunityHealthAdministration(CHA)The CHA’s (formerly the Maternal andFamilyHealthAdministration)TitleVBlockGrantApplication5YearNeedsAssessment(October 2005) cites the need for mentalhealth services, and forprimarypreventionprograms,ashighpriorities inthecity.Thisreport indicates that one of five priority areas are to “Increase awareness of the role of mental health in adolescent risk behaviors,school achievement and perinatal outcomes;

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and increase availability of preventiveservices”(pg.2).TheneedfortheCHAtobe more strategic about collaborating withDMHisnotedandtheirrecommendationto“Establish(andinstitutionalize)acoordinatingcommittee tostrengthensystemlinks”withpublicmentalhealthisaninvitationforDMHtostrengthenit’sinteragencyrelationship.

Early Care and Education Administration“Linking school mental health to a model like this, as a way to sort out what we might do for children that are younger so they are ready to learn, is very promising”.BarbaraKamara, formerDirectorof EarlyCareandEducationAdministration,personalcommunication,August7,2007.

The Early Care and Education Administration(ECEA)providessupportforandcollaborateswithotherpublicandprivatechildandfamilyorganizationstoformulateaneffectivecontinuumof servicesandcareforDistrictchildren5yearsof ageandyounger.ECEAalsoprovidesaccesstobeforeandafterschoolservicesforeligiblechildrenuptoage12.

There are a number of activities that are focusingontheearlychildhoodmentalhealthneedsof DC’syoungest residents. The Early Childhood MentalHealth Taskforce, a subcommittee of the Mayor’sAdvisoryCouncilonEarlyChildhoodDevelopment,is examining best practices in the promotion of mentalhealthandsocio-emotionallearningwithinthe0-5population.TheEarlyChildhoodComprehensiveSystems Steering Committee, of which DMH is amember,isfocusedonthedevelopmentof asystemof care approach to benefit young children and their families.

Important Committees and Council members within the City Council of the District of Columbia

DavidCatania,Chairman,CommitteeonHealthVincent Gray, Chairman-At-Large and Chair of the Council’s Special Committee to Prevent YouthViolenceTommy Wells, Chairman, Committee on HumanServices

AdditionalcityagenciesthathavecollaboratedinthepastwithDMHaroundtheSMHPincludetheMetropolitan

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PoliceDepartment,Departmentof ParksandRecreation,ChildandYouthServicesAdministration,Departmentof HumanServices,andtheYouthRehabilitationServices.Although specific information about these agencies is not includedhere,anexaminationof theirpreventionandearlyinterventioninitiativesandprioritieswouldgreatlyserveDMH inorder to forward the integrationof supportsofferedinschoolsettings.

Recommendations for DMHPrimary Recommendations

At present there are a significant number of plans and initiatives that aredriving thedevelopmentof school-connected interventions for youth in D.C.(refer to Appendix F for a list of school healthprograms and initiatives for 2008). AlthoughICSICisintendedtocoordinatechildren’sprograms,initiatives, and funding, fragmentation continuesto affect management, implementation, andpriority-setting of child health initiatives. Thebroad scope of the Commission makes a focuseddiscussion on school mental health programs andpolicies difficult. Furthermore, the law establishing theICSIClimitsitsmembershiptoDistrictagencies,preventing direct input from public charter schooladministrators, community health and mentalhealth providers, academic institutions (i.e., D.C.universities and colleges), and other non-profit or privateorganizationswithavestedinterest inchild-serving initiatives. Given these weaknesses, DMHleadership might suggest leading or co-leading anICSIC workgroup specifically on school mental health thatwouldencourageparticipation fromadditionalorganizationsinD.C.Thisworkgroupwoulddesign,implement,evaluateandadvocateforan integratedschoolmentalhealthmasterplanthatwouldincorporateall related mandates and programs across cityagenciesimpactingpublicschools.(AppendixGoffersaguideformappingexistinginitiatives.)

Secondary RecommendationsAlthough theClinicalAdministratorof Preventionand Early Intervention Programs from DMHparticipates in a number of meetings about thedevelopment of children’s services in DC, theDirector of DMH and his staff (i.e., the Directorof Children’sServices,theClinicalAdministratorof Prevention and Early Intervention Programs, and

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theProgramManagerof theSchoolMentalHealthProgram)shouldcontinue tomonitorand trackallchild-related initiatives, activities, and reforms inorder to expand and sustain school mental healthprogramsinD.C.Buildingcitywidealliancesrequiressustainededucation,advocacy,andnetworkingbytheleadadministratorsatDMHwithcolleaguesacrosscitygovernmenttoensurethewell-beingof theprogram.Meetinginformallywithcorrespondingadministratorsateachkeyagencylistedabove,at leastannually, tohighlightprogressonprojects/programs,outlinenewinitiativesforthefuture,anddiscussopportunitiesforcollaborationwillfostertheinter-agencysupportvitaltothecontinuedsuccessof theSMHP.

Giventhehighratesof suicideattemptsintheDistrictand the significant risk among GLBTQ youth in particular, preventing suicide among youth shouldbe a public health priority for DMH and DOH.DMH, through the previously awarded SAMHSASTOPSuicidegrant,engagedinaproactivestrategyforpreventingsuicidethat includedevidence-basedscreening, classroom-based prevention strategies,and gatekeeper training implemented primarilyby the DMH school mental health clinicians. Inaddition, in 2007, DMH submitted their ChildMentalHealthPlantocityadministratorswithgoalsrelatedtoreducingdepressionandpreventingsuicideamongyouth. Logically, thesepreliminaryactivitieswould culminate in thedevelopmentof a citywidesuicide prevention plan that includes school-basedinterventions. Unfortunately, there isnosuchplanin DC, although 47 of 50 states have a statewidesuicidepreventionplancurrentlyinplace(seeSuicidePrevention Resource Center; http://www.sprc.org/stateinformation/plans.asp). SAMHSA has alsopreviouslymadefundingavailablethroughtheState/TribalYouthSuicidePreventionGrants(alsocalledthe Cooperative Agreement for State-SponsoredYouthSuicidePreventionandEarlyIntervention)toassist states in thedevelopmentof theirplans andfuturefundingmaybeavailableagain.Theabsenceof a citywide plan signifies a lack of appreciation for theseverityof the risksexperiencedbyDCyouth.Suicidepreventionmustbeelevatedtoamuchhigherlevelof importanceamongDOH,DMH,andOSSEleaders.

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SECTIONIII:FINDINGSANDOBSERVATIONS

While direct provision of services requires investment in staffing, supervision, training, and clinical documentation, overseeing direct provision of services requires investment in an institutional infrastructure that enables the contracting agency to carry out its obligation to assure that those who are served receive the right care in the right way at the right time. And a corollary of the oversight function is assuring that the direct provider organizations have the capacity to provide the needed services.

“The school-based mental health program works. We are very excited about its growth and plan to continue this expansion early next year.”StephenT.Baron,Directorof theDepartmentof MentalHealth,DMHPressRelease,November21,2007.

Organizational management

There is no consensus on ‘best practices’ in themanagement of school mental health programs at thestatelevel,especiallyasitrelatestoarrangementsbetweenschooldistrictsor localschoolsandcommunitymentalhealth providers. State public mental health agenciesdonottypicallyprovidedirectservicesintheschoolstostudentsandtheirfamilies,buttheydosubcontract,eitherdirectlyorindirectly,throughvariousarrangementswithcommunitymentalhealthproviderswhodelivermutuallyagreeduponservices(Brener,2007).Whiledirectprovisionof services requires investment in staffing, supervision, training, and clinical documentation, overseeing directprovisionof servicesrequiresinvestmentinaninstitutionalinfrastructurethatenablesthecontractingagencytocarryout its obligation to assure that those who are servedreceivetherightcareintherightwayattherighttime.Andacorollaryof theoversightfunctionisassuringthatthedirectproviderorganizationshavethecapacitytoprovidetheneededservices.

There are various options that are available withrelative advantages and disadvantages with regardto quality control and cost effectiveness. In sum, inplanninghowtoexpandschoolmentalhealthprogramsin the city, DMH will need to do three things: confirm theavailabilityof community-basedproviderswhoarecompetent and willing to provide or effectively linkprevention, early intervention, and treatment servicesfor children and their families in schools; delineate the functions that DMH will undertake if it assumesan oversight role, and identify the resources andinstitutional structures essential to do its new job. Asnoted above, most states are not in the business of direct service delivery, but instead function as statepublicmentalhealthauthorities.

What the research and the experts say about organizing school mental health programs

Althoughnationalprinciplesforbestpracticesinschoolmentalhealthhavebeendeveloped(Weist,etal.,2005),these principles do not yet provide specific guidance to state and local agencieson implementation. Amentalhealth authority should generally perform five main functions: 1) foster and monitor high quality care through performance-based accountability and qualitymanagement processes, 2) provide technical assistanceandtrainingaroundprogramsandpracticesthatwouldstrengthenthedeliveryof schoolmentalhealthservices,3)createand implementanadvocacy/communicationsstrategy that successfully engages leading stakeholdersand decision-makers about the public health approachto school mental health, 4) build sustained and variedfundingtosupportthecontinuumof servicesprovidedthrough school mental health programs, and 5) createand/or support policies that ensure high qualitycomprehensivementalhealthcare.Whileeffortstostrengtheninternalsystemsoperationsare underway, DMH will need to simultaneouslyexamine ways to mobilize external resources so thatthegoalsof integration,sustainability,andtheultimateinstitutionalization of school mental health programsareachieved.PatiencewillberequiredbyDMHanditsstakeholderswhilethisprocessplaysoutsinceanumberof years are required before system-wide reforms and



organizational changes take hold and yield desiredimpacts (Chorpita & Donkervoet, 2006; Daleiden, Chorpita, Donkervoet, Arensdorf, & Brogan, 2006).


Althoughfocusedonstateandlocaleducationagencies,the recently launched School Mental Health CapacityBuilding Partnership (CDC funded initiative managedby the National Assembly on School-Based HealthCare- NASBHC) offers insights that are applicable.This initiative aims to improve access to high quality,school-based mental health services by disseminatingmodelmentalhealthpolicies,programs,andservicestoStateEducationAgencies (SEAs)andLocalEducationAgencies (LEAs). An in-depth analysis of schoolmental health policy and practice in four states(Maryland, Missouri, Ohio and Oregon)identified challenges commonly experienced.Typically the four states:

Lacked a unified statewide vision for school mental health, lacked a statewide agenda, and experiencedfragmentation/duplication of programs across thestateLacked organizational infrastructure andaccountabilitymechanismsLacked sustainable funding models to supportcomprehensiveschoolmentalhealthprogramsContended with attitudes that believed that therequirements for academic progress requiredlimitationsonschoolmentalhealthprogramsHadlimitedyouthandfamilyinvolvementHad limited professional development andpre-servicetrainingforeducatorsandmentalhealthprovidersHad difficulty identifying and implementingevidence-based SMH programs and modelsappropriateforschoolsettingsLacked effective social marketing or publicawarenessefforts,andLacked coordinated and uniform data collectionsystems

Similar to Maryland, Missouri, Ohio and Oregon theDistrictof ColumbiaandDMHstrugglewithamajorityof thesechallengesthatwillrequireremediationbeforestrongstatewideprogramsemerge.

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Making it happen: strengthening and improving systems operationsImprovements in child academic, emotional, andbehavioral functioning require greater attention byDMHaswell asotherDistrict agencieson theuniqueneedsof youth.TheDCBehavioralHealthAssociation(BHA),anorganizationof mentalhealthprovidersinthepublicandprivatesectorsthatprovidecommunitybasedmental health and support services, identified a number of barriers and proposed solutions to the delivery of children’s mental health services. The mission of theBHAistoexpandandimprovecommunitybasedservicesthroughitsactivitiesinpolicyadvocacyandprofessionalstaff development. In a proposal provided to DMH,the BHA states that the Children’s Division of DMHis“severelyunderstaffedandunderdeveloped”andthatDMH should hire staff specifically assigned to develop children’sservices(Districtof ColumbiaBehavioralHealthAssociation,2007).Further,asisthecasewiththeStudentSupport Center (SSC), a number of children’s mentalhealthproviderswhoaremembersof BHAare leavingtheDMHMedicaidstructurebecausetheyareunabletomeet theirexpenses throughDMHbillingmechanismsandcannotaffordtoremainaCoreServiceAgency(E.Brooks,personalcommunication,February8,2007).Thisexodus results in fewer qualified providers and diminished clinicalcapacityforSMH,negativelyimpactingplansforprogramexpansion.

The majority of the offices within DMH are structured to support the implementation of the Mental HealthRehabilitation Services (MHRS) system, the fee-for-servicemodelthatallowstheDistricttobereimbursedby Medicaid for delivering mental health services. Asnotedbytheformerdirectorof behavioralhealthservicesfor SSC, in order for SMHPs to survive and thrive acommunityneeds“theorganizational investment tobethere inspiteof thefactthat individualscomeandgo-thishastobeanorganizationalprioritythatissupportedbyadequatelocalandstatefundingsources.”(O.Bubel,personalcommunication,August31,2007).Suggestionsare offered below on adjustments to the roles andfunctions of various DMH offices that would facilitate thecontinueddevelopmentof SMHservicesinD.C.

Child and Youth Services Division, Prevention and Early Intervention ProgramsThe Deputy Director of the Office of Programs, Policies,andPlanning(OPPP)overseesthedevelopment,management,andfundingforallchildandadultmentalhealthservicesofferedthroughDMH.TheDirectorof Child and Youth Services, who reports to the DeputyDirector, is in chargeof all child and youth initiativesand services atDMH,bothprevention and treatment.TheDirectorof ChildandYouthServicespositionwasvacant for six months and the position was filled in the Fallof 2008.TheCYSClinicalProgramAdministratorforPreventionandEarlyInterventionProgramsreportstotheDirectorof ChildandYouthServices,whothenreportstotheDeputyDirectorof OPPP,andmanagesa number of prevention/early intervention initiatives,includingtwoschool-connectedprograms,theSAMHSAfundedSTOPSuicidegrantandtheSchoolMentalHealthProgram(SMHP).TheClinicalProgramAdministratorissupportedbytwoadministrativestaff thathelpmanageanumber of grant awards and a significant number of staff. (AppendixHoutlinesatableof organizationfortheOPPPandthePreventionandEarlyInterventionProgramsatDMH.)InadditiontoaProgramManager(whohandlestheday-to-dayoperations), the48clinicianswithin theSMHPhaveaccess toandaresupportedbyevaluationstaff (anEvaluationManager andProgramEvaluator)andthreesupervisors(asupervisorypsychologistandtwosupervisorysocialworkers).

Quality Management and Performance-Based AccountabilityThere are four main offices/divisions within DMH that have direct influence on the agency’s ability to hold providers accountable for meeting high quality standards: the Office of Accountability, Office of ProviderRelations,ContractsandProcurement,andInformationSystems. The role of each office as it relates to the managementof schoolmentalhealthprogramsunderanauthorityarrangementisoutlinedbelow.

Office of AccountabilityThe Office of Accountability provides input regarding all issues involving provider compliance with MentalHealth Rehabilitation Services (MHRS) certification standards.WithregardtoprovidingfutureoversightoverSMH programs, this office would monitor providers and



agenciesofferingschoolmentalhealthservicesthroughcontracts let through DMH and implement qualitymanagement review procedures and audit activities tomonitorperformance.Wehavelearnedfromseveralcountiesandcitiesaroundthecountrythatinordertoeffectivelymonitorthequalityof mentalhealthservices,thoseworkingto assure accountability should have expertise in thecontentareasmonitored.Forexample,theMontgomeryCounty Department of Health and Human Servicesemploysalicensedcliniciantomonitorcontractsfortheirschool-basedmentalhealthprograms.WehaveincludeddocumentsinAppendixBfromothercities/states(e.g.,Seattle,WA,Baltimore,MD,TexasDepartmentof StateHealthServices)thatdetailrequirementsmadeof vendorsaspartof theiragreementwiththecontractingagency.If a unique certification of school-based providers is developed in the future, this office could also assist in the implementationof thatprocess.

Office of Provider RelationsThis office provides input to DMH on clinical/administrative issues specific to the MHRS community mental health provider. The office plays an important consultative role and is the liaisonbetweenDMHandcommunity mental health providers. Staff within thisoffice could help strengthen the capacity of agencies delivering school-based mental health care throughtraining,coaching,andmonitoringof care.Inaddition,ProviderRelations liaisonscouldidentifygaps inpolicyand practice guidelines from a provider’s perspectivethat would improve the delivery of services tochildrenandtheirfamilies.

Contracts and Procurement OfficeStaff within this office manage the contracting process and ensure that binding agreements are developedand competed in compliance with DC governmentregulations.Theprocurementprocesscandrivequalityand the implementationof policiesdeemed importantto creating a cohesive vision for public mental health.ARequestforProposals(RFP)forSMHshouldoutlinenationalbestpracticesandstandards,withincentivesthatreinforceadherencetopoliciesandstandards.Inaddition,RFPscansetperformancemeasures/indicatorstogaugecontractorprogress.Forexample,Seattle,WAprovidesapercentageof theirpaymenttoacontractoronlywhencertaintargetsaremetandtheTexasDepartmentof State



Health Services has issued an RFP that details specific performancemeasureguidelinesforapplicantsexpandingtheirmentalhealthservicesinschools(seeAppendixBfor theseRFPs). Accountabilityprocessescanalsobeoutlinedincontracts,suchasisfoundinCharlotte,NCwhere internalutilizationandrandomchartreviewsarerequiredonaregularbasis.

Thecontractingprocess isonewaytoensureparticularstandardsandperformancebenchmarksaremet.DMHcan also set standards around staffing ratios (i.e., the number of FTEsperschool),staff diversity,educational/trainingqualifications, and can determine allowable contracting periods(allowingforclinicianstobeemployedduringa10-monthschoolyearasopposedto12months).TheRFPshouldsupporttimeforsupervision,qualitymanagementactivities,andstaff meetingssincetheseactivitiesincreasethelikelihoodthatqualitycareisprovided.

Office of Information SystemsThe degree to which DMH can monitor services andperformanceof providers isdirectlydependentontheamount and quality of data collected from provideragencies.Oneof themainweaknessesof theDMHSMHP,as noted by the Office of the Inspector General (OIG), isthecontinuedabsenceof anelectronicdatasystemforcollecting, storing, analyzing, displaying, and reportingdata (OIG, 2008). The Office of Information Systems hasreviewedplansforaweb-basedprogramtobeusedwiththeDMHSMHPbuttodatenoinformationsystemhas been developed. This office should develop a plan of actionfortheimplementationof aninformationsystemwithabillingplatformthatwouldhelpDMHmonitorprogressandoutcomesamongschool-basedmentalhealthprogramsacrossthecity.Othercityagencieshaveofferedtheirsoftwareprogramstocollectdata,butDMHisnotclearhowcompatiblethesesystemsarewiththeirbroaderbillingsystems.Whateversystemischosen,itwillneedtobeincompliancewithregulationsdistributedthroughtheDC Office of the Chief Technology Officer (OCTO).

Technical Assistance and TrainingThe DMH Training Institute was created to providethe agency with system-wide staff development and“to develop strong working relationships with localuniversities and other professional resources, and toprovideacontinuouslearningenvironmentforconsumers,community stakeholders, staff and providers.” The

Training Institute should continue to provide trainingfreeof chargearoundbestpracticesandevidence-basedprograms, strategies and tools that would foster dual-diagnosiscapabilitieswithchild-servingproviders,aswellasclarifythemandatesandpoliciesenforcedbyDMH.Astrongerfocusoncriticalissuesandeffectivepracticesin school mental health would aid efforts at capacitybuilding. (Please refer to the “Training/ProfessionalDevelopment”sectionformoredetailedinformationandrecommendationsontraining.)

Advocacy/Communications StrategyThe Communications Office within DMH manages communicationsacrossagencies,withthecommunity,andwithvariousmediaoutlets.Tosupportthedevelopmentof SMH programs, a communications strategy fordevelopinganddisseminatinginformationandprogressregularly with stakeholders would help brand schoolmentalhealthservicesandsustainthisparticularinitiative.Currently there is no systematic way in which DMHdisseminatesinformationaboutSMHPtothepublicorits elected representatives. The Office of Consumer and FamilyAffairscouldalsobehelpfulinlinkingDMHtosocialmarketingeffortsorstigmareductioncampaignsaimed at consumer groups, parents, youth, and otherstakeholdergroups.

Sustained and Varied FundingDMHplaysakeyroleinilluminatingviablefundingoptionsavailabletosupportthemaintenanceandexpansionof SMHPs,aswellasleveragingexistingdollarswithinDMHandinothercityagenciesinvolvedinimprovingschoolhealthcare.(Pleaserefertothe“Financing”sectionformore detailed information and specific recommendations on financing.)

Policy/Standards DevelopmentThere are a number of offices and staff within DMH thathaveinputintothecreationanddisseminationof mental health policies and practice standards (i.e., Office of StrategicPlanning,PolicyandEvaluation,GeneralCounsel,ProviderRelations,Accountability).Someof theseindividualswouldalsomonitorandclarifyexistingpoliciesandregulationsthatimpactSMHservicedelivery,suchaspoliciesrelatedtodatacollectionanddissemination,legalissuesaroundinformationsharingandprivacylaws(MentalHealthInformationAct,DCMinorConsentLaw,MentalHealthEstablishmentAct,



HIPPA,andFERPA),andprocessesforconsentingforservices.DMHshouldalsopartnerwithotheragenciesandorganizationsinD.C.inthedevelopmentof policiesandplansthatsupportpreventioneffortscitywide(i.e.,statesuicidepreventionplan,socio-emotionallearningstandards,childhealthstandards,etc.).

Our investigation found that there are no nationaluniform school mental health practice standards. Fewstateandcountymentalhealthagencieshavedevelopedpracticestandardsforschoolmentalhealthprofessionalsor practice guidelines for the scope, duration, andfrequencyof servicesoffered.NewYorkCityusestheirstateoutpatientmentalhealthstandardsandappliesthemto certified providers working in schools. In most other states,aclinicianpracticesunderrequirementssetforthbytheirstatelicensingandcredentialingboard(Weist&Paternite,2006).Withstrongerservicestandards,clearreportingrequirements,trainingandconsultationsupport,aswellasasmoothcontractingprocess,therewouldbeagreateropportunitytoengagelocalcommunitymentalhealth agencies in addressing children’s mental healthproblems.Aspartof theagreementdevelopedbyDMH,SSC and CHHCS, draft practice standards for schoolmental health have been developed that reflect standards developedforsimilarschoolhealthprogramsacrossthecountry (see Appendix I: Template for the Development of StandardsforSchoolMentalHealthProgramsinD.C.).Itisrecommendedthatthisdraftbeusedastartingpointfor seeking community input that can lead to a final product.

Mobilizing ResourcesIn expanding school mental health services, DMHmust strengthen mechanisms for communication andcollaboration within the agency, between the agencyand other public entities in the District, and betweentheagencyandcommunityorganizations.Thecreationof mechanisms for cross-communication and thedevelopmentof structures to fostermissionalignmentandsharedadvocacyareessentialforsuccess(Hunter,etal.,2005).Acommonagendaandsharedownershipof

theSchoolMentalHealthProgrambetweenpublicmentalhealthandeducationisessential,butitisalsoimportantthatDMHcollaboratewiththepublichealthagencyanditsschoolhealth initiativesaswellaswithchildwelfareandjuvenilejusticeagenciesaroundinitiativesfocusedonthepreventionof social,environmental,andpersonalriskfactors.

Otherstates/citiesthathavebuiltcollaborativepartnershipsinclude:

Texas. The Texas Collaborative for EmotionalDevelopment in Schools (TxCEDS) project, thatincludesrepresentativesof numerousorganizations(i.e.,TexasEducationAgency,severalTexasschooldistricts, Regional Education Service Centers,TexasAssociationof SchoolPsychologists, severalUniversities, numerous state departments andcommissions, and Family to Family Network), aregenerating activities to develop a guiding policyfocusedon thewell-beingandmentalhealthof allstudents; identifying barriers to student learning and performance; identifying existing and emerging evidence-based interventions and systems of support; anddesigningasystemforaccessingandreportingdata.ThisCollaborativehasdevelopedaTexasSchool-Based Social/Emotional Wellness Model based onthe framework of the Positive Behavior Supports(PBS)thatwillrecommendpoliciesandpracticestosupportschool-ownedprogramsthatare integrated(orbraided)withcommunity-ownedresources.

Maryland. To build a systematic state initiative forschoolmentalhealth(SMH),andto integrateotherinitiatives(suchasPositiveBehaviorSupports-PBS),keylocalandstateagenciesinMaryland,alongwiththeir national partners, formed the School MentalHealthAlliance.Thegoalof theAllianceistoadvanceschool-mentalhealthsystemintegrationinMaryland,and it involves the Maryland State Department of Education, the Governor’s Office for Children, the MarylandCoalitionof FamiliesforChildren’sMentalHealth,theMarylandDepartmentof JuvenileServices,andtheMentalHygieneAdministrationDepartmentof HealthandMentalHygiene,amongothers.

Illinois.TheIllinoisChildren’sMentalHealthActof 2003 created the Illinois Children’s Mental Health

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Our investigation found that there are no national uniform school mental health practice standards.



Partnership (ICMHP), a collaboration of stateagencyleadersandotherkeystakeholdergroups,andchargeditwithdevelopingthestate-wideChildren’sMentalHealthPlancontainingshort-termandlong-termrecommendationsforprovidingcomprehensive,coordinated mental health prevention, earlyintervention,andtreatmentservicesforchildrenfrombirth to age18. (Refer toAppendixB for IllinoisChildren’sMentalHealthPartnershipStrategicPlanfor Building a Comprehensive Children’s MentalHealth System in Illinois, 2006 Annual Report totheGovernor). Thepartnership isalsoworkingtointegrate state-wide initiatives including PositiveBehaviorSupport(PBS),Socio-EmotionalLearning(SEL)standards,SMHSupports,studentassistanceprograms,andResponsetoIntervention(RTI).ThepartnershipincludesrepresentativesfromtheIllinoisState Board of Education, Illinois Department of Human Services, the Office of the Governor, and manyothers.

Michigan. TheMichiganDepartmentof Education,MichiganDepartmentof CommunityHealth,andtheSchoolCommunityHealthAllianceof MichiganwererecentlyawardedagrantbytheUSDepartmentof Educationtodevelopastatewidepolicy,theStudentMentalHealthLinkagepolicy,whichwouldcoordinateschoolandcommunityservicesforchildrenthroughthe formation of an Integration of Schools andMentalHealthCommittee.

Berkeley, California. The goals of the BerkeleyAlliance, a partnership between the Berkeley Unified SchoolDistrict, theCityof Berkeley, theUniversityof California-Berkeley, and Berkeley communityorganizations,werebroadenedtoincludeafocusonthe integrationof schoolandcommunityresourcesaimed at improving student wellness and learning.TheinitiativeisbeingcalledtheBerkeleyIntegratedResourcesInitiative(BIRI),andthoseinvolvedinBIRIwillutilizetheComprehensiveSystemicInterventionFramework(refertotheCenterforMentalinSchoolsfor more information on this framework, http://smhp.psych.ucla.edu)inordertodevelopacontinuumof interconnectedinterventionsystems.

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Communication and Collaboration“The partnership with education is really critical. One of the big misunderstandings is that prevention competes with deep end interventions, but we can do a lot to reframe and rethink this issue”. JoyceSebian,SeniorPolicyAssociate,NationalTechnicalAssistanceCenterforChildren’sMentalHealth,personalcommunication,January4,2008.

Partnership development at the agency level andinterdisciplinarycollaborationarecriticaltothesuccessfulexpansion of SMH (Rappaport, Osher, Garrison,Anderson-Ketchmark,&Dwyer,2003).Everyindividualinterviewed for this report stated that “it’s all aboutthe relationships”when it comes to thekey ingredientof sustained collaboration. Dr. Al Zachik, AssistantDirector,ChildandAdolescentServices,MarylandStateDeptartmentof HealthandMentalHygienestates“successof school mental health really is a matter of personalrelationships and building collaborative partnerships”(personalcommunication,January15,2008). Someof ourkeyinformantsnotedthattheNoChildLeftBehind(NCLB) legislationand its accountabilitymeasurescanmake it difficult to maintain the attention of education partners.Understandingeducationmandatesandlinkingearly intervention/early identification initiatives to these mandateswill improveopportunities forDMHto linkwith education efforts and align with programs, suchasSSTandPBS,used in thepublicandpubliccharterschools. One way to facilitate communication andinstitutionalizecollaborationistoestablishjobpositionsand/orprogrammaticinitiativesthatarejointlyfundedbyseveralstateorlocalagencies.

Efforts that have integrated the work of severalagencies in other states and localities include:

Ohio. The Ohio Department of Mental Health(ODMH)and theOhioDepartmentof Education(ODE) jointly funded the Ohio Mental Health

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Some of our key informants noted that the No Child Left Behind (NCLB) legisla-tion and its accountability measures can make it difficult to maintain the attention of education partners.

NetworkforSchoolSuccess,asetof actionnetworksin six regionsof Ohio that areworking to informstakeholdersabouttheavailableschool-basedmentalhealthresourcesintheirarea.

Pennsylvania.ThePennsylvaniaStateDepartmentof Mental Health and Substance Abuse and the StateDepartmentof Education areworking together toimplementPBSinallschoolsacrossthestate.TheDepartments of Mental Health, Education, andHealth are also jointly funding the implementationof studentassistanceprogramsacrossthestateasanimportantearlyinterventionprocess.

Illinois. In Illinois, the State Board of Education,the Department of Human Services, Division of MentalHealth,Departmentof JuvenileJustice,andthe Illinois Children’s Mental Health Partnership(ICMHP) jointlyappliedandwereawardedagrantfromtheUSDepartmentof Educationtofundtwopositions (oneat theBoardof EducationandoneattheDivisionof MentalHealth).Thesetwostaff members will work together to provide technicalassistance to schools funded by the 2007 SchoolMentalHealthSupportGrants,formalizeagreementsbetweenthestatepartners,andtodevelopastate-levelevaluation process. Both the Board of EducationandtheDivisionof MentalHealthplantocontinuefundingthesepositionsafterthegrantendsaspartof theirplanforsustainability.

California. The California Department of MentalHealth has agreements with the State Departmentof EducationandCaliforniaDepartmentof HealthServicestofundpositionstoimproveintegrationandsustainabilityof schoolhealthservicesandhaveusedsomeadministrative funds fromtheMentalHealthServicesActforthispurpose.

New York City and Baltimore, MD.InNewYorkCity,thepositionof Directorof SchoolMentalHealthServicesintheDepartmentof EducationwasestablishedandfundedjointlybytheDepartmentsof EducationandHealthandMentalHygiene.Similarly,theCoordinatorof SchoolMentalHealthatBaltimoreMentalHealthSystems,Inc.isajointlyfundedpositionsupportedbythelocaleducationandmentalhealthagencies.

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Building Program ChampionsMany interviewees concurred that champions areneeded inside the participating systems to advancethedevelopmentof schoolmentalhealth services. InMaryland, SouthCarolina, andCaliforniaparentshavebeenstrongadvocatesinmaintainingorexpandingSMHservicesinthoseStates.Asnotedbyastatementalhealthadministrator,“parentsareunderutilizedintermsof theiradvocacyandtheirabilitytogeneratethecompellingneedfortheleadershipacrosssystemstoaddressschoolmentalhealth.Astrongparentvoicecanmakeabigdifference.”(K.Rietz, personal communication, January 17, 2008).Whileparentparticipationhas longbeenrecognizedasa key piece to program effectiveness, big agendas andlimited staffing can get in the way of developing a long-termstrategyforparentinclusion.Furtherconsultationwith thosewhohavehadsuccess in thisarenamaybefruitfulstrategiestopursue.

Recommendations for DMHDMHshouldbeacknowledgedfortheestablishmentof a nationally recognized program. There are additionalconsiderations that may strengthen the organizationalstructureandmanagementof thisexpandingprogram.

Primary RecommendationsOnce DMH has evaluated the costs and benefits of using contracted providers to staff the SMHPa determination should be made of the long-termfeasibilityof thisapproach. Regardlessof whetherDMH remains the direct provider or subcontractsthat service, there are significant management costs thatDMHwillincurandareallocationof resourcesthat DMH must consider if it is to provide sufficient oversighttotheprogram.

Secondary RecommendationsEvaluatetherolesandresponsibilitiesof keyDMHadministratorsanddelineatetasksmoreappropriately.For example:

Clinical Administrator of Preventionand Early Intervention Services –alignsinteragencymissions,buildsrelationshipswithimportant stakeholders including educationleaders, participates in key leadershipmeetings, helps to develop overarchingplansforchildren’sservices,helpsdetermine

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supportingfamilyandcommunity involvementandconsultationmayalsobeapathworthpursuing.Institutionalize program and services informationinto existing orientation programs. For example,DMH can help orient new principals to some of thecritical issuesfacingtheirstudentsandteachers.DMHshouldalsohostanannualorientation/planningmeetingwith school leadership asway togaugeorreaffirm commitment, share new information, and build a network of supporters. In order for thisto be successful, this requires the support of theChancellor and the Office of State Superintendent of Education.

Program development and evidence-based practices

The establishment of school-based mental healthprograms require the developer to find a balance betweenaddressingtheuniqueneedsandcharacteristicsof individual students and individual schools andinstitutionalizingwhat constitutes ‘bestpractice’ in thecareof allstudents.Toachievethosegoals,aprogramhas to adopt both specific evidence-based programs to be usedinschoolsandconsultwitheducators,families,andtheProgram’smentalhealthprovidersontherealworldapplicabilityof theinterventionschosen(seeAppendixJforalistof evidence-basedandpromisingprogramsusedintheDMHSMHP).Akeystepindevelopinganeffectiveschoolmentalhealthprogramisgathering informationontheneeds,availableresources,andgapsinservicethatcan inform program administrators and mental healthprovidersaboutthemosteffectivestrategiestoachieveprogramgoals.

While the value of evidence-based programs inachievingdesiredprogramoutcomesseemsself-evident,the challenges to identifying the right programs andimplementingthemsuccessfullyarelesswellunderstoodandfrequentlyunderappreciated.Theimpactof particularschool-basedmentalhealthinterventionsisdeterminedbya number of factors: receptivity of the school staff and student body, the fit between the types of interventions and theneedsof thestudentsand theschool,and theskillsof thementalhealthclinicianorschoolstaff memberproviding the interventions. In this sectionwe reviewboth research and experience related to implementingevidence-based programs and conclude that insufficient

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citywide priorities for children’s health andassists with decisions about service andprogram expansion, advocates for a publicmental health model that includes schoolmentalhealthprograms,createsopportunitiesforbraidedfundingforSMH.Managerof SchoolMentalHealth-developsrequest for proposals, drafts program,clinician, and supervision standards andcertification processes, helps organize and implement relevant trainings, conductsoutreach to localprincipalsandassistswithcommunity awareness and education, aidsin thedevelopmentof qualitymanagementmechanismsincludingmonitoringof programfidelity.Staff within other divisions - programevaluationstaff wouldcollectandsummarizekey data; accountability staff would monitor contractors providing school mental healthservices; provider relations staff would assist agencies in implementingDMHregulationsandrequirements.

Implementacommunications/socialmarketingplanthatwouldbrandtheSMHmodelandsimultaneouslyexplain the role of mental health prevention andearlyinterventionwithinasystemof careframework.This would address fears that funding preventionwill mean less money for those needing intensiveservices.Theplancouldinvolveaweb-basedstrategyto educate local constituents of developments inchildren’s mental health, which could be modeledafterawebsitecreatedforthegreaterCincinnatiarea(see http://www.mindpeacecincinnati.org/aboutUs.shtml#jlctext).Inaddition,communicationstrategieswouldincludetacticsforregularlysharinginformationwith stakeholder groupson theprogress for SMHprograms (e.g., monthly newsletter for principals,news storyorOp-Ed for thenewspaper, quarterlybriefstothechancellor/mayor).Identify localchampionswhocanadoptthiscause,including finding ways to have family advocates centrallyinvolvedandinsomecases,leadingtheway.The School Mental Health Coalition, an advisorygroupfortheDMHSMHP,canandshouldbeusedmore effectively in forwarding some of the goalsrelatedtothecommunicationandadvocacyneedsforSMH in D.C. Exploring the possibility of financially

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attention to any one of these factors can significantly undermineattemptsatpositiveoutcomes.Thetimethatcommunities,organizations,andindividualsdedicatetomaking careful judgments aboutwhat interventions touseandhowtoimplementthemarewellworththetimededicated.Overview of what the research and the experts say

Thereisagooddealof helpavailabletoDMHandthecityasitplanstoimplementhighqualityprograms.Thefederal Substance Abuse and Mental Health ServicesAdministration (SAMHSA) defines a prevention or treatment intervention as evidenced-based if it drawson theory and if it has undergone ‘scientific’ evaluation. Thementalhealthauthorityinthestateof Oregonusesabroader definition by stating that evidence-based practices are“programsorpracticesthateffectively integratethebest research evidence with clinical expertise, culturalcompetenceandthevaluesof thepersonsreceivingtheservices.Theseprogramsorpracticeswillhaveconsistentscientific evidence showing improved outcomes for clients, participants or communities. Evidence-based practicesmayincludeindividualclinicalinterventions,population-based interventions,or administrative and system-levelpracticesorprograms” (OregonAddictionandMentalHealthDivision,2007).

There is no single understanding of evidence-basedpracticeinmentalhealthandthecontroversiesaffectingthis field underscore the challenges of making sure that findings from research inform school mental health programs.ArecentarticleinHealthAffairssuggeststhedifficulties (Tanenbaum, 2005). While ‘evidence-based practice’ has wide-spread support in clinical settings,mentalhealthresearchinitiatives,andpublicpolicyvenues,thereareat leastthreekeycontroversiesthatcloudthediscussionof thistopic.First,thereisnoagreementonthemeaningof ‘evidence’.Second,thereisnoagreementon how to translate research evidence (however defined) intoclinicalorprogrammaticpractice.And,thirdthereisnoagreementonthemeaningof theword‘effective.’Whatdoesitmeanforaprogramto‘work’?Andhowarewetoweightheoutcomesassociatedwitharigorouslyevaluated randomized clinical trial with the outcomesof an intervention study inwhichparticipantsmaybemoreculturallyandraciallydiversebutthestudywasnotexperimentalindesign?Theseareseriousquestionswith

realimplicationsforschoolmentalhealthprogramsthatwant touse theverybest interventionspossible. TheDCSchoolMentalHealthProgramwill be challengedto design its interventions informed by research butrecognizingthattherearenostraightpathstoselectingevidence-basedinterventions.

Reviews of the effects of child therapy programs foryouthwithdiagnosableproblemsindicatethatevidence-based treatmentprogramsaregenerallymore effectivethanprovidingno treatmentoroffering theusualcareprovided in clinical settings (Weisz & Simpson Gray,2008). Althoughourknowledgeof this aspectof thefield has grown, evidence-based programs are still not widelyusedineverydaypracticesettings,suchasschools.Concernsabouttheapplicabilityof suchprograms(whichare typically designed for single problem areas) withyouth presenting with multiple and chronic disorders,the perceived inflexibility of these programs, and the investmentintrainingtimerequiredbeforeimplementationcanbeginaccountformuchof theresistancefoundamongpracticingclinicians.Theseviewswerecorroboratedbyalocalstudythatfoundthatschool-basedcliniciansinDCrequiredto implementevidence-basedprogramswithintheir assigned schools cited program length, ease of implementation, colleague opinion, and perceived fit with theschool/studentcultureasimportantfactorsimpactingtheirchoices(Anderson-Hoagland,2008).

A number of interventions and programs have beendeemed effective by evaluation researchers (Wilson &Lipsey, 2007) and other authorities using well defined butvaryingcriteria(Hahn,etal.,2007).Muchpressureexists around the identification and selection of the ‘right’ programtopilotinacommunitystrugglingwithlimitedresources. Resource constraints are made more difficult by apropensitytowanttoaddressallriskfactorsthatimpactmentalwell-beingatonce.Onecaneasilyfeeloverwhelmedandconfusedbythenumberof programsthatappeartodeserveconsiderationforandlendthemselvesto large-scaleimplementationacrossschooldistrictsandcities(seeAppendixKforsitesfeaturingschool-basedinterventionsthathavebeenshowntoproducedesirableoutcomes).Researchillustratesthatonelargecategoryof evidence-basedprograms,clinicaltreatmentprograms,canactuallybedistilledintoasmallergroupingof effectivestrategiescommon to many of the treatment programs for usein clinical settings (Chorpita, Becker, & Daleiden, 2007;



Chorpita, Daleiden, & Weisz, 2005). These findings have significant implications for the training of mental health providersandtheallocationof resources.Ensuringsuccessful implementationandsecuring long-term commitment to effective programs at a schoollevel,though,ismuchmorecomplicatedthanmatchingaprogramto localneeds.Onechallenge issimply thatthe evidence-base is always changing and, therefore,creatinganinfrastructureforanyservicedeliverymodelthat relies on a specific evidence-based program creates afaultyfoundationfromwhichtobuildaneffectiveandresponsivesystemof care. “There can be risks associated with institutionalizing any particular evidence-based program, because in theory practices should be replaced or updated as the lteratiure evolves. A system should be in a position to embrace new and effective programsastheyareidentified,andthoseupdatesandinnovationsneedtobeefficient.”BruceChorpita,Director,CenterforCognitive Behavior Therapy, personal communication,February,19,2008.

Introducing new ideas about innovative programs,practices and policies is never easy and takes carefulplanning. Implementation involves “a specified set of activities designed to put into practice an activity orprogramof knowndimensions”(Fixsen,Naoom,Blase,Friedman,&Wallace,2005)andisnotasingleeventbutcanbe accomplished throughanumberof stages (seeTable6).

Expertsdevelopingthesciencebehind implementationwarnthatdecisionsaboutwhichevidence-basedprogramstoadopt cannotbedivorced fromdecisions about thequality of implementation efforts, the feasibility of adopting particular approaches, concerns of fidelity, and

determinationsof school,organizational,andcommunityreadiness.Researchersrecommendtheuseof evidence-based processes and tools to help communities assessreadiness of practitioners, organizations, schools, andcommunitiestogaugeawareness,interest,andmotivationinmakingchanges topractice (Flashpohler,Anderson-Butcher,Bean,Burke,&Paternite,2008).Oneinstrumentthathasbeenusednationally toassessperspectivesof schoolmentalhealthneedsandservicesistheSurveyof theCharacteristicsandFundingof SchoolMentalHealthServices School Questionnaire 2002-2003 (SAMHSA,2003).

Researchers have also found that there are interactiveprocesses (i.e., implementation drivers) that influence theextenttowhichaprogramorinnovationisadoptedintoasystemandwhicharekeytoprogrammaticsuccess(seeTable7). Finally,however,manyagreethatunlessthe individualdeliveringtheessentialcomponentsof aprogram is well-prepared and confident in his/her skills, efforts to implementeventhemostwidelyknownandeffective national programs will not succeed.Training and coaching are, therefore, key activitiesin bringing about effective implementation of newprogramsorpractices.Context(theelementsnecessaryforhighperformance),compliance(thecoreintervention

Exploration and Adoption Assess the fit between program and community needsProgram Instillation Gather resources and initiate supports necessary to implementInitial Implementation Push for change in the overall practice environmentFull Operation Run program with full staff complements and full client loadsInnovation Review information on impact and make adjustments to practice or programSustainability Ensure long-term survival of a program despite changing conditions

Table 6. Stages of the Implementation Process

ProgramStage Description

Source: Fixsen, et al., 2005

“People use what they know, so even though individuals are trained in new methods or to run new programs, it takes a lot to have them actually change their practice.” Lisa Jaycox, Senior Sci-entist, RAND, personal communication, August 28, 2007.



components),andcompetence(thedegreetowhichthecomponents are delivered with skill) fidelity measures will thenhelpdetermine thedegree towhichaprogram islikelytoproducethepositiveeffects itwas intendedto(Fixsenetal.,2005).

Knowing that a program has demonstrated strongoutcomes in a given community does not necessarilyspeaktotheprogram’savailability,affordability,feasibilityorultimatesuccessfulimplementationinnewcontextsorcommunities (Han & Weiss, 2005; Andrews & Buettner, 2004), especially as it relates to the implementationof classroombasedprograms(Han&Weiss,2005).Giventhediversityof populationsandtheidiosyncratic issuesimpactinglocalcommunities,manyagreethatachievingfidelity to model implementation is not an all or none proposition. Evidence-based programs can rarely beimplementedexactlyasdescribedinothercommunities.Communitydemographics,theculturalnuances,aswellastheprogramdesignmustbetakenintoaccount.Coreprogram components, which must not be tamperedwith,needtobewelldescribedandunderstoodsothatnecessary adaptations to reflect cultural norms can be madewithsomeassurancethattheprogramwillcontinuetodemonstrateitsintendedresults.

Twoelements inparticularmayhaveparticular impacton the successful identification and implementation of evidence-based programs: the involvement of local stakeholders in the selection of programs and thedevelopmentof acommitteeortaskforcemadeupof parents and youth, stakeholders, community leaders,and local experts that has meaningful input into theimplementationprocess(Fixsenetal.,2005).Assessingthefeasibilityof programimplementationinaparticularschool or geographic region is best done with input

from local stakeholders knowledgeable about social,political, and environmental conditions. Key decision-makerscanassess theaspectsof theprogram that areconsidered core intervention components and makedeterminations about whether those core componentscanbemaintainedgiventhelocalclimateandresources.Local experts (such as university faculty or localresearchers)canthenbeengagedtocreatemeasurestoassess fidelity to the intervention model and monitor theappropriateadoptionof coreprogramelementsof selectedprograms.

Apart from making important choices about whatprograms to implement in local public schools,administratorsmustalsomakedecisionsaboutstrategiesor processes that will influence the adoption of selected programs. Experts point to the central, yet oftenoverlooked, role teachersandothereducatorscanplayin thedevelopmentof schoolmentalhealthprograms(Paternite&Johnston,2005).Atruly integratedsystemof school mental health acknowledges that educatorsarenotsimplywitnessestothedeliveryof mentalhealthservicesortherecipientsof mentalhealthconsultation,but can become effective implementers of preventionandearly interventionservicesandpowerfuladvocatesfor the expansion of school mental health programs.“If you keep socio-emotional learning and instruction implementation conducted by mental health professionals alone, then you never build the capacity of schools to implement these programs and you undercut their sustainability” (LucilleEber,IllinoisStatewideDirector,PBISNetwork,personalcommunication,March7,2008.)Thevalueof educatorsasprogramimplementers,though,can only be realized if adequate attention is given tofactorsknowntopromotetheircontinuedsuccess(Han&Weiss,2005).Examplesof successfulengagementof educatorsasschoolmentalhealthpartnerscanexpandthebreadthof possibilitiesforD.C.initsquesttomeetthegrowingmentalhealthneedsof childrenandyouth(Atkins, Graczyk, Frazier, and Abdul-Adil, 2003; Paternite, 2004).


Ohio. Miami University and Ohio StateUniversity have both worked closely withthe state departments of education andmentalhealthinOhiotoassesstheeffective

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Staff selectionPre-service and in-service trainingOngoing consultation and coachingStaff performance assessmentDecision support data systemsFacilitative administrative supportSystems interventions

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Table 7. List of Core ‘Implementation Drivers’

Source: Wallace, Blase, Fixsen, & Naoom, 2007



disseminationandadoptionof evidence-basedprograms and practices in various countiesand school districts across the state. Thesepartners have jointly designed indicatorsand engaged in a number of systematicevaluationsof schoolreadinesstoimplementvarious initiatives. In selectingpilot schoolsfortheOhioCommunityCollaborativeModelforSchoolImprovement(OCCMSI)andfortheHealthFoundationof GreaterCincinnati’sEvidence-Based Practices for School-WidePrevention Programs Initiatives, universitycollaborators found responses to certaindemandsmadeof schoolsorschooldistrictsreflected readiness for change and ultimately related to the smoother implementationof newprograms.Strategiessuchasmandatingthat school teams be formed to participatein informational orientation meetings, thatpotentialpilotschoolscollectnewandshareexisting data on readiness, and that schooladministrators obtain formal commitmentsfrom stakeholders helped to differentiateschoolsatvaryinglevelsof readinessandtheircapacitytoforwardaninitiative.Inaddition,schoolsreportedthatactivelyparticipatinginassessingtheirownreadiness increasedtheirappreciationforandcompetencewithdata-driven decision-making, a very useful skillforschoolpersonnelrespondingtopressuresaround accountability. Those involvedconclude“asystematicassessmentof readiness[is]anintegralpartof movingeffectiveSMHpractices, programs, or innovations intonew contexts…” (Flashpohler et al., 2008).Additionally,22schooldistrictsacrossOhiohaveused theSurveyof theCharacteristicsandFundingof SchoolMentalHealthServicesSchool Questionnaire 2002-2003 to assessschoolmentalhealthneedsandservices.

Chicago, Illinois.ResearchfromtheUniversityof IllinoisatChicagoconductedwiththeChicagoPublicSchoolshasledtotheestablishmentof processesthatidentifyandutilizeleadteachers,alsoknownasKeyOpinionLeaders(KOL),to implement classroom-based behaviormanagementstrategiesforstudents insome

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of their low-incomeurban schools (Atkins,Graczyk,Frazier,&Abdul-Adil,2003).Theutilizationof school teams involvingKOLsandmentalhealthprovidersisyieldingsomepromise as a strategy for implementinginnovationwithinclassrooms.

Hawaii. TheStateof HawaiiDepartmentof HealthandtheDepartmentof Educationwerechargedwithstrengtheningtheirsystemof caretoaddresstheinadequacies inmentalhealthand special education services for childrenand youth asdictatedby theFelixConsentDecree. Partof this state reform involvedthedisseminationof evidence-basedservicesandtheir role in improvingchildoutcomes.Thefocuswasindesigningacomprehensivetreatment system and developing a clinicaldecision-making process that is evidence-based, influenced by existing services research literature, and that relies on case-specific historicalevidence(throughthedevelopmentof on-line clinical reports called “clinicaldashboards”).Theseclinicaldashboardsarealsoaggregatedacrossproviders,yieldatimelyreflection of the effectiveness of the statewide system, and offer a mechanism for qualitymanagement. The Child and AdolescentMental Health Division (CAMHD) withinthe Department of Health has dedicatedagency resources to collect, analyze, anddigest relevant information which informsthe development of Department standardsand guidelines and directs performancecontract monitoring activities across thedivision. Furthermore, a statewide traininginstitute/ practice development office was established to disseminate current serviceresearch information and provide training,mentoring, and consultation through state-fundedpracticedevelopmentspecialistswhoprovide case-based ‘expert’ consultationto providers (Daleiden & Chorpita, 2005; Daleiden,Chorpita,Donkervoet,Arensdorf,&Brogan,2006).

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Recommendations for DMH

Primary RecommendationsDMHshouldactivelyparticipate in,andpotentiallyco-lead, a multi-agency citywide team that wouldoversee the selection and implementation of evidence-basedmentalhealthprogramsimplementedinDCpublic schools. Thiswould allow for someconsensus tobe achievedbetweenboth theDMHandSSCSMHprograms,twoagenciesthathavebothinvestedheavilyinanumberof evidence-basedandpromisingprograms.Resourceswouldthenbemoreefficiently utilized, infrastructure development can be undertaken,andsustainabilityof individualprogramspursued.

Giventhecurrentorganizationalstructures inplaceinDC,aschoolmentalhealthteamcouldoperateasaworkgroupunderICSIC,assumingthatcommunityexperts(suchascommunity-basedpractitionersandacademicresearchers)couldparticipateandsharetheirknowledgeandexperiencewithICSICmembers.Thecollectivegroupof expertswouldbecharged,alongwithanumberof tasksoutlinedbelow,withassessingaschool’scapacityandreadinessto implementnewprograms and to help decrease the likelihood of duplicationorfragmentationof servicesoffered inschools.Theworkgroupcouldassessthatsystemic,organizational, and programmatic supports are inplace in a school to increase the likelihood that aproposedinitiativewouldbeasoundinvestment inthatschool.Tosucceed,theworkgroupwouldneedconsistentsupportfromtheMayor,DMHDirector,theChancellorof DCPS,andtheStateSuperintendentof Educationinordertoeffectivelyguidesuccessfulimplementation of model programs. The team orwork group could undertake a number of criticaltasks, including:

Examining and identifying appropriateevidence-based programs, reviewing therelevantresearchliteratureandemergingbestpracticesinformationAssessing the fit between program, local populationneeds,andcitywidegoalsObtaining clarity around the core practiceand implementation components of aprogram

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Accounting for and authorizing use of relevantresourcesMonitoring and supporting efforts fortrainingandcoachingof practitionersCreating structures and processes toimprove implementation (i.e., developingcommunitiesof practice)Developing school readiness assessmentsand application processes requiring anexamination of the school’s capacity forthe integration of school mental healthserviceswithimportantschoolpersonnel(i.e.,principal,SSTchair,counselor,schoolnurse)Setting the bar for fidelity and determining accountabilitymeasuresDeveloping long-term sustainability plansand creating a reasonable timeline fordeterminingaprogram’seffectivenessbeforeeffortsareabandonedorexpanded

Training/professional development

“The tendency in the field tends to be to narrowly use practice standards of the discipline for the person being hired. This, in my view, contributes to the problem we face with staff being inadequately prepared/trained to work in the cross- and interdisciplinary world of school mental health.” CarlPaternite,Director, Center for School-Based Mental HealthPrograms, Miami University of Ohio, personalcommunication,January3,2008.

DMHhasan importantandunique role in supportingtheprofessionaldevelopmentof mentalhealthproviderspracticinginDCandinutilizingthemosteffectiveandcost efficient methods available to impart knowledge and increaseprovidercompetence.ThereisalsoaroleDMHcanandshouldplaytoenhancethetrainingandskillsof

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DMH has an important and unique role in supporting the professional development of mental health providers practicing in DC and in utilizing the most effective and cost efficient methods available to impart knowledge and increase provider competence.



educatorsandmentalhealthprofessionalsworkingintheDCpublicschools,whomayormaynotbelicensedorcertified, but who nonetheless provide support services to youthandtheirfamilies.Asresearchpapersandexpertopiniontellus,thequalityof anyschool-basedprogramis determined not only by its effectiveness or efficacy but alsobythecompetenceof theindividualwhodeliversit.

Overview of what the research and the experts say

Professional Development for Mental Health ProvidersWhilethereisapushfortheimplementationof evidence-basedprograms,theselectionof therightstaff toconductmental health interventions, while equally critical tosuccess, often can be overlooked (Fixen, et al., 2005).Commonly,organizationshavefocusedtheirlimitedtimeand resourceson recruitmentefforts andscreeningof candidates to ensure they meet minimal qualifications. Less timeandattentionisgiventopersonalitycharacteristics,depthof trainingandexperience,andinteractionstyles.Failuretotakethetimetomatchtheindividualandhis/herstrengthsandskillstotheexpectedtaskscancontributetoongoingstaff burnout, turnover,andweakprogramimplementation. In the childmental health arena andmore significantly in the school mental health arena, there arenograduate trainingprograms thatpreparementalhealth professionals with the skills, competencies, andtechniquesnecessary to successfully implement schoolmental health programs. Currently there is only oneknownpost-doctoralfellowshipinschoolmentalhealthlocatedattheUniversityof Maryland,Baltimore.

Beyondclinicaltraining,thereisalsoalackof understandingaboutcriticaleducationlawsandregulationsthatimpacttheschoolenvironmentwhereservicesarebeingdelivered.Lackof knowledgeandconsiderationfortheeducationsystemalsoleadstoclinicianfrustrationandburnout.

The Annapolis Coalition on the Behavioral HealthWorkforce (2007) developed a comprehensive plan toaddressthenation’growingcrisisaroundeffortstorecruit,retain, andeffectively trainapreventionand treatmentworkforce in the mental health and addiction fields. The authorswarnthatthebehavioralhealthworkforceisnotequippedinskillsor innumberstorespondadequatelytotheneedsof Americanconsumersof mentalhealth

care. Thehumancapitalresourcesareevensmallerforthe number of behavioral health professionals trainedtoprovidepreventionand intervention services inourschools.Evenmorerarearegraduateswithknowledgeor experience in using strengths-based and resilience-orientedstrategies.

Thereisalsoadisappointedlysmallnumberof childandadolescent mental health providers adequately trainedtowork in schools andwhocaneffectively implementevidence-basedprograms.Findingawell-trainedmentalhealth provider who is also dual-diagnosis capable isalmost impossible. The Annapolis Coalition pointsoutthe incidenceof co-occurringmentalandaddictivedisordershasincreaseddramaticallyinthiscountrywithD.C.beingnoexception. Mostof theworkforce lackstheneededcomplementof skillstoeffectivelyworkwithindividuals with such complex needs. They state that“training andeducationprograms largelyhave ignoredtheneedtoaltertheircurriculatoaddressthisproblemand,thus,thenationcontinuestopreparenewmembersof theworkforcewhosimplyareunderpreparedfromthe moment they complete their training.” (AnnapolisCoalition,2007,p.1)

Mental health providers need to be firmly grounded as cliniciansandinterventionists.Theyalsoneedtobewellpreparedtodeliverthecomponentsof agivenprograminorderforemotionalorbehavioralimprovementstobeachieved. Fixenandhiscolleagues(2005) indicatethatalthough training in an identified program is absolutely necessary, it is not sufficient and alone does not lead to positiveoutcomes.Knowinghowtomaximizelearning

The Annapolis Coalition on the Behav-ioral Health Workforce (2007) developed a comprehensive plan to address the nation’ growing crisis around efforts to recruit, retain, and effectively train a pre-vention and treatment workforce in the mental health and addiction fields. The authors warn that the behavioral health workforce is not equipped in skills or in numbers to respond adequately to the needs of American consumers of mental health care.



among participants is key given limited resources andtime.Essentialtothereinforcementof trainingandskilldevelopment is staff coaching that requires time andcommitment. Beyond identifying the ‘right’ programsfor DC youth and families there is a responsibility toensureacommitmenttouseof limitedresourcesandtimeinordertobesuccessful.

Professional development for school-based/school-hired professionalsTheSchoolMentalHealthAlliance(SMHA),agroupof over fifty experts in the field of school mental health, developedapositionpaperthatrecommendedstrategiestostrengthenthelinkbetweenmentalhealthandschoolperformance(Hunter,etal.,2005).TheSMHAstatedthatanimportantobstacletotheimplementationof evidence-basedschoolmentalhealthinterventionswasinadequatementalhealthprofessionaldevelopmentforschoolstaff.Manyschool-hiredmentalhealthproviders(i.e.,schoolcounselors,psychologists,socialworkers)lackthetrainingneededtodeliverhighqualityinterventionsalongthefullcontinuumof care (prevention,early intervention,andtreatment). When sufficiently trained, they often are unabletoimplementtheirknowledgeduetocompetingacademic/schooldemands.Schoolcounselors,consideredimportantcontributorsto improvements inemotional/behavioralfunctioningforstudentsinregulareducation,aretypicallyconsideredanunderutilizedgroupof schoolprofessionals(A.Brown,personalcommunication,April28,2008).Schoolcounselorshavebeenknowntospendagreatdealof theirtimeonacademic/vocationalcounseling,scheduling, and college assistance (Texas EducationAgency,2005),andhavestruggledwithexpectationsthattheymanagediscipline,monitorattendance,orcoordinateacademictestingsessionsinlocalschools,tasksthatdivertthem fromcounseling students on theirmental healthchallenges.

Teachersandotherschoolstaff frequentlylackeducationin mental health issues and child development (Weist&Paternite,2006). Knowing themanyenvironmentaland individual risk factors facing youth and thepotential for their issues to spill over into classroomconduct problems, it is not surprising that teachers inschool classrooms find behavior management both challengingandoverwhelming.Acomprehensiveschoolmentalhealthmodelmustincludeteacherandschoolstaff consultationasan integralpartof theservicesoffered.

Givingalladults inschools the information,skills,andtechniques to manage problem situations allows themtofeelpreparedandcompetenttohandlethedynamicsof anyclassroomorschoolsetting.Whilethisremainsacriticalpartof theSMHmodelitisnotafundedorbillableactivityandthereforenotalwaysappreciated,discussed,orimplemented.

Asmentionedpreviously,teachersareimportantpartnersintheimplementationof classroom-basedmentalhealthpreventionprograms(Paternite&Johnston,2005).Thereare examples of school districts that have encouragedmentalhealthprofessionals,parents,andteacherstopartnertodeterminethebestinterventionsavailableinaddressingdisruptivebehaviorsamongstudents(i.e.,ChicagoPublicSchools)(M.Akins,personalcommunication,January2,2008).Theavailabilityof resourcestosupportteachersinprogramimplementationisoftentimestenuous.Thereforeefforts to maintain program fidelity require a long-term visionandstrategicplanning.

Researchers have found that specific school, teacher, and program factors predict the level of fidelity and durationof programimplementation.Criticalfactorsthatinfluence outcomes include support provided by school principals,amountof teacherburnout,thematchbetweentheprogramtypeandseverityof emotional/behavioralproblemsencountered,andtheprovisionof performancefeedback (Han & Weiss, 2005). These factors haveimplicationsforteachertrainingdeliveredbycommunitymentalhealthprofessionalsbutalsoforthedevelopmentof system-wide policies and priorities around schoolmentalhealthtraining.


New York City.Amodelfortrainingcliniciansin evidence-based childpsychotherapypro-gramshasbeendevelopedandisbeingdis-seminated (refer to the Reach Institute; http://www.thereachinstitute.org). These intensivetrainingprograms(whichincludeafewdaysof on-sitetraining,regularphoneconsultationwith national experts, and result in a certifi-cate from the Office of Mental Health upon completion)arecostly(estimatesrangefrom$1200-$1500pertrainee)buttheattentionto

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the fidelity of quality treatment approaches makethisapromisingmethodforenhancingtheskillsof theclinicalworkforce.

Illinois.TheIllinoisStateBoardof EducationandIllinoisDepartmentof HumanServices,Division of Mental Health created andimplemented a joint training series: The Integration of Mental Health in SchoolsTraining and Networking Series. Thepurpose of the trainings is to assist schooldistricts awarded the IllinoisSchoolMentalHealth Support Grants through provisionof information on best practices, targetedtechnicalassistance,andfosteringcollaborationacrossgranteesites.Inaddition,thegoalof implementingPBSacrossIllinoishasrequiredthedevelopmentof astatestructuretosupportongoingtrainingthroughoutthestate.

North Carolina.InNorthCarolina,orientationof new school-based mental health staff requires them to perform ‘nontraditional’workinanassignedschoolfor3weeksandthenshadowaveteranclinicianfor3weeks.After this period, a mentor is assignedfrom within the program to help with theclinician’s ongoing adjustment and withprogramdevelopment.

Los Angeles. Officials in Los Angeles County, California have only a limited number of evidence-based programs they will endorseand support at a given time. This allows aunified vision and sustained efforts around trainingandsupervisionnecessarytomaintainthequalityof services. Someexpertsarguethat the underlying risk factor influencing behavioral problems are similar and canbe effective in obtaining the mental healthoutcomes desired – leading to the use of fewer programs in schools. The underlyingpremise is that more does not necessarilyequalbetter.

Maryland. To address recruitment, trainingand retention of qualified professionals and paraprofessionals who work with children

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andyouthwithmentalhealthneedsandtheirfamilies,theDivisionof SpecialEducation/Early InterventionServices,MarylandStateDepartment of Education and the MentalHygiene Administration within the StateDepartmentof HealthandMentalHygienejointlysponsoredtheMentalHealthWorkforceSummitin2005.

Missouri. TheCenterfortheAdvancementof MentalHealthPracticesinSchoolsinMissouricreated the first online graduate programs accredited by the American PsychologicalAssociation (http://education.missouri.edu/orgs/camhps).Thepurposewas toeducateschool-based personnel (i.e., educators,administrators,healthservicesprofessionals)onprevalentmentalhealthproblemsandtheimpactonacademicsuccessfortoday’syouth.The courses offer practical applications of psychologicalconceptsandutilize research-based techniques to help school-basedprofessionals address the risk factors thatthreaten the mental health of children andadolescents. Professionals learn skills topromote positive mental health, encouragepositive social emotional development, andincreasestudentlearning.


Primary RecommendationDMH, through its Training Institute, should offertrainingsgearedtowardthedevelopmentof clinicalskillsforchildmentalhealthprovidersinDC,especiallythoseworkingincommunitysettingssuchasschools.TheDCSchoolMentalHealthCoalitionandschoolpartners should provide input on topics and qualified trainers.Policiesshoulddiscourageengagementin‘oneshot’ trainings. Instead, resources should be identified anddedicatedtocoachingandongoingconsultationfor trainees. Acontinual investment in trainingof mentalhealth staff is likely tohelp improvework-relatedstressandreducestaff turnover,achallengeforbothSMHprograms. DMHwouldyieldgreatbenefit from working closely with DC public school system personnel, charter school administrators,and managers of health professional groups (i.e.,

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schoolnurses)todevelopandimplementaplanforcross training of various mental health and healthprovidersworkinginschools.Anunderstandingof roles,abilities,knowledge,standards,andregulationspertainingtoeachgroupwouldenhancecollaborationandfacilitatetheintegrationof services.

Secondary RecommendationsDMHshoulddevelopguidelinesthatassistcommunitymentalhealthproviders intheeffectiverecruitmentand retention of mental health professionals.Guidelinesshouldaddresswhattraining,experiences,andpersonal characteristics a schoolmentalhealthcandidateshouldpossessinordertosuccessfullyworkinschools.

TheDMHshouldrevisittheCCISC(Comprehensive,Continuous,IntegratedSystemof Care)initiative.Thisinitiativerepresentsamissedopportunitytopromotethedevelopmentof adualdiagnosiscompetentchildmentalhealthsystemof providers.Earlyeffortsandtraining under this program focused only on adultservices and consumers and failed to address theuniqueneedsof DCyouth.TheCCISCinitiative,asystemschangemodel,aimedtomovebothagenciesandtheirsubcontractedproviderstowardbecoming“dualdiagnosiscompetent”incaringforthosepersonsaddictedtosubstancesandwithmentalillness.

DMHAdministratorsareencouragedtoworkwithlocal universities and other training programs todevelop courses, certification programs, and/or professionaldevelopmentapproachesforindividualsinterestedindevelopinganexpertiseinschoolmentalhealth.Theseprogramsneedtoreinforcedevelopmentof thecorecompetenciesoutlinedbytheAnnapolisCoalitionontheBehavioralHealthWorkforce.

Financing school mental health: Some initial thoughts

Although this report on the DC school mental healthprogramfocusesonoperationalissueswithinthecontextof similar initiatives across the nation, ignoring whatwe have learned about financing school mental health programswouldnotservetheDMHschoolmentalhealthprogramwell.Thus, thissectionoffersanoverviewof currentfundingarrangements,andsuggestsdirectionsforfutureexaminations.

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Current funding arrangements for the DC school mental health program

TheprogramssponsoredbyDMHandbytheStudentSupportCenterareseparatefromthoseprovidedbytheDCPublicandCharterSchoolstostudentsenrolled inspecialeducation.Specialeducationstudentshavebeenassessed as requiring mental health services to benefit fromeducationalservices.TheDMHandSSCservicesalso do not reflect the guidance counselor and social work preventionandmentalhealthpromotionservicesofferedbyschools.The DC School Mental Health Program and StudentSupport Center services are primarily funded by city-appropriateddollarsandfederalgrants.InFY2007,theseDC-supported mental health services fully subsidized63 mental health professionals (48 through the DCDepartmentof MentalHealthand15throughtheStudentSupportCenter)toprovideservicesinschoolsthroughoutthecity.TheannualcostinFY2007was$4.2millionforDMH (paid through DMH city appropriated dollars)and$1millionfor theSSC(paidthroughfederalgrantdollars).InFY2008,DMHexpandedintomoreschoolsbycontractingwithtwocommunity-basedagenciesthathired6mentalhealthprofessionalswhowereassignedto6 schools.Thus,DMHsupported48mental healthproviders to serve 58 public schools and spent $4.35million,whiletheSSCschoolmentalhealthservicesbegantodiminishastheirsecondSS/HSgrantneareditsend.

As noted previously, development of the DC SMHPwasinitiatedwithsupportfromafederalSafeSchools/HealthyStudentsgrantin1999andinitiallyimplementedin public charter schools. To date the city has benefited fromapproximately$8million inschoolmentalhealthservices provided through three Safe Schools/HealthyStudents (SS/HS)grantsawardedtoDC(twoawardedtotheCharterSchoolsandonetoDCPS).Intheearlyyears,SS/HSgrantdollarstypicallysupportedtotalcostsassociated with program staffing. When the initial SS/HS grantconcluded, thecity– throughDMH–agreed topickupthecostof theinitial16mentalhealthprovidersassigned to public charter schools, and thereafterembarkedonadeliberatepathtoexpandmentalhealthservices,increasingaccessforDCstudents.DuringthethirdSS/HSgrant,publiccharterschoolsbegantoco-fundcliniciansalariesinordertoaddressoneof thegoals



of theSS/HSgranttobuildbraidedfundingforschool-basedservices.AccordingtoEveBrooks,founderof theStudentSupportCenter,allschoolscurrentlyparticipatingintheSafeSchools/HealthyStudentsinitiativespaid20%of thesalaryandfringecostof theclinicianshiredbythe SSC under the SS/HS grant (E. Brooks, personalcommunication,February8,2007).

Inthe2008-2009schoolyear,astheSS/HSgrantphasesout,themajorityof the8chartersschoolscollaboratingwith SSC assumed 50% of the cost of their mentalhealthcliniciansandonecharterdeclined toprovideamatch.ThatsomanypubliccharterschoolsinDCwerewilling to finance 50% of a SMH clinician encourages re-examinationof thewaysinwhicheducationcaninvestinthe sustainability and financing of school mental health services(Cooper,2008).WhetherthecitywillbewillingtosustainthementalhealthservicesinthepubliccharterschoolsbyreplacingtheSafeSchools/HealthyStudentsmoneywhenthegrantfundsrunoutattheendof 2008–2009schoolyearremainsanunansweredquestionbutthe SSC and public charter school leaders do not feelencouragedabouttheprospectsof futurecityfunding.Althoughthefundsprovidedbythesecharterschoolswillmaintainsomepreexistingschoolmentalhealthservices,cityandgrantsubsidizedservicesforregulareducationstudentsinthecharterschoolswilllikelydiminishby50%whileservicestoDCPSschoolsthroughDMHandotherCitysourcesareincreasing(seeTable8).

Future sources of funding

The potential role of Medicaid reimbursement insustaining the school mental health services has beena subject of long-running debate. Until very recently,theCityMedicaidmanagedcareplanwouldnotpermitschoolstobillMedicaidforservicesprovidedtoregulareducationstudents.Manyincitygovernmentbelievethat,becauseanumberof servicesofferedthroughtheSMHPareMedicaid-coveredandprovidedtoMedicaid-enrolledstudents,Medicaid(andhencetheFederalgovernment)shouldhelppayfortheprogram.Thisapproachwouldenablestate-appropriateddollarstogofurther.However,during the first seven years of the SMHP, DC Medicaid and theDepartmentof MentalHealth concluded thatbillingMedicaidforservicesdeliveredbyDMH-employedstaff was not possible given the program’s structure.In the last twoyears,DMHhasbegun theprocessof

credentialingtheirSMHPstaff inordertofacilitatefutureMedicaidbilling.InMayof 2008,changesweremadetoacknowledgeschoolsasapprovedplacesof service,whichwillallowforthereimbursementof schoolmentalhealthservicesinthenearfuture.

Recently the DC Assembly on School Health Carecompletedapreliminaryanalysisof challengesthatpreventMedicaidreimbursementforschool-basedhealthcentersinDC(seeAppendixBforreporttitledOpportunitiesandBarriersforMedicaidReimbursementsforSchoolHealthCentersinWashington,DC).Althoughsomeof theissuesoutlined in thisbrief reportmaybeunique to school-basedhealthcenters,manyof therecommendationscanbegeneralizedtoschoolmentalhealthprograms.Theseschoolhealthadvocateshaveconcludedthatif theDistrictof Columbia clarifies its Medicaid rules, it can make the changesnecessarytopermittheDMHSMHPandprivateproviderstobillforservicesprovidedtostudents.

Overthelasteightyears,theDCDepartmentof MentalHealthhasexplored thepossibilityof utilizingvariousfunding streams to support its school mental healthservicesbuthasbeenunable todedicate the resourcestoresearch,design,andimplementaneffectivefundingstrategy.

During thispast year,DMHadministrators respondedto the city’s interest in diversifying the School MentalHealthProgramfundingsourcesbypilotingacontractualarrangementwiththecity’sCoreServiceAgencies.Underthis arrangement, the Core Service Agencies (CSA),organizations that have been certified by Medicaid to be reimbursed for approved mental health services,could compete for DMH funding to initiate school-basedtreatmentservicesthatcanbereimbursedbythirdpartypayers. WhenDMHestablished theprogram, itwasexpectedthat33%of theclinicians’timewouldbespent providing brief treatments to students and that50-70%of theseserviceswouldbebillabletoMedicaid.(See Appendix B for the DMH solicitation to expandSMHservicesin2007).Becausethecontractsunderthisinitiativebeganofferingserviceslessthanoneyearago,informationonthesuccessesandchallengesof thepilotwillnotbeavailableuntil latethisWinter. However, ithasbeenreportedthatthesolicitationforbidsdidnotenticemanyCSAstocompeteforcontracts.If true,thissuggests that financing mechanisms will be challenged to



overcome structural difficulties in the city’s mental health servicedeliverysystem.

Anotherpotentialsourceof fundingisthelocaleducationagency (either DCPS or the public charter schools).Asnotedearlier,DCPSand thepubliccharter schoolsreceived a base foundation of $7,600 per student inFiscal Year (FY) 2007 as determined by the UniformPerStudentFundingFormula(UPSFF). Thisformula,whichvariesannually,istheminimumfoundationamountthatisneededtoprovideanadequatelevelof servicestotheschoolsystemonaper-studentbasis. Oncea localeducationagency(LEA)receivesthisfundingfromthecity,budgetsareestablishedthatallocatefundsneededtocoverfacilitiescosts,operations,specialeducation,professionaldevelopment and central overhead. The remainder of funding(usuallyabout50percentof thetotal)isallocated

to local schools, using the Weighted Student Formula(WSF).UndertheWSF,similartotheUPSFF,acertainamountof basefundingisallocatedtoeachstudent,withadditionalfundingprovidedif thestudentisdeemedtohave special needs. Unlike the UPSFF, the WSF alsoincreasesfundingtoaccountforthestudent’seconomicstatus.Thisfundingisintendedtofolloweachstudenttohis or her school and to provide a sufficient proportion of thetotalfundingforthelocalschooltofullystaff itslocaladministration,classroomsandcustodialoperationsto best serve its students. Difficulties around the equity of thesystemandthepurchasingpowerheldbylocalschoolprincipalshavebeennoted(DCPublicSchoolsMasterEducationPlan,2006).DCPSschoolprincipalsalsohaveaccesstoaportionof theDCPSLEAbudgettosupportadditionalstaff orpayforlocalschoolplanningefforts.

SchoolYear FundingSource

DCPSSMH

Schools**

CharterSMH

Schools** SubtotalGrandTotal Provider

2000-2002(Covers 2 years) Federal 0 16 16 16 DMH

2002-03DMH Appropriated Funds 16 10 26

29DMH

Federal 0 3 3 SSC


29DMH

Federal 0 3 3 SSC


36DMH

Federal 0 5 5 SSC


47DMH

Federal 0 13* 13 SSC


63DMH


2007-08

DMH Appropriated Funds 37 11 48

65

DMH & DMH Contractors

DC Funds 2 0 2 Dept Mayor of Ed


2008-09


82


DC Funds 15 0 15 Dept Mayor of Ed & OOSE

Federal/School (50-50) 0 9* 9 SCC

2009-10(projection)


73


DC Funds 15 0 15 Dept Mayor of Ed & OOSE

Federal/School (50-50) 0 0 0 SCC

Table 8. School Mental Health Services in the District of Columbia for Regular Education Students by Year, Source of Funding, & Number of Schools Served

*Served both special and regular education students**These numbers represent the number of schools served and not the number of FTEs dedicated



Overview of what the experts say

Thenationalexperienceof school-basedmentalhealthprograms reflect a variety of funding sources, including federal and state grants, local and national foundationfunds,fee-for-servicebillingsto insurers,andcontractswithlocalpublicagencies.ArecentreportsuggeststhatbehavioralhealthservicesinschoolsmaybebestsustainedthroughbillingMedicaid.InOhio,itwasfoundthatatleast28Medicaidencountersperweekwerenecessarytocoverthecostof careforacommunitymentalhealthproviderandstillbeabletooffersomepreventiveservicestotheuninsured(seeAppendixBforthepreliminaryreporttotheHealthFoundationof GreaterCincinnatiaboutthesustainabilityof schoolbasedmentalhealth).ThisstrategyhasnotyetbeenimplementedinOhioanditsfeasibilityremainsunknown.Further,eachstatedevelops itsownMedicaidprogramthatcomplieswithitsstateregulations.While Federal law requires that Medicaid be the first payer formedicalandmentalhealthservicesprovidedunderIEPs,there isnobestpracticefortheuseof Medicaidfundstopayforschoolbasedservicesprovidedtoregulareducationstudents.Federalregulations,however,requirethatschoolschoosingtobillMedicaidforservicesforchildren in regulareducationprogramscannotprovidethesameservicestonon-Medicaideligiblestudentsunlesstheyestablishaslidingscalefeestructureandthecapacitytobillprivateinsuranceplans.

Recommendations about the successful provision andreimbursement of mental health services in primarycaresettingsofferedinarecentreportjointlyfundedbythree federal agencies bear direct relevance to school-based services (Kautz, Mauch, & Smith, 2008). Theexperts contributing to the report stresseda) theneedto clarify policies, definitions, and allowable services, b) the importance of broadly disseminating the clarifications through training and technical assistance, and c) thevalueof targetedcollaborationamong the localpublicagencyandnationalorganizationsascriticalactionslikelyto improve Medicaid reimbursement of mental healthservices. Although these analyses offer some promisefor diversified funding, in terms of dollar totals federal grantsandprogramsremainthelargestcontributortothedevelopmentandexpansionof fullserviceschoolmentalhealthprogramsnationwide(seeAppendixLforalistof federalgrantprogramsusedtofundschoolmentalhealthprograms).

Funding sourcesoftenpose restrictionsor regulationsmandatinghowfundsmayormaynotbeused.Fundingfrom state and county public mental health agenciesare traditionallydesignedtopayfor treatmentservicesfor diagnosable illnesses and not for mental healthpreventionorpromotionactivities.Preventionandmentalhealth promotion activities are more often supportedthrough grant dollars and require ongoing advocacyandworktosustain. Thisrealitycontrastswithrecentrecommendations from the public policy arena wherean increased focus on early identification and treatment has resulted in new dollars for prevention and earlyintervention.Especiallywithinthelasttwoyears,therehasbeenapushtomovepolicyandprogramsupportatthestateandfederallevelsinthedirectionof prevention,early intervention, and mental health promotion (e.g.,MentalHealthServicesActof California,theMinnesotaComprehensiveChildren’sMentalHealthAct, and theIllinoisChildren’sMentalHealthAct-seeAppendixEforotherexamplesof statementalhealthlawsthataddressacontinuumof children’smentalhealthcareandtheroleof schools).

At the federal level there are some promising billspendingthatwilleitherincreasedollarsavailableorhelpmakeprogrammaticchanges so thatSMHPswillhaveaccesstoestablishedgrantfunds.BillsincludeH.R.3430MentalHealth inSchoolsActof 2007,whosepurposeis to amend the existingPublicHealthServiceAct soit revises andextendsprojects and increases access toschool-based comprehensive mental health programs; S. 1337: Children’s Mental Health Parity Act which is a bill to amendTitleXXIof theSocial SecurityAct toensureequalcoverageof mentalhealthservicesundertheState Children’s Health Insurance Program; and S. 578: ProtectingChildren’sHealthinSchoolsActof 2007,abilltoamendTitleXIXof theSocialSecurityActtoimproverequirementsundertheMedicaidprogramforitemsandservicesfurnishedinorthroughaneducationalprogramorsettingtochildren,includingchildrenwithdevelopmental,physical,ormentalhealthneeds.Althoughthesebillswilllikelynotbeadoptedearly inthisCongressionalcycle,their consideration reflects a growing federal interest in school-basedmentalhealthcare.




In Baltimore, Maryland, a 10-year old cityinitiativesuggeststhepossibilityof sustaininga school mental health program long-termwhenthecityandstatecollaborate.Marylandhassomeof themostwell-establishedschoolmentalhealthprogramsinthecountry.Thecityof Baltimore,inparticular,hassucceededin diversifying its funding of school-basedservicessothatmentalhealthsupportatalllevels of care are financially supported. In 2004, Baltimore Mental Health Systems(BMHS), the single core service agency inBaltimore,was fundedprimarilyby thecitytocreateanRFPformentalhealthproviderstoofferpreventionandconsultationservicesin schools. These services are consideredhighly desirable by school officials but are not includedasbillableservicesunderMedicaid(seeAppendixBforBaltimoreCityRequestfor Proposals, February 23, 2007). Withcontracts from BMHS and fee-for-serviceMedicaid billings, outpatient mental healthcentershavebeenprovidinga full rangeof services inschools formore thanadecade.Theschooldistrictprovidesthemajorityof thefundingtosupportschool-basedmentalhealth services through its office of third party billing (approximately $1.6million).Fifteenyearsago,theschooldistrictcreatedthisentitytobillMedicaidforservicesprovidedbytheschooldistricttochildrenenrolledinspecialeducation. The office receives the Medicaid reimbursements and allocates these dollarsamong its school-based services. The Office of Third Party Billing sets aside 10% of theseMedicaidrevenuestoprovideon-goingfunding forprevention services. Baltimoreofficials are adamant that a blend of fee-for-serviceandcontract funding isessentialif localgovernmentsaretomaintainschoolmentalhealthprograms, and thatprogramsbuiltonfee-for-servicedollarsalonearenotsustainable.

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In New York State,anothercity-statepartnershiphaslaunchedaschool-connectedmentalhealthinitiativethatservesanarrowerpurpose.In2007, the New York State Office of Mental Health launched a $33 million program,“ChildandFamilyClinicPlus”thatprovidesfreevoluntaryscreening,prevention,andearlyintervention in community settings such asschoolstohelpidentifyyouthneedingmentalhealth care. The program is also intendedto increase use of evidence-based servicesofferedinnaturalsettingssuchasinthehome,school, or community (New York State Office of MentalHealthGuidanceDocument,2007).TheprogramispartlyfundedthroughMedicaidenhancements provided to the community-basedorganizationdeliveringtheservices.Forexample,inNewYorkCity,underacontractbetweentheproviderandtheCityMedicaidoffice, enhanced rates will be provided for homevisitsandface-to-facecontactsat$50morethanthehourlytreatmentratenormallyreimbursed. Contractsforscreeningwillbe$8perscreeningperchild.

Arkansas. TheSchool-BasedMentalHealthNetwork programs monitored by the stateDepartment of Education defines bestpracticeas30%of amentalhealthproviders’timededicatedtonon-billableservices(suchasprevention,education,andearlyinterventionservices) and 70% time dedicated to directbillableservices.Medicaidbillingisconsideredone important aspect of a program’s financial sustainability (although not the only one).Inorder tobillMedicaid formental healthservices,onememberof thepartnership(theschooldistrictorthementalhealthprovider)mustbeenrolledasaMedicaidproviderandschool districts that receive reimbursementfromMedicaidarerequiredtousestateandlocalfundstopaythelocalmatch.Additionalrecommendations made to the Networkincludethatschooldistrictscontribute$25,000per therapistperyear for thementalhealthservicesprovided.

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Severalstateshaveinitiatedgrantprogramsasvehiclestodrivetheexpansionof schoolmentalhealthprograms.

In Minnesota, in late 2007, the Departmentof Human Services, through its Children’sMentalHealthDivision, released aRequestforProposals totaling$12.5milliontofundprojectsthatwoulddeveloptheinfrastructurefor school-based mental health throughoutthestate.Successfulapplicantswouldreceive3-year contracts with an option for one ortwo-yearextensions(MinnesotaDepartmentof HumanServicesChildren’sMentalHealthDivision Request for Proposals, 2007; see Appendix B for this document). Underthis initiative, mental health centers will berequiredtoprovideatleastoneof anumberof school-located or school-linked mentalhealthinterventions.Theseinterventionsaretreatment-oriented but these funds can beusedtosupportservicescloselyconnectedtoclinicalcare,suchasconsultationwithparentsandschoolstaff,twopre-diagnosticmeetingswiththestudentand/orfamily,participationin IEP meetings, or use of translationservices. Applicantsmayrequestadditionalfunds for starting up and phasing in theinfrastructurecomponentsof aschoolmentalhealth program. These funds could coverestablishing billing procedures, developingpartnershipswithschoolpersonnel,providingstaff developmentinmentalhealthandsocio-emotional learning, and building outreachactivitiesandreferralnetworks.

In Illinois, the Illinois Children’s MentalHealth Act of 2003 established theIllinoisChildren’sMentalHealthPartnership(ICMHP) and authorized it to develop astatewide strategic plan for reforming thechildren’smentalhealthsystem.Inlinewiththegoalsof this strategicplan, inFY2007theGovernorauthorized$850,000inSchoolMental Health Support Grants to supportthe pursuit of three goals across the state: 1) to increase the capacity of schools toprovidementalhealthsupportsforstudents,with an emphasis on early intervention

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services; 2) to coordinate the student mental health support system and integrate thatsystem with community mental healthagencies, and 3) to reduce the stigmaassociatedwithmentalillnesswithintheschoolcommunity (Illinois Violence PreventionAuthority,2006).

In California,innovativelegislation(knownastheMentalHealthServicesAct,orProposition63) currently authorizes the CaliforniaDepartment of Mental Health to establishguidelines and dispense funds to countiesfor community planning, infrastructuredevelopment, the implementation of prevention and early intervention activities,and workforce education and training(California Department of Mental Health,2007).Administratorsacknowledgethatif theact did not specifically include a provision for preventionandearlyinterventiontherewouldlikelybenoemphasisonpreventioninmentalhealth throughout the state of California.Thus, a lesson fromCalifornia is that statelegislatorscanplayavery important role increatingabroadvisionandsustainedsupportforpreventionandpromotion.Assessmentsof the impact of this policy change are inprogress(CenterforMentalHealthinSchools,2008).

In Michigan,astrongschool-basedhealthcenter(SBHC) initiative offers mental health carethroughmanyof its87 sites.Core fundingfor this initiative comes primarily throughthe state department of education. SBHCleadershaverecentlyconcludedanagreementwithlocalmanagedcareplansthatwillallowforthereimbursementof servicesdeliveredto children through SBHCs. Under thisagreement,thecentersandplanshavebegunapilot program in which qualified school social workerswillprovidementalhealthcarethroughtheSBHCsandcanbereimbursedforservices.Additionally,increasedfundsforschool-basedhealthcarewillsoonbeavailableinanumberof countiesthroughoutMichiganasaresultof an agreement between the local public

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health office and the board of commissioners thatallowsschooldistrictsdollarstransferredtothe localpublichealthagencytobeusedtodrawdownadditionalfederalfunds.Thelocalpublichealthsystemthensubcontractswithcommunitymentalhealthproviders todeliver school-based services across theschoolsinthatdistrict(D.Brinson,personalcommunication, January 10, 2008). Whileno data is available yet to determine theefficiency of this new financing model, such innovativeapproachesbearwatching.

In Pennsylvania,mentalhealthservicesinschoolsare partly funded through EPSDT dollars.OnceachildhasbeendesignatedasmeetingtheEPSDTstandardof disabilityheorshecanbecategorizedasa“familyof one”andbeautomaticallyeligibleforMedicaid.StateregulationsaroundEPSDTinterpretfederalguidelines to allow both psychiatrists andlicensedpsychologists todeterminemedicalnecessity and prescribe needed behavioralhealth services (S. Mrozowski, personalcommunication,January16,2008).

In Ohioand South Carolina, localfoundationshavebeenimportantpartners insupportinginnovationinschoolmentalhealth.InOhiotheHealthFoundationof GreaterCincinnatihas funded pilot schools to implementpreventionprogrammingacrosscounties inthestate.InSouthCarolinatheBlueCross/BlueShieldFoundationhasmadeseedgrantsavailable tohelp supplement schoolmentalhealth clinician salaries in order to retainthem inprofessional shortage areas aroundthestate.


Primary RecommendationAuthorizeacomprehensiveexaminationof allviablefundingoptionsforSMHinD.C., includinggrants,contracts, fee-for-service payments, interagencyagreements, and pooled funding to advance youthinitiatives. The goal of this examination would be

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a comprehensive plan to guide development of asystematicblended-fundingstrategytosupportschoolmentalhealthprograms.

Secondary RecommendationsIn partnership with OSSE, conduct an analysis of federalandstate/cityeducationfundstodeterminetheiravailabilitytounderwritenon-academiclearningsupports.

Inadditiontofederalgrants,foundationfunds,localagency dollars, and contracts with local educationagencies(LEAs),DMHshouldworkcollaborativelywith the Mayor’s Interagency Collaboration andServicesIntegrationCommission(ICSIC)toexplorethedesirabilityof poolingvariousblockgrantfundstosupportearlyinterventionmentalhealthservices.InadditiontotheCommunityMentalHealthServicesBlock Grant, other potential sources include theSocialServicesblockgrant, JuvenileAccountabilityblockgrant,Educationblockgrants,EarlyChildhoodblockgrants,andtheCommunityDevelopmentblockgrants.

Align SMHP goals with education priorities andexplorethepossibilitiesfordirecteducationfundingformentalhealthpromotionandearly intervention.In Ohio and North Carolina federal educationfundshavebeenusedtosupportimplementationof evidence-basedmentalhealthprogramsandpractices.Among the sources of support from the federaleducation act: Title I, Part D: Children and Youth Who are Neglected, Delinquent or At-Risk; Title IV, Part A: Safe and Drug Free Schools and Communities, Part B: 21st Century Community Learning Centers; Title V: Promoting Informed Parental Choice and Innovative Programs. Additionally, the IndividualswithDisabilitiesEducationAct(IDEA)allowsforapercentageof specialeducationdollarsgiventothestate to be used for youth who have not yet qualified forservicesbutareearlierintheinterventiontrajectory,meaningthatearlyinterventionworkcanbefundedwiththesedollars.Provisionsof IDEA2004requirethat 15% of the IDEA dollars be spent on earlyintervention services if disproportionality is identified inalocaldistrict.Thereisdebateaboutwhetherthisprovisioncreatesatargetedpotof moneythatwould

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fundtheimplementationof newstrategiestodivertchildren from special education or if these fundsareearmarkedtoimprovethequalityof instructionforallstudentsincludingthoseingeneraleducation.The flexibility and the possible interpretations of this legislation could result in a significant funding stream for a segment of school mental health care and,therefore,furtherexplorationiswarranted.

FollowingtheMichiganexample,theDistrictmightalsoconsiderlookingatthepossibilityof fundingschoolmentalhealthasacomponentof acomprehensiveschool-basedhealthcenter initiative. Several stateshave specifically increased funding for SBHCs to expandandimprovementalhealthservicesdeliveredinschools(i.e.,Texas,NewMexico,Colorado,NewYork,Michigan).Giventhecity’sinterestinexpandingthe number of SBHCs, especially in high schools,possibility of additional support may become areality.

DCmayalsoexplorethepossibilityof committinggeneralschooldistrictfunds(i.e.,districttaxdollarsthat are not tied to any particular program) tosupport the delivery of mental health services inschools ashasbeenachieved inotherpartsof thecountry (Los Angeles County in California andthe 2004 Families and Education Levy in Seattle,Washington).

Buildthecapacityof DMHandothercityorganizationsto compete successfully for federal grant funds.Successfulapproacheswill include institutionalizingcollaborativepartnerships,strengtheninginter-agencycommunications, refining system of care models, and continuingto identifychampionswhoadvocateforpolicyandprogramchanges.

Program evaluation and outcomes research

“One of the only mental health services that have worked in the past 15 years has been school mental health. It is one of the only programs that has worked in this city”. TommyWells,CityCouncilMember, personal communication,March30,2007.

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Mental health programming in District of Columbiaschoolsisatacrossroads.Increasedrecognitionof mentalhealthneedsamongthecity’syoungpeopletogetherwithbroadcommunitysupportformeetingtheseneedsthroughschool-basedprogramshascreatedasolidfoundationforexpanding theexistingprograms.Thenextchallengingquestion is: How best to proceed? What are the most effectivewaystoorganizetheseservices?Whichservicesandprogramshavethemostimpact?Andwhathasbeenlearned about the best way to document the benefits of schoolmentalhealth?ThischapterreviewscurrenteffortsintheDistricttoassesstheimpactof itsschoolmentalhealth programs, summarizes findings from research and evaluationstudiesof schoolmentalhealthprograms,andsuggestslessonstobelearnedfromothercityandstateprogramevaluations.

Current approaches to evaluating school mental health services in the District of Columbia

Program development and evaluation depend on theavailabilityof datadescribingtheprevalenceof mentalhealthconditionsamongDistrictchildrenandadolescentsas well as services utilization by this population. Theavailability of these “baseline” data is critical to thecity’sabilitytomeasureprogressoncenewservicesareimplemented.AccordingtoarecentstudybytheRANDCorporation, thesedata are almostnon-existent in theDistrict of Columbia, and this deficiency exists across allDistrictof Columbiaservicesystems(Lurie,Gresenz,Blanchard,Ruder,Chandra, et al., 2008). The lackof baselineinformationonfunctioning,bothforindividualchildren as well as the systems that serve them, putsdecision-makers at a significant disadvantage for making informed choices about the distribution of limitedresources.Despitethissystem-widelimitation,boththeDMHSMHPandSSChavecollecteddataonkeyaspectsof theirprogramsforanumberof years.

Evaluation objectives: Measuring program and service goals

TheDMHSMHPandSCChaveeachestablishedgoalsandoutcomesfortheirprograms.AsindicatedinTable9, these organizations have focused particularly oninstitutionalgoals.OvertheyearstheDMHSMHPandtheSSCprogramshavecollectedsubstantialquantitiesof datathatdescribeserviceutilizationandstaff productivity,

student-clientsatisfactionandsatisfactionamongothersaffectedbytheservices,andyouthemotional,behavioral,andeducationaloutcomes.

Thedifferencesbetweenthetwoprograms’goalsevidentinTable9 canbe attributed to a) the requirementsof the primary funding sources, b) the need to focus oninfrastructurebuildingtosupportmentalhealthservicedelivery, especially for the charter schools, and c)variations in theprogrammodelsbeingused. Fromacitywideperspective,standardizingschoolmentalhealthprogram goals across service providers would helppolicymakers assure consistency in benefitsto students and families across the programs.

Evaluation of clinical servicesThe DMH SMHP and the SSC SMHP have providedstudentsintheDCpublicandpubliccharterschoolswithin-schoolmentalhealthservicesforthepast8years.Alargenumberof youthhaveutilizedtheseservices.Descriptivestatisticsonserviceusershavebeenreportedregularlytothecity’sprogramandpoliticalleadership.Dataelementshave included demographic information on students,referral sources, reasons for student referrals, clinicianproductivity, typesof servicesprovidedandmodalitiesof treatmentoffered.Theabsenceof nationalandlocalstandards makes it impossible to determine whetherprogrammatic benchmarks around staffing, productivity, penetrationrate,andthescope/breadthof serviceshavebeenmet.



Theneedtoidentifyclinicalmeasuresthatwererelativelyeasytoadminister,score,andinterpretandthatassessedstrengths and weaknesses using information obtainedfrom numerous sources, led both the DMH SMHPandtheSSCSMHPtoadopttheOhioYouthProblem,Functioning, and Satisfaction Scales (“Ohio Scales”; Ogles,Melendez,Davis,&Lunnen,1999). Thescalesidentify student problems, guide treatment planningandtrackprogressforstudentsreceivingservices,whilemeasuring problem severity, functioning, hopefulness,andsatisfactionamongstudentsbeingtreatedaswellastheircaregiversandtheirmentalhealthproviders.Whenusedtoscreenforproblems,studentsdemonstratinghighscoresonparticularsubscalesof thetoolreceiveasecondroundof screeningfordepression,angerandaggressionusingothervalidatedmeasures.

Afteradeterminationismadeaboutthefocusof treatmentandthelevelof careneeded,progressonemotionalandbehavioraloutcomesaretrackedusingadditionalclinicaltools.Table10liststhechild/youthoutcomesusedintheDMHSMHPprogramevaluationplanandthemeasuresemployedtoindicatechangesinemotionalandbehavioralfunctioning.

The DMH SMHP has documented significant improvement inpsychologicalfunctioningamongitsstudent-clientsovertime.Pre-posttestingfollowingtreatment interventions

Increase the availability of school-based early intervention assessments and mental health coun-seling services for pre-K through high school in the charter schools

Develop functioning Student Support Teams (SSTs) in every school site Develop and pilot braided funding and sustainability techniques for schools

DMHSMHPProgramGoals SSCProgramGoals(MHPrevandIntervention)

Assure continuous quality improve-ment of services to align operations, curriculum and program to achieve desired outcomes

Facilitate student improvement in functioning

Assess stakeholder satisfaction

Document the program’s impact on important systems surrounding the child

Sources: Acosta Price, Mack & Spencer (2005) & Brooks, SS/HS Grant Report Yr 2 (2007)

Table 9. Program Goals for the DMH and SSC School Mental Health Programs



has demonstrated clinically significant changes in self-reportedexperiencesof emotionaldistressespecially inreducedlevelsof depression,anger,andaggressionamongstudents.(Acosta,Mack,&Spencer,2005).Thesechangesarerobustforinternalizingproblems,butlessisknownabouttheimpactof theprogram’sservicesonstudents’externalizingproblemssuchasdisciplinaryinfractionsandbehavioralactingout.Toassessthatimpact,DMHwillneedaccesstobehavioraldatacollectedbyschoolsandthiswillrequiregreatercollaborationbetweenindividualschools,theschoolsystem,andDMHSMHP.Thisaccessmaynotbeeasilyachieved,butwouldcertainlyenhancethe agencies’ knowledge about how to help troubledstudents.

Administrators at SSC have invested significantly in the developmentof individualizedassessmentsof progressamongchildrenreceivingtreatmentservices.Followingup from the Ohio Scales, SSC clinicians have trackedindividualclientchangesandmadeclinicaldecisionsusingthe Reynolds Child and Adolescent Depression Scale(RCADS) and the Global Assessment of Functioning(GAF).Additionally,SSChasimplementedanumberof

evidence-basedprogramsthathaveassociatedmeasuresinorder todocument functioningbeforeandafter theintervention (e.g., the Incredible Years program andGuiding Good Choices) (Carolyn Gardner, personalcommunication,May5,2008).

AmongstudentsparticipatinginmentalhealthinterventionsprovidedintheSSCschools,anindependentevaluationforthe2006-2007academicyearfoundimprovementsinemotionalfunctioning,particularlywithself-reporteddepression and anxiety among high school students.Reportsof bullying,beingbullied,andcarryingweaponsshowed lower rates asdid self-reportedabsences fromschool and days skipped (Youth Policy Institute, 2007a; 2007b).Aggression,violence,andalcohol/drugusedidnotdiminishduring the same timeperiod, particularlyamong high school students (Youth Policy Institute,2007b).

There are anumberof limitations associatedwith theevaluations of both DMH SMHP and SSC programs.While thedescriptivedata characterizing studentswhousetheservicesofferavaluablelookatriskfactorsand

Monthly Report Form

Child/Youth, Parent, Teacher Satisfaction Forms

Beck Anger Inventory for Youth & Children’s Inventory of Anger

Beck Disruptive Behavior Inventory for Youth & The Aggression Questionnaire

Reynolds Child & Adolescent Depression Scale

Trauma Symptom Checklist for Children

Attendance data, suspension data, truancy data, drop-out data (obtained from participating schools/school district)

Table 10. Child/Youth Outcomes and Measures for DMH School Mental Health Program

Emotional&BehavioralOutcomes Measurement/Tool

Increase Utilization of MH Services

Improved Satisfaction

Reduce Anger

Reduce Aggressive Behavior

Reduce Levels of Depression

Reduce Symptoms of Trauma

Improve attendance, reduce suspensions

Source: Joel Dubinetz, personal communication, February 15, 2008



thestudent’ssocialcontext, littlecanbesaidabouttheeffectiveness of any specific program, component, or serviceasa resultof these investigations.Additionally,themajorityof outcomedataisbasedonself-report(i.e.,student,parent,teacher)thatisinfrequentlycorroboratedbyotherobjectiveinformation(i.e.,collateralobservationsorreports,attendancedata,disciplinaryreports)duetotheorganizationalbarriersoftenexperiencedbyprogramadministrators and evaluators. Furthermore, it is difficult toattributeanystudentorschool-levelimprovementstotheinterventionsprovidedbyDMHorSSCclinicalstaff withoutmorecarefullycontrolledstudies.

Thelackof rigorousexperimentalorquasi-experimentalresearchthathasbeenconductedinDChindersprogramdevelopment, especially in light of the significant financial andsocialinvestmentsmadeintheseprograms.Althoughfindings have been encouraging, the absence of control groups for which to compare results of any previousevaluation studies significantly limits the interpretation of emotional,behavioral,oracademicchangesseenamongstudentsreceivingschool-basedmentalhealthservices.

Theabsenceof carefullycontrolledstudies isespeciallytroublesomeinlightof thechangesrecentlymadetotheDMHSMHP.Fiscalconstraintsandexternalpressureshavenecessitatedanexpansionof theDCSMHPintoan additional 10 DC public schools in the 2008-2009schoolyear,withoutanincreaseinfundingfromDMH,CityCouncil,or theMayor. Thischangewill result intheimplementationof atwo-tieredapproach,withTier1schoolsmaintainingthecurrentmodelof prevention,early intervention, and brief treatment services andTier2 schoolsbeingoffered specialized servicesor anabbreviated version of the model. In twenty schools,whereenrollmentisgenerallylessthan200studentsand/orschoolsdonotdemonstrateareadinessforafull-timeclinician,aschoolmentalhealthproviderwillbeassignedto the school on a part-time basis to conduct a specific program or curriculum, depending on the identified needs of theschoolcommunity.DMHleadersandadministratorsreporttheyhaveaplan inplacetomonitorthe impactthis modification will have on clinical, behavioral, and academic outcomes exhibited by student, school staff,andfamilies.Evaluation of organizational structureAn organization’s structure determines how well their

functions and processes ease the attainment of anexpressed goal – in this case the expansion of schoolmentalhealthprogramsthroughoutWashington,D.C.Aneffectiveorganizationalstructureenablesbetterworkingrelationshipsamongvariousentitieswithinandoutsideof the organization and sets controls to monitor theefficiency of important processes. The evaluation of DMH andSSCorganizational infrastructurescouldincludeanexaminationof staff selectioncriteria,thedevelopmentof processestomonitorstaff competenceandproductivity,ananalysisof internalandexternalcommunications,theimplementation of supervision and training standards,andotheractivitiesthatassessqualityof schoolmentalhealthservices(Weist&Paternite,2006).Althoughtheseareprocessesthatcan,theoretically,beevaluated,neitherorganizationhasdemonstratedadvancementsinthisarea.Resourceswouldbeneededtoconducttheseactivities,butthe investmentwouldfacilitatedata-baseddecision-making.

OverthelastseveralyearsDMHSMHPadministratorshave implemented a continuous quality improvement(CQI)plantoassessthequalityof servicesandestablishstructuresforaccountability.TheDMHSMHPformedan internal CQI committee, that is not formally partof the Office of Accountability, that meets monthly to address a specific focus area. The committee has developedaclinicalchartreviewprocessandproceduresfor the completion of clinical paperwork (i.e., intakeforms, assessments, treatment plans, etc.). Additionalaspectsof school-basedcarethatarebeingdevelopedbythecommitteeincludeproceduresforconductingneedsassessments, identifying and implementing evidence-based practices, increasing stakeholder involvementand feedback,utilizing clinicaloutcomeandutilizationdata in clinical decision-making, demonstratingimprovements in staff developmentefforts, facilitatinglinkages to community resources, anddelineatingclearproceduresforaccesstocare/crisisresponses.

There has been no consistent quality improvementprogram at the SSC due mainly to the absence of aclinical director to manage these activities. The SSCisnowengaged indiscussionsatanagency levelaboutthequality indicators theywould like to track (CarolynGardiner, personal communication, May 5, 2008).



Research findings on school mental health programsNational studies have confirmed that the unique advantage of school-basedmentalhealthservices is that theyareaccessible and utilized by students with identified mental healthneedsmoreoftenthanservicesofferedthroughcommunity-based settings (Atkins, et al., 2006; Armbruster & Lichtman, 1999; Weist, 1997). Although establishing successfulschool-basedmentalhealthprogramsrequiresattentiontoanumberof contextualandsystemicfactors(Acosta,Tashman,Prodente,&Proescher,2002), suchefforts have been known to yield benefits for students frominner-citypublicschoolsinparticular(Atkins,etal.,2006; Costello-Wells, McFarland, Reed, & Walton, 2003; Jennings,Pearson,&Harris,2000).Researchersinterestedintheimpactof school-basedmentalhealthserviceshavegenerally studied outcomes related to two areas: emotional/behavioral functioning and academic performance. Anumberof school-basedinterventionsandprogramshavedemonstratedpositiveoutcomesinbothof thesedomains(Catron, Harris, & Weiss, 1998; Rones & Hoagwood, 2000; Stoep, Weiss, Kuo, Cheney, & Cohen, 2003; Tsoi-A-Fatt, 2008; Walter, 2007; Woodruff, et al., 1999).

Prevention and positive long-term outcomes While the societal benefits and cost-effectiveness of mental health promotion and prevention efforts arenowmoreclearlyarticulatedandunderstood(SAMHSA,2007), prevention researchers warn that school-basedprogramsmustbecoordinatedwithschooloperations,integratedwith existing initiatives, andutilizepracticesand programs that can yield obvious improvements(Greenberg, et al., 2003). A review of preventionprograms and their capacity to prevent risk of psychopathologyinyouthconcludedthatmulti-yearandmulti-component prevention programs are more likelyto show long-term impact than short-term programs(Greenberg, Domitrovich, & Bumbarger, 2000). Thisreview also states that the impact of preventionprogramsistypicallyunderestimatedsincesomeof themoreeffectiveprogramsdemonstratestrongerimpactsatlong-termfollowupthanattheendof theintervention.The bottom line is that clinicians, administrators, andevaluatorsmustcommittoaprogramorsetof programsthat will be implemented consistently over a numberof years and assessed for immediate and longer-termimpacts.

School mental health and emotional/behavioral outcomesResearch reviews indicate that a number of schoolmentalhealthinterventionsdemonstrateimprovementsinpsychosocialfunctioningandareductionof symptomsacrossavarietyof emotionalandbehavioralproblemsin children (Walter, 2007; Rones & Hoagwood, 2000; Catron, Harris, & Weiss, 1998). These improvementsincludethereductionof aggressivebehaviors(Wilson,Lipsey, & Derzon, 2003) enhancements in studentfunctioning as well as cognitive-behavioral changes(Hoagwood & Erwin, 1997) and behavioral (Wilson,Lipsey, & Derzon, 2003). Programs with a strongimpact on individual symptom reduction share five common elements:

consistentprogramimplementation,involvementof parents,teachersorpeersintheintervention,useof multiplemodalitiesandthefocusonchanging specific behaviors and skills, integration of program content into theclassroomcurriculum,andinclusion of developmentally appropriateprogramcomponents(Rones&Hoagwood,2000).

To achieve notable improvements in student social,emotional, and behavioral functioning requires aninvestmentof timeandeffortforthoseimplementing,managing,andfundingschoolmentalhealthprograms.The development of a standardized evaluation planwithdetailsof dataelementsthatshouldbemonitoredovertimewillrequireapreliminarydecisionabouttheintervention(s)thatwillbeemployedcitywide.

School mental health and educational outcomes Previousresearchhassuggestedthatschoolmentalhealthprogramshaveapositiveimpactonacademicfunctioning(Jennings,Pearson,&Harris, 2000). A recent review

1.2.

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5.

Prevention researchers warn that school-based programs must be coordinated with school operations, integrated with existing initiatives, and utilize practices and programs that can yield obvious improvements (Greenberg, et al., 2003).



of studiesthatlookedatthementalhealthandacademicoutcomesof schoolmentalhealthprogramsfoundalackof rigorinbothresearchareas(Hoagwood,etal.,2007).Despitetheseandotherlimits,severalconclusionscanbedrawnfromthereviewbyHoagwoodandhercolleagues.First, the impactof schoolmentalhealth interventionsoneducationaloutcomesappearsmodest,doesnotseemtolast,andispoorlyunderstood.Thelackof persuasiveresearch makes it difficult to urge the inclusion of specific academic and education-related data elements in anyschoolmentalhealthprogramevaluation.Yet,programsupporters and funders consistently view attendance,grades,scoresonstandardizedtests,disciplinaryreferrals,suspensions,referralstospecialeducationforemotionaldisturbance (ED), promotion rates, and changes innumbers of drop outs as key indicators to monitor– despite the difficulty of establishing causality between thementalhealthandeducationaloutcomesanddespitethe difficulties of securing education information from schoolsystems.

The Hoagwood review cautions that the academic outcomes included in many research studies (i.e., grades, test scores, school drop out) do not necessarily have a direct relationship to the mental health interventions.Othervariablessuchasthenumberof disciplinaryactionsandclassroomfactors(i.e.,teacherbehaviors,classroomorganization, and school climate) appear to have astrongereffectonacademicoutcomesandeducationalperformance and are more readily influenced by mental healthinterventions.Ontheotherhand,giventhehighcorrelationbetweenfailuretocompletesecondaryschoolandthepresenceof anemotional/behavioraldisability(Stoep, Weiss, Kuo, Cheney, & Cohen, 2003; Tsoi-A-Fatt, 2008; Woodruff, et al., 1999) and the strong relationship between education, health, and future success (RobertWoodJohnsonCommissiontoBuildaHealthierAmerica,2008),includingacademicvariablesinanevaluationof theimpactof schoolmentalhealthservicesisrational.

The importantpointhere is thataprogramevaluationplan needs to examine the impact of school-basedinterventions with an understanding of the primaryfocus of the intervention and to look for outcomesthat demonstrate changes in that arena. For example,universalpreventionprograms that targetchanges inastudent’sabilitytomakegoodchoicesordeveloppositiverelationships should not be expected to demonstrateimmediategradeimprovementssincethatisnotthefocusof theintervention.

School mental health and school climate “Whole school climate has to do with everyone’s efforts to promote mental health. Everyone is involved. The entire school community can feel they can have an impact on making every child feel valued in terms of their social and emotional well-being. Qualified mental health providers can be important resources in this process”. JoyceSebian,SeniorPolicyAssociate,NationalTechnicalAssistanceCenterforChildren’sMentalHealth,personalcommunication,January4,2008.

Growingevidencesuggeststhatschool-wideinterventionsaimedatimprovingschoolclimatecomplimentthemoretargetedcurriculum-basedinterventionsfrequentlyusedin school mental health programs. “School climate reflects thephysicalandpsychologicalaspectsof theschoolthatare more susceptible to change and that provide thepreconditions necessary for teaching and learning totakeplace”(Tableman,2004,pg.2).Poorschoolclimatecontributes to a number of negative outcomes forstudents includingbehavioral andemotionalproblems,alcoholandtobaccouse,andincreasedaggression,whileprogramsaimedat improvingschoolclimateeffectivelypromote a number of positive outcomes (Greenberg,Domitrovich,Graczyk&Zins,2005).Recently,researchhas confirmed that changes made to a schools’ overall organization,policies,practices,culture,orenvironmentwere associated with increased student participation,improved relationships, greater connection to schools,improvementsintruancy,andreduceddruguse(Fletcher,Bonell,&Hargreaves,2008).Inparticular,theconnectiontoschool,ortheextenttowhichastudentfeelsaccepted,welcomed,andrespectedinhis/herschool,ismeaningfullyrelated to better academic and psychosocial outcomes(Shochet et al., 2006). Interventions that focus onfosteringschoolconnectednesshelpameliorateavarietyof emotionalandbehavioralproblems,suchasdecreasesin depression, substance use, and violent or deviantbehavior, and support better academic performance(Anderman, 2002; Blum, 2005; Shochet et al., 2006).

The benefits are not only evident among students but canalsobeseenamongteachers.Schoolmentalhealthprogramshavebeenshowntoimproveteacherretentionandreduceburnout.Stressamongteachershasneverbeensohigh(Bauer,etal.,2007)andeducatorsopenlyreportfeelingoverwhelmedandhelplesswhenfacedwith thementalhealthneedsof their students (Williams, et. al,



2007). This challenge is not confined to the U.S., with internationalstatisticsindicatingthatalmost50%of newteacherswill leavetheprofessionwithina5-yearperiod(Bauer,etal.,2007),whichhelpsexplainateacherturnoverrateof almost17%nationallyandover20%amongteachersworking inurbanschools(NCTAF,2007). Asaresult,effective school mental health programs must supporttheadvancementof nurturingconditionsinclassroomstoaddressbothteacherstressandstudentpsychosocialproblems(Weston,Anderson-Butcher,&Burke,2008).AstudythatcomparedBaltimoreCityelementaryschoolswithandwithoutschoolmentalhealthprogramsfoundthat teachers in schools with mental health programsreferredfewerstudentstospecialeducationforemotionalorbehavioralproblemsandfelttheyhadmoresupportsavailabletothemthanteachersinschoolswithoutthatresource (Bruns,Walrath,Glass-Siegel,&Weist,2004).This outcome suggests the possibility of real financial benefits from implementing comprehensive mental health programsinschools.

The relationships between school climate and studentachievement, teacher retention and satisfaction, andschoolviolencearestrong--suggestingthat leadersof school mental health programs may wish to developandusewell-designedassessmenttoolstotrackchangesin school climate and levels of school connectedness.Severalorganizationshave rated instruments thatbothmeasure school climate and can be used to monitorimprovementsinschoolenvironments(Tableman,2004).These include:

TheCollaborativeforAcademic,SocialandEmotional Learning (CASEL, http://www.casel.org/assessment/climate.php),The Center for Social and EmotionalEducation (CSEE, http://csee.net/climate/csciassessment/csci_survey.aspx), andTheWesternAlliancefortheStudyof SchoolClimate-WAASCweb-basedclassroomclimatesurveys (http://www.calstatela.edu/centers/schoolclimate/classroom_survey.html) and school climate surveys (http://www.calstatela.edu/centers/schoolclimate/school_survey.html#culture)

Onestateagency, theOhioDepartmentof Education,has acknowledged the influence environmental conditions haveonacademicperformanceandasaresultimplemented

1.

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theOhioSchoolClimateGuidelinestoencourageschooldistrictsthroughoutOhioto invest inthemaintenanceof positive learning environments (http://www.ode.state.oh.us/GD/Templates/Pages/ODE/ODEDetail.aspx?Page=3&TopicRelationID=433&ContentID=1841&Content=47610).

Appropriate clinical evaluation tools

The impactof a clinically-focusedprogramevaluationdependsonthequalityandreliabilityof theassessmenttools used, their psychometric properties and theirrelevancetothe intendedoutcomes.Selectingtherightinstrumentsforscreeningandassessingstudentsatschoolis a complex endeavor requiring a keenunderstandingof strengths and weaknesses of available instruments(Levitt,Saka,Romanelli,&Hoagwood,2007).Someweb-basedresourcesofferhelpin identifyingtherighttoolsfor particular symptom clusters and audiences (www.schoolpsychiatry.org),buttypicallytheydonotprovideinformationonthepsychometricpropertiesof thetools.A national push to implement universal screening inschoolshasnotbeenaccompaniedbyguidanceonhowtoeffectivelyscreenlargepopulationsof children(NewFreedomCommission,2003).Onlyrecentlyhavecriteriabeen suggested to help educators and mental healthprofessionalsmake informeddecisionsaboutthemostsuitabletoolstouseinassessingstudentswithinschoolsettings(Glover&Albers,2007).

Quality assessment in school mental health programs

Inadditiontoexaminingtheoutcomesassociatedwithschoolmentalhealthservices,well-establishedprogramshavededicatedresourcestocontinuouslyassessthequalityof services provided. The Center for School MentalHealth, oneof thenational centers for schoolmentalhealth at the University of Maryland, has developedresources on quality improvement to help programadministrators identify priority areas for enhancingschoolmentalhealthservices(Lever,Ambrose,Anthony,Stephan,Moore,etal.,2007).TheSchoolMentalHealthQuality Assessment Questionnaire (SMHQAQ; Weist, Stephan,Lever,Moore,&Lewis,2006) is a toolusing40 indicators reflecting 10 principles of care that can beusedbyschoolmentalhealthpractitionerstoassessstrengthsandweaknessesof theirprograms.TheMentalHealth Planning and Evaluation Template (MHPET;



NASBHC, 2007), a similar tool developed jointly bythe National Assembly on School-Based Health Care(NASBHC) and theCenter for SchoolMentalHealth,istypicallyusedbyadministratorsormanagerstoassessprogrammaticstrengthsandweaknesses.TheMHPETisa 34-item measure that is organized into eight dimensions: 1)operations,2) stakeholder involvement,3) staff andtraining, 4) identification, referral, and assessment, 5) servicedelivery,6)schoolcoordinationandcollaboration,7) community coordination and collaboration, and 8)quality assessment and improvement. Because theseare both recently developed tools, findings on their effectivenessarenotyetavailable.

Program evaluation is a worthwhile endeavor and anecessary investment for a state agency, but there area number of challenges in conducting school mentalhealthprogramevaluation thatmust bebalancedwiththeimportanceof documentingprogramimpact.Thesechallenges include addressing the realistic difficulties of conducting research in the field where many factors cannot becontrolled,allowingclinician’sthetimeandresourcesto be involved in evaluation activities, and convincingteachers,parents,andschooladministratorsof themeritof supporting and participating in evaluation (Weist,Nabors, Myers, & Armbruster, 2000). To the extentthat schoolmentalhealthcliniciansareexpected tobethemainsourcefordatagathering,informationsystemsshould be identified or designed that allow information to becapturedinthecourseof ‘businessasusual’toreducedrainonclinicalstaff.


Schoolmentalhealthprogramsinotherstatesandcounties,thier experiences with the use of specific data elements, measurementtools,andinformationmanagementsystems,caninformdecisionsmadeinDC.

Evaluation data collectedBaltimore, MD. The Baltimore school system hashistorically provided school-level data but onlyrecently has the Division of Research, Evaluation,andAccountabilityagreedtoprovidechild-leveldatadirectly to the city school mental health programsusing the student identification number. In the near future, agencies that provide school-based mentalhealth services will calculate attendance, academicperformanceandpromotionrates,suspensions,andspecial education placements for students seen intreatmentatleast4timesandcomparethemagainstthestudent’sownperformancebeforeheorshebegantreatment,aswellasagainsttheirsame-agedpeers.

Measurement tools usedOhio & Texas. TheOhioscalesareusedatthestatelevelbothinOhioandTexas,butonlyforstudentsengagedintreatmentservices. Ohiocollectsyouthself-reportonthehealthyandwell-beingmeasuresof theOhioScalesandcollectslifesatisfactiondatafromallstudentsnotengagedintreatmentservices(usingthe Strengths and Difficulties Questionnaire - SDQ; http://www.sdqinfo.com/b1.html). In addition, 25 school-based health centers (SBHCs) in Texas willbeusingtheMentalHealthPlanningandEvaluationTemplate(NASBHC,2007)toassessthedevelopmentof theirmentalhealthservices.South Carolina. The South Carolina Departmentof Mental Health, School Based Mental HealthProgramsassessall schoolmentalhealthprogramsusing a clinician-rated instrument (the Child andAdolescent Functional Assessment Scale- CAFAS)andbyanalyzingsatisfactionsurveysfromchildren,family members, and school administrators. Thelatest published program evaluation report (theDepartmentof MentalHealthOutcomeReportFY2006-2007)summarizesthatschool-basedprogramsare serving children with needs as severe as thoseattendingothercommunitymentalhealthprogramsand are demonstrating significant impact on children’s functioning (through statistically significant differences between CAFAS admission and discharge scores)(SouthCarolinaDepartmentof Health,2008).

Data SystemsThe data management systems used in many state

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To the extent that school mental health clinicians are expected to be the main source for data gathering, information systems should be identified or designed that allow information to be captured in the course of ‘business as usual’ to reduce drain on clinical staff.



and county school mental health programs arerudimentary.Somecounties/citiescollectevaluationdatausingExcelspreadsheets(Seattle,WA).OthershavedevelopedAccessdatabases(SouthCarolina),orreport data to a central office using Microsoft Word (Baltimore,MD).Otherjurisdictionshavedecidedtouseavailablecountydollarstodevelop‘homegrown’software programs that can examine correlationsbetweentreatmenttransactionsandchildattendance,suspensions,andgrades(MontgomeryCounty,MD).In states where there are statewide initiatives thatrequire specific data collection systems (such as School-WideInformationSystems(SWIS)usedwithinPBS–referbacktopage11formoreinformationonPBS),schoolandmentalhealthadministratorsaretryingtodetermineif school-baseddatacollectioneffortscanbestreamlined(i.e.,inIllinois).


Primary Recommendation:Without a method to reliably collect and analyzeschool-levelandstudent-leveldata, theDepartmentof Mental Health will remain handicapped in itsabilitytomakedata-drivenordata-informeddecisionsabouttheallocationof resourcesforschoolmentalhealthprograms.TheDepartmentmustimmediatelydeveloporidentifyaninformationsystemtomonitorand evaluate all school mental health programsacrossthecity.Thissystemmustcollectutilization,satisfaction, and outcome data. The informationsystemmustalsosupportthecontinueddevelopmentof quality improvement initiatives. Encouragingly,progressinthisregardhasbeenreportedfromDMH(Joel Dubinetz, personal communication, February15, 2008), but delays in implementation are significant andfrustratesthebesteffortsof providers.Oncethesystem is established, DMH will need to track itsaccuracyandfunctionalabilitiesbyobtainingregularfeedbackfromclinicians.Toensuresustainabilityof thisdatagatheringtool,DMHshouldexplorehowtheinformationsystem,particularlyif web-based,canbeusednotonlybyDMHSMHPproviders,butbyallotherschool-basedmentalhealthproviders,suchasthose intheSSCprogramandothercommunitymental health agencies. The information systemshouldbeassessedfor itspotentialto integrateand

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‘talk’withotherdatacollectionprogramsusedbyotherchild-servingagencies(i.e.,publicschoolsystem,childwelfare,publichealthsystem,juvenilejustice).

Secondary Recommendations:One benefit of greater involvement by DMH in citywideevaluationactivitieswouldbetheexecutionof acoordinatedplanthatwouldinvolveallschool-based mental health providers and agencies usingstandardized tools and common definitions of targetoutcomes.(RefertoAppendixMtoviewdraftproposaltoimplementcitywideschoolmentalhealthevaluationplan.)

DMHshouldadvocatefor,andwhenpossiblefund,researchonoutcomesassociatedwiththeSMHPsthatemploymorerigorousstudydesigns. Forexample,await-listcontrolstudyoramatchedschooldesigncomparing DC SMHP schools with SSC schoolsandcontrolschoolsthathavenotreceivedservicesundereitherprogramwouldnotnecessarilybecostly(especially if existingdatawereutilized) andcouldsufficiently highlight the strengths and weaknesses of eitherprogram.Thiscomparisonshouldincludecarefully selected school-leveloutcomes (related tobotheducationandschoolclimate)andstudent-leveloutcomes(bothindividualacademicperformanceandemotional/behavioralfunctioning).Researchpartnerscan be critical players in the identification, design, implementation,and/oranalysisof futurestudies.

Research continues to suggest that a strongrelationshipexistsbetweenSMHPinterventionsandschoolclimate. DMHshouldcontinuediscussionswithDCPSandcharterschoolleaderstodeterminethepossibilityof collectingschool-wideclimatedatainordertoassesstheimpactof mentalhealthservicesdelivered inschools. Again, localresearchpartnerscanbeof greathelpinadvancingtheseefforts.

CONCLUSION

Theever-changinglandscapeinD.C.–newcityleaders,newchildhealthpriorities,andmyriadotheralterationsinthepolicylandscapethatinevitablyaccompanythearrivalof anewadministration–challengedthedevelopmentof areportwhoserecommendationswouldremainrelevant.

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However,despitethisrapidlyevolvingenvironment,onefactor has remained constant during the past 18 months: school-basedmentalhealthserviceshaveprovenareliableand valuable service delivery model for school-agedchildrenandadolescentswhootherwisemightnotreceiveneededattention.Buildingonthepassion,commitments,relationships, and advocacy evident for school mentalhealth programs, the following recommendations areofferedtostrengthentheorganizationandmanagementof thegrowingnumbersof schoolmentalhealthprogramsinD.C.

Toward a Vision for School Mental Health Expansion“There is a systemic problem but not a systemic approach as a solution”. Angela Brown, Office of the State Superintendents Office of Education,Washington,D.C.,personalcommunication,April28,2008.

Implementing a Framework for a Full Continuum of School-based Mental Health Promotion and Care

As the city’s authority on the mental health issuesimpacting itsresidents,DMHisobligedtooverseethedeliveryof mentalhealthservices, forgepolicies,offerongoingtrainingandtechnicalassistance,andestablishmonitoringstandardsandsystemsthatenableproviderstobuildasystemof supportsthatarecoordinatedwithotherimportantcitywideinitiatives.ThegreatestchallengefacingtheDistrictof Columbiainitsdesiretomeetthementalhealthneedsof childrenandyouththroughschool-connectedprogramsistheproliferationof disconnectedinitiatives.Missingfromthesemyriadeffortsisconsensusonanoverarchingframeworkfororganizing,implementingandassessingschool-basedstrategies.

Assuggestedearlierinthisreport,theauthorsrecommendaschool-basedmentalhealthmodelfoundedonapublichealthapproachthatoffersarangeof interventionsandprograms reflecting differing levels of care (see framework onpage51).Usingthisapproach,theneedsof allstudentscanbeconsidered–thoseingeneraleducationaswellasspecial education, and all qualified mental health providers canbeutilized.Inaddition,thisorganizingstructureorframeworkwouldclarifyhowpastandcurrentinitiativescanbecoordinated,where impactsshouldbeexpected,where gaps might still exist, and how resources aredeployed.



TheDMHSMHPhas,sinceitsinception,usedapublichealthapproachtodrivetheorganizationanddeliveryof school-basedinterventions.However,toensureafullintegration of services, a refinement of this model is warranted(refer toCappella,et.al., inpress).Aspartof thisapproach,mentalhealthreferralprocessesneedtobeclearlyestablishedandarticulated,screeningsandassessments should be coordinated, roles of mentalhealth professionals who work in schools need tobe clearly defined and explained to school staff and parents, and the availability of various prevention,early intervention, and treatment services should beincorporatedintothefabricof schooloperationssothatstudentsareabletotakefulladvantageof anysupportavailable tothemwithout thefearof marginalization.Theinabilityof eithertheschoolsystemorcommunitymentalhealthsystemalonetomeettheemotionalandbehavioral needs of all students (Weist & Paternite,2006)requiresbothsystemstocollaborate(Taras,et.al.,2004).Expertsnotethatsuccessfulimplementationof innovativemodels,programs,strategies,orapproachesrequires the identification of existing school and communityresourcesandawillingnessforrealignmentwhennecessary(Atkins,Graczyk,Frazier,&Abdul-Adil,2003)

For realignment to be successful, policy and practiceguidanceisavailabletolocalschoolsandschooldistrictsengagedinrestructuringeffortsandschoolimprovementplanning. Much of this guidance incorporatesrecommendationsforaddressingbarrierstolearningandteaching(seetheCenterforMentalHealth inSchoolsat UCLA at http://smhp.psych.ucla.edu for materials focusedonschoolreorganizationandondevelopingacomprehensive,multifacetedcontinuumof interventionstosupport learningandhealthydevelopment. Foranupdateddiscussion refer toFrameworks forSystemicTransformation of Student and Learning Supports,2008).

Certainlypublichealthagenciesandcommunityhealthorganizationshavearoletoplayinsupportingschoolsundertaking systemic reforms. Yet, it is clear thatsystems outside of the school often have little influence orauthorityinthedevelopmentorimplementationof reformscarriedoutbyschools.Furthermore,pressuresfrom federal and state mandates force schools tomarginalizeanythingnotdirectlyrelatedtoinstruction.



Figure1.

Main Providers

School- & Community-

Hired

Student Population

Levels of Need

School PsychologistsSchool Social Workers

SMHP Clinicians

SMHP CliniciansSchool Psychologists

School Social WorkersSchool Counselors

School CounselorsTeachers

School NursesSMHP Clinicians

Students With MoreSevere/Chronic Problems(IEPs or DSM Diagnosis)

Students At-Risk forDeveloping MH

Problems

All Students

Services/Programs

Best Practices

Community ServiceAgency (CSA)

Providers

Source: Adapted from “Communication Planning and Message Development: Promoting School-Based MentalHealth Services” in Communique´, Vol.35, No. 1. National Association of School Psychologists, 2006

Students With SomeActive MH Symptoms

Universal Screening

Student Support Team- Early Intervention Process

Multi-Disciplinary Team for IEP Determination

Diagnostic Assessment

A Framework for the Allocation of Resources for School MentalHealth Services in the District of Columbia

Intensive Individualized,Community Interventions

with School Support

Intensive School Interventions withCommunity Support

i.e., Solution-focused Therapy

Indicated Prevention Interventionsi.e., individual, group, & family

counseling

Selected Prevention Interventions,Consultation and Psycho-education

Universal Prevention & Promotion ActivitiesSchool Climate Interventions

i.e., SEL Programs

inordertofunctioneffectivelyinschool.Studentswithsomeactivementalhealthsymptomsbutwhodonotmeetcriteriaforapsychiatricdiagnosis(andthereforedonotmeet‘medicalnecessity’criteriaestablishedbyMedicaid)wouldbeappropriaterecipientsof indicatedpreventioninterventions.Althoughschoolcounselors,psychologists,and social workers might provide these services, theirprimary responsibility for servicedeliverywithinotherlevelsof carewouldsuggest that schoolmentalhealthprovidersarethebestprofessionalstoservethisgroupof youth.

For students with severe mental health problems thatrequirepsychiatric interventionoraconsistentamountof adultsupervision,acoreserviceagency(CSA), thatis,acommunity-basedmentalhealthagency,maybebestequippedtoserveasthemainproviderof caretotheseyouth and their families. Certification standards in the Districtof Columbia requireCSAs tohave safeguardsinplacethatmakethemthebestprovidersof careforyouthwithmoreintensivementalhealthneeds,including24hourclinicalcoverage.Bestpracticedictates,though,thatintensivecommunityandhome-basedinterventions,toyieldthegreatesteffect,shouldbecoordinatedwithanyschool-locatedmentalhealthprogramsforstudents..

CommonElementsofEffectiveSchoolMentalHealthProgrammingandManagement

The Department of Mental Health has been workingto establish a separate “Authority” role for the agencysince 2001 when it finalized a court-ordered plan that wouldallowDMHtoemergefromreceivership(Jones,2001).If DMHisto“…establishamentalhealthagencywithameaningfulseparationbetweenitsauthorityandprovider functions” (pg. 3), particularly as it relates toschool-basedmentalhealthservices,thereareanumberof recommendationsDMHmustconsider.

Recommendations Regarding Intra-agency Functioning

I. DMH must be explicit in its commitment to the School Mental Health Program and put in place the infrastructure that will support this commitment:

Strong leadership and support for schoolmental health should be exemplified at both theexecutiveandprogram/policylevels.DMH must make a firm commitment to data-driven decision making processes

1.

2.

Thatoftenleavespublichealthsystemsfeelingpowerlessandleftoutof majorchildhealthandeducationinitiativesleadbyschoolsystems.Althoughthisisrealityformanystates and counties around the country, there is still ameaningful role thatpublicmentalhealthagencies likeDMHcanplayinfortifyingeffortstosustainandexpandschool-basedmentalhealthservicessothatcollaborationmovesbeyondthesimpleco-locationof mentalhealthstaff onschoolsites.Amoredetailedconceptualizationof theorganizationof schoolmentalhealthresourcesandoperationsisprovidednext.AsFigure1illustrates,mentalhealthservicesandprogramsfallintodifferentlevelsof intensityandthoseservicesandprogramscanbeprovidedbyschool-hiredorcommunity-hiredprofessionals.Ideally,schoolcounselorswouldbeassignedtoeverypublicschoolinD.C.andwouldacquiretherequisiteskillsandtrainingtoconductuniversalandselected prevention strategies across the entire schoolsystem. Teachers could also be enlisted as partners inimplementingclassroom-basedpreventionprograms,asisseeninotherschoolsystems,butonlyif time,training,andcoachingaremadeavailable.GiventheurgencyforschoolreformintheDistrictof Columbia,itisimpracticalto expect teachers tobe responsible for implementinganything outside the academic curricula in the nearfuture.Ontheotherhand,buildingthefoundationfortheexpansionof effectiveschoolmentalhealthprogramswithoutincludingstrategiesforbuildingthecapacityof schoolstaff topromotepositivementalhealthwouldbea lostopportunity.Schoolnurses,anotherkeyresource,can effectively identify and assist students who needhelp. Currently the nurses in the DC school nursingprogramarenotpositioned toassumetheseadditionalresponsibilities. As a result, communitymental healthproviders,assignedthroughDMHorSCC,continuetohaveacentralroleinthedeliveryof preventionandearlyintervention services for the District’s students. Theextent to which school-hired professionals and otherswithintheeducationsystemacquiretheskills,supportsandstaff toimplementpreventionandearlyinterventionactivities,woulddetermineatwhatpointclinicianscoulddrawbackintomoretreatment-focusedandconsultationactivities.

The lackof recentepidemiologicaldataon thementalhealth needs among DC youth prevents us fromestimating thepercentageof studentswhoneedmorethanpreventionservicesandwhorequiremoresupport



and invest in information systems that arecompatible across systems and agencies,thatareweb-based,thatsupportbilling,andthat are flexible enough to grow with the expansionof theprogram.Aweakapproachto gathering, analyzing, and reporting datawill significantly undermine the program’s potential tocreate andsustainfundamentalchange. Furthermore, accountability andqualityimprovementpracticesmustintegrate‘real time’ information for maximum benefit andeffectiveness.Execution of a communications and socialmarketing plan that articulates the benefits associated with this school mental healthprogram model and builds support for thedisseminationof promisingpracticesamongparents,mentalhealthagencies,schools,andotherpartnersisanimportantroleforDMHtoundertake.

II. If DMH is to adopt a primary role as oversight authority for school-based mental health services, the agency must be prepared to:

Supportthedevelopmentof clinicalcapacitybuilding among community mental healthproviders who can deliver a continuum of school-basedservices.TheManagerof SchoolMentalHealthcould leadthischarge,alongwith staff fromProviderRelations and theDirectorof theTrainingInstitutes.Additionalschool mental health staff would likely benecessary to effectively build communitycapacitytodeliverschoolmentalhealthcare,particularlyasdetailedinthedraftstandards(i.e.,Levels1-3asoutlinedinAppendixI).Fosterandmonitorhighqualitycarethroughperformance-basedaccountabilityandqualitymanagementprocesses. Thiswouldincludea role for the Clinical Administrator, theManagerof SchoolMentalHealthandselectstaff within the Office of Accountability, as well as child-focused staff within theOffice of Information Systems/Evaluation Department.Providetechnicalassistanceandtrainingforprogramsandpracticesthatwouldstrengthenthedeliveryof schoolmentalhealthservices.Thiswoulddirectly involvetheManagerof

3.

1.

2.

3.

SchoolMentalHealthandtheDirectorof theTrainingInstituteatDMH.Additionalschoolmentalhealthtrainersandconsultantswouldlikelybenecessarytoachievethisgoal.Create and implement an advocacy/communications strategy that successfullyengages leading stakeholders and decision-makers about the public health approachto school mental health. The ClinicalAdministratorandManagerof SchoolMentalHealth would work closely with the DMHPublic Information Officer to accomplish this objective.Buildsustainedandvariedfundingtosupportthe full array of services provided throughschoolmentalhealthprograms,anddevelopa process for contracting services that istransparent. The Clinical Administratorwould have a significant role to play in the development of creative funding strategies,while the Manager of School MentalHealthandselectstaff withinContractandProcurementDivisionwouldberesponsiblefortheimplementationof thesestrategies.Create and/or support policies that ensurehigh quality comprehensive mental healthcaredeliveredthroughschoolmentalhealthproviders. The Clinical Administrator andManager of School Mental Health wouldhaveprimary responsibility for this task, aswellasstaff withinthePolicyandEvaluationDivisions.

Recommendations Regarding Inter-agency Functioning

DMH should propose the creation of a school mental health workgroup within ICSIC to ensure interagency collaboration, communication, and accountability for school-based initiatives.

DMH must be prepared to assume leadership in thedevelopmentof aschoolmentalhealthservicesmasterplan that includes specific strategies around strengthening andconnectinguniversalprevention,early intervention,and treatment services into a coordinated continuumof care for school-based and community-based youthprograms. Themenuof servicesandprograms,whichwouldbeassessedfortheirapplicabilityandeffectivenesswithurbanchildrenof ethnicminoritydescent,should

4.

5.

6.



beofferedtoschools inproportiontothe intensityof needs,amountof availableresources,andthereadinessforimplementation.

Havingasingledecision-makingbodywouldfacilitateanintegrationof programs,reducefragmentation,andhelpilluminatewhereserviceandpolicygapscontinuetoexist.Thisgroup,whichshouldbeco-facilitatedbyDMHandDCPS, would maintain a focus on the specific delivery of mentalhealthservicesandprogramsinschoolsandwouldhelpdetermine theprogramsandpractices thatbest match DC’s strengths, challenges, resources, andgaps. Furthermore,understandingwhat resourcesandsupports are available in schools, regardless of whoprovidesthem,willleadtoamorereliableassessmentof whatagencyororganization(withinthementalhealthoreducationalsystems)arebestsuitedtotakeresponsibilityfor sustaining the various components associatedwitheach intervention level. This group would work toensureacohesivecitywideplanforSMHisdesignedandimplemented, that limited resources are used efficiently, andthatintegrationof initiativesandeffortsareachieved.Ensuringthatsystemic,organizational,andprogrammaticsupportsareinplaceinschoolswillincreasethelikelihoodthatanyproposedinitiativewouldbeasoundinvestment.Toensuresustainabilityof successful interventions,thework group would need consistent support from theMayor,theDMHDirector,theChancellorof DCPS,andtheStateSuperintendentof Education.

DMHshouldalsoexaminethepossibilityof establishingaregionalcoordinatingnetwork in theDCmetroarea.ThenetworkwouldbringtogetherSMHadministratorsfrom Baltimore City, Montgomery County, NorthernVirginia,PrinceGeorgesCountyandWashington,DCtocreateaforumforexchangeof information,sharingof resources,andanetworkof supportacrosstheregion.Thenetworkcouldworktowardconsensusonregionalstandards for schoolmentalhealthand jointlydeveloplocalorganizationalstructurestosupportthemaintenanceand expansion of school-based health care in the DCmetroregion.

Thoughts on Expanding into Additional Public Schools

Despite fiscal constraints, agency leadership and political leadershipshouldcometogethertodevelopamodelof interventionthatwouldallowallschoolstohaveschoolmentalhealthexpertiseavailable to them. Forschools

that do not have a mental health clinician assigned tothem,DMHcouldconsidersubcontractingwithacadreof trainedprofessionals thatwouldmeetwith schoolsquarterlytosupportschool leadersandschoolstaff byprovidinginformationonaccessiblecommunitymentalhealthresourcesandservices,consultonhowtohandleparticularemotionalorbehavioral issuesthatarise,andassist them on assessing and tracking their students’needs.AlthoughnotthecomprehensiveSMHPmodel,this outreach and education would serve to bridgecommunitymentalhealthresourcesandservicesandtheschoolcommunity.WherefullSMHPsupportsarenotpossibleorindicated,someconsultation,training,orearlyidentification services can be offered. (Refer to standards document in Appendix I). Like Baltimore, Marylandconceptualizes,District leaders can establish a processthatwouldequitablydistribute theseservicesbasedonthedatacollectedbyschoolsandotherDistrictagencies.

Aformidablealliancebetweentheeducationandmentalhealth sectors must be created in order to achievecomprehensiveandcomplimentarychildhealthpriorities,initiatives,andservices.Childadvocatesandparentsbitterlyrecall thatahostof community-basedchildandyouthprogramshavecomeandgoneovertheyearsandcautionthat program implementation without infrastructurebuildingwillno longerbepublicly supported.Politicalleadersmuststepforwardtosupportschoolmentalhealthprogramsandinvest ina long-termexaminationof therefinements needed to yield the most effective system developmentstrategy.Analignmentisalsoneededbetweenthepoliticalsupportandagencysupport.Aformerschooldistrict administratorwarns that theway toensure thefailureof programexpansionisto“rushtorampitupto scale”. A predictable consequence of diving headfirst intoexpansionwithout lookingforwardorbackisthatDistrictleaderswillmakeavoidableandcostlymistakes.Mappingoutaplanforsuccess includesconsiderationsof capacitybuilding,communityengagement,effectivecommunications,andlong-termsustainability.Shortcutswill only lead to deserving communities being short-changed.Ourresidentsandourchildrenhavearighttoexpectourbestthinkingandourbesteffortaswemoveastrongerchildmentalhealthagendaforward.



8



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APPENDICES:

Howard AdelmanCo-DirectorSchoolMentalHealthProjectCenterforMentalHealthinSchoolsDepartmentof PsychologyUniversityof California,LosAngelesLosAngeles,CA

Steve AdelsheimProfessorUniversityof NewMexicoDepartmentof PsychiatryAlbuquerque,NM

Dawn Anderson-ButcherAssociateProfessorCollegeof SocialWork,OhioStateUniversityColumbus,OH

Anita AppelActingDirectorNew York City Field Office, New York State Office of Mental HealthNewYork,NY

Marc AtkinsProfessorof PsychologyinPsychiatry,Universityof IllinoisatChicagoDirector,PsychologyTrainingInstituteforJuvenileResearchChicago,IL

Steve BaronDirectorDCDepartmentof MentalHealthWashington,DC

Lisa BetzSchoolMentalHealthCoordinatorIllinoisDepartmentof Health,Divisionof MentalHealthChicago,IL

Scott BloomDirectorof SchoolMentalHealthServicesNewYorkCityDepartmentof EducationNewYork,NY

Jackie BowensVicePresidentandChiefGovernment and External Affairs OfficerChildren’sNationalMedicalCenterWashington,D.C

Debbie BrinsonExecutiveDirectorSchoolCommunityHealthAllianceof MichiganOkemos,Michigan

Eve BrooksExecutiveDirectorStudentSupportCenterWashington,DC

Angela BrownCoordinatorof BehaviorSupportsOffice of the State Superintendent of EducationWashington,DC

Owen BubelVicePresidentClinicalOperationsforUnitedBehavioralHealthPhiladelphia,PA

Juana BurchelSchoolMentalHealthCoordinatorIllinoisStateBoardof EducationDepartmentof SpecializedSupportSchoolandMentalHealthIntegrationSpringfield, IL

Carlos CanoActingDirectorDCDepartmentof HealthWashington,DC

Bruce ChorpitaDirectorCenterforCognitiveBehaviorTherapyUniversityof HawaiiHonolulu,HI

TJ CosgroveDepartmentof PublicHealth,CommunityHealthServicesDivision,Seattle,WA

Ray CrowellVicePresidentICFInternationalFairfax,VA

Dana CunninghamCoordinatorPrinceGeorge’sSchoolMentalHealthInitiativeForestville,MD

Laura DannaAssistantClinicalDirectorMercyFamilyCenterMetairie,LA

Jacqueline Duval-HarveyDirector,EastBaltimoreMentalHealthPartnershipBaltimore,MD

Lisa DeShong SadzewiczOperation’sDirectorBiopolymerCoreFacilityUniversityof MarylandSchoolof MedicineBaltimore,MD

Anthony DialloProgramManager,CommunityServicesDivision,Departmentof HumanServicesWashington,DC

Joel DubenitzProgramEvaluatorSchoolMentalHealthProgramD.C.Departmentof MentalHealthWashington,DC

Albert DuchnowskiProfessorandDeputyDirectorResearchandTrainingCenterforChildren’sMentalHealthFloridaMentalHealthInstituteUniversityof SouthFloridaTampa,FL

Lucille EberStatewideDirectorIllinoisStatewideTechnicalAssistanceCenterPBISNetworkLaGrangePark,IL

AppendixA: Interviewees for DMH school mental health report



Nancy EichnerSchoolHealthProgramChildHealthandSafetyGroupTexasDepartmentof StateHealthServicesAustin,Texas

Pia EscuderoField Coordinator; Crisis Counseling andInterventionServicesProjectManagerLAUSD/RAND/UCLATraumaServicesLos Angeles Unified School DistrictLosAngeles,CA

Paul FlashpohlerAssistantProfessorDeptartmentof PsychologyandCenterforSchool-BasedMentalHealthProgramsMiamiUniversityof OhioOxford,OH

Andrea Foggy PaxtonProgram Officer, EducationBill&MelindaGatesFoundationWashington,DC

Evelyn FrankfordFounderFrankfordConsultingPeabody,MA

Elizabeth FreemanProgramDirectorSchoolBasedServicesSCDepartmentof MentalHealthColumbia,SC

Carolyn GardnerDeputyDirectorStudentSupportCenterWashington,DC

Marcia Glass SiegelCoordinator,School-BasedMentalHealthServicesBaltimoreMentalHealthSystems,Inc.Baltimore,MD

Charity HallmanSpecialAssistantSpecialEducationReformOffice of the State Superintendent of EducationWashington,DC

Sherri HammackOffice of Program Coordination forChildrenandYouthHealthandHumanServicesCommissionAustin,TX

Jacqueline Duval-HarveyDirector,Community-BasedServicesEastBaltimoreMentalHealthPartnershipBaltimore,MD

John Hatakeyama FormerDeputyChief of CountyServicesforLACountyDepartmentof MentalHealthLosAngeles,CA

Kimberley HoagwoodProfessor,Directorof ResearchonChildandAdolescentServices,ColumbiaUniversity,CenterfortheAdvancementof Children’sMentalHealthNewYork,NY

Julie HudmanFormerLeadStaff of InteragencyCommissionD.C. Office of the MayorWashington,DC

Laura HurwitzSchoolMentalHealthCoordinatorNationalAssemblyof School-BasedHealthCareWashington,DC

Deborah IrvinAssociateDirectorFamilySupportCenterBethesda,MD

Lisa Jaycox, PhDSeniorBehavioralScientistRANDCorporationArlington,VA

Deborah JohnsonPrimaryProjectChildren’sInstituteRochester,NY

Barbara KamaraFormerDirectorEarlyCareandEducationAdministrationDCDepartmentof HumanServicesWashington,DC

Kate KellerSenior Program OfficerTheHealthFoundationof GreaterCincinnatiCincinnati,OH

Susan KeysFormerChiefPreventionInitiativesandPriorityProgramsDevelopmentBranchDivisionof PreventionCenterforMentalHealthServicesSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)Rockville,MD

Laura KieslerOffice of the Deputy Mayor forEducationWashington,DC

James KollerCo-DirectorCenterfortheAdvancementof MentalHealthPracticesintheSchoolsUniversityof MissouriColumbia,MOKrista KutashProfessorandDeputyDirectorResearchandTrainingCenterforChildren’sMentalHealthFloridaMentalHealthInstituteUniversityof SouthFloridaTampa,FL

Eric S. LerumChief of StaffDeputyMayorforEducationWashington,DC

Nancy LeverCo-DirectorandDirectorof TrainingOutreachandDisseminationSchoolMentalHealthProgramUniversityof MarylandandCSMHABaltimore,MD

Tamaria LewisOffice of the State superintendent of EducationWashington,DC



Julie Liu FormerEvaluationCoordinatorDCDepartmentof MentalHealthWashington,DC

Molly LopezCommunityMentalHealthSubstanceAbuseServicesTexasDepartmentof StateHealthServicesAustin,TX

Kymber Lovett Directorof CounselingCatholic Schools Office of the Archdioceseof WashingtonWashington,DC

Colette LueckManagingDirectorIllinoisChildren’sMentalHealthPartnershipChicago,IL

Monica MartinManager,LinkagestoLearning,MontgomeryCountyDepartmentof HealthandHumanServicesRockville,MD

Rufus MayfieldChief of CommunityServicesDivisionDCDepartmentof HumanServicesWashington,DC

Heather McCabeSeniorHealthPolicyAdvisorforMedicaidDC Office of the Chief Financial OfficerWashington,DC

Dawna-Cricket-Martita MeehanCoordinatorof SchoolMentalHealthProjectsDepartmentof PsychologyandCenterforSchool-BasedMentalHealthPrograms,MiamiUniversityOxford,OH

Corinne MejierDirector,Child&AdolescentServicesProgramCommunityConnectionsWashington,DC

Stanley MrozowskiDirectorChildren’sBureauOffice of Mental Health andSubstanceAbuseServicesHarrisburg,PA

Emily NahatChiefPreventionandEarlyInterventionServicesCaliforniaDepartmentof MentalHealthSacramento,CA

Richard NyankoriSpecialAssistanttoChancellorRheeDistrictof ColumbiaPublicSchoolsWashington,DC

Peter Parham FormerChief of StaffDistrictof ColumbiaPublicSchoolsWashington,DC

Barbara ParksClinicalAdministrator,Prevention&EarlyInterventionProgramsDCDepartmentof MentalHealthWashington,DC

Carl PaterniteDirector,ProfessorandChairCenterforSchool-BasedMentalHealthPrograms,Departmentof PsychologyMiamiUniversityof OhioOxford,OH

Paula PerelmanDirectorof DisputeResolutionandSettlementDistrictof ColumbiaPublicSchoolsOffice of Special EducationWashington,DC

Annmarie PerezSchoolMentalHealthClinicianDCDepartmentof MentalHealthWashington,DC

Diane PowellAssistantSuperintendent,Divisionof StudentandSchoolSupportDistrictof ColumbiaPublicSchoolsWashington,DC

Kay RietzAssistantDeputyDirectorOhioDepartmentof MentalHealthOffice of Children’s ServicesandPreventionColumbus,OH

Mark SanderSeniorClinicalPsychologistandMentalHealthCoordinatorHennepinCountyandMinneapolisPublicSchoolsSpecialEducationMinneapolis,MN

Barbara ScottExecutiveDirectorSchoolNurseProgramChildren’sNationalMedicalCenterWashington,DC

Charneta ScottProgramManagerSchoolMentalHealthProgramD.C.Departmentof MentalHealthWashington,DC

Joyce SebianSeniorPolicyAssociateNationalTACenterforChildren’sMentalHealth,GeorgetownUniversityWashington,DC

Richard SheolaPresidentValueOptions,PublicSectorBoston,MA

Joanne SobolewskiManagerSchool-BasedMentalHealthProgram,BehavioralHealthaCenterCarolina’sHealthCareCenterCharlotte,NC

Michael Southam-GerowAssociateProfessorVirginiaCommonwealthUniversity

Shauna Spencer FormerAssociateDeputyDirectorDivisionof Children’sServicesDCDepartmentof MentalHealthWashington,DC



Rose StarrDirectorof PolicyandResearchSchoolMentalHealthAlliance,NorthShoreLongIslandJewishHealthSystemNewHydePark,NY

Meghan SullivanProgramEvaluatorSchoolMentalHealthProgramD.C.Departmentof MentalHealthWashington,DC

Linda TaylorCo-DirectorSchoolMentalHealthProjectCenterforMetnalHealthinSchoolsDepartmentof PsychologyUniversityof California,LosAngeles

Susan Thaler FieldCoordinatorNew York City Field Office, Office of Mental HealthNewYork,NY

Joyce ThomasPresidentCenterforChildProtectionandFamilySupportWashington,DC

Eugene ThompsonAssistantProjectDirector/TACoordinatorCommunitiesof CareWorcester,MA

Robin TurnerConsultantCoordinatorSchoolCommunityHealthAllianceOkemos,Michigan

Philip UninskyLocalEvaluator,DCSS/HSgrant,ProjectDirectorCayugaCountySafeSchools/HealthyStudentsPartnerships,Inc.Auburn,NY

Robert VitelaInteragencyDivisionStateDepartmentof EducationforTexasAustin,TX

Doug WalkerClinicalDirectorMercyFamilyCenterMandeville,LA

Frances WallaceAssociateDirectorNationalImplementationResearchNetworkUniversityof SouthFloridaLouisdelaParteFloridaMentalHealthInstituteDepartmentof ChildandFamilyStudiesTampa,FL

Mark WeistDirectorCenterforSchoolMentalHealthAnalysisandActionUniversityof Maryland,BaltimoreBaltimore,MD

Tommy WellsCouncilMember,Ward6DCCityCouncilWashington,DC

Denise Wheatley RoeCoordinatorExpandedBaltimoreMentalHealthSystemsBaltimore,MD

Tori WhitneyFormerPolicyDirectorforCouncilmanCataniaDCCityCouncilWashington,DC

Tyra WilliamsPublicPolicyAnalystDCActionForChildrenWashingtonDC

Alice WilsonClinicalSupervisorTheChristChildSociety,WashingtonDCChapterWashington,DC

Marlene WongDirectorCrisisCounselingandInterventionServicesLosAngelesUnitedSchoolDistrictLosAngeles,CA

Stephanie Wood-GarnettFormerExecutiveDirectorStateIncentiveGrantforD.C.DCPublicSchoolsWashington,DC

Joseph WrightExecutiveDirectorChildHealthAdvocacyInstituteatChildren’sNationalMedicalCenterWashington,DC

Linda YaterExecutiveDirectorDallasIndependentSchoolDistrictStudentServicesDallas,TX

Kristin YochumSpecialAssistantOffice of the State Superintendentof EducationWashington,DC



Examplesof RequestforProposalstoFundSchoolMentalHealthServicesa.ExpandedSchoolMentalHealthProgramsinBaltimoreCityPublicSchools,RequestforProposals,February23,2007b.IllinoisViolencePreventionAuthority,RequestforProposalsFY07,SchoolMentalHealthSupportGrants,February,2007.c.TexasDepartmentof StateHealthServices,FY09CompetitiveRequestforProposals(RFP)forSchool-BasedHealth Centers, DSHS School Health Program, RFP#: DPIS/SCHOOL-0276.1, February 19, 2008.d. Minnesota Department of Human Services Children’s Mental Health Division Request for Proposals for Qualified Grantees toProvideSchool-LinkedMentalHealthServices,December10,2007e.Districtof Columbia,Departmentof MentalHealth,SchoolMentalHealthExpansionProgram,RM-07-N-0082-VM,June25,2007

2.OtherRelevantReportsa.DCAssemblyonSchoolHealthCare,OpportunitiesandBarriersforMedicaidReimbursementsforSchoolHealthCentersin

Washington,DCb.BaltimoreCityExpandedSchoolMentalHealthProgramsFindingsandRecommendations,August2006c.SouthCarolinaDepartmentof MentalHealthSchoolBasedMentalHealthProgramsAnnualReportSummaryFY2004-2005d.SouthCarolinaDepartmentof MentalHealthSchoolBasedMentalHealthProgramsOutcomeReportFY2006-2007, http://www.state.sc.us/dmh/best_practices/sb_annual_report.pdfe.IllinoisChildren’sMentalHealthPartnershipStrategicPlanforBuildingaComprehensiveChildren’sMentalHealthSysteminIllinois,2006AnnualReporttotheGovernorf. New York State Office of Mental Health Guidance Document, June 2007, http://www.ohm.state.ny.us/omhweb/clinicplus/ support_network/providers/guidance.htmlg. Arkansas Department of Education, Special Education Unit. School-Based Mental Health Network: Policy and Procedures Manual, http://arksped.k12.ar.us/documents/medicaid/SBMHPandPManual.pdfh. Health Foundation of Greater Cincinnati, Preliminary Report: Sustainability of School Based Mental Health in Ohio, July12,2005i. Children’s Mental Health in Texas: A State Of The State Report. Children’s Hospital Association of Texas, May, 2006.j. Office of Special Education Programs, Center for Positive Behavioral Interventions and Supports, University of Oregon (2004).School-widePositiveBehaviorSupport,Implementers’BlueprintandSelf-Assessment. http://www.nichcy.org/toolkit/pdf/SchoolwideBehaviorSupport.pdf

3.OtherRelatedDocumentsa. Mental Health Services Quality Review: Supporting School Success. Seattle & King County School-Based Mental HealthScopeof Servicesb.BaltimoreMentalHealthSystems,Inc.,ContractDeliverablesandProviderProgressReportc.School-BasedMentalHealthPrograms,compositeProgramSummaryof StatisticalInformation,Baltimore,Maryland.d.ArkansasSchoolBasedMentalHealthStudentAssessmentandReferralApplication(SARA),User’sGuide,January2007

1.

AppendixB: List of supplemental reports available upon request



AppendixC: District of Columbia schools with school mental health professionals

Department of Mental Health School Mental Health Professionals - Public ES, MS, and Junior HS

(SY 2007-08)

School Ward Grades Included

Student

Enrollment

# Students Receiving

>50% Special

Education Instruction

# English

Language

Learners

% Eligible for

Free/ Reduced

Lunch†

Benning ES 7 PS-6 178 26 * 46

Bunker Hill ES 5 PK-6 246 20 3 52

Burrville ES 7 PS-6 419 38 5 69

Charles Young ES 5 PK-6 313 49 3 81

Davis ES 7 PS-5 287 44 * 71

Drew ES 7 PS-6 319 52 7 51

Emery ES 5 PS-6 200 45 8 77

Ferrebee-Hope ES 8 PS-5 277 45 * 68

Garrison ES 2 PS-6 272 23 33 79

Gibbs ES 6 PS-6 296 19 4 88

Houston ES 7 PS-6 303 31 3 43

JC Nalle ES 7 PS-5 421 36 3 52

LaSalle ES 4 PS-6 268 25 19 62

MC Terrell ES 8 PS-6 371 64 * 74

Myrtilla Miner ES 6 PS-6 506 93 4 73

River Terrace ES 7 PS-6 246 29 * 60

RK Webb ES 5 PS-6 379 39 1 54

J.O. Wilson ES 6 PS-6 & ungraded 319 40 5 70

Harriet Tubman ES 1 PK-6 & ungraded 420 59 163 55

Turner ES 8 PK-6 387 37 1 79

Merritt MS 7 PS-8 247 53 1 68

PR Harris Educational

Center8 PS-8 636 90 *

72

Thurgood Marshall

Educational Center5 PS-8 256 39 3

60

Bertie Backus MS 5 6-8 188 36 9 60

Garnett-Patterson MS 1 6-8 & ungraded 265 60 22 94

Kelly Miller MS 7 6-8 & ungraded 401 81 * 51

Kramer MS 8 6-8 343 91 * 72

Lincoln Multicultural MS 1 6-8 454 52 123 *

MacFarland MS 4 6-8 295 57 56 66

Ron Brown Junior HS 7 6-8 & ungraded 254 58 * 74

Eliot Junior HS 6 7-9 274 84 1 *

Browne Junior HS 5 7-9 335 111 * 81

† Calculated based on the number of students eligible for free/reduced lunch and the student enrollment reported by the Government

of the District of Columbia (see citation below).

* None reported

Source: Government of the District of Columbia. (2007). DC school search. Retrieved January 28, 2008, from

http://dcschoolsearch.dc.gov/schools/index.asp



AppendixC, cont.: District of Columbia schools with school mental health professionals

Department of Mental Health School Mental Health Professionals - Public Senior HS (SY 2007-08)


Student

Enrollment


>50% Special


# English

Language

Learners

% Eligible for

Free/ Reduced

Lunch†

Bell Multicultural Senior

HS1 9-12 808 59 360

*

Eastern Senior HS 6 9-12 674 137 * 51

HD Woodson Senior HS 7 9-12 714 160 1 49

M.M. Washington Career

HS5 9-12 264 34 1

*

Spingarn Senior HS 5 9-12 520 154 6 *

Department of Mental Health School Mental Health Professionals - Public Charter Schools


Student

Enrollment


>50% Special


# English

Language

Learners

% Eligible for

Free/ Reduced

Lunch†

Booker T. Washington PCS

for the Technical Arts 1 9-12 & adult 293 15 6 55

Cesar Chavez PCS HS 1 9-12 423 62 26 *

Children's Studio ES 1 PS-6 82 6 11 72

Friendship Blow-Pierce

PCS 7 6-8 764 91 * *

Friendship Collegiate

Academy, PCS 7 9-12 1213 107 * *

Friendship Woodridge PCS 5 PK-8 665 56 * *

Maya Angelou PCS MS 7 6-7 75 * * *

Maya Angelou PCS HS

(Shaw campus) 1 9-12 116 32 * *

Meridian PCS 1 PS-8 547 64 43 87

Nia Community PCS 8 PK-3 118 4 * 89

Options PCS MS 6 5-8 237 130 * 87

† Calculated based on the number of students eligible for free/reduced lunch and the student enrollment reported by the Government

of the District of Columbia (see citation below).

* None reported

Source for Maya Angelou PC Middle School: See Forever Foundation & Maya Angelou Public Charter School. (2007). Maya

Angelou Public Charter School. Retrieved January 31, 2008, from http://www.seeforever.org/MAPCS/index.html

Source for all others: Government of the District of Columbia. (2007). DC school search. Retrieved January 28, 2008, from

http://dcschoolsearch.dc.gov/schools/index.asp



AppendixC, cont.: District of Columbia schools with school mental health professionals

Student Support Center School Mental Health Professionals - Public Charter Schools (SY 2006-07)

School WardGrades

IncludedStudent

Enrollment

# Students Recciving >50% Special Education

Instruction

# English Language Learners

% Eligible for Free/ Reduced

Lunch†

Academic Bilingue de la Co-munidad (ABC) 1 6-8 108 17 23 *

Academy for Learning Through Arts (ALTA) PCS 1 PK-6 86 4 * *

Appletree Early Learning PCS 6 PS-PK 36 * * 50

Barbara Jordan PCS 4 5-8 107 20 * 79

Bridges PCS 4 PS-PK 67 24 35 *

City Lights PCS 5 9-12 54 54 * 100

Community Academy PCS-Butler Bilingual Campus 2 PS-4 171 7 48 *

Community Academy PCS-Rand Campus 4 PS-8 304 43 27 *

D.C. Bilingual PCS 1 PS-2 193 20 132 85

Hyde Leadership PCS 5 K-12 760 91 1 74

E.L. Haynes PCS 1 PK-4 191 27 48 64

Friendship PCS-Chamerlain Campus 6 PS-6 771 38 0 70

Latin American Montessori Bilingual (LAMB) PCS 4 PS-2 104 8 40 25

Mary McLeod Bethune PCS-16th St. Campus 4 PK-3 76 2 * *

Mary McLeod Bethune PCS-42nd St. Campus 7 PK-6 66 8 * *

Tree of Life Community PCS 5 PK-8 253 18 * 90

Tri-Community PCS 4 PK-5 107 2 0 78

Two Rivers PCS 6 PS-5 261 25 4 30

Washington Academy PCS - Kingsman Campus 6 PK-3 127 12 * *

Washington Academy PCS - Pennsylvania Ave. Campus 7 PK-3 134 20 * *

Washington Academy PCS - Castle Campus 6 4-7 176 38 * *

William E. Doar Jr. PCS for the Performing Arts 5 PK-9 360 20 * 65

Young America Works PCS 4 9-11 221 59 * 48

† Calculated based on the number of students eligible for free/reduced lunch and the student enrollment reported by the Government of the District of Columbia (see citation below).* None reportedSource: Government of the District of Columbia. (2007). DC school search. Retrieved January 28, 2008, fromhttp://dcschoolsearch.dc.gov/schools/index.asp & DC Public Charter School Board (2008), retrieved from http://www.dcpubliccharter.com/publications/docs/SPR2008BOOK.pdf

Location Staffrequirement Rangeofcostperclinician

ProductivityRequirements/BillableServices

Washington,DC(SMHP)

Doctorinpsychology,Masterof socialwork,orcounseling,withalicenseinmentalhealthintheDistrictof Columbiapreferred,includingtheareasof socialwork(LICSW,LGSW,LISW),psychology(Ph.D.,Psy.D.),andcounseling(LPC).Completionof requiredcrimi-nalbackgroundcheck.

$40,000-$92,000perFTEi(dependentupondisciplineandlicensurelevel)

Aminimumof tenstudentsonacaseload,maximum2010hoursperweekconductingpreventionprogramming10hoursperweekconductingtargetedinterventions12hoursperweekprovidingbrief treatmentservices2in-servicepresentationsforschoolstaff1parentworkshopperschoolyearCurrentlyrequireatleast2evidence-basedprevention/earlyinterven-tion/treatmentprogramsimplementedperschoolyearineachschoolwiththefocus/topicdeterminedbyschoolneed.

Washington,DC(SSC)

Mastersordoctorallevelclini-cianwithlicensepreferred.If unlicensed,clinicianwillbesupervisedandworkingonlicensingrequirements.

$46,000-75,000perFTE(dependentupondis-ciplineandlicensurelevel)

Caseloadsof 15-20WeeklyparticipationinSST

Washington,DCSMHP(ContractedProvider)ii

IncompliancewithMHRSstandardsiii.LicensedIndepen-dentSocialWorkers

$50,000-$60,000perFTE

10-12cases/1.0FTE/week10hoursperweekconductingpreventionprogramming10hoursperweekconductingtargetedinterventions12hoursperweekprovidingbrief treatmentservices(Projected10hoursof billableservicesperweek)Currentlyrequireatleast2evidence-basedprevention/earlyinterventionprogramsimple-mentedineachschooldeterminedbyschoolneed.

Baltimore,MD LicensedMHproviderorauthorizedperCOMARstandardsiv

$65,000-$79,000perFTEv; contract covers $20,000per0.5FTE,$40,000per1.0FTEvi

Per0.5FTEvii:60 consultations to teachers and other school staff;30 group prevention activities/groups per school year;5 school teams and committee meetings per school year;2in-servicepresentationsforschoolstaff,Per1.0FTEviii:Sameasfor0.5FTE,except60grouppreventionactivities,9schoolteamsandcommitteemeetings,and3in-servicepresentationsperschoolyear.

Seattle,WA PreferlicensedMHproviderbutwillhireMA-levelif super-visedbylicensedstaffix

Approximately$57,500-$74,000perFTE

5 mental health encounters/ 1.0 FTE/dayx

Charlotte,NC LicensedMHprovider(socialworkers,licensedprofessionalcounselors,orpsychologists)

$38,355-57,072(Inactualitythepayrangeis31,348-46,099sincecliniciansare10monthemploy-eesandarenotpaidduringthesummermonths)

5treatmentcases/1.0FTE/day(55%directbill)

SouthCarolina MAlevelMHprovider+2yearsexperience

$40,000-$52,000perFTExi

4-5billablehours/1.0FTE/day



AppendixD: Comparison of Staff Requirements, Cost, and Productivity Between DC and Other Cities



Sources:iAcostaPrice,O.M.,Mack,A.,&Spencer,S.(2005).SchoolMentalHealthProgramRetrospectiveReport: 2000-2005. Washington, D.C.: DC Department of Mental Health

iiDistrictof Columbia,Departmentof MentalHealth,SolicitationNumberRM-07-N-0082-VM(IssuedJune25,2007)

iii Mental Health Rehabilitation Services Provider Certification Standards, Chapter 34, Title 22A, D.C. Codeof MunicipalRegulations5682

ivBaltimoreCityExpandedSchoolMentalHealthProgramsFindingsandRecommendations-August2006,page11

vFundingRequestFebruary15,2007

viBaltimoreCityExpandedSchoolMentalHealthProgramsFindingsandRecommendations-August2006,page5

viiBaltimoreMentalHealthSystems,Inc.FY08Appendix“A”ContractDeliverables&ProviderProg-ressReport,page12

viiiBaltimoreMentalHealthSystems,Inc.FY08Appendix“A”ContractDeliverables&ProviderProg-ressReport,page12

ix Personal communication with TJ Cosgrove: Email 01/03/08; Interview (December 6, 2007)

xScopeof Work,PugetSoundNeighborhoodHealthCenters,September1,2007-August31,2008,page 3; and Personal communication with TJ Cosgrove Interview (December 6, 2007)xiPersonalCommunicationwithElizabethFreeman,Interview(January19,2008)

AppendixD, cont.:Comparison of Staff Requirements, Cost, and Productivity Between DC and Other Cities



AppendixE: Examples of state mental health laws that address a continuum of children’s mental health care and the role of schools

State NameofLegislation Source/CitationCalifornia MentalHealthServicesActof California http://www.dmh.ca.gov/prop_63/MHSA/docs/Mental_

Health_Services_Act_Full_Text.pdfIllinois IllinoisChildren’sMentalHealthAct http://www.hfs.illinois.gov/cmh/930495.html

Indiana Children’sSocial,Emotional,andBehavioralHealthPlan

http://www.in.gov/legislative/ic/code/title20/ar19/ch5.html

Missouri Children’sMentalHealthReformAct http://www.senate.mo.gov/04info/billtext/tat/sb1003.htm

Minnesota MinnesotaComprehensiveChildren’sMentalHealthAct

https://www.revisor.leg.state.mn.us/statutes/?id=245.487

NewYork Children’sMentalHealthActof 2006 http://assembly.state.ny.us/leg/?bn=A06931&sh=t



AppendixF: List of school health programs and initiatives in DC for 2008 (as of April 2008)

InitiativeName

LeadEntity(Person)

SchoolLevel(s)

# ExpansionPlan InterventionLevel BriefDescription

DCStart ICSIC(PhilipUninsky)

Elementaryschools

2 4-6elementaryschoolsinthe08-09SY

EarlyIntervention&Treatment

Useof multidisciplinaryassessmentUseof EBtreatments(CBTandchildcenteredplaytherapy)Cliniciantodoservicecoordinationandplan-ningUseof interagencydatabase

FullCommunitySchools(MiddleSchoolProject)

OSSE/DMH(KnuteRotto)

Middleschools 8 Tostartin08-09SY EarlyIntervention&Treatment

Partof Blackman-JonesagreementInvolvesPBIS,wraparoundcarecoordinator,behavioralskillbuilding,&clinicalservicesInclusionaryspecedprogramSecondaryandtertiaryschool-basedinterven-tionsprovided

CaseManage-mentProgram

FirstHomeCare(CSA)(RoseBruzzo)

Pre-k-12 * Upto400-500youthinprogram

Intervention&Treatment

Partof Blackman-JonesagreementChildrenwithIEPshavecasemanager-agreedtohire30casemanagers15childrenpercasemanager

School-WideApplicationsModel(SAM)

DCPS(RichardNyan-kori)

Elementaryschools

8 Tostartin08-09SY Prevention,EarlyInter-vention&Treatment

StructuralschoolreformmodelEmphasizesPBS,data-drivendecisionmaking,andRTIlogicmodel

SchoolWellnessTeams

DCPS(RichardNyan-kori)

Pre-k-12 * Tobegin08-09SY Prevention,&EarlyInter-vention?

StructuralschoolreformmodelEmphasizesPBS,data-drivendecisionmaking,andRTIlogicmodel

QualityServiceReview(QSR)

OSSE(PaulVincent)

Pre-k-12 * Unknown ProgramEvaluation Staffing model of student support teams to be requiredineveryDCPSTeamtoincludesocialworker,counselor,psy-chologist,behaviorinterventionist,&nurse

IncentiveSeats OSSE(TamiLewis)

* 8 Tobegin08-09SY Treatment Partof Blackman-JonesagreementPilotwillprovideincentivestohighqualityschoolstoincreasethenumberof ‘seats’tospecedstudentsreturningfromnon-publicplacementsWillreceive%of moneyspentonnonpublicplacementtoinvestinservices

SMHP DMH(BarbaraParks)

Pre-k-12 48 Toexpandintoanad-ditional10schoolsfor08-09SY1

Prevention,EarlyInter-vention&Treatment

School-basedprevention,earlyintervention,andbrief treatmentservicesWillshifttotwotierservicemodel(1withFTclinicianand1withPTclinician)

STOPSuicideProject

DMH(JulieGoldstein)

MiddleSchools&HighSchools

21 Unknown(dependsonwhethertheycanac-quireadditionalfunds)

UniversalScreening&SuicidePrevention

UniversalScreening(usingColumbiaTeen-Screen)QPRtrainingforschoolstaff andparentsSOStraininginclassrooms

SS/HS SSC(EveBrooks)

Pre-k-12(Charters)

18 Fundingwillendin2009


Integratedcommunity-schoolcollaborativeusingEBPAddresses6coreelements,includingsafetyplan-ning,violenceandSAprevention,SMHpreven-tionandtreatment,earlychildhoodservices,andsafeschoolpolicies(i.e.,PBIS)HopetobesustainedthroughDCfunding

CoordinatedSchoolHealth

DOH(CarlosCano)

HighSchools 1 BeingnegotiatedtopilotanewSBHCinahighschoolfor08-09SY


SBHCtoincludeMHservices

SchoolNurseProgram

DOH/CNMC(JoeWright&BarbaraScott&CarlosCano)

Pre-k-12 * Goalistohaveatleastahalf timenurseineverypublicschoolinDC

Prevention&EarlyIntervention

TrackandreferforimmunizationsHearingandvisionscreeningsProvideservicestostudentswithspecialhealthcareneeds

*Someinformationisunknowntotheauthors.1Alsoin7schoolstobeclosed,so17newschoolsfor08-09SY



AppendixG: A guide for mapping school-based mental health activities

Programmatic Activities* Levels or Systems of Interventions

Screening/ Prevention Early Intervention Treatment ServicesSchoolenvironmentinterven-tions/School-focusedstrategiesClassroom-focusedstrategies

Schoolstaff consultation/educationonMHissuesFamily-centeredinterventions/assistanceChild-centeredinterventions/assistance(individualorgroup)

Brief Counseling (no MH diagnosis and/or few symptoms)-More intensive (active symptoms and/or MH diagnosis)-Continuing Care/ more intensive services (MH diagnosis)-

Casemanagement/coordina-tionof servicesandsupportsOthertraining/educationactivitiesCrisisprevention,management,andresponseLinkageandreferrals

*Thistableisnotintendedtobecomprehensive.Itissuggestedthatrepresentativesfromallrelevantagenciesandorganizationsconvenetojointlymaplocalresourcesandidentifyinitiativesunderway.



AppendixH:

D.C. Department of Mental HealthOffice of Programs

Table of Organization

Deputy Director

Integrated Care

CSR Review Unit

Clinical Infomatics and Research

Training and Workforce

Development

Supported Housing

Supporting Employment

ACT

Homeless Services

Access Helpline

Forensics

School Based Mental Health

Children/Youth Clinical Practice

RTC Monitoring and

Re-Investment

System of Care Service

Coordination

Assessment Center

Authorization/ Utilization Review

Care Management

Organizational Development

Adult Services Care CoordinationChildren and Youth

Services

Dr. Meghan Sullivan

Program Manager DS-12

Dr. Charneta Scott

Program Manager DS-14

Erica Barnes

Crisis Coordinator DS-13

Dr. Julie Goldstein-Grumet

Stop Suicide Grant DS-14

Shana Bellow

Supervisory Psychologist DS-13 Jaqueline Droddy

Supervisory Social Worker DS-13

Gregory Pretlow

Supervisory Social Worker DS-13

Social Workers

DS-12 (12)

Psychologists

DS-11-13 (6)

Mental Health Specialists

DS-11 (12)

Pat Valentine

Program Assistant DS-7

Social Workers

DS-12 (14)

Mental Health Specialists

DS-11 (2)



AppendixH: continued

D.C. Department of Mental HealthPrevention & Early Intervention Programs

Table of Organization

Dr. Barbara Bazron

Deputy Director

Office of Program Policy Planning

Marie Morilus-Black

Director of OPP

Child & Youth Services

Barbara Parks

Clinical Program Administrator

Prevention & Early Intervention DS-15

Monica Bullard

Program Specialist DS-9

C. Keisha Richardson

Program Assistant DS-8

Kanetha Queen

Admin & Org. Analyst DS-12

Dr. Joel Dubenitz

Evaluation Manager DS-13



AppendixI: Template for the development of standards for school mental health programs in DC

Atemplateforthedevelopmentof standardsforthepracticeof school mental health is provided (the essential sectionsareinbold),withdraftlanguageorexamplesincludedbelowwhereinformationhaspreviouslybeencraftedbyotherstatedepartmentsof mentalhealthorbytheDCDepartmentof MentalHealth(DMH). Contentfor thestandardswillvarydepending on whether DMH transitions into a contractingrelationshipwithcommunitymentalhealthorganizationsasthemainprovidersof careorwhetherDMHwillmaintainprimaryresponsibility for program implementation in addition toexercisingoversightauthorityovercommunity-basedagenciesthatalsoprovidementalhealthcareintheschools.

Thisdraftdoesnotrepresentacomprehensivedraftandmaynotidentifyallrelevantandapplicablecityorfederalregulations,statues, or rules. It is strongly encouraged that a final set of standards be developed that will define minimum requirements forallcommunitymentalhealthprovidersconductingschoolmentalhealthservices.Thesestandardsshouldbetheproductof a collaborative process with key education and healthpartners,communitymentalhealthproviders,familymembersandstudentsparticipating.

Section1.0Vision,Mission,Goals,andGuidingPrinciples

1.1 Vision2

The vision of the SMH program is: 1.1.1 To positively impact every student in allschoolswithaSMHpresence.1.1.2 To foster and develop student and family’sutilization of internal and external resources topromote student’s academic, social and emotionalsuccess.1.1.3 To ensure that all students learn in a safe,supportiveandresponsiveenvironment.1.1.4 To consult and collaborate with all serviceprovidersinvolvedinthesystemof careforstudentswith mental health and co-occurring disorders toaddress thediverseneedsof the studentsand theirfamilies.1.1.5 Toreducethestigmaassociatedwithreceivingmentalhealthservices.1.1.6 To provide technical assistance to keystakeholderslocallyandnationally.

1.2 Mission2

The mission of the Department of Mental Health (DMH)School Mental Health (SMH) Program is to maximize thepotential for students to become successful learners andresponsiblecitizensbyreducingthebarriersto learningandfosteringresiliency.TheSMHprogramwillactivelycollaboratewithkeystakeholders(students,families,Districtof ColumbiaPublicandPublicCharterSchools,coreserviceagencies,publicand private community agencies, and the faith community)to enhance the system of care’s ability to deliver culturallycompetentanddevelopmentallyappropriateservicestoschool-agedchildrenandtheirfamilies.

1.3 GoalThegoalof schoolmentalhealthprogramsintheDistrictof Columbiaistoimprovetheemotionalandbehavioralhealthof studentsinordertoreducebarrierstolearning.

1.4 Guiding Principles7

1.4.1 All youth and families are able to accessappropriatecareregardlessof theirabilitytopay.1.4.2 Programsareimplementedtoaddressneedsand strengthen assets for students, families, school,andcommunities.1.4.3 Programs and services focus on reducingbarrierstodevelopmentandlearning,arestudentandfamilyfriends,andarebasedonevidenceof positiveimpact.1.4.4 Students, families, teachers and otherimportantgroupsareactivelyinvolvedintheprogram’sdevelopment, oversight, evaluation, and continuousimprovement.1.4.5 Quality assessment and improvementactivities continually guide andprovide feedback totheprogram.1.4.6 Acontinuumof care isprovided, includingschool-wide mental health promotion, earlyintervention,andtreatment.1.4.7 Staff holds to high ethical standards, iscommittedtochildren,adolescents,andfamilies,anddisplays an energetic, flexible, responsive and proactive styleindeliveringservices.1.4.8 Staff is respectful of, and competentlyaddresses developmental, cultural, and personaldifferencesamongstudents,familiesandstaff.1.4.9 Staff buildsandmaintainsstrongrelationshipswith other mental health and health providers andeducatorsintheschool,andathemeof interdisciplinarycollaborationcharacterizesallefforts.1.4.10 Mental health programs in the school arecoordinatedwithrelatedprogramsinothercommunitysettings.



Section 2.0: Staffing

2.1 Minimum Job Qualifications2

2.1.1 Schoolmentalhealthprogramsshallhire qualified mental health professionals to provide services, interventions, and consultation in schools.Job qualifications will vary depending on the level of service provided (prevention, early intervention, ortreatmentservice). 2.1.2 Prevention/ Early Intervention-Individuals providing school-based mental healthpreventionandearly interventionservicesshallhaveatleastaBachelorsdegreeinpsychology,socialwork,orcounseling.AMastersdegreeinpsychology,socialwork,orcounselingwithpreviousexperienceinchildandadolescentmentalhealthispreferred. 2.1.3 Treatment- Qualified mental health practitioners shall include professionals from thefollowing disciplines (i) a psychiatrist; (ii) a psychologist; (iii) an independent clinical social worker; (iv) a licensed professional counselor; (v) an independent social worker; and (vi) an addiction counselor, and are defined as follows4: 2.1.3.1 Psychologist - a psychologist is a personlicensed to practice psychology in accordance withapplicableDistrictlawsandregulations. 2.1.3.2. Psychiatrist - a psychiatrist is aphysicianlicensedinaccordancewithapplicableDistrictlawsandregulationswhohascompletedaresidencyprogram in psychiatry accredited by the ResidencyReviewCommitteeforPsychiatryof theAccreditationCouncilforGraduateMedicalEducationandiseligibletositforthepsychiatricboardexamination. 2.1.3.3 Social work- Independent clinicalsocial worker (LlCSW) and Licensed independentsocial worker (LlSW) are persons licensed in socialworkinaccordancewithapplicableDistrictlawsandregulations. An LlCSW and an LISW are qualified practitioners. 2.1.3.4Counselor

i. Addiction counselor – an addictioncounselorisapersonwhoprovidesaddictioncounseling services to persons with co-occurringpsychiatricandaddictivedisordersand is licensed or certified in accordance with applicableDistrictlawsandregulations.ii. Licensed professional counselor (LPC)-alicensedprofessionalcounselorislicensedinaccordancewithapplicableDistrictlawsandregulations.

2.1.4. All mental health professionals working inschoolmentalhealthprogramsandhiredbyDMHor

acontractingagencyshallprovidedocumentationof completionof requiredcriminalbackgroundcheck,asstipulatedbytheCriminalBackgroundChecksfortheProtectionof ChildrenActof 2004,mandatorydrugandalcoholtesting,asstipulatedintheChildandYouth,SafetyandHealthOmnibusActof 2004,andannualhealthscreeningsasrequiredbyDMHpolicy(DMHPolicyNumber716.1).

2.5 Preliminary List of Core Workforce Competencies for Advanced Interdisciplinary Mental Health Practice in Schools3

2.5.1 Participate effectively in planning, needsassessmentandresourcemappingwithfamiliesandschool and community stakeholders to develop,introduce,andsustainSMHprogramandservices.2.5.2 Developandsustainrelationshipswithschooladministrators,school-employedmentalhealthstaff,teachersandsupportstaff, families,andcommunitypartners.2.5.3 Maintainthoroughandup-to-dateknowledgeof majoreducationalinitiativesandpolicesthatimpactschools at the federal/national, state, and local level; and ensure that SMH practices align with thoseeducationalrealities.2.5.4 In all work, demonstrate an understandingof factors influencing school culture and climate, educators’potential roles asmentalhealth/wellnesschangeagents.2.5.5 Demonstrate a thorough understandingof systems change theory and best practices anddemonstrateanabilitytoworkincomplexsystems.2.5.6 Effectively represent SMH to the school(orallyandinwriting)anddevelopprogramandservicedelivery referral mechanisms that are responsive tolocalneeds.Implementafullcontinuumof school-wide mental health promotion, prevention, earlyintervention and treatment available to all studentsincludingthoseingeneralandspecialeducation.2.5.7 Demonstrateanabilitytosustainprioritizedfocusonmentalhealthpromotion,prevention, andearly intervention; rather than succumbing to exclusive (ornearexclusive)deliveryof intensive interventionservices.2.5.8 Develop and continuously enhancecommunicationchannelsandrelationshipswithschoolstaff.2.5.9 Developandcontinuouslyenhancestrategiesforoutreachtostudentsandfamiliesforservicesandforactiveprogramguidance.



2.5.10 Maintain appropriate student and familyprivacy and confidentiality, guided by standards of practice.2.5.11 Develop and continuously enhancecollaborative relations with teachers in workingtogether to improve classroom environments andstudentbehaviors.2.5.12 Assist teachers in learningskills thatcanbesharedwithstudentsthatreducemental healthbarrierstolearning.2.5.13 Assist teachers in proactively identifyingstudentscontendingwithstress/riskand/orpresentingemotional/behavioralproblems.2.5.14 Participate effectively in school decision-makingteamsincludingthosefocusingonservicesandsupportsforindividualstudentsandthosefocusingonschoolimprovement.2.5.15 Participate in collaborative actions thatimprovetheschoolenvironmentand/orbroadlyteachstudentsimportantandevidence-basedlifeskills.2.5.16 Implementpreventionandskilltraininggroupinterventionsthatarebasedonevidenceof positiveimpactwithsimilarstudents.2.5.17 Inallwork,demonstrateanunderstandingof normalpatternsof humanphysical,cognitiveandsocial-emotionaldevelopment,patternsof developmentthatinfluence optimism and resiliency, varieties of human diversity,andhowissuesof diversity(culture,ethnicity,race economics, gender) influence mental health.2.5.18 In all work, demonstrate an understandingof differences between a deficit and strengths-based model for mental health; and frame SMH programs andservicesinpositiveandproactivewaystoadvocateformentalwellness.2.5.19 In all work, demonstrate an understandingof common childhood and adolescent stressorsand effective coping strategies, common problemsimpactingdevelopment,andcommonmentalhealthchallenges facedby all stakeholders connectedwithschools(students,staff,families).2.5.20 Conduct integrated academic and mentalhealthassessmentsinamannerthatistherapeuticforstudentsandfamilies.2.5.21 Appropriately use paper and pencilassessments, behavioral observations, and othermeasures toenhanceassessment for studentsbeingconsideredfororinearlystagesof services.2.5.22 Actively share assessment findings withstudentsandfamilies(andwhenappropriate,schoolstaff)andinvolvethemasactiveandequalcollaboratorsindecision-making.2.5.23 Implement preventive and supportive

interventionsforyouthpresentingneedsforassistance,including thosewithoutpsychiatricdiagnoses,usingevidence-basedstrategies.2.5.24 Implement treatment for youth meetingcriteriaforpsychiatricdiagnosesusingevidence-basedstrategies.2.5.25 Implement systematic quality assessmentand improvement (QAI) strategies to monitor andcontinuallyimprovethequalityof allservices.2.5.26 Actively and on an ongoing basis useappropriateevaluationmethodsfocusingonacademicandbehavioraloutcomesthatarevaluedbyfamiliesand schools, and that are proximal to deliveredinterventions.2.5.27 Share evaluation findings and outcome data withstudents,families,andschoolstaff andintegratetheirfeedbackintoQAIplanningandaction.2.5.28 Assist the school in developing andimplementing strategies to prevent and reduce allformsof violence,aswellasassiststudentsandstaff whoareexposedtoviolence.2.5.29 Assist the school in developing andimplementingeffectiveplanstopreventandrespondtocrises.2.5.30 Addresshigh-riskstudentproblems,includingreportsof abuseandneglect,andsuicidalandhomicidalideationandbehavior.2.5.31 Enthusiastically participate in training,supervision and ongoing coaching and supportiveactions toenhanceschoolmentalhealthpromotionandinterventioncompetenciesof allstakeholders,inallinstancesutilizingevidence-basedapproaches.

Section3.0LevelsofService

3.1 Minimum RequirementsAtaminimum,allschoolmentalhealthprofessionalsshallworkcollaborativelywith school-hired student support staff (i.e.,school counselors, socialworkers,psychologists), educators,andothercommunityproviderstoimplementanintegratedsetof services and supports that reflect a public health approach tomentalhealthservicedelivery.Thepublichealthapproachincludesprevention,earlyintervention,andtreatmentservicesavailableon-siteor througha school-linked referralprocesswithcommunityproviders.Thefollowingthreelevelsof careoutline incremental stages to service delivery and detail staffing requirements.

3.2 Level I: Comprehensive School Mental Health Designation1

Definition-LevelIorComprehensiveSMHprogramsshalldeliverconsultation,crisismanagementservices,



treatmentservices,participationinearlyinterventionteamplanning,andassistancewithuniversalpreventionprograms by a qualified professional. Additional servicesshall includeearly interventionservicesanda full arrayof preventionservices. ComprehensiveSMHprogramsmayrelyonothercommunitymentalhealthproviders foryear-roundaccessibilityand/ortwenty-four hour coverage. Comprehensive SMHservicesarenotavailableduringthesummerorwhenschoolisnotinsession.

Availability of Services- Level I SMH programs shallbe available five days per week for a minimum of 40 hours, with 36 hours for on-site services to theschool. SMHPprofessionalsmusthaveaminimumcaseloadof 20students,conductatleasttwotherapyorpreventiongroupsperweek,andprovideat least100 consultations during the school year. SMHprofessionalsshallimplementapolicyforreferralstoother qualified mental health professionals in and out of theschooltoprovideothernecessaryservices.

Staffing Requirements- Level I SMH programs shallinclude,ataminimum,a licensedor licenseeligiblementalhealthprofessional.

3.3 Level II: Expanded School Mental Health Designation1

Definition-LevelIIorExpandedSMHprogramsshalldeliverconsultation,crisismanagement,participationin early intervention team planning, and assistancewith universal prevention programs by a qualified professional.Additionalservicesshallincludementalhealth treatmentservices (individual, family,and/orgroupcounseling/therapy).ExpandedSMHprogramsmayrelyonothercommunitymentalhealthprovidersforyear-roundaccessibilityand/ortwenty-fourhourcoverage.ExpandedSMHservicesarenotavailableduringthesummerorwhenschoolisnotinsession.Availability of Services-LevelIISMHprogramsshallbeoperationalaminimumof 20hoursperweek,withatleast16hourforon-siteservicestotheschool.SMHPprofessionalsmusthaveaminimumcaseloadof tenstudents,conductat leastonetherapyorpreventiongroupperweek,andprovideatleast50consultationsduring the school year. SMH professionals shallimplement a policy for referrals to other qualified mentalhealthprofessionalsinandoutof theschooltoaddresssomestudentandfamilytreatmentneedsandprovideothernecessaryservices.

Staffing Requirements- Level II SMH programs shallinclude,ataminimum,a licensedor licenseeligiblementalhealthprofessional.

3.4 Level III: Core School Mental Health Designation1

Definition-LevelIIIorCoreSMHprogramsshalldeliverconsultation to teachers, school staff, and parentsand crisis management services by a qualified mental healthprofessional. Servicescan includeassistancewith implementing school-wideor classroom-baseduniversalpreventionservices,aswellasparticipationinearlyinterventionteamplanning.CoreSMHprogramsmayrelyonothercommunitymentalhealthprovidersforyear-roundaccessibilityand/ortwenty-fourhourcoverage.CoreSMHservicesarenotavailableduringthesummerorwhenschoolisnotinsession.

Availability of Services-LevelIIISMHprogramsshallhaveaminimumof fourandamaximumof eighthoursperweek with a qualified mental health professional. SMH professionalsshallimplementapolicyforreferralstoother qualified mental health professionals in and out of theschooltoaddressstudentandfamilytreatmentneedsandprovideothernecessaryservices.

StaffingRequirements- Level III SMH programs shallinclude,ataminimum,a licensedor license-eligiblementalhealthprofessional.

Section4.0FacilityRequirements/Premises4.1 Space Requirements

4.1.1 The provider of service shall maintainpremises which are adequate and appropriate forthesafeandeffectiveoperationof a schoolmentalhealth program that complies with all applicableDistrict, federal, and HIPAA requirements. Schooladministrators shall designate a private office for school mentalhealthprofessionalstoconducttheirservices.This private office shall allow for proper adherence to confidentiality and shall be consistent with the capacity andpurposeof theprogram.

4.1.2 The SMHP office shall be easily and safely accessible to students and parents. If an intercomsystem exists for the school at large, one shall beprovided to the central SMHP office or an adequate alternativewillbeprovided inorder for theSMHPprofessional to be notified of school announcements andemergencies.



4.2 Equipment Requirements4.2.1 Schoolmentalhealthprogramsshallprovideforappropriateequipment,therapeuticmaterials,andsupplies for the school mental health professionalconsistentwiththepurposeof theprogramandthepopulationbeingserved.

4.2.2 School administrators shall provide forappropriate furnishings for the designated office, including:

4.2.2.1 Adeskandchairs4.2.2.2 A locking filing cabinet4.2.2.3 Aphoneanddedicatedphoneline4.2.2.4 Acomputer(preferablyconnected totheinternet)andprinteroraccess toaprinter4.2.2.5 Answeringmachineorvoicemail system

4.3 Administrative Requirements4.3.1Thehoursaschoolmentalhealthprofessionalisavailableshallbeclearlyposted.4.3.2 Medical, fire, and emergency instructions and otherprocedures,includingtelephonenumbers,shallbepostedinacentrallocation.4.3.3 AssignedSMHPstaff shallhavekeys foralllocked areas, the locked office, and the locking filing cabinet.

Section5.0SponsoringAgenciesorContractingOrganizationRequirements*ForsponsoringagenciesthatcontractwiththeDCDepartmentof MentalHealthandthatarerequiredtobeacoreserviceagency,guidanceisprovidedbytheMentalHealthRehabilitationServices Provider Certification Standards- Chapter 34 Title 22A 52DCR56824.

5.1 The sponsoring agency or contractingorganization shall have a written agreement/Memorandum of Understanding with DMH andwiththeschoolsystemtoprovideanapprovedsetof services.5.2 The sponsoring agency or contractingorganizationshallberesponsiblefordevelopingnecessarypoliciesandoverseeingqualityimprovementmeasures.

Section6.0ConsentandAuthorization 6.1 Identification/Screening

6.1.1 Everyschoolmentalhealthprogramsponsor

agencyshallworkcollaborativelywiththelocalschoolto determine how students will be identified and/or screenedforschoolmentalhealthselectiveorindicatedservices.6.1.2 Any students screened with mental healthneeds shall be provided mental health services orreferred to a qualified mental health provider within areasonableperiodof timeaftersuchscreeninghasbeenconcluded.

6.2 Eligibility6.2.1 All students enrolled in the school shallbeeligibletoparticipateinschoolmentalhealthservicesand interventions regardless of insurance status orabilitytopay,withtheexceptionof treatmentservicesas defined by MHRS standards4.6.2.2 Theschoolmentalhealthprogramsponsoragency shall determine the eligibility requirementsfortheirschoolmentalhealthtreatmentservicesandwhetheranAxisImentalhealthdiagnosisisrequiredbeforeastudentcanreceivementalhealthtreatment.6.2.3 These requirements shall comply with theMentalHealthRehabilitationServicesstandardsif theagency is certified to provide Medicaid reimbursable services (refer to Chapter 34 Title 22A 52 DCR56824).

6.3 Referral Process2

6.3.1 Everyschoolmentalhealthprogramshallhaveaclearlywrittenreferralprocessdevelopedtorequestmental health services for a child/adolescent. Theearlyinterventionteams(EIT)studentsupportteams(SST)withinpublicschoolsshallbeusedtotriagecases,coordinateservices,andfacilitateappropriatereferrals.Theschool-basedclinicianshallbeanactivememberof theSSTorequivalentmentalhealthteam.6.3.2 Referrals shall be received from any partyconcerned with the student’s welfare through thewrittenreferralprocessdevelopedforthatschool.Areferralformshallbeusedtodocumentthedateof thereferral,theurgencyof thereferral,andthepresentingproblem.Policiesoutlininghowlongaclinicianwilltake to make contact with a referred child shall bedevelopedbythesponsoringagency.6.3.3 Feedback shall be provided to the referralsourceincompliancewithMentalHealthInformationActregulations,onthestatusof thereferralasquicklyaspossibleaftertheinitialreferralismade.Extremecareshall be taken to protect the students’ confidentiality. 6.3.4 Referrals,whennecessary, shallbemade tooutside agencies for more intensive or specialized



services. An “Authorization to Use or DiscloseProtected Health Information” shall be obtainedfromtheparent/guardian(ortheadolescentif he/sheprovidedtheoriginalconsenttoservices)tosendorreceiveinformationregardingtheclient(D.C.MentalHealth Information Act; DMH Policy 645.1). The SMHclinicianshallfacilitatethereferralforthefamilyand monitor whether contact is made between thechild/familyandthereferralagency.

6.4 Consent2

6.4.1 InaccordancewiththeMentalHealthServiceDeliveryReformActof 2001,theschoolmentalhealthprovider shall make every effort to obtain consentfrom the child’s parent or legal guardian prior toprovidingmentalhealthservices.Writtenconsentshallberequiredforallstudents.However,aclinicianmaydeliveroutpatientmentalhealthservicesandmentalhealthsupportstoaminorwhoisvoluntarilyseekingsuchserviceswithoutparentalorguardianconsentforaperiodof 90daysif thecliniciandeterminesthat1)theminorisknowinglyandvoluntarilyseekingservicesand2)theprovisionof servicesisclinicallyindicatedfortheminor’swell-being.Attheendof the90-dayperiod,theclinicianshallmakeanewdeterminationthat mental health services are voluntary and areclinicallyindicated.6.4.2 Mental health clinicians shall routinelyencourage students to inform and involve theirparents in treatment,andconcertedefforts shallbedemonstratedinthisregard.6.4.3 In emergency situations, such as potentialfor dangerousness to self and/or others, and childprotective services involvement, a clinician shallintervene, regardless of whether consent has beenobtainedfromaparentorguardian,yetconsentforservices shall be sought before interventions areofferedwheneverpossible.

6.5 Authorization for Release of Information2

6.5.1 An “Authorization to Use or DiscloseProtectedHealthInformation”formshallbesignedby the individual who consented to services if theclinicianistoobtainorshareclinicalinformationwithanyothersourceorprovideroutsideof theDMH/SMH program (D.C. Mental Health Information Act; DMHPolicy645.1).

Section7.0ScopeofServices

7.1 Services Requirements 7.1.1 MentalHealthRiskandDiagnostic

Assessment7.1.2 MentalHealthTreatment

7.1.2.1Individualcounseling/therapy 7.1.2.2Familycounseling/therapy 7.1.2.3 Groupcounseling/therapy 7.1.3 MentalHealthCrisisIntervention 7.1.4 Teacher/Staff/FamilyConsultation 7.1.5 CaseManagement 7.1.6 PsychiatricEvaluation 7.1.7 PsychiatricMedicationManagement 7.1.8 Drug/AlcoholUseRiskAssessment 7.1.9 Drug/AlcoholTreatment

Section8.0MentalHealthRecordsandConfidentiality

8.1 Mental Health Record Content2

8.1.1 Individualclinicalrecordsshallbedevelopedforstudentswhoareseenforintensivementalhealthservices. Recordsshallbemaintainedinaccordancewithrecognizedandacceptablestandardsof recordkeepingasfollows5

8.1.1.1Recordentriesshallbemadeinnon- erasableinkortypewriter 8.1.1.2Recordsshallbelegible 8.1.1.3Recordsshallbeperiodically reviewedforqualityandcompleteness,and 8.1.1.4Allentriesshallbedatedandsigned byappropriatestaff 8.1.1.5 Allentriesshallbecompletedwithin 48hoursfollowingaclinicalencounter8.1.2 Students seen in individual counseling orin therapeuticgroupcounselingshallbeconsideredclientsof thesponsoringagencyandchartswillincludemandatoryformsasoutlinedbythisagencyaswellasthoserequiredbyDMH.8.1.3 A mental health record shall at minimuminclude the following:

8.1.3.1Contactinformation8.1.3.2Informedconsent(fromstudentand/orguardian)8.1.3.3JointConsentForm(HIPAA)8.1.3.4 Authorization for Disclosure Form(HIPAA)8.1.3.5Referralform8.1.3.6Intakeform/Clienthistory8.1.3.7Diagnosticassessment8.1.3.8Treatmentplanandreviews8.1.3.9Progressnotes8.1.3.10Dischargeplanandsummary

8.1.4 Where applicable, themental health record



may also include the following: 8.1.4.1Psychologicalevaluations 8.1.4.2Educationalreportsandinformation 8.1.4.3Pre-andPost-tests 8.1.4.4Correspondence 8.1.4.5Worksamples 8.1.4.6Referralsforoutsideservices

8.2 Mental Health Record Confidentiality2

8.2.1 All mental health providers shall abide bythe Mental Health Information Act, a DC statutethatdictateshowmentalhealth informationshouldbesharedandwithwhom,andwithHIPAA(HealthInsurance Portability and Accountability Act)regulationsandFERPA(FamilyEducationRightsandPrivacyAct)laws.8.2.2 Confidentiality must be respected andmaintainedatalltimes.Detailsof aclinicalcasecannotbe shared with school staff due to confidentiality guidelines unless an emergency occurs where theclinician is obligated to break confidentiality to protect thechildand/orothersorwhenwrittenauthorizationisprovided.8.2.3 Limitations on confidentiality (danger to self, others,orendangermentduetoabuseorneglect)willbeclearlystatedattheinitialmeetingwiththestudentandhis/herfamily(D.C.MentalHealthInformationAct; DMH Policy 645.1).

8.3 Mental Health Record Storage2

8.3.1 Charts shall be kept in locked and secureplaces (i.e., a locking filing cabinet) on school premises to ensure confidentiality of records and timely access toinformation,asrequiredbyHIPAAguidelines.8.3.2 MentalHealthrecordsshallbekeptseparatefromanyhealthinformationthatispartof thestudent’seducationalrecord.8.3.3 Apolicyshallbeestablishedbythesponsoringagencyconcerningwhohasaccesstothementalhealthrecord (i.e., clinician, supervisor), who shall havea copy of the key to the filing cabinet (i.e., agency administrator,supervisor),andwhoshallhaveacopyof the key to the school office occupied by the mental healthprofessional(i.e.,principal,buildingjanitor).

8.4 Sharing of Mental Health Information2

8.4.1 Whenaclinicalcaseisopened,anyinformationobtainedasaresultfromthisactionshallbelongtothesponsoringagencyandtheclientandcannotbesharedwithanyonewithoutawrittenauthorizationfordisclosureprovidedbytheparent,guardian,orclient(D.C. Mental Health Information Act; DMH Policy

645.1).8.4.2 In the District of Columbia a court orderor subpoena and qualified protective order signed bya judgeisrequiredbeforeamentalhealthrecordcanbereleasedtothecourts. If acourtorderorasubpoenaisservedtothe“custodianof therecords”and theyare referring to thementalhealth records,the mental health professional shall be responsiblefor following appropriate procedures outlined byDMHandcomplyingwiththelawinregardstothisrequest. Consultationwithaclinicalsupervisorandthesponsoringagency’sgeneralcounselshouldoccuroncasesinvolvingcourtordersorsubpoenasbeforeanycommunicationorrecordisgiven.8.4.3 Inordertoappropriatelycoordinatementalhealthservicesforstudents,toinformotherprovidersof servicesbeingofferedandreceived,andtoassistinauthorizeddatacollectionactivities,administrativeinformationrelatedtothestudentmaybesharedwiththePrincipaloradesigneewithoutaformalreleaseof information. Informationsuchastheclient’sname,age, sex, dates and modality of treatment used insessions(individualorgroup)shallbedisclosedif suchdisclosureisdeemedtobenecessaryfortheprovisionandcoordinationof theseservices.8.4.4 Documentationintheclinicalrecordregardingunauthorized disclosures (such as for mandatedreporting) shall include: date of disclosure, name of persontowhominformationwasdisclosed,natureof informationdisclosed,andpurposeof disclosure.

8.5 Mandated Reporting2

8.5.1 When a clinician suspects child abuse orneglect he/she shall immediately make a report toChildandFamilyServicesAgency(CFSA)at202-671-SAFE.8.5.2 ThePrincipalandtheSMHclinicalsupervisorshallbeinformedthatareportwasmadetoCFSAbytheclinician.

Section9.0DataCollectionandReporting

9.1 Anyindividualorprogramparticipatinginthedeliveryof schoolmentalhealthservicesintheDistrictof ColumbiashallsubmitrequiredreportstotheDCDepartmentof MentalHealth.Schoolmentalhealthprogramsponsorsshallcompletedocumentation,datacollection,andreportingrequirements.

9.2 Data Collection Requirements 9.2.1 Thesponsoringagencyof theSMHprogramshall maintain a data collection system, preferably



electronic, which allows for data input, export,aggregation,andanalysis.9.2.2 The data collected shall comply with DCDepartmentof MentalHealth,SchoolMentalHealthrequirements.9.2.3 Data shall include elements that will trackutilization of services, staff productivity, clientsatisfaction with services provided, emotional,behavioral,andacademicoutcomes.

9.3 Data Reporting Requirements 9.3.1 The SMHP shall complete the (monthly,quarterly, annual) Productivity Report by (requireddate)forservicesofferedduringthe(identifyschoolyear).9.3.2. This information shall be provided to theClinical Administrator at DMH at regular intervalsdeterminedbyDMH.

Section10.0QualityAssurance

10.1 Continuous Quality Improvement Requirements10.1.1 TheSMHprogramand it’s sponsoragencymustdevelopamechanismtomonitortheirclinicalservices and evaluate the goals of their overallprogram.10.1.2 The SMH program will either a) set up acontinuous quality improvement program, or b)develop a comprehensive practice managementimprovementplanthatincorporatesCQImonitoring.10.1.3 ItisrecommendedthattheSMHprogramuseCQI and PMI tools that have been field-tested (for example,theMentalHealthPlanningandEvaluationTemplate(MHPET)canbeusedinevaluatingactivitiesand services across the field of school-based mental health, forneworestablished schoolmentalhealthprograms.6)10.1.4 InternalCQIauditsshallbeconductedatleastonceayear10.1.5 SMHprograms shall complywithprogramaudits conducted by DC Department of MentalHealth.

Section11.0Finance/FiscalManagement

11.1 Budget Thesponsorof theSMHprogramshallhaveanannualbud-getthatdescribessourcesandusesof funding.

11.2 Billing11.2.1 TheSMHprogramsponsoragencyshallhaveawrittenpolicythatdescribeshowservicesrendered

are recorded, charged, billed, and collected (whenapplicable).11.2.2 Information on dollar amounts of claimssubmitted to claims paid by the DC Departmentof Mental Health or MHRS4 services provided indesignatedschoolsshallbereported.

Section12.0Evaluation

12.1 Needs Assessment12.1.1 To help define the scope and level of services needed,SMHprogramsshallcompleteacommunityandlocalschoolneedsassessmentbeforeservicesareprovidedinschools.12.1.2 Aschoolneedsassessmentshallbeupdatedannuallytomonitorchangesinstudentdemographics,staffing, resources, and school district requirements.12.1.3 A community needs assessment shall beconducted every three to five years to monitor the community’sneeds,concerns,andresourcesfor thephysical,mental,behavioral,andacademicneedsof itschildrenandadolescents.

12.2 Process Evaluation 12.2.1 SMH programs shall conduct processevaluations annually to address client satisfaction,servicedelivery,andprogrammanagement.12.2.2 Satisfaction survey- SMH programs shallconduct client, parent, and school administratorsatisfactionsurveysonanannualbasisaspartof theprocessevaluation.12.2.3 Focus groups may also be conducted toidentifybothsatisfactionlevelsaswellasperceptionsamongclients,families,andschoolstaff concerningthefunctioningof theprogram.12.2.4 Service-deliveryeffectivenessmaybeassessedusing quarterly data reports to calculate providerproductivityasmeasuredbynumberof visits,numberof evidence-based interventions implemented,minimumcaseloads,amountof timebetweenreferraland first visit, etc.12.2.5 Programmanagement effectivenessmaybemonitoredbyusingmeasuresof transparency–e.g.,availability of information on the SMH programweb site; annual report to the public on program performance; supervisory ratios; numbers of presentationstoandcommunicationswithcommunitygroups, school representatives, and key programstakeholders.

12.3 Utilization SMHprogramsshallmonitorandreportserviceutilizationforallprevention,early intervention,assessment,treatment,and



consultationservicesprovided.

12.4 Outcome/Impact Evaluation12.4.1 SMHprogramsshallevaluatetheimpactof services provided, using pre and post-assessmentsto evaluate outcomes for predominant symptomsexhibitedbythelocalstudentpopulation.12.4.2 Measures shall be conducted the first year programservicesareoffered toestablishabaselineandthenannuallythereafter.12.4.3 SMHprogramsshallhaveindicatedstudentscompletetheOhioYouthProblems,Functioning,andSatisfactionScales-Shortform.12.4.4 Assessmentsshallbeconductedusingvalidatedandreliablemeasurementsandtools,includingbutnotlimited to:

12.4.4.1Depression(e.g.,theReynoldsChildDepressionScaleortheReynoldsAdolescentDepressionScale)12.4.4.2Aggression(e.g.,theBeckDisruptiveBehaviorInventoryforYouth,theAggressionQuestionnaire)12.4.4.3Anger(e.g.,theBeckAngerInventoryfor Youth or the Children’s Inventory of Anger)12.4.4.4Trauma (e.g., Trauma SymptomChecklistforChildren)

Section13.0EnforcementofStandards5

13.1 A provider of service shall exercise duediligence in complying with the requirements of outlinedstandards.Duediligencemeanstheexerciseof reasonable and appropriate efforts to ensurecompliance with the standards set forth in thesestandards.13.2 TheDCDepartmentof MentalHealthshallreview the program and practices of the providerof service inordertofacilitatedeterminationsastowhether providers are exercising the requisite duediligenceandareotherwiseincompliancewiththesestandards.13.3 If, based on a review of the program andpracticeof aproviderof service,theDCDepartment of Mental Health determines that aproviderof serviceisnotexercisingduediligenceincomplyingwiththerequirementsof thesestandards,theDCDepartmentof MentalHealthshallgivenoticeof the deficiency to the provider of service and may also initiate the following:

13.3.1 Requestthattheproviderof serviceprepareaplanof correction,whichshallbesubjecttoapprovalbytheDCDepartmentof Mental Health; 13.3.2 Providesuchtechnicalassistanceas

theDCDepartmentof MentalHealthdeemsnecessarytoassisttheproviderof serviceindevelopingandimplementinganappropriateplanof correction.13.3.3 If the provider of service fails toprepare an acceptable plan of correctionwithinareasonabletimeorrefusestopermitthe DC Department of Mental Healthto provide technical assistance or fails topromptlyoreffectivelyimplementaplanof correctionwhichhasbeenapprovedby theDCDepartmentof MentalHealth,itshallbedeterminedthattheproviderof serviceisinviolationof thesestandards.13.3.4 Upondeterminationthataproviderof service is inviolationof thesestandardsor upon determination that a provider of servicehas failed tootherwisecomplywithapplicablestatutes, rules,or regulations, theDCDepartmentof MentalHealthmayrevoke,suspendorlimittheprovider’soperations.

Note: Preceding standards have been adapted from the sources referenced below.

Maryland School-Based Health Center Policy AdvisoryCouncil,MarylandSchool-BasedHealthCenterStandards,April2006Districtof ColumbiaDepartmentof MentalHealth,SchoolMentalHealthProgramGeneralOperatingProcedures,October11,2006Paternite,C.E.,Weist,M.D.,Axelrod, J.,Weston,K.,&Anderson-Butcher, D. (2006). School Mental HealthWorkforceIssues.InAnactionplanforbehavioralhealthworkforce development: A framework for discussion. Cincinnati, Ohio: Annapolis Coalition on the Behavioral Health Workforce, January 17, 2006. http://www.annapoliscoalition.org,Mental Health Rehabilitation Services Provider Certification Standards,Chapter34,Title22A,D.C.Codeof MunicipalRegulations 5682, http://dmh.dc.gov/dmh/frames.asp?doc=/dmh/lib/dmh/pdf/policy/Chap_34_Title_22A_52_DCR_5682.pdfNewYorkCodes,RulesandRegulations,Parts587and588, http://www.omh.state.ny.us/omhweb/policy/policy.htmNational Assembly on School-Based Health Care(NASBHC), Mental Health Planning and EvaluationTemplate (MHPET), http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.3015469Weist,M.D.,Sander,M.A.,Walrath,C.,Link,B.,Nabors,L.,etal. (2005). Developingprinciplesforbestpracticeinexpandedschoolmentalhealth.Journalof YouthandAdolescence,34(1),7-13.Revised5/5/08

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AppendixJ: List of evidenced based programs or data driven practices or programs for use in the School Mental Health Program for SY 2007-2008

Evidenced-BasedSMHPClinicinLEDPrograms

Screening:Columbia Teen Screen – Evidence-Based Prevention – The National Suicide Prevention Resource Center A screening program developed by Columbia University.Its purpose is to identify and help youth who suffer fromdepressionandotheremotionalproblems.

Prevention Programs:Connect with Kids – Evidenced Informed – What Works ClearinghouseEvidenced informedprogram improvesstudentbehavior insignificant and important ways across multiple character skills, includingteasingandbullyingbehaviors,cheatingand lying,respectforclassmatesandteachers,violenceprevention,andacademicperseverance.

Good Touch/Bad Touch – Evidenced Based – The National Mental Health Association’s ClearinghouseEvidence-based primary prevention/education curriculum,3-7sessions.Developedforpre-school–6thgradestudentsasatooltoteachchildrentheskillstheyneedtopreventorinterruptabuse.

Botvin’s Life Skills Training Program – Evidenced Based – SAMHSA Model ProgramEvidence-base Substance abuse prevention program (15-20 sessions), addresses the most important factors leadingadolescentstousedrugsbyteachingacombinationof healthinformation,generallifeskills,anddrugresistanceskills.

Taking Action – Evidenced Based – National Institute of Health funded studyAn18-sessionprogramforthetreatmentandpreventionof pre-teendepression.Theprogramcanbedeliveredusingeitheragrouporindividualformat.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) – Evidence Based – SAMHSA Model ProgramCBITSisacognitivebehavioraltherapygroupinterventionforreducingchildren’ssymptomsof post-traumaticstressdisorder(PTSD)anddepressioncausedbyexposuretoviolence.CBITShas three main goals: to reduce symptoms related to trauma, to buildresilience,andtoincreasepeerandparentsupport.

Too Good for Violence-Evidence Based – SAMHSA Model ProgramA school based prevention program that address the mostsignificant risk and protective factor developmental level to help students learn the skills andattitudes theyneed togetalongpeacefullywithothers.Toogoodforviolencepromotesprotective factors that help youth get along peacefully: bonding, normsandsocial/emotionalskills.

Parenting for Emotional Growth – Evidenced InformedHenriParens,MDandhiscollaboratorshavebeenusingthismodel for over thirty years. They have added new ideas astheir experience and current scientific knowledge suggested. Thiswellresearchedanddocumentedseriesof workshopsforparentsisbasedinthebelief thatallchildrencanachievetheirbest individualadaptiveabilitiesandmentalhealthpotentialwhen facilitated by parents, family, teachers, and others of significant importance in the family

Evidence-Based School Driven Programs:Olweus Bullying Prevention – Evidenced Based – SAMHSA Model ProgramTheOlweusBullyingPreventionProgramisacomprehensive,school-wideprogramdesignedforuseinelementary,middle,orjuniorhighschools.Itsgoalsaretoreduceandpreventbullyingproblemsamongschoolchildrenandtoimprovepeerrelationsatschool.

Second Step – Evidenced Based – SAMHSA Model ProgramAschoolbasedsocialskillscurriculumforchildreninpreschoolthrough juniorhigh school. Spanninga full academicyear,the program teaches social skills to reduce impulsive andaggressivebehaviorinchildrenandincreasetheirlevelof socialcompetence.

I Can Problem Solve – Evidenced Based – SAMHSA Promising PracticeEvidence-basedprogramthattrainschildren ingeneratingavarietyof solutionstointerpersonalproblems,consideringtheconsequencesof these solutions, and recognizing thoughts,feelings, andmotives thatgenerateproblemssituations. Byteaching children to think, rather than what to think, theprogram changes thinking styles and, as a result enhanceschildren’ssocialadjustment,promotespro-socialbehavior,anddecreasesimpulsivityandinhibition.

Positive Behavioral Interventions and Supports (PBIS) – Evidence Based – National Forum for Change PBISisanevidence-basedprogramthatencouragesacademicperformanceandpositiveclassroomclimatesinschools.PBISseekstocreateeffectivelearningenvironmentsbyreducingthedisruptionscausedbyproblembehaviorsandbyencouragingconstructivebehaviors.



Supplemental Programs:Love and Life: The G-TREM Model – Evidenced InformedEvidenced-basedprogram,16+sessions,Enhanceadolescentsfemales’traumarecoveryandcopingskills,decreaseriskof re-victimization and inspire girls to grow into healthy confident women.

Three Dimensional Grief – Promising PracticeTherapeutic grief and loss groups for grieving students orstudentswhohaveexperiencedthedeathof alovedone(PreK-12thgrade).

Trauma Intervention Programs – Promising PracticeShort-termtraumainterventionforchildren(6-12yearsold)andadolescents (13-18yearsold)organizedasan8 sessioninterventionmodel.

RETHINK Program – Evidenced InformedDeveloped by Institute for Mental Health Initiatives andGeorgeWashingtonUniversitySchoolof PublicHealthandHealthServices,40sessionsforgradesKthroughhighschool.Empowerment program that provides individuals with theknowledgeandskillstomanagetheirangryfeelings,situations,and conflicts in constructive ways. Incorporates a service-learningproject.

The Empower Program – Evidenced Informed Evidence-based program 12-20 gender specific sessions – violence/bullyingprevention/interventionprogram,examinesandchallengessocietalandculturalstereotypesandpressures.

RESPECT Program – Promising PracticeEvidence-based program on Violence, bullying, and sexualharassment awareness and prevention program for middleschoolandhighschoolstudents,(4-6sessions).



AppendixK: Sources that have reviewed evidence-based or promising programs for use in schools

Substance Abuse and Mental Health Services Administration (SAMHSA)

The National Registry of Evidence-based Programs andPractices(NREPP)isasearchableonlineregistry,createdbySAMHSA,of mentalhealthandsubstanceabuseinterventionsthathavebeenreviewedandratedbyindependentreviewers.The purpose of this registry is to identify approaches topreventingandtreatingmentaland/orsubstanceusedisordersthat have been scientifically tested and that can be readily disseminated to the field. A search of interventions offered intheschoolsettingyielded40evidence-basedprogramstochoose from. NREPPpublishesan interventionsummaryforeveryinterventionitreviews.Eachinterventionsummaryincludes:

Descriptive informationabout the interventionand itstargetedoutcomesQuality of Research and Readiness for DisseminationratingsAlistof studiesandmaterialssubmittedforreviewContact information for the intervention developerhttp://www.nrepp.samhsa.gov/index.htm

Collaborative for Academic, Social, and Emotional Learning (CASEL)

CASELisacollaborativethatworkstoadvancethescienceandevidence-basedpracticeof socialandemotionallearning(SEL). They synthesize scientific evidence around SEL and provide practitioners and school administrators with theguidelines, tools, informational resources,policies, training,and supports theyneed to improve and expand their SELprogramming.Oneresourcetheymakeavailableisalistof recommendedtoolsforevaluatingthesocialandemotionalclimateof schools,withdescriptionsandsurveysavailabletodownload. http://www.casel.org/assessment/climate.php

CASELalsoconductedanextensivereviewof SELprogramsanddevelopedaguideof 80multiyearSELprogramsdesignedfor use in general education classrooms. Safe and Sound: An Educational Leader’s Guide to Evidence-Based Social andEmotionalLearning(SEL)Programisacomprehensivereportof SEL programming that provides specific strategies for schoolsanddistrictsinterestedinlaunchingsocial,emotional,andacademiclearningprograms.CollaborativeforAcademic,Social, and Emotional Learning. (2003). Safe and Sound: An Educational Leader’s Guide to Evidence-Based Social andEmotional Learning (SEL) Programs. Chicago, IL: Author.http://www.casel.org/pub/safeandsound.php

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Center for the Study and Prevention of Violence (CSPV)CSPVdesignedandlaunchedanationalviolencepreventioninitiative to identifyeffectiveviolencepreventionprograms,callingtheprojectBlueprintsforViolencePrevention.Outof morethan600programsthathavebeenreviewed,theCenterhas identified 11 prevention and intervention programs that meet a strict scientific standard of program effectiveness and areconsideredmodelprograms,andanother18programshavebeen identified as promising programs. http://www.colorado.edu/cspv/blueprints/index.html

Center for Learning Excellence

TheEvidence-BasedProgramDatabasecontainsinformationon evidence-based programs recommended by research-oriented government agencies, non-profit agencies, and independentpublications.Theprogramsinthisdatabasehaveallbeenshowntobeeffectiveatchangingyouthbehaviors.http://www.alted-mh.org/ebpd/

Lifecourse Interventions to Nurture Kids Successfully (LINKS)

LINKS,aprogramof ChildTrends,anonpartisanresearchcenterfocusedexclusivelyonchildren’sissues,featuresexperimentalevaluationsof socialprogramsdesignedtoenhancechildren’sdevelopment.Theyarepresentedinauser-friendlyformatforpolicymakers,programdesigners,andfunders.Thepurposeof LINKSistocompileacompendiumof interventionsforchildren based on the following criteria:

Allprogramsincludedaresocialinterventions(i.e.,notmedical).Everystudyhasatreatmentgroupandacontrolgroup.Onlyresultsbasedonanintent-to-treatanalysis[includingallrandomizedsubjects’data intheanalysis,regardlessof theircompliancewiththeprotocolof thestudy]arereported.Randomassignment(i.e.,alotterysystem)wasusedtodetermineplacement(of children,classrooms,schools,districts,etc.)intotreatmentandcontrolgroups.

Results were reported if they met the .05 level of significance; any results significant at the .05 to .10 level are described as marginally significant.

StudieswereconductedaroundtheworldbutallreportsareinEnglish.Studiesareincludedif theyhavearesponserateaslowas50%,butevaluationswith lowresponseratesandothermajormethodologicallimitationsarenoted.Norestrictionsweremadebasedonsamplesize.Nostatisticalre-analyseshavebeendonetoadjustorrevisetheresultspresentedbythestudies’authors.

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Programslistedinthe‘school-based’categoryontheLINKSwebsitehavesomeorallof theprogramadministeredintheclassroomoracrosstheschool.http://www.childtrends.org/_catdisp_page.cfm?LID=C69A59D5-7C1A-47C1-AB7C751AD5A71718

Additional resources:Jaycox,L.H.,Morse,L.K.,Tanielian,T.&Stein,B.D.(2006).How Schools Can Help Students Recover from TraumaticExperiences: A Tool Kit for Supporting Long-term Recovery. Santa Monica, CA: RAND. http://www.rand.org

This tool kit is intended to help school administrators andmentalhealthprofessionalsdecidehowtoaddressthementalhealthrecoveryof studentsfollowingatraumaticevent.Theauthors gathered information about programs that can beimplemented in schools, examined the evidence supportingtheiruse,andcategorizedthe informationbasedontypeof trauma.Theresearchandthereportwereguidedbytheworkoutof theNationalChildTraumaticStressNetwork(NCTSN)andwerefundedbySAMHSA.

Duchnowski,A.J.,&Kutash,K.,(2007).Family-drivencare.Tampa, FL: University of South Florida, The Louis de la ParteFloridaMentalHealthInstitute,Departmentof Child&Family Studies (Appendix C: Compendium of Evidence-Based Behavioral Health Programs, pgs. 44-46). http://cfs.fmhi.usf.edu/resources/publications/fam_driven_care.pdf

Thisreport isaimedathelpingfamilymembersandmiddleleveladministratorsintheeducationandmentalhealthsystemsunderstandandimplementtheconceptof ‘family-drivencare’.There are two major aims of this report. The first is to acquaint readerswiththeconceptof family-drivencareforchildrenwhohaveemotionalandbehavioraldisturbances.Thesecondistopresent informationaboutevidence-basedpractices thatareeffectiveinterventionstohelpchildrenandtheirfamilies.



AppendixL: Sources of Federal funding for school-based mental health care

SUBSTANCEABUSEANDMENTALHEALTHSERVICESADMINISTRATION(SAMHSA)

The Safe Schools/Healthy Students InitiativeThepurposeof theSS/HSInitiativeistopromotethementalhealthof students,toenhanceacademicachievement,topreventviolenceandsubstanceuse,andtocreatesafeandrespectfulclimatesthroughsustainableschool-family-communitypartnershipsandtheuseof research-basedpreventionandearlyinterventionprograms,policies,andprocedures.

Systems of Care ProgramSystemsof carearedevelopedonthepremisethatthementalhealthneedsof children,adolescents,andtheirfamiliescanbemetwithintheirhome,school,andcommunityenvironments.Thesesystemsarealsodevelopedaroundtheprinciplesof beingchild-centered,family-driven,strength-based,andculturallycompetentandinvolvinginteragencycollaboration.

Cooperative Agreements for State-Sponsored Youth Suicide Prevention and Early InterventionMoneymadeavailablefromtheGarrettLeeSmithSuicidePreventionActsupportsthisprogramdesignedtoassistindevelopingandimplementingstatewideyouthsuicidepreventionandearlyinterventionstrategies,groundedinpublic/privatecollaboration.

Mental Health Transformation State Incentive Grant ProgramThisprogramwillsupportanarrayof infrastructureandservicedeliveryimprovementactivitiestohelpgranteesbuildasolidfoundationfordeliveringandsustainingeffectivementalhealthandrelatedservices.Thesegrantsareuniqueinthattheywillsupportnewandexpandedplanninganddevelopmenttopromotetransformationtosystemsexplicitlydesignedtofosterrecoveryandmeetthemultipleneedsof consumers.

U.S.DEPARTMENTOFEDUCATION

Mental Health and Education Integration GrantThisprogramprovidesgrantsforthepurposeof increasingstudentaccesstoqualitymentalhealthcarebydevelopinginnovativeprogramsthatlinkschoolsystemswithlocalmentalhealthsystems.

Safe and Drug-Free Schools and Communities Act State Grants ProgramThisprogramauthorizesandsupportsavarietyof activitiesdesignedtopreventschoolviolenceandyouthdruguse,andtohelpschoolsandcommunitiescreatesafe,disciplined,anddrug-freeenvironmentsthatsupportstudentacademicachievement.



AppendixM:Proposed plan to implement a citywide school mental health evaluation plan

Acti

vit

yD

eli

verab

les

Resp

on

sib

leTim

eli

ne

1.

Descriptive info

rmation a

nd n

arr

ative

sum

maries o

n s

chools

, serv

ices/p

rogra

ms a

nd

recip

ients

of

MH

inte

rventions

2.

Data

analy

sis

, data

table

s a

nd illustr

ations

for

a S

MH

P E

valu

ation r

eport

for

SY 2

005-

2006 &

2006-2

007

3.

Executive s

um

mary

, annual re

port

s f

or

2005-2

006,

2006-2

007 s

chool year

4.

Recom

mendations f

or

str

egth

enin

g d

ata

collection

5.

Tem

pla

te f

or

futu

re a

nnual re

port

ing o

f

SM

HP d

ata

1.

Matc

h S

MH

P inte

nded o

utc

om

es w

ith I

CSIC

& C

ap S

tat

goals

2.

Revie

w p

revio

us q

uestions &

identify

new

are

as f

or

explo

ration

3.

Outlin

e r

esearc

h m

eth

odolo

gy,

identify

resourc

e n

eeds,

and d

evelo

p p

lan/t

imeline

4.

Consid

er

develo

pin

g o

ngoin

g r

ela

tionship

with local univ

ers

ity t

o e

nhance r

esearc

h

capabilitie

s

1.

Identify

or

cre

ate

DM

H info

rmation s

yste

m

for

SM

HP

2.

Consid

er

use o

f W

ellBAT w

ith S

MH

P

treatm

ent

serv

ices

3.

Assess inte

ractivity o

f D

MH

syste

m w

ith

CH

ARI

(Childre

n a

t Ris

k I

nfo

rmation)

data

base

4.

Revis

e/U

pdate

syste

m p

er

clinic

ian a

nd

agency f

eedback.

SM

HP

Develo

p d

ata

gath

ering a

nd

inte

rpre

ting c

apacitie

s

Fall 2

008

See s

uggeste

d d

ata

ele

ments

table

Issue S

MH

P E

valu

ation C

ontr

act

for

Independent

Eval TM

Fall 2

008 -

sum

mer

2009

Confirm

or

Identify

Critical

Researc

h Q

uestions

SM

HP

SM

HP

Fall 2

008

Ap

pen

dix

L:

Pro

po

sed

pla

n t

o i

mp

lem

en

t a c

ity-w

ide s

ch

oo

l m

en

tal

healt

h

evalu

ati

on

to

ol

Fin

alize D

ata

Sets

and C

onfirm

Definitio

n o

f D

ata

Ele

ments

SM

HP

Ap

pen

dix

M:



Acti

vit

yD

eli

verab

les

Resp

on

sib

leTim

eli

ne

Ap

pen

dix

L:

Pro

po

sed

pla

n t

o i

mp

lem

en

t a c

ity-w

ide s

ch

oo

l m

en

tal

healt

h

evalu

ati

on

to

ol

1.

Utilization d

ata

SM

HP a

nd s

ponsor

agencie

s

2.

Pro

cess e

valu

ation

SM

HP a

nd s

ponsor

agencie

s

3.

Outc

om

es -

Pre

vention &

Early I

nte

rvention S

MH

P, s

ponsor

agencie

s,

schools

4.

Outc

om

es -

Clinic

al

SM

HP,

sponsor

agencie

s,

identified

stu

dents

5.

Outc

om

es -

Academ

ic

DCPS,

Chart

er

Schools

,OSSE

1.

Utilization d

ata

Sponsor

agency &

DM

H

2.

Pro

cess e

valu

ation

Sponsor

agency &

DM

H

3.

Outc

om

es -

Pre

vention &

Early I

nte

rvention S

ponsor

agency &

DM

H

4.

Outc

om

es -

Clinic

al

Sponsor

agency &

DM

H

5.

Outc

om

es -

Academ

ic

Sponsor

agency,

DM

H,

local school, s

chool

dis

tric

t

1.

Utilization d

ata

betw

een a

. sponsor

agency

& D

MH

, b.

sponsor

agency a

nd s

chool

2.

Pro

cess e

valu

ation b

etw

een a

. sponsor

agency &

DM

H,

b.

sponsor

agency a

nd s

chool

3.

Outc

om

es -

Pre

vention &

Early I

nte

rvention

betw

een a

. sponsor

agency &

DM

H,

b.

sponsor

agency a

nd s

chool

4.

Outc

om

es -

Clinic

al betw

een a

. sponsor

agency &

DM

H,

b.

sponsor

agency a

nd s

chool

5.

Outc

om

es -

Academ

ic b

etw

een a

. sponsor

agency &

local school and b

. D

MH

and s

chool

dis

tric

t

Assess c

apacity o

f in

form

ation

syste

ms a

nd c

larify

technolo

gy

requirem

ents

Identify

sourc

es f

or

each d

ata

set

Com

ple

te M

em

ora

ndum

of

Unders

tandin

g A

gre

em

ents

with

rele

vant

sourc

es

Sponsor

agency

Ap

pen

dix

M:

AppendixM, cont.:Proposed plan to implement a citywide school mental health evaluation plan



Acti

vit

yD

eli

verab

les

Resp

on

sib

leTim

eli

ne

Ap

pen

dix

L:

Pro

po

sed

pla

n t

o i

mp

lem

en

t a c

ity-w

ide s

ch

oo

l m

en

tal

healt

h

evalu

ati

on

to

ol

1.

Univ

ers

al pre

vention

2.

Early inte

rvention

3.

Tre

atm

ent

serv

ices

4.

Crisis

serv

ices

1.

Utilization d

ata

Sponsor

agency

2.

Pro

cess e

valu

ation

Sponsor

agency

3.

Outc

om

es -

Pre

vention &

Early I

nte

rvention S

ponsor

agency &

local

school

4.

Outc

om

es -

Clinic

al

Sponsor

agency

5.

Outc

om

es -

Academ

ic

Sponsor

agency &

local

school

1.

Identify

school clim

ate

indic

ato

rs

2.

Identify

and/o

r cre

ate

measure

ment

tool

3.

Develo

p p

lan f

or

imple

menta

tion

4.

Obta

in a

gre

em

ents

fro

m s

chool dis

tric

ts

and local schools

1.

Identify

part

ners

(m

ay inclu

de D

CPS,

Chart

er

Schools

, D

OH

, O

SSE,

Deputy

Mayor

of

Education,

CSAs o

r com

munity M

H

pro

vid

ers

, IC

SIC

2.

Identify

resourc

e n

eeds (

fundin

g,

expert

ise,

capacity,

tim

e)

3.

Identify

possib

le f

undin

g s

ourc

es (

DM

H,

City C

ounci, O

SSE,

DCPS,

Local fo

undations,

blo

ck g

rants

)

Cre

ate

Fid

elity

Assessm

ent

Tools

for

EBPs

Sponsor

agency &

DM

H

Collect

indic

ate

d b

aseline o

r pre

-

test

data

Expand S

MH

P E

valu

action t

o

Inclu

de A

ssessm

ent

of

School

Clim

ate

Imple

ment

DM

H E

valu

ation P

lan

Ap

pen

dix

M:




Data Type Data Category Possible Data Measurements

Administrators

Teachers

Parents

Other Students

Self

Other Programs

Gender

Age

Grades

Race/Ethnicity

Prevention

Early Intervention

Identification, Screening &

Assessment

Treatment

Consultation

Home Visits

Child

Youth

Parents

Teachers/Staff

Administrators

# of EB interventions implemented

Active Caseloads

Amount of time between referral

and first visit

Availability of program information

Annua report to the public on

program performance

Numbers of presentations to and

communications with stakeholders

Ratios of Supervisor to Clinician

Assets Protective Factors Among Students

School/climate

perceptions of safety in school and

classrooms

Staff and parent awareness of MH

issues

Staff and parent attitudes about

MH issues

Problem Severity Ohio Scales

Depression

Anger

Aggression

Trauma

Substance Use

Attendance

Drop-out Rates

Truancy

Discipline Referrals

Special Education Referrals for ED

Behavior

School discipline & behavior

policies

Staffing

Existence and functioning of School

early Intervention programs

Utilization

Referrals to SMHP & Referral

Sources

Student Demographics

Services Delivered

Process Evaluation

Satisfaction Surveys

Service-delivery effectiveness

Program Management

Effectiveness

Outcomes - Prevention &

Early Intervention

MH Awareness & attitudes

Outcomes - Clinical

Outcomes - Academic

Pre-post assessments

Pre-post Assessment


l

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Adelman, H. S., & Taylor, L. (1999). Mental health in schools and system restructuring. Clinical Psychology Review, 19, 137-163.

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