Pennsylvania s Community of Practice on School-Based Behavioral Health

Pennsylvania’s

Community of Practice on

School-Based Behavioral Health

by Connell O’Brien

In 2013 the Community of Practice (COP) on School-Based Behavioral Health developed and refined their Core Statement. This statement begins: “We are a community of cross sector stakeholders that share a commitment to the advancement of early childhood, school age and adult behavioral health and wellness within the Commonwealth of Pennsylvania.”

The membership of the community of practice includes a wide vari-ety of state, county and community agencies – all who have a vested interest in the future growth of the COP, which formally started in 2006. This edition of the PAPBS newsletter includes articles from many mem-bers of the COP.

School-Based Behavioral Health: That Long and Winding

Road

For more than 30 years, I was responsible for developing and over-seeing education programs in child and adolescent mental health settings and developing mental health programs in schools. Now, for more than a decade, as a “children’s policy specialist” working on behalf of community providers, I have had the opportunity to participate in unprecedented developments in school-based behavioral health (SBBH) services. Today is the era of community partnerships and a multi-tiered framework of School and Program Wide Positive Behavior Intervention and Supports (PBIS). There are only a few of us left who have traveled the road to this important milestone, so it seems useful to provide a brief travelogue of the policies that have brought us to where we stand today (I’ll skip the lawsuits and other detours).

1985. Federal and state policy makers advanced the principles of the Child and Adolescent Service System Program, or CASSP. Pennsylvania saw its leaders craft a Memorandum of Understanding between the Departments of Welfare, Health and Education creating the Student

Fifth Annual

Implementers’ Forum

More than 1000 administra-tors, educaadministra-tors, and behavioral health agency personnel will at-tend the Fifth Annual

Pennsylvania Positive Behav-ior Support Implementers' Forum at the Hershey Lodge and Convention Center in Her-shey on May 27-28, 2015. The two-day forum features several national and Pennsylvania-spe-cific presentations. This year’s invited PBIS colleagues include national presenters Dr. Rob Horner, University of Oregon; Dr. Kevin Moore, University of Ore-gon; Dr. Pamela Higgins, Mid At-lantic Equity Center; and Dr. Timothy Runge, Indiana Univer-sity of Pennsylvania. The forum will also include presentations in various content strands: Tier 1-Universal Supports for Students; Tier 2- Secondary Supports and Interventions; Tier 3- Tertiary Supports and Interventions; Higher Education; Family and Community Partnerships; Coach-ing; and Early Childhood Setting Implementation. Attendees will be able to network and collabo-rate throughout the conference.

Don’t miss this opportunity to cheer on the largest number of Pennsylvania schools being recognized for high fidelity im-plementation of SWPBIS. Regis-ter at http://tiny.cc/208twx. Parent scholarships are also

Assistance Program (SAP). “Now [2015] in its 30th year, SAP helps schools identify students who are experiencing behavior and or aca-demic difficulties that are posing a barrier to their learning and suc-cess in school.”

1980-1998. Schools, SAP Teams and community mental health providers worked to address the mental health and educational needs of students by “referring out” students with social and emotional challenges. A small number of schools and community providers also worked to imple-ment an array of therapeutic classrooms, partial hospitals with education services, outpatient satellites in schools and other stu-dent focused models of collabora-tive mental health programming. 1998-2002. Early Periodic Screening, Diagnosis and Treat-ment (EPSDT) brought Pennsylva-nia into the era of mobile

Medicaid-funded home, school and community-based services known as wrapround or Behav-ioral Health Rehabilitation Serv-ices (BHRS). This brought

increased, but often not well-inte-grated or coordinated, mental health treatment and support services into schools.

2000-2002. The U.S. Depart-ment of Education’s Office of Spe-cial Education Programs (OSEP) finds Pennsylvania (specifically, the Departments of Education and Public Welfare) are not meeting IDEA standards for the “Provision of Psychological Counseling” serv-ices. OSEP finds that counseling services were excluded from IEPs and that students are “referred out” for psychological counseling. 2003. PDE provides guidance to schools to assist them in

OSEP-logical counseling) services through the use of SAP teams, Positive Behavior Support, coun-seling by qualified school person-nel, and collaborative agreements with community mental health providers for BHRS and other mental health services.

2004. The Education Law Center and what was then the PA Com-munity Providers Association com-plete an analysis of educational services in free-standing partial hospitals. This study found a clear need for more and better ways to meet the mental health and aca-demic needs of students in a more coordinated and collaborative way. The Secretaries of Education and Public Welfare meet with advo-cates, educators and community mental health providers to forge a new and productive relationship. The seeds of the School-Based Behavioral Health Community of Practice (SBBH CoP) are planted. 2005. The Bureau of Special Edu-cation funds the first wave of 10 “Performance Grants” to schools. Grants require a partnership be-tween local schools and commu-nity mental health agencies to

health services to students in their schools.

2006. Pennsylvania convenes the first conference sponsored by PATTAN and the former CASSP Training and Technical Assistance Institute. The SBBH Community of

Practice sees the goal as meeting the students’ emotional wellness and mental health needs in their own school. The foundation for success is the partnership be-tween schools and community providers, and the “Gold Stan-dard” approach to prevention and intervention is SWPBIS.

Today there are hundreds of schools working in partnership with community providers to ad-dress the mental health barriers to student success. More than a quarter of a million students are now educated in schools imple-menting SWPBIS. Together we have a long way to go, but as they say, the rest is history. Connell O'Brien, M Ed, is policy specialist for the Rehabilitation and Community Providers Associ-ation (RCPA).

PATTAN, OMHSAS and mental health provider partners in SBBH, 2005. Who can identify them all?

As noted in the December 2014 issue of the PAPBS newsletter, 173 school buildings achieved full implementation of School-Wide Positive Be-havioral Interventions and Supports (SWPBIS) by Spring 2014. A common universal outcome tracked within the SWPBIS com-munity is trends in dis-ruptive behavior that result in an office disci-pline referral (ODR). While fully-implementing SWPBIS sites are accus-tomed to routinely re-viewing monthly ODR data, schools should also consider reviewing ODR Triangle Data, which pro-vides summative, end-of-year information regarding the proportion of students in a building who receive ODRs. Generally, these data offer insight into the efficacy of SWPBIS for the entire student population.

ODR Triangle Data are the percentage of the school’s student body that receives 0-1 ODR, 2-5 ODRs, and 6 or more

ODRs in an academic year. Typi-cally, ODR Triangle Data are not available prior to implementing SWPBIS. This meant that we were not able to conduct pre-post SWP-BIS analyses; however, both co-horts’ data were combined to maximize available data for post-implementation analyses. Results of data analyses revealed that a significantly higher percentage of elementary students received 0-1

ODRs in a school year with the implementation of SWPBIS com-pared to secondary grade rates of ODRs. Similarly, significantly fewer proportions of elementary students received two or more ODRs compared to their second-ary counterparts. A visual repre-sentation of this can be found in Figure 1, although readers are cautioned to note that the figure’s ordinate is set at 70 percent to fa-cilitate an easier interpretation of

the data via a re-scaling of the y-axis.

Longitudinal analyses were conducted with ele-mentary schools that had implemented SWPBIS with integrity for up to six con-secutive years to further analyze trends in ODR tri-angle data across multiple years. There were no sig-nificant mean differences found for any of the annual pairings, leading us to con-clude that stable ODR rates are observed across multi-ple years of SWPBIS immulti-plementa- implementa-tion. These data can be seen visually in Figure 2.

Approximately 90 percent of all elementary students received one or no ODRs in an academic year, while 6 percent and 2-3 per-cent of elementary students re-ceived 2-5 and 6+ ODRs,

respectively, in an academic year. The data suggest that SWPBIS

What ODR Triangle Data Tell Us

by Timothy J. Runge and Douglas A. Longwill Indiana University of Pennsylvania

Figure 1: ODR Triangle Data by Building Level – Combined Cohorts

Figure 2: Longitudinal ODR Triangle Data for Elemen-tary Schools Implementing SWPBIS for 4 Consecutive Years – Combined Cohorts

behavioral needs and leads to similar results across multiple years.

Longitudinal analy-ses were conducted with secondary schools to further investigate ODR Triangle Data trends. The data for these schools included programs that had im-plemented SWPBIS with integrity for up to four consecutive years. No significant mean differences were found for any of the annual pairings, indicating that ODR Triangle Data at the secondary level remained stable across

multiple years of high fidelity SW-PBIS implementation. A visual representation of the data can be found in Figure 3. Again, readers are reminded that the ordinate begins at 70 percent to facilitate an easier visual scan of data.

The relatively high number of students receiving 0-1 ODRs in an academic year shows support for

most students in a building. Fur-ther, the relatively low proportions of students receiving two or more ODRs gives more support to the

effectiveness of SWPBIS. In addi-tion, present results show the sustainability of such outcomes across multiple years. Because these results are maintained across multiple years, it provides support for sustaining implemen-tation of SWPBIS over the long term as opposed to dismissing the novelty of a newly established school-wide program.

analyzing the factors which lead to the effectiveness of SWPBIS. For example, future research in the area may consider analyzing

which reinforcements in-cluded in SWPBIS pro-grams are more effective at reducing problem be-haviors. In addition, fu-ture research may analyze which factors are more intrinsically moti-vating for students to ex-hibit appropriate

behaviors, such as being able to attend entertain-ment events or receive tangible reinforcers. This is important because such information could be used to help educa-tors determine whether different reinforcers are more ef-fective at promoting positive be-haviors. Such information could also be further used to develop new methods of motivating stu-dents to exhibit positive behaviors outside of the currently estab-lished motivators purchased with the tokens.

Figure 3: Longitudinal ODR Triangle Data for Secondary Schools Implementing SWPBIS for 3 Consecutive Years – Combined Cohorts

Youth Suicide Prevention and Project LAUNCH

Grants Fund New Initiatives

Youth Suicide Prevention

The Substance Abuse and Mental Health Services

Administration (SAMHSA) recently awarded the Office of Mental Health and Substance Abuse Services (OMHSAS) $3.68 million focus youth suicide prevention ef-forts in school districts, commu-nity colleges, and universities

throughout the state over the next 5 years. The project team is in the final planning stages before full rollout this summer.

Using an approach that includes our previous efforts in primary care, as well as our new partnerships with schools, col-leges, and behavioral health providers, the project goals

in-clude: a) increasing the number of persons in schools, colleges, and universities, trained to iden-tify and refer youth at risk for sui-cide; b) increasing the number of clinical service providers (includ-ing those work(includ-ing in schools, mental health, and substance abuse) trained to assess, manage, and treat youth at risk for suicide; c) increasing awareness about

youth suicide prevention, specifi-cally including the promotion and utilization of the National Suicide Prevention Lifeline; d) compre-hensively implementing applicable sections of the 2012 National Strategy for Suicide Prevention to reduce rates of suicidal ideation, suicide attempts, and suicide deaths in their communities; and e) promoting state systems-level change to advance suicide pre-vention efforts in our public schools.

We will provide technical as-sistance for developing suicide prevention plans, training for staff, and screening with facili-tated referral for diagnosis and treatment. We will be working with the Student Assistance Teams in schools throughout the state, and with the SAP Liaison agencies. This grant includes funding to assist provider agen-cies to have staff trained in vali-dated screening instruments and in providing evidenced based treatment for students who are identified through the screening process to be in need of mental health or substance abuse serv-ices. In the end, this project will serve our Pennsylvania school dis-tricts to not only meet their new Act 71 requirements, but also make a larger impact in their schools and communities. To learn more about how school districts can get involved in the project, please visit

www.payspi.org/gls/schools.

Matthew Wintersteen, Ph.D., Thomas Jefferson University Philadelphia, PA

Project LAUNCH

The Commonwealth of Penn-sylvania has been given an oppor-tunity to create something that heretofore has not existed: an in-tegrated and comprehensive plan to promote the wellness of young children, from conception to age 8. This opportunity is through a SAMHSA grant to implement Proj-ect LAUNCH: Linking Actions for Unmet Needs in Children’s Health. This five-year collaborative agree-ment enhances the partnerships between OMHSAS Children’s Bu-reau, the Department of Health (DOH), the Office of Child Devel-opment and Early Learning (OCDEL), and our local partner, Allegheny County Department of Human Services.

Project LAUNCH will enable Pennsylvania to create and imple-ment a plan to address physical, cognitive, social, emotional, and behavioral aspects of children’s development in a holistic and coordinated manner. This partner-ship will bring together proven ap-proaches for supporting health and mental health development in an integrated strategy that will be tested in Allegheny County and be a model for other Pennsylvania communities. Families,

pediatri-cians, child care providers, treat-ment professionals and educators will work together across the three demonstration sites in Al-legheny County with the goal of countywide implementation in the last two years of the grant. The experience in Allegheny County will be shared with other counties in the state to encourage

statewide expansion.

As a public health initiative, Project LAUNCH is aimed at improving infrastructures that encourage prevention and promotion activities and reducing health disparities among subpopu-lations. Project LAUNCH focuses on promotion and prevention and includes five core strategies: • family strengthening and parent

skill building;

• enhanced home visitation; • early childhood mental hHealth

consultation;

• screening and assessment; and • integration of physical and

be-havioral health.

Project LAUNCH implementa-tion will build on the naimplementa-tionally recognized Pyramid Model for Supporting Social Emotional Competence in Infants and Young Children from the Center on the Social and Emotional Foundations for Early Learning (CSEFEL) (http://csefel.vanderbilt.edu/). One result of the Project LAUNCH environmental scan, currently un-derway, will be to determine which evidence-based practices (EBPs) will best meet the needs of young children and families and how they can be fully imple-mented with fidelity. The work of the PAPBS Network has been highlighted in the scan for both program-wide and school-wide PBIS in Allegheny County and statewide.

Coaches’ Corner

It’s that time of year again. Be sure to schedule time for your faculty to complete the Self-Assessment and School Safety surveys. Access to these online surveys should be arranged through your local facilitator. After your staff has completed these surveys, it is time to sched-ule the Benchmarks of Quality (BOQ). This assessment enables your school team to reflect on the year’s implementation and set goals for the upcoming school year. At a minimum, the following 2013-2014 school data should be included in the pTrack data sys-tem:

• suspensions; • total ODRs; and

• number of school days stu-dents are in session. If you have colleagues who would like to see elementary, mid-dle or high schools implementing tier 1 with high fidelity, please contact your local facilitator to schedule a site visit at one of the following schools:

SWPBIS Model Sites

Tina Lawson, [email protected] Penn Delco SD- Sun Valley High School

www.pdsd.org/Domain/92 Facilitator: Karen Neifer [email protected]

Jim Thorpe Area SD- Penn Kidder Campus

www.jimthorpesd.org/education/s

chool/school.php?sec-tionid=2036&

Facilitator: Donna Halpin [email protected]

Central Region

Laura Moran, [email protected]

Middle School

http://middle.lasd.us/ Facilitator: Jess Harry [email protected]

State College Area SD

-Lemont/Houserville Elementary School K-5

www.scasd.org/houservillelemont Facilitator: Dawn Moss,

[email protected], or Christin Sanker, [email protected] Western Region

Kathryn Poggi, [email protected] Quaker Valley SD - Quaker Valley Middle School

www.qvsd.org/page.cfm?p=82 Facilitator: Leanna Lawson [email protected] Highlands SD - Fawn Primary www.goldenrams.com/fawn Facilitator: Leanna Lawson [email protected]

Individual Student

Information System

Individual Student Information System (ISIS-SWIS) training took place at the PaTTAN King of Prussia office on March 17, 2015. This training was made possible due to the continued partnership between the University of Connecticut and PaTTAN to pro-vide reciprocal technical assis-tance for statewide SWIS training opportunities. Susannah Everett, Ph.D., University of Connecticut, and Tina Lawson, Ed.D., PaTTAN King of Prussia, provided one-day certification training for current SWIS facilitators. Pennsylvania now has a large number of ISIS-SWIS trainers available to support Tier 3 implementation teams. ISIS-SWIS is a decision system for students receiving more

inten-or mental health services. Minten-ore information is at

www.pbisapps.org.

Positive Behavior

Support International

Conference

Pennsylvania was represented at the 12th International

Conference on Positive Behavior Support, “The Expanding World of PBS,” held March 11-14, 2015 in Boston. Pennsylvania was well-represented on the conference agenda. Lucille Eber and Kelly Perales presented a pre-confer-ence session on Integrating Men-tal Health Within a School-wide System of PBIS. Drs. T. Runge, J. Palmiero, and T. Knoster pre-sented a session entitled “Initiat-ing and Sustain“Initiat-ing

Inter-connected Frameworks of Behav-ior and Mental Health Supports.” Drs. T. Lawson, K. Lane, and W. Oakes presented a session enti-tled “Universal Screening for Be-havior: Pennsylvania’s

Collaboration with Researchers and District Level Implementers.” Additionally, Drs. T. Knoster and J. Palmiero submitted a poster for display during the poster session: “APBS Pennsylvania Network Overview.”

Youth Mental Health

First Aid

Youth Mental Health First Aid USA is an eight-hour public edu-cation program that introduces participants to the unique risk factors and warning signs of men-tal health problems in adoles-cents, builds understanding of the importance of early intervention, and teaches individuals how to

help an adolescent in crisis or ex-periencing a mental health chal-lenge. Youth Mental Health First Aid uses role-playing and simula-tions to demonstrate how to as-sess a mental health crisis; select interventions and provide initial help; and connect young people to professional, peer, social, and self-help care.

The course teaches partici-pants the risk factors and warning signs of a variety of mental health challenges common among adolescents, including anxiety, depression, psychosis, eating dis-orders, AD/HD, disruptive behav-ior disorders, and substance use disorder. Participants do not learn to diagnose, nor how to provide any therapy or counseling; rather, participants learn to support a youth developing signs and symp-toms of a mental illness or in an emotional crisis by applying a core five-step action plan.

The Youth Mental Health First Aid USA curriculum is primarily fo-cused on information participants can use to help adolescents and transition-age youth, ages 12-18. PaTTAN offered this training event to school teams throughout the 2014-2015 school year with the focus of building capacity within LEAs of supporting youth with mental health challenges.

A Changing Landscape

Community Resource Program I have been involved in the changing landscape of behavioral health services for students for over 40 years. After 35 years in the classroom, I am now working with a community-based behav-ioral health agency. When I started in education in the 1960s, students with behavioral health

issues were placed in special education or residential placement and the juvenile justice system was often involved. Principals and guidance counselors were ill-prepared to deal with students outside of the norm and relied on hit and miss personal skills.

The onset of the Child and Adolescent Service System Pro-gram (CASSP) in the 1980s and the creation of Student Assistance Program (SAP) teams in schools created a whole new venue for the identification of students with behavioral health problems and the process for finding help for those individuals. As a SAP Coordinator of an urban school district, I had an opportunity to be on the front lines of assessing and developing what services were available and what services were needed for students with behav-ioral health issues.

This new coordinated effort to address student behavioral health issues acted as a catalyst in the 90s for new research and new ideas on how to best approach be-havioral health issues in our schools. My school implemented a training program for the entire staff on “Resiliency.” From that foundation, we developed a cur-riculum with “Resiliency as a Basis for Pro-Social Development.” This new basis was then coordinated with the “Communities That Care” movement and the Pennsylvania Youth Survey (PAYS). These pro-grams created a whole new level of interaction with the students and a new level of understanding of the problems of providing the necessary behavioral health sup-port for those students. SAP Teams worked with county agen-cies in identifying students in need of therapy; however, the backlog was detrimental to the process. At that time our school

district submitted a grant for a school-based therapist at our mid-dle school. The response to and the success of the school-based therapist was overwhelming. A need had been met and a gap filled.

The continued expansion of SAP and the development of School-Wide Positive Behavioral Interventions and Support (SWPBIS) took student-based services to another new level. SWPBIS created a complete framework and structured action plan for the process. It also added the data component for verifica-tion and measurement of fidelity.

Our agency received our first grant to provide school-based be-havioral health services in 2006. We now have school-based thera-pists in every school building in our county and some in neighbor-ing counties. The three-tier Pyramid Model for behavioral and academic support has provided a framework for the development and implementation of numerous programs at all three levels. When people ask for the elevator speech on SWPBIS, I tell them “someone came up with the concept that a positive climate in a school build-ing and classroom decreases discipline problems and increases academic performance.” Then I say, “that is what good teachers have always known and done.”

SWPBIS and SBBH

Using the Framework and

Creativity to Fill the Gaps

SWPBIS is a three-tiered framework and ongoing process of creating a positive school culture that maximizes the academic and

dents by proactively teaching, modeling, practicing, and reinforcing social and behavioral expectations. Schools, families, and community mental health agencies recognize that 1 in 5 students may display symptoms and behaviors of a mental health challenge but only a small portion of students with a mental health concern will obtain the treatment that can maximize their academic and behavioral success. School-Based Behavioral Health Services (SBBH) have answered the need by bringing a variety of options for mental health treatment within the school setting.

Wesley Spectrum has been implementing mental health in schools for over 10 years. School districts were looking for in-house services for the students most in need, often as a means to deter out-of-district placement. As each year of implementation pro-gressed, we were surprised to find the services impacted not only the students, but also the teachers and principals and the entire school. For example, strategies offered to teachers for targeted students were successful and adopted for the rest of the class-room. We found that a mental intervention can be more success-ful than a suspension for a stu-dent who didn’t want to be at school anyway.

The adoption and expansion of SWPBIS helped to provide a framework and language to target services and interventions based on positive reinforcement and teaching of skills as opposed to traditional discipline. In addition, implementation of universal pro-gramming helped schools to de-crease and better identify those students who needed more. When Tier 3 services were implemented in addition to universal, the result

Tier 2 and then refine and en-hance Tier 3.

When SWPBIS and SBBH are truly embraced and blended, there is room for creativity on both sides. SWPBIS tiers become the guide post for where and how a mental health provider may strategically intervene with serv-ices thus maximizing the time and financial resources for both enti-ties. For example:

• Tier 1 - Staff training on mental health barriers to learning, and participation on the SWPBS Core Team;

• Tier 2/3 - Clinical consultation with school counselors or the Tier 2/3 team, and targeted group counseling options for specific populations;

• Tier 3 - Mental health thera-pists to provide a full array of modalities for students whose behaviors and symptoms inter-fere with learning.

When SBBH embraces the structure and core principles of SWPBIS, creativity is possible in both mental health service deliv-ery and in identifying and provid-ing the most beneficial and cost effective services for students, families, and the community.

Legislative Updates

On March 2, the newly-formed bi-partisan Pennsylvania House of Representatives Mental Health Caucus held its first meeting, the subject of which was School-Based Behavioral Health (SBBH) and School-Wide Positive Behav-ioral Interventions and Support (SWPBIS). The purpose of this

proximately one in four Pennsyl-vanians who have mental health related issues, as well as to re-verse the stigma that tragically persists surrounding mental ill-ness. Presenters from the SBBH Community of Practice included Jim Palmiero, Tina Lawson, Tim Knoster, Betsy Gustafson, Deanna Moehrer, and Connell O’Brien. Caucus members and legislative staff who attended were highly impressed with the array of initia-tives to support students with be-havioral health needs and all students to overcome non-acade-mic barriers to learning.

On a federal level, on February 12, Congressman Don Beyer (D-VA) introduced the Keeping All Students Safe Act, H.R. 927, the legislation champi-oned by Rep. George Miller before his retirement. Congressman Bobby Scott (D-VA), ranking member of the Education and Workforce Committee, is the bill’s primary original co-sponsor. The Keeping All Students Safe Act will require states to limit restraint and seclusion to imminent threats of physical danger; require same-day parental notification; ban dangerous mechanical and chemi-cal restraints and those that im-pede breathing; implement training; and shift schools toward preventative measures. If

enacted, the legislation would also authorize the U.S. Department of Education to award grants to states and through them to locale education agencies (LEAs) to (1) establish, implement, and enforce policies and procedures to meet such standards; (2) improve their capacity to collect and analyze data related to physical restraint and seclusion; and (3) implement school-wide positive behavior supports. H.R. 927 can be found at www.congress.gov/bill/114th-congress/house-bill/927.