Comprehensive Children s Mental Health Services in Schools and Communities

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2 Comprehensive Children s Mental Health Services in Schools and Communities A Public Health Problem-Solving Model Robyn S. Hess Rick Jay Short Cynthia E. Hazel New York London

3 Routledge Taylor & Francis Group 711 Third Avenue New York, NY Routledge Taylor & Francis Group 27 Church Road Hove, East Sussex BN3 2FA 2012 by Taylor & Francis Group, LLC Routledge is an imprint of Taylor & Francis Group, an Informa business Printed in the United States of America on acid-free paper Version Date: International Standard Book Number: (Hardback) (Paperback) For permission to photocopy or use material electronically from this work, please access com ( or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Hess, Robyn. Comprehensive children s mental health services in schools and communities : a public health problem-solving model / Robyn S. Hess, Rick Jay Short & Cynthia E. Hazel. p. cm. Summary: In this text, the authors propose a public health model for comprehensive children s mental health services that encompasses, rather than replaces, the traditional model in school psychology -- Provided by publisher. Includes bibliographical references and index. ISBN (hardback) -- ISBN (paperback) 1. Child mental health services. I. Short, Rick Jay. II. Hazel, Cynthia E. III. Title. RJ499.H dc Visit the Taylor & Francis Web site at and the Routledge Web site at

4 Contents List of Figures...ix List of Tables...xi Series Editors Foreword... xiii SECTION I Reconceptualizing Our Work Chapter 1 Intersection of Public Health, Children s Mental Health, and School Psychology... 3 Chapter 2 The Continuum of Services Within a Public Health Model Chapter 3 Building Capacity Through Collaboration and Coalition Building SECTION II Public Health Problem-Solving Model Chapter 4 Problem Identification Through Applied Epidemiology Chapter 5 Problem Analysis of Risk Factors and Protective Factors Chapter 6 Defining Risk and Protective Factors in Child Environment Interactions Chapter 7 Ecological Plan Implementation Chapter 8 Monitoring and Evaluating Outcomes vii

5 viii Contents SECTION III From Concept to Action Chapter 9 Case Study in Public Health Problem-Solving 113 Chapter 10 Changing Role of School Psychologists Chapter 11 Sustaining Change in the Public Health Problem-Solving Model References Index CD Contents

6 One Intersection of Public Health, Children s Mental Health, and School Psychology Imagine a pediatric health care system where nobody receives treatment until their physical state is so bad that they are incapacitated. No checkups, no diagnosis or treatment of minor symptoms, no visits to the doctor s office. Symptoms that might indicate a more serious condition are ignored, covered up with a bandage, or dismissed as growing pains or laziness or immaturity. When illnesses are finally diagnosed, they have become so severe and disruptive that patients must be removed from their normal environment and placed in hospitals for intensive care but only after diabetes has been diagnosed or a life-threatening asthma attack has occurred. In this system, insurance companies and caregivers are not concerned about routine wellness checks to monitor growth, there are no vaccines, and families are not informed that these things could be related to problems later on. No education about healthy diet and exercise is provided, and there are no walking trails, fun runs, or nutrition programs. Instead, the only approach is to treat those individuals who demonstrate such advanced and chronic levels of disease that their lives, and those of their families, are disrupted. In many ways, this scenario describes our present approach to addressing children s mental health needs. Every day, children come to school unable to focus on academics because of family and peer conflict, environmental stressors, and increasing rates of mental health problems. According to a report from the U.S. Department of Health and Human Services (1999), about 20% of children will experience some sort of 3

7 4 Comprehensive Children's Mental Health Services mental health problem in a given year. Of the children who will receive mental health services, the majority will receive them within the school setting (Burns et al., 1995). As in our example described above, most of these problems will have a significant effect on children s quality of life and educational outcomes but won t be recognized or treated until they become so problematic that they disrupt lives. Children who ultimately exhibit severe educational, behavioral, or emotional difficulties typically receive no formal recognition or help until their problems have forced them into failure. There is a growing recognition that we cannot provide effective support services by waiting until each child, one child at a time, succumbs to the weight of educational and mental health problems and fails. This recognition has led to the consideration of alternative methods of service delivery. In fact, one of the pervasive themes of the 2001 Conference on the Future of School Psychology was the need for comprehensive, integrated services that promote positive outcomes and prevent problems (Cummings et al., 2004; Dawson et al., 2004). We cannot deal with significant problems of childhood and adolescence by waiting for them to become so severe that lives are disrupted and expensive specialized services are required. We must consider ways in which our schools can foster the adaptive functioning and social-emotional growth of all children. We must develop effective systems for recognizing and dealing with early signs of developing problems as they occur in schools and communities before they result in failure and disruption. To do so, we must think about our roles differently and consider how we can create the broadest level of service delivery through our own services and through our collaboration with others (Sheridan & Gutkin, 2000). Systemic approaches such as primary prevention programs and schoolcommunity linkages help to ensure that services are provided to all students. RECONCEPTUALIZING SCHOOL-BASED MENTAL HEALTH SERVICES Accomplishing this goal will probably require a significant reconceptualization of school psychological services as they relate to children s mental health (Sheridan & Gutkin, 2000). In this book, we propose a reconceptualization of services from the deficit-centric, late-intervention orientation associated

8 Public Health, Children s Mental Health, and School Psychology 5 with the traditional clinical model to a more systemic, comprehensive perspective that comprises the public health model. Mainstream school psychology presently reflects a variant of the traditional clinical model, wherein services typically are delivered to individual children who have been identified as having a problem. By definition, the problem resides within the child; treatment focuses on changing the child s characteristics to resolve the problem. Although efficient in directing services toward those who need them, this model is reactive and weakness oriented. It fails to recognize and address environmental and systemic contributors to problem behaviors and generally initiates interventions late in the development of these problems. One approach that holds promise for meeting this difficult goal incorporates a systemic, preventive approach while providing resources to address a broad range of mental health needs. Nastasi (2004) and others have advocated for conceptualizing school mental health from a public health model, specifically, a model in which mental health is considered to be an issue of health and services are directed toward populations rather than individuals. The U.S. Department of Health and Human Services (1999) supports an approach that emphasizes screening of the general population, provides prevention and mental health promotion, increases access to services for all, attends to environmental resources, and evaluates services. A public health model promotes the idea of a continuum of services available to meet the broadest needs, with an emphasis on prevention. DEFINING PUBLIC HEALTH When people think of public health, they often consider policies related to clean air and water, or perhaps they envision a dramatic public service announcement or a local campaign encouraging children to wear bike helmets. These examples are part of the services of public health. There is no agreedupon definition of public health; however, in the document titled The Future of Public Health (Institute of Medicine, 1988), public health is defined as what society does collectively to assure the conditions for people to be healthy (p. 1). Public health can also be viewed as a social movement. For example, Dan E. Beauchamp (1976), a professor and philosopher on public health, wrote that public health should be a way of doing justice, a way of asserting the value and priority of all human life (p. 8).

9 6 Comprehensive Children's Mental Health Services These broad statements capture one of the key ideas of public health. The focus is on the population rather than the person. When the emphasis is placed on meeting the needs of many rather than a few, change must occur in the environment. Further, a public health model focuses on prevention and promotion of positive outcomes. To best understand where there is a need from a public health-based approach, population-based assessments are carried out. These assessments not only help to pinpoint in which areas intervention is most needed, but they also help to identify the determinants of health. According to Miles, Esperitu, Horen, Sebian, & Waetzig (2010), determinants are malleable factors that are part of the social, economic, physical, or geographical environment, can be influenced by policies and programs, and contribute to the good and poor health of a population in order to determine which factors, if modified, would lead to positive outcomes (p. 40). A public health model also refers to a process for addressing health-related needs within a community. As noted above, assessment is key and is considered a core function in this process. The second core function is policy development. In a school setting, this second component might include both policy development and intervention/prevention implementation. For example, if school leaders decide that a healthy lifestyle program is to be included as part of the broader academic curriculum, that reflects policy development. The programming delivered in each setting (e.g., physical education classes, nutrition awareness programs) is considered the intervention. The final core function, assurance, refers to the idea that whatever is put in place, the policy and/or the intervention, is actually carried out. This general process should seem familiar; both problem-solving and public health models include efforts to define an issue or a problem, to create an intervention, and to ensure that it has been implemented with fidelity. Within a public health model, there are also a number of steps within each of these broad core functions or actions that provide further guidance on the process for addressing an issue. These steps are referred to as the Ten Essential Services and define each of these functions in an operationalized manner (Miles et al., 2010). Table 1.1 provides the essential services associated with each core function. From a public health perspective, prevention planning is accomplished through information and empowerment, the training of caregivers and service providers, coordination of

10 Public Health, Children s Mental Health, and School Psychology 7 Table 1.1 Core Functions and Essential Services of Public Health Core Function: Assessment 1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. Core Function: Policy Development 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. Core Function: Assurance 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure a competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems. services, and policy and advocacy actions. However, there are other available frameworks that allow us to focus even more broadly in our systemic change efforts. These other frameworks are similar to a public health model in that they outline levels and strategies for building a coalition, empowering stakeholders, and advocating and impacting public policy. Even though these models have been developed and implemented in different contexts (e.g., schools, community), each of them covers similar concepts. We refer interested readers to the works of Cohen and Swift (1999), Dowrick (1998), and Nastasi (2004). CD Activity 1.1 invites readers to consider their practices and perspectives on children s mental health as related to their own settings. PRACTICE IN ACTION CURRENT APPROACHES TO ADDRESSING CHILDREN S MENTAL HEALTH IN THE SCHOOLS To accompany our new approach, we need to define what we mean by children s mental health. Historically, we have not had a clear vision for what constitutes mental health and instead have defined it as the absence of disorder (Doll & Yoon, 2010). In this work, we have adopted the definition provided in the Surgeon General s Report (U.S. Department of Health and Human Services, 1999) that child mental health is characterized by achievement of expected developmental cognitive,

11 8 Comprehensive Children's Mental Health Services emotional, and social milestones as well as secure attachments, satisfying social relationships, and effective coping skills (p. 123). This definition conforms to the comprehensive precepts of diagnosis, prevention, and treatment underlying the broad field of developmental psychopathology (Cichetti, 2010; Drabick & Kendall, 2010; Ialongo et al., 2006). Within the field of school psychology, we have witnessed a similar shift toward positive approaches rather than simply addressing what is wrong with an individual. As early as the late 1950s, efforts to attend to the positive aspects of human experience within adult populations were beginning. However, it has only been in the past 20 years that concepts such as wellness (Cowen, 1991), primary prevention (Coie et al., 1993), developmental assets (Scales & Leffert, 1999), and positive youth development (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004) have focused on children and adolescents. With the publication of a special issue on positive psychology in American Psychologist (Seligman & Csikszentmihalyi, 2000), the shift toward ideas of prevention, promotion, and optimizing life experiences have grown exponentially. Although there are subtle differences between primary prevention, wellness, and positive psychology (Cowen & Kilmer, 2002), each of these movements delivers a consistent message: It is no longer sufficient to use a medical model to understand children s mental health. A public health model, which emphasizes prevention, promotion of positive outcomes, population-based assessment and interventions, and comprehensive services, may provide a better paradigm for children s mental health services in the schools. The public health model defines issues and clinical problems as being multi-determined and existing along a developmental spectrum. Effective public health interventions rely on careful diagnosis of system problems and focus treatment on important individual, family, school, and community targets. Rather than replacing the traditional clinical model, the public health model broadens the scope and definition of children s mental health services to include a full continuum of service provision. APPLYING A PUBLIC HEALTH MODEL TO THE PRACTICE OF SCHOOL PSYCHOLOGY Although the language used to define these services is different than what is familiar to school psychology practice, it is easy

12 Public Health, Children s Mental Health, and School Psychology 9 to see the areas of overlap. Public health conceptualizations of school-based practice are evident in School Psychology: A Blueprint for Training and Practice III [Blueprint III] (Ysseldyke et al., 2006). As in previous versions, the latest document outlines a set of competency domains that underlie school psychology; it also adds several new domains, including Systems Thinking and Wellness, Mental Health, & Development of Life Competencies, which clearly reflect movement toward population-based conceptualizations of practice. Further, Blueprint III was organized to reflect a continuum of services, ranging from universal delivery (assessment of and intervention with populations to improve functioning or prevent problems) to intensive services (assessment of and intervention with individuals or small groups that exhibit clear problems). Indeed, Ysseldyke and his colleagues (2006) proposed that the dual goals of school psychologists were to (1) improve competencies for all children, and (2) build and maintain the capacities of systems to meet the needs of all children, suggesting that traditional problem-based individual services should be superseded by systemic, population-based conceptualizations of training and practice. In support of this conclusion, the authors stated, If the goals of school psychology are to improve competencies for children and build and maintain systems capacity, then the logical next question is: What is the mechanism by which these goals can be attained? (Ysseldyke et al., 2008, p. 44). Blueprint III depicts a service delivery system characterized by variably intensive interventions depending on the severity of student need. Without a doubt, school psychology is evolving from its clinical roots to a broader, more comprehensive specialty, as shown in Figure 1.1. This blueprint helped to create the foundation for the new revision in the standards for school psychology practice and training. In their revision of practice standards, the National Association of School Psychologists (NASP; 2010) outlined 10 competency domains, which serve as a foundation for how school psychologists should organize and evaluate their practice. The competency domains are organized into three broad dimensions of practice and training: Practices that Permeate All Aspects of Service Delivery; Direct and Indirect Services for Children, Families, and Schools (further divided into Student- Level Services and System-Level Services); and Foundations of School Psychological Service Delivery. Competency domains in the NASP standards are presented in Table 1.2.

13 10 Comprehensive Children's Mental Health Services Functional Competencies Domains of Competence Enhancing the Development of Cognitive and Academic Skills Data-Based Decision Making & Accountablity Training and Practice in School Psychology Enhancing the Development of Wellness, Social Skills, Mental Health, and Life Competencies Systems-Based Service Delivery Contextual Issues and Challenges Delivery System Intensive Outcomes Build Capacity of Systems Foundational Competencies Professional, Legal, Ethical, and Social Responsibility Technological Applications Diversity Awareness and Sensitive Service Delivery Interpersonal and Collaborative Skills Targeted Universal Improved Competencies for All Students Psychological and Educational Principles Application of Science and Scientific Method Continuous Improvement Figure 1.1 Blueprint for training and practice model. (Copyright 2010 by the National Association of School Psychologists, Bethesda, MD. Reprinted with permission of the publisher. NASP has also provided a graphic representation of these components (see Figure 1.2) that illustrates their relationship in practice. In this model, two aspects of service delivery data-based decision-making and consultation and collaboration are key to the delivery of services. There is a continual feedback loop in which the outcomes of services drive additional decision-making and collaborative efforts. Underlying all aspects of these professional services are competencies related to meeting the needs of diverse populations, conducting ongoing research and program evaluation, and functioning in a legal and ethical manner (NASP, 2010). Many of these competencies align with the Essential Services presented as part of the public health model. For example, one of the 10 competency domains outlined by NASP is data-based decision-making, which is similar to two of the Essential Services which describe monitoring health status and diagnosing problems as the first two services (see Table 1.1). In the traditional school psychology model focusing on services to individuals and small groups, data-based decision-making typically refers to individual assessment and diagnosis. In the public health model, however, a school

14 Public Health, Children s Mental Health, and School Psychology 11 psychologist might exhibit competency within the same domain by performing a needs assessment within the school to determine areas of strength and concern, and subsequently help to develop school-wide programming to address identified needs. The target of these efforts would focus on assessment and diagnosis of the school or community population rather than on individual students or small groups of students. Similar parallels can be drawn for consultation, home school linkages, and program evaluation, as well as other dimensions of competence in school psychology. A comparative table (Table 10.1) is provided in Chapter 10. The new practice model, titled the Model for Comprehensive and Integrated School Psychological Services (NASP, 2010), provides a framework for service delivery. One of the goals of this model, also called the NASP Practice Model, is to support more consistent practice between school psychology practitioners across different states, districts, and schools. For schools that adopt this model, the document advocates for a lower recommended ratio of school psychologists per students than previously. The new ratio, 1: , is thought to provide school psychologists the opportunity to become more involved at different levels of service delivery. We believe that this model aligns well with a public health model, and by integrating the two approaches, school psychologists will be able to better meet the needs of students, families, schools, and communities through comprehensive, preventive programming that is developed and implemented in collaboration with others. CONCLUSION Reconceptualizing school psychology services through a public health lens is aligned with the NASP competence domains and training and practice guidelines. It is also in keeping with students needs and what the public wants for our students: comprehensive mental health supports that assist all students in meeting their academic potential. In the subsequent chapters of this book, we present in detail the components of the public health model applied to the practice of psychology in the school, relate those components to comprehensive children s mental health services, and provide practical examples of school psychological services within the model. Finally, we address new roles for school psychologists, focusing on prevention and promotion, that will likely accrue to our identification with the public health model.

15 12 Comprehensive Children's Mental Health Services Table 1.2 NASP Competency Domains (NASP, 2010) Practices That Permeate All Aspects of Service Delivery Data-Based Decision-Making and Accountability School psychologists have knowledge of varied models and methods of assessment and data collection methods for identifying strengths and needs, developing effective services and programs, and measuring progress and outcomes. As part of a systematic and comprehensive process of effective decision-making and problem-solving that permeates all aspects of service delivery, school psychologists demonstrate skills to use psychological and educational assessment, data collection strategies, and technology resources, and apply results to design, implement, and evaluate response to services and programs. Consultation and Collaboration School psychologists have knowledge of varied models and strategies of consultation, collaboration, and communication applicable to individuals, families, groups, and systems, and methods to promote effective implementation of services. As part of a systematic and comprehensive process of effective decision-making and problem-solving that permeates all aspects of service delivery, school psychologists demonstrate skills to consult, collaborate, and communicate effectively with others. Direct and Indirect Services for Children, Families, and Schools Student-Level Services Interventions and Instructional Support to Develop Academic Skills School psychologists have knowledge of biological, cultural, and social influences on academic skills; human learning, cognitive, and developmental processes; and evidencebased curricula and instructional strategies. School psychologists, in collaboration with others, demonstrate skills to use assessment and data collection methods and to implement and evaluate services that support cognitive and academic skills. Interventions and Mental Health Services to Develop Social and Life Skills School psychologists have knowledge of biological, cultural, developmental, and social influences on behavior and mental health, behavioral and emotional impacts on learning and life skills, and evidence-based strategies to promote social emotional functioning and mental health. School psychologists, in collaboration with others, demonstrate skills to use assessment and data-collection methods and to implement and evaluate services that support socialization, learning, and mental health. Systems-Level Services School-Wide Practices to Promote Learning School psychologists have knowledge of school and systems structure, organization, and theory; general and special education; technology resources; and evidence-based school practices that promote learning and mental health. School psychologists, in collaboration with others, demonstrate skills to develop and implement practices and strategies to create and maintain effective and supportive learning environments for children and others.

16 Public Health, Children s Mental Health, and School Psychology 13 Table 1.2 (continued) NASP Competency Domains (NASP, 2010) Preventive and Responsive Services School psychologists have knowledge of principles and research related to resilience and risk factors in learning and mental health, services in schools and communities to support multi-tiered prevention, and evidence-based strategies for effective crisis response. School psychologists, in collaboration with others, demonstrate skills to promote services that enhance learning, mental health, safety, and physical well-being through protective and adaptive factors and to implement effective crisis preparation, response, and recovery. Family-School Collaboration Services School psychologists have knowledge of principles and research related to family systems, strengths, needs, and culture; evidence-based strategies to support family influences on children s learning and mental health; and strategies to develop collaboration between families and schools. School psychologists, in collaboration with others, demonstrate skills to design, implement, and evaluate services that respond to culture and context and facilitate family and school partnerships and interactions with community agencies for enhancement of academic and social behavioral outcomes for children. Foundations of School Psychological Service Delivery Diversity in Development and Learning School psychologists have knowledge of individual differences, abilities, disabilities, and other diverse characteristics; principles and research related to diversity factors for children, families, and schools, including factors related to culture, context, and individual and role differences; and evidence-based strategies to enhance services and address potential influences related to diversity. School psychologists demonstrate skills to provide effective professional services that promote effective functioning for indivi duals, families, and schools with diverse characteristics, cultures, and backgrounds and across multiple contexts, with recognition that an understanding and respect for diversity in development and learning and advocacy for social justice are foundations for all aspects of service delivery. Research and Program Evaluation School psychologists have knowledge of research design, statistics, measurement, varied data collection and analysis techniques, and program evaluation sufficient for under standing research and interpreting data in applied settings. School psychologists demonstrate skills to evaluate and apply research as a foundation for service delivery and, in collaboration with others, use various techniques and technology resources for data collection, measurement, and analysis to support effective practices at the individual, group, and/or systems levels. Continued

17 14 Comprehensive Children's Mental Health Services Table 1.2 (continued) NASP Competency Domains (NASP, 2010) Legal, Ethical, and Professional Practice School psychologists have knowledge of the history and foundations of school psychology; multiple service models and methods; ethical, legal, and professional standards; and other factors related to professional identity and effective practice as school psychologists. School psychologists demonstrate skills to provide services consistent with ethical, legal, and professional standards; engage in responsive ethical and professional decision-making; collaborate with other professionals; and apply professional work characteristics needed for effective practice as school psychologists, including respect for human diversity and social justice, commun ication skills, effective interpersonal skills, responsibility, adaptability, initiative, dependability, and technology skills. Source: Copyright 2010 by the National Association of School Psychologists, Bethesda, MD. Reprinted with permission of the publisher. Professional Services by School Psychologists Practices That Permeate All Aspects of Service Delivery Data-Based Decision Making and Accountability Consultation and Collaboration Direct and Indirect Services for Children, Families, and Schools Student-Level Services Systems-Level Services Interventions and Instructional Support to Develop Academic Skills Interventions an Mental Health Services to Develop Social and Life Skills School-Wide Practices to Promote Learning Preventive and Responsive Services Family-School Collaboration Services Diversity in Development and Learning Foundations of School Psychologists Service Delivery Research and Program Evaluation Legal, Ethical, and Professional Practice Figure 1.2 Model of comprehensive and integrated school psychological services. (Copyright 2010 by the National Association of School Psychologists, Bethesda, MD. Reprinted with permission of the publisher.