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School- and Community-Based Mental Health

Overview
School-based Mental Health Services
The State of Children’s Mental Health
Barriers to Care

School-Based Services Overcome Barriers to Care
AIP’s Approach
Standard of Care for School-Based Mental Health
Full-Time School-Based Clinicians
School-Based Care Extends Into Home and Community
Evidence-Based Practice: Home-Based Multisystemic Therapy
Policy Implications
Rosie D. - Massachusetts Children’s Behavioral Health System Reform
Massachusetts Children’s Mental Health Bill
Policy Forums

 

Overview


Increasing access to children’s mental health care is a critical policy issue for AIP and the communities we serve.

Because school is such a powerful socializing influence and key predictor of future success, AIP views schools as an opportune place to promote positive change and healthy development. We introduce mental health services in schools as positive interventions that build on children’s existing strengths. In addition, we deliver selected community-based and home-based treatment as extensions of our school-based work.

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School-Based Mental Health Services


School-based mental health is a promising approach to reform in the children’s mental health care system. AIP has innovated in the area of school-based mental health services since our inception in 1995. We aim to develop new models for how clinical services are organized, funded, and delivered. Three examples:

  • AIP’s therapeutic special education-focused full-service schools model.
  • AIP’s development of therapeutic afterschool programs as core delivery sites for mental health and prevention supports.
  • AIP’s new Connecting With Care program, which combines full-time school-based clinicians with a community Evening Family Clinic.

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The State of Children’s Mental Health

Locally, over the past decade we have witnessed a dramatic reduction in the volume of school-based mental health services provided in Boston Public Schools. Yet, more mental health services are among the very top services that school principals say they need in their buildings. More than 140,000 children and youth in Massachusetts need mental health services, but 71% of them do not receive the services they need. (Source: Health Care for All of Massachusetts)

AIP’s policy efforts seek to address this disconnect. For more information, click here.

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Barriers to Care


What keeps youth and families from receiving the care and support they deserve?

Key barriers include:

  • Shortage of providers (inadequate mental health infrastructure for community/school-based access)
  • Access barriers (insurance, transportation, childcare, hours of service, lack of paid time off)
  • Attitudinal barriers (mental health stigma, cultural attitudes toward mental health)
  • Service delivery system barriers (outpatient clinic locaton, hours, waiting lists, language barriers)

For a detailed explanation of these barriers, click here.

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School-Based Services Overcome Barriers to Care


School-based services address many typical barriers to care that AIP’s urban, low-income, culturally/racially diverse population faces. Schools are promising sites for overcoming many of the barriers to care because:

  • In the school context, mental health services come without the stigma often associated with seeking out mental health treatment. Mental health services become an extension of the learning environment, a service that the school can provide to help the child succeed.
  • Mental health clinicians working in schools can observe children in their natural settings and can consult with teachers, to gain a broad understanding of children’s strengths and weaknesses. This informs high-quality treatment.
  • When clinicians are in schools—in children’s natural setting—they are available when the child needs them, where the child needs them.
  • While outpatient clinics struggle with the impact of high rates of missed appointments, “no-show” rates in the school setting are extremely low. School-sited services directly address most of the key access barriers that often keep children from appointments. Treatment is more consistent and likely to last as long as needed. The U.S. Surgeon General estimates that 20% of American children have a diagnosable mental disorder, and only 20% of that group receives treatment. (1999) When mental health services are sited in schools, children are much more likely to receive the care they need.
  • In school, mental health problems can often be identified early. Prevention work can be done with large groups of children, reducing the need for more intensive (and more expensive) services later.

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AIP’s Approach


AIP’s full-service schools and Connecting With Care program pilot innovations in organizing school-based mental health services and maximizing children’s access to mental health treatment:

AIP’s full-service school programs place clinical mental health professionals in core staffing positions at each school in order to leverage additional mental health resources for the school. Most of these staff positions are in non-traditional mental health settings, such as summer camp, homework help, tutoring, and afterschool programs, so that clinicians can observe children’s strengths and work with children at the very moments that children are facing stresses and challenges. The milieu environment gives the clinicians stronger tools to do their work. It gives the children many more hours of support from mental health professionals than they would receive from a typical weekly clinic or outpatient office visit.

AIP’s Connecting With Care Program demonstrates that a modest subsidy, combined with strong coordination and supervision, makes it possible for private agencies to place salaried practitioners full-time in schools. This directly addresses the problems with the existing fee-for-service model, where the clinician is not available on demand and the clinician is unable to collaborate with teachers or other important adults in the child’s life.

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Standard of Care for School-Based Mental Health


AIP’s school-based programs aim to elevate the standard of care for school-based mental health and to establish specific quality standards. We model a systematic method of organizing service delivery, working with evidence-based practice protocols when possible.

Clinicians who are based full-time in the school, whose funding allows for time to collaborate with teachers and families and to observe children, are key elements of quality care. Linguistic and cultural competency are two other core standards for practitioners serving minority communities or schools with minority or immigrant populations. For children dealing with trauma, an additional set of standards and supports are necessary. AIP’s Connecting With Care program organizes its work with children exhibiting trauma symptoms through Trauma Systems Therapy, a treatment approach that coordinates a multidisciplinary response to a child’s traumatic stress through a series of predictable, empirically validated steps.

AIP has been a longstanding participant in the Boston area School-Based Mental Health Collaborative. In 2002 the Collaborative developed its first School-Based Standards of Care document, codifying standards and expectations for quality school-based services. These standards offer providers and school districts a good starting point for developing a quality school-based practice.

For Additional information on our Standards of Care, click here.

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Full-Time School-Based Clinicians


AIP advocates for the placement in schools of full-time, salaried clinicians from outside agencies that specialize in children’s mental health. Such partnerships bring into the schools the infrastructure, supervision, and expertise of mental health clinics, while allowing the schools to retain their focus on their core educational mission. Full-time clinical positions inside school buildings allow therapists to become integrated into the school environment, joining with the corps of adults in the building who are working together to help children succeed.

Our position is a challenge to the current cost-saving trend in school-based services for private mental health agencies to place fee-for-service clinicians in schools for a limited number of hours each week. We advocate for full-time, salaried clinicians because the incentives implicit in the fee-for-service system run counter to the needs of children and schools. With full-time clinicians whose time can be divided between treatment, collateral work, consultation, crisis intervention, and prevention, clinical services can be deployed strategically to the place where they will have the most impact.

Placing clinicians full time in schools, rather than for just a few hours a week as is typical nationally, is a critical element of quality care. These full-time positions can be funded in a variety of ways. AIP’s program models demonstrate innovative approaches to bridging the education, mental health, health care, child welfare, and criminal justice funding “silos” so that mental health practitioners from accredited mental health agencies can work full-time inside schools.

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School-Based Care Extends Into Home and Community


AIP blends its school-based care with community-based and home-based service elements because we are committed to bringing our services to the places where children naturally spend their time. Families are a key ingredient of quality care and family involvement is vital for children’s school success, so we go to where the families are.

  1. Home-based family support teams participate in AIP’s Connecting With Care program as part of our Trauma Systems Therapy team. They provide in-home family treatment to children identified at school as needing this service.
  2. Community-based therapy is provided to families of Connecting With Care children through our Evening Family Clinic, an outpatient clinic we operate at the centrally located Lilla G. Frederick Pilot Middle School. The Evening Clinic offers a place for the therapist and parents/guardians to collaborate at a time that is accessible to families. The fact that services are located in a school building reduces the stigma often associated with mental illness. The mental health services become folded into the family’s overall involvement with their child’s school.
  3. Home and family collaboration are central to AIP’s Therapeutic Afterschool Programs and Inclusion Day Program. When children enroll in our full-service school programs, we meet with parents and ask them to make a formal commitment to involvement in their child’s program. We stay in touch, building the collaborative relationship, through phone calls and by consulting with parents when they pick up their children at the close of the afterschool program. When appropriate, our school staff makes home visits to meet with parents/guardians in their own setting, at a time and place most convenient to them.

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Evidence-Based Practice: Home-Based Multisystemic Therapy


In 2006 AIP launched its Multisystemic Therapy program. MST is a federally recognized evidence-based practice. This is our first children’s mental health program that is entirely home-based.

AIP’s MST program grew out of the need of the school district and, later, of the state Department of Children and Families, to provide more intensive services to youth who are at risk for needing out-of-home placements due to serious behavior issues. The expectation is that with intensive services, the number of youth who require out-of-home placements will decrease.

MST is widely regarded as a major advance in the treatment of youth with serious behavioral disorders. It has more than 20 years’ experience and $10 million of research that demonstrate its highly effective long-term outcomes.

AIP’s launch of MST was particularly significant because AIP was the first licensed provider of MST services in the state of Massachusetts. This made a highly effective service for seriously misbehaving children available in Massachusetts for the first time.

The school district’s foresight in contracting with AIP to provide MST opened up new options for children’s services in Massachusetts, with repercussions that are gradually being felt in more and more communities in the state:

  • AIP’s initial contract to provide MST services to Boston Public Schools students made an entirely new service for troubled children available in Massachusetts for the very first time.
  • Once MST services were in place through Boston’s schools, the Massachusetts Department of Children and Families asked us to provide the same services to children and youth across the Boston Region who are involved in the state’s child protection system. In addition to the City of Boston, this extended MST services to Chelsea, Revere, Everett, and Winthrop, Massachusetts, doubling the size of our MST team and doubling the number of children and youth served.
  • The Massachusetts Department of Children and Families’ decision to contract for MST services led at least one other Massachusetts provider to create an MST team. This further increased the volume of MST services available to youth and families in Massachusetts.

As a result of this sequence of events, a gap in services is slowly being filled in the Commonwealth of Massachusetts, with more children receiving services every year.

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Policy Implications


AIP aims to demonstrate through our programs better ways to address problems for youth at high risk. We are active in multiple forums that promote state policies that reflect the value we place on school-based and home-based mental health services. We advocate for the following principles:

  1. School-based services are valuable
  2. Children benefit when clinicians are placed full-time in schools
  3. Children and families benefit from evidence-based practices
  4. Programs are needed that can bridge student supports at school and at home

These principles are especially important right now, when significant policy change is underway in Massachusetts.

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Rosie D. - Massachusetts Children’s Behavioral Health System Reform


Rosie D. is the 2006 federal court order for sweeping reform in the Massachusetts Children’s Mental Health System. Through the Rosie D. reforms, which will be implemented beginning in June 2009, Massachusetts children in the Medicaid system who have serious emotional disturbances will be provided with extensive in-home and in-community services.

In the years of planning for the Rosie D. Massachusetts Children’s Mental Health System reforms, AIP has been active in key policy circles and forums to make sure that the views and knowledge of school-based providers of services to children with serious emotional disturbances are incorporated into the new system.

Rosie D. will improve community supports for children with serious emotional disturbances. AIP’s programs serving this population demonstrate the positive outcomes from community-based services for children with these challenges. Our programs also demonstrate the sustainability potential of these programs through a well-structured public/private partnership. We will continue to give our input into the implementation plan for Rosie D. so that school-based coordination becomes part of the service plans of children living in the home and community who have serious emotional disturbances. Our experience with school-based service coordination and with the costs of such care will inform state policymakers as Massachusetts implements Rosie D.

For more information about Rosie D. and the Mass. Executive Office of Health and Human Services’ plan for court-ordered Children’s Mental Health System Reform in Massachusetts:
RosieD.org
EOHHS Children's Behavioral Health Initiative

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Massachusetts Children’s Mental Health Bill


An estimated 100,000 Massachusetts children do not receive the mental health care they need. Many children with serious mental health issues either don’t receive enough care or else are “stuck” in overly restrictive mental health settings because the Commonwealth lacks sufficient community-based services. (Source: Health Care for All of Massachusetts)

AIP joined the Health Care for All of Massachusetts’s Children’s Mental Health Working Group to collaborate on advocacy for State Bill 2804, “An Act Relative to Children’s Mental Health,” which addresses these problems.

In September 2008 the Governor of Massachuseetts, Deval Patrick, signed the bill into law.

Key components of this legislation:

  • It provides early routine screenings to identify children in need of mental health care.
  • It prevents unnecessarily long stays in hospitals and mental health treatment centers by mandating community-based services.
  • It improves coordination of services and collaboration among providers.
  • It gives schools the mental health resources that children in school need.
  • It increases insurance coverage for children’s mental health needs.

The school-based element of this bill gives school staff access to a mental health professional for consultation and advice when a student is experiencing behavioral health problems or risks. This consultation will help school staff to better understand students’ mental health needs and will improve early identification, access to information, support, treatment, and resources.

For more information:
Health Care for All – Children’s Mental Health Campaign

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Policy Forums

Boston School-Based Mental Health Collaborative – This voluntary collaborative of all the major school-based mental health providers working in the Boston Public Schools is chaired by Metro Boston Dept. of Mental Health. We meet monthly to exchange ideas and information, develop policy recommendations, and communicate needs and opportunities to the school district, Boston Public Health Commission, Medicaid, Mass. Dept. of Mental Health, Mass. Executive Office of Health and Human Services, and other policy entities. With the Collaborative, we have convened meetings with key leaders designing the Rosie D. reforms and have drafted policy recommendations for incorporating school-based services into Rosie D.’s implementation.

Health Care for All of Massachusetts – Children’s Mental Health Campaign – This is a statewide coalition of providers and other stakeholders joining to advocate for State Bill 2804, “An Act Relative to Children’s Mental Health", now passed into law, and to oversee it's implementation.

Boston Full-Service Schools Roundtable – This coalition of providers, school district, Mass. state human services leaders, and other stakeholders leads the local policy and advocacy agenda to promote full-service schools in Boston and in Massachusetts. School-based mental health has been one of the Roundtable’s key high-interest areas, as more schools and providers seek to develop methods for integrating mental health into full-service schools. As a founder and steering committee member, AIP has been a leader in educating this broad constituency about mental health and system design. The group has studied the implications of Rosie D. for full-service schools and has advocated for a school-based component of the upcoming Massachusetts children’s mental health system reform.

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