School Behavioral Health: Interconnecting Comprehensive School Mental Health and Positive Behavior Support [1st ed. 2020] 3030561119, 9783030561116

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Mark D. Weist Kathleen B. Franke Robert N. Stevens  Editors

School Behavioral Health

Interconnecting Comprehensive School Mental Health and Positive Behavior Support

School Behavioral Health

Mark D. Weist  •  Kathleen B. Franke Robert N. Stevens Editors

School Behavioral Health Interconnecting Comprehensive School Mental Health and Positive Behavior Support

Editors Mark D. Weist Department of Psychology University of South Carolina Columbia, SC, USA

Kathleen B. Franke The Unumb Center for Neurodevelopment University of South Carolina Columbia, SC, USA

Robert N. Stevens Medical University of South Carolina Goose Creek, SC, USA

ISBN 978-3-030-56111-6    ISBN 978-3-030-56112-3 (eBook) https://doi.org/10.1007/978-3-030-56112-3 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

My work in the disability field began over three decades ago with an early career position as a paraprofessional. I subsequently have held positions as a special education teacher, mental health provider, consultant, and researcher. My commitment to the particular population of children and adolescents with emotional and behavioral problems began early on, as I was challenged by intervention limits, the excessive use of punitive procedures, and the lack of advocacy for this group of students. Much has changed over the past 30 years. Highly punitive procedures that were conventional as recently as a decade ago have become far less standard, in favor of approaches that endeavor to understand the causes of problem behavior as well as the role of childhood experiences, such as trauma. Many schools have adopted universal screening procedures, with efforts to discover all students who might need behavioral and mental health support. Tiered systems of support in schools are on the rise, promising efficient and effective intervention matched to student needs. Preventive and instructional programs are being introduced to children at a young age, with follow-through efforts as children age. Finally, the education field has recognized and embraced the importance of research- and evidence-based programs and practices. Still, outcome data do not bode well for our efforts. Little change is evident across many indicators of progress. Students with emotional and behavioral problems continue to surpass all other disability groups across measures of disciplinary referrals, suspensions, grade retention, and school dropout. Suicide rates among adolescents have seen a recent acceleration, according to data from the Centers for Disease Control and Prevention. And, poor outcomes endure into adulthood, with unemployment and underemployment, limited enrollment in postsecondary education, and high rates of involvement with the criminal justice system. The presumably favorable shift in the nature of positive intervention approaches, the earlier onset of preventive efforts, and the adoption of more rigorously researched intervention strategies and programs does not seem to align with the persistently poor outcome data for students with social and emotional needs. So, how do we explain the incongruent data? I believe one explanation is that we have overwhelmingly focused on prevention. We have seen a recent surge in implementation of v

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interventions targeted at the universal (tier 1) level. Intervention at this level brings about much contentment, as large decreases in problem behaviors (e.g., disciplinary referrals) ensue. While these efforts should be applauded, they often occur at the expense of the population of students with more intensive needs. This lack of attention to problems of greater concern and severity is exacerbated by the persistent aversion and stigma toward behaviors (internalizing and externalizing) that leach the boundaries of conventional school behavior. So, how do we move forward? Indeed, we must continue (and perhaps expand) early prevention and intervention efforts. There is ample evidence from rigorous research studies that tiered and preventive systems of support work. For instance, school-wide efforts, such as Positive Behavioral Interventions and Supports (PBIS), have a substantial impact. These efforts need to be further expanded to all school settings. Most importantly, in spite of PBIS, teachers continue to struggle with students who exhibit emotional and behavioral problems in their classrooms, the setting where students spend most of their school day. This is just one area where attention should be directed. There is an abundance of evidence that pre-service training and in-service support and induction programs are deficient for preparing teachers to support students with challenging behaviors. This must be improved. At the same time, school- and program-wide data cannot obscure the outcome data for students with the most intensive needs (tier 3). The data must be parceled, which will compel us to direct attention to also improving intervention for students with more intensive needs at tier 3. Moreover, there are no data to suggest that mental health problems can be entirely eliminated for a variety of risks and environmental reasons. This is supported with convincing models of illness and disease that have been approximated in medicine, public health, and other fields. We must consider intervention a routine practice. At the same time, there is compelling evidence that emotional and behavioral problems can be greatly reduced. This brings us back to the topic of school behavioral health. The efforts we have undertaken over the past several decades are undeniably insufficient. As yet, the pieces have not come together to forge a meaningful impact. And, as this book attests, the answer is not simple. What this book offers is a blueprint for moving forward. The authors spell out the collective effort that is needed to accomplish the important goal of providing comprehensive and effective school behavioral health services. To do so, the authors lay out five themes: (a) building partnerships between education, families, mental health, and other youth-serving systems; (b) developing effective school-wide approaches; (c) promoting cultural responsiveness and humility; (d) improving the quality of services and increasing the use of evidence-based practices; and (e) improving implementation support for evidence-based practices. In addition to these five theme areas, three priority populations – students connecting to child welfare and juvenile justice systems and from military families – are addressed. The authors take a deep dive, rely on community members with unique expertise, and explore issues in a way that has not been previously seen. Three unique features of the book render it of great value to our field. First, the five themes and three priority populations are jointly addressed. For many years, we

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have seen efforts to tackle a single theme. For instance, researchers and practitioners have illustrated ways to build partnerships between education, families, mental health, and other youth-serving systems. More recently, attention has been paid to school-wide approaches, culturally responsive and humble interventions, and evidence-­based practices. This book brings the themes together within a common framework, with the underlying premise that all themes are essential for successful school behavioral health. Second, diverse stakeholders were convened to contemplate the five themes and three priority populations and consider ways to move our field forward. While we often speak to the need to consider opinions from a variety of stakeholders with an interest in and commitment to children’s behavioral health needs, seldom do we accomplish this feat. Real (logistics, time) and perhaps perceived (territorial) barriers make this a challenge. In this book, the voices of many stakeholders emerge. These include sometimes overlooked groups, including youth and their families involved with juvenile justice, child welfare, and the military. The issues distinctive to these various groups and the related systems that provide services and supports demand unique consideration, as offered in this text. Finally, this book confronts barriers and generates potential solutions in a way that has not been previously accomplished. The perspectives of multiple stakeholders, particularly direct care providers, are evident. The rich and deep analyses that transpired from the focus group format heighten our understanding of real obstacles and propose practical solutions. Each chapter draws in pertinent research and reflects upon current practice as experienced by those in the field. This book will be of great value to a range of individuals, including pre-service personnel, in-service practitioners, program and school administrators, families, researchers, and others. The authors, innovative thinkers, dedicated practitioners, and exceptional researchers assembled an equally talented group of collaborators. The result is thoughtful considerations and recommendations that should serve as a critical launching point for advancing school behavioral health in a way that will yield meaningful outcomes. Lee Kern Lehigh University Bethlehem, PA, USA

Acknowledgments

We would like to convey our sincere thanks to the Patient Centered Outcomes Research Institute (PCORI) for the Eugene Washington Engagement Award (EAIN-2874, 2015–2017) that enabled the eight focus groups on school behavioral health (SBH) reviewed in this book and our program officer, Lia Hotchkiss, and advisor, Marina Broitman, for providing insight and guidance throughout the project. We would also like to thank the National Center for School Mental Health (SMH; see www.schoolmentalhealth.org) and the Center on Positive Behavioral Interventions and Supports (PBIS; see www.pbis.org), and leaders of a national workgroup on interconnecting SMH and PBIS: Lucille Eber, Susan Barrett, Kelly Perales, Robert Putnam, and Joni Splett. We are grateful for the systems integration and the leadership of state leaders in South Carolina, particularly state Department of Education (https://ed.sc.gov) and Department of Mental Health (https://scdmh. net). We also extend our gratitude to the more than 100 diverse stakeholders (teachers, clinicians, families, advocates, healthcare professionals, systems leaders, researchers) who participated in the forums and shared their ideas for expanding and strengthening SBH programs. Finally, we express appreciation to chapter authors, Darien Collins and June Greenlaw, who also provided significant assistance in organizing this book.

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 Advancing Effective School Behavioral Health��������������������������������������������    1 Mark D. Weist, Kathleen B. Franke, and Robert N. Stevens  Collaboration: An Essential Ingredient for Effective School Behavioral Health��������������������������������������������������������������������������������������������    9 Kathleen B. Franke, John Terry, Tristan Collier, and June Greenlaw  Improving School-wide Approaches in School Behavioral Health��������������   21 Tristan Collier and Victoria Rizzardi  Cultural Humility and School Behavioral Health����������������������������������������   35 Victoria Rizzardi, Sommer C. Blair, Barbara Kumari, and June Greenlaw  Improving School Behavioral Health Quality ����������������������������������������������   47 Sommer C. Blair, Darien Collins, and Kathleen B. Franke  Enhancing Implementation Support for Effective School Behavioral Health��������������������������������������������������������������������������������������������   59 Samantha N. Hartley and Carissa Orlando  Youth with Connections to the Juvenile Justice System: A Priority Population for School Behavioral Health������������������������������������   75 Linden Atelsek and Alex M. Roberts  Addressing the Unique Needs of Children and Families Within the Child Welfare System ������������������������������������������������������������������   95 Samantha Martinez, Tara Kenworthy, Sommer C. Blair, Lee Fletcher, Yanfeng Xu, and Robert N. Stevens

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Contents

 Serving Those Who Serve: Increasing Understanding of Mental Health Needs in Military Families������������������������������������������������  107 Marissa Miller and John Terry  Furthering the Advancement of School Behavioral Health in Your Community ����������������������������������������������������������������������������  123 Mark D. Weist, Darien Collins, Samantha Martinez, and June Greenlaw Index������������������������������������������������������������������������������������������������������������������  129

Contributors

Linden Atelsek  University of Virginia School of Law, Charlottesville, VA, USA Sommer C. Blair  South Carolina Department of Social Services, Lexington, SC, USA Tristan Collier  Psychology Department, University of South Carolina, Columbia, SC, USA Darien  Collins  Department of Psychology, University of South Carolina, Columbia, SC, USA Lee Fletcher  South Carolina Department of Social Services, Lexington, SC, USA Kathleen B. Franke  The Unumb Center for Neurodevelopment, Columbia, SC, USA Psychology Department, University of South Carolina, Columbia, SC, USA June Greenlaw  Psychology Department, University of South Carolina, Columbia, SC, USA Samantha  N.  Hartley  Psychology Department, University of South Carolina, Columbia, SC, USA Tara  Kenworthy  Psychology Department, University of South Carolina, Columbia, SC, USA Lee Kern  Lehigh University, Bethlehem, PA, USA Barbara  Kumari  Department of Psychology, Arizona State University, Tempe, AZ, USA Samantha  Martinez  Department of Psychology, University of South Carolina, Columbia, SC, USA Marissa Miller  University of South Carolina, Columbia, SC, USA

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Contributors

Carissa  Orlando  Psychology Department, University of South Carolina, Columbia, SC, USA Victoria  Rizzardi  Psychology Department, University of South Carolina, Columbia, SC, USA Alex M. Roberts  Psychology Department, University of North Carolina, Chapel Hill, NC, USA Robert  N.  Stevens  South Carolina Association for Positive Behavior Supports, Johns Island, SC, USA John Terry  Psychology Department, University of South Carolina, Columbia, SC, USA Mark D. Weist  Psychology Department, University of South Carolina, Columbia, SC, USA Yanfeng Xu  University of South Carolina College of Social Work, Columbia, SC, USA

Glossary of Acronyms

AAPCSH American Academy of Pediatrics Committee on School Heath ACF Administration for Children and Families ADHD Attention Deficit Hyperactivity Disorder APA American Psychological Association BH Behavioral Health BHOP Behavioral Heath Optimization Program CONUS Continental US CW Child Welfare DJJ Department of Juvenile Justice DMH Department of Mental Health DoD Department of Defense DSS Department of Social Services DV Domestic Violence EB Emotional/Behavioral EBD Emotional/Behavioral Disorder EBP Evidence-Based Practice ED Emotional Disability EFMP Exceptional Family Member Program FBA Functional Behavior Assessment FERPA Family Educational Rights and Privacy Act FHC Family Health Clinic HHS U.S. Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act IDEA Individuals with Disabilities Education Act IEP Individualized Education Plan IS Implementation Support ISF Interconnected Systems Framework JJIY Juvenile Justice-Involved Youth LbC Leading by Convening MCE Modular Common Elements MCY Military-Connected Youth xv

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MFLC MH MI MOS MTF MTSS NLTS OCONUS OSEP PBIS PCM PCORI PCS PTSD RTI SBH SES SBMI SC SES SMH SOP SSBHC US USC Y-AP

Glossary of Acronyms

Military Family Life Counselor Mental Health Motivational Interviewing Military One Source Military Treatment Facility Multi-Tiered Systems of Support National Longitudinal Transition Study Outside the Continental US Office of Special Education Programs Positive Behavioral Intervention and Supports Primary Care Managers Patient-Centered Outcomes Research Institute Permanent Change of Station Post-Traumatic Stress Disorder Response to Intervention School Behavioral Health Socioeconomic Status School-Based Motivational Interviewing South Carolina Socioeconomic Status School Mental Health Standard Operating Procedure Southeastern School Behavioral Health Community United States University of South Carolina Youth-Adult Program

Advancing Effective School Behavioral Health Mark D. Weist, Kathleen B. Franke, and Robert N. Stevens

Beginning in 2012, teams from the University of South Carolina (USC), state Departments of Education and Mental Health, and the South Carolina (SC) Association of Positive Behavior Supports began to meet to try to expand and improve, and make school behavioral health programs in the state more coherent and impactful. Early on, it was agreed the term school behavioral health (SBH) would be used to convey clinicians from the mental health system joining schools’ multitiered systems of support (MTSS) toward greater depth and quality in programs/services delivered at Tier 1 – promotion/prevention, Tier 2 – early intervention, and Tier 3 – more intensive intervention. A decision was made to develop a community of practice (see Wenger, & Snyder, 2000) for SBH in SC, reaching out to diverse stakeholders with a vested interest in these programs, beginning to convene regularly, and moving from discussion to dialogue to collaboration and policy change/resource enhancement, toward capacity building of effective programs throughout the state. The community connected stakeholders in education, youth-serving systems (e.g., mental health, child welfare, juvenile justice, disabilities, primary health care, allied healthcare services, family, and youth advocacy) from every county in SC and its first conference was held in Columbia, SC, in 2014. Following this meeting, a website and listserv were established, and a second conference was held in Charleston, SC, in 2015. During this conference, the diverse stakeholders, students with emotional/behavioral (EB) concerns, and families participated in a research forum. Together, the participants M. D. Weist () Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected] K. Franke The Unumb Center for Neurodevelopment, Columbia, SC, USA e-mail: [email protected] R. Stevens South Carolina Association for Positive Behavior Supports, Johns Island, SC, USA © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_1

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identified five critical themes for the advancement of SBH in SC: (1) building partnerships between education, families, mental health, and other youth-serving systems, (2) developing effective school-wide approaches, (3) promoting cultural responsiveness and humility, (4) improving the quality of services and increasing the use of EBPs (evidence-based practices), and (5) improving implementation support for EBPs (Weist & Stevens, 2017). The innovative work of the community was recognized in 2015 by the Patient-­ Centered Outcomes Research Institute (PCORI), who provided a Eugene Washington Engagement Award for the community’s work, specifically to support the third conference held in Myrtle Beach, SC, in the Spring of 2016. In addition, as part of this application, the core team assembled a diverse panel of stakeholders, including researchers, leaders, and staff from education, mental health, family and youth advocacy, juvenile justice, child welfare, and primary care. This group convened as part of a research preconference prior to the 2016 conference and made recommendations on stakeholder engagement in SBH research, and practice and policy improvement, including the recommendation to conduct focus groups on each of the five prioritized themes. In 2016–2017, these five focus groups were conducted in locations around SC. In addition, during this time, based on a recommendation from PCORI leaders, the community expanded to become the Southeastern School Behavioral Health Community (SSBHC) in order to promote regional capacity building (see www.schoolbehavioralhealth.org).  As a regional collaborative, the SSBHC held its first conference in Myrtle Beach, SC, in 2017, and through the PCORI Engagement Award, another preconference meeting was held with the diverse stakeholder panel. During this meeting, preliminary themes from the five focus groups were presented, panel members reacted to them, and they offered ideas for research, practice, and policy enhancement. In addition, participants also recommended that additional forums be held to advance services for three priority populations: youth in the child welfare system, those with connections to the juvenile justice system, and youth from military families. These additional forums were conducted in the remaining 7 months of 2017, again at different locations throughout SC. An application for exempt research on human subjects was approved by the University of South Carolina (USC) Institutional Review Board to conduct the focus groups. Each of the eight focus groups included 11–25 participants, again representing diverse stakeholder groups with vested interest in SBH, including researchers, systems leaders and staff, and youth and families. Participants were anonymous in all focus groups, responding to seven to ten discussion questions. All focus groups were audiotaped, tapes were transcribed, and the NVIVO program (https://www.qsrinternational.com/nvivo-­qualitative-­data-­analysis-­software/home) was used for formal qualitative analysis. This book includes nine additional chapters following this introduction. Chapters 2 through 9 provide background and stakeholder reactions/recommendations for each of the eight focus groups and the particular theme being explored (five dimensions of effective SBH, and three priority populations), and Chap. 10 summarizes themes and presents ideas for advancing this agenda at a community level.

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It should be noted that the conceptual framework for our work in advancing SBH in SC and in the Southeast region of the United States (US) has been the Interconnected Systems Framework (ISF) for School Mental Health (SMH; see Weist, Lever, Bradshaw, & Owens, 2014) and Positive Behavioral Interventions and Supports (PBIS; see Sugai & Horner, 2006). This conceptual framework merges two national movements  – for more comprehensive mental health services in schools as in SMH, and for PBIS. Prior to around 2008, in general, these initiatives were operating separately. With support of national centers for PBIS (see www.pbis. org), and SMH (see www.schoolmentalhealth.org), a meeting was held of leaders from these fields and an e-book on the ISF (Barrett, Eber, & Weist, 2013) was developed and since then has been widely disseminated and viewed/downloaded (> 50,000 times). The ISF provides specific guidance for mental health system integration into schools’ MTSS, including clinician involvement on teams; assuring teams are operating effectively; using data for decision making, implementing, monitoring, and refining evidence-based practices at tiers 1, 2, and 3; and building effective strategies at classroom, school building, school district, and state levels. In 2019, a second edition of the ISF e-book was developed (Eber et al., 2019) and, at the time of this writing, is being widely disseminated and discussed by school and district teams for action planning (see www.midwestpbisnetwork.org). Thus, the current book serves to further illustrate critical themes for effective school behavioral health as in the ISF, and provides rich qualitative information reflecting views from diverse stakeholders on strengthening these programs. All authors have a connection to the University of South Carolina, as faculty, graduate, or undergraduate students or as close collaborators (e.g., from the SC Association of Positive Behavior Supports, from a state agency, a close colleague from another university).

Overview of Book Following this introductory chapter (Chap. 1), in Chap. 2, Kathleen Franke, John Terry, Tristan Collier, and June Greenlaw discuss the importance of collaboration in implementing successful strategies for prevention and interventions related to SBH. Particular attention is paid to the importance of strong partnerships between schools, mental health clinicians, families, students, and youth-serving organizations in multiple dimensions to increase the impact of programs. Prominent themes include decreasing stigma and increasing awareness of mental health challenges for students, growing collaborative teams to build program capacity, engaging families and other stakeholders, and assuring that appropriate services are available to students with special needs. Recommendations are suggested for collaborative approaches to improving coordination of care, empowering students as leaders in services they receive, eliminating blame, engaging families, and building in empathy and understanding when addressing SBH improvements.

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In Chap. 3, Tristan Collier and Victoria Rizzardi discuss the critical importance of school-wide approaches to programming. These programs build from effective multitiered systems of support (MTSS), which are best exemplified by PBIS (Sugai & Horner, 2006, see www.pbis.org). Highlighted themes include the importance of implementing school-wide approaches with fidelity; obtaining buy-in and ongoing guidance from diverse stakeholders, especially students and families; providing ongoing professional development, coaching, and implementation support; and assuring statewide support. The authors provide guidance for school staff, mental health clinicians, families, and other stakeholders to implement collaborative strategies across all three tiers of the MTSS. Chap. 4 reviews issues related to cultural responsiveness and humility. Following review of the fundamental importance of this construct, Victoria Rizzardi, Sommer Blair, Barbara Kumari, and June Greenlaw summarize participants’ responses regarding barriers that may prevent access to SBH for racial, ethnic, and sexual minority students. Barriers may include lack of trust, stigma regarding mental health, stereotypes, and disciplinary actions that remove students from school. The authors also describe the importance of increasing active involvement of important individuals (e.g., parents, school staff, community leaders) in students’ lives in order to enhance and increase the positive impact of culturally responsive SBH programs. In Chap. 5, Sommer Blair, Darien Collins, and Kathleen Franke review dimensions of high-quality SBH. Key themes include purposeful attention to strong collaboration between school service providers, families, students, and other stakeholders; enabling youth to be in leadership roles; actively using data for decision making; and prioritizing SBH as a way to remove/reduce barriers to student learning. In addition, systemic challenges of addressing mental health issues within school systems and ways to overcome them are presented. Other themes include empowering parents and students to collaborate with service providers, expanding funding to strengthen SBH programming, and restructuring aspects of the school day to improve learning for students who may need additional support. Chap. 6 by Samantha Hartley and Carissa Orlando reviews the critical importance of implementation support (IS). Potential barriers and facilitators to successful implementation are addressed with themes such as staff capacity, community partnerships, and interdisciplinary collaboration all critical to effective IS.  The authors underscore that without substantial emphasis on IS, SBH programs are likely to have attenuated impacts. A range of strategies for IS are presented, along with discussion on enhancing IS for particular staff in schools. For example, suggestions are offered for teachers to become skilled change agents in supporting school-wide programs and implementing evidence-based classroom interventions. In Chap. 7, Linden Atelsek and Alex Roberts discuss participants’ perspectives regarding SBH for juvenile justice-involved youth (JJIY). During this forum, themes emerged regarding risk factors for this population, the quality of education received

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prior to juvenile justice interactions, failure of the behavioral health system to address students’ needs, and the need for a continuum of care, including supports for students leaving this system. Short- and long-term effects of youth involvement in the juvenile justice system are discussed such as increased drop-out rates, adult unemployment for ex-juvenile offenders, and recidivism. Recommendations for decreasing rates of JJIY are suggested with education of stakeholders in social-­ emotional learning (SEL) strategies being at the top of the list along with early identification of learning disabilities and co-occurring mental health conditions. The need for enhanced funding of programs for these youth is emphasized, along with the need for all involved to be willing to focus on rehabilitation of JJIY rather than punishment. In Chap. 8, Samantha Martinez, Tara Kenworthy, Sommer Blair, Lee Fletcher, Yanfeng Xu, and Robert Stevens underscore critical needs of students connected to child welfare systems, including students in foster and congregant care such as group homes. Themes emphasize challenges that affect SBH, including poor communication between service providers, underutilization of family and community supports, and prevention of juvenile justice involvement. Participants provided several recommendations and examples of effective programs for this priority population. Recommendations include providing families with opportunities to work with state agencies to create a system of communication to increase collaboration between families, schools, and organizations; as well as developing community and family supports to aid in removing barriers to care. In Chap. 9, Marissa Miller and John Terry review challenges experienced by students in military families, and the growing urgency to increase attention to these needs through tailored SBH programs for military-connected youth (MCY). Emphasized themes include services that currently exist for MCY, gaps in available services, and ongoing needs for these students, particularly the lack of programs for children. Authors describe potential supports for MCY in schools and outline the benefits of having military-connected parents and community members involved in the development of SBH programs tailored for this population. Recommendations for improving current services that are offered include comparing the emotional/ behavioral needs of MCY to non-MCY and developing a theoretical model of the experiences of these students’ unique experiences, and using insight from military family members to inform innovations in practice. Other identified recommendations include enhancing statewide leadership to encourage collaboration and developing holistic programs for MCY and families. In Chap. 10, Mark Weist, Darien Collins, Samantha Martinez, and June Greenlaw distill recommendations from all eight focus groups toward a comprehensive set of recommendations and action agenda for improving and expanding SBH programs going forward. These recommendations include suggestions for action at the individual, school, district, state, and national levels toward a more coherent and impactful agenda for SBH, which is relevant to all stakeholder groups in a community.

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Completing this Book in April 2020 Four years after the research this book was started, we bring it to a close in a very challenging time for the US and the world, as we are contending with the novel COVID-19 virus. At the time of this writing, there are around 1.6 million documented cases and around 97,000 deaths worldwide. Numerous reports are documenting widespread increase in stress, domestic violence, abuse and neglect, anxiety, depression, and other problems. For example, in recent days, Indiana has seen a 25-fold increase in calls to a helpline that addresses citizen mental health and other concerns (https:// www.wane.com/top-­stories/covid-­19-­stress-­affecting-­hoosier-­mental-­health/). Currently in the US, almost all school buildings are closed, and educators and all staff connected to schools, including those involved in SBH, are trying to learn how to support student learning and be generally helpful to them and their families, in the middle of unprecedented challenges. Countless students are experiencing an unexpected change in their access to mental health care and for those receiving tier 3 supports, may no longer be in contact with someone who was very important in helping and supporting them (e.g., school counselor, mental health clinician). Without question, the mental health impacts of this pandemic will continue for years to come, underscoring the importance of well-done SBH, integrating more comprehensive school mental health and PBIS. As leaders in SBH and our Southeastern School Behavioral Health Community (www.schoolbehavioralhealth.org), and along with many groups nationwide, we are scrambling to identify and organize a range of resources that are helpful to students, families, and schools (see https://drive.google. com/drive/u/1/folders/1kU12en8023QbdpcPgwN-­ziLHe_Z3SAKO). In this work, it is clear that planning for effective learning and effective SBH in this new reality will also continue for years to come. For example, as the pandemic requires school districts across the country to begin using home-based academic instruction, there is a need for SBH researchers and clinicians to find ways to deliver evidence-based practices using these new instructional paths, and capitalizing on technological advances. Indeed, one apparent positive in the middle of this crisis is the dramatic increase in telecommuting and telehealth technology, along with breaking down barriers for using these technologies (e.g., HIPAA, FERPA compliance), and broadly increased appreciation for them. A critical challenge being confronted is no or inconsistent access to the Internet for many families, and in other cases challenges are being encountered in increasing family/student comfort for the telehealth experience, and addressing issues like finding private spaces in homes for these sessions. It is highly likely that the distance, online, and telehealth learning strategies being developed now will continue to be a major instructional system at later stages of and after the pandemic, and we need to advance our knowledge on using these technologies to deliver effective SBH in the context of all tiers of schools’ multitiered systems of support.

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Further, an important foundation of SBH is to assure continuity in programming during extended school breaks, including over the summer, and during holiday breaks. What we are learning now to support children and families during this extended physical break from school should build knowledge on year-round programming. In addition, this knowledge should better prepare education, mental health, and other systems leaders for improved responsiveness following inevitable future population-wide challenges such as natural disasters, significant health challenges as in the current pandemic, or acts of terrorism/war (see Weist et al., 2002). A prominent theme in focus groups reviewed in this book was the emphasis by diverse stakeholders on the essential need for meaningful and consistent communication between the student/family, education staff, and SBH staff. Moreover, youth and families expressed the expectation to be equal collaborators in this work and desire training in PBIS, mental health literacy, effective behavioral management, and other areas (see Garbacz, Minch, Jordan, Young, & Weist, in press). The COVID-19 pandemic has shown this to be a glaring weakness, as schools and collaborating mental health centers are struggling to consistently communicate with families, and a large percentage of students are not participating in online learning. We hope that enhanced family-school-mental health collaboration and other core themes emphasized in this book assist communities and schools in strengthening SBH in general, as well as contributing to the refinement and tailoring of efforts to increase effectiveness and impact in the challenging times we find ourselves in.

References Barrett, S., Eber, L., & Weist, M. D. (2013). Advancing education effectiveness: An Interconnected systems framework for Positive Behavioral Interventions and Supports (PBIS) and school mental health (Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, US Department of Education)). Eugene, OR: University of Oregon Press. Eber, L., Barrett, S., Perales, K., Jeffrey-Pearsall, J., Pohlman, K., Putnam, R., et  al. (2019). Advancing education effectiveness: Interconnecting school mental health and school-wide PBIS, volume 2: An implementation guide (Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S.  Department of Education)). Eugene, OR: University of Oregon Press. Garbacz, S.  A., Minch, D., Jordan, P., Young, K., & Weist, M.  D. (in press). Moving towards meaningful and significant family partnerships in education. Adolescent Psychiatry. Sugai, G., & Horner, R. (2006). A promising approach for expanding and sustaining school-wide positive behavior support. School Psychology Review, 35, 249–255. Weist, M.  D., Lever, N., Bradshaw, C., & Owens, J.  S. (2014). Further advancing the field of school mental health. In M. Weist, N. Lever, C. Bradshaw, & J. Owens (Eds.), Handbook of school mental health: Research, training, practice, and policy (2nd ed., pp. 1–16). New York: Springer. Weist, M.  D., Sander, M.  A., Lever, N.  A., Rosner, L.  E., Pruitt, D.  B., Lowie, J.  A., et  al. (2002). School mental health’s response to terrorism and disaster. Journal of School Violence, 1(4), 5–31.

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Weist, M. D., & Stevens, R. (2017). Advancing school behavioral health. Report on Emotional & Behavioral Disorders in Youth, 17, 1–5. Wenger, E. C., & Snyder W. M. (2000). Communities of practice: Organizational Frontier. Harvard Business Review, 78(1), 139–145.

Collaboration: An Essential Ingredient for Effective School Behavioral Health Kathleen B. Franke, John Terry, Tristan Collier, and June Greenlaw

Strong partnerships increase the ability to provide services to youth with mental health challenges. School behavioral health (SBH) allows for broad collaboration on a range of prevention and intervention services across youth-serving systems and cooperation among various helping agencies. The objective is a true “shared agenda” between schools, mental health agencies, families, students, and the community to promote student mental health and school success (Andis et al., 2002; Weist et al., 2012). Actively partnering to collaborate allows a full continuum of services to students in schools among school staff, mental health professionals, families, and community providers (American Academy of Pediatrics Committee on School Health [AAPCSH], 2004; Weist, Lowie, Flaherty, & Pruitt, 2001; Zellman & Waterman, 1998). Collaborative approaches improve coordination of care and empower students and families as leaders in the services they receive (Rones & Hoagwood, 2000; Weist, Garbacz, Lane, & Kincaid, 2017). Collaboration within SBH means more than schools referring students to another agency to receive services and then waiting for resolution of the referral concern. Commonplace language, such as “Referral,” “Co-located,” “Pull-out Programs,” “On-site,” and “Outside Clinician,” connotes a passive and hands-off approach to collaboration. Extensive scholarship indicates that teaming between families, schools, and community partners is beneficial for student outcomes (Splett et al., 2017). For example, in the general education setting, the parent-reported level of involvement in school is associated with increased reading performance and teacher ratings of lower learning problems for students (Zellman & Waterman, 1998). During a series of focus groups with school and community-based behavioral health K. B. Franke (*) The Unumb Center for Neurodevelopment, Columbia, SC, USA e-mail: [email protected] J. Terry · T. Collier · J. Greenlaw Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_2

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professionals from a large and urban school district, students and families repeatedly described collaboration as a critical element of successful SBH programs (Mellin & Weist, 2011). Robust collaboration often fails to be realized across systems despite its documented benefits. Literature in the field of public administration identifies five required antecedents for collaboration: the need for resources and risk sharing, resource scarcity, previous history of efforts to collaborate, a situation in which each partner has resources that other partners need, and complex issues (Thomson & Perry, 2006). For example, in a qualitative study of school bullying, parents indicated that they felt excluded from schools’ responses to bullying, and some parents reported that they did not know if administrators received notification of their concerns (Brown, Aalsma, & Ott, 2013). In this sample, several parents reported failing to receive a callback when reporting bullying to the school, and others reported experiencing resistance from the school (Brown et al., 2013). Importantly, school and community collaboration were most likely to be successful when administrators and other school personnel prioritized SBH services for students and frequent communication with community providers, which prevented both gaps and duplication in services (AAPCSH, 2004; Mellin & Weist, 2011). The Leading by Convening (LbC) framework is a blueprint for authentic stakeholder engagement developed by the IDEA Partnership to address common challenges in collaboration (Cashman et  al., 2014). The “Partnership Way” was developed by the Council of Special Education Administrators and the National Association of School Psychologists to describe best practices in collaboration and the type of partnership needed to impact student outcomes (Cashman et al., 2014). LbC emphasizes the main principles of coalescing around issues, doing the work together, and ensuring relevant participation as well as tools and strategies for increasing collaboration. Coalescing around issues is the practice of organizations coming together around shared concerns (Cashman et al., 2014). Doing the work together describes the interactions between and among the participants with an emphasis on effective teamwork to achieve outcomes across agencies at broad levels (Cashman et al., 2014). Ensuring relevant participation refers to guaranteeing that the correct combination of stakeholders is recognized and participating (Cashman et al., 2014). Here, we review prominent themes relevant to this focus group related to partnerships and collaboration in SBH.  These themes were: 1) Increasing awareness of mental health needs of children and youth, 2) capacity of programs to meet needs, 3) stigma, 4) increasing actions that convey empathy and understanding, and 5) increasing family engagement in care.

Awareness There is an estimated 1 in 5 children and adolescents that experience a mental health disorder with anxiety, depression, and behavioral functioning most prevalent (Bitsko et  al., 2018; Ghandour et  al., 2019). The onset of mental health concerns first

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presents by 14 years of age in approximately half of the children and adolescents with mental health problems (Kessler et  al., 2007). These data demonstrate that mental health problems in children and adolescents are substantial and are widely understood to be problematic. The literature calls for a paradigm shift away from just increasing awareness of mental health concerns faced by children and adolescents toward the implementation of real prevention services. The critical question is – what are schools, collaborating youth-serving agencies, and communities doing with these data to raise awareness of unmet needs and to create a sense of urgency for broadening programs to meet these needs? Awareness in SBH allows for coalescing around issues and then importantly emphasizing real prevention to address mental health concerns (Cashman et al., 2014).

Limited Capacity SBH emphasizes doing the work together and active teamwork to achieve outcomes across broad levels (Cashman et al., 2014). During a series of focus groups examining SBH collaboration, school personnel and community providers indicated significant barriers to effective cooperation (Ouellette, Briscoe, & Tyson, 2004). These participants described insufficient time for consistent communication, unclear roles and responsibilities, difficulty navigating external health care systems, challenges communicating with relevant parties and outside behavioral health providers, and constraints when scheduling meetings as common barriers (Ouellette et al., 2004). In a noteworthy survey, 89% of preschool and elementary school teacher respondents indicated that schools should address students’ behavioral health concerns, and most teachers endorsed teaching students with emotional and behavioral concerns, including disruptive behavior, aggression, and depression. Despite this significant support, only 34% of teachers reported possessing the knowledge and skills necessary to meet students’ behavioral health needs in the classroom. Further, many teachers indicated they have a keen interest in receiving training to better understanding the behavioral health needs of children, as well as strategies for collaborating with families (Reinke, Stormont, Herman, Puri, & Goel, 2011).

Stigma There is a broad consensus that stigma is a significant barrier to student access to mental health services in schools (Bowers, Manion, Papadopoulos, & Gauvreau, 2013; Chandra & Minkovitz, 2007; Huggins et al., 2016). Students will avoid talking to teachers, guidance counselors, peers, and even parents and about mental health concerns out of fear of being stigmatized (Bowers et  al., 2013; Hartman et al., 2013). Parents often feel blamed by others as being the cause of their child’s mental health concern, and this decreases the likelihood of effective collaboration

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between parents and school-based mental health providers (Hinshaw, 2005). To ensure relevant participation, reducing stigma in stakeholders that may feel marginalized is crucial for true collaboration.

Increasing Actions that Convey Understanding and Empathy Seeking to understand and support students and their families in need of services is at the heart of effective collaboration and providing high-quality SBH services. For effective collaboration, school personnel must know the families whom they serve, as well as understand families’ perceptions regarding school and SBH (Knopf & Swick, 2008; Minke & Vickers, 2014). For example, school personnel and behavioral health providers should seek to understand families’ cultural backgrounds, as well as whether families view the school as a partner or as working against their child. They should also try to understand whether families see behavioral health symptoms and treatment as stigmatizing, or whether they openly seek support for behavioral health concerns. A non-judgmental understanding of families’ perceptions may assist schools in effectively building empathic relationships with them, which sets the stage for effective programs and services (Minke & Vickers, 2014). Motivational interviewing (MI) is an increasingly prominent strategy for schools and SBH staff to develop empathic relationships with students and families while at the same time promoting improvement in their functioning (Strait et  al., 2020). Motivational Interviewing-based treatments such as the Family Check-up and Classroom Check-up intend to increase the utilization of evidence-based parenting and classroom management practices (Dishion, Nelson, & Kavanagh, 2003; Reinke, Lewis-Palmer, & Merrell, 2008). The Student Check-up, 2019 addresses student issues that frequently require support (Strait et al., 2017; see https://studentcheckup. org Strait et al., 2012; Terry, Smith, Strait, & McQuillin, 2013). These interventions express support for the emotional/behavioral needs of youth, parents, and teachers in an understanding manner consistent with the Spirit of MI. The developers of MI describe the Spirit of MI featuring core values of evocation, collaboration, autonomy, acceptance, and compassion (Miller & Rollnick, 2012). Evocation refers to eliciting motivation to change from the individual as opposed to educating them about the need to change. Collaboration refers to the counselor allowing and supporting the individual to lead the dialogue and direction of the interaction. Autonomy is the counselor’s acknowledgment and support of the individual’s freedom to choose his or her goals and behaviors. Foundational to MI and these approaches are acceptance and compassion, which will increase the likelihood of ensuring participation and authentic collaboration (Miller & Rollnick, 2012).

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Family Engagement Seeking to understand the perspectives of families and develop genuine rapport will increase the likelihood of collaborative and engaged partnerships and effective SBH services (Weist et al., 2017). Family engagement in SBH includes promoting the involvement of the family as a participant in a student’s behavioral health team, as well as reducing barriers that may prevent families from participating in the student’s team. Common barriers to family engagement include lack of transportation to meetings, lack of childcare for children who may not participate in the collaboration meetings, and difficulties scheduling meetings outside of parental work hours (Ouellette et al., 2004). Emotional barriers to family engagement include schools initiating contact with families only after a behavioral problem or disciplinary action has occurred, rather than regularly communicating about student behavior, with an emphasis on communication regarding positive behavior (Ouellette et al., 2004).

Method Seventeen diverse participants in SBH partook in a 2017 focus group to explore awareness of mental health concerns in the classroom, availability of services, resources and limited capacity, stigma, support for emotional concerns and understanding services in schools, family engagement, and collaboration. The stakeholders consisted of five university staff and faculty members, one professional counselor, three parents, one family advocate, one school liaison officer, and one neuropsychologist. The following questions guided the conversation. 1. In your experience, how have youth and families, schools, mental health, and other youth-serving systems collaborated to advance SBH in South Carolina (SC)? 2. What barriers prevent such collaboration? 3. How can these barriers be overcome? 4. Are there examples of middle and high school students helping to lead SBH efforts? If so, please describe. 5. What has limited student involvement in guiding SBH in SC and how can these factors be changed? 6. Are there examples of family members helping to lead SBH efforts? If so, please describe. 7. What has limited family involvement in guiding SBH in SC and how can these factors be changed? 8. What are the most important strategies for students, families, and youth-serving systems leaders and staff to truly collaborate in advancing SBH in SC? 9. What other recommendations do you have to move this work forward?

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Results In general, participants reported that stigma regarding SBH utilization was a barrier to collaboration for students and families. One participant noted, “There’s still a stigma involved with even getting called to the office for their next appointment; it’s even more difficult to advocate for them…” Similarly, another participant identified, the stigma of just being identified as having a mental health issue in the school environment. Kids are really driven by their peers, and with their peers not having the education to understand that another peer needs support in this area, it could turn out to be ugly instead of something helpful.

These participants also stated that stigma regarding behavioral health extends beyond the school setting, identifying the existence of “stigma in our society in general and we need to address it outside our schools as well.” Several participants expressed concerns regarding limited resources and capacity for SBH that preclude collaboration. One participant noted that, “…they [school-­ based clinicians] also have the care of the entire school so sometimes it would get overwhelming.” Additionally, funding limitations might prevent students without Medicaid from receiving school-based behavioral health supports. One participant stated, “…they need the mental health services for the other students that are not on Medicaid... They need those services as well.” Awareness of available services also emerged as a barrier to collaboration. Several participants identified that students and families might be unaware of beneficial services until symptoms have escalated. One participant indicated, No one tells a parent when they come in the door that this behavior may need mental health services. The first thing they label the behavior as…this child has a behavioral issue. No one goes to say that we have services that we can assist him... That connection never occurs unless the parent is constantly going to the school saying that there is something else going on here and I need additional support. But there has to be a willingness of the school to say that we may see these behaviors, we want to help you help him to ensure that his school life runs much more smoothly as he finishes out with us. No one says that. Parents get this news from another parent or someone else who works in the mental health field or they stumble across just having a conversation with someone to say ‘Oh, you’re having that problem? This is what I did.’ But there’s not an upfront effort to say if your child is having issues that may be behaviorally related, please come see us. We’ll connect you with the right services… Instead of at the back end.

This lack of collaboration and awareness contributes to feelings of isolation and judgment for students and families. As one participant summarized, “It’s just making it aware that you can go get help without feeling there is just something wrong with me or someone is going to judge me.” Participants emphasized the need for support and understanding services in schools. One participant called for “trauma-informed schools and organizations…

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sensitivity and… classrooms too that also address social/emotional health.” Participants also called for increased understanding at an individual level stating, To me, it’s understanding a behavior and the proper interventions for behaviors, instead of okay that kid get them out… when you actually sit down with a student, you actually understand what is behind the behavior. But if you’re constantly saying “Well, you constantly do this,” and not even take a chance to sit down and have a conversation and to see what’s underlining that behavior, you’ll never know. You’ll just keep putting the student out until finally they’re disengaged.

Supportive services extend beyond traditional SBH clinicians. Participants called for the training of all personnel, including resource officers, noting “if a person is going to be in our schools responding to these kinds of issues, we absolutely have to make sure we have the right kind of training for them.” Participants frequently identified both physical and emotional barriers that prevent family collaboration. Several participants noted frequent blaming of caregivers and parents for behavioral health concerns, expressing, “I have been blamed as a parent for my child’s behavior and shamed by school personnel. I think that’s a big barrier to getting parents to come on board and participate.” One participant stated, “…staff are still blaming parents for the inconsistencies or shortcoming or behavior of their children.” Finally, participants noted specific difficulties experienced by twice-exceptional children, meaning those gifted students who also present emotional/behavioral challenges (Dole, 2001). A parent of a twice-exceptional student reported, I think it’s difficult to have your child recognized and served under both. We just sort of pick and choose one. With my son was in all the honors and gifted, and they’ll say he’s gifted, but they said he couldn’t be in this program anymore because he was having these issues. And to me means that’s missing a large part of who he is.

Recommendations Participants provided several recommendations to improve collaboration between schools, families, and the community. Five participants stated that education and training are vital to enhancing collaboration and student outcomes, recommending “education for parents and students and staff… I also think workshops for all parents for early identification and understanding.” In addition to training on behavioral health symptoms, participants also recommended training for supportive, understanding environments, stating, “You’ve got to teach patience and… sensitivity training.” Participants also discussed strategies to improve barriers to engagement, with one participant stating, If you want to engage families, sometimes you need to go where the families are, you need to go look at their schedules and those kinds of things… I think that school environment… raises their own issues of whether they were good in school or didn’t do well at math or got in trouble or whatever. So I think about being creative a lot of times in how do you engage the families as a whole for the school.

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Another participant added, There are real life obstacles for single parents who are working two jobs, folks that don’t have transportation, people who have language barriers, all sorts of things; if we aren’t identifying those real barriers and are just ignoring them and calling them bad parents or they won’t be involved, we won’t get anywhere.

Participants recommended that a single individual identified as the school-based point of contact to facilitate collaboration between relevant individuals is best. One participant noted that “having someone at the school who knew her [child with a behavioral health concern] and knew how to help her [was beneficial]. When she needed to go to the high school, we had someone we knew guiding us through the process.” Additionally, recommendations included “greater funding and infrastructure” for SBH. According to one participant, I think we also may want to look at how difficult it may be for teacher in the classroom to balance all these different needs, all of these different [Individualized Education Plan; IEPs]… and 504s and hearing what they need to be able to manage. I don’t think most of them are out to disregard or hurt anyone, but at the same time they have to try to balance the workload… I’ve always wondered… why in elementary schools there are teacher’s assistant but not in middle and high schools.

Finally, recommendations were made for schools to identify and acknowledge the complexities of students who are twice-exceptional, or gifted but also contending with a disability, and to increase their access to relevant services. In the words of the participant whose child was twice-exceptional, “somehow learning how to manage both [exceptionalities]” is crucial for appropriately serving the student. For example, collaboration must occur between general and special education teachers, school-based behavioral health clinicians, families, and community providers. Participants’ suggestions are consistent with recommendations from the SBH literature. It is essential to provide school personnel with information regarding the importance of family-school collaboration to increase buy-in for it (Symeou, Roussounidou, & Michaelides, 2012). Crucial components of communication are also an important area of emphasis, including practical training including modeling essential skills, using role-plays, providing supportive feedback, addressing parents by their preferred name, active listening, and asking open-ended questions (Shute, 2016). In addition, schools should communicate positive information (e.g., writing an email to a caregiver when a child has behaved well) to families to foster a positive, collaborative relationship (Ouellette et al., 2004; Shute, 2016). Moreover, there is a significant need to train teachers in promoting positive classroom environments, creating and maintaining positive relationships with all students (as learning is mediated through the student-teacher relationship), and identifying students with more intensive needs so connections to appropriate supports can be suggested (Kern, George, & Weist, 2016; Reinke et al., 2011). Collaboration through the creation of teams is commonplace in schools, and teaming is relied upon heavily to implement frameworks such as Positive Behavior Intervention and Support, Response to Intervention, and the Interconnected Systems Framework (Barrett, Eber, & Weist, 2013; Brown-Chidsey & Steege, 2005; Nellis, 2012; Splett et al., 2017). Teaming enhances the capacity to implement innovation,

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however, group dynamics created through teaming can lead to additional challenges (i.e., Forming, Storming, Norming, Performing, Adjourning) that must be managed to ensure effectiveness (Bonebright, 2010). School staff members can feel dissatisfied with team functioning, resulting in the absence of true collaboration and student outcomes not being achieved (Doll et al., 2005; Lee-Tarver, 2006).

Conclusion Authentic and strong collaboration is required to serve students appropriately; however, true collaboration is difficult to achieve. Here, focus group participants and the literature identified important themes related to successful collaboration in SBH. Increased awareness of mental health challenges youth face and coalescing around this issue are the initial steps to enhancing readiness for action. Importantly, awareness campaigns are only beneficial if they create a sense of urgency to make meaningful change through collaboration and agencies doing the work together. The limited capacity of individual organizations to address an issue as significant as child and adolescent mental health is the foundational rationale for collaboration. Enhancing collaboration and ensuring relevant participation within SBH teams should intentionally include individuals from all related areas of students’ lives, including general and special education teachers, mental health providers (schooland community-employed), allied health providers (e.g., nursing, speech, and occupational therapy), family members, and students. Improving engagement with families and students is crucial and highly challenging at the same time. Families’ perceptions of explicit or implicit blame for the mental health challenges faced by a youth causes increased stigma and results in decreased motivation to work collaboratively to address these issues. In the future, training in collaborative approaches and effective strategies for collaboration will lead to effective SBH practices in schools. Utilizing strategies that convey understanding and empathy are vital to reducing stigma and promoting collaboration. LbC and the principles of coalescing around issues, doing the work together, and ensuring relevant participation increase the likelihood of effective collaboration (Cashman et  al., 2014). School-based techniques like MI are helpful strategies; however, more importantly, the foundational Spirit of MI that emphasizes actions that convey acceptance and compassion is what truly improves a sense of understanding and empathy. Importantly, frequent and effective communication between school personnel, families, and community providers positively contributes to positive development for twice-exceptional students (Dole, 2001). School psychologists, special education teachers, and general/gifted educational personnel must work together to develop enrichment plans to promote growth in areas of a particular talent, as well as interventions to support areas of need (Reis, Baum, & Burke, 2014). It will also be helpful for SBH teams to identify supports for the student outside of traditional behavioral health services, including connecting the student with affirmative community programs, such as sports teams (Weist et al., 2012).

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References American Academy of Pediatrics Committee on School Health. (2004). Policy statement: School-­ based mental health services. Pediatrics, 113(6), 1839–1845. Andis, P., Cashman, J., Praschil, R., Oglesby, D., Adelman, H., Taylor, L., et al. (2002). A strategic and shared agenda to advance mental health in schools through family and system partnerships. International Journal of Mental Health Promotion, 4(4), 28–35. Barrett, S., Eber, L., & Weist, M. (2013). Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support. http://www.pbis.org/school/ school-­mental-­health/interconnected-­systems Bitsko, R., Holbrook, J., Ghandour, R., Blumberg, S., Visser, S., Perou, R., et  al. (2018). Epidemiology and impact of healthcare provider diagnosed anxiety and depression among US children. Journal of Developmental and Behavioral Pediatrics, 39(5), 395–403. Bonebright, D. (2010). 40 years of storming: A historical review of Tuckman’s model of small group development. Human Resource Development International, 13(1), 111–120. Bowers, H., Manion, I., Papadopoulos, D., & Gauvreau, E. (2013). Stigma in school-based mental health: Perceptions of young people and service providers. Child and Adolescent Mental Health, 18(3), 165–170. Brown, J. R., Aalsma, M. C., & Ott, M. A. (2013). The experiences of parents who report youth bullying victimization to school officials. Journal of Interpersonal Violence, 28(3), 494–518. Brown-Chidsey, R., & Steege, M. W. (2005). Response to intervention: Principles and strategies for effective practice. New York: Guilford Press. Cashman, J., Linehan, P., Purcell, L., Rosser, M., Schultz, S., & Skalski, S. (2014). Leading by convening: A blueprint for authentic engagement. Alexandria, VA: National Association of State Directors of Special Education. Chandra, A., & Minkovitz, C. S. (2007). Factors that influence mental health stigma among 8th grade adolescents. Journal of Youth and Adolescence, 36(6), 763–774. Dishion, T. J., Nelson, S. E., & Kavanagh, K. (2003). The family check-up with high-risk young adolescents: Preventing early-onset substance use by parent monitoring. Behavior Therapy, 34(4), 553–571. Dole, S. (2001). Reconciling contradictions: Identity formation in individuals with giftedness and learning disabilities. Journal for the Education of the Gifted, 25(2), 103–137. Doll, B., Haack, K., Kosse, S., Osterloh, M., Siemers, E., & Pray, B. (2005). The dilemma of pragmatics: Why schools don’t use quality team consultation practices. Journal of Educational and Psychological Consultation, 16(3), 127–155. Ghandour, R., Sherman, L., Vladutiu, C., Ali, M., Lynch, S., Bitsko, R., et al. (2019). Prevalence and treatment of depression, anxiety, and conduct problems in U.S. children. The Journal of Pediatrics, 206(1), 256–267. Hartman, L. I., Michel, N. M., Winter, A., Young, R. E., Flett, G. L., & Goldberg, J. O. (2013). Self-stigma of mental illness in high school youth. Canadian Journal of School Psychology, 28(1), 28–42. Hinshaw, S. P. (2005). The stigmatization of mental illness in children and parents: Developmental issues, family concerns, and research needs. Journal of Child Psychology and Psychiatry, 46(7), 714–734. Huggins, A., Weist, M. D., McCall, M., Kloos, B., Miller, E., & George, M. W. (2016). Qualitative analysis of key informant interviews about adolescent stigma surrounding use of school mental health services. International Journal of Mental Health Promotion, 18(1), 21–32. Kern, L., George, M., & Weist, M. D. (2016). Step by step support for students with emotional and behavioral problems: Prevention and intervention strategies. Baltimore, MD: Brookes Publishing. Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustün, T. B. (2007). Age of onset of mental disorders: A review of recent literature. Current Opinion in Psychiatry, 20(4), 359–364.

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Knopf, H. T., & Swick, K. J. (2008). Using our understanding of families to strengthen family involvement. Early Childhood Education Journal, 35(1), 419–427. Lee-Tarver, A. (2006). A survey of teachers’ perceptions of the function and purpose of student support team. Education, 126(6), 525–533. Mellin, E. A., & Weist, M. D. (2011). Exploring school mental health collaboration in an urban community: A social capital perspective. School Mental Health, 3(1), 81–92. Miller, W., & Rollnick, S. (2012). Motivational interviewing (3rd ed.). New  York: The Guilford Press. Minke, K. M., & Vickers, H. S. (2014). Get families on board to navigate mental health issues. Phi Delta Kappan, 96(4), 22–28. Nellis, L. M. (2012). Maximizing the effectiveness of building teams in response to intervention implementation. Psychology in the Schools, 49(3), 245–256. Ouellette, P. M., Briscoe, R., & Tyson, C. (2004). Parent-school and community partnerships in children’s mental health: Networking challenges, dilemmas, and solutions. Journal of Child and Family Studies, 13(2), 295–308. Reinke, W. M., Lewis-Palmer, T., & Merrell, K. (2008). The classroom check-up: A class wide teacher consultation model for increasing praise and decreasing disruptive behavior. School Psychology Review, 37(3), 315–332. Reinke, W. M., Stormont, M., Herman, K. C., Puri, R., & Goel, N. (2011). Supporting children’s mental health in schools: Teacher perceptions of needs, roles, and barriers. School Psychology Quarterly, 26(1), 1–13. Reis, S.  M., Baum, S.  M., & Burke, E. (2014). An operational definition of twice-exceptional learners: Implications and applications. The Gifted Child Quarterly, 58(3), 217–230. Rones, M., & Hoagwood, K. (2000). School-based mental health services: A research review. Clinical Child and Family Psychology Review, 3(4), 223–241. Shute, R. H. (2016). Promotion with parents is challenging: The role of teacher communication skills and parent-teacher partnerships in school-based mental health initiatives. In R. H. Shute & P. T. Slee (Eds.), Mental health and wellbeing through schools: The way forward (pp. 64–74). New York: Routledge/Taylor & Francis Group. Splett, J. W., Perales, K., Halliday-Boykins, C. A., Gilchrest, C., Gibson, N., & Weist, M. D. (2017). Best practices for teaming and collaboration in the interconnected systems framework. Journal of Applied School Psychology, 33(4), 347–368. Strait, G., Smith, B., McQuillin, S., Terry, J., Swan, S., & Malone, P. (2012). A randomized trial of motivational interviewing to improve middle school students’ academic performance. Journal of Community Psychology, 40(8), 1032–1039. Strait, G. G., Strait, J. E., Schanding, T., Anderson, J. R., Stinson, D., Schmidt, S., et al. (2020). Ethical considerations for using school-based motivational interviewing with parents, teachers, and students. Journal of Applied School Psychology, 36(1), 62–75. Symeou, L., Roussounidou, E., & Michaelides, M. (2012). “I feel much more confident now to talk with parents:” an evaluation of in-service training on teacher-parent communication. School Community Journal, 22(1), 65–87. Terry, J., Smith, B., Strait, G., & McQuillin, S. (2013). Replication of motivational interviewing to improve middle school students’ academic performance. Journal of Community Psychology, 41(7), 902–909. The Student Check-up. (2019). A school-based and student focused motivational interviewing resource. Retrieved June 25th 2019, from https://studentcheckup.org Thomson, A., & Perry, J. (2006). Collaboration processes: Inside the black box. Public Administration Review, 66, 20–32. Weist, M. D., Garbacz, A., Lane, K. E., & Kincaid, D. (2017). Aligning and integrating family engagement in Positive Behavioral Interventions and Supports (PBIS): Concepts and strategies for families and schools in key contexts (Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S.  Department of Education)). Eugene, OR: University of Oregon Press.

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Weist, M. D., Lowie, J. A., Flaherty, L. T., & Pruitt, D. (2001). Collaboration among the education, mental health, and public health systems to promote youth mental health. Psychiatric Services, 52(10), 1348–1351. Weist, M.  D., Mellin, E.  A., Chambers, K.  L., Lever, N.  A., Haber, D., & Blaber, C. (2012). Challenges to collaboration in school mental health and strategies for overcoming them. Journal of School Health, 82(2), 97–105. Zellman, G. L., & Waterman, J. M. (1998). Understanding the impact of parent school involvement on children’s educational outcomes. The Journal of Educational Research, 91(6), 370–380.

Improving School-wide Approaches in School Behavioral Health Tristan Collier and Victoria Rizzardi

In 1997, the United States Congress approved the Individuals with Disabilities Education Act (IDEA), which in addition to mandating supports for students with disabilities in all public schools, called for more research to prevent childhood emotional and behavioral problems before students reached a level of need that could only be provided by special education services (Sugai & Horner, 2002). Comprehensive, school-wide systems of prevention called multitiered systems of support (MTSS) were developed to provide a continuum of supports covering promotion/prevention at Tier 1, early intervention at Tier 2, and more intensive intervention at Tier 3 (Sugai & Horner, 2002). MTSS provide a range of supports across domains of student social, emotional, behavioral, and academic (SEBA) functioning, with specialized supports for students with higher degrees of need (Shogren, Wehmeyer, Lane, & Quirk, 2017). An earlier form of school-wide academic supports, Response to Intervention (RTI), reflects similar concepts of MTSS but is more focused on student academic performance (Shogren et al., 2017). Perhaps best articulating the concept of MTSS is Positive Behavioral Interventions and Supports (PBIS), which initially reflected effective applied behavioral analysis to assist individual students (Carr et al., 2002), but has since undergone dramatic expansion to reflect all dimensions of effective multitiered assessment, prevention, and intervention in schools (Shogren et al., 2017). PBIS emphasizes effective use of data, and installing systems and practices to implement and refine evidence-based practices across the MTSS (Sugai & Horner, 2006), and is being implemented in over 26,000 schools in the United States (Center on PBIS, U.S. Office of Special Education Programs, 2018). PBIS has been demonstrated to significantly reduce office discipline referrals (Bradshaw, Mitchell, & Leaf, 2010), reduce suspensions (Bradshaw et al., 2010), increase perceptions of safety (Horner et al., 2009), and increase academic test scores (Simonsen et al., 2012) in elementary schools with T. Collier (*) · V. Rizzardi Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_3

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similar effects found in middle schools (Lassen, Steele, & Sailor, 2006). Although research into PBIS in high schools has demonstrated similar reductions in office discipline referrals and suspensions (Bohanon et al., 2006; Morrissey, Bohanon, & Fenning, 2010; Muscott, Mann, & LeBrun, 2008) and improvements in academic test scores (Muscott et al., 2008), effective implementation of PBIS is often difficult because of the complex organizational structure of high schools (Bohanon, Flannery, Malloy, & Fenning, 2009). School-wide approaches to school behavioral health, most notably PBIS, have seen marked success across several studies (Barrett, Bradshaw, & Lewis-Palmer, 2008; Bradshaw et al., 2010; Horner et al., 2009; McIntosh, Bennett, & Price, 2011). Implementing and maintaining PBIS with fidelity, however, poses a significant challenge for schools (Bohanon et al., 2009). Although some schools may implement Tier 1 supports with fidelity, Tier 2 and 3 interventions have been found to be more difficult to implement (Hoyle, Marshall, & Yell, 2011; Scott, Anderson, Mancil, & Alter, 2009). Barriers to the successful implementation of PBIS across all Tiers include those related to implementing evidence-based practices (EBPs; Hoyle et al., 2011), having enough time to conduct effective trainings for staff (Scott et  al., 2009), limited building-level administrative support (Scott et al., 2009), and resistance from staff to change their student behavior management techniques (Scott et al., 2009). Barriers such as these can vary depending on the school’s demographics (e.g., rural, urban, suburban, high, or low SES, etc.), warranting different techniques for successful implementation (Dexter, Hughes, & Farmer, 2008; Putnam, McCart, Griggs, & Choi, 2009). For instance, PBIS implementers in rural school districts have found that conducting communication using email and video chats help to avoid excessive travel times in districts that cover large geographic areas (Steed, Pomerleau, Muscott, & Rohde, 2013). Additionally, barriers such as a lack of interagency and intraschool collaboration, as well as a lack of family engagement, can have negative effects on PBIS implementation (Bradshaw, Koth, Bevans, Ialongo, & Leaf, 2008; Garbacz et al., 2016). Literature on PBIS and effective MTSS is growing rapidly. In our literature review, five themes were particularly prominent: (1) Implementing PBIS with fidelity, (2) assuring program buy-in, (3) providing effective training for staff, (4) increasing family engagement and leadership in programming, and (5) moving to large-scale implementation. These themes are reviewed in more detail in the following, and are also prominently represented in findings from the focus group reviewed later.

Implementing PBIS with Fidelity Implementation fidelity is a measure of how well a program is being executed as intended by the program’s developers and original model (Breitensten et al., 2010). As programs are implemented in ecologically valid settings such as schools, a downside is that buy-in and resources may be less than optimal, contributing to

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challenges in program delivery within the MTSS (Dane & Schneider, 1998). Programs that are implemented with low fidelity are less likely to produce the desired results. Further, the effects that are present may be masked by the inconsistencies, lowering buy-in for the program (Dane & Schneider, 1998). Reduction in students’ office discipline referrals and suspensions is significantly related to the level of fidelity with which PBIS is implemented, meaning schools implementing PBIS with high fidelity will see a larger reduction in office discipline referrals and suspensions than schools implementing with lower levels of fidelity (Flannery, Fenning, McGrath, & McIntosh, 2014; Simonsen et al., 2012). Similarly, one study demonstrated that schools that met PBIS implementation criteria had a higher number of students achieving mastery on state standardized math tests (Simonsen et al., 2012). There are clear benefits of strong implementation fidelity, but achieving the recommended benchmark for successful PBIS implementation requires strong staff buy-in, administrative support, and coaching (see Eber et al., 2019; Sugai & Horner, 2006).

Assuring Buy-in School staff buy-in has been identified as a critical component of successful implementation of PBIS (Kincaid, Childs, Blase, & Wallace, 2007), with a recommendation of 80% of staff buy-in before implementation (DeStefano, Dailey, Berman, & McInerney, 2001). Buy-in can encounter several barriers, including school staff satisfaction with the implementation plan, staff willingness to try new approaches, and staff continued the use of PBIS practices (Hieneman & Dunlap, 2000). Handler et al. (2007) recommend that staff buy-in be formally assessed by regularly evaluating staff use of PBIS practices, with data on this helping to inform implementation processes. Administrator and senior faculty buy-in is a critical component in the implementation of PBIS as it can help to both encourage teacher buy-in and facilitate interventions (Flannery, Sugai, & Anderson, 2009; Hershfeldt, Pell, Sechrest, Pas, & Bradshaw, 2012; Kam, Greenberg, & Walls, 2003). For instance, Hershfeldt et al. (2012) found that senior teacher resistance was also associated with negative attitudes about PBIS. Additionally, principal support for a school-wide practice can impact both the sustainability of the practice (Benz, Lindstrom, Unruh, & Waintrup, 2004) and the effects of the practice on student outcomes (Kam et al., 2003).

Providing Effective Training For school staff to effectively implement PBIS, they must receive both training in PBIS practices as well as ongoing coaching on the use of those practices (Bradshaw, Reinke, Brown, Bevans, & Leaf, 2008). Effective and ongoing staff training in PBIS practices creates consistent behavioral expectations and discipline practices across

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classrooms, which in turn can lead to reductions in office discipline referrals and suspensions (Barrett et al., 2008; Bradshaw et al., 2010). These benefits, however, are contingent on teachers’ familiarity with the supports available; Stormont, Reinke, and Herman (2011) found that, within a sample of general education teachers, 57% were unsure if their school provided functional behavioral assessment and intervention planning. Initial training in PBIS should include a plan for continued professional development around PBIS practices as well as thoughtful planning to maintain buy-in and implementation fidelity.

Family Engagement Familial involvement with the school experience of children and adolescents is associated with a variety of positive outcomes, including improved school attendance, academic achievement, and positive student behavior (for a review, see Garbacz et al., 2016). A major goal of improving family engagement in a MTSS system such as PBIS is to promote improvements in children’s behavior both in school and at home. Unfortunately, the typical implementation of PBIS does not always incorporate a formal system of family engagement (Garbacz et al., 2016). The Center on PBIS developed a comprehensive guide to increase family and youth engagement and leadership in schools in 2017 (Weist, Garbacz, Lane, & Kincaid, 2017). This e-book documented the promise of this work, and that relatively little progress has made. Emanating from the e-book was the creation of the Family-­ School-­Community Alliance (FSCA, see https://fscalliance.org), an international organization seeking to elevate planning in research, practice, and policy forums to significantly increase family and youth leadership in schools.

Large-Scale PBIS Implementation For school-wide PBIS to be sustained, systemic support must extend beyond the school to include support from district and state leadership. Organizing and collaborating between several schools establishes a common vision, improving the efficiency of resource allocation and implementation processes (Eber et  al., 2019; OSEP Technical Assistance Center on PBIS, 2017). Fortunately, the three-tiered approach of PBIS/MTSS maps on to state efforts to implement this programming, for example, statewide efforts (e.g., web-based support, conferences) corresponding to Tier 1, targeted support to districts corresponding to Tier 2, and more intensive work with schools/districts corresponding to Tier 3 (see Barrett et  al., 2008). Statewide PBIS implementation increases the number of schools implementing with fidelity and improves student outcomes (Barrett et al., 2008; Simonsen et al., 2012). Nevertheless, Simonsen et al. (2012) and Barrett et al. (2008) assert that the improved student outcomes are likely due to increased implementation fidelity rather than simply the scaling up of PBIS at the state level.

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Method Fourteen stakeholders gathered to discuss the strengths and weaknesses associated with effective school-wide approaches in South Carolina (SC). This group was comprised of six members from youth and family-serving agencies, three K-12 school staff members, four university staff and faculty members, and one student. Five of the participants were parents of students who were attending or previously attended school in SC.  The discussion was organized using the following ten questions: 1. In your experiences at a school, what factors are most important for building high-quality school behavioral health (SBH) programs? What factors are most important at the District level? 2. What have your experiences been with PBIS? 3. How should PBIS efforts be strengthened? 4. What should we do to improve school-wide approaches that are for all students and focus on promotion and prevention? 5. What strategies can be employed to increase advocacy with the SC Departments of Education, Mental Health, and Health and Human Services for growing PBIS in schools? 6. What are the key resource needs in SC schools to effectively implement SBH? How do these needs vary based on school classification (e.g., rural, urban, suburban, higher vs moderate vs lower SES)? 7. What has limited family involvement in guiding SBH in your school/district and how can these limiting factors be changed? 8. What are the most important strategies for effectively engaging school administrators as leaders of SBH in schools? 9. What other recommendations do you have to advance SBH in SC schools?

Results Implementing PBIS with Fidelity A major concern for participants in this forum was that PBIS is not being practiced by all individuals within a school. As mentioned, PBIS is intended to be in place within an entire school (e.g., all classrooms, hallways, the cafeteria, library, etc.) and practiced by at least 80% of school staff (OSEP Technical Assistance Center on PBIS, 2017). Concern over too few teachers practicing PBIS was mentioned twice during the research forum, suggesting that PBIS is not being implemented with fidelity.

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A similar concern regarding fidelity was also mentioned twice during the research forum. This concern surrounded the lack of understanding of PBIS, resulting in poor implementation of PBIS practices. One participant, a PBIS coach, mentioned that it took several years of working as a coach before she truly understood PBIS: “A lot of teachers say they are using PBIS but then turning around and doing some sort of negative response as well, and it’s confusing for children.”

Assuring Buy-in Participants brought up the issue of buy-in to PBIS as an important aspect of successful implementation. Specifically, the participants discussed the need for top-­ down buy-in within a school: “I also feel like the administrators are still a missing piece, like we don’t have buy-in from the administrators... It doesn’t feel like the administrators are involved in the treatment as well.” Another participant felt that part of the problem of low buy-in is how PBIS is presented to school staff: “When I’m listening to folks, there’s a disconnect, they really haven’t been sold. I think selling it in a way that teachers, school administrators, school board members, can consume it is something I think can go a long way.” Participants continued to discuss ways to bridge the gap in understanding and to garner stronger buy-in from administrators, district administration, and school boards: I think speaking their language in two ways. One is aligning the effects of PBIS with the outcomes they care about. like … ways that PBIS will improve educational outcomes. Also from a dollar perspective, the extent to which investing in PBIS will decrease the cost of other things like alternative education – things that cost a lot of money.

Lastly, participants also noted the need for buy-in at the state level, stating “The only way to really assure that it is a statewide activity and not district wide activity... is for the state Department of Education to promote PBIS to the point of providing staff to support it.”

Providing Effective Training Participants discussed the need for effective training and professional development for effective implementation of school-wide systems, such as PBIS. One participant elaborated on how to best implement and maintain teacher and school staff training:

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I think one thing that needs to be happening is [after] training teachers, providing materials that they need, especially something that’s like a school-wide, like SOPs [standard operating procedures], or things like that, that’s actually going around in the schools so that everyone’s on board doing it, and then having monthly meetings.

Additionally, one participant noted the need for training to be at all levels: Professional development, it has to be at all levels it cannot just be to the teachers or to the specialized groups like school psychologists and guidance counselors. It needs to be principals; it has to start from the top. It has to be the superintendent. It has to be at every level. Every department has to understand the philosophy and the importance of the initiatives that we are working on and trying to get students’ support for whatever mental health issues they have.

Family Engagement Throughout the forum, Participants discussed their experiences with family/school interactions, as well as the need for effective family engagement. Several participants mentioned their feeling excluded and ignored during meetings with school staff, with one student participant noting, “There have been instances where people have listened in on my [Individualized Education Plan; IEP] meetings and also have totally discarded what my parents’ thought.” Another participant noted the difficult position parents are often put in when meeting with school personnel to discuss their child’s behavioral health challenges: “There’s a lot of blame game going on, and for students with disabilities, those disabilities are just kind of ignored as not [being] a contributing factor, and so they also attribute characteristics to parents that their children are exhibiting.” The forum participants also discussed how to improve family and school interactions through youth empowerment: We really need to empower the students as well and develop opportunities for ways students can have a voice... we really need to develop a way for students to have opportunities to, in a safe environment, be able to say what they need.

The participants also talked about positive experiences they have had working with school staff: Great things have come out of those meetings though... At the end of that meeting, the administrator did take two DVDs I had on bipolar disorder. He held a training for his faculty on Bipolar Disorder and showed the DVDs…Sometimes out of a little bit of conflict then comes great growth.

Large-Scale PBIS Implementation The need for universal implementation of PBIS was explicitly mentioned three times throughout this research forum and several other times in relation to implementation fidelity. Participants expressed their concern that a lack of statewide

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implementation prevents students from receiving the necessary resources due to attending a non-PBIS school, noting: There are a lot of kids that I know that are currently in the school that I was at that have problems, but there’s no way for them to get any kind of help… so I think one of the first things is we have to make sure it’s integrated across the board in every school, in the entire state, at all three tiers.

Moving Forward Our view is the most prominent theme from this focus group focused on assuring buy-in. When implementing PBIS, it is critical to garner support from administrators to ensure the values and practices of PBIS are supported from the top-down within a school. Administrators may be resistant to some of the school-wide changes needed for the effective implementation of PBIS.  To help guide administrators toward PBIS practices, Hershfeldt et al. (2012) recommend that PBIS implementers spend time learning the overarching school structure (e.g., administrative priorities, common practices, explicit and implicit goals, etc.) including reviewing the district or school’s School Improvement Plan. Understanding a school’s culture and goals can help implementers “sell” the PBIS system to administrators to meet those goals (e.g., improving behavior can improve academic outcomes; Hershfeldt et al., 2012). This strategy aligns with qualitative findings from McIntosh, Kelm, and Canizal Delabra (2016), which indicates that principals are more likely to buy-in to PBIS when they feel it aligns with their personal values. In addition to administrative buy-in, teacher buy-in must occur for PBIS to be implemented with fidelity. Some teachers, however, may be resistant to changing their teaching strategies and they may vocalize their dissent, which could have a negative impact on the willingness of other teachers to accept PBIS practices. Hershfeldt et al. (2012) note that senior teachers can greatly facilitate or hinder the acceptance of PBIS practices among other teachers; therefore, it may be advantageous for PBIS implementers to have individual conversations with senior teachers about PBIS practices and how they may help teachers meet their classroom goals. Following steps to assure buy-in, critical to school-wide PBIS is ongoing and effective training and coaching. For example, Reinke, Herman, and Stormont (2013) emphasize that teacher use of evidence-based PBIS practices in the classroom (e.g., specific praise to students versus general classroom praise, giving students opportunities to respond) after an initial training will not meet optimal levels without additional coaching. They recommend the use of data-based performance feedback when training teachers in new PBIS practices, which can help increase their use of effective strategies in the classroom. While standard training models of PBIS for teachers emphasize creating behavioral expectations and effective classroom management (Hershfeldt et  al., 2012; Reinke et al., 2013), training in mental health and crisis response is increasingly seen as a necessary skill for teachers to possess. Schools interested in promoting

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mental health awareness among staff and students could utilize school-wide mental health literacy programs, such as The Guide (Kutcher, Wei, & Morgan, 2015). Additionally, there are more intensive crisis response and mental health training programs designed for professionals who work with youth such as Mental Health First Aid (Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010). Also underscored by the literature reviewed and themes brought up in this focus group, increasing family engagement in SBH programming is essential. For example, enhanced family engagement in PBIS can help to bridge behavioral expectations between the school and home (Garbacz et  al., 2016). This consistency in behavioral expectations can both help improve student behavior in both settings (Feil et al., 2014) and improve students’ attitudes toward attending school (Allen & Tracy, 2004). Additionally, the effective use of family engagement within school-­ based interventions has also been found to improve social, emotional, behavioral, and academic (SEBA) outcomes beyond interventions that do not include this emphasis (Feil et al., 2014; Pearce, 2009; Sénéchal & Young, 2008). Therefore, both school staff and parents should have a vested interest in creating strong partnerships to enhance the school experience for children and improve their SEBA outcomes. To improve family engagement in schools implementing PBIS, Fix et al. (2017) have made several suggestions across all three Tiers of the MTSS. For example, at Tier 1, schools should have a range of resources and materials available to families (at the school, and web and email-based), hold family-focused mental health promotion workshops to provide psychoeducation about a variety of topics including mental concerns common in students, and empower students to develop training and awareness-raising programs related to mental health. Families and youth should also be on school teams, guiding planning for all actions within the MTSS. At Tier 2, students and families can be guiding supportive programs for students presenting early signs of problems, including mentoring-based programs, and can help connect families together who are contending with similar SEBA challenges to promote information sharing and mutual support. At Tier 3, school- and communityemployed mental health staff in schools should work with students and families as collaborators in care versus taking an expert stance in therapy. This forum also included consideration of moving school-wide approaches to larger-scale at district and state levels. Themes underscored that this is a complex process requiring the district/state to have an initial level of readiness to begin implementation supported by detailed planning and on-going evaluation. For detailed support on scaling-up PBIS, there are several articles and manuals supporting large-scale implementation; for example, the School-wide Positive Behavior Support: Implementers’ Blueprint and Self-Assessment (Lewis, Barrett, Sugai, & Horner, 2010). The Center on PBIS (2017) has identified four key components for successful large-scale implementation of PBIS: (1) There is a strong leadership team to coordinate implementation; (2) the leadership team and participants in planning work from a solid organizational framework that includes emphases on funding, visibility, and political support; (3) solid plans are in place for ongoing training, coaching, and evaluation; and (4) a group of exemplar schools are identified and lessons

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learns, findings from their experiences are shared with other schools to promote scaling up of effective practices. The Association for Positive Behavior Support (n.d.) emphasizes the importance of leadership teams in statewide implementation. These teams are integral in facilitating training and technical assistance planning, evaluation, and interagency collaboration. Leadership teams should facilitate interagency coordination, connecting other human service agencies (e.g., mental health, child welfare, juvenile justice) to schools to promote collaboration in planning and program a shared agenda of providing a continuum of interventions and supports for all students within a school. Implementors of PBIS are more likely to be successful when they are regularly engaging in meetings around training, troubleshooting, and planning of PBIS implementation, and these efforts should be more intense in early years (Barrett et al., 2008). Participants noted an important link between training, school staff buy-in, and implementation fidelity. For instance, one participant expressed the need to ensure that PBIS training include all teachers, administrators, and even superintendents to increase unilateral buy-in, which in turn could facilitate implementation fidelity. Additionally, participants recommended aligning the goals of PBIS with multiple levels of outcomes that are valued by school personnel. For example, well done PBIS helps to improve academic outcomes as well as reducing costs for more intensive placements, which in turn facilitates buy-in from teachers, administrators, and district leaders, which in turn can strengthen resources for PBIS, in a positive snowballing growth curve. This process would help reach the goal emphasized by participants in this forum of universal PBIS across SC, consistent with the goal of equitable programming for all students in the state. An area of critical importance the forum participants brought up is the need for meaningful inclusion of families in SBH planning and implementation. For instance, several participants reflected on negative experiences at school meetings where they felt their voice was not heard, that school staff had a lack of understanding of their or their children’s needs, and even felt blamed and stigmatized for having identified diagnoses/disabilities. Participants recommended creating opportunities and spaces for students to voice their concerns and express their needs to school staff, consistent with recommendations from Fix et  al. (2017). Additionally, one participant reflected on how increasing the mental health literacy of school staff can reduce stigmatizing attitudes toward students and families with mental health concerns. Fortunately, there is a growing national movement around the expansion of mental health literacy to reduce stigma with the proliferation of evidence-based programs such as Youth Mental Health First Aid (Kelly et  al., 2011), Kognito (Eisenberg, Hunt, & Speer, 2012), and The Guide (Kutcher et al., 2015). We strongly encourage schools to examine how mental health stigma may impact the functioning of their MTSS and/or special education processes and furthermore how to meaningfully incorporate student and family voice in ongoing planning to improve these processes.

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References Allen, S. F., & Tracy, E. M. (2004). Revitalizing the role of home visiting by school social workers. Children & School, 26(4), 197–208. Barrett, S. B., Bradshaw, C. P., & Lewis-Palmer, T. (2008). Maryland statewide PBIS initiative: Systems, evaluation, and next steps. Journal of Positive Behavior Intervention, 10(2), 105–114. Benz, M. R., Lindstrom, L., Unruh, D., & Waintrup, M. (2004). Sustaining secondary transition programs in local schools. Remedial and Special Education, 25(1), 39–50. Bohanon, H., Fenning, P., Carney, K. L., Minnis-Kim, M. J., Anderson-Harriss, S., Moroz, K. B., et al. (2006). Schoolwide application of positive behavior support in an urban high school: A case study. Journal of Positive Behavior Interventions, 8(3), 131–145. Bohanon, H., Flannery, K. B., Malloy, J., & Fenning, P. (2009). Utilizing positive behavior supports in high school settings to improve school completion rates for students with high incidence conditions. Exceptionality, 17(1), 30–44. Bradshaw, C.  P., Koth, C.  W., Bevans, K.  B., Ialongo, N., & Leaf, P.  J. (2008). The impact of school-wide positive behavioral interventions and supports (PBIS) on the organizational health of elementary schools. School Psychology Quarterly, 23(4), 462. Bradshaw, C. P., Mitchell, M. M., & Leaf, P. J. (2010). Examining the effects of schoolwide positive behavioral interventions and supports on student outcomes: Results from a randomized controlled effectiveness trial in elementary schools. Journal of Positive Behavior Interventions, 12(3), 133–148. Bradshaw, C. P., Reinke, W. M., Brown, L. D., Bevans, K. B., & Leaf, P. J. (2008). Implementation of school-wide positive behavioral interventions and supports (PBIS) in elementary schools: Observations from a randomized trial. Education and Treatment of Children, 31(1), 1–26. Breitensten, S. M., Gross, D., Garvey, C., Hill, C., Fogg, L., & Resnick, B. (2010). Implementation fidelity in community-based interventions. Research in Nursing and Health, 33(2), 164–173. Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., et al. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions, 4(1), 4–16. Dane, A. V., & Schneider, B. H. (1998). Program integrity in primary and early secondary prevention: Are implementation effects out of control? Clinical Psychological Review, 18(1), 23–45. DeStefano, L., Dailey, D., Berman, K., & McInerney, M. (2001). Synthesis of discussions about scaling up effective practices (OSEP Publication Number HS970 17002). U.S. Department of Education, Office of Special Education Programs. Dexter, D. D., Hughes, C. A., & Farmer, T. W. (2008). Responsiveness to intervention: A review of field studies and implications for rural special education. Rural Special Education Quarterly, 27(4), 3–9. District level PBIS. National Technical Assistance Center on Positive Behavior Interventions and Support. https://www.pbis.org/topics/districtstate-­pbis Eber, L., Barrett, S., Perales, K., Jeffrey-Pearsall, J., Pohlman, K., Putnam, R., et  al. (2019). Advancing education effectiveness: Interconnecting school mental health and school-wide PBIS, volume 2: An implementation guide (Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S.  Department of Education)). Eugene, OR: University of Oregon Press. Eisenberg, D., Hunt, J., & Speer, N. (2012). Help seeking for mental health on college campuses: Review of evidence and next steps for research and practice. Harvard Review of Psychiatry, 20(4), 222–232. Feil, E. G., Frey, A. J., Walker, H. M., Small, J. W., Seeley, J. R., Golly, A., et al. (2014). The efficacy of a home-school intervention for preschoolers with challenging behaviors: A randomized controlled trial of preschool first step to success. Journal of Early Intervention, 36(3), 151–170.

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Fix, R.  L., Mayworm, A., Lawson, G.  M., Becker, K.  D., Lever, N.  A., & Hoover, S. (2017). Strategies for effective family engagement in elementary and middle schools. In M. D. Weist, S. A. Garbacz, K. L. Lane, & D. Kindcaid (Eds.), Aligning and integrating family engagement in positive behavioral interventions and supports (PBIS): Concepts and strategies for families and schools in key contexts (Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education)). Eugene, OR: University of Oregon Press. Flannery, K. B., Fenning, P., McGrath, M., & McIntosh, K. (2014). Effects of school-wide positive behavioral interventions and supports and fidelity of implementation on problem behavior in high schools. American Psychological Association, 29(2), 111–124. Flannery, K. B., Sugai, G., & Anderson, C. M. (2009). School-wide positive behavior support in high school: Early lessons learned. Journal of Positive Behavior Interventions, 11(3), 177–185. Garbacz, S.  A., McIntosh, K., Eagle, J.  W., Dowd-Eagle, S.  E., Hirano, K.  A., & Ruppert, T. (2016). Family engagement within schoolwide positive behavioral interventions and supports. Preventing School Failure: Alternative Education for Children and Youth, 60(1), 60–69. Handler, M. W., Rey, J., Connell, J., Thier, K., Feinberg, A., & Putnam, R. (2007). Practical considerations in creating school-wide positive behavior support in public schools. Psychology in the Schools, 44(1), 29–39. Hershfeldt, P.  A., Pell, K., Sechrest, R., Pas, E.  T., & Bradshaw, C.  P. (2012). Lessons learned coaching teachers in behavior management: The PBIS plus coaching model. Journal of Educational and Psychological Consultation, 22(4), 280–299. Hieneman, M., & Dunlap, G. (2000). Factors affecting the outcomes of community-based behavioral support: I. identification and description of factor categories. Journal of Positive Behavior Interventions, 2(3), 161–178. Horner, R. H., Sugai, G., Smolkowski, K., Eber, L., Nakasato, J., Todd, A. W., et al. (2009). A randomized, wait-list controlled effectiveness trial assessing school-wide positive behavior support in elementary schools. Journal of Positive Behavior Interventions, 11(3), 133–144. Hoyle, C. G., Marshall, K. J., & Yell, M. L. (2011). Positive behavior supports: Tier 2 interventions in middle schools. Preventing School Failure, 55(3), 164–170. Individuals with Disability Education Act Amendments of 1997 [IDEA]. (1997). https://www. congress.gov/105/plaws/publ17/PLAW-­105publ17.pdf Jorm, A. F., Kitchener, B. A., Sawyer, M. G., Scales, H., & Cvetkovski, S. (2010). Mental health first aid training for high school teachers: A cluster randomized trial. BMC Psychiatry, 10(1), 51. Kam, C. M., Greenberg, M. T., & Walls, C. T. (2003). Examining the role of implementation quality in school-based prevention using the PATHS curriculum. Prevention Science, 4(1), 55–63. Kelly, C.  M., Mithen, J.  M., Fischer, J.  A., Kitchener, B.  A., Jorm, A.  F., Lowe, A., et  al. (2011). Youth mental health first aid: A description of the program and an initial evaluation. International Journal of Mental Health Systems, 5(1), 4. Kincaid, D., Childs, K., Blase, K.  A., & Wallace, F. (2007). Identifying barriers and facilitators in implementing schoolwide positive behavior support. Journal of Positive Behavior Interventions, 9(3), 174–184. Kutcher, S., Wei, Y., & Morgan, C. (2015). Successful application of a Canadian mental health curriculum resource by usual classroom teachers in significantly and sustainably improving student mental health literacy. The Canadian Journal of Psychiatry, 60(12), 580–586. Lassen, S. R., Steele, M. M., & Sailor, W. (2006). The relationship of school-wide positive behavior support to academic achievement in an urban middle school. Psychology in the Schools, 43(6), 701–712. Lewis, T.  J., Barrett, S., Sugai, G., & Horner, R.  H. (2010). Blueprint for schoolwide positive behavior support training and professional development. Eugene, OR: National Technical Assistance Center on Positive Behavior Interventions and Support. McIntosh, K., Bennett, J.  L., & Price, K. (2011). Evaluation of social and academic effects of school-wide positive behaviour support in a Canadian school district. Exceptionality Education International, 21(1), 46–60.

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McIntosh, K., Kelm, J.  L., & Canizal Delabra, A. (2016). In search of how principals change: A qualitative study of events that help and hinder administrator support for school-wide PBIS. Journal of Positive Behavior Interventions, 18(2), 100–110. Morrissey, K.  L., Bohanon, H., & Fenning, P. (2010). Positive behavior support: Teaching and acknowledging expected behaviors in an urban high school. Teaching Exceptional Children, 42(5), 26–35. Muscott, H. S., Mann, E. L., & LeBrun, M. R. (2008). Positive behavioral interventions and supports in New Hampshire: Effects of large-scale implementation of schoolwide positive behavior support on student discipline and academic achievement. Journal of Positive Behavior Interventions, 10(3), 190–205. OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports (2017). Positive Behavioral Interventions & Supports. www.pbis.org. Pearce, L.  R. (2009). Helping children with emotional difficulties: A response to intervention investigation. The Rural Educator, 30(2), 34–46. Putnam, R., McCart, A., Griggs, P., & Choi, J. H. (2009). Implementation of schoolwide positive behavior support in urban settings. In W.  Sailor, G.  Dunlap, G.  Sugai, & R.  Horner (Eds.), Handbook of positive behavior support. Boston, MA: Springer. Reinke, W. M., Herman, K. C., & Stormont, M. (2013). Classroom-level positive behavior supports in schools implementing SW-PBIS: Identifying areas for enhancement. Journal of Positive Behavior Interventions, 15(1), 39–50. Scott, T. M., Anderson, C., Mancil, R., & Alter, P. (2009). Function-based supports for individual students in school settings. In W. Sailor, G. Dunlap, G. Sugai, & R. Horner (Eds.), Handbook of positive behavior support (pp. 421–441). New York: Springer. Sénéchal, M., & Young, L. (2008). The effect of family literacy interventions on children’s acquisition of reading from kindergarten to grade 3: A meta-analytic review. Review of Educational Research, 78(4), 880–907. Shogren, K. A., Wehmeyer, M. L., Lane, K. L., & Quirk, C. (2017). Multitiered systems of supports. In M. L. Wehmeyer & K. A. Shogren (Eds.), Handbook of research-based practices for educating students with intellectual disability (pp. 185–198). New York: Routledge/Taylor & Francis Group. Simonsen, B., Eber, L., Black, A. C., Sugai, G., Lewandowski, H., Sims, B., et al. (2012). Illinois statewide positive behavioral interventions and supports: Evolutions and impact on student outcomes across years. Journal of Positive Behavior Interventions, 14(1), 5–16. Statewide leadership: Description and links. Association for Positive Behavior Support. http:// www.apbs.org/new_apbs/statewide-­leadership.html Steed, E.  A., Pomerleau, T., Muscott, H., & Rohde, L. (2013). Program-wide positive behavioral interventions and supports in rural preschools. Rural Special Education Quarterly, 32(1), 38–46. Stormont, M., Reinke, W., & Herman, K. (2011). Teachers’ knowledge of evidence-based interventions and available school resources for children with emotional and behavioral problems. Journal of Behavioral Education, 20(2), 138. Sugai, G., & Horner, R. (2006). A promising approach for expanding and sustaining school-wide positive behavior support. School Psychology Review, 35, 249–255. Sugai, G., & Horner, R. H. (2002). Introduction to the special series on positive behavior supports in schools. Journal of Emotional and Behavioral Disorders, 10(3), 130–135. SWPBIS for beginners. National Technical Assistance Center on Positive Behavior Interventions and Support. https://www.pbis.org/school/swpbis-­for-­beginners Weist, M. D., Garbacz, S. A., Lane, K. L., & Kincaid, D. (2017). Enhancing progress for meaningful family engagement in all aspects of positive behavioral interventions and supports and multi-tiered Systems of Support. In M. D. Weist, S. A. Garbacz, K. L. Lane, & D. Kindcaid (Eds.), Aligning and integrating family engagement in Positive Behavioral Interventions and Supports (PBIS): Concepts and strategies for families and schools in key contexts (Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education)). Eugene, OR: University of Oregon Press.

Cultural Humility and School Behavioral Health Victoria Rizzardi, Sommer C. Blair, Barbara Kumari, and June Greenlaw

While researchers and practitioners may first think of race and ethnicity when discussing cultural competency, these variables represent only one form of diversity. Religious affiliation, sexual orientation, gender, age, language, beliefs, socioeconomic status (SES), occupation, peers, interests, and many other variables are aspects of cultural diversity (Clauss-Ehlers, Serpell, & Weist, 2013). As a response to growing diversity, cultural competency has become increasingly emphasized in health and mental health care (see Sue, 2001; Sue et al., 1982; Sue, Arredondo, & McDavis, 1992). Due to the unique ways culture can manifest in each individual, the goal of having mastery or competence of all cultures may not be realized or feasible. An additional criticism of the concept of cultural competency lies in its lack of recognition of factors that contribute to an individual’s development that may be unique to that individual and not reflective of the culture with which they identify (Fisher-Borne, Cain, & Martin, 2014). Related to these and other factors, the concept of cultural competence has evolved to emphasize cultural humility, which focused on self-reflection and empathy and frankly acknowledges the inherent challenge in becoming “culturally competent.” Cultural humility is the ability to be open to new ideas and other cultures while still being true to your own. When practicing cultural humility, the person in the helping role is cautious to ask others about their culture versus prematurely making conclusions about cultural background and preferences (American Psychological V. Rizzardi · J. Greenlaw Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected] S. C. Blair (*) South Carolina Department of Social Services, Lexington, SC, USA e-mail: [email protected] B. Kumari Department of Psychology, Arizona State University, Tempe, AZ, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_4

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Association [APA], 2018). To further elaborate, cultural humility is characterized by the professional: deliberately reflecting on the aspects of one’s own culture, being intentional about one’s role as a learner rather than as an expert, searching for chances to develop partnerships, and adopting a lifelong growth mindset (Mosher et al., 2017). Importantly, the limited focus on cultural humility is particularly important for minority students, where there continue to be inequities for these students in relation to both their receipt of needed programs and services, and receipt of exclusionary discipline (Carpenter-Song, Schwallie, & Longhofer, 2007; Fisher-Borne et al., 2014). Further, traditional approaches to address this problem are limited; for example, cultural competency training programs that encourage teachers to learn about different cultures in a standardized process with a focus on a few, simplistic, core characteristics (Elhoweris, Parameswaran, & Alsheikh, 2004; Tervalon & Murray-­ Garcia, 1998) to the neglect of a more nuanced and in-depth analyses of cultural differences (Guo, Arthur, & Lund, 2009). In this regard, four themes are necessary to consider, stereotypes, stigma, lack of trust, and school discipline practices.

Stereotypes Social stereotypes were defined as early as 1922 by journalist Walter Lippmann as flawed generalizations about certain groups (Judd & Park, 1993), with these generalizations typically accompanied by stigma (Heary, Hennessy, Swords, & Corrigan, 2017). Stereotypes and stigma threaten students’ academic performance and overall well-being. For example, when asked to look at photos of children that were similarly dressed, a majority of teachers identified black males as the most likely to be involved with gangs and to drop out of school (DeCastro-Ambrosetti & Cho, 2011). Stereotypes regarding SES also negatively affect students. In one study, fourth, sixth, and eighth-grade students were asked to consider the academic performance of “rich” and “poor” students. All ages indicated that “rich” students are more likely to perform better academically compared to their “poor” counterparts (Woods, Kurtz-Costes, & Rowley, 2005). When children’s SES is made salient, this negatively impacts disadvantaged children, as they are then less likely to perform well in school and more likely to buy into the stereotype that they will always live in poverty (Woods et  al., 2005). As young as first grade, children recognize that being wealthy is desirable while being poor is not (Woods et al., 2005). Some students are affected by multiple stereotypes. For example, in addition to ethnic stereotypes, African American and Hispanic students are more likely to be challenged by poverty and stay impoverished longer (Schmitz, 1995) and thus may face stereotypes related to SES.  Additionally, stereotypes exist past race and SES. Stigma is associated with minorities related to sexual orientation, religion, family structure, etc. For example, professional circles often label single-parent households as a problem, and such households are rarely referred to as a healthy choice for a family system (Schmitz, 1995). When diversity is demonized, instead

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of normalized or celebrated, there can be adverse effects on anyone who is stereotyped or stigmatized.

Mental Health Stigma Stigma includes a variety of distorted beliefs that involve labeling, stereotyping, and isolating the group that is not the majority (Knifton, 2012). Public stigma, or stigma that is accepted by most of society, sets the foundation for all other forms of stigma because it is the majority’s misguided belief about a specific group (Parcesepe & Cabassa, 2013). Public stigma has often associated mental health with negative words such as “weak” or “crazy.” For example, Abdullah and Brown (2011) found that over 50% of Americans do not want a person with mental illness to marry into their family, work with them, or socialize with them. Self-stigma differs from public stigma. For mental health, self-stigma is a person’s internalization of public stigma regarding mental health concerns (Abdullah & Brown, 2011). In their review, Clement et  al. (2015) identified self-stigma as a barrier to seeking mental health treatment. If a person is concerned with stigma, they are less likely to accurately perceive their need for mental health treatment (Miranda, Soffer, Polanco-Roman, Wheeler, & Moore, 2015). Additionally, one research study reported that 32% of individuals recognized they had a mental health issue but would not seek treatment due to stigma (Alvidrez, Snowden, & Kaiser, 2008). Further, stigma issues may be more significant for minority youth. For example, within the rural African American community, there is a cultural mistrust of mental health providers (Haynes et al., 2017). African American parents report more stigma and less positive attitudes when it comes to receiving mental health services (Turner, Jensen-Doss, & Heffer, 2015), and some suggest stigma is the largest contributor to lower help-seeking by African Americans for mental health services (Haynes et al., 2017; Turner et  al., 2015). This conclusion is consistent with findings from a national survey of over 14,000 students that found that minority students were less likely to seek mental health counseling than their majority-race peers (Miranda et al., 2015).

Lack of Trust Several frameworks consider the interactions between mental health care providers and consumers as one of the most critical factors in mental health care (Rosenheck, 2001; Tansella & Thornicroft, 1998). Within this relationship, trust is the most essential variable for promoting healthy, effective interactions (Mechanic, 1998; Murray & McCrone, 2014). However, as a result of stigma, mental health consumers may distance themselves from those associated with mental health services, including mental health providers, creating distrust with those associated with the

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mental health care field (Verhaeghe & Bracke, 2011). Not only are self-stigma experiences related to distrust in mental health care providers, but distrust is also significantly related to mental health consumers’ service satisfaction (Verhaeghe & Bracke, 2011). Further, consumers’ lack of trust in their providers may reduce treatment adherence and prevent them from seeking care (Thom, Hall, & Pawlson, 2004). Compared to their White counterparts, African American and Latino patients are less likely to trust their care providers (Berrios-Rivera et al., 2006; Bova et al., 2012) especially when their care provider is a different race/ethnicity from their own (Gordon, Street, Sharf, Kelly, & Souchek, 2006).

Discipline Practices Since the 1990s, school discipline rates for most racial and ethnic groups have declined (Wallace, Goodkind, Wallace, & Bachman, 2008); however, suspension and expulsion rates among racial and ethnic minority groups have increased (American Academy of Pediatrics Committee on School Health, 2003). Despite this increase, research consistently demonstrates the negative effects of suspension, including higher rates of academic failure and dropout (Arcia, 2006), failure to graduate on time (Mendez, 2003), increased risk of drug and alcohol use, and a greater likelihood of engaging in antisocial behavior (American Academy of Pediatrics Committee on School Health, 2003; Hemphill et al., 2012). Moreover, suspension from school does not reduce the likelihood of future discipline referrals (Tobin & Sugai, 1996). Conversely, Hemphill et al. (2012) found that suspension predicts future nonviolent antisocial behavior and suspension, as well as poor academic performance. Issues associated with suspensions are especially problematic given that the majority of students who receive suspensions belong to a minority group or are of low SES (Vavrus & Cole, 2002). It has been consistently shown that African American youth experience the highest rates of suspension, with Hispanic and American Indian youth trailing closely behind (Wallace et al., 2008). Even more concerning is that the racial disproportionality in suspension rates is related to a similar rate of disproportional referrals to the juvenile justice system (Nicholson-­ Crotty, Birchmeier, & Valentine, 2009). While suspension predicts future victimization, criminal activity, and incarceration in adulthood for all students, African American students are significantly more likely to experience these long-lasting consequences as adults (Wolf & Kupchik, 2017). One explanation for the increased suspension rate for minority youth is that they participate in antisocial behaviors that result in suspensions more often than White students. However, Skiba et  al. (2011) found that African American and Hispanic students are more often suspended than White students for similar discipline referrals.

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Method This forum included these participants from different stakeholder groups, with several overlaps within individual participants. There were 15 attendees, including parents, teachers, faculty members, a graduate student, and staff members from a university hospital. The questions below were asked to create a dialogue surrounding cultural humility as it relates to improving school behavioral health (SBH): 1. In your experiences in South Carolina (SC) schools, what factors are most important for building high-quality SBH programs? What factors of SBH programs are most important for improving cultural humility in the school? 2. What have your experiences been with training on disparities in schools with SBH programs? 3. How can Positive Behavioral Interventions and Supports (PBIS) and other SBH initiatives be strengthened to reflect cultural humility and empathy? 4. What should we do to improve school-wide approaches that help all stakeholders recognize personal factors that affect their views and actions about disparities? 5. What emphases are needed to improve policies and practices that reduce restrictive placement and discipline of minority students? 6. How can we improve SBH initiatives to include families and communities that have been traditionally underserved? How do the family needs of students vary based on school classification (e.g., rural, urban, suburban, higher vs. moderate vs. lower SES)? 7. Due to schools’ limited resources, how can the role of other community groups and members, such as the faith community and businesses, help in eliminating disparities? How can school-based SBH stakeholders work smarter? 8. Can the SBH initiative stakeholders help in identifying biases? How can the initiative help change these biases? 9. What other recommendations do you have to advance cultural humility in SC schools?

Results Four main themes relating to cultural humility and SBH arose from the discussion in the forum. The topics of these themes have been defined earlier in this chapter as a prelude to the discussion of the dialogue with these stakeholders. The first identified theme in this forum was stereotypes and the problems that stem from them, especially within some cultures. The second theme surrounded stigma. Participants believed that parents do not reach out for services due to the stigma associated with mental health, particularly in minority and low-income communities. The third theme centered around a lack of trust between families and schools, accompanied by the need to build these relationships. The final theme regarding discipline practices arose out of dialogue involving students being

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removed from the classroom because of their behaviors. Suggestions for handling this issue included trying to find more of the root causes and, once again, looking closely at the impact on minority and low-income families. Participants consistently mentioned involving more people in the students’ lives as another way to combat these issues. Furthering the conversation, participants identified utilizing interdisciplinary meetings, more support staff, and embracing “the village” mentality as ways to overcome effects of stigma, stereotypes, and building trust. The themes focused on by these stakeholders are vital to consider when exploring cultural humility and how it relates to SBH.

Stereotypes The first problem identified by the participants was stereotypes. One participant explained that, “The communication is about the most important factor here because mental health has always been stereotyped.” Another participant recognized that she struggled with stereotypes when her child was referred to mental health services. Regarding her child’s referral, the participant shared, I even struggled with it because of mental health in the black community. That is one thing we suffer, it is stereotyped, like something is wrong with you if you seek mental health. We need to really look at these labels.

One participant spoke further on this issue related to stereotypes, as well as cultural humility in general through their lived experience. The participant explained, A lot of times we throw the word ‘cultural’ and ‘culture’ and ‘cultural competencies’ and ‘cultural humility.’ We throw these words around so lightly but the culture between my house and her house even though we’re both African American women, it can be completely different.

Mental Health Stigma Mental health stigma was also recognized during the forum. The participants believed that minority and low-income communities were at a greater risk of perpetuating mental health stigma within their own families and neighborhoods. One participant said, We talk a lot about our administration and teachers, but with the parents and many people who are apprehensive of mental health services, especially in different cultures such as African American cultures [and] Hispanic cultures, when they hear mental health or behavioral health…it has a stigma to it...

The discussion then shifted to overcoming this barrier. The same participant went on to say, “We definitely need to go in these communities and educate them about what we’re doing with their children.” Communicating with parents regarding their children’s care drew the greatest consensus among the group on how to combat the stigma.

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Parental Lack of Trust This forum identified a general lack of trust between families and school personnel. One participant emphasized that, before any further relationships can be built with the family, the existing relationship with the student(s) must be repaired. The participant said, “We have to find a way to undo all of the mistrust and repair some things to our young people.” After beginning with the students, efforts must be turned toward the parents. One participant emphasized this plan of action saying, “We have to bridge a level of respect between school authority and parents.” The group spoke of how school personnel cannot skip the steps of building trust with all parties involved. A participant spoke to this process, “When [parents] feel they can trust you, you get a little bit more from them, but you have to start there.” Other participants agreed that it would be difficult to continue any other type of service without a strong initial relationship. One participant indicated that it is important to show parents support, saying, when they can see that they’re all working as a team to understand them better and to work more, I think that will take us to the point that we can really get something done and then have the expectation that this is the team that’s going to follow me all year and if I’ve got more than one person I know there’s some significant system concerned about what I’m going to do. I think that could start to shift to make a significant change on the outcome that we’re looking for.

Another forum participant spoke to the current, broken state of these relationships stating, “These parents, my heart goes out to them because... they need somebody to say this is where to start [and] this is how we’re going to help you.”

Discipline Practices The impact on minority and low-income students was discussed further within the subtheme of removing students from school due to behavioral issues. Forum participants were angered by both their personal experiences and those they had witnessed. One participant described racial inequity, stating, “[Of] twenty-four children that were expelled from an alternative school, twenty-two were African American children.” Parents within the group discussed that, often times, parents are not provided with alternative options when their child is suspended from school for their behavior. They are instructed to pick their child up from school and take them home as soon as their behavior becomes unmanageable. A participant who went through such experiences with her child said, “It wasn’t, ‘How can we help?’ ‘These are the resources.’ None of that was available...” The forum offered alternatives to simply sending a child home such as, Instead of you talking to him as principal, send him [to the school-based counselor], let her or him talk to him and let them do something about it instead of you just throwing him out of school, and then he’s not getting the help and he’s going to act out more.

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Working harder to find the underlying issues to behavioral problems, as opposed to utilizing suspensions, was something the forum participants discussed with great fervor.

Recommendations for Moving Forward Reducing Punitive Discipline Practices While overall school discipline rates have declined since the 1990s, those rates have increased for African American students (Wallace et al., 2008). Skiba et al. (2014) explored the impact that school-level characteristics, like school climate and emphasis on diversity, play on discipline disproportionality. They found that these characteristics may be better predictors of suspension and expulsion than student behavior. In their work, they found that principals’ orientation toward discipline, school-wide academic achievement, and percentage of African American enrollment explained racial and ethnic disproportionality above student behavior or student-level characteristics (Skiba et  al., 2014). Given the contribution of school-level variables on discipline disparities, policy, and practice interventions with a focus on reorienting administrators’ views toward less punitive practices, developing their capacity to change practices within their school, and introducing instructional interventions with an emphasis on reducing implicit bias may be effective at reducing discipline disparities (Skiba et al., 2014). Additionally, interventions to improve the quality of academic instruction and develop a positive school climate for all student groups are likely to lead to improvements in student behavior and academic performance (Rausch & Skiba, 2005; Scott, Nelson, & Liaupsin, 2001). In addition to reducing discipline disparities, it is important to ensure that students who are suspended or expelled from school are supported upon their return to school. Absences from school may have negative effects on students’ academic progress, as well as provide students with the opportunity to associate with other youth exhibiting antisocial behavior, thus increasing the likelihood of future suspensions (Hemphill et al., 2012). Schools may be able to alleviate negative outcomes during suspensions by providing students with schoolwork and partnering with parents and the community to provide supervision during suspension (Hemphill et al., 2012).

Greater Involvement in Students’ Lives Forum participants agreed that handling the complex issues involved in effective and culturally humble SBH requires all stakeholder groups to be actively involved, including leaders and staff from education, mental health, and other youth-serving

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systems, along with families and students, and community leaders. Many participants mentioned that involving different groups in the child’s life could have a more significant impact on the student. Participants would like to see school systems embrace how it was, “back in the day,” according to one participant when “the village raised the child.” Many participants agreed that “...more support staff in schools” is essential to this work. The participants hoped that “more school social workers, school nurses,” would, in turn, “get the people... in the community and show them how to access services.” Involving everyone in the neighborhood would ease the burden of individual parents. Additionally, participants felt that the more people who consistently impact a child’s life, the less likely it would be for the child to fall through the cracks and not receive the care or services they need.

Developing Trust The relationship between families and their children’s schools plays an essential role in children’s social and academic outcomes (Jeynes, 2005; Serpell & Mashburn, 2011). Schools can capitalize on mental health providers who are already connected to their schools to foster effective school-family partnerships. Mental health providers can promote the sharing of information and connecting of schools, families, and other organizations (Talapatra, Miller, & Schumacher-Martinez, 2019). Mental health providers possess counseling and communication skills to help promote group functioning and resolve conflicts as they arise, as well as knowledge of evidence-­based practices when designing plans for students (Talapatra et al., 2019). Further, their connections with school staff and other community providers make mental health providers well-suited to develop plans for students that generalize to real-world situations and can be applied at home or in the classroom (Talapatra et al., 2019). A critical skill for mental health providers, and one that may encourage effective teaming, is learning how to facilitate consumers’ trust in the provider (Hall, Dugan, Zheng, & Mishra, 2001; Thom et al., 2004). In a comprehensive review, Murray and McCrone (2014) identified several characteristics mental health providers should possess to gain the trust of those in their care: effort, continuity and time, caring, personal knowing, and respect; interpersonal skills; competence; and patient-­ provider partnering. Facilitating trust with clients requires a conscious effort from providers (Hem, Heggen, & Ruyter, 2008) and commitment to continuity and time, or regularly meeting with them (Eriksson & Nilsson, 2008). Equally important is the provider’s ability to understand the client’s individual experience (Thom & Campbell, 1997), to be empathetic to their concerns (Sheppard, Zambrana, & O’Malley, 2004; Thom, 2001), and to show acceptance and encouragement (McAlearney, Robbins, Kowalczyk, Chisolm, & Song, 2012; Thom, 2001).

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Conclusion The concerns voiced by stakeholders in this forum were all evidence of a need for increased emphasis on cultural humility in schools and in SBH programs. The reality is that insufficient attention to cultural humility will limit the effectiveness and relevance of these programs, and work is needed to infuse this emphasis in ongoing interactions with students and families in planning and implementing all aspects of programming within the MTSS (Waters & Asbill, 2013). In this work, mutual trust is foundational, and this can only be achieved through ongoing collaborative interactions between educators, SBH staff, students, and families, seeking understanding of cultural issues, effective, and respectful ways to communicate about them, and ways to transparently identify and work to remove barriers to effective programming related to culture.

References Abdullah, T., & Brown, T. L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clinical Psychology Review, 31(6), 934–948. Alvidrez, J., Snowden, L. R., & Kaiser, D. M. (2008). The experience of stigma among black mental health consumers. Journal of Health Care for the Poor and Underserved, 19(3), 874–893. American Psychological Association. (2018, January). APA adopts new multicultural guidelines. https://www.apa.org/monitor/2018/01/multicultural-­guidelines Arcia, E. (2006). Achievement and enrollment status of suspended students: Outcomes in a large, multicultural school district. Education and Urban Society, 38(3), 359–369. Berrios-Rivera, J. P., Street, R. L., Popa-Lisseanu, M. G. G., Kallen, M. A., Richardson, M. N., Janssen, N. M., et al. (2006). Trust in physicians and elements of the medical interaction in patents with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Care & Research, 55(3), 385–393. Bova, C., Route, P.  S., Fennie, K., Ettinger, W., Manchester, G.  W., & Weinstein, B. (2012). Measuring patient-provider trust in primary care population: Refinement of the health care relationship trust scale. Research in Nursing & Health, 35(4), 397–408. Carpenter-Song, E. A., Schwallie, M. N., & Longhofer, J. (2007). Cultural competence reexamined: Critique and directions for the future. Psychiatric Services, 58(10), 1362–1365. Clauss-Ehlers, C., Serpell, Z., & Weist, M. D. (2013). Handbook of culturally responsive school mental health: Advancing research, training, practice, and policy. New York: Springer. Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., et al. (2015). What is the impact of mental health-related stigma on help seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1), 11–27. Committee on School Health. (2003). Out-of-school suspension and expulsion. Pediatrics, 112(5), 1206–1209. DeCastro-Ambrosetti, D., & Cho, G. (2011). A look at “lookism”: A critical analysis of teachers’ expectations based on students’ appearance. Multicultural Education, 18(2), 51–54. Elhoweris, H., Parameswaran, G., & Alsheikh, N. (2004). College students’ myths about diversity and what college faculty can do. Multicultural Education, 12(2), 13–18. Eriksson, I., & Nilsson, K. (2008). Preconditions needed for establishing a trusting relationship during health counselling – An interview study. Journal of Clinical Nursing, 17(17), 2352–2359. Fisher-Borne, M., Cain, J., & Martin, S. (2014). From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education, 34(2), 165–181.

Cultural Humility and School Behavioral Health

45

Gordon, H. S., Street, R. L., Sharf, B. F., Kelly, A., & Souchek, J. (2006). Racial differences in trust and lung cancer patients’ perceptions of physician communication. Journal of Clinical Oncology, 24(6), 904–909. Guo, Y., Arthur, N., & Lund, D. (2009). Intercultural inquiry with pre-service teachers. Intercultural Education, 20(6), 565–577. Hall, M. A., Dugan, E., Zheng, B., & Mishra, A. K. (2001). Trust in physicians and medical institutions: What is it, can it be measured, and does it matter? The Milbank Quarterly, 79(4), 613–639. Haynes, T. F., Cheney, A. M., Sullivan, J. G., Bryant, K., Curran, G. M., Olson, M., et al. (2017). Addressing mental health needs: Perspectives of African Americans living in the rural south. Psychiatric Services, 68(6), 573–578. Heary, C., Hennessy, E., Swords, L., & Corrigan, P. (2017). Stigma towards mental health problems during childhood and adolescence: Theory, research, and intervention approaches. Journal of Child and Family Studies, 26(11), 2949–2959. Hem, M. H., Heggen, K., & Ruyter, K. W. (2008). Creating trust in an acute psychiatric ward. Nursing Ethics, 15(6), 777–788. Hemphill, S. A., Herrenkohl, T. I., Plenty, S. M., Toumbourou, J. W., Catalano, R. F., & McMorris, B. J. (2012). Pathways from school suspension to adolescent nonviolent antisocial behavior in students in Victoria, Australia and Washington state United States. Journal of Community Psychology, 40(3), 301–318. Jeynes, W. H. (2005). A meta-analysis of the relation of parental involvement to urban elementary school student academic achievement. Urban Education, 40(3), 237–269. Judd, C.  M., & Park, B. (1993). Definition and assessment of accuracy in social stereotypes. Psychological Review, 100(1), 109–128. Knifton, L. (2012). Understanding and addressing the stigma of mental illness with ethnic minority communities. Health Sociology Review, 21(3), 287–298. McAlearney, A. S., Robbins, J., Kowalczyk, N., Chisolm, D. J., & Song, P. H. (2012). The role of cognitive and learning theories in supporting successful EHR system implementation training: A qualitative study. Medical Care Research & Review, 69(3), 294. Mechanic, D. (1998). The functions and limitations of trust in the provision of medical care. Journal of Health Politics, Policy, and Law, 23(4), 661–686. Mendez, L.  M. (2003). Predictors of suspension and negative school outcomes: A longitudinal investigation. New Directions for Youth Development, 99(1), 17–33. Miranda, R., Soffer, A., Polanco-Roman, L., Wheeler, A., & Moore, A. (2015). Mental health treatment barriers among racial/ethnic minority versus white young adults 6 months after intake at a college counseling center. Journal of American College Health, 63(5), 291–298. Mosher, D., Hook, J., Captari, L., Davis, D., DeBlaere, C., & Owen, J. (2017). Cultural humility: A therapeutic framework for engaging diverse clients. Practice Innovations, 2(4), 221–233. Murray, B., & McCrone, S. (2014). An integrative review of promoting trust in the patient-primary care provider relationship. Journal of Advance Nursing, 71(1), 3–23. Nicholson-Crotty, S., Birchmeier, Z., & Valentine, D. (2009). Exploring the impact of school discipline on racial disproportion in the juvenile justice system. Social Science Quarterly, 90(4), 1003–1018. Parcesepe, A. M., & Cabassa, L. J. (2013). Public stigma of mental illness in the United States: A systematic literature review. Administration and Policy in Mental Health and Mental Health Services Research, 40(5), 384–399. Rausch, M.  K. & Skiba, R.  J. (2005, April). The academic cost of discipline: The contribution of school discipline to achievement (Paper presented at the Annual Meeting of the American Educational Research Association, Montreal, Canada). Rosenheck, R. A. (2001). Organizational process: A missing link between research and practice. Psychiatric Services, 52(12), 1607–1612. Schmitz, C. L. (1995). Reframing the dialogue on female-headed single-parent families. Affilia: Journal of Women & Social Work, 10(4), 426–441.

46

V. Rizzardi et al.

Scott, T. M., Nelson, C. M., & Liaupsin, C. J. (2001). Effective instruction: The forgotten component in preventing school violence. Education and Treatment of Children, 24(3), 309–322. Serpell, Z. N., & Mashburn, A. J. (2011). Family-school connectedness and children’s early social development. Social Development, 21(1), 21–46. Sheppard, V. B., Zambrana, R. E., & O’Malley, A. S. (2004). Providing health care to low-income women: A matter of trust. Family Practice, 21(5), 484–491. Skiba, R. J., Chung, C., Trachok, M., Baker, T. L., Sheya, A., & Hughes, R. L. (2014). Parsing disciplinary disproportionality: Contributions of infraction, student, and school characteristics to out-of-school suspension and expulsion. American Educational Research Journal, 51(4), 640–670. Skiba, R. J., Horner, R. H., Chung, C., Rausch, M. K., May, S. L., & Tobin, T. (2011). Race is not neutral: A national investigation of African American and Latino disproportionality in school discipline. School Psychology Review, 40(1), 85–107. Sue, D. W. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), 790–821. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64–88. Sue, D.  W., Bernier, J.  E„ Durran, A., Feinberg, L„ Pedersen, P., Smith, E.  J., & Vasquez-­ Nuttall, E. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10(2), 45–52. Talapatra, D., Miller, G.  E., & Schumacher-Martinez, R. (2019). Improving family-school collaboration in transition services for students with intellectual disabilities: A framework for school psychologists. Journal of Educational and Psychological Consultation, 29(3), 314–336. Tansella, M., & Thornicroft, G. (1998). A conceptual framework for mental health services: The matrix model. Psychological Medicine, 28(3), 503–508. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. Thom, D. H. (2001). Physician behaviors that predict patient trust. The Journal of Family Practice, 50(4), 323–328. Thom, D. H., & Campbell, B. (1997). Patient-physician trust: An exploratory study. The Journal of Family Practice, 44(2), 169–176. Thom, D. H., Hall, M. A., & Pawlson, G. (2004). Measuring patients’ trust in physicians when assessing quality of care. Health Affairs, 23(4), 124–132. Tobin, T., & Sugai, G. (1996). Patterns in middle school discipline records. Journal of Emotional and Behavioral Disorders, 4(2), 82–94. Turner, E.  A., Jensen-Doss, A., & Heffer, R.  W. (2015). Ethnicity as a moderator of how parents’ attitudes and perceived stigma influence intentions to seek child mental health services. Cultural Diversity and Ethnic Minority Psychology, 21(4), 613–618. Vavrus, F., & Cole, K. (2002). “I didn’t do nothin’”: The discursive construction of school suspension. The Urban Review, 34(2), 87–111. Verhaeghe, M., & Bracke, P. (2011). Stigma and trust among mental health service users. Archives of Psychiatric Nursing, 25(4), 294–302. Wallace, J.  M., Goodkind, S., Wallace, C.  M., & Bachman, J.  G. (2008). Racial, ethnic, and gender differences in school discipline among U.S. high school students: 1991-2005. Negro Educational Review, 59(1–2), 47–62. Waters, A., & Asbill, L. (2013). Reflections on cultural humility. American Psychological Association. https://www.apa.org/pi/families/resources/newsletter/2013/08/cultural-­humility Wolf, K.  C., & Kupchik, A. (2017). School suspensions and adverse experiences in adulthood. Justice Quarterly, 34(3), 407–430. Woods, T. A., Kurtz-Costes, B., & Rowley, S. J. (2005). The development of stereotypes about the rich and poor: Age, race, and family income differences in beliefs. Journal of Youth and Adolescence, 34(5), 437–445.

Improving School Behavioral Health Quality Sommer C. Blair, Darien Collins, and Kathleen B. Franke

Youth spend most of their time either at school or at home, which places schools in a unique position to identify and address emotional/behavioral (EB) problems in students. This level of care helps to remove barriers to students’ learning and promote academic gains (Hess, Pearrow, Hazel, Sander, & Willie, 2017; Kase et al., 2017). As reflected in the chapters in this book, there is a significant national movement to integrate education and mental health systems to provide high-quality school behavioral health (SBH) programs (Barrett, Eber, & Weist, 2013; Weist, Lever, Bradshaw, & Owens, 2014). Quality SBH programs address needs across all levels of schools’ multitiered systems of supports (MTSS), including universal or schoolwide approaches (Tier 1), selective or early interventions (Tier 2), and targeted interventions (Tier 3) to address behavioral health needs (Hess et al., 2017). This chapter reviews qualitative data from a focus group of parents, school principals, clinicians, and other school personnel who discussed characteristics of high-­ quality SBH, roles for key stakeholders, and ways to further improve the quality of this innovative approach to improving student mental health and school success.

Critical Quality Dimension in SBH High-quality SBH services include several important factors (see Weist et al., 2007). Collaboration between school service providers, parents, students, and other stakeholders promotes responsive, supportive environments and learning for all students S. C. Blair Department of Social Services, South Carolina, Columbia, SC, USA e-mail: [email protected] D. Collins (*) · K. B. Franke Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_5

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(Hess et al., 2017). Including youth in services improves overall knowledge of mental health and increases the likelihood that students will become actively involved in promoting their mental health and receiving effective mental health services (Salerno, 2016). With universal screening and effective data-based decision-­making, schools support students who may not seek services, with problems flagged by screening data followed by proactive actions by school staff (Dowdy et al., 2015). Prioritization of mental health at the school level can contribute to enhanced school climate, which may result in fewer barriers to service delivery (Townsend et  al., 2017; DeFosset, Gase, Ijadi-Maghsood, & Kuo, 2017). Collaboration  The Individuals with Disabilities Education Act (IDEA) emphasizes parental involvement in their children’s education, as parents provide unique knowledge about their child (Jung, 2011; Yell, Katsiyannis, & Losinski, 2015). Parental/familial involvement is thus legally mandated in Individualized Education Plan (IEP) meetings, which are designed to develop a curriculum road map for special education services (Jung, 2011; Lo, 2012; Yell et  al., 2015; Wilson, 2015, Dilberto & Brewer, 2014). The IEP is an individually designed educational plan designed to meet the needs of a student with a disability (Galemore & Sheetz, 2015). Sect. 504 plans are similar, in that they protect all people with disabilities from discrimination in educational settings (Galemore & Sheetz, 2015). An IEP is unsuccessful without open communication between the school and family (Diliberto & Brewer, 2014). Even when the legal requirements for participation are satisfied, collaboration between parents, educators, mental health clinicians, and other parties in attendance of the meetings can be poor or missing altogether. A 2005 National Longitudinal Transition Study found that one-third of parents with children who have a disability desire greater involvement in the IEP decision-making process (Wilson, 2015). Approaching this plan of intervention holistically (i.e., involving all important individuals in a child’s life) rather than individually (e.g., involving teachers and parents separately) can improve children’s behavior and reduce the probability that behavior problems will escalate (Dilberto & Brewer, 2014). Parents often feel a power imbalance and are treated as recipients, instead of participants, in their children’s educational plans (Jung, 2011; Scanlon, Saenz, & Kelly, 2018; Wilson, 2015). This imbalance can occur if professionals within the school setting blame the parent, choose not to acknowledge the parent’s expertise, are insensitive to certain cultural differences – whether religious or otherwise, and/ or use educational jargon with which only they are familiar (Jung, 2011). Clinicians walking parents through initial diagnostic and special education eligibility processes need to take time to communicate unknown acronyms and technical terms to both the parents and the teachers (Dunn et al., 2016). Parents and school personnel must view each other as allies throughout the entire IEP collaboration process (Carlson et al., in press; Scanlon et al., 2018). Clinicians should approach meetings with a mindset of emphasizing students’ strengths, discussing challenges, and program directions based on data, rather than prescribing families an explicit sequence of steps they must follow (Dunn, Constable, Martins, & Cammuso, 2016).

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Youth Involvement/Training  Youth are often considered “half-members” when it comes to interacting with mental health practitioners, their parents, and other adults regarding their care, and they are often considered to not have full interaction rights in their own care (O’Reilly, Lester, & Muskett, 2016). Little research describes how professionals should communicate with youth regarding their mental health (Wasserman et  al., 2018). Yet, various interventions and frameworks have been shown to improve knowledge of mental health, attitudes toward mental health, and help-seeking behaviors when school-based mental awareness programs are implemented (Salerno, 2016). For example, the Youth-Adult Program (Y-AP) is an American program that generates a forum for adults and youth to discuss youths’ health care concerns (Heffernan et al., 2017). Although this program is designed for more general areas of health, it provides a framework that could be tailored to mental health, allowing youth to be decision-makers rather than solely consumers of information or services. Y-AP views neither the youth nor the adults as experts, but it operates under the assumption that everyone has something to learn (Heffernan et al., 2017). Entering meetings with the mentality that everyone has a voice could encourage youth to become more involved in mental health services. Relatedly, giving youth a voice in their own care and allowing them the opportunity to communicate with their peers openly in the school setting about their issues may prove beneficial. Peer support provides a buffer from loneliness (Rasalingam, Raanaas, & Clench-Aas, 2017), and most students reach out to their peers for this support, including support regarding mental health, before they reach out to a professional (Byrom, 2018). Peer support has been shown to have a greater effect than even parental support on mental health and victimization issues, as these problems often occur in school settings where parental response is not accessible (Rasalingam et al., 2017). Furthermore, mental health interventions delivered by peers are shown to decrease stigma (Gopalan, Jung Lee, Harris, & Acri, 2017), as well as promote positive outcomes. For example, in one study on treatment for depression, a peer-­ facilitated program performed just as well as an intervention led by professionals (Byrom, 2018). Providing students with connections to peers for support may facilitate discussion of mental health issues and promote mental health awareness in schools. Data-Based Decision-Making  Students often only receive mental health services after significant symptoms of distress are present (Dowdy et al., 2015). Universal screening for mental health issues increases emphasis on prevention, early intervention, and promotion of mental health (Dowdy et al., 2015). There are often structural barriers between education and mental health services, however, with no joint data system for service coordination between schools and community agencies (Heflinger, Shaw, Higa-McMillan, Lunn, & Brannan, 2015). Coordinated use of screening data can be used to refine and expand mental health service delivery in schools (Dowdy et  al., 2015). Performance measurement of existing service systems is an integral piece to ensure that service systems are implementing these principles (Heflinger et al., 2015). A solution to lack of coordinated data utilization in schools would be partnering with local community agencies. Partnerships

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between schools and mental health agencies can assist in closing the research-to-­ practice gap, improving uptake, and implementing evidence-based practices (EBPs; Connors et al., 2018). Community-partnered school behavioral health is a model in which clinicians are trained in modular “common elements” (MCE) practices and deliver services in schools (Connors et al., 2018). The MCE approach utilizes data-­ driven selection and sequencing of interventions (Connors et al., 2018). Clinicians report that standardized evidence-based practices can be incompatible with some aspects of school behavioral health, requiring adaptation of EBPs to fit the student’s needs (Connors et al., 2018). Students who require extensive crisis management and those who lack basic needs or family structure, for example, may not benefit wholly from standardized practices (Connors et al., 2018). Providing training and support for SBH clinicians and school staff in data-based decision-making, as in functional behavioral assessment (FBA), can help to address some of these issues (Pence & St. Peter, 2018). Prioritize Mental Health  Some schools may not address the mental health needs of their students for fear of reflecting negatively on the school. However, school-­ level variables, such as school climate, can inform whole-school improvement efforts (Hopson, Schiller, & Lawson, 2014). For example, students who reported a more supportive school climate were three times as likely to report average or better behavior mental health, and less perceived stigma about mental health concerns (Hopson et al., 2014; Townsend et al., 2017). Further, regular assessment of school climate can help school staff and students to recognize and understand mental health concerns (Townsend et al., 2017). Even then, referrals from teachers or other professionals may not lead to services (DeFosset et  al., 2017). Instead, mental health needs are often addressed when there is disciplinary action involved or when needs have reached higher levels of severity (DeFosset et  al., 2017; Merikangas et  al., 2010); in many schools, there is a need for a more proactive stance about addressing student mental health issues (DeFosset et al., 2017). Routine measurement of school climate from the perspectives of key stakeholders, including students, parents, teachers, and administrators, is a critical strategy for prioritizing student mental health issues (Townsend et al., 2017). Despite these recommendations, a reality is that a focus on fiscal issues may constrain schools’ focus on student social, emotional, and behavioral functioning (Hardin, 2016). For example, some states only require districts to report summary information on budgets and expenditures versus more detailed reports on how these funds are allocated (Hardin, 2016). Incomplete policy guidance at the national level has produced a patchwork of fragmented services provided by federal, state, and local agencies that may be highly variable from community to community. Further, there may be competition between communities to obtain funding (Eiraldi, Wolk, Locke, & Beidas, 2015). Funding constraints in school districts also affect training, continuing education, and licensure status of mental health professionals in schools

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and the quality of services they provide (Demissie & Brener, 2017). These findings also underscore the critical role of school principals in advocating for sufficient funding for high-quality SBH professionals (Iachini, Pitner, Morgan, & Rhodes, 2015). Overcoming Inertia in Systems  In some instances, data are not utilized to support improved student functioning. For example, a number of studies support delayed starts to school to enable more sleep for students (Au et  al., 2014, Wahlstrom, Berger, & Winome, 2017); yet, many school districts have failed to make this change (Wheaton, Chapman, & Croft, 2016). Similarly, smaller class sizes and increased individualized and supportive interactions with students have been shown to improve student performance, but related to fiscal constraints, many schools are unable to make these critically needed changes (Weeden, Wills, Kottowitz, & Kamps, 2016). A final example is integrating of students with significant EB challenges into general education classrooms, with differentiated instruction strategies to enable their learning. Despite evidence of the effectiveness of this approach, many schools continue to teach these students in segregated environments (Conderman & Hedin, 2015).

Method A focus group on improving quality in SBH was held with 13 diverse stakeholders, including four parents, five mental health providers (from disciplines of counseling, school psychology, and social work), one researcher, one research coordinator, and two community agency leaders. The method for the forum and strategy for analysis is reviewed in the introductory chapter. Forum participants were presented with all questions below, followed by a discussion on each of them. 1. What are the characteristics of high-quality SBH programs at Tier 1? At Tier 2? At Tier 3? 2. Thinking about your experiences in our schools, what factors are most important for building high-quality SBH programs? Which of these factors are frequently missing in our schools? Why? 3. What is the top priority for quality improvement in SBH programs at Tier 1? At Tier 2? At Tier 3? 4. How have schools used data to help make decisions about or improve the quality of SBH services? Provide examples of schools doing this well at Tier 1, 2, and/or 3. 5. There are many research-based EBPs available for schools at Tier 1, Tier 2, and Tier 3. What challenges exist for adopting and implementing these programs in schools? What recommendations do you have for overcoming these challenges?

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6. How can students and families be more involved in collaboratively guiding and implementing EBPs in schools? 7. What other recommendations do you have to advance SBH in SC schools?

Results The results of the forum were collected and categorized into five different subthemes related to improving SBH quality. A number of these subthemes map onto critical dimensions of quality reviewed in the introduction to this chapter. First, many of the participants voiced the need for stronger collaboration between school personnel and parents, particularly concerning behavioral plans such as IEPs and Sect. 504 plans. A forum participant who works within a school noted, “Everyone is in crisis mode…,” when mental health issues are being addressed, stating, “We struggle; staff, admin, psychologists, and social workers of putting fires out. [We] put a band aid on something that clearly needs some stitches.” The group discussed ways to facilitate communication between all parties involved in the decision-­ making process, including students. Participants suggested avenues, such as education or peer groups, as possible ways to engage students in mental health services. Again, mapping onto the literature review, subthemes of data-based decision-­ making, training, and prioritizing mental health were discussed. Reflecting a cogent summary, one participant stated, “I think that people don’t see [students’ mental health] as a priority unless they are experiencing it personally within themselves.”

Collaboration Participants emphasized the need for greater collaboration between school personnel and parents. One participant stated, “Family education will be very important, meaning schools modeling to the parents how to interact with the schools and explain what services are actually available at the schools.” The same participant went on to say, “A lot of times parents don’t approach the schools because they don’t think they can help and think that DSS (The Department of Social Services) is going to come after them.” Fears, as well as other thoughts and feelings, “can be overwhelming for them [parents],” and another participant empathized, “because we don’t know what a parent is going through.” Instead of being bombarded with disheartening outlooks, parents should be empowered to collaborate with their child’s education and SBH personnel. As one participant put it, parents should feel they can take on a, “nothing about us, without us,” mentality when it comes to the decisions regarding their students’ well-being. A collaborative partnership between schools and families can decrease caregivers’ fears and allow them to have an active voice in their child’s care.

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Youth Involvement/Training A participant noticed that mental health service providers “don’t take input from the youth very often, if at all.” The forum participants noted that youth, like their caregivers, need to be active contributors in the discussion and planning of any type of services provided. One participant mentioned the importance of giving youth a voice so that they can “be vocal about what they need instead of [professionals] telling them what they need.” Participants also emphasized the need for peer support among students. One participant suggested helping “the youth be more engaged with other students, because a lot of times they are completely isolated… and don’t really interact.” Such interactions would provide a space for the youth to engage with one another about mental health and promote healthy social skills.

Data-Based Decision-Making Many participants emphasized the importance of data-based decision-making throughout the forum. One participant said: I always go back to the data; the data helps us make decisions and get past personalities, and that’s important. So, anything that we can do to get better, more consistent, and more accurate data in the hands of the right people… is what we need to do.

Utilizing data to prevent bias and to present clear, measurable goals was repeated throughout the meeting. One participant noted that one characteristic of high-­quality SBH programs was “some way to collect baseline data on everyone as to their mental health issues.” However, another participant brought up another issue concerning data, stating, “Our dilemma with school people is that they are wonderful at admiring data, but they do not know how to problem solve with data.” Incorporating training to help school personnel use data more effectively and efficiently was proposed as a solution by participants. One participant stated, “They have to have a team that’s responsible, and those people are trained in collecting data and understanding and knowing what to do with it.”

Prioritize Mental Health Participants agreed that no steps can or will be taken by schools until mental health is prioritized. The participants gave several reasons regarding why they believed schools were not addressing their students’ mental health. One explanation was, “Some of the schools seem like they do what is best for them, like their image… or how they are perceived by others, not what is in the best interest of their students or what their students actually want.” This was quite concerning for forum group members who also mentioned that schools prioritize fiscal needs and disregard

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students’ social, emotional, and behavioral needs. Simply put by one participant, “The social-emotional piece tends to fall aside in favor of the immediate fiscal needs.” Another participant added, “There should be a balance. The social-­emotional needs should be just as important as the other needs.” Schools must be a place for learning, but also a place where students are taken care of, both physically and mentally.

System Failures A final concern that was discussed in the forum was the overall failure of the school system, specifically dealing with traditional school structure, including class size and environment. Although many of the participants agreed on the problem, they offered various solutions. One participant believed a simple solution is smaller class sizes, explaining, “Smaller class sizes would allow teachers to build individualized instruction and provide needs for students who may need a smaller class environment to better learn. That would allow the teacher to better address the needs of students.” Another participant thought the size of the class was not the problem, but instead thought the setting to be the biggest issue. This participant’s solution was to create an alternate learning environment: If we could do a setting … like Apex online learning [program]… where they come to the school, so they have the social setting but cut down the area where they feel the anxiety of being forced to move 4-5 times a day with 30 kids in a classroom. We could see graduation rates go up and drop- out rates decrease…

Similarly, another participant recommended a “… program for kids that traditional settings do not meet their needs, so they are allowed to go to a different site… instead of a traditional school setting…” Taking students’ needs into account when structuring the school day may be a way to improve learning for students who may have difficulties in a traditional school setting.

Recommendations for Moving Forward Here, we summarize recommendations for improving the quality of SBH. Recommendations follow from those of participants in the focus group, and research/literature that was reviewed. Recommendations by the Participants  Among focus group participants, next steps focused on proper training of individuals who are delivering services and communication between key stakeholders involved in SBH. One participant described one of the most important factors for building high-quality SBH:

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Coming out of schools that I worked in, the factor of the ability of the folks who have been to school and all these different groups to get out of their silo and to communicate with each other. If they are not able to do that, I don’t care how high quality a program is, it will not be as effective as it could be until there is communication across different groups within a school.

Another participant highlighted the need for use of data to improve the quality of SBH services: “Training. They have to have a team that’s responsible and those people are trained in collecting data and understanding and knowing what do with it when they see it.” Recommendations from Previous Research  Research documents that well-done SBH improves access to care, reduces stigma regarding seeking treatment, and increases training opportunities due to targeted responsibilities of clinicians working in schools (Connors et al., 2018). However, organizational factors and attitudes toward SBH services can present complex challenges to implementation (Connors et al., 2018). There are several recommendations in the literature to promote high-­ quality SBH services through the use of EBPs. Examples of these recommendations include assessing clinicians’ attitudes regarding the use EBPs, effectively using interdisciplinary teams, and finding cost-effective strategies for building capacity for mental health services (Eiraldi et al., 2015). Inexperienced clinicians may lack therapeutic competencies, while more experienced providers may not be willing to change their existing practices (Eiraldi et al., 2015). This suggests that assessing attitudes to EBPs, promoting a culture of lifelong learning, and providing ongoing training and technical support for clinicians implementing EBPs are important strategies to combat this barrier. Considering interdisciplinary teams, under-resourced schools may experience barriers related to staff allocation, level of expertise, and turnover (Eiraldi et  al., 2015). All of these factors affect the cost of services, which could be decreased by providing periodic booster training to sustain implementation efforts and reduce turnover (Eiraldi et al. 2015). Improvements in cost-effectiveness could be facilitated by requiring fiscal transparency from public school districts, with states making budgets easier to locate and understand (Hardin, 2016). Additionally, findings suggest that school administrators’ knowledge of mental health services should be enhanced (Iachini et  al., 2015; O’Malley, Wendt, & Pate, 2018). Administrator knowledge of collaborative decision-making structures, partnership development, and resource allocation can maximize the role of mental health professionals in the school and reduce barriers to their effective provision of services (Iachini et al., 2015). A simple solution for facilitating collaboration between all parties would be to provide parents with the agenda of the meeting beforehand to allow the opportunity for them to prepare (Wilson, 2015). Parents often go into school meetings unaware of the agenda, so a provisional itinerary or having the parents complete a pre-­ meeting questionnaire could increase the effectiveness and efficiency of the meeting (Wilson, 2015). Research has demonstrated that parental involvement leads to better student outcomes and, therefore, healthy communication with parents is essential for collaboration success (Wilson, 2015). Support for this parental involvement in

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SBH programming should be a part of the larger infrastructure in schools and districts focused on effective training, coaching, and ongoing support for SBH clinicians and educators to help to assure the highest quality programming within the multitiered system of support (Eiraldi et al., 2015; Weist et al., 2007).

References Au, R., Carskadon, M., Millman, R., Wolfson, A., Braverman, P.  K., Adelman, W.  P., Breuner, C. C., Levine, D. A., Marcell, A. V., Murray, P. J., O’Brien, R. F., Devore, C. D., Allison, M., Ancona, R., Barnett, S.  E., Gunther, R., Holmes, B., Lerner, M., Minier, M., … & Young, T. (2014). School start times for adolescents. Pediatrics, 134(3), 642–649. ​Barrett, S., Eber, L., & Weist, M.D. (2013). Advancing education effectiveness: An Interconnected systems framework for Positive Behavioral Interventions and Supports (PBIS) and school mental health. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, US Department of Education). Eugene, Oregon: University of Oregon Press. Byrom, N. (2018). An evaluation of a peer support intervention for student mental health. Journal of Mental Health, 27(3), 240–246. Conderman, G., & Hedin, L. (2015). Differentiating instruction in co-taught classrooms for students with emotional/behaviour difficulties. Emotional & Behavioural Difficulties, 20(4), 349–361. Connors, E. H., Schiffman, J., Stein, K., LeDoux, S., Landsverk, J., & Hoover, S. (2018). Factors associated with community-partnered school behavioral health clinicians’ adoption and implementation of evidence-based practices. Administration and Policy in Mental Health and Mental Health Services Research, 46(1), 91–104. DeFosset, A. R., Gase, L. R., Ijadi-Maghsood, R., & Kuo, T. (2017). Youth descriptions of mental health needs and experiences with school-based services: Identifying ways to meet the needs of underserved adolescents. Journal of Health Care for the Poor and Underserved, 28(3), 1191–1207. Demissie, Z., & Brener, N. (2017). Demographic differences in district-level policies related to school mental health and social services-United States, 2012. Journal of School Health, 87(4), 227–235. Diliberto, J. A., & Brewer, D. (2014). Six tips for successful IEP meetings. Teaching Exceptional Children, 47(2), 128–135. Dowdy, E., Furlong, M., Raines, T. C., Price, M., Murdock, J., Kamphaus, R. W., et al. (2015). Enhancing school-based mental health services with a preventive and promotive approach to universal screening for complete mental health. Journal of Educational & Psychological Consultation, 25(2/3), 178–197. Dunn, B., Constable, S., Martins, T., & Cammuso, K. (2016). Educating children with autism: Collaboration between parents, teachers, and medical specialists. Brown University Child & Adolescent Behavior Letter, 32(7), 1–6. Eiraldi, R., Wolk, C. B., Locke, J., & Beidas, R. (2015). Clearing hurdles: The challenges of implementation of mental health evidence-based practices in under-resourced schools. Advances in School Mental Health Promotion, 8(3), 124–145. Galemore, C. A., & Sheetz, A. H. (2015). IEP, IHP, and section 504 primer for new school nurses. NASN School Nurse, 30(2), 85–88. Gopalan, G., Jung Lee, S., Harris, R., & Acri, M. (2017). Utilization of peers in services for youth with emotional and behavioral challenges: A scoping review. Journal of Adolescence, 55(1), 88–115.

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Hardin, M.  B. (2016). “Show me your budget and i will tell you what you value”: Why states should require school districts to publicize their budgets. Iowa Law Review, 101(2), 807–839. Heffernan, O. S., Herzog, T. M., Schiralli, J. E., Hawke, L. D., Chaim, G., & Henderson, J. L. (2017). Implementation of a youth-adult partnership model in youth mental health systems research: Challenges and successes. Health Expectations, 20(6), 1183–1188. Heflinger, C. A., Shaw, V., Higa-McMillan, C., Lunn, L., & Brannan, A. M. (2015). Patterns of child mental health delivery in a public system: Rural children and the role of rural residence. The Journal of Behavioral Health Services and Research, 42(3), 292–309. Hess, R. S., Pearrow, M., Hazel, C. E., Sander, J. B., & Wille, A. M. (2017). Enhancing the behavioral and mental health services within school-based contexts. Journal of Applied School Psychology, 33(3), 214–232. Hopson, L. M., Schiller, K. S., & Lawson, H. A. (2014). Exploring linkages between school climate, behavioral norms, social supports, and academic success. Social Work Research, 38(4), 197–209. Iachini, A. L., Pitner, R. O., Morgan, F., & Rhodes, K. (2015). Exploring the principal perspective: Implications for expanded school improvement and school mental health. Children & Schools, 38(1), 40–48. Jung, A. W. (2011). Individualized education programs (IEPs) and barriers for parents from culturally and linguistically diverse backgrounds. Multicultural Education, 18(3), 21–25. Kase, C., Hoover, S., Boyd, G., West, K. D., Dubenitz, J., Trivedi, P. A., et al. (2017). Educational outcomes associated with school behavioral health interventions: A review of the literature. Journal of School Health, 87(7), 554–562. Lo, L. l. (2012). Demystifying the IEP process for diverse parents of children with disabilities. Teaching Exceptional Children, 44(3), 14–20. Merikangas, K.  R., He, J., Burstein, M., Swanson, S.  A., Avenevoli, S., Cui, L., et  al. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989. O’Malley, M., Wendt, S.  J., & Pate, C. (2018). A view from the top: Superintendents’ perceptions of mental health supports in rural school districts. Educational Administration Quarterly, 54(5), 781–821. O’Reilly, M., Lester, J. N., & Muskett, T. (2016). Children’s claims to knowledge regarding their mental health experiences and practitioners’ negotiation of the problem. Patient Education and Counseling, 99(6), 905–910. Pence, S. T., & St. Peter, C. C. (2018). Training educators to collect descriptive-assessment data. Education and Treatment of Children, 41(2), 197–222. Rasalingam, A., Raanaas, R. K., & Clench-Aas, J. (2017). Peer victimization and related mental health problems in early adolescence: The mediating role of parental and peer support. Journal of Early Adolescence, 37(8), 1142–1162. Salerno, J. P. (2016). Effectiveness of universal school-based mental health awareness programs among youth in the United States: A systematic review. Journal of School Health, 86(12), 922–931. Scanlon, D. S., Saenz, L., & Kelly, M. P. (2018). The effectiveness of alternative IEP dispute resolution practices. Learning Disability Quarterly, 41(2), 68–78. Townsend, L., Musci, R., Stuart, E., Ruble, A., Beaudry, M. B., Schweizer, B., et al. (2017). The association of school climate, depression literacy, and mental health stigma among high school students. Journal of School Health, 87(8), 567. U.S. Census Bureau, U.S. Department of Health and Human Services. Frequently asked questions: 2016 National Survey of Children’s Health. Washington, DC; 2017. Wahlstrom, K.  L., Berger, A.  T., & Widome, R. (2017). Relationships between school start time, sleep duration, and adolescent behaviors. Sleep Health: Journal of the National Sleep Foundation, 3(3), 216–221.

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Wasserman, C., Postuvan, V., Herta, D., Iosue, M., Värnik, P., & Carli, V. (2018). Interactions between youth and mental health professionals: The youth aware of mental health (YAM) program experience. PLoS One, 13(2), 1–33. Weeden, M., Wills, H. P., Kottwitz, E., & Kamps, D. (2016). The effects of a class-wide behavior intervention for students with emotional and behavioral disorders. Behavioral Disorders, 42(1), 285–293. Weist, M.  D., Stephan, S., Lever, N., Moore, E., Flaspohler, P., Maras, M., Paternite, C., & Cosgrove, T.J. (2007). Quality and school mental health. In S. Evans, M. Weist, & Z. Serpell (Eds.), Advances in school-based mental health interventions (pp. 4:1–4:14). Civic Research Institute. Weist, M. D., Lever, N., Bradshaw, C., & Owens, J. S. (2014). Further advancing the field of school mental health. In M. Weist, N. Lever, C. Bradshaw, & J. Owens (Eds.), Handbook of school mental health: Research, training, practice, and policy, 2nd edition (pp. 1–16). Springer. Wheaton, A. G., Chapman, D. P., & Croft, J. B. (2016). School start times, sleep, behavioral health, and academic outcomes: A review of the literature. Journal of School Health, 86(5), 363–381. Wilson, N. M. (2015). Question-asking and advocacy by African American parents at individualized education program meetings: A social and cultural capital perspective. Multiple Voices For Ethnically Diverse Exceptional Learners, 15(2), 36–49. Yell, M. L., Katsiyannis, A., & Losinski, M. (2015). “Doug C. v. Hawaii Department of Education”: Parental participation in IEP development. Intervention in School and Clinic, 51(2), 118–121.

Enhancing Implementation Support for Effective School Behavioral Health Samantha N. Hartley and Carissa Orlando

Studies have shown that one in five youth will experience a mental health disorder; however, many will not receive treatment (Merikangas et al., 2010). A variety of barriers contribute to treatment engagement and retention including personal barriers to seeking help. These include perceived stigma and embarrassment, poor mental health literacy, and a preference for self-reliance (Gulliver, Griffiths, & Christensen, 2010), situational barriers that complicate treatment engagement (e.g., lack of resources, logistical barriers; Prinz & Miller, 1994), and structural barriers to receiving quality care (e.g., lack of coordination between youth-serving systems, lack of reimbursement for prevention; Baker-Ericzén, Jenkins, & Haine-Schlagel, 2013; Bringewatt & Gershoff, 2010). These barriers should be considered and addressed to assure the effectiveness of school behavioral health (SBH) programs. Providing youth with mental health services within schools can be challenging (Anderson & Lowen, 2010). While school mental health programs yield evidence of positive outcomes for youth and schools alike (e.g., Atkins et  al., 2006; Catron, Harris, & Weiss, 1998; Center for School Mental Health, 2013), an essential first step to providing these services is to successfully integrate the programs into the school setting. Researchers, mental health professionals, and school staff are often faced with the challenge of successful implementation. High-quality implementation of a program is often just as important as the evidence base surrounding the program (Durlak & DuPre, 2008). Reviews of SBH programs have found that implementation is consistently one of the most critical factors affecting program outcomes with quality implementation linked to more significant program benefits for the individuals served (Durlak & DuPre, 2008). Before schools can expect students to benefit from evidence-based programs, high-quality implementation of the program must be achieved. Frequently, barriers exist in school systems that impede quality implementation (Langley, S. N. Hartley (*) · C. Orlando Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_6

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Nadeem, Kataoka, Stein, & Jaycox, 2010) (Atkins, Frazier, Adil, & Talbott, 2003). Exploring and understanding these barriers and developing support for successful implementation is crucial to improving outcomes for students. Staff capacity, community partnerships, interdisciplinary collaboration, and data sharing between child-serving entities have been identified as critical themes for successful SBH implementation, with these themes reviewed in the following.

Staff Capacity Staff capacity reflects both general and intervention-specific abilities (Flaspohler, Duffy, Wandersman, Stillman, & Maras, 2008). Individual-level staff capacity may be understood as the skills, education, and expertise required for an individual to successfully function in their professional role. Intervention-specific capacities may include possessing an adequate understanding and knowledge of the intervention, motivation/buy-in for implementing the intervention, and perceiving oneself as capable of delivering the intervention successfully (Flaspohler et al., 2008; Scaccia et al., 2015). Promoting school staff capacity to implement evidence-based mental health interventions requires both training and organizational support for delivering the intervention as intended. Schools interested in delivering a new intervention should seek high-quality training and ongoing coaching to build a sufficient understanding of the intervention, troubleshoot implementation challenges as they occur, and promote fidelity (Forman, Olin, Hoagwood, Crowe, & Saka, 2009). Interventions delivered by teachers or other non-specialist school staff may require additional training and support, as many teachers feel that they lack sufficient education and experience to support their students’ mental health needs (Reinke, Stormont, Herman, Puri, & Goel, 2011). Even when delivered well, training alone does not guarantee staff capacity to implement an intervention. Contrary to the belief that implementation will succeed with enough staff training, one of the more prominent barriers cited by clinicians in school settings is competing responsibilities. For example, in a study of a trauma-focused group protocol delivered in schools, insufficient time to deliver the intervention was identified as the strongest impediment to program implementation by unsuccessful implementers. Even those experiencing success named competing responsibilities as the second most frequent challenge (Langley et al., 2010). Limited time for the intervention in the school day and competing priorities are also cited as barriers to implementation in schools by developers of evidence-based interventions (Forman et al., 2009). It is essential for administrators striving to make SBH a priority to address these issues and potentially realign staff responsibilities to allow quality delivery of interventions by teachers and other non-clinical staff. (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005).

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Community Partnerships Community partnerships improve the effectiveness of SBH (see Lehman, Clark, Bullis, Rinkin, & Castellanos, 2002). These partnerships also have the potential to improve a school’s capacity to inform, monitor, and address student mental health concerns, both individually and at a population-level (Dowdy, Ritchey, & Kamphaus, 2010). Partnering with community-based agencies enhances schools’ abilities to provide their students with access to mental health services (Weist, Grady Ambrose, & Lewis, 2006). Frameworks for mental health service delivery, such as systems-of-­ care, can help schools and community agencies develop the infrastructure needed to support students with a wide variety of mental health needs (Powers, Webber, & Bower, 2011). Under a systems-of-care model, schools and community partners coordinate care for students in a manner that is strength-based, family-driven, culturally competent, and individualized (Smith, Anderson, & Abell, 2008). Investing in developing strong collaborative relationships between schools and community resources can help overcome barriers to quality implementation of evidence-based practices in schools. Partnerships between schools and community resources, including universities, can promote quality implementation. Conducting research relevant to schools, supporting the development of school district organizational capacity, creating platforms for ongoing knowledge exchange, and promoting the use of local data and evaluation to support evidence-based decision-making about SBH are just a few of the ways these collaborations can enhance success in delivery of interventions (Short, Weist, Manion, & Evans, 2012). Although sustaining community–school partnerships requires strong leadership and a commitment to consistent communication, collaboration, and coordination (Anderson-Butcher, Stetler, & Midle, 2006), these partnerships are an important tool for increasing school and community abilities to promote the mental health and well-being of their students.

Interdisciplinary Collaboration Collaboration between SBH personnel, school faculty/staff, other youth-serving professionals, and families is foundational to effective implementation (Weist et al., 2005). Collaborative processes, such as shared decision-making between relevant parties, coordination and partnerships across agencies, and communication between all partners are factors that positively impact successful implementation (Durlak & DuPre, 2008). These interdisciplinary collaborations have the potential to increase productivity, improve outcomes for students receiving services, decrease the risk of duplicative or disjointed services (which may, in turn, decrease the financial burden of services), and raise satisfaction with mental health services (Anderson-Butcher & Ashton, 2004; Lever et  al., 2003; Rappaport, Osher, Greenberg Garrison,

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Anderson-Ketchmark, & Dwyer, 2003; Weist, Proescher, Prodente, Ambrose, & Waxman, 2001). Forming interdisciplinary teams can be an excellent way to facilitate collaboration and effective provision of school-based services. These teams should include not only school mental health personnel, but also school staff members (e.g., school counselors, social workers, nurses, resources officers, etc.), school administration, community partners and providers, as well as representative family members (Anderson-Butcher & Ashton, 2004; Barrett, Eber, & Weist, 2013; Waxman, Weist, & Benson, 1999). These school teams can work together to ensure that school-based interventions are implemented appropriately through activities such as goal-setting, determining intervention delivery methods, coordinating on the identification of additional resources, progress-monitoring, and coordinating responses to any issues that arise (Anderson-Butcher & Ashton, 2004; Waxman et al., 1999).

Information/Data Sharing A natural benefit of collaboration is the ease of information and data sharing between youth-serving entities (e.g., between school-based clinicians and community care, such as physicians or psychiatrists). It can often be difficult to share information across agencies due to client protection laws, such as the Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA), as well as the ethical boundaries of client confidentiality to which licensed mental health providers must adhere. However, with proper permission obtained from parents/caregivers, as well as the student when appropriate, regular communication and sharing of pertinent information related to students’ needs and treatment can facilitate them receiving quality care across systems (Waxman et al., 1999; Weist et al., 2001). Although some mental health professionals may adopt an “expert” model when sharing or obtaining information, this hierarchical perspective may hinder assessment and treatment processes. Rather, information-sharing is best conducted through an egalitarian perspective, where each partner is recognized for the unique and helpful knowledge they possess (Rappaport et al., 2003; Weist et al., 2001). Regular information gathering and sharing with a student’s parent/caregiver can also be a helpful component of treatment, as parents can serve as helpful collaborators and possess vital information regarding their child’s symptoms and behavior (Becker, Buckingham, & Brand, 2015).

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Method Eleven stakeholders, including three parents, three researchers, two university staff, two teachers, and one family advocate, assembled to discuss barriers to and ways to improve implementation support for evidence-based SBH. The following questions were presented to participants to guide the discussion on implementation support: (1) What school behavioral health (SBH) initiatives are your schools currently implementing? (2) In your mind, what is the quality of implementation of these programs; for example, are programs implemented as intended, with consistency, with strong involvement of school staff and students? (3) What are the factors that help these programs to be implemented well? (4) What are the challenges encountered in implementing these programs well? (5) What recommendations do you have for overcoming these challenges? (6) How can school, family, mental health, and partnerships with other community systems help improve the implementation of high quality, evidence-based programs across the three tiers toward effective and high impact SBH? (7) What other recommendations do you have?

Results During the discussion, participants identified a number of themes that either served as barriers to or facilitators of quality SBH implementation. The questions above were selected to reflect prominent themes in the literature and helped to serve as a foundation for this discussion. In this portion of the chapter, we will review the comments and recommendations of forum participants on these themes.

Staff Capacity Participants identified insufficient staff capacity as a barrier to quality implementation of SBH. Insufficient capacity was conceptualized both as a lack of training and knowledge for existing staff and the inadequate availability of specialized staff to provide essential services to students. Not having the capacity to address mental health concerns in schools may disrupt a child’s education. One participant expressed frustration at being able to identify a child’s mental health needs and the associated recommended treatment approach but ending up “losing that student for a year” to residential or home-based services because their school was unable to provide indicated services.

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Addressing insufficient staff capacity may include hiring additional specialized staff to provide mental health services to students. Existing school staff, such as school counselors, are often unable to provide those services on top of their other job responsibilities. Having enough mental health support “available for the kids when they need it” was identified as being “key” by another participant. To address the needs of students who require support beyond what a teacher provides in the classroom, but whose needs do not yet rise to the level of requiring resource-­ intensive individualized intervention, some schools have chosen to use their Title I funds (related to having relatively high levels of disadvantaged students) to hire behavioral interventionists. When a child is exhibiting behavior-based difficulties in the classroom, behavioral interventionists intervene early, conduct classroom observations, and consult with teachers to provide individual strategies for successfully managing that student’s behavior. Leveraging specialist knowledge at an earlier stage (i.e., “before it gets to the district support level”) is responsive to the presenting need, builds teacher capacity, and demonstrates an effort to keep students within the least restrictive learning environment. Participants also emphasized the importance of providing staff with appropriate training to support student mental health at all levels of need. Participants noted that recent shifts to a more inclusive mindset promoting the inclusion of children with disabilities in general education classroom settings have increased requests for staff-wide training and professional development. Whereas schools in the past may have “always kind of assumed that the special education teacher was the only one who needed to have those bag of tricks, that toolbox,” one district-level behavioral specialist indicated that “schools as a whole – elementary, middle, and high – have really stepped up to the game in asking for training.” Another participant noted that, although many teachers, “especially special content teachers at the secondary level,” may not have a background in behavior, professional development “providing them with the knowledge to feel confident in understanding behavior and how to intervene” is ‘huge.’” Trainings that allow specialists to consult with teachers through classroom observation, modeling, and supervised practice of behavioral intervention strategies were viewed as especially meaningful in supporting teachers’ classroom behavior management capacity. As one group member noted, “you can’t just hold a meeting and say what you can and can’t do.” Although the group was generally optimistic about district efforts to provide training and support to teachers, they expressed frustration with the apparent lack of quality training demonstrated by mental health clinicians tasked with treating individual students. One participant lamented the lack of specialized knowledge evidenced in their approach to care, saying, “there’s not requirements for them to have any training in any particular area, and they are dealing with some of our most difficult children and it’s not working.”

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Community Partnerships Participants recognized that creating connections between schools and community mental health resources was an essential step for facilitating appropriate referrals and ensuring that students receive appropriate specialist care. However, the strength and nature of school-community partnerships varied extensively across sites. Although some schools had a general awareness of the existence of community-­ based resources, specific knowledge necessary for making student referrals was often unavailable. As one participant reflected, “We knew there were a lot of different agencies out in the community, but to know who did what and the scope of their expertise was lacking.” Other districts demonstrated stronger partnerships with community mental health agencies, including contracts with them to provide school- and home-based clinical services to students. These partnerships have allowed them not only to provide access to care “as crises arrive,” but to offer proactive services such as a monthly preschool parenting class “to help…our parents to work with early onsite behaviors that we are seeing and that the parents are seeing in the homes.” When student mental health needs cannot be met with school-based services, strong partnerships between school districts and residential treatment programs can help decrease the time students spend out of school and facilitate a smoother transition back into the school community that empowers students and their parents. One participant described the success of this partnership despite obstacles, stating A lot of families are having to drive to us from an hour or more away… but we have 100% participation of family in our action, they come in once a week for family therapy… they are going out with their families on the weekends, it is hard but they do it anyways.

Interdisciplinary Collaboration One of the themes discussed by forum participants was the importance of interdisciplinary collaboration in effectively meeting the needs of youth. Participants discussed the benefits of multiple professionals (e.g., mental health professionals, teachers, behavior specialists, physicians) caring for the child, sharing information, and working together to treat the child. One participant noted, The cases in which we’ve made the biggest difference in students are the cases in which the district support, behavioral specialist, and instructional support specialist and other support people have actually gone to doctors’ appointments and gone with them to a therapist and gone with the parents and have had that open round table discussion.

This participant also stressed that this collaboration should begin as early as possible rather than “waiting ‘till we are all in crisis, because first we need to get through the crisis before we can start working with the child.” It was discussed that collaboration should entail a partnership between agencies, with an assumption of equal status between members and a

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Participants also stressed the importance of conceptualizing the parent as the “expert” on their child and forming a partnership with the parent, regardless of the students’ walk of life. One participant noted, “There is nothing like sitting at a table with everyone and having that open conversation with the parents there about the child’s whole plan… I wish we were able to do more of that.” A parent participant shared an appreciation for an inclusion in the team-based collaboration of transitioning their child back into the public school system, stating that Their therapist from the children’s program actually came to a meeting with [school administrator] … and told the teachers and his school what worked for him and what they could do to make the transition more successful….They didn’t leave me to go into the school to say this is what they say and this is what works.

Data Sharing This collaboration between interdisciplinary professionals also facilitates information sharing regarding care for the child, which was another theme discussed by forum participants. One medical professional discussed the benefits of being able to receive information about a child’s school functioning, stating, “There’s a flow [of information] that happens, so if I am starting a kid on a stimulant, I’m able to get feedback very quickly on what is working in the classroom and what is not.” Another participant stressed the importance of this ease of information sharing, noting, “you want schools to feel comfortable and to get a response from the psychologist, psychiatrist as quickly as possible so that they don’t do anything that would undermine treatment.” This ease of sharing of information can allow professionals to communicate directly to each other rather than relying on the parent to act as a “mediator” between different systems, which one participant pointed out can be “so overwhelming for them.” While participants agreed that this collaboration and sharing of information is essential, it was noted that it can be difficult to achieve due to a variety of barriers. Indeed, from the perspective of an individual working outside of the school, professionals working with children often operate in silos, making it very difficult to access information about the child’s functioning in school. This participant explained, I can look at anything, pediatrician records…therapy records from a mental health center, but I have no clue what goes on in school, because getting that data back is next to impossible, because you never have a conversation with a teacher, never have a conversation with a counselor from the school. So there has to be some way to figure out how to connect what is happening in the school settings to what is actually happening in the medical settings or any other settings in general.

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This participant noted that this lack of collaboration results in “two incomplete sets of plans that sit on each side of the kid.” Several other participants noted that currently, it can be difficult to access records from various professionals. As presented earlier, some of these difficulties with information sharing come from legal parameters surrounding sharing of information, such as HIPAA and FERPA. A participant noted that “with teachers sometimes…it is like, ‘how much do I share, how much do I not share?’” and “‘what is my liability, if I say it?” Additionally, participants pointed out that parameters surrounding information sharing vary by school; one participant noted, “some schools are forthcoming and others are, ‘We can’t send that over the Internet.’” Parameters surrounding information sharing also may vary by type of school (e.g., public schools versus charter schools). Another participant stated that when working in a charter school, “I’m able to access whatever I need to access, I’m able to look at it and share the information back and forth,” noting that charter schools “are smaller and there are different rules, but you are really able to be in a partnership, whereas with a public school it is much more difficult to develop that partnership.” This participant suggested that this difficulty may be due to “a much larger bureaucracy and you are not sure who you are interacting with and so there is not a built-in information flow that is going back and forth at any level.” For individuals working within the school, time constraints were noted as a barrier to interdisciplinary collaboration, as well as sustainability of collaboration. For example, one participant noted the benefits of mental health staff and teachers working together to implement indicated behavioral interventions, but noted “these kinds of things don’t happen on a 30-minute schedule.” Lack of awareness was also noted as an additional barrier; another participant explained that, “we knew there were a lot of different agencies out in the community but to know who did what and the scope of their expertise was lacking.” This participant went on to explain that their position was created to address this lack of collaboration.

Recommendations for Moving Forward Participants had a few suggestions for improving the implementation of quality SBH practices. For schools implementing a multitiered system of support (MTSS) and instituting more inclusive educational practices, participants felt it necessary for administrators to support training for teachers to be skilled agents at prevention and promotion-oriented universal classroom interventions. By conducting intensive all-­ staff training, working on specific behavior management strategies with individual teachers, and consistently setting and teaching positive expectations to students, one behavior specialist was optimistic that many of the behaviors that may have once led to more resource-intensive intervention referrals could be prevented. This individual noted,

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S. N. Hartley and C. Orlando We’re really starting to see a change in mindset there; opening the doors for us to do intensive trainings with teachers as a whole and with individual teachers really working on behavior management at the very front, and setting positive expectations and teaching those expectations to prevent behaviors from reaching tier 2 or tier 3.

Quality implementation of SBH interventions takes time. Without hiring additional staff, reallocation of existing staff time and responsibilities is imperative to allow for meaningful engagement in delivery and coordination of quality SBH. One participant spoke to the importance of school leadership in facilitating this reallocation, saying that her school’s Director of Counseling “has actually done a huge push for our counselors to not be in charge of testing and other things, so our schoolbased counselors are now part of our tiered level of support.” Facilitating the meaningful and significant involvement of school counselors in MTSS “starts at the top. The top-down needs to say that this is a priority.” As a result of this prioritization, these school-based counselors were able to overcome barriers to mental health service access (e.g., part-time, itinerant staff, insurance challenges) and provide students with a continuum of mental health supports (see Owens et al., 2002). At this participant’s school, this included creating a role for school counselors in teaching coping skills and mental health literacy in the classroom (Tier I), conducting small groups for anger management (Tier 2), and providing counseling to students who have been identified as needing individualized services but do not qualify for special education services (Tier 3). To address the issue of a lack of awareness of community-based mental health resources, one school-sponsored an “agency fair” for all teachers to attend. Reflecting on the experience, this participant felt that “it opened up the door to all the different agencies and supports within our community that are offered and that our teachers weren’t aware of…and equipping our teachers with that knowledge.” Although parents were not invited to attend last year’s agency fair, the district is considering coordinating a similar resource fair for parents who “are saying that they need help, to be pointed in the right direction.” After addressing the initial step of increasing awareness of what resources exist in their community, schools, and community agencies are coming together through memorandums of agreement to improve access by allowing services to be provided in schools. Although the initial establishment of district-community partnerships through these documents may require the involvement of the entities’ legal departments, access after this point “is not an issue because of the written legal document between the two,” according to one participant.

The Importance of Partnerships A major theme discussed by participants was creating partnerships with community and state organizations, which has been found to improve the implementation of effective services for children and youth (Nastasi, 2000; Power, 2003). One participant discussed the partnerships formed between several school districts and the

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local mental health centers, which enabled clinicians from the mental health centers to work with students in the schools. The participants agreed that although there are a few outstanding examples, there is no wide-scale adoption of effective partnerships between families, schools, and other youth-serving systems. While some of the programs that participants discussed seemed to be helpful, a number of barriers (e.g., stigma, transportation problems, insurance issues) hinder the reach of these programs (see Cummings, Lucas, & Druss, 2013; Ouellette, Briscoe, & Tyson, 2004). One participant brought up that some families must drive up to an hour to access programs for their children. Additionally, the participants said that teachers and school administrators are not aware of the programs available to schools or families, which precludes any potential partnership from forming. According to one participant, a district has attempted to solve this problem by hiring an individual to connect and coordinate all available services with the schools.

Need to Enhance Communication Participants identified a lack of communication between schools, caregivers, and youth behavioral and physical health care providers as a significant major challenge to effective early intervention and treatment. Specifically, the participants thought that being able to share information across caregivers and providers would improve the coordination of services and, in turn, the support students receive. In addition to enhancing support, this collaborative method of support could foster a greater sense of collaboration and mutual respect among school and community members involved in the child’s life. This method of treatment coordination would then keep the responsibility of communicating a child’s needs and treatment between doctor, clinician, and school from resting solely on the parents’ shoulders. Although there are legal hurdles to a system of collaborative care (such as communication restrictions associated with FERPA), one of the participants cited a charter school that has partnered with a local hospital system to establish a flow of information between the school, the hospital, and clinicians involved in SBH services.

Addressing Insurance Challenges Participants recognized insurance problems as another major barrier to students accessing appropriate services. One district that has addressed a structural barrier by having mental health clinicians deliver services in the schools still deals with the challenge of costs as uninsured students cannot receive services. In an extreme case, one participant noted that an uninsured student with more severe emotional/behavioral concerns was sent to a residential treatment center because it was the only way of receiving affordable treatment. One school was able to address the cost barrier by

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acquiring social and fiscal support from the director of counseling at the local Department of Mental Health, who was able to allocate some funding for treatment for uninsured students.

Helping Families Find Help Participants also discussed that parents want help to understand their children’s behavioral health issues, but they often do not know where they can go to receive that help. One school has created a parent academy that focuses on helping parents understand their role in the treatment process and as an advocate for their child. Another school held an agency fair for parents to learn about programs and services available for their families. Some of the participants felt that general education teachers are not receiving enough training in integrating special education students into standard classrooms, as many schools are moving toward more inclusive classrooms. This lack of training is of particular importance as some evidence suggests that without some training on interacting with students with disabilities, teachers can focus on the disability rather than the student (Carroll, Forlin, & Jobling, 2003).

Increasing Implementation Supports Participants had a few suggestions for moving forward with implementation support in schools. First, schools should make resources about programs and services readily available to families and teachers. Second, partnerships between behavioral health care providers and schools should be emphasized to coordinate services for students. Third, more teachers should be trained in understanding adverse childhood experiences, with this helping to increase empathy for student situations, and enthusiasm for implementing effective programs to help them. Finally, team meetings should be interdisciplinary when developing treatment plans for students as participants have noticed the greatest impacts for students needing intensive interventions occur when all individuals involved in the student’s treatment come together to discuss a comprehensive treatment plan.

Conclusion The perspectives of the stakeholders present for this forum were unique and valuable, underscoring the consequences of insufficient capacity and coordination for high-quality implementation of SBH. Based on findings from this forum, an important direction going forward would be to solicit feedback from school-based interdisciplinary teams responsible for implementing MTSS on their recommendations

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for improving implementation. Speaking with individuals who have direct experience with implementation will allow us to better understand the current level of implementation at each tier as well as challenges and facilitators to quality implementation, and ideas for improved implementation support, training, and technical assistance. These conversations would have the potential to inform implementation support that is ideally connected from the school building to district and state levels, ultimately improving the quality, reach, and impact of school behavioral health.

References Anderson, J.  E., & Lowen, C.  A. (2010). Connecting youth with health services: Systematic review. Canadian Family Physician, 56(8), 778–784. Anderson-Butcher, D., & Ashton, D. (2004). Innovative models of collaboration to serve children, youths, families, and communities. Children & Schools, 26(1), 39–53. Anderson-Butcher, D., Stetler, E. G., & Midle, T. (2006). A case for expanded school-community partnerships in support of positive youth development. Children & Schools, 28(3), 155–163. Atkins, M. S., Frazier, S. L., Adil, J. A., & Talbott, E. (2003). School-based mental health services in urban communities. In Handbook of school mental health advancing practice and research (pp. 165–178). Boston, MA: Springer. Atkins, M. S., Frazier, S. L., Birman, D., Adil, J. A., Jackson, M., Graczyk, P. A., et al. (2006). School-based mental health services for children living in high poverty urban communities. Administration and Policy in Mental Health and Mental Health Services Research, 33(2), 146–159. Baker-Ericzén, M. J., Jenkins, M. M., & Haine-Schlagel, R. (2013). Therapist, parent, and youth perspectives of treatment barriers to family-focused community outpatient mental health services. Journal of Child and Family Studies, 22(6), 854–868. Barrett, S., Eber, L., & Weist, M. D. (2013). Advancing education effectiveness: An interconnected systems framework for positive behavioral interventions and supports (PBIS) and school mental health. In Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, US Department of education). Eugene, OR: University of Oregon Press. Becker, K. D., Buckingham, S. L., & Brand, N. E. (2015). Engaging youth and families in school mental health services. Child and Adolescent Psychiatric Clinics of North America, 24(2), 385–398. Bringewatt, E.  H., & Gershoff, E.  T. (2010). Falling through the cracks: Gaps and barriers in the mental health system for America’s disadvantaged children. Children and Youth Services Review, 32(10), 1291–1299. Carroll, A., Forlin, C., & Jobling, A. (2003). The impact of teacher training in special education on the attitudes of Australian preservice general educators towards people with disabilities. Teacher Education Quarterly, 30(3), 65–79. Catron, T., Harris, V. S., & Weiss, B. (1998). Posttreatment results after 2 years of services in the Vanderbilt school-based counseling project. In M. H. Epstein, K. Kutash, & A. Ducknowski (Eds.), Outcomes for children and youth with behavioral and emotional disorders and their families: Programs and evaluation best practices (pp. 633–656). Austin, TX: Pro-Ed. Center for School Mental Health. (2013). The impact of school mental health: Educational, social, emotional, and behavioral outcomes. University of Maryland School of Medicine. http:// csmh.umaryland.edu/media/SOM/Microsites/CSMH/docs/CSMH-SMH-Impact-SummaryJuly-2013-.pdf

72

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Cummings, J. R., Lucas, S. M., & Druss, B. G. (2013). Addressing public stigma and disparities among persons with mental illness: The role of federal policy. American Journal of Public Health, 103(5), 781–785. Dowdy, E., Ritchey, K., & Kamphaus, R. W. (2010). School-based screening: A population-based approach to inform and monitor children’s mental health needs. School Mental Health, 2(4), 166–176. Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology, 41(3–4), 327–350. Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network. Flaspohler, P., Duffy, J., Wandersman, A., Stillman, L., & Maras, M. A. (2008). Unpacking prevention capacity: An intersection of research- to- practice models and community-centered models. American Journal of Community Psychology, 41(3–4), 182–196. Forman, S.  G., Olin, S.  S., Hoagwood, K.  E., Crowe, M., & Saka, N. (2009). Evidence-based interventions in schools: Developers’ views of implementation barriers and facilitators. School Mental Health, 1(1), 26–36. Gulliver, A., Griffiths, K. M., & Christensen, H. (2010). Perceived barriers and facilitators to mental health help-seeking in young people: A systematic review. BMC Psychiatry, 10(1), 113. Langley, A. K., Nadeem, E., Kataoka, S. H., Stein, B. D., & Jaycox, L. H. (2010). Evidence-based mental health programs in schools: Barriers and facilitators of successful implementation. School Mental Health, 2(3), 105–113. Lehman, C. M., Clark, H. B., Bullis, M., Rinkin, J., & Castellanos, L. A. (2002). Transition from school to adult life: Empowering youth through community ownership and accountability. Journal of Child and Family Studies, 11(1), 127–141. Lever, N. A., Adelsheim, S., Prodente, C. A., Christodulu, K. V., Ambrose, M. G., Schlitt, J., et al. (2003). System, agency, and stakeholder collaboration to advance mental health programs in schools. In M. D. Weist, S. W. Evans, & N. A. Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp. 149–162). Boston, MA: Springer. Merikangas, K.  R., He, J., Burstein, M., Swanson, S.  A., Avenevoli, S., Cui, L., et  al. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989. Nastasi, B. K. (2000). School psychologists as health-care providers in the 21st century: Conceptual framework, professional identity, and professional practice. School Psychology Review, 29(4), 540–554. Ouellette, P. M., Briscoe, R., & Tyson, C. (2004). Parent-school and community partnerships in children’s mental health: Networking challenges, dilemmas, and solutions. Journal of Child and Family Studies, 13(3), 295–308. Owens, P.  L., Hoagwood, K., Horwitz, S.  M., Leaf, P.  J., Poduska, J.  M., Kellam, S.  G., et  al. (2002). Barriers to children’s mental health services. Journal of the American Academy of Child & Adolescent Psychiatry, 41(6), 731–738. Power, T.  J. (2003). Promoting children’s mental health: Reform through interdisciplinary and community partnerships. School Psychology Review, 32(1), 3–16. Powers, J.  D., Webber, K.  C., & Bower, H.  A. (2011). Promoting school mental health with a Systems of Care approach: Perspectives from community partners. Social Work in Mental Health, 9(3), 147–162. Prinz, R.  J., & Miller, G.  E. (1994). Family-based treatment for childhood antisocial behavior: Experimental influences on dropout and engagement. Journal of Consulting and Clinical Psychology, 62(3), 645. Rappaport, N., Osher, D., Greenberg Garrison, E., Anderson-Ketchmark, C., & Dwyer, K. (2003). Enhancing collaboration within and across disciplines to advance mental health programs in

Enhancing Implementation Support for Effective School Behavioral Health

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schools. In M.  D. Weist, S.  Evans, & N.  Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp.  107–118). Boston, MA: Kluwer Academic/Plenum Publishers. Reinke, W. M., Stormont, M., Herman, K. C., Puri, R., & Goel, N. (2011). Supporting children’s mental health in schools: Teacher perceptions of needs, roles, and barriers. School Psychology Quarterly, 26(1), 1–13. Scaccia, J. P., Cook, B. S., Lamont, A., Wandersman, A., Castellow, J., Katz, J., et al. (2015). A practical implementation science heuristic for organizational readiness: R= MC2. Journal of Community Psychology, 43(4), 484–501. Short, K. H., Weist, M. D., Manion, I. G., & Evans, S. W. (2012). Tying together research and practice: Using ROPE for successful partnerships in school mental health. Administration and Policy in Mental Health and Mental Health Services Research, 39(4), 238–247. Smith, J. S., Anderson, J. A., & Abell, A. K. (2008). Preliminary evaluation of the full-purpose partnership schoolwide model. Preventing School Failure: Alternative Education for Children and Youth, 53(1), 28–38. Waxman, R.  P., Weist, M.  D., & Benson, D.  M. (1999). Toward collaboration in the growing education-mental health interface. Clinical Psychology Review, 19(2), 239–253. Weist, M. D., Grady Ambrose, M., & Lewis, C. P. (2006). Expanded school mental health: A collaborative community-school example. Children & Schools, 28(1), 45–50. Weist, M. D., Proescher, E., Prodente, C., Ambrose, M. G., & Waxman, R. P. (2001). Mental health, health, and education staff working together in schools. Child and Adolescent Psychiatric Clinics of North America, 10(1), 33–43. Weist, M.  D., Sander, M.  A., Walrath, C., Link, B., Nabors, L., Adelsheim, S., et  al. (2005). Developing principles for best practice in expanded school mental health. Journal of Youth and Adolescence, 34(1), 7–13.

Youth with Connections to the Juvenile Justice System: A Priority Population for School Behavioral Health Linden Atelsek and Alex M. Roberts

More than 50,000 juveniles were incarcerated in the United States in 2014, making juvenile justice involvement disproportionately likely for youth in the United States compared to other countries (Petteruti & Fenster, 2011; Puzzanchera, Hockenberry, Sladky, & Kang, 2018). The juvenile justice system originally separated from the rest of the justice system due to the notion that children are more “redeemable” than adults and should thus be treated with rehabilitation in mind (American Bar Association, 2007). However, the past 40 years have seen a return to a retributive form of justice (Advancement Project, 2010; American Bar Association, 2007). The juvenile justice system is regarded as having a more punitive mindset, compared to education and mental health professionals working with juvenile offenders, who typically view delinquency as a treatable condition (Kapp, Petr, Robbins, & Choi, 2013). Juvenile justice involvement is inextricably linked to behavioral health (BH). Studies show that the majority of juvenile justice-involved youth (JJIY) experience mental health challenges, often depression and anxiety (Abram, Teplin, McClelland, & Dulcan, 2003; Burke, Mulvey, & Schubert, 2015; Skowyra & Cocozza, 2006; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). Despite this, JJIY rarely access mental health services (Burke et al., 2015). This is important given the finding that mental health support in childhood (e.g., school- or community-based services, inpatient and/or outpatient treatment) may protect against juvenile incarceration in at-risk youth (Burke et  al., 2015; Liebenberg & Ungar, 2014). Additionally, youth’s ability to access mental health services decreases after they become involved with the justice system: only one-fourth of juvenile justice facilities screen for suicide risk, and fewer than half screen for general mental health L. Atelsek (*) University of Virginia School of Law, Charlottesville, VA, USA A. M. Roberts Psychology Department, University of North Carolina, Chapel Hill, NC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_7

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needs. Further, 90% of JJIY reside in facilities with no mental health professionals (McPherson & Sedlak, 2010). Justice involvement has profound short- and long-term effects on youth. Short-­ term effects include decreases in overall educational attainment, partially due to reduced rates of high school graduation (Sweeten, 2006; Tanner, Davies, & O’Grady, 1999). Even juveniles who are motivated to return to school after their incarceration may face unexpected barriers. For example, school administrators are often systemically motivated to block the reentry of juvenile offenders into the mainstream school system, as these youth tend to display problem behavior and may decrease the school’s average level of academic achievement (Mayer, 2005). Additionally, JJIY are often primed to re-offend because of negative peer influences during incarceration (Mathys, Hyde, Shaw, & Born, 2013; Shapiro, Smith, Malone, & Collaro, 2010). Recent evidence suggests that juvenile justice involvement also has long-term effects on youth in multiple domains. Early incarceration is linked with poor mental and physical health later in life (Barnert et al., 2017), and arrest before age 18 predicts felony conviction by 26 (Ou & Reynolds, 2010). Even those JJIY who manage to escape the cycle of recidivism face significant life challenges throughout adulthood, as justice involvement in childhood predicts greater difficulty gaining and maintaining employment in adulthood (van der Geest, Bijleveld, Blokland, & Nagin, 2016). Research suggests the existence of a vicious cycle: early arrest leads to school dropout, which leads to lower occupational attainment, ultimately resulting in higher rates of arrest in adulthood (Kirk & Sampson, 2013). All JJIY do not experience these negative effects equally. Poor and non-White students bear the brunt of punitive school policies, likely contributing to the finding that non-White students report feeling less safe in school than do White students (Lacoe, 2015; Mallett, 2016). Regarding sentencing for juvenile offenses, White youth are more likely to be assigned to therapeutic programs, while Black youth are more likely to be assigned to physical labor programs (Cochran & Mears, 2015; Fader, Kurlychek, & Morgan, 2014; Lehmann, Chiricos, & Bales, 2017). Additionally, Black youth receive fewer resources while in the juvenile justice system and are more likely to be placed in high-security facilities (Cochran & Mears, 2015). Black ex-juvenile offenders are more likely to be unemployed than other adults who were not justice-involved in their youth; they also receive lower wages if they are employed—a trend that does not exist for White or Hispanic ex-juvenile offenders (Taylor, 2016; van der Geest et al., 2016). Gender and sexual orientation also play a role in juvenile justice involvement. Although females are less likely to be sentenced to prison than males, they are significantly more likely to be held in an alternative residential facility than to be put on probation or in other “outpatient” programs (Tam, Abrams, Freisthler, & Ryan, 2016). Females who are imprisoned are typically sentenced to longer periods of confinement, particularly for status offenses (i.e., truancy, curfew violations; Espinosa & Sorensen, 2016). Nearly 40% of incarcerated female JJIY identify as lesbian or bisexual (Wilson et al., 2017). This is in addition to the overrepresentation of sexual minority youth in the entire JJIY population, with approximately 12%

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of juvenile offenders identifying as sexual minorities (Wilson et al., 2017). Youth who identify as sexual minorities are disproportionately subject to punishment in schools compared to non-sexual minority peers; they are also more vulnerable to exclusionary discipline like suspension and expulsion, which may increase overall dropout rate and lead to initial offense and re-offense (Fabelo et al., 2011; Poteat, Scheer, & Chong, 2016). Schools play an integral part in the “school-to-prison pipeline,” which refers to the connection between school discipline, education policy, and juvenile justice involvement. Rates of in-school arrests are rising (in Pennsylvania, they recently tripled over a seven-year period), along with a 300% increase in police presence in schools (Advancement Project, 2010; Mallett, 2016). Despite this, students do not report feeling safer when police are present (Advancement Project, 2010). In fact, police presence may result in educational disruption, as students are temporarily or permanently removed from the classroom for minor misbehavior (Mallett, 2016). Students who are given in-school suspension are nearly five times more likely to drop out of school than other students (Cholewa, Hull, Babcock, & Smith, 2017); school suspension of any kind is directly related to dropout, grade retention, and failure to graduate and inversely related to academic achievement (Fabelo et  al., 2011; Noltemeyer, Ward, & Mcloughlin, 2015). A relationship also exists between school suspension and juvenile justice involvement, as students who receive suspensions are up to three times more likely to engage with the juvenile justice system in the year following their suspension (Fabelo et al., 2011).

Method A guided panel discussion on JJIY was conducted to assess a range of stakeholder opinions with the following objectives: (1) to better understand youth paths to and through the juvenile justice system and (2) to identify interventions effective in mitigating the negative effects of youth incarceration. The panel consisted of 16 people: 7 representatives from state agencies (two from juvenile justice), 5 individuals from a mental health center, 2 individuals involved with foster care (one a foster parent), 1 university staff member, and 1 school district leader. The discussion included the unique needs of JJIY, weaknesses in the juvenile justice and education systems, and how to better serve the students who interact with each system. The following questions were used to help guide the discussion: 1. What are the unique emotional and behavioral needs of youth with connections to juvenile justice? 2. How well are those needs being met? 3. Are you aware of school-based programs or initiatives focused on improving emotional and behavioral functioning for youth with juvenile justice connections? Please describe these programs. Would any be considered exemplary? How could we share innovative practices from these sites?

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4. What are the existing infrastructure or organizational supports for this work? How can this be strengthened? 5. What has limited family involvement in guiding school-based programs for youth with juvenile justice connections, and how can these limiting factors be changed? 6. Do you think it would be worthwhile to establish a statewide leadership team that would help to guide and coordinate training and implementation support for school BH programs for youth with juvenile justice connections? 7. How can we increase outreach and involvement with policy leaders from correctional systems to explore mechanisms to advance school BH programs for incarcerated youth? 8. How can departments of juvenile justice, mental health, social services, education, and other youth-serving systems work better to develop and improve school BH programs for youth with juvenile justice connections? 9. What other recommendations do you have? Per methods described in the introductory chapter, the forum was recorded and transcribed. Following transcription of the forum, the discussion was analyzed qualitatively. Six major themes emerged, which are described below.

Results Risk Factors Problems Participants noted several risk factors that might predict justice involvement or misbehavior in classrooms that may lead to suspension. The two most frequently cited risk factors were mental health issues and difficulty learning. One participant said, “We also see a lot of kids with some depression that manifests itself in aggressive behaviors without a form of treatment… those are the top ones we get. The trauma, the depression, the ADHD (attention deficit/hyperactivity disorder).” Research indicates that untreated mental health issues are one major factor predicting juvenile justice interaction, even when oppositional behavior is not considered. Specifically, 41.7% of JJIY meet diagnostic criteria for ADHD, and between 10 and 20% meet diagnostic criteria for major depression (Abram et  al., 2003; Teplin et al., 2002). However, participants demonstrated particular concern about student trauma, with one participant stating, “So many of these youth do have trauma in their history. A history of adversity that is somewhat unique, maybe not so much in what they encounter, but in the intensity or frequency of those traumas.” As many as 93% of JJIY experience some form of trauma before entering the juvenile justice system, which can lead to increased aggression via a learned inability to self-regulate the threat response (Ford, Chapman, Connor, & Cruise, 2012; Rosenberg et al., 2014). Specifically, JJIY average 14.6 separate traumas per youth,

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three-quarters of which are violent trauma, such as being physically assaulted by a family member or forced into a sexual situation (Rosenberg et al., 2014). Seventy percent of JJIY report at least one type of family dysfunction in their past (Logan-­ Greene, Tennyson, Nurius, & Borja, 2017). This unique history of adversity may contribute to the development of maladaptive coping mechanisms in these youth. This may contribute to risky behavior, as one participant stated: Another thing is, many of them self-medicate. So, when you think about drugs, whether it’s alcohol or marijuana, cocaine… many times those are the students who really need mental health assistance. Many of those students should be taking medication for ADHD… but somewhere from the social point of things, from the parental standpoint, the society standpoint, they’re not getting what they need… Sometimes they’ll say, ‘Well, I took marijuana, I smoke before school. I know I shouldn’t, but that calms me down; I can do my work; I can take my test.’

Indeed, around half of JJIY meet the diagnostic criteria for a substance use disorder, and between 11 and 14% of incarcerated juveniles meet criteria for a BH disorder (major depressive, dysthymic, manic, psychotic, panic, anxiety, attention deficit-­hyperactivity, conduct, or oppositional defiant disorder) and a substance use disorder (Abram et al., 2003; Teplin et al., 2002). The odds of meeting criteria for a substance use disorder were much higher for youth who did have BH disorders, compared to those with no BH diagnosis (Abram et al., 2003). Participants also named a variety of learning difficulties as risk factors for juvenile justice involvement, specifically referencing Greene’s (2013) lagging skills model, which postulates that “kids are challenging because they lack the skills to not be challenging.” This is a valid concern, as a sample of JJIY with a mean age of 16 was only reading at an eighth-grade level (Baltodano, Harris, & Rutherford, 2005): Kids who have difficulty reading are going to struggle wherever they are, because so much of what we do in school is reading-based… If you think about the fact that you can’t read… what’s being presented, it’s like us being in this room and speaking in French and trying to figure that out. Like maybe one person had a year’s worth of French and they’re trying to figure this out and they get exhausted.

Participants noted that this exhaustion often results in mutual frustration between the student and the teacher. The student is frustrated because they are asked to perform tasks they are incapable of; the teacher is frustrated because their students consistently fall short of expectations. When discussing this issue, participants indicated that this frustration could lead to students acting out in class, potentially resulting in their removal from the classroom and subsequent placement in either a special education classroom or, depending on the severity of the behavior, an alternative school. Indeed, while youth with disabilities are overrepresented in the juvenile justice system, and nearly 40% of those disabilities are learning disabilities (Quinn, Rutherford, Leone, Osher, & Poirier, 2005), it is important to note that behavioral problems, and not just academic skills, also hold JJIY back in the classroom. Regardless, an examination of whether schools are effectively serving youth with special learning needs is warranted (Quinn et al., 2005). These findings would contribute to both a better understanding of how learning disabilities in JJIY

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contribute to behavioral difficulties (and vice versa) and possible avenues of intervention for these youth. Participant Recommendations While it is impossible to eliminate risk factors entirely, there is potential in reducing their impact on juveniles. For example, educating stakeholders and other professionals about the identification of untreated mental health conditions may help facilitate their treatment in schools via school behavioral health services and ultimately prevent a student from being removed from the general education environment (Mallett, 2016). Similarly, in regard to academic difficulties, screening for specific learning disabilities could increase early and ongoing identification and thus help ensure students’ academic needs are met. Further, increasing mental health screenings during entry to the juvenile justice system may increase the accessibility and efficacy of treatment (McPherson & Sedlak, 2010). Lastly, trauma-informed care is an integral component in effectively addressing the mental health needs of JJIY and should be considered at all stages of justice involvement (Branson, Baetz, Horwitz, & Hoagwood, 2017).

Educational Quality Problems Participants discussed the quality of education JJIY had received before their interaction with the justice system and how that might contribute to their involvement with the Department of Juvenile Justice (DJJ), with one participant stating, “We are not servicing them appropriately—we don’t have resources and programming available to meet their basic needs academically, so I know their emotional needs are not being met because their academic needs are not being met.” Participants were particularly concerned about how social skills deficits may contribute to special education referrals, as well as how schools meet students’ needs in this domain. One participant noted that under-resourced school personnel may contribute to poor social skills development: I think we don’t have anyone with expertise in the schools around social [skills] – we have lots of people who are really good at behavior intervention but we don’t have anybody there with expertise just on the social skills training.

A lack of social skills may manifest as aggression, sometimes resulting in youth qualifying for special education services for emotional disability (ED; Mallett, 2016). There is a greater likelihood of at-risk youth being suspended or expelled after they are transferred to a special education classroom (Espelage, Low, Polanin, & Brown, 2013; Wagner et al., 2006). In many schools, there is no structure in place to broadly teach social skills; after-school programs, where social skills are often acquired via increased opportunities for positive peer interactions, often prohibit enrollment of children with even a history of moderate behavioral problems and are

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ultimately inaccessible to families without ample resources (i.e., money, time, transportation; Mahoney, Parente, & Lord, 2007). Deficits in social skills are not the only thing that may lead to a disturbance in students’ mainstream education. As one participant noted, school transitions can be difficult for students: In elementary school you have pretty much one teacher who is with the kids five hours a day, five days a week, 180 days a year, for years, and oftentimes that teacher is a second mom. And then those kids move onto middle school, where they do not have the permanency of the one adult who cares for them, and so they have lost a caring relationship with an adult who makes a difference in their lives — and the key of having that caring adult, that one turnaround teacher, that one person who is showing caring, high expectations, and just coaching all the time, is not there.

Furthermore, participants said that positive and efficacious teaching practices, as well as effective behavior management strategies, have a profound effect on students’ educational experience. As one participant expressed: Teacher training on behavior is a big missing component. Because the way that students are referred for special education … if they were with a stronger teacher who had better classroom management skills, they probably wouldn’t even be in that situation.

This underscores the importance of educating and providing ongoing training to teachers on the psychological and behavioral needs of youth. Whether children remain in their mainstream classrooms can significantly influence their overall school experience. The quality of education provided in non-­ mainstream classrooms is not equal to that provided in mainstream classrooms, which means improper removal from the general education environment can have negative effects on academic progress (Morgan, Frisco, Farkas, & Hibel, 2010; Peetsma, Vergeer, Roeleveld, & Karsten, 2001). For example, students in special education classrooms showed lagging cognitive development compared to peers with similar special education needs who remained in mainstream classrooms (Peetsma et al., 2001). Students in non-mainstream classrooms also perform worse in math and reading than their mainstream counterparts (Morgan et  al., 2010). Research also suggests that social skills development in special education classrooms may vary greatly depending on the individual classroom environment and quality of instruction (Morgan et al., 2010; Peetsma et al., 2001). Regardless, the academic delay alone is sufficient to make mainstream reentry difficult. One participant expressed this concern: Even if a student goes into special ed[ucation] for emotional and behavioral disorders without an academic problem, often after having been removed from general education for so long, they are very behind academically… As a former special ed[ucation] teacher, they really weren’t where they needed to be when I got them, maybe even behaviorally, really, they couldn’t handle going into a general ed[ucation] classroom, because they just didn’t have the skills.

The importance of reentry into mainstream classrooms is one of academic attainment. Students with emotional disturbances in special education classrooms are significantly more likely to be retained in a grade than other students, leading to

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significant declines in graduation rates (Wagner et al., 2006). This may have long-­ term effects, as a participant noted, “We’re looking at the employability… for the students who have special needs; less than 50% are graduating.” Participant Recommendations Schools often do not adequately prepare students to handle their emotions and control their behavior, and being removed from mainstream classrooms for behavioral problems is potentially the first step on a child’s path to justice involvement (Mallett, 2016). Participants suggested that one way to improve children’s social-emotional competence was to implement a social-emotional learning curriculum as a broad preventative measure, with one participant stating, “I think that’s a major concern, that the social-emotional learning aspect is not a part of the curriculum here. We have all these graduation requirements but that’s not in place, for students who need that social-emotional learning curriculum.” Curricula such as You Can Do It! Early Childhood Education Program and Second Step: Student Success Through Prevention have shown promise in reducing children’s aggression and increasing social skills (Ashdown & Bernard, 2012; Espelage et al., 2013). However, participants emphasized that these curricula should not be viewed as a panacea. Extracurricular programs should be made more accessible to youth who may not have access to transportation or the money to purchase equipment. Particularly for at-risk youth, attendance in after-school programs can act as a protective factor (Eisman, Stoddard, Bauermeister, Caldwell, & Zimmerman, 2016). However, youth who need it most may be least able to participate, so it is important to consider individual factors when implementing after-school programs intended to promote social competency. While improving social competency and emotional control is one solution to the problem of students being removed from mainstream classrooms for behavioral problems, it is also important to educate teachers about how to identify BH problems. According to teacher interviews, teachers take their responsibilities to identify and deal with BH needs seriously, but they lack the knowledge and training to do so (Rothì, Leavey, & Best, 2008). To try to eliminate the possibility that poor classroom management may cause classroom misbehavior, participants also suggested that teachers should receive additional training to increase their skills at preventing disruptive behavior. Classroom management training has been shown to be an effective behavioral intervention, particularly when the training is intended to increase the skills of both teachers and students (Korpershoek, Harms, de Boer, van Kuijk, & Doolaard, 2016).

System Failure Problems Some children are simply caught up in an institutional confusion of priorities, noted one participant:

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There’s a fine line between the thinking process of discipline and corrections and education and the mental aspect. And sometimes there’s some confusion and different people’s philosophies can be different. … Your philosophy has to be the same. If you’re the kind of person who’s looking at it from more of a discipline, a behavioral, a punishment phase, it’s going to be different to move to a ‘there’s something else going on here,’ a more mental health, a social standpoint.

Despite the fact that the juvenile justice system was initially formed to rehabilitate children, it is typically viewed as disciplinary, rather than focused on mental health and/or rehabilitation (American Bar Association, 2007; Kapp et al., 2013). Participants worried that the higher administration of juvenile justice institutions, alternative schools, or even mainstream schools dealing with emotional disturbances in their students were not sufficiently educated about the mental health needs of children under their care. One participant stated, “They don’t feel the need is that important, and they cut in that area before they cut anywhere else … we need to acknowledge that these needs need to be fulfilled.” While many administrators rarely, if ever, directly work with juveniles, they are in charge of a critical piece of the machinery for providing BH care: funding. If administrators are not properly educated on the BH needs of their students or do not advocate for BH resources, support for these services diminishes and students with BH needs suffer: One of the things is definitely funding… We’ve tried several times, and it took us a couple of years, to just get a social worker or a psychologist because we didn’t have the funding. We had the idea of what we wanted the program to look like, we had the idea of what we wanted them to do for our students, but we didn’t have the funds to do it… we had to cut teachers and support staff… there’s another need now, because you cut in one area to bring someone to assist in a different area.

This de-prioritization of mental health and corresponding lack of funds to support such services leads to another problem: a lack of staff with behavioral training. Interviews with teachers indicate that they believe behavioral support is necessary and take their responsibility in this domain seriously; yet, they admit that they do not have the knowledge to deliver such services and require supplemental education to do so (Rothì et al., 2008). Forum participants who were teachers said that they were not equipped to identify behavioral needs and did not know how to provide students with the resources they needed. Regardless, the major underlying theme of these problems centers around lack of funding; as one participant shared, this precludes hiring of trained clinical practitioners: I think we don’t have anyone with expertise in the schools… we have lots of people who are really good at behavior intervention, but we don’t have anybody there with expertise on just the social skills training… I think it’s just that we don’t have the expertise to know what people who have the skills in counseling would notice and would know what to do… our fishbowl is limited by not having people there with specialized expertise.

Even when experts are present, they are often overloaded with work (Kapp et al., 2013). Consequently, burnout and attrition are high (Kapp et al., 2013). One participant noted that practitioners’ workloads may not even be related to their counseling expertise: “The counselors are inundated with lots of other things besides

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counseling… doing schedules and testing and other things. I think that’s the biggest issue.” Participant Recommendations It is important that administration and staff who serve JJIY agree on the purpose of their services. According to participants, a disconnect on whether the juvenile justice system ought to be punitive or rehabilitative creates confusion and muddies priorities. They recommended that there be an open discussion to create cohesive administrative philosophy. One participant suggested that another potential solution would be sharing leadership between administration, clinical professionals, and educators: “Oftentimes people at the very top are in their own bubble… if you’re going to do a leadership team, you need people who are actually on the ground providing services.” However, at present, there are certain matters (i.e., funding) that these administration members control, and these must be addressed: Another issue is that, from being on both sides, the administrators – the principals, assistant principals, superintendents – need to be more educated, more aware of mental health needs. Because a lot of times they don’t feel the need is that important, and they cut in that area before they cut anywhere else, so I think that education is important, and we need to acknowledge that these needs need to be fulfilled so we can be preventive with kids in the system.

However, because educating administrators on the necessity of BH services is a daunting and time-consuming task, participants advised that simply seeking out administrators sympathetic to the need could be a possible stopgap measure. Indeed, case studies of organizational change in juvenile justice systems have found that a cooperative administration is vital to successful reform (Elwyn, Esaki, & Smith, 2017; Rocque, Welsh, Greenwood, & King, 2014). As such, it is possible and sometimes necessary to bypass administration and educate legislators and other government officials who are in a position to provide funding (Rocque et al., 2014).

Continuum of Care Problems Participants identified several ways JJIY fall through the cracks of the system and end up removed from mainstream classrooms or involved in delinquency, stating “We have to always think of the whole trajectory of… what happened with each child, from the beginning of their career in school to where they are now, and where did the breakdowns occur.” There are several transitional points in a student’s life where they may be without consistent adult monitoring, including when students are out of school for summer break. Significant changes in behavior or underlying mental health symptomatology may either increase or go unnoticed during these periods.

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Additionally, participants were concerned that even when a BH issue was identified, teachers and other staff might be intimidated by the responsibility of addressing BH issues and ignore them, leaving the student to struggle without help: No one person can handle everything, because those are your most complex kids, and those are the kids who are ultimately probably moving into the DJJ system as they age… they’re hard, and we don’t know what to do… and it goes back to that… thing of, ‘Oh, it’s a guidance counselor problem,’ or ‘Oh, the special ed[ucation] teacher needs to work with them,’ but no, it’s everybody, because they are so complex…We need to have teams that work well together, because I’m not sure we know how to do that yet.

Another potential point where care can become inconsistent is during the transition into special education. Students who have behavioral disorders and other disabilities are often shuffled between classrooms, despite the benefits of classroom stability (Wagner et al., 2006). Many students in special education classrooms are not there because of any special educational need, but instead because of a behavioral need that may not necessarily warrant special education services (Mallett, 2016). As one participant pointed out, there may be disparities in mental health care between mainstream and special education environments: What happens is that there’s a lot of focus on kids in the regular education environment, making sure they get counseling… but all these children who have been labeled special education—and oftentimes only because of some behavioral issue—are not able to access that. Because we haven’t figured out how to make sure that we’re merging special education and the services that are provided through Response to Intervention.

Participant Recommendations Participants identified two steps to improve the continuum of care for JJIY. First, examine the breakdowns that occur in the continuum, with emphasis on where agencies fail to collaborate and youth slip through the cracks. Second, find ways to close those gaps. To detect points in the continuum where youth are inadequately served, participants suggested a series of open forums for stakeholders to discuss how to best integrate the juvenile justice, education, and mental health systems. They noted one particular group, JJIY themselves, whose feedback is rarely solicited in the overall aim of improving continuum of care: “You need the youth who are… involved in the system, too. They know their challenges and what kind of support they need.” Participants also noted that a continuum-wide team of professionals might be helpful in connecting schools, the juvenile justice system, and mental health services to each other: “I think that would be a good team to put in place and… meet continually and help us work with the schools, and the probation officers, and the mental health people in the community, because right now it’s not happening.” After identifying where breakdowns occur between a community’s service agencies, participants suggested that one of the best ways to bridge the gaps might be to identify community partners. In fact, research has found that forming community partnerships was significantly related to the use of best practices in juvenile justice settings (Farrell, Young, & Taxman, 2011). For example, if agencies that serve children outside of school were to provide information to schools regarding a child’s

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home life, educational personnel might be better able to address that child’s specific needs. If schools and mental health professionals partner with local businesses, those businesses might be able to provide resources to youth that neither schools nor families are able to afford. One participant shared a story from her agency’s experience: We built partnerships with not just the mental health agencies, we built partnerships with drugstores and facilities, exercise programs… We knew if we were having a student with a particular problem, we could contact specific agencies and they would send someone to us free of charge to assist us as a group… I’ll give you a specific example. One of the problems we would have is that the parents would not fulfill Medicaid requirements. And even if they did, we had problems getting medical assistance for the kids, getting medication. So we actually partnered with the pharmacy. The pharmacy would actually deliver the medications to the school … We had partnership with a gym—they gave us exercise equipment, so after those students took their meds, they exercised, they did sports a little bit faster, and they were able to be successful during the day.

Environmental Considerations Problems Due to the number of risk factors and social influences that may affect the trajectory of youth in the justice system, it is important to consider each as an individual case in both intervention development and individual treatment. Understanding environmental influences on JJIY involves working closely with their families. The juvenile justice system has a checkered history with involving parents, as previous attempts to collaborate have often placed a substantial amount of blame on caregivers for children’s deviant behavior. Due to this, many caregivers still experience stress and guilt when involved, often resulting in them disconnecting from their children’s experiences (Walker, Bishop, Pullmann, & Bauer, 2015). As one participant pointed out, this sometimes perpetuates the underlying problem: We call them to tell them there’s a problem with their child and we’re suspending them, or we’re doing whatever, and then they don’t know what to do with them or how to respond… we encourage a sense of helplessness on their part, because they don’t know what to do. If they knew what to do, they would do it.

Even when caregivers do not experience helplessness and desire to be informed about their children, there is often a breakdown in communication, resulting in limited information exchange between parties (Walker et al., 2015). Therefore, even though parent involvement is generally regarded as a positive influence in children’s overall mental health, parents are often not consulted with about possible interventions for their child (Walker et al., 2015). Participants believed this could be due to a lack of common language between parents, teachers, and students. For example, while teachers and other school personnel are sometimes trained in how to address behavioral problems, parents likely do not have similar training and experience significant barriers to effective communication because of this lack of education.

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Additionally, parents or caregivers may not always be the appropriate person from whom children should seek support, which should be considered when identifying current and possible future family support for juveniles: In the system we have a lot of grandparents, and they don’t know what to do. I always get on teachers about talking their language to them, because they don’t know some of the basic terms, sometimes, what the juveniles are saying, what they’re talking about. So we need to provide a lot of support because we have a lot of grandparents — because the parents are young, or incarcerated themselves, or not involved with the juveniles’ lives, so a lot of the grandparents are taking over the roles of being a parent.

This is important to consider when attempting to address mental health needs in juvenile justice populations, as youth in grandparent-headed homes are up to three times more likely to have mental health needs than youth in their parents’ homes (Campbell, Hu, & Oberle, 2006). Regardless of who the family support system consists of, however, accessibility is a concern: We only allow them the time that we’re available, not the time that they’re available, and then we say they’re not involved. How do you be involved when you have to work or when you have childcare issues or other issues that need support?

Participant Recommendations When working with JJIY, it is important to consider individual differences and the uniqueness of each youth’s history. Interventions for these children should embrace trauma-informed care and consider their current family supports. Participants emphasized the importance of involving parents and caregivers in interventions, and research shows that family-centered interventions for children are more effective than interventions involving only the child (Dowell & Ogles, 2010). Special concern should be given to involving parents of JJIY, as they are likely to have problems accessing services and may have unique service needs. The programs that are most effective at keeping youth out of residential facilities share at least one trait—a specific effort to increase service accessibility (Lee et al., 2014).

Transition from the Juvenile Justice System Problems The main goal of many interventions targeted at JJIY is to reduce recidivism. Participants named a number of contributing factors to high recidivism rates, including deviancy training, lack of adequate support when exiting the system, and a vicious cycle of social influences. While there is some conflicting data on the long-­ term effect of deviancy training, research indicates that the majority of interventions that harm rather than help JJIY are group interventions (Welsh & Rocque, 2014). When grouped together, delinquent youth engage in more antisocial talk; when housed together in residential juvenile justice facilities, they have higher recidivism rates (Mathys et al., 2013; Shapiro et al., 2010). Moreover, as one participant noted, youth may also grow accustomed to the environment itself:

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Given this acclimatization to the prison environment, participants were concerned by the dearth of transition support that juveniles receive when exiting the system. There is little follow-through with juveniles after they complete their sentences; their records may not be transferred to schools for months after their release, and there may be no behavior, learning, or transition plans in place (Goldkind, 2011). Although it is particularly important to continue monitoring the mental health of juveniles after their release to prevent recidivism and improve their future mental health outcomes (Underwood & Washington, 2016), participants were concerned that such support was not always in place. With no support, juveniles may have little incentive to continue working toward goals to keep them from returning to the system or little ability to maintain a healthy emotional and behavioral state. This lack of transition support may exacerbate an already-existing cycle of recidivism. One participant described the pattern of re-offense: “You see a lot of the crimes are petty… to gain things like cell phones, gym shoes, things out of a store, to get access to the funding.” After being incarcerated for a crime, youth experience significant difficulty gaining access to and maintaining employment due to their past incarceration (van der Geest et  al., 2016). This could lead to re-offense out of necessity, and this cycle often repeats after their next release. Additionally, even a single arrest is related to higher rates of school dropout, which limits educational attainment (Kirk & Sampson, 2013). Downstream effects of this include reduced ability to find employment later in life and the perpetuation of a life-course cycle of negative outcomes originating with their involvement with DJJ. Participant Recommendations Participants suggested several possible steps that could be taken toward reducing the high recidivism rates that characterize our juvenile justice system. The first was mindfulness-based social-emotional training for institutionalized juveniles, which one participant anecdotally said had reduced recidivism at her workplace. Indeed, there is evidence that mindfulness-based programs do reduce violence, substance use, and recidivism in JJIY (Himelstein, Saul, Garcia-Romeu, & Pinedo, 2014; Hoogsteder et al., 2014). But, as another participant pointed out, that is not the only training youth needed in order to help JJIY succeed in their transition back into the general population: “Job training and skills that can promote independence — fiscal, financial means for them — I think that’s the biggest issue to stop them from re-entering DJJ.” While outcomes from vocational training vary depending on the training, its positive effects are more consistent when this training includes vocational experience (Altschuler & Brash, 2004). In addition to vocational training, youth benefit

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from increased educational opportunity while in custody, particularly since they often exit detention at an academic disadvantage in comparison to their never-­ detained peers, making their transition back into a mainstream school setting difficult (Baltodano et al., 2005). However, skill building does not solve all transitional problems. One participant proposed a way to assist youth during periods of inadequate support during the transition from DJJ: I was talking to my superintendent about transition specialists… having those people set up, because I think that’s where we lose them… For the past two months, we were just having juveniles coming back, I mean, within two weeks … more often because I think they’re not getting those supportive services once they leave, so we have someone who’s kind of checking in with them, making sure that they’re staying on track, you know they’ve established all those goals and that they’re working towards those goals.

Conclusion Several major themes regarding JJIY emerged throughout this forum—some regarding prevention, some regarding intervention, and some regarding the process as a whole. First, the reoccurring concern from participants regarding the lack of transition support services for JJIY exposes a potential area to target for future prevention and intervention efforts. Fully supporting transitions between grades or teachers could prevent entry to the justice system, or supporting youth entering and exiting the justice system could prevent reentry. Participants suggested transition support could come in several forms, though they stressed the importance of having a consistent adult (i.e., social worker, transition specialist) responsible for guiding youth through these transitions. Second, communication is necessary to the success of all intervention and preventative measures. Direct, accessible lines of communication between the staff of juvenile justice facilities, educational facilities, and mental health facilities are essential to providing comprehensive, continuous care for JJIY. Furthermore, families are a vital piece of the puzzle when crafting effective interventions for JJIY; helping parents/caregivers overcome feelings of blame and guilt, as well as ensuring that DJJ personnel do not perpetuate those feelings in their interactions, is essential to encouraging family involvement. This may require educating caregivers to ensure that all involved parties are familiar with the basic ideas of school BH. Additionally, youth themselves appear to be an untapped resource in identifying and selecting interventions, and mental health professionals should solicit JJIY feedback. Third, because schools play such an important role in the school-to-prison pipeline, it is critical we educate policy makers and administration who control funding opportunities used to improve teachers’ identification of students’ behavioral health difficulties. One of the major problems reported by teachers, and supported by research, is undiagnosed mental health issues in students. Integrating courses into educational degree programs that specifically address identification of mental and behavioral health issues in students may help ensure new teachers are effectively

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equipped to handle these challenges. Providing funds for continuing education for current teachers, specifically to facilitate acquisition of these skills, could significantly impact their students’ outcomes. Providing more education to all stakeholders in schools could help make sure students are referred for appropriate mental health services in order to safeguard them from the negative effects of potentially avoidable involvement in the juvenile justice system. Lastly, it is important to establish a cohesive vision of mental health for both the juvenile justice system as a whole and its interactions with mental health and educational systems. Producing favorable outcomes for JJIY when each component of the care system functions in isolation is unlikely. Overall, this vision must address how the current system fails to properly serve youth. One participant advocated for examining those youth who avoided the pitfalls addressed in this chapter: “Let’s take a look at what worked for those kids who haven’t returned to the system. What was done on those kids, not just looking at the kids who are always coming back. Those are the kids who get our attention all the time, but what about the kids who have done well? What was the key?”

References Abram, K. M., Teplin, L. A., McClelland, G. M., & Dulcan, M. K. (2003). Comorbid psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 60(11), 1097–1108. Advancement Project. (2010). Report: How zero tolerance and high stakes testing funnel youth into the school-to prison pipeline. http://www.advancementproject.org/sites/default/files/publications/01 -­EducationReport-­2009v8-­HiRes.pdf Altschuler, D. M., & Brash, R. (2004). Adolescent and teenage offenders confronting the challenges and opportunities of reentry. Youth Violence and Juvenile Justice, 2(1), 72–87. American Bar Association. (2007). The history of juvenile justice. Dialogue on Youth and Justice. https://www.americanbar.org/content/dam/aba/administrative/public_education/resources/ DYJfull.authcheckdam.pdf Ashdown, D. M., & Bernard, M. E. (2012). Can explicit instruction in social and emotional learning skills benefit the social-emotional development, well-being, and academic achievement of young children? Early Childhood Education Journal, 39(6), 397–405. Baltodano, H. M., Harris, P. J., & Rutherford, R. B. (2005). Academic achievement in juvenile corrections: Examining the impact of age, ethnicity and disability. Education & Treatment of Children, 28(4), 361–379. Barnert, E. S., Dudovitz, R., Nelson, B. B., Coker, T. R., Biely, C., Li, N., et al. (2017). How does incarcerating young people affect their adult health outcomes? Pediatrics, 139(2), 1–11. Branson, C. E., Baetz, C. L., Horwitz, S. M., & Hoagwood, K. E. (2017). Trauma-informed juvenile justice systems: A systematic review of definitions and core components. Psychological Trauma: Theory, Research, Practice, And Policy, 9(6), 635–646. Burke, J. D., Mulvey, E. P., & Schubert, C. A. (2015). Prevalence of mental health problems and service use among first-time juvenile offenders. Journal of Child and Family Studies, 24(12), 3774–3781. Campbell, L. R., Hu, J., & Oberle, S. (2006). Factors associated with future offending: Comparing youth in grandparent-headed homes with those in parent-headed homes. Archives of Psychiatric Nursing, 20(6), 258–267.

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Cholewa, B., Hull, M. F., Babcock, C. R., & Smith, A. D. (2017). Predictors and academic outcomes associated with in-school suspension. School Psychology Quarterly, 33(2), 191. Cochran, J. C., & Mears, D. P. (2015). Race, ethnic, and gender divides in juvenile court sanctioning and rehabilitative intervention. Journal of Research in Crime and Delinquency, 52(2), 181–212. Dowell, K. A., & Ogles, B. M. (2010). The effects of parent participation on child psychotherapy outcome: A meta-analytic review. Journal of Clinical Child and Adolescent Psychology, 39(2), 151–162. Eisman, A. B., Stoddard, S. A., Bauermeister, J. A., Caldwell, C. H., & Zimmerman, M. A. (2016). Trajectories of organized activity participation among urban adolescents: An analysis of predisposing factors. Journal of Youth and Adolescence, 45(1), 225–238. Elwyn, L. J., Esaki, N., & Smith, C. A. (2017). Importance of leadership and employee engagement in trauma-informed organizational change at a girls’ juvenile justice facility. Human Service Organizations: Management, Leadership & Governance, 41(2), 106–118. Espelage, D. L., Low, S., Polanin, J. R., & Brown, E. C. (2013). The impact of a middle school program to reduce aggression, victimization, and sexual violence. Journal of Adolescent Health, 53(2), 180–186. Espinosa, E.  M., & Sorensen, J.  R. (2016). The influence of gender and traumatic experiences on length of time served in juvenile justice settings. Criminal Justice and Behavior, 43(2), 187–203. Fabelo, T., Thompson, M.  D., Plotkin, M., Carmichael, D., Marchbanks, M.  P., & Booth, E. A. (2011). Breaking schools’ rules: A statewide study of how school discipline relates to students’ success and juvenile justice involvement. New York, NY: Council of State Governments Justice Center. Fader, J. J., Kurlychek, M. C., & Morgan, K. A. (2014). The color of juvenile justice: Racial disparities in dispositional decisions. Social Science Research, 44(1), 126–140. Farrell, J. L., Young, D. W., & Taxman, F. S. (2011). Effects of organizational factors on use of juvenile supervision practices. Criminal Justice and Behavior, 38(6), 565–583. Ford, J. D., Chapman, J., Connor, D. F., & Cruise, K. R. (2012). Complex trauma and aggression in secure juvenile justice settings. Criminal Justice and Behavior, 39(6), 694–724. Goldkind, L. (2011). A leadership opportunity for school social workers: Bridging the gaps in school reentry for juvenile justice system youths. Children and Schools, 33(4), 229–239. Greene, R. (2013). Collaborative and proactive solutions: The next generation of solving problems collaboratively. http://www.dce.ndsu.nodak.edu/conferences/pdfs/Using%20the%20 ALSUP.pdf Himelstein, S., Saul, S., Garcia-Romeu, A., & Pinedo, D. (2014). Mindfulness training as an intervention for substance user incarcerated adolescents: A pilot grounded theory study. Substance Use and Misuse, 49(5), 560–570. Hoogsteder, L.  M., Kuijpers, N., Stams, G.  M., van Horn, J.  E., Hendriks, J., & Wissink, I. B. (2014). Study on the effectiveness of responsive aggression regulation therapy (Re-ART). The International Journal of Forensic Mental Health, 13(1), 25–35. Kapp, S. A., Petr, C. G., Robbins, M. L., & Choi, J. J. (2013). Collaboration between community mental health and juvenile justice systems: Barriers and facilitators. Child and Adolescent Social Work Journal, 30(6), 505–517. Kirk, D.  S., & Sampson, R.  J. (2013). Juvenile arrest and collateral educational damage in the transition to adulthood. Sociology of Education, 86(1), 36–62. Korpershoek, H., Harms, T., de Boer, H., van Kuijk, M., & Doolaard, S. (2016). A meta-analysis of the effects of classroom management strategies and classroom management programs on students’ academic, behavioral, emotional, and motivational outcomes. Review of Educational Research, 86(3), 643–680. Lacoe, J. R. (2015). Unequally safe: The race gap in school safety. Youth Violence and Juvenile Justice, 13(2), 143–168.

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Lee, B. R., Ebesutani, C., Kolivoski, K. M., Becker, K. D., Lindsey, M. A., Brandt, N. E., et al. (2014). Program and practice elements for placement prevention: A review of interventions and their effectiveness in promoting home-based care. American Journal of Orthopsychiatry, 84(3), 244–256. Lehmann, P. S., Chiricos, T., & Bales, W. D. (2017). Sentencing transferred juveniles in the adult criminal court: The direct and interactive effects of race and ethnicity. Youth Violence and Juvenile Justice, 15(2), 172–190. Liebenberg, L., & Ungar, M. (2014). A comparison of service use among youth involved with juvenile justice and mental health. Children and Youth Services Review, 39(1), 117–122. Logan-Greene, P., Tennyson, R. L., Nurius, P. S., & Borja, S. (2017). Adverse childhood experiences, coping resources, and mental health problems among court-involved youth. Child & Youth Care Forum, 46(1), 923–946. Mahoney, J. L., Parente, M. E., & Lord, H. (2007). After-school program engagement: Links to child competence and program quality and content. The Elementary School Journal, 107(4), 385–404. Mallett, C. A. (2016). The school-to-prison pipeline: A critical review of the punitive paradigm shift. Child and Adolescent Social Work Journal, 33(1), 15–24. Mathys, C., Hyde, L. W., Shaw, D. S., & Born, M. (2013). Deviancy and normative training processes in experimental groups of delinquent and nondelinquent male adolescents. Aggressive Behavior, 39(1), 30–44. Mayer, S. (2005). Educating Chicago’s court-involved youth: Mission and policy in conflict. Chicago, IL: Chapin Hall Center for Children. McPherson, K. S., & Sedlak, A. J. (2010). Youth’s needs and services: Findings from the survey of youth in residential placement. OJJDP Juvenile Justice Bulletin, 10–11. Morgan, P. L., Frisco, M. L., Farkas, G., & Hibel, J. (2010). A propensity score matching analysis of the effects of special education services. The Journal of Special Education, 43(1), 236–254. Noltemeyer, A. L., Ward, R. M., & Mcloughlin, C. (2015). Relationship between school suspension and student outcomes: A meta-analysis. School Psychology Review, 44(2), 224–240. Ou, S.-R., & Reynolds, A. J. (2010). Childhood predictors of young adult male crime. Children and Youth Services Review, 32(8), 1097–1107. Peetsma, T., Vergeer, M., Roeleveld, J., & Karsten, S. (2001). Inclusion in education: Comparing pupils’ development in special and regular education. Educational Review, 53(2), 125–135. Petteruti, A., & Fenster, J. (2011). Finding direction: Expanding criminal justice options by considering policies of other nations. Washington D.C.: Justice Policy Institute. Poteat, V. P., Scheer, J. R., & Chong, E. K. (2016). Sexual orientation-based disparities in school and juvenile justice discipline: A multiple group comparison of contributing factors. Journal of Educational Psychology, 108(2), 229–241. Puzzanchera, C., Hockenberry, S., Sladky, T. J., & Kang, W. (2018). Juvenile residential facility census databook. Pittsburgh, PA: Office of Juvenile Justice and Delinquency Prevention. Quinn, M. M., Rutherford, R. B., Leone, P. E., Osher, D. M., & Poirier, J. M. (2005). Youth with disabilities in juvenile corrections: A national survey. Exceptional Children, 71(1), 339–345. Rocque, M., Welsh, B. C., Greenwood, P. W., & King, E. (2014). Implementing and sustaining evidence-based practice in juvenile justice: A case study of a rural state. International Journal of Offender Therapy and Comparative Criminology, 58(9), 1033–1057. Rosenberg, H.  J., Vance, J.  E., Rosenberg, S.  D., Wolford, G.  L., Ashley, S.  W., & Howard, M.  L. (2014). Trauma exposure, psychiatric disorders, and resiliency in juvenile-justice-­ involved youth. Psychological Trauma: Theory, Research, Practice, And Policy, 6(4), 430–437. Rothì, D. M., Leavey, G., & Best, R. (2008). On the front-line: Teachers as active observers of pupils’ mental health. Teaching and Teacher Education, 24(5), 1217–1231. Shapiro, C. J., Smith, B. H., Malone, P. S., & Collaro, A. L. (2010). Natural experiment in deviant peer exposure and youth recidivism. Journal of Clinical Child and Adolescent Psychology, 39(2), 242–251.

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Skowyra, K., & Cocozza, J. J. (2006). A blueprint for change: Improving the system response to youth with mental health needs involved with the juvenile justice system. NCMHJJ Research and Program Brief, 1–12. Sweeten, G. (2006). Who will graduate? Disruption of high school education by arrest and court involvement. Justice Quarterly, 23(4), 462–480. Tam, C. C., Abrams, L. S., Freisthler, B., & Ryan, J. P. (2016). Juvenile justice sentencing: Do gender and child welfare involvement matter? Children and Youth Services Review, 64(1), 60–65. Tanner, J., Davies, S., & O’Grady, B. (1999). Whatever happened to yesterday’s rebels? Longitudinal effects of youth delinquency on education and employment. Social Problems, 46(2), 250–274. Taylor, M. (2016). Adult earnings of juvenile delinquents: The interaction of race/ethnicity, gender, and juvenile justice status on future earnings. Justice Policy, 13(2), 1–24. Teplin, L.  A., Abram, K.  M., McClelland, G.  M., Dulcan, M.  K., & Mericle, A.  A. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59(12), 1133–1143. Underwood, L. A., & Washington, A. (2016). Mental illness and juvenile offenders. International Journal of Environmental Research and Public Health, 13(2), 228. van der Geest, V. R., Bijleveld, C. H., Blokland, A. J., & Nagin, D. S. (2016). The effects of incarceration on longitudinal trajectories of employment: A follow-up in high-risk youth from ages 23 to 32. Crime and Delinquency, 62(1), 107–140. Wagner, M., Friend, M., Bursuck, W. D., Kutash, K., Duchnowski, A. J., Sumi, W. C., et al. (2006). Educating students with emotional disturbances: A national perspective on school programs and services. Journal of Emotional and Behavioral Disorders, 14(1), 12–30. Walker, S. C., Bishop, A., Pullmann, M., & Bauer, G. (2015). A research framework for understanding the practical impact of family involvement in the juvenile justice system: The juvenile justice family involvement model. American Journal of Community Psychology, 56(3–4), 408–421. Welsh, B.  C., & Rocque, M. (2014). When crime prevention harms: A review of systematic reviews. Journal of Experimental Criminology, 10(3), 245–266. Wilson, B. M., Jordan, S. P., Meyer, I. H., Flores, A. R., Stemple, L., & Herman, J. L. (2017). Disproportionality and disparities among sexual minority youth in custody. Journal of Youth and Adolescence, 46(7), 1547–1561.

Addressing the Unique Needs of Children and Families Within the Child Welfare System Samantha Martinez, Tara Kenworthy, Sommer C. Blair, Lee Fletcher, Yanfeng Xu, and Robert N. Stevens

Child welfare (CW) systems are systems that are funded by both state and federal entities to ensure children have safe and permanent living environments. CW agencies offer child protective services, foster care, kinship care, adoptive services, and family preservation and reunification services to achieve children’s safety, permanence, and well-being outcomes (Pecora, Whittaker, Maluccio, Barth, & Plotnick, 2017). Voluntary kinship care occurs when a child is living with a family member and has the support of a CW agency, but the legal court system is not involved. Formal kinship care is when the child resides with a family member but is legally placed in the custody of the state or a CW agency (Office of the Assistant Secretary for Planning and Evaluation, 2000). The CW system is also involved in cases that involve family reunification after the child has been temporarily removed from the home. A child enters foster care when they are temporarily placed into legal custody of the state, which could include living with caregivers in a foster family or in a group home. In addition to foster and kinship placements, the CW system is also involved with adoption services. Adoption is the result of the permanent and legal placement of a child with a family different from their birth parents. In 2016, nearly 500,000 children were adopted out of foster care, highlighting the substantial number of persons affected by the CW system (U.S. Department of Health and Human S. Martinez (*) · T. Kenworthy Psychology Department, University of South Carolina, Columbia, SC, USA e-mail: [email protected]; [email protected] S. C. Blair · L. Fletcher South Carolina Department of Social Services, Lexington, SC, USA e-mail: [email protected]; [email protected] Y. Xu University of South Carolina College of Social Work, Columbia, SC, USA e-mail: [email protected] R. N. Stevens South Carolina Association for Positive Behavior Supports, Johns Island, SC, USA © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_8

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Services (HHS), Administration for Children and Families (ACF), Children’s Bureau, 2016). These well-known services of the CW system have been essential to establishing safe environments for children.

 ental Health Needs of Youth within the Child Welfare M System Children in the CW system experience greater difficulties with mental health than the general population (Burns et al., 2004). Specifically, youth in the CW system experience this heightened risk due to the increased levels of abuse, neglect, domestic violence, and parental substance abuse (Burns et al., 2004). Between 50% and 80% of children who are involved with CW agencies experience difficulties with emotional, developmental, or behavioral disorders (Burns et al., 2004; Farmer et al., 2001; Landsverk, Garland, & Leslie, 2002; Taussig, 2002). For example, approximately 25% of children in foster care will be diagnosed with post-traumatic stress disorder, a rate twice as frequent as that of United States war veterans (Pecora et al., 2005) and more than 4 times (6.3%) as frequent as youth from the general population (Giaconia et al., 1995). Additionally, youth in foster care are prescribed psychotropic drugs at a higher rate than their non-foster counterparts, and many are prescribed dosages that exceed guidelines (U. S. Government Accountability Office, 2011). The suicidal ideation rate for youth within the CW system is 27%, compared to 16% for children in the general population (Anderson, 2011). There is a critical need for effective mental health treatment for youth in this system, as mental health challenges increase the number of placements, and threaten academic performance and long-term functioning if effective treatment is not provided (Garcia, Circo, DeNard, & Hernandez, 2015; Morton, 2018; Newton, Litrownik, & Landsverk, 2000; Zlotnick, Tam, & Soman, 2012). By definition, the families and children served by CW agencies have significant challenges with mental health service needs (Pecora et al., 2017). As stated above about half of these children require interventions to assist with emotional, developmental, or behavioral disorders (Burns et al., 2004). One of the critical needs for children and families in CW is a demonstrated need for mental health services. Unfortunately, barriers exist that prevent youth in the welfare system from accessing necessary mental health treatment. Youth are often unable to connect to resources due to bureaucratic difficulties within most CW agencies (Yoo, Brooks, & Patti, 2007). CW personnel have reported feeling unsupported by the overall system due to ineffective training, which affects their ability to address the mental health needs of youth (Van der Geest, Bijleveld, Blokland, & Nagin, 2016). CW organizations should be more intentional about providing personnel with professional development and supervision as it relates to complex cases (Mundy, Neufeld, & Wells, 2016). Children who enter foster care face a compounded set of challenges in the educational system. The average reading level of 17- to 18-year-old youth in foster care

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is the seventh grade (Breslau, Lane, Sampson, & Kessler, 2008). They are less than half as likely as their non-foster care peers to enroll in college and 3–11% of former foster youth attain a bachelor’s degree (Breslau et al., 2008). CW-involved youth will continue to lag behind their noninvolved peers educationally without improved mental health care service. Additionally, research shows a link between child abuse and delinquency (Ireland, Smith, & Thornberry, 2002). From 2001 to 2005, 14% of youth who were in CW placement due to physical abuse, neglect, emotional abuse, or sexual abuse were arrested (Ryan, Marshall, Herz, & Hernandez, 2008), while only 6% of the general population was arrested over the same timeframe (Office of Juvenile Justice and Delinquency Prevention, 2019). Further complicating the issue is the high number of youth in the juvenile justice system with mental health issues (Vincent, Grisso, Terry, & Banks, 2008) underscoring the amplified needs of youth in CW, and the potential of school behavioral health (SBH) to better address these needs.

 hallenges to Addressing Mental Health Needs for Students C in Child Welfare Systems There are many challenges for youth in CW to receive effective mental health services. Four prominent challenges are: (1) Lack of collaboration between schools, parents, caregivers, clinicians, and other organizations in students’ lives; (2) increasing family and community support; and (3) concern about increased involvement of CW students in the juvenile justice system.

Collaboration Lack of collaboration between schools and other organizations (e.g., Department of Mental Health, Department of Social Services, and Department of Juvenile Justice) has been a long-standing challenge for children accessing the child welfare system and using Temporary Assistance for Needy Families, and the Supplemental Nutrition Assistance Program (Altshuler, 2003). Collaboration between these organizations and programs is often limited by administrative policies or funding (Garcia et al., 2015). A lack of communication between different service providers can lead to confusion about what services a child is receiving, resulting in duplication of services, or provide a systemic barrier for a child’s receipt of services (AndersonButcher & Asher, 2004). Thus, it is important that collaborative efforts between the CW, education, mental health, and other systems be strengthened. Examples include, collaborative SBH that supports these children, education about abuse and neglect, life skills enhancements, and school fairs of various emphases (e.g., career, health, and wellness; Anderson-Butcher & Asher, 2004).

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Knowledge of available resources is a critical component of a school’s ability to collaborate with CW agencies. Teachers and other school personnel report feeling as though they do not have sufficient education on how to address child abuse and neglect among their students (Abrahams, Casey, & Daro, 1992). Practices such as educating teachers on current literature about domestic violence (DV) or conducting evaluations after DV training have shown to be effective in improving their response to children exposed to DV (Turner et al., 2017). In addition, some research has examined organizational factors, such as incorporating community members when making decisions, and collaboration within and between CW organizations as a way to better understand access to services (He, 2017; Herlihy, 2016; Lee, Benson, Klein, & Franke, 2015; Yoo et al., 2007). Collaborating across agencies may include working with community stakeholders to schedule workshops and opportunities to visit the organizations as a way for community agencies to increase awareness of each other’s services provided in other agencies (Anderson-Butcher & Asher, 2004). Determining ways for schools, community organizations, caregivers, and CW agencies to stay connected will better ensure that youth are connected with the multifaceted services they are likely to need.

Increasing Family and Community Support Unfortunately, family unity is not always possible while ensuring the safety of a child; in many cases, children benefit from out-of-home foster placements (Conn, Szilagyi, Jee, Blimkin, & Szilagyi, 2015), but almost two-thirds of these children experience multiple placements (Office of the Administration of Children and Families, 2017). Multiple placements are related to increased emotional/behavioral challenges in these students and the need for more intensive mental health services (Jones & Wells, 2008; Rubin, O’Reilly, Luan, & Localio, 2007). To promote stability in a child’s placement and to promote better child adjustment, it is important to include the child’s family as well as important community members, such as teachers, school support staff, and faith leaders in their care (see Owens et al., 2004). Family-centered and driven care helps to ensure that families are actively involved in their child’s treatment, along with active exploration of strategies for reunification and the child’s return home (Anderson-Butcher & Asher, 2004). School personnel, such as school-employed mental health staff (counselors, psychologists, social workers) could play an active role in this family-centered care, but too often are not involved, pointing to a critical gap and potentially enhanced role for SBH (Austin, 2004).

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Preventing Juvenile Justice Involvement Children who have experienced maltreatment enter the juvenile justice system at much higher rates than the general population, due to the association of maltreatment with antisocial behaviors and criminal activity (Van Wert, Mishna, & Malti, 2016). Further, schools may inadvertently increase the likelihood of students entering the juvenile justice system through ineffective and punitive disciplinary policies. For example, a study of schools in Texas showed that suspended or expelled students were three times more likely to have contact with the juvenile justice system in the following year (Fabelo et al., 2011). Punitive disciplinary policies do not consider previous trauma such as physical abuse or neglect that is currently affecting the child. Knowing the complexities that contribute to a child’s behavior and considering these factors, that are often out of the child’s control may lead to more empathic and compassionate decision-making, such as avoiding exclusionary discipline and the attendant risk of increased juvenile justice involvement (Van Wert et al., 2016).

Method The information collected for this chapter came from an open forum held with CW stakeholders in the community. The forum consisted of a diverse group of twenty individuals, including one parent, ten mental health clinicians, one school staff member, one lawmaker, one social worker, one community member, and five members of the research team. The forum was conducted using the guiding questions presented below. Please see the introduction for the method used in the forum. Responses presented in the forum (reviewed below) also helped to inform the literature review presented above. The following questions guided discussion: 1. What barriers prevent collaboration between CW and SBH staff? How can they be overcome? 2. What CW organizations (either governmental or non-profit) have you worked with or are you aware of that support behavioral health initiatives? 3. What are the existing infrastructure supports for working with CW agencies? How should the infrastructure and efforts be strengthened? 4. Are there examples of SBH and CW staff working effectively together? What are the characteristics of these relationships? Are there SBH programs that could be considered exemplary in this area (name them)? 5. With the identification of exemplary sites, how can we publicize their experiences and promote generalization of successful programming strategies to other CW sites and agencies? 6. What recommendations do you have for collaborative training of SBH and CW staff?

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7. What can be done to improve family involvement in guiding CW activities? Can the factors that prevent or reduce family involvement be changed? 8. Do you think it would be worthwhile to establish a state-wide leadership team that would help to guide and coordinate training and implementation support for effective behavioral health in CW organizations? 9. What other recommendations do you have to move this work forward in our CW systems and agencies?

Results The results of the forum were collected and divided into four challenges or subthemes, many of which were derived from participants’ personal experiences and interactions with the CW system; these themes are consistent with those reviewed in the introduction.

Themes Related to Collaboration The participants felt that increased collaboration between schools, parents, clinicians, and other organizations involved in students’ lives would reduce duplication of services and ensure that clients receive appropriate services. One participant identified the difficulties with sharing information across agencies: “[We] want to share information with agencies, but it’s hard to share outside of mental health.” Some of the participants indicated that collaboration between these organizations is limited by policies or funding, which results in multiple organizations providing the same services to the child, rather than pooling their resources. Simply put by a participant, “No communication equals duplicating services.” Collaboration is also important to ensure students are complying with the rules and regulations of all organizations (e.g., collaboration with Department of Juvenile Justice (DJJ) would be important if a student is on probation). One forum participant discussed a program in the community that helps students facing truancy: “[this] program works with [the] solicitor’s office to hold pre-judicial truancy court. Students come in front of representatives from a bunch of different agencies.” Due to the collaboration within this program, students often do not have to go to truancy or family court as a result of truancy. Instead, students are able to discuss their individual experience with stakeholders in the community. According to participants, the collaboration between organizations is critically hampered by poor communication. One participant stated, “[The Department of Social Services; DSS] may have a plan for the child and family but the school has a different plan and the two are not communicating.” Furthermore, if a student is receiving services from multiple organizations (e.g., school, the Department of Mental Health [DMH], DSS), each organization is often unaware of the other ser-

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vices the student is receiving, unless the caregiver explicitly communicates this information. For example, if a student is receiving services from DSS and DMH, the DSS worker not only does not know if the student is receiving other services, but also does not have a direct route to finding out which services (and from which organizations) the child is receiving them. One participant suggested: Try to establish a home-school link. Help [the] caregiver take accountability for the young person, because a lot of the times families feel the school is working against them, so they don’t want to try. Try to model how to approach the school because a lot of parents had bad experiences when they were in school.

This suggestion could be the direct route for agencies to collaborate with one another. Another participant stated, “Schools don’t understand children in foster care and that some behaviors are a result of traumas. More trauma-informed training would help with out-of-school placement. Instead of suspending, find another solution.” Providing training for school personnel would act as an additional support for those in the CW systems.

Themes Related to Family and Community Support The participants also emphasized the importance of utilizing family and community support when working with children. A participant stated, “Try to harness family and community support first.” Another participant built on this comment, mentioning a program that works with local places of worship to provide mentors to students who had been referred by DJJ for nonviolent offenses. This participant stated, “[this] faith-based program [was beneficial] for non-violent offenders… Most people and youth were in the church, and we met every month with different representatives from the mental health agencies.” A participant noted another program that used a car dealership as a catalyst to prepare foster children for life outside of the foster care system by teaching them about the consequences of impulsivity. The participants recognized that, despite the importance of collaborating with the family, it can be difficult to involve families, particularly those in the CW system, in their child’s mental health care. Participants noted that caregivers may feel intimidated by the school environment and may even be worried that the school will criticize their parenting without offering collaborative solutions. Thus, schools and other CW agencies must work to be more inclusive with families. This way, schools and agencies can work with the community members rather than separately from them. Multiple participants suggested, “they [schools] work towards having the family play a more active role in the child’s treatment and leaning away from individualized treatment.” Overall, participants supported the utilization of both community and family supports to better work with children in the child welfare system.

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Themes Related to Prevention of Juvenile Justice Involvement Participants also agreed that it is important to provide support to students and take preventative measures to keep them out of the juvenile justice system. A participant shared: As a foster parent… I try to keep them out of DJJ and the alternative school, but it’s a struggle when dealing with DSS. I dropped charges on the child, and they wanted the child to suffer consequences… if I dropped charges then she couldn’t suffer consequences. My thing is to keep them out of the system if we can.

It appears that the current system emphasizes punishing children rather than working with them to find other solutions. One caregiver stated that someone must Make sure the school knows the kid is in foster care and therapy. [The foster parent] tries to keep kids out of DJJ, but it’s hard working with DSS. [DSS] wants kids to suffer consequences, but [the] foster parent doesn’t want them to go to DJJ.

Participants’ concerns regarding children in the juvenile justice system extended beyond merely keeping them out of the system, but also included possible consequences for employment opportunities in the future. One participant voiced that it is often difficult for young adults to obtain jobs when they have a record with the justice system. Such concerns led many participants to search for positive outlets to help children in the CW system. One participant mentioned a community program that uses positive support as a preventative measure to keep children out of DJJ. With a large emphasis on the need for support, one participant stated, “the positive support earlier in the child’s welfare process could potentially work to prevent negative outcomes, such as DJJ involvement.”

Recommendations for Moving Forward After discussing the implications of SBH for children in the CW system, participants provided recommendations for the CW community. Many of the proposed recommendations are supported by existing research. This section will highlight responses from participants, paired with supporting evidence. First, the forum participants suggested several strategies to improve the CW system’s interaction with schools. The focus group participants indicated that families may resist engaging with the school system. They reported that previous negative interactions with the school system, as well as fear of judgment about their parenting may impact families’ willingness to participate. The participants provided recommendations on how to interact with the school system and community members. One participant stated, “I’m wondering if… we have a memorandum of agreement [between] DSS, DJJ, Education, MH [mental health], family advocacy - and we get the state leaders together” to create a system of communication between various youth organizations and increase collaboration. Furthermore, a signed HIPAA [Health Insurance Portability and Accountability Act] release form as outlined in 45

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CFR §164.506 (HIPAA Journal, 2017) would allow MH clinicians to disclose treatment progress and share protected health information. If parents have the opportunity to work with state leaders and community organizations in an effort to advocate for their child, it provides opportunities for more positive interactions with the school system as well (Swanson, 2002). Participants also recommended using social media to enhance communication with students and families. It is critical for stakeholders and representatives of child-serving organizations to create social media platforms that allow for more engagement with youth participants (Brandtzaeg, Folstad, & Mainsah, 2012). Second, participants believed that a collaborative system between CW institutions and other agencies would allow for more effective treatment. One participant suggested a collaboration with the Children’s Law Center to advocate for legislation that supports behavioral health initiatives. The Children’s Law Center in Columbia, South Carolina advocates for the well-being of children in the community and could help provide both legal assistance and political advocacy. The initiative to have better communication between mental health institutions and the CW community has shown positive outcomes for the children’s mental health (Kerns et  al., 2014). Stronger and more effective communication between programs may help to bridge the gap between the mental health and CW communities. Third, the participants suggested that a state leadership committee identify the points of contact for organizations. This committee could also create an information-sharing agreement template. A similar council was implemented in Maryland, where an advisory board was created that included members from various disciplines who were all involved in CW. The initiative created an open forum of communication between providers (Vulin-Reynolds, Lever, Stephan, & Ghunney, 2008). If expanded to other states, this template could greatly impact collaboration between organizations within the CW system. Each state has a responsibility to ensure that children in the CW system receive proper services (Stoltzfus, 2017). Thus, state legislators should be encouraged to support efforts, such as sharing a template, to ensure effective services for children. The fourth suggestion was to encourage more community outreach on behalf of youth-serving organizations. Such outreach would inform the public of the services that are available for families within the community. Additionally, agencies who specifically work with children and families should advance their efforts to connect with the community (Pecora et al., 2017). Relationships between organizations and the community are important to implement any initiative, such as improving school services (Aarons, Sommerfeld, & Willging, 2011; Powell, Son, File, & Froiland, 2012). Communities of practice have been shown to be effective methods to bring organizations together to work on similar goals (Wenger, 2011). It is critical that schools help close communication gaps between the community and agencies by learning about the resources within the community to help enhance community collaboration (e.g., He, Lim, Lecklitner, Olson, & Traube, 2015). Engaging family and community support ensure the continuity or early onset of services, regardless of whether the services are interrupted at any point in time, which can benefit the child’s mental health needs (Austin, 2004).

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Finally, participants insisted on effective, trauma-informed training for teachers and school personnel, since so many children in the CW system have experienced trauma. They also suggested that teachers and staff be taught the signs of trauma, so they are more aware of what to look for. Research also supports a trauma-informed approach when working with children in the CW system (Donisch, Bray, & Gewirtz, 2015). Changes to statewide and district-level policies could be made that focus on the child’s basic needs to feel safe and develop their social and emotional skills (Harper & Temkin, 2019). The Compassionate Schools Initiative helps educators understand the impact of trauma on the children they serve and how it can affect those who care for them. It also provides strategies for instruction and discipline that move the classroom from being trauma-informed to being trauma-responsive (Wolpow, Johnson, Hertel, & Kincaid, 2009). Psychoeducation through the dissemination of guides such as the Child Trauma Toolkit for Educators provided by the National Child Traumatic Stress Network would help teachers and staff better understand how to help children who have been traumatized (National Child Traumatic Stress Network Schools Committee, 2008), not just those who are involved in the CW system. Ultimately, a system-wide approach is necessary to provide the benefits of a trauma-informed learning environment that children involved in CW need (Harper & Temkin, 2019).

References Aarons, G.  A., Sommerfeld, D.  H., & Willging, C.  E. (2011). The soft underbelly of system change: The role of leadership and organizational climate in turnover during statewide behavioral health reform. Psychological Services, 8(4), 269–281. Abrahams, N., Casey, K., & Daro, D. (1992). Teachers’ knowledge, attitudes, and beliefs about child abuse and its prevention. Child Abuse and Neglect, 16(2), 229–238. Altshuler, S. J. (2003). From barriers to successful collaboration: Public schools and child welfare working together. Social Work, 48(1), 52–63. Anderson, H.  D. (2011). Suicide ideation, depressive symptoms, and out-of-home placement among youth in the U.S. child welfare system. Journal of Clinical Child and Adolescent Psychology, 40(6), 790–796. Anderson-Butcher, D., & Asher, D. (2004). Innovative models of collaboration to serve children, youths, families, and communities. Children & Schools, 26(1), 39–53. Austin, L. (2004). Mental health needs of youth in foster care: Challenges and strategies. The Connection, 20(4), 6–13. Brandtzaeg, B. P., Folstad, A., & Mainsah, H. (2012). Designing for youth civic engagement in social media (Full paper). Lisbon, Portugal: IADIS International Conferences Web Based Communities and Social Media. Breslau, J., Lane, M., Sampson, N., & Kessler, R. C. (2008). Mental disorders and subsequent educational attainment in a US national sample. Journal of Psychiatric Research, 42(9), 708–716. Burns, J. B., Philips, D. S., Wagner, R. H., Barth, P. R., Kolko, J. D., Campbell, Y., et al. (2004). Mental health need and access to mental health services by youths involved with child welfare: A national survey. Child Adolescents Psychiatry, 43(8), 960–970. Conn, A., Szilagyi, M. A., Jee, S. H., Blimkin, A. K., & Szilagyi, P. G. (2015). Mental health outcomes among child welfare investigated children: In-home versus out-of-home care. Children and Youth Services Review, 57(1), 106–111.

Addressing the Unique Needs of Children and Families Within the Child Welfare System

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Donisch, K., Bray, C., & Gewirtz, A. (2015). Child welfare, juvenile justice, mental health, and education providers’ conceptualizations of trauma-informed practice. Child Maltreatment, 21(2), 125–134. Fabelo, T., Thompson, M. D., Plotkin, M., Carmichael, D., Marchbanks, M. P., & Booth, E. A. (2011). Breaking schools’ rules: A statewide study of how school discipline relates to students’ success and juvenile justice involvement. New  York: Council of State Governments Justice Center. https://csgjusticecenter.org/wp-content/uploads/2012/08/Breaking_Schools_Rules_ Report_Final.pdf Farmer, E.  M. Z., Burns, B.  J., Chapman, M.  V., Phillips, S.  D., Angold, A., & Costello, E.  J. (2001). Use of mental health services by youth in contact with social services. Social Service Review, 75(4), 605–624. Garcia, A. R., Circo, E., DeNard, C., & Hernandez, N. (2015). Barriers and facilitators to delivering effective mental health practice strategies for youth and families served by the child welfare system. Children and Youth Services Review, 52(1), 110–122. Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A. K., & Cohen, E. (1995). Traumas and posttraumatic stress disorder in a community population of older adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 34(10), 1369–1380. Harper, K. & Temkin, D. (2019). Responding to trauma through policies to create supportive learning environments [Issue brief]. Child Trends. https://www.childtrends.org/wp-content/ uploads/2019/01/RespondingTraumaPolicyGuidance_ChildTrends_January2019.pdf He, A. S. (2017). Interagency collaboration and receipt of substance abuse treatment services for child welfare-involved caregivers. Journal of Substance Abuse Treatment, 79(1), 20–28. He, A. S., Lim, C. S., Lecklitner, G., Olson, A., & Traube, D. E. (2015). Interagency collaboration and identifying mental health needs in child welfare: Findings from Los Angeles County. Children and Youth Services Review, 53(1), 39–43. Herlihy, M. (2016). Conceptualising and facilitating success in interagency collaborations: Implications for practice from the literature. Journal of Psychologists and Counsellors in Schools, 26(1), 117–124. Ireland, T. O., Smith, C. A., & Thornberry, T. P. (2002). Developmental issues in the impact of child maltreatment on later delinquency and drug use. Criminology, 40(2), 359–399. Jones, A. S. & Wells, S. J. (2008). PATH/Wisconsin-Bremer Project: Preventing placement disruptions in foster care. https://cascw.umn.edu/portfolio-items/path-bremer-placement-disruption-pub/ HIPAA Journal. (2017). HIPAA release form. https://www.hipaajournal.com/wp-content/ uploads/2017/09/HIPAA-Journal-sample-HIPAA-release-form-v1.pdf Kerns, E. U. S., Pullmann, D. M., Putnam, B., Buher, A., Holland, S., Berliner, L., et al. (2014). Child welfare and mental health: Facilitators of barriers to connecting children and youths in out-of-home care with effective mental health treatment. Children and Youth Services, 46(1), 315–324. Landsverk, J., Garland, A. F., & Leslie, L. K. (2002). Mental health services for children reported to child protective services. In J. E. B. Myers, C. T. Hendrix, L. Berliner, C. Jenny, J. Briere, & T. Reid (Eds.), APSAC handbook on child maltreatment (2nd ed., pp. 487–507). Los Angeles: Sage Publishing. Lee, S., Benson, S. M., Klein, S. M., & Franke, T. M. (2015). Accessing quality care and education for children in child welfare: Stakeholders’ perspectives on barriers and opportunities for interagency collaboration. Children and Youth Services Review, 55(1), 170–181. Morton, B. M. (2018). The grip of trauma: How trauma disrupts the academic aspirations of foster youth. Child Abuse and Neglect, 75(1), 73–81. Mundy, C. L., Neufeld, A. N., & Wells, S. J. (2016). A culturally relevant measure of client satisfaction in child welfare services. Children and Youth Services Review, 70(1), 177–189. National Child Traumatic Stress Network Schools Committee. (2008). Child trauma toolkit for educators. The National Child Traumatic Stress Network. Newton, R. R., Litrownik, A. J., & Landsverk, J. A. (2000). Children and youth in foster care: Disentangling the relationship between problem behaviors and number of placements. Child Abuse and Neglect, 24(10), 1363–1374.

106

S. Martinez et al.

Office of Juvenile Justice and Delinquency Prevention. (2019, October 31). Juvenile arrest rate trends. https://www.ojjdp.gov/ojstatbb/crime/JAR_Display.asp Office of the Administration of Children and Families. (2017, July 14). Child welfare outcomes 2010–2014: Report to congress. https://www.acf.hhs.gov/cb/resource/cwo-10-14 Office of The Assistant Secretary for Planning and Evaluation. (2000, June 1). Report to the congress on kinship foster care. https://aspe.hhs.gov/report/report-congress-kinship-foster-care Pecora, J. P., Whittaker, K. J., Maluccio, N. A., Barth, P. R., & Plotnick, D. R. (2017). Second edition: The child welfare challenge: Policy, practice and research. London\New York: Routledge\ Taylor and Francis Group. Pecora, P. J., Kessler, R. C., Williams, J., O’Brien, K., Downs, A. C., English, D., et al. (2005). Improving family foster care: Findings from the Northwest foster care alumni study. Seattle, WA: Casey Family Programs. Powell, D. R., Son, S.-H., File, N., & Froiland, J. M. (2012). Changes in parent involvement across the transition from public school prekindergarten to first grade and children’s academic outcomes. The Elementary School Journal, 113(2), 276–300. Rubin, D. M., O’Reilly, A. L., Luan, X., & Localio, A. R. (2007). The impact of placement stability on behavioral Well-being for children in foster care. Pediatrics, 119(2), 336–344. Ryan, J. P., Marshall, J. M., Herz, D., & Hernandez, P. M. (2008). Juvenile delinquency in child welfare: Investigating group home effects. Children and Youth Services Review, 30(9), 1088–1099. Stoltzfus, E. (2017). Child welfare: An overview of future programs and their current funding. Washington, DC: Congressional Research Services. https://fas.org/sgp/crs/misc/R43458.pdf Swanson, T. (2002). Cycles of support. American Libraries, 33(5), 44–46. Taussig, H. N. (2002). Risk behaviors in maltreated youth placed in foster care: A longitudinal study of protective and vulnerability factors. Child Abuse and Neglect, 26(11), 1179–1199. Turner, W., Hester, M., Broad, J., Szilassy, E., Feder, G., Drinkwater, J., et al. (2017). Interventions to improve the response of professionals to children exposed to domestic violence and abuse: A systematic review. Child Abuse Review, 26(1), 19–29. U. S. Government Accountability Office. (2011). Foster children: HHS guidance could help states improve oversight of psychotropic prescriptions [Reissued on December 15, 2011]. Www.Gao. Gov, (GAO-12-201). https://www.gao.gov/products/GAO-12-201 van der Geest, V. R., Bijleveld, C. C. J. H., Blokland, A. A., & Nagin, D. S. (2016). The effects of incarceration on longitudinal trajectories of employment: A follow-up in high-risk youth from ages 23 to 32. Crime & Delinquency, 62(1), 107–140. Van Wert, M., Mishna, F., & Malti, T. (2016). A conceptual model of the relationship between maltreatment and externalizing, antisocial, and criminal behavior problems, and the intervening role of child welfare service delivery. Aggression and Violent Behavior, 29(1), 10–19. Vincent, G. M., Grisso, T., Terry, A., & Banks, S. M. (2008). Sex and race differences in mental health symptoms in juvenile justice: The MAYSI-2 national meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 47(3), 282–290. Vulin-Reynolds, M., Lever, N., Stephan, S., & Ghunney, A. (2008). School mental health and foster care: A logical partnership. Advances in School Mental Health Promotion, 1(2), 29–40. Wenger, E. (2011). Communities of practices: A brief introduction. National Science Foundation (U.S.). https://scholarsbank.uoregon.edu/xmlui/handle/1794/11736 Wolpow, R., Johnson, M. M., Hertel, R., & Kincaid, S. (2009). Washington (State). In The heart of learning and teaching: compassion, resiliency, and academic success. Superintendent of Public Instruction, & Washington State Library. Electronic State Publications. Yoo, J., Brooks, D., & Patti, R. (2007). Organizational constructs as predictors of effectiveness in child welfare interventions. Child Welfare, 86(1), 53–78. Zlotnick, C., Tam, T. W., & Soman, L. A. (2012). Life course outcomes on mental and physical health: The impact of foster care on adulthood. American Journal of Public Health, 102(3), 534–540.

Serving Those Who Serve: Increasing Understanding of Mental Health Needs in Military Families Marissa Miller and John Terry

There are approximately 3.5 million US military personnel including active duty military personnel and coast guard members, reserve members, and civilian personnel (Department of Defense [DoD], 2017). There are more than 2.5 million spouses, adult dependents, and children (i.e., military-connected youth [MCY]) in the immediate families of active duty and Selected Reserve personnel alone (DoD, 2017); these are military families, and they serve in conjunction with the military member. Despite their often robust resilience (Easterbrooks, Ginsburg, & Lerner, 2013; Masten, 2013), military families, including MCY, experience stressors generated by the unique characteristics of the military lifestyle, as well as stressors secondary to those of their family member or members (Trail et  al., 2018). Current research efforts are aimed at increasing positive development and minimizing stressors, barriers, and adverse outcomes for MCY and their families. In this chapter, a literature review and themes in qualitative data from a focus group of military family members and military mental health providers describe existing services, ongoing needs, and recommendations for future directions that military families may access or experience in prevention and intervention. These efforts aim to increase positive development and minimize stressors, barriers, and negative outcomes for MCY and their families.

Background and Demographics Military family members exceed the number of active duty and Selected Reserve members (i.e., approximately 2,100,000 military members versus approximately 2,700,000 military family members), with nearly 40% of families including dependent children under age 22 (DoD, 2017). Southeastern states have a particularly M. Miller (*) · J. Terry University of South Carolina, Columbia, SC, USA © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_9

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high concentration of military families: Virginia, Texas, North Carolina, Georgia, Florida, and South Carolina rank among the ten states with the highest number of active duty military populations. In Virginia, North Carolina, Georgia, and Florida, the number of military-connected dependents exceeds the number of military personnel (DoD, 2017). Military families are dispersed across the world, with distinctions often made between families stationed inside the Continental United States (CONUS), within US Territories (e.g., United States, Puerto Rico, Gaum, Virgin Islands, American Samoa, Wake Island), and outside CONUS (OCONUS). For example, roughly 80,000 dependents reside in Europe, 76,000 in Asia, and 12,000 in Africa/the Middle East (DoD, 2017). Mental Health in Military Members and Families Between the September 2001 terror attacks and September 2015, 2.77 million individual military service members deployed to various military operations (Wenger, O’Connell, & Cottrell, 2018). Importantly, military service members often deploy multiple times; recent data indicate that there were 5.4 million unique deployments across this period of time (Wenger et al., 2018). Operation Enduring Freedom and Operation Iraqi Freedom veterans are distinctive, as these military personnel repeatedly deployed on tours of duty that lasted longer than previous tours, with shorter breaks between deployments. Signature injuries of these military operations are traumatic brain injury, post-traumatic stress disorder (PTSD), military sexual trauma, and combat-related physical injuries (Hoge et al., 2004; Hoge, Terhakopian, Castro, Messer, & Engel, 2007). In addition to the same mental health challenges experienced by civilian families, military families face unique stressors of military life such as deployment, impacts of war-related trauma or physical disability, fear of a military family member being killed or injured, reintegration, frequent moves/transitions, and changing household dynamics. In addition, these families transition frequently between multiple systems of care. One study suggested that military families may transition up to nine times across a service member’s career, with an average of 2.9 years at each duty location (Esqueda, Astor, & De Pedro, 2012). Frequent transitions increase the possibility of families experiencing difficulty accessing care, disrupt care, and may result in the family transitioning to an area without resources to address family members’ needs. Military families must then attempt to access services in new schools, community supports, and helping agencies, with new clinical providers, including both military-connected and civilian providers. At the same time, few civilian medical personnel, who may be the providers of these community-based services, report feeling confident in their knowledge of military-connected families’ needs or gifts (Esqueda et al., 2012; Harrison & Vannest, 2008). Needs of Military-Connected Youth As noted previously, approximately 40% of military families include dependent children under age 22 (DoD, 2017). MCY are typically young, with most children aged under 11 years old (DoD, 2017). Their young age alone makes it more likely for MCY to experience the onset of a mental health disorder during their parent’s service (Chandra et al., 2011).

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Depressive and psychiatric symptoms among military adolescents occur significantly more frequently than they do in civilian adolescents (Cederbaum et al., 2014; Chartrand & Siegel, 2007; Gorman, Eide, & Hisle-Gorman, 2010; Hoshmand & Hoshmand, 2007; Huebner, Mancini, Bowen, & Orthner, 2009). Additionally, deployment-related stressors, such as prolonged or repeated separation, financial stress, parent anxiety, and exposure to the veteran’s war trauma, are associated with poorer mental health outcomes in MCY (Chandra, Martin, Hawkins, & Richardson, 2010; Chartrand & Siegel, 2007; Hoshmand & Hoshmand, 2007; Huebner et al., 2009; Lester & Flake, 2013).

Gaps in Available Services Given the gaps in the available services, it is important to turn to the stakeholders, including parents, caregivers, and children, who note both the strengths and needs of military families, as well as recommendations for working with military-­ connected individuals. Review of the existing literature suggests several driving themes (with specific sub-themes italicized within): (1) existing services and service providers (e.g., Military Family Life Counselors [MFLC], installation-based supports); (2) ongoing needs related to programming and support for MCY (e.g., lack of programs for children); and (3) future directions in research, policy, and practice (e.g., research ideas, goals for a state-wide leadership team, and community supports). Existing Services Military installation-based helping agencies exist to meet a variety of needs of military families. These agencies offer a range of services, and each agency has its own area of focus and strengths; however, military families often experience barriers and gaps in services. Military treatment facilities (MTFs) provide medical services to military members and beneficiaries as well as retirees, National Guard, and Reserve members. Within MTFs, primary care managers (PCMs) are medical providers, usually in the Family Health Clinic (FHC), and are the main point of contact for patient care. The Behavioral Health Optimization Program (BHOP) exists within the FHC and is designed to increase access to mental health care by having a credentialed mental health provider embedded in the FHC and available to all military beneficiaries and dependents. The Exceptional Family Member Program (EFMP) aims to address the needs of military family members with special needs, especially on the issue of frequent transitions due to permanent change of station (PCS) or deployment. EFMP identifies military families with a child or spouse who needs special health-care services, experiences elevated mental health concerns, or requires special education services. Military families are then supported with information, non-medical case management, and referral services (Aronson, Kyler, Moeller, & Perkins, 2016). An estimated 128,500 families are enrolled in EFMP; nearly two-thirds of participants are children and youth (DoD, 2016; Johnson,

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Knauss, Faran, & Ban, 2014), though availability of specific services may vary across settings. Non-medical counselors such as those connected with Military OneSource (MOS) are short-term and solution-focused forms of mental health support for subclinical issues (Trail et al., 2018). MOS services are offered in person or via technology such as through telephone or the Internet to improve access. MFLCs are part of a DoD program that provides mental health services to military members and military families. MFLC services are short-term and solution-focused forms of mental health support for subclinical symptoms (Trail et al., 2018). MFLCs also provide assistance for conventional problems for which individuals commonly seek mental health support (Trail et al., 2018). MFLCs are licensed mental health providers who serve military families for 12 free sessions per each presenting problem for each person (Trail et al., 2018). Confidentiality, no requirement of medical record keeping, and accessibility are key features of MFLC. MFLCs meet with individuals in convenient locations (e.g., embedded in military units, study rooms in base libraries) and are often located in schools. Importantly, a recent program evaluation of MFLC found that military members and military families reported decreases in problem severity, stress, and interference with work/daily routines after engaging in MFLC services (Trail et al., 2018). Participants in this evaluation also reported high satisfaction with their connection to the MFLC counselors as well as high satisfaction with the level of confidentiality/privacy of their personal information (Trail et al., 2018). Additional personnel noted to provide care across domains of health (e.g., physical, emotional) include military chaplains, who provide services that may consist of spiritual support and counseling (Besterman-Dahan, Gibbons, Barnett, & Hickling, 2012). Regarding services for MCY specifically, prevention programs for youth across stages of the deployment cycle include school-based services, summer camps (e.g., Operation: Military Kids, Operation Purple), and family-based supports (e.g., Families OverComing Under Stress; Esposito-Smythers et  al., 2011). Resources range from less formalized supports such as readings and videos to more formalized treatment approaches (e.g., psychotherapy); however, services for MCY vary depending on the installation. For example, pediatric clinics may not be available at all MTFs, and dependents may not be able to receive services in some mental health clinics (Esposito-Smythers et al., 2011). Ongoing Needs  Few qualitative studies have examined the perspectives of military families, particularly youth. Much of the existing literature references the stress of the deployment cycle for families of active duty military members. The deployment cycle includes at least four phases (i.e., pre-deployment, deployment, reunion, and post-deployment) throughout which the military member receives the notification of their departure, leaves for service, returns, and reunites with their community (Johnson et al., 2007). MCY also report stressors across broader domains of their lives, including school, family, and peer relationships, with older children facing more difficulties during both deployment and the post-deployment process of reunification, according to caregiver reports (Chandra, Martin, et al., 2010). Limitations

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also extend to a variety of barriers for military-connected families seeking services, including confidentiality, stigma, and external barriers such as financial and logistical concerns. Lack of Programs for Children  While MCY face many stressors, programming may be limited or inconsistent as they transition from one location to another. In addition to a lack of programs for children, Esposito-Smythers et al. (2011) note that many of the available programs have not been rigorously evaluated, with a need for more empirically supported prevention and treatment programs, to include cognitive-­behavioral therapy and skills training for both youth and parents. Moore, Fairchild, Wooten, and Ng (2017) completed a systematic review of research on behavioral health programs for MCY and found poor to fair methodological rigor in the evaluation of MCY programs. The initial search results for the authors’ review produced 3324 articles; only 14 studies met inclusion criteria (Moore et al., 2017). It is important to point out that evidence-based treatment is available to MCY (see the Penn State Military Family Clearinghouse; https://militaryfamilies.psu.edu); however, there is a dearth of high-quality research on this population in the literature (Moore et al., 2017). Research, Policy, and Practice  With this knowledge, previous literature has identified a variety of next steps in the realms of research, government-based support, and community support, commensurate with the sub-themes referenced previously. Research Ideas  Esposito-Smythers et al. (2011) offer nine recommendations for continued growth in supports for MCY: empirically supported treatment, skills training for youth, skills training for the non-deployed parent, stress management technique instruction for parents, preparing the non-deployed parent for re-­ integration, using group-based delivery formats, ensuring intervention is sensitive to military culture, using techniques that address multiple behavioral and emotional problems simultaneously, and taking sustainability and accessibility of services into consideration. Limitations and future directions noted in other studies have additionally noted similar needs, as well as goals for conducting research to provide more clarity in these areas (Chandra et al., 2011; Moore et al., 2017; etc.). State-Wide Leadership Team  Given that military service occurs at a federal level, many supports initially arise at the federal level and are implemented through installations or more local resources. However, states provide individual supports and climates for military families, as noted in the adoption of the interstate compact by each state. State-based supports have also been utilized in services for veterans and in some interventions. One such example is HomeFront Strong (Kees, Nerenberg, Bachrach, & Sommer, 2015; Kees & Rosenblum, 2015), a resiliency intervention for military and veteran partners delivered through collaboration across community providers, college campuses, the Department of Health and Human Services, and others. A 2011 Presidential Report noted the potential of the DoD’s Inter-service Family Assistance Committee model to generate a state-wide effort to address ­military family issues (Obama, 2011). The literature notes few other state-level efforts that specifically engage or address the needs of children in military families

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in addition to military members and partners. In the southeastern United States,  the  South Carolina Education Oversight Committee  publishes the Annual Report on Educational Performance of Military-Connected Students which describes MCY academic performance and activities and resources available to support MCY (SC Education Oversight Committee, 2017). Community Supports  A 2011 report from the Center for Military Health Policy Research includes specific recommendations for promoting the emotional and behavioral health of military families, including the provision of support services for both MCY-particularly those experiencing emotional difficulties and long deployments and caregivers, with family communication integrated into these services. Esposito-Smythers et  al. (2011) also suggested screening for family emotional health and improved empirical support for programs focused on military families. Focus groups with military families indicate that MCY and military-connected parents with stronger social connections (e.g., to other family members, peers, and local community) were reported to better adjust to the challenges of military life (Mmari, Bradshaw, Sudhinaraset, & Blum, 2010). Similarly, research with children and families observed fewer deployment challenges for families who live on military installations (Chandra, Martin, et al., 2010). Contributors to more challenges have included caregivers’ employment status (e.g., more challenges for those who are employed) and experience of mental health difficulties. The present focus group sought to further develop knowledge in each of these areas: strengths (i.e., existing school-based supports for MCY), needs (i.e., those unique to MCY and families and perceived barriers to receiving supports), and recommendations for future directions (i.e., strategies for building up and learning from current supports and overcoming barriers in areas of need).

Method Thirteen diverse stakeholders in military family behavioral health participated in a 2017 focus group to explore perceptions related to existing behavioral health supports, ongoing needs, and potential approaches to maximizing services available to military families, particularly in the Southeastern United States (e.g., South Carolina). The stakeholders consisted of 14 people: 5 university staff and faculty members, 2 active duty service members, 3 military spouses, 2 school liaisons, 1 school-based clinician, and 1 military clinician. Five of these participants were also parents of MCY. The following questions were used to guide the conversation: 1. What organizations (either governmental or non-profit) have you worked with or are aware of that support behavioral health (BH) initiatives with military families?

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2. What are some of the unique needs for military families in this work? In what ways should the infrastructure and efforts be strengthened? 3. What has limited family involvement in guiding BH for military families in local schools? How can these limiting factors be changed? 4. Do you think it would be worthwhile to establish a state-wide leadership team that would help to guide and coordinate training and Implementation Support (IS) for effective school behavioral health (SBH) for military families? 5. How can we increase outreach and involvement with policy leaders from our military systems to explore mechanisms to build the SBH workforce? 6. Are you aware of any schools that are effectively implementing true system-­ wide SBH for military families? Is it being done at all tiers? Can these facilities be named “exemplar”? 7. With the identification of exemplary sites, how can we publicize their experiences and promote generalization of successful programming strategies to other sites with large military populations? 8. What strategies can be employed to increase advocacy within military communities? 9. If resources are limited, how can military SBH stakeholders work “smarter”? 10. What other recommendations do you have to move this work forward in schools that serve military families?

Results Existing Services Consistent with the growing movement to provide behavioral and mental health supports in schools (see “Advancing Effective School Behavioral Health”), the focus group noted schools as an avenue for receiving services. Participants’ exposure to school behavioral health (SBH) services varied widely depending on several factors, such as whether the school was DoD-based, a public school with few military-­connected persons, or another academic setting. Some families also noted that they informed and helped to create the supports at each school their child attended (e.g., creating clubs or advocating with school leadership). This was particularly necessary when school personnel were unfamiliar with commonalities of life on an installation or as an MCY, either due to inexperience in a military-focused school or being in a non-DoD school setting. As one of the participants stated: I really think that you can spend all the time that you want to going in and educating the counselors, the guidance counselors, and school psychologists, etc. that work in the schools [so that they] know about what these children might be facing, but unless they’ve had some experience with it, unless they’ve experienced it with themselves, it’s going to take a long time for them to acclimate and see enough of it, to really get a feel and understanding for it.

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Group participants also described a variety of informal supports, such as events organized by installation-based churches or schools; however, these varied by installation/location. Further, few of these supports directly engaged children as well as spouses. This quote illustrates these themes: It is really a base-to-base difference. Every base that you go to is different; they have different things, and that comes down to letting people know what’s there. We never really hear anything from our family readiness center or anything like that. When people are deployed, the only thing we ever hear about is spouse dinners, which they’ll do like once a quarter.

Participants indicated familiarity with several more structured programs designed to provide support to military members and their families. Some examples included Strong Bonds (see www.strongbonds.org), Families OverComing Under Stress (see www.focusproject.org), and Smooth Move workshops available through some installations. However, when describing these programs during the session, participants reported that most available programs lacked therapeutic supports specific to children, with an exception found in the MFLC Program, discussed in more detail below. MFLC  Participants often discussed the MFLC program in conjunction with other services, such as school supports or additional mental health services. The group discussed the limited scope of the program, praising the benefits of having someone to check in with their children or assist with the transition process, but noting the need for sufficient funds for MFLCs in various settings or for supplemental services. As a participant stated: We’ve used the MFLC on base for personal use, and we’ve also had the luxury of having [provider’s name] at our school, which has really helped my kids get through. My kids have been through four deployments in four years since we’ve been here in [city], and it’s been rough. Having that MFLC in the school has made a huge difference in their lives. She knows them, not just as who they are in an office setting, but she knows them in the lunchroom, down the hall, how they’re doing in school… I think that plays a really big part in how they handle the military life part of things.

Often, discussion of existing services turned to ongoing needs, with participants raising questions or describing gaps. One contributor described turning to the internet for resources addressing problems beyond the scope of MFLCs: A lot of clinics… won’t see children because we don’t have the manning or we don’t have pediatric specialists. So, what happens is, when problems go beyond the scope of MFLC or guidance counselors, military families – who are often times new to the area – end up going out into the community to try to find mental health assets for themselves… [People ask me], ‘If my kid is having problems with anxiety or whatever, and it’s beyond the scope of what MFLCs can do, who should they go to?’ And then I’m Googling clinics or different therapists. So, I think there is a gap there.

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Ongoing Needs While participants demonstrated some knowledge of existing services for military families, several participants described resources they were able to access only through strong self-advocacy (e.g., making requests of the school, identifying other families in the community with a similar experience, etc.). Focus group participants and the literature describe stressors created by the deployment and reintegration processes, when family structure shifts and a parent may return with very different behaviors, needs, and role in the family post-deployment (Chandra, Lara-Cinisomo, et al., 2010). It is these periods, the greatest times of whole-family need, that demand the most resources from the families themselves. These difficulties, in combination with a lack of programming, resulted in participants in this sample engaging in self-­ advocacy to meet their needs. With a lack of programs for service members, spouses/ partners, and youth, families may be left to their self-advocacy for supports or what one participant described as “people that approach them” outside of a program already in place or lack of information about available services and programs: There’s counselors and things like that on base…, but there is nothing in place that teaches [MCY]: this is how it all works, this is what to expect, things like that… Especially if it’s your first deployment, or the parent hasn’t left in a really long time, and so when you’re five and your parent leaves, it’s a lot different than when you’re nine and your parent leaves, and the issues that you go through. There’s nothing there in place for kids, not a real curriculum anyway, that teaches them how to deal with that. Other than people that approach them, like our MFLC that will talk them through it, but nothing in place.

Some of the participants felt that another substantial barrier to accessing behavioral health services for their children was the lack of information about the different services or resources at each base. One participant noted that the only family-­oriented service they were informed of was spouse dinners hosted by the on-base church. Another participant added that when their partner deployed, there was no outreach from base personnel to provide resources to their family. Although the participants agreed that resources and outreach efforts vary base to base, they suggested a more unified effort to inform military families of the services available, regardless of the branch or base. Lack of Programs for Children  Needs among families were noted to fall broadly into two categories: (1) awareness in the family’s community, which in turn provides indirect support to MCY, and (2) more direct support to children seeking to build coping strategies and resilience. One participant described a program they had led that addressed both needs: I went to the principal and asked for permission to run a deployment group during lunch, because I identified that we had many children that were going through the same thing… In fact, at one point, I had to split it up [kindergarten through second grade] and [third through fifth grade], because the needs were a little different. It was a great opportunity to kind of coach them through some of those transitions, and then also allow them to be creative and artistic, because they would create things to send to their parents or think of ways, like role play of how to communicate to their friends why they may be sad one day… For example,

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In this program, the leader noted a lack of understanding among the classmates of a group member handling an experience that was uncommon in her setting. The strategy for building awareness in this case was a form of self-advocacy: teaching children how to communicate aspects of their experience to others. The primary focus of the group, however, was to support elementary-aged children in going through transitions and to provide opportunities to express themselves creatively and facilitating communication with parents and friends. While this provides a foundation for supports for MCY, further support was needed in this situation and in many others.

Future Directions Research Ideas  Because some participants were connected directly or indirectly to research institutions, research questions arose as part of the discussion. Research was frequently referenced as part of a mechanism to move practical application forward (e.g., starting a service under the momentum and funding of a research study). Some examples of research ideas included: • Assessing “the differences in BH issues in military kids versus non-military kids in schools [and] in the various grade levels.” • Developing “a theoretical model of the unique experience of a MCY.” • Identifying “a military parent willing to volunteer in the schools [and evaluating effectiveness]. We could start it off as research project and say that we’re going to identify some moms to go into these various schools, and then we’re going to evaluate whether the BH… incidents go down in those schools where there is a military mom in place to provide the education and any kind of help that might be needed.” Group members also noted some concerns for research used to initiate practice, such as the potential lack of sustainability after the departure of involved parties and the stigma of the required “paper trail” in research, when confidentiality and limited documentation are sometimes preferred by military-connected individuals: One thing that makes a program successful [in military populations], is the confidentiality and the lack of consistent documentation. I think if you were to go and do research or push more documented mental health services, that could be something that might shy some military family members away. There’s always been that stigma of, ‘If I have a paper trail, it’s going to hurt me long term,’ so I don’t know how we could get around that.

State-Wide Leadership Team  Participants expanded on the identified needs for future research and discussed potential opportunities for immediate application through a “resource mapping” of supports that were available within the state or could feasibly be brought into local areas. More specifically, recommendations for

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next steps for a state-wide leadership team relied on continuing the momentum of existing gatherings (e.g., the focus group, annual meetings in the state), encouraging collaboration amongst universities and government agencies such as state departments of education and mental health, and utilizing existing collections of resources (e.g., the Penn State Military Family Clearinghouse; see https://militaryfamilies. psu.edu). Participants also acknowledged that creating movement at the state level and engaging across organizations and resources would require training or education for members of leadership relatively new to military family-focused supports: I think the biggest thing is educating non-military folks on what the issues are. I think we should invite [specific personnel] to be on this state-wide committee so that [they] also can be educated by parents who have these issues and other professionals who have seen the issues. And if we could get the people at the top to understand what the issues are, they can mandate going down what needs to happen… [If we could] develop a curriculum for a new program, a training program, I think that would be great.

Community Supports  As mentioned previously, some participants referenced engaging with their communities through their schools, such as in calling a school counselor or principal to make them aware of their needs. Participants spoke positively of times that school personnel or others had responded to their expressed need and similarly requested more of these community supports across settings: It would be nice if… they could meet other kids that are going through the same [experiences]. One of our chaplains on base… just deployed for the first time and they have four kids, and she homeschools. So her kids at church this week were like, ‘I wish we knew somebody that was going through this,’ and I’m like, ‘Well, we have [provider’s name]…’ she can get them together like, ‘Oh, you’re new here; here are three other kids that have only been here a year, so they’re kind of new, too.’ There needs to be a program on base that gets the kids together and helps them learn how to cope with everything that goes on.

Notably, several of the supports that participants referenced as being particularly helpful were those that they did not need to initiate themselves upon their arrival (e.g., an ongoing group with other “new” children, a system of welcoming new families to a base with a packet, etc.). However, many participants also noted that they felt there was much they needed to advocate for on their own, as referenced previously.

Recommendations for Moving Forward Given the prominence and service of military-connected individuals in the United States, questions arise about methods and avenues for service provision not only for members of the military but also for their families. Participants in the focus group and previous literature evaluating the current state of services/supports provide recommendations for next steps.

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Participant Recommendations Among focus group participants, next steps focused on increased child-specific services and having more services in place for families to prevent the need for developing and seeking out new supports at each stage of the deployment cycle. As noted above, several themes arose in the participants’ discussion of strategies for reaching these goals, such as maximizing use of MFLCs, developing services aimed specifically at children’s unique and developing needs, mobilizing community support and state-wide leadership, and continuing research. One participant indicated that an ideal circumstance should incorporate these components together consistently: It would make a huge difference to the kids to have, ‘Dad’s gone but there is this Air Force guy who can come and eat lunch with you just to see how you’re doing,’ just little things like that make a big difference. At other bases… we got there, and we got a packet and we had lunch with some people that had been there for a few years. My husband’s shop set it up, and we got to meet these people. I was able to immediately ask questions. My kids immediately met new people and made friends, and it made a big difference to them.

Recommendations from Previous Literature Similarly, the literature notes the positive aspects of military-connectedness (e.g., resiliency, being part of an essential community) as well as the difficulties (e.g., risk for behavioral and mental health concerns, being misunderstood). Results of previous research suggest that military-connected individuals with strong social connections may better adjust to challenges (Mmari et al., 2010). Looking forward, authors have called for programs with more empirical support and services targeting needs across the family system and stages of the deployment cycle (Chandra et al., 2011; Esposito-Smythers et al., 2011).

Limitations The group in the current study considered the existing services, ongoing needs, and future directions for services for military-connected families, and they brought to light strong suggestions for forward movement. Despite this contribution, many needs still remain. First, MCY were noted to be frequently overlooked in programming, and their voices and opinions are also lacking here. Focus groups with MCY, considering their views of existing services and ongoing needs, will be a significantly valuable contribution to the literature. Further, MCY’s  preferred future directions may include strategies for engaging their same-aged peers as well as adults and systems to promote community and successful development across children and settings.

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Second, this group focused primarily on mobilizing services in South Carolina, though several other steps to provide stronger and more consistent services to military-­connected families have been taken in other states both within and outside of the southeastern United States. Future research might consider existing models of service in other states or territories and military-connected families’ responses to them, as well as evaluate and discuss the process of developing new services and collaborations. Existing developmental theories are comprehensive and robust; however, given the unique developmental experiences of MCY, additional research is needed to determine if existing developmental theories adequately describe, predict, and explain developmental outcomes for MCY.  The research recommendation of the focus group participant proposing “a theoretical model of the unique experience of a MCY” is highly relevant. While MCY do access evidence-based treatments, there is an alarming dearth of quality research published evaluating behavioral health programs specifically for MCY (Moore et al., 2017). There appears to be an assumption that evidence-based programs will generalize to this population and their contexts; however, research and program evaluation is a significant need in this area.

References Aronson, K. R., Kyler, S. J., Moeller, J. D., & Perkins, D. F. (2016). Understanding military families who have dependents with special health care and/or educational needs. Disability and Health Journal, 9(3), 423–430. Besterman-Dahan, K., Gibbons, S., Barnett, S., & Hickling, E. (2012). The role of military chaplains in mental health care of the deployed service member. Military Medicine, 177(9), 1028–1033. Cederbaum, J. A., Gilreath, T. D., Benbenishty, R., Astor, R. A., Pineda, D., DePedro, K. T., et al. (2014). Well-being and suicidal ideation of secondary school students from military families. Journal of Adolescent Health, 54(6), 672–677. Chandra, A., Lara-Cinisomo, S., Jaycox, L. H., Tanielian, T., Burns, R. M., Ruder, T., et al. (2010). Children on the homefront: The experience of children from military families. Pediatrics, 125(1), 16–25. Chandra, A., Lara-Cinisomo, S., Jaycox, L. H., Tanielian, T., Han, B., Burns, R. M., et al. (2011). Views from the homefront: The experiences of youth and spouses from military families. Rand Health Quarterly, 1(1), 16–25. Chandra, A., Martin, L.  T., Hawkins, S.  A., & Richardson, A. (2010). The impact of parental deployment on child social and emotional functioning: Perspectives of school staff. Journal of Adolescent Health, 46(3), 218–223. Chartrand, M. M., & Siegel, B. (2007). At war in Iraq and Afghanistan: Children in US military families. Ambulatory Pediatrics, 7(1), 1–2. Department of Defense. (2016). Annual report to the Congressional Defense Committees on families with special needs. Retrieved July 25, 2018, from http://download.militaryonesource. mil/12038/MOS/Reports/MOS-­OSN-­Report-­to-­Congress-­2016.pdf Department of Defense. (2017). 2017 Demographics: Profile of the military community, deputy assistant secretary of defense (military community and family policy), ICF International. Retrieved May 22, 2019, from http://download.militaryonesource.mil/12038/MOS/ Reports/2017-­demographics-­report.pdf

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Easterbrooks, M. A., Ginsburg, K., & Lerner, R. M. (2013). Resilience among military youth. The Future of Children, 23(2), 99–120. Esposito-Smythers, C., Wolff, J., Lemmon, K. M., Bodzy, M., Swenson, R. R., & Spirito, A. (2011). Military youth and the deployment cycle: Emotional health consequences and recommendations for intervention. Journal of Family Psychology, 25(4), 497–507. Esqueda, M.  C., Astor, R.  A., & De Pedro, K. (2012). A call to duty: Educational policy and school reform addressing the needs of children from military families. Educational Researcher, 41(2), 65–70. Gorman, G. H., Eide, M., & Hisle-Gorman, E. (2010). Wartime military deployment and increased pediatric mental and behavioral health complaints. Pediatrics, 126(6), 1058–1066. Harrison, J., & Vannest, K. J. (2008). Educators supporting families in times of crisis: Military reserve deployments. Preventing School Failure: Alternative Education for Children and Youth, 52(4), 17–24. Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D., & Koffman, R. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S. C., & Engel, C. C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164(1), 150–153. Hoshmand, L.  T., & Hoshmand, A.  L. (2007). Support for military families and communities. Journal of Community Psychology, 35(2), 171–180. Huebner, A. J., Mancini, J. A., Bowen, G. L., & Orthner, D. K. (2009). Shadowed by war: Building community capacity to support military families. Family Relations, 58(2), 216–228. Johnson, P. L., Knauss, L. G., Faran, M., & Ban, P. (2014). Military children and programs that meet their needs. In S. J. Cozza, M. N. Goldenberg, & R. J. Ursano (Eds.), Care of military service members, veterans, and their families (pp. 41–52). American Psychiatric Publishing, Inc. Johnson, S.  J., Sherman, M.  D., Hoffman, J.  S., James, L.  C., Johnson, P.  L., Lochman, J.  E., Magee, T. N., Riggs, D. R., & Nichols-Howarth, B. (2007). The psychological needs of US military service members and their families: A preliminary report. American Psychological Association. https://www.apa.org/about/policy/military-­deployment-­services.pdf Kees, M., Nerenberg, L. S., Bachrach, J., & Sommer, L. A. (2015). Changing the personal narrative: A pilot study of a resiliency intervention for military spouses. Contemporary Family Therapy, 37(3), 221–231. Kees, M., & Rosenblum, K. (2015). Evaluation of a psychological health and resilience intervention for military spouses: A pilot study. Psychological Services, 12(3), 222–230. Lester, P., & Flake, L. C. E. (2013). How wartime military service affects children and families. The Future of Children, 23(2), 121–141. Masten, A. S. (2013). Competence, risk, and resilience in military families: Conceptual commentary. Clinical Child and Family Psychology Review, 16(3), 278–281. Mmari, K. N., Bradshaw, C. P., Sudhinaraset, M., & Blum, R. (2010). Exploring the role of social connectedness among military youth: Perceptions from youth, parents, and school personnel. Child & Youth Care Forum, 39(5), 351–366. Moore, K. D., Fairchild, A. J., Wooten, N. R., & Ng, Z. J. (2017). Evaluating behavioral health interventions for military-connected youth: A systematic review. Military Medicine, 182(11), 1836–1845. Obama, B. (2011). Strengthening our military families: Meeting America’s commitment. http:// www.dtic.mil/dtic/tr/fulltext/u2/a550567.pdf SC Educational Oversight Committee. (2017). Annual report on educational performance of military-­connected students. https://www.scstatehouse.gov/reports/EducationOversightComm/ Military-­Connected%20Students%20Report%204.10.17.pdf Trail, T.  E., Martin, L T., Burgette, L.  F., May, L.  W., Mahmud, A., Nanda, N., & Chandra, A. (2018). Charting Progress: U.S. military non-medical counseling programs. RAND Corporation. https://www.rand.org/pubs/research_reports/RR1861z1.html

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Wenger, J., O’Connell, C., & Cottrell, L. (2018). Examination of recent deployment experience across the services and components. RAND Corporation. https://www.rand.org/pubs/research_ reports/RR1928.html

Furthering the Advancement of School Behavioral Health in Your Community Mark D. Weist, Darien Collins, Samantha Martinez, and June Greenlaw

The above chapters reflect a deep analysis on strategies to improve school behavioral health (SBH) across five content dimensions, collaboration, schoolwide approaches, cultural responsiveness, quality of services, and implementation support, and three populations, students connecting to juvenile justice, child welfare, or the military, with these themes and populations prioritized through our research funded by the Patient-Centered Outcomes Research Institute (PCORI). In synthesizing the contents of this focused book, the diverse team of individuals involved in developing it reviewed findings from all the focus groups and brain-stormed ideas in relation to our collective experiences in advancing the SBH agenda in South Carolina and the Southeast region of the United States (US). Collaborators on this book include disciplines of family members (of youth with emotional/behavioral challenges), veterans, school and clinical psychologists, mental health consultants, social workers, teachers, advocates, and undergraduate students, graduate students, research staff, program evaluators, post-doctoral fellows, and faculty members. Collectively, this group has over 100 years of experience in SBH. Ideas presented in the following amplify and add to themes/recommendations emanating from focus groups, are consistent with research and literature on effective SBH, and can be viewed as a menu of options for strengthening programs at both school and district levels. Here, we distill from all chapters critical themes, with 34 identified and reviewed here: 1. Expand the voices of family and diverse community members in driving the SBH agenda, and build relationships among school and mental health staff, students, and families. 2. Attend to “siloing” among systems and groups of people and pursue cross-­ system collaboration. M. D. Weist (*) · D. Collins · S. Martinez · J. Greenlaw Department of Psychology, University of South Carolina, Columbia, SC, USA e-mail: [email protected]; [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2020 M. D. Weist et al. (eds.), School Behavioral Health, https://doi.org/10.1007/978-3-030-56112-3_10

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3. Improve family-school-community partnerships in developing resources for guiding and expanding SBH programs. 4. Maintain user-friendly directories of school and community resources, to help students, families, and school staff connect to these resources and provide ongoing staff support to assure they are up to date. 5. Conduct community fairs, planned by school staff, families, and students to involve other community agencies and resources to help build connections with them. 6. Stigma is a significant issue limiting the use and impact of SBH, and there is a compelling need to train teachers and students together in mental health literacy, which reduces stigma and is associated with improved help seeking and functioning. 7. Build wellness-focused training (e.g., coping, exercise, nutrition, stress management, mindfulness) programming for students, families, teachers, and school staff including SBH staff from community agencies. 8. Train staff, families, and students on trauma and trauma-sensitive approaches in schools. 9. Improve training and classroom support for teachers on promoting positive behavior, effective classroom management, and assuring positive relationships with students. 10. Improve communication to assure all schools/districts have teams and points of contact for advancing the SBH agenda. 11. Guided by district level leadership teams, implement effective memoranda of agreement (MOAs) between schools and community mental health (and other) agencies, and assure confidentiality and breakdown confidentiality-related barriers (e.g., pertaining to HIPAA, FERPA). 12. Build paraprofessional staff in schools to provide support to educators and increase staff support especially for Tier 1 and Tier 2 programming. 13. Implement mentoring-based programs at Tier 2 (e.g., Check In- Check Out; Crone, Hawken, & Horner, 2010), augmented with training in social emotional learning (SEL) and skills-training programs. 14. Expand teams to ensure they are inclusive of all disciplines, include families and students, and assure clarity of roles for all team members and effective team meetings. 15. Empower students and families as decision-makers in schools and support them in roles to co-create the education environment with school staff and mental health system collaborators. 16. Embrace technology to improve communication among all professionals and stakeholder groups. 17. Evaluate all programs delivered across Tiers 1, 2, and 3, to assure they are evidence-­based and consider input from multiple sources within the community. 18. Align programs to eliminate those lacking evidence and/or satisfaction. 19. Make data easier to use and involve diverse school staff, families, and students in reviewing and making data-driven recommendations for SBH interventions.

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20. Focus on equity of services and in discipline practices to escalate actions to reduce disproportionality for negatively affected groups such as males and youth of color. 21. Increase compassionate and effective approaches for students receiving exclusionary discipline (e.g., suspension/expulsion) to move toward reducing blame and building supportive programs to help reintegrate them into their schools. 22. Reduce use of alternative school programming for at-risk students, and when these programs are used, assure appropriate and supportive transitions to the program and then back to their home school. 23. Assure all programs and services within the multi-tiered system of support (MTSS) including Tier 3 treatment services are available to all students/families regardless of health insurance status, and significantly involve private insurers more in funding SBH. 24. Make mental health in schools a funding priority through cohesive policies at the local and state levels, and capitalize on federal funding opportunities. 25. In SBH initiatives, include experts on policy and funding to explore traditionally used (e.g., Title 1, special education funding to schools, Medicaid) and less commonly used (e.g., funds from juvenile justice and child welfare) funding mechanisms, to expand programming across schools within districts. 26. Move beyond ad hoc involvement of clinicians from the mental health system toward their more consistent and meaningful involvement in schools (e.g., no assignments less than half-time at one school building). 27. Develop strategies to be able to identify students involved in juvenile justice and/or child welfare systems and provide supportive services in school to them and their caregivers. 28. Provide training to school staff on common problems encountered by students in juvenile justice and child welfare systems (e.g., abuse, neglect, domestic violence, substance abuse) and transition support strategies. 29. Provide supportive liaison/case management services to families/caregivers with connections to juvenile justice and child welfare to assist them and their students to stay connected to the school, its curriculum, and supportive programs. 30. Include caregivers with experience in juvenile justice and child welfare in developing and implementing district- and state-wide policies to improve programs and supports for students encountering these systems. 31. Develop a state-wide advisory group that includes older youth and families to coordinate cross-system collaboration between education, mental health, child welfare, and juvenile justice in developing SBH programs accessible to the range of students who are impacted by these additional systems. 32. In communities that have higher percentages of military families, provide supports within the MTSS for the unique stressors these families and students encounter (e.g., frequent moves, changes in school systems, family member deployments, and reintegration).

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33. In communities including more military stakeholders, assure that soldiers, officers, and other family members have a role in decision-making at the district and school levels. 34. Devote time to data infrastructure, considering use of non-proprietary measures, strong information technology support, and aligning data systems to assure that all data collected are actually used for SBH program improvement and expansion. Powerful arguments can be made that growing and improving SBH is an agenda relevant to any community in the United States, since these programs, when done well, reduce/remove barriers to student learning and help to assure students’ positive social, emotional, behavioral, and academic functioning (see Eber et al., 2019; Weist, Lever, Bradshaw, & Owens, 2014). Thus, this agenda is relevant to the diverse stakeholder groups mentioned throughout the book including families and youth, leaders and staff of youth-serving systems (e.g., education, mental health, child welfare, juvenile justice, primary care, disabilities, military involved), government officials, researchers, and members of faith and business communities (see Andis et  al., 2002; Lever et  al., 2003). Further, as presented in the introductory chapter, the current COVID-19 pandemic is leading to significantly increased mental health challenges for all people, including children and adolescents, underscoring the importance of SBH as an accessible, ecologically valid, and effective framework for delivering mental health services in the years to come. As diverse people meet within school districts and the communities served by them, embracing a community of practice approach (Cashman et al., 2014; Wenger, McDermott, & Snyder, 2002) and planning systematically to build capacity for SBH programs would be a critical strategy for improving the positive adjustment and wellness of students and families. The above menu of 34 strategies could be used to help guide these discussions. To support progress in advancing the SBH agenda in your community, the following resources would likely be of assistance. National centers for Positive Behavioral Interventions and Supports (PBIS; see www.pbis.org) and school mental health (see www.schoolmentalhealth.org) provide a range of relevant resources for improving SBH practice and for building policy support for these programs, including many free, public domain materials and resources regarding effective assessment and programming in all levels of schools’ multi-tiered systems of support. The Midwest PBIS Network (see www.midwestpbis.org) is a partner with the National Center for PBIS and also works to develop the capacity of schools to support the success of all students, including those with elevated needs, with a particular emphasis on resources from the increasingly prominent Interconnected Systems Framework (ISF) for PBIS and SMH (also see Barrett, Eber, & Weist, 2013; Eber et al., 2019). Similarly, the Family-School-Community Alliance (see https://fscalliance.org) supports outreach, empowerment, and engagement of family, youth, and community partnerships in research, practice, and policy. The Southeastern School Behavioral Health Community (SSBHC; see www.schoolbehavioralhealth.org) represents one of a range of regional collaboratives also focusing on the advancement of SBH. We

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hope that themes and recommendations in this focused book, including voices from diverse stakeholders, especially youth and families, helps to inform the development and expansions of achievable strategies to build capacity for effective SBH in diverse communities.

References Andis, P., Cashman, J., Praschil, R., Oglesby, D., Adelman, H., Taylor, L., et al. (2002). A strategic and shared agenda to advance mental health in schools through family and system partnerships. International Journal of Mental Health Promotion, 4, 28–35. Barrett, S., Eber, L., & Weist, M. D. (2013). Advancing education effectiveness: An interconnected systems framework for Positive Behavioral Interventions and Supports (PBIS) and school mental health. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education). University of Oregon Press. Cashman, J., Linehan, P., Purcell, L., Rosser, M., Schultz, S., & Skalski, S. (2014). Leading by convening: A blueprint for authentic engagement. Alexandria, VA: National Association of State Directors of Special Education. Crone, D. A., Hawken, L. S., & Horner, R. H. (2010). Responding to problem behavior in schools, second edition: The behavior education program. New York: Guilford Publications. Eber, L., Barrett, S., Perales, K., Jeffrey-Pearsall, J., Pohlman, K., Putnam, R., Splett, J., & Weist, M.  D. (2019). Advancing education effectiveness: Interconnecting school mental health and school-wide PBIS, Volume 2: An implementation guide. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education). University of Oregon Press. Lever, N. A., Adelsheim, S., Prodente, C., Christodulu, K. V., Ambrose, M. G., Schlitt, J., et al. (2003). System, agency and stakeholder collaboration to advance mental health programs in schools. In M. D. Weist, S. W. Evans, & N. A. Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp. 149–162). Springer. Weist, M. D., Lever, N., Bradshaw, C., & Owens, J. S. (2014). Further advancing the field of school mental health. In M. Weist, N. Lever, C. Bradshaw, & J. Owens (Eds.), Handbook of school mental health: Research, training, practice, and policy (2nd ed., pp. 1–16). Springer. Wenger, E., McDermott, R.A., & Snyder, W. (2002). Cultivating communities of practice: A guide to managing knowledge. Harvard Business Press.

Index

A Association for Positive Behavior Support, 30 Attention deficit/hyperactivity disorder (ADHD), 78, 79 Autonomy, 12 B Behavioral health (BH) educating administrators, services, 84 juvenile justice involvement, 75 programs, 78 Behavioral Health Optimization Program (BHOP), 109 Buy-in administrator and senior faculty, 23 barriers, 23 interventions, 23 participants, 26 PBIS, 23, 26, 28 recommendation, 23 school staff, 30 school-wide PBIS, 28 C Child abuse, 97, 98 Child welfare (CW) systems, 2, 5 adoption services, 95 collaboration, 97, 98, 100, 101 family and community support, 98, 101 formal kinship care, 95 juvenile justice involvement, 99 juvenile justice system, 102 mental health, 96, 97

method, 99, 100 recommendations, 102–104 voluntary kinship care, 95 Civilian families, 108 Classroom check-up, 12 Classroom management training, 82 Collaboration approaches, 9 and autonomy, 12 and awareness, 14 commonplace language, 9 family engagement, 13 LbC framework, 10 and partnerships, 10 recommendations, improvement, 15, 16 required antecedents, 10 school and community, 10 stigma, 12 teaming, 16 Collaborative approaches, 9, 17 Commonplace language, 9 Communication, 11, 13, 16, 17 Community-employed mental health, 29 Community of practice, 1, 126 Community partnerships, 61, 65 Community support, 97, 103 Continuum of care, 85 COVID-19, 6, 7, 126 Cultural competency criticism, 35 health and mental health care, 35 humanity (see Cultural humility) race and ethnicity, 35 training programs, 36

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Index

130 Cultural humility characterization, 36 definition, 35 discipline practices, 38, 41, 42 lack of trust, 37, 38, 41 minority students, 36 SBH methods, 39 SBH programs, 44 stereotypes, 36, 40 stigma, 37, 39, 40 themes, 39 Culturally competent, 35 Culturally humble SBH, 42 Curricula, 82 D Data sharing, 66, 67 Department of Juvenile Justice (DJJ), 80, 85, 88, 89 Depression, 78 Discipline disproportionality, 77 Discipline practices antisocial behavior and suspension, 38 behavioral problems, 42 drug and alcohol use, 38 forum participants, 41 long-lasting consequences, 38 racial and ethnic groups, 38 Diversity, 123, 124, 126, 127 Domestic violence (DV), 98 E Educational disruption, 77 Emotional/behavioral (EB) problems, 47 Emotional control, 82 Emotional disability (ED), 80 Evidence-based PBIS practices, 28 Evidence-based practices (EBPs), 22, 50 Exceptional Family Member Program (EFMP), 109 Exclusionary discipline, 36 F Family-centered interventions, 87 Family check-up, 12 Family Educational Rights and Privacy Act (FERPA), 62 Family engagement, 10, 13, 15, 17 Family-focused mental health promotion workshops, 29

Family-School-Community Alliance (FSCA), 24, 126 Family-school-community partnerships, 124 Foster care, 95–97, 102 Functional behavioral assessment (FBA), 50 Funding, 83 G Gender and sexual orientation, 76 General education environment, 81 H Health Insurance Portability and Accountability Act (HIPAA), 62 HomeFront Strong, 111 Human service agencies, 30 I Implementation fidelity, 22, 24, 27, 30 Implementation support child-serving entities, 60 community partnerships, 61, 65 data sharing, 66, 67 information/data sharing, 62 interdisciplinary collaboration, 61, 62, 65, 66 mental health disorder, 59 method, 63 quality, 59 recommendations addressing insurance challenges, 69 behavior management strategies, 67 communication, 69 district-community partnerships, 68 helping families, 70 lack of awareness, 68 mental health literacy, 68 mental health supports, 68 partnerships, 68, 69 quality, 68 resource-intensive intervention, 67 school leadership, 68 supports, 70 teaching coping skills, 68 school setting, 59 staff capacity, 60, 63, 64 treatment engagement and retention, 59 Implementation support (IS), 4 Individualized Education Plan (IEP), 27, 48 Individuals with Disabilities Education Act (IDEA), 21, 48

Index Information/data sharing, 62 Information sharing, 66, 67 Interconnected Systems Framework (ISF), 3 Interdisciplinary collaboration, 61, 62, 65, 66 J Juvenile incarceration, 75 Juvenile justice-involved youth (JJIY), 4 black ex-juvenile offenders, 76 continuum of care, 84–86 depression and anxiety, 75 early incarceration, 76 educational quality, 80–82 environmental influences, 86–87 gender and sexual orientation, 76 mental health support in childhood, 75 non-White students, 76 risk factors ADHD, 78, 79 depression, 78 learning difficulties, 79 learning disabilities, 79 mutual frustration, 79 participant recommendations, 80 student trauma, 78 violent trauma, 79 school administrators, 76 school-based programs, 77 school-to-prison pipeline, 77, 89 short-term effects, 76 stakeholder opinions, 77 system failure, 82–84 transition from DJJ, 87–89 Juvenile justice involvement, 75 Juvenile justice system, 38, 75 L Lack of trust, 37, 38, 41 Large-scale PBIS implementation, 29 Leadership teams, 30 Leading by Convening (LbC) framework, 10, 17 Learning disabilities, 79, 80 M Mental health disorder, 10, 59 Mental Health First Aid, 29 Mental health literacy, 59, 68 Mental health providers, 43

131 Mental health services, 75, 85, 90 MI-based treatments, 12 Midwest PBIS Network, 126 Military-connected youth (MCY), 5 community supports, 112, 117, 118 deployment cycle, 110 deployment-related stressors, 109 EFMP, 109 existing services, 109 future directions, 118, 119 gaps in available services, 109 indirect support, 115 lack of programs, 111 MFLC program, 114 MFLC services, 110 military-focused/non-DoD school setting, 113 prevention programs, 110 recommendations, 111 research institutions, 116 SBH services, 113 Smooth Move workshops, 114 state-based supports, 111 state-wide leadership team, 117, 118 Strong Bonds, 114 young age, 108 Military families active duty and Selected Reserve members, 107 EFMP, 109 emotional and behavioral health, 112 existing services, 109, 114, 115 MCY, 107 (see also Military-connected youth (MCY)) MCY and military-connected parents, 112 mental health challenges by civilian families, 108 need of MCY, 108 signature injuries, 108 MFLCs, 110 MTFs, 109 stakeholder involvement, 112 state-wide effort, 111 stressors, military life, 108 supports, 117 in Virginia, 108 Military family life counselors (MFLCs), 110, 114, 115, 118 Military OneSource (MOS), 110 Military stakeholders, 126 Military treatment facilities (MTFs), 109 Modular “common elements” (MCE), 50 Motivational interviewing (MI), 12, 17

Index

132 Multitiered systems of supports (MTSS), 1, 3, 4, 47, 67 buy-in, 23, 26 familial involvement, 24, 27 implementation fidelity, 26 large-scale PBIS implementation, 24, 27, 28 methods, 25 PBIS (see Positive Behavioral Interventions and Supports (PBIS)) providing effective training, 23, 26, 27 RTI, 21 school-wide systems, 21 supports across domains, 21 themes, 22 Mutual trust, 44 N Neglect, 96, 97, 99 Non-medical counselors, 110 NVIVO program, 2 O Outpatient programs, 76 P Partnership, 10, 13 PBIS implementation with fidelity barriers, 22 EBPs, 22 ecologically valid settings, 22 measures, 22 negative response, 26 office discipline referrals reduction, 23 research forum, 25, 26 rural school districts, 22 school challenges, 22 PBIS/MTSS maps, 24 Positive Behavioral Interventions and Supports (PBIS), 126 academic outcomes, 30 administrators, 28 emphasizes, 21 enhanced family engagement, 29 family engagement, 29 implementation fidelity (see PBIS implementation with fidelity) implementers, 28 implementors, 30 office discipline referrals reduction, 21 practices, 28

scaling-up, 29 school-wide approaches, 22 SEBA, 29 standard training models, 28 Priority populations, 2, 5 Punitive discipline practices reduction absences, 42 academic instruction, 42 discipline disproportionality, 42 disparities, 42 school discipline rates, 42 student-level characteristics, 42 suspensions, 42 Q Quality of services, 51 R Response to Intervention (RTI), 21 S SBH planning and implementation, 30 SBH programming, 29 School-based programs, 77 School behavioral health (SBH) awareness, 11 behavioral plans, 52 collaboration, 12, 47, 48, 52 collaborative approaches, 9, 10, 14 (see also Collaboration) community connected stakeholders, 1 community of practice, 1 content dimensions, 123 COVID-19 virus, 6 critical themes for advancement in SC, 2 cultural responsiveness and humility, 4 data-based decision-making, 49, 50, 53 education, 47 family engagement, 13 IS, 4 for JJIY, 4, 5 leadership roles, 4 mental health services, 48 mentoring-based programs, 124 method, 51 MI, 12 MTSS, 1, 3, 4 for MCY, 5 national centers, 3 national movements, 3

Index NVIVO program, 2 overcoming inertia, 51 participants, 52 partnerships and collaboration, 10 practice and policy improvement, 2 prevention and interventions, 3, 9 prioritize mental health, 50, 51, 53, 54 qualitative data, 47 quality, 52 recommendations, 54, 55 services for priority populations, 2 Spirit of MI, 12 stigma, 11, 12, 14 strengthening programs, 123 system failures, 54 understanding and empathy, 12 wellness-focused training, 124 youth involvement/training, 49, 53 School bullying, 10 School Improvement Plan, 28 School systems, 43 School-to-prison pipeline, 77, 89 School-wide mental health literacy programs, 29 School-wide practice, 23 Self-advocacy, 115, 116 Self-stigma, 37, 38 Social competency, 82 Social skills deficits, 80, 81 Social, emotional, behavioral, and academic (SEBA), 21, 29 Social-emotional learning (SEL), 5, 82 Socioeconomic status (SES), 35 Southeastern School Behavioral Health Community (SSBHC), 2, 126 Special education environments, 85 Special education services, 21 Spirit of MI, 12, 17 Staff capacity, 60, 63, 64 Stakeholder involvement, 109 State-wide leadership team, 117, 118 Statewide PBIS implementation, 24

133 Stereotypes definition, 36 mental health services, 40 participants, 40 SES, 36 single-parent households, 36 threaten students’ academic performance, 36 Stigma, 10–14, 17, 124 associated mental health, 37 barriers, 40 distorted beliefs, 37 forum, 40 lower help-seeking, 37 mental health treatment, 37 self-stigma, 37 society, 37 Student check-up, 12 Substance use disorder, 79 Supportive services, 15 Systems partnerships, 2, 3 T Teacher training on behavior, 81 Teaching practices, 81 Teaming, 9, 16 Therapeutic programs, 76 Trauma-informed care, 101 Trust development clients, 43 individual experience, 43 mental health providers, 43 relationship, 43 W Wellness-focused training, 124 Y Youth and families, 125, 127 Youth Mental Health First Aid, 30