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Clay Cook, Ph.D.Professor
John and Nancy Peyton Faculty Fel low in Child and
Adolescent Wellbeing
University of Minnesota
Co-Founder
School Mental Health, Assessment, Research,
& Training (SMART) Center
Core Faculty
Institute for Translational Research in
Children’s Mental Health
School Psychologists as Mental
Health Advocates, Providers, and
Implementation Intermediaries
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Testing /
report writing
How I spend my time at work?
InterventionConsultation /
teaming
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IS MENTAL HEALTH SOMETHING THAT
STUDENTS AND STAFF CAN HANG UP AT
THE SCHOOL HOUSE DOOR?
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Does mental health involve thoughts?
Does mental health involve feelings/emotions?
Does mental health involve behavior?
Does mental health involve relationships?
WHAT IS MENTAL HEALTH?
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MENTAL HEALTH DEFINED
“Mental health is…how a person thinks, feels, and
acts when faced with life’s
situations... This includes
handling stress, relating to
other people, being able to
concentrate, and making
responsible decisions.”
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OLD VIEW OF MENTAL HEALTH
Old View of Mental Health
Unwell/ill/unhealthy Well/healthy
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DUAL CONTINUA OF MENTAL HEALTH
HIGH distress/problems
LOW
flourishing/thriving
Dual Continua View of Mental Health
HIGH
flourishing/thriving
LOW distress/suffering
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Dual Continua of Mental Health
Keyes (2011)
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Low Thriving / Flourishing
High
Mental distress /
problems
Low
Mental distress/
problems
Struggling but
content:
15-20%
Complete mental
health:
50-60%
Languishing:
10-15%
Complacent or
ambivalent:
5-10%
Breakdown of the Dual Continua of Mental Health
High Thriving / Flourishing
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CO-MORBIDITY
One
problem
or disorder
Another
problem
or disorder
Both
problems or
disorders
When problems or
disorders combine
to increase the
likelihood of
negative outcomes
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CO-VITALITY
One
strength or
asset
Another
strength or
asset
Both
strengths or
assets
When strengths or
assets combine to
increase the
likelihood of positive
experiences and
outcomes
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ADAPTED FROM: Geierstanger, S. P., & Amaral, G. (2004). School-Based Health Centers and Academic Performance: What is the
Intersection? April 2004 Meeting Proceedings. White Paper. Washington, D.C.: National Assembly on School-Based Health Care.
Mental
Health FactorsStudent mental health
problems (anxiety,
depression, anger, trauma)
High-risk Behaviors
(e.g. Substance use)
Student social-emotional
wellbeing & resilience
Educator social-emotional
wellbeing
Attendance
Behavioral problems
Academic engagement
Interpersonal problems
Academic motivation
Attitudes Toward School
School Connection
• Graduation/Drop-out
• College entry
• Grades/ school performance
• Standardized test scores
• School climate
• Teacher Retention
MENTAL HEALTH AND ACADEMIC OUTCOMES
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ARE WE OBJECTIVELY SEEING A PROBLEM
WITH CHILDREN’S MENTAL HEALTH THAT
CALLS FOR ALL HANDS ON DECK?
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THE PROBLEMS THAT NECESSITATE CHANGE
1 out of 4 children experience
social, emotional, and
behavioral needs that interfere
with their academic
functioning
Vast majority of students with
a mental health need will
never access proper care
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MOST COMMON PROBLEMS
Depression and anxietyare the leading causes of illness among adolescents
Anxiety and disruptive behaviors are the most common problems that primary care physicians hear from parents about their kids
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ADVERSE CHILDHOOD EXPERIENCES
18%
34%
7%
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33% Report
0 ACES
51% Report
1-3 ACES
16% Report
4-10 ACES
With 0 ACESs
1 in 16 smoke
1 in 69 are alcoholic
1 in 480 use IV drugs
1 in 14 has heart disease
1 in 96 attempts suicide
With 1-3 ACESs
1 in 9 smoke
1 in 9 are alcoholic
1 in 43 use IV drugs
1 in 7 has heart disease
1 in 10 attempts suicide
With 4-10 ACESs
1 in 6 smoke
1 in 6 are alcoholic
1 in 30 use IV drugs
1 in 6 has heart disease
1 in 5 attempts suicide
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The main behavior of concern
The purpose or reason why the problembehavior occurs(i.e., function)
Setting Events
An event that increases the likelihood that the trigger will provoke the behavior
TriggeringAntecedents
MaintainingConsequences
ProblemBehavior
The Science of Human Behavior
The immediate event that provokes the behavior
Refusing to do
academic
work
Instructed to
do unwanted
work
Stressed and
fatiguedAvoid unwanted
academic work
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SETTING EVENTS
Factors outside the immediate situation that
increases the probability that a given situation
will provoke a behavior
= =
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SCHOOL IS FILLED WITH MATCHES
=Certain social
interactions
Preferred to
non-preferred
transitions
Academic
requests /
activities
Noises
Unanticipated
changes in
routine
Availability of
attention
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HOSPITALIZATIONS
SUICIDAL IDEATION & ATTEMPTS
Biggest
increase
among 6-11
year olds
100%
increase over
8 years
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Experiential avoidance
attempts to avoid unwanted thoughts,
feelings, memories, physical sensations, and
other internal experiences that cause
impairment in short- and long-term
MOST MENTAL HEALTH PROBLEMS
TowardsAway
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Sense of Belonging
40% of middle school
students report lack of sense
of belonging
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THE PROBLEMS THAT NECESSITATE CHANGE
Longstanding disparities for students living in
poverty and from historically marginalized
groups
Less likely to have secure relationships with
educators
Less likely to receive effective services
More likely to receive exclusionary discipline
More likely to be referred for special education
under EBD and placed in restrictive settings
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SCHOOLS IMPROVE SERVICE ACCESS FOR
UNDERSERVED YOUTH (LYON,COOK ET AL. , 2013)
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Now listed as one of the most potent risk
factors for the development of mental health
problems
HIGH PERFORMING SCHOOLS
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Counseling centers are overwhelmed w/ need
30% dropout of 4-year institutions
CRISIS ON COLLEGE CAMPUSES
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STRESS AND BURNOUT
Top sources Students with
challenging behavior
Limited self-efficacy to meet the needs of students with social, emotional, behavioral needs
Implementation overload
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WHERE DO KIDS NATURALLY EXIST?
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SCHOOLS AS THE DE FACTO
MENTAL HEALTH SETTING
Student accessibility
Reduced stigma
Affordability
Coordination of care
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“School psychologists are uniquely positioned in schools to facilitate the development, delivery, and monitoring of prompt, effective, and culturally responsive mental and behavioral health services of prevention and intervention.”
“School Psychologists: Qualified Health Professionals Providing Child and Adolescent Mental and Behavioral Health Services”
NASP STATEMENT
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How do school psychologists have an actual measurable influence on the mental health outcomes of children and adolescents?
How can school psychologists optimize the impact they have on the mental health outcomes of children and adolescents?
BIG QUESTIONS FOR THE FIELD
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Are school psychologists taking up
the torch of mental health?
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School psychologists are in a key position to
advance school mental health, but research
suggests that the majority of school psychologists
are not assuming this role (Curtis, Grier, & Hunley, 2003; Friedrich, 2010; Cook et al., 2017)
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SO, WHAT CAN WE DO TO
TAKE UP THE TORCH OF
CHILDREN’S MENTAL HEALTH?
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ROLES WE CAN PLAY
Mental health
advocacy
Mental health
provider
Mental health
implementation
intermediary
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Strategic support for a particular cause
Outcomes of advocacy = awareness,
knowledge, and motivation
MENTAL HEALTH ADVOCACY
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Advocacy to influence local and state policy
District policy that allocates money, protected
time, and supports
Levy-funding dedicated to school mental
health
Lobbying for state level policy
MENTAL HEALTH ADVOCACY
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Advocacy to promote mental health literacydefined as understanding how to obtain and maintain
positive mental health; understanding mental
health problems and their treatments; decreasing stigma related to mental health problems; and, enhancing help-seeking efficacy.
MENTAL HEALTH LITERACY
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MENTAL HEALTH LITERACY
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Who are these people?
SCHOOL-BASED MENTAL
HEALTH PROVIDERS
Counselor
Social worker
Co-located mental health
provider
School psychologist???
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Scope of practice The range of activities
that a qualified practitioner of an occupation may perform
Scope of competenceDeveloping the
competence to perform certain activities through learning,
SCOPE OF PRACTICE AND
COMPETENCE
Scope of practice
Current
practice
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Tier 2
Small group & brief therapeutic interventions
Tier 3
Function-based behavior intervention planning
Cognitive behavior therapy
Trauma, anger, anxiety, depression
Evidence-based parent training intervention
REPERTOIRE OF
EVIDENCE-BASED PRACTICES
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The main behavior(s) ofconcern
The purpose or reason why the problembehavior occurs(i.e., function)
Setting Events
An event that increases the likelihood that the trigger will provoke the behavior
TriggeringAntecedents
MaintainingConsequences
ProblemBehavior
The immediate event that provokes the behavior
Prevention/Proactive Supports Teaching SkillsConsequent
Strategies
Function-based Behavior Intervention Programming
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The main behavior of concern that is having a negativeimpact
What happens after the behaviorthat maintains it(i.e., function)
3. Setting Events
An event that increases the likelihood that the trigger will provoke the behavior
2. TriggeringAntecedents
4. MaintainingConsequences
1. ProblemBehavior
5. DesiredAlternative
6. TypicalConsequence
Pathway Chart
A functionally-equivalent replacementbehavior that is socially acceptable
7. Socially, acceptable FERB
In the presence of the trigger, what we want all students to do
What the naturally available consequences (i.e., typical payoff) are for exhibiting the desired behavior
The immediate event that provokes the behavior
Key question:
Does the student have
the prerequisite skills to
go the upper pathway
when faced with the
trigger?
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C
on Disa
and Comm
enter
bility
STRATEGIES WE SELECT AND USE
Setting EventStrategies
AntecedentStrategies
TeachingStrategies
ConsequenceStrategies
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THE COGNITIVE
BEHAVIORAL MODEL
Situation
Thoughts &
Meaning Making
Reaction
(Emotional, Behavioral and Physiological)
Consequences
(Perceived and actual)
Awareness of triggers &
exposure activities
CBT
STRATEGIES
Teaching skills:
relaxation, coping,
problem-solving
Cognitive restructuring (helpful
vs. unhelpful thoughts)
Contingency
management &
reactive strategies
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Typical child
Darn it! I
stepped in dog
poop. I better
clean it off so I
can go to
school.
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Depressed child
Of course, I step
in dog CRAP.
How symbolic. I
can’t do anything
right. I am a
piece of crap.
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Anxious child
OMG! This is
horrible! I can’t
go to school.
Everyone will
call me stinky
dog poop boy!!!
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Aggressive child
@#$%# dog!! I bet
the owner made
the dog poop here
on purpose. If I
saw the owner, I’d
kick his butt.
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Child with ADHD
Hmmm..something
felt squishy. Oh
look at that bird.
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EVIDENCE-BASED PARENT TRAINING
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A person with expertise in implementation who is able to work with and through others to influence the successful adoption, delivery, and sustainment of evidence-based programs and practices
Translates implementation science into everyday implementation practice
IMPLEMENTATION INTERMEDIARY
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On one hand…..School Psychs cannot carry
the burden of knowing all the existing
evidence-based practices to prevent and
address social, emotional, behavioral needs.
On the other hand….School Psychs can carry
the burden of having a deep understanding of
the science of implementation to apply it in
practice to support the successful
implementation of evidence-based practices
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LET TALK ABOUT “THINGS”
• Programs (e.g., SW-PBIS; SEL curriculum)
• Practices (e.g., positive greetings at the door)
• Principles (e.g., equity, early intervention)
• Procedures (e.g., screening for behavior)
• Products (e.g., FastBridge; Aimsweb)
• Policies (e.g., alternative to suspension)
• Processes (e.g., problem-solving process)
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WHAT ‘THINGS’ CAN BE INTEGRATED TO
PROMOTE STUDENT MENTAL HEALTH?
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Targeted/Intensive
(FEW High-risk students)
Individual Interventions(3-5%)
Selected(SOME At-risk Students)
Small Group &Individual Strategies
(10-25% of students)
Universal
(ALL Students)
School-wide, Culturally-responsive
Systems of Support
(75-90% of students)
Tier 3 Menu of Individual Supports for a FEW:
• FBA-based Behavior Intervention Plan w/
Replacement Behavior Training
• Individualized Cognitive Behavior Therapy
• Home and Community Supports
Tier 2 Menu of Default Supports for SOME:
• Self monitoring
• School-home communication system
• Structured mentor-based program
• Class pass intervention
• Positive peer reporting
• Small group SEL & SST
Tier I Menu of Supports for ALL:
• School-wide PBIS
• SEL curriculum & instruction
• Proactive classroom management
• + Relationships w/ ALL Students
•
MTSS: Continuum of
evidence-based
supports
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Relationships with others that cultivate a sense of belonging
Environments characterized as positive, safe, predictable, and structured
Intentionally taught social-emotional skills
Basic needs met – sleep, food, physical activity,
ENABLING CONDITIONS FOR
POSITIVE MENTAL HEALTH
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DISSEMINATION AND IMPLEMENTATION
Methods and
strategies to help
people/places DO
THE ‘THING’
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• Dissemination is the stuff we
do to increase people’s
AWARENESS, KNOWLEDGE,
AND MOTIVATION about the
‘THING’
• Implementation strategies
are the stuff we do to try to
HELP PEOPLE/PLACES DO
the ‘THING’
• Implementation outcomes
are HOW WELL people
PERCEIVE and DO THE THING
SOME ADDITIONAL STUFF ABOUT THE ‘THING”
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WHAT IS IMPLEMENTATION?
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Implementation – the process of supporting the
successful adoption, delivery, and sustainment
of known effective “THINGS” to improve the
quality of and outcomes associated with routine
practice
Successfully implementing = fidelity
Adherence – delivering the core steps/components
Dosage – delivering the right amount
Competency – delivering it skillfully & in an
engaging way
IMPLEMENTATION DEFINED
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WHY DOES FIDELITY MATTER?
Mechanic Pilot
Physician Educator
Engineer
Farmer
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MAKING IT HAPPEN:
LEADERSHIP
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That which gets allocated, gets implemented
Allocation of what:
Protected time for reflection
Resources: materials, professional development
MAKING IT HAPPEN:
ALLOCATING TIME, ATTENTION, AND RESOURCES
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Purposeful, active, and effective
implementation work (making it
happen) is done
by Dissemination &
Implementation Teams
MAKING IT HAPPEN:DISSEMINATION & IMPLEMENTATION TEAMS
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Recipe for Successful
Implementation
Distributed Leadership
Team
Secure Staff Commitment
Expectations, recognition, and support
Allocating protected
time & resources
Gathering fidelity data as part of
continuous improvement
process
Training & Coaching
RECIPE FOR IMPLEMENTATION SUCCESS
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SITED-BASED DISTRIBUTED LEADERSHIP
TEAM
Distributed Leadership
Team
Secure and Maintain Staff Commitment
Allocate Time and Resources
Training and Coaching
Gather fidelity to drive continuous
improvement
Expectations, recognition, &
support
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Mental health advocate
Mental health provider
Mental health implementation intermediary
SCHOOL PSYCHS CAN TRANSFORM THE
LANDSCAPE OF CHILDREN’S MENTAL HEALTH
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THE PLATE
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SCHOOL PSYCHOLOGISTS
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WHAT SHOULD GO ON OUR PLATES?