Public education has been referred to as the de facto mental health system for children. This is not surprising given that nearly 75 percent of the children who receive mental health services are provided them through schools (Rones & Hoagwood, 2000). Prevalence rates also suggest that one in five young people between ages 13–18 experience a serious mental health condition (Merikangas et. al., 2010). In this context, piecemeal approaches and ad hoc responses are no longer adequate. That's why Boston Public Schools has engaged with community partners to create a public health model for children that's grounded in a multi-tiered intervention system.
Within urban communities, a comprehensive public health approach is particularly important. Students living in metropolitan areas are 20 percent more likely to experience an adverse childhood experience (ACE), such as separation from parents, parental unemployment, and substance abuse, and may need more intensive support than their rural or suburban counterparts (Mersky, Topitzes, & Reynolds, 2013). Increased exposure to ACEs predict a range of negative outcomes, including increased severity of behavioral health issues, diminished life satisfaction, and poor academic performance. When behavioral health services are integrated into schools and supported with partnering community agencies, students have access to best practices and comprehensive care to address these issues.
Serving Boston's Students
Boston Public Schools is made up of approximately 125 schools, educating nearly 57,000 students from diverse racial and socioeconomic backgrounds. Boston district families speak more than 75 languages and come from nearly 140 countries.
In 2014, the Boston Public Health Commission and Boston Children's Hospital authored the "Health of Boston Children" report, noting that 20 percent of Boston children experienced two or more ACEs. The report also notes that there are vast inequities in access to school-based services, such as individual and group therapeutic supports and crisis services (Boston Public Health Commission, 2013). A resource mapping activity showed that only 70 percent of Boston public schools had a partnership with a community behavioral health agency.
Given the needs of students and the inequities in access, Boston's school psychologists designed the Comprehensive Behavioral Health Model (CBHM) to address educational and behavioral health needs. Designed in partnership with Boston Children's Hospital and the University of Massachusetts Boston School Psychology program, this model aims to promote positive behaviors, address the social and emotional needs of students, create safe and supportive learning environments, and reduce barriers to learning. As partners, each agency brought its resources of health service provision, professional development and training, and district leadership to collaboratively address these barriers. We used our roles in our respective agencies (Melissa at University of Massachusetts Boston and Andria at Boston Public Schools) to help build the model. After six months of planning, CBHM launched in 10 pilot schools during the 2012–2013 school year. Since then, 10 more schools have joined the model each year. The program now reaches 60 schools serving nearly 30,000 students.
Three-Tiered Approach
The Comprehensive Behavioral Health Model has provided schools with the structure and guidance to implement a tiered system of interventions grounded in instruction, assessment, and data-based decision making. This preventative model includes the use of an evidence-based, social-emotional curriculum in all classrooms; universal screening of behavioral skills; and designated teams to review students' needs. CBHM schools also provide students with Tier I universal supports, such as Positive Behavior in Schools and behavior matrixes to articulate expectations in the classroom, hallways, and other areas of the school. The universal screening data, completed by classroom teachers twice each year, is used to identify students with elevated risk for behavioral issues.
Tier II supports, which are typically needed for 10–15 percent of students, include evidence-based interventions to support the development of coping, organization, or other targeted skills. With one intervention called Check In/Check Out, a school staff member makes a personal connection with a student on a daily basis and provides organizational support. Another intervention, called Coping Cat, is a psychoeducational program to help children with anxiety.
Students who don't respond to this support or exhibit serious needs receive targeted Tier III interventions, including functional behavioral assessments and behavior-improvement plans, which identify the specific needs of a student and identify necessary services. When students need more intensive services, they can be referred to partnering behavioral health and community services where they can access individual and family therapy, case management, crisis supports, and psychiatric consults.
Building the Model
The team that developed the Comprehensive Behavioral Health Model consisted of school psychologists, social workers, professors, district administrators, and community providers. In the beginning stages, this leadership team had the initial goal of creating a model that ensured efficacy, scaled-up capability, and sustainability. We learned from school districts and state agencies around the nation that were engaging in similar work, consulted with experts and key stakeholders, attended conferences, and reviewed existing models and programs. Drawing on this input, we conceptualized a logic model, designed an implementation plan, planned professional development, compiled training materials, determined policies and protocols, and discussed new research.
For the first two years of development, the leadership team met weekly. As the number of participating schools has increased, the group (while meeting less frequently) has taken on an advisory role that focuses on sustainability and community leadership, while promoting the outcomes with internal and external stakeholders.
We've organized subcommittees to target the major areas of work—partnerships, implementation, communications, and research. Each subcommittee has specific goals. For example, the partnership committee works with community behavioral health agencies to host an annual training for clinicians to expand the use of evidence-based practices. The implementation committee creates resources, procedures, professional development, and coaching. The communications committee develops fact sheets and oversees the website. Finally, the research committee collects and analyzes data to examine outcomes. Each of these subcommittees includes district staff members and community partners working in tandem.
Key Takeaways
We have learned many lessons from this work and offer these recommendations to school leaders seeking new strategies to support the behavioral health needs of students:
- Seek out partnerships with agencies that share ownership of children and families. It has been easier to sustain our partnership because all agencies involved benefit from the collaboration. For the hospital, community-based interventions reduce the need for emergency care. For the university, enhancing training opportunities for pre-service professionals has improved practice. For the school district, the improvements in social, emotional, and behavioral functioning boost students' academic performance, plus staff members have increased their capacity to support students with intensive needs. We recognize that not every school district has a hospital or university to partner with, but there are pediatricians, mental health clinicians, and social service agencies that engage with some of your families. Seek out these connections.
- Establish goals for your partnership. We spent the first six months preparing the Comprehensive Behavioral Health Model in a way that met the mission of each agency. In the process of developing a logic model, we clarified the outcomes for students, schools, and the district. By collaboratively establishing goals and creating solutions to the gaps in services, we secured buy-in and developed greater ownership of the work.
- Ensure that each agency represents the partnership to their stakeholders and community. At the hospital, we highlight the trainings and clinical services offered to students and schools. At the university, we emphasize effective supervision of pre-service professionals and share presentations and publications with school staff—several of whom are alumni of the university's school psychology training program. Boston Public Schools promotes its improved services and students' gains.
- Plan targeted professional development that builds both professional and process skills. Building the capacity of stakeholders is the heart of our work. For the school-based mental health staff, our trainings build technical skills in areas such as trauma-sensitive learning environments, social-emotional learning, behavior screening, and classroom engagement. We have also learned the importance of other professional skills, such as facilitation strategies, implementation stages, and leadership skills.
- Create learning spaces where people can make mistakes. Learning a new skill set comes with mistakes. Coaches have provided specific feedback to school mental health staff, and small learning communities have allowed district and agency staff to work through implementation barriers. In addition, we offer separate trainings for school principals three times a year. These events give school leaders the opportunity to share ideas, develop yearly action plans, and check progress.
- Build the capacity of school teams. In our school-based trainings, we engage the principal, school psychologist, school nurse, classroom teachers, and specialty teachers. We want every adult to be familiar with the basic components of the model and for building-level teams to be accountable for implementation and student outcomes.
- Develop strategies for data management and consumption. To accomplish our goals and to allocate resources where they are needed most, we make sure to have access to consistent universal behavioral screening data. After piloting five universal screening tools, we chose the Behavior Intervention Monitoring Assessment System to collect data (McDougal, Bardos, & Meier, 2011). With an agreed-upon tool, our schools next needed protocols for collecting and disseminating their findings to inform interventions. Creating step-by-step screening directions; developing protocols for data review; and building mechanisms to share student, school, and district data are all important ways to make data meaningful.
- Share your work. We have created communication tools for describing our vision, goals, actions steps, and resources. The logic model helped us visually represent the goals and anticipated outcomes for CBHM. We've also prepared fact sheets to share our narrative and toolkits and to offer guidance to schools as they begin their journey. Our website allows for easy access to materials.
- Celebrate your success. At our annual CBHM Showcase, agencies come together to share student, school, and district outcomes. The showcase hosts a variety of stakeholders, including mental health partners, hospitals, universities, school and district staff, as well as funders. The event fosters a sense of community and demonstrates the value of this work.
And there is plenty of value in this work. Our longitudinal outcomes studies demonstrate that students with some level of risk show significant gains in school conduct and social functioning that are sustained over three years. We are also finding that students in CBHM schools are performing better academically compared with other schools. The greatest, and most sustainable, result is that more of Boston's students have equitable access to high-quality services and the school district has enhanced its capacity to support the social and emotional development of all students.
