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Meeting children's mental health needs where they are: Clinical services in schools and communities.

This one-day workshop will prepare practicing clinicians to have a greater impact on young people and their schools.
by

Fran Kuehn

on 9 May 2013

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Transcript of Meeting children's mental health needs where they are: Clinical services in schools and communities.

- When a crisis happens, communication is key. Quickly identify who will lead the communication following the event (typically the school Principal) and filter all information through them.
- When communicating, stick to the facts. Avoid conjecture, editorializing, blaming, etc. Address rumors quickly and state clearly what you know to be true.
- Identify those people who are closest to the crisis, and move out in concentric circles, modifying your intervention as people’s proximity to the crisis lessens.
- For the individual, a session; for the class, a group; for the school, an announcement.
- For the individuals most affected, reach out to each one and bring them into contact with needed services, counseling, home visits, etc. Many of these individuals, especially if they are adolescents, will seek out their friends first and not you.
- Open counseling centers in evenings and weekends as a support to the community.
- Offer productive activities that can help focus energies and create a sense of purpose. Use letter writing, card-making, message boards, cooking meals, delivering homework, offering to play with siblings, etc.
- For all involved, returning to a predictable routine is healthy. Encourage students to focus on their academics and return to their activities.
- Memorials can be effective ways for students to express grief. There can be pressure to make memorials permanent. Instead, offer to change or adapt the memorial, not destroy it. Cards and notes can be made into a book. White-boards can be photographed and sent to families. Returning the space to its original condition is a healthy next step. How School and Community Clinicians can support student well-being Meeting Children's Mental Health Needs where they are: "You have Special Powers" The skills you'll need: How to be an effective clinician in a school School Climate and student discipline: How to help schools be safer places for us all. Ethics and the law. What you need to know. Responding to a mental health crisis 1. Do's and Dont's of school crisis intervention and response. CASE STUDY.
2. Concentric circles of support.
3. Navigating a healthy grief response.
4. The BRYT program model. http://www.lifp.org/html/project/ProjectOnePagers%5Conepager_51441.pdf From the outside in:
How Clinicians can navigate the environment of a school. Schools as systems: Academic Press and Sense of Community.
Alliances and detractors - your interpretation guides your intervention. Check your lenses. Reasons vs. Excuses.
Proving your worth - they won't know they need you until they know what you can do.
Fear and Anxiety - How to help teachers and administrators develop faith in your approach.
Key steps for a community clinician to develop a relationship with a school. Respond, Inquire and Validate. Be locked in a conspiracy to ensure student success.
School Clinicians have special powers!
CASE STUDY Why Should Schools Address Mental Health Needs in the first place? 1. A long history of school mental health
2. School mental health removes barriers to learning
3. Data supports the need for school mental health
4. Mentally healthy students and schools achieve better outcomes 1. Enhancing motivation for change.
2. Collaborative problem solving.
3. Substance Abuse interventions.
4. CBT techniques for students. 1. What are your responsibilities under the special education law?
2. Chapter 123, Section 12 and you.
3. Bullying Intervention Protocol. Chapter 92. Critical interventions and know-how for supporting the mental health of students and schools. 1. The Power of Our Words.
2. Trauma Sensitive approaches in schools.
3. Interpersonal Effectiveness and student discipline.
4. Restorative Justice vs. at-home Suspension.
5. Creating positive school climate. http://smhp.psych.ucla.edu/pdfdocs/schoolclassroomclimate.pdf
http://www.responsiveclassroom.org/sites/default/files/pdf_files/rc_fact_sheet.pdf
6. Challenging student case study. “This is the first step to meet a need of which the school system has been conscious for some time. It is an undisputed fact that in the environment of the child outside of school are to be found forces which will often thwart the school in its endeavors. The appointment of visiting teachers is an attempt on the part of the school to meet its responsibility for the whole welfare of the child and to maximize cooperation between the home and the school.”
Report from the School Board of Rochester, NY. 1913 Where we are coming from
If real success is to attend to the effort of bringing a man to a definite position, one must first of all take pains to find him where he is and begin there .... This is the secret of the art of helping others.... All true effort to help does not mean to be a sovereign but to be a servant; that to help does not mean to be ambitious but to be patient...to be a teacher in the right sense is to be a learner.... Instruction begins when you, the teacher, learn from the learner, put yourself in his place so that you may understand what he understands and in the way he understands it. Soren Kierkegaard, The Journals, 1864 The Art of Helping Others School-based mental health services include a broad spectrum of assessment, prevention, intervention, counseling, consultation, and referral activities and services. These services are essential to a school’s ability to ensure a safe and healthy learning environment for all students, address classroom behavior and discipline, promote students’ academic success, prevent and respond to crisis, support students’ social-emotional needs, identify and respond to a serious mental health problem, and support and partner with at-risk families. Ideally, school-based services dovetail with community-based services so that children and youth receive the support they need in a seamless, coordinated, and comprehensive system of care. What are school based mental health services? 1954 - Brown vs. Board of Ed. - Ended segregation in schools. Chief Justice Warren wrote: “Today, education is perhaps the most important function of state and local governments. Compulsory school attendance laws and the great expenditures for education both demonstrate our recognition of the importance of education to our democratic society. It is required in the performance of our most basic public responsibilities, even service in the armed forces. It is the very foundation of good citizenship. Today it is a principal instrument in awakening the child to cultural values, in preparing him for later professional training, and in helping him to adjust normally to his environment. In these days, it is doubtful that any child may reasonably be expected to succeed in life if he is denied the opportunity of an education. Such an opportunity, where the state has undertaken to provide it, is a right which must be made available to all on equal terms.” Legislation impacting School Mental Health PL 94-142: IDEA 1975 - Education for all handicapped children act.
1990 - 94-142 Reauthorized and renamed IDEA. Established social work services as a related service in an IEP.
1997 - Reauthorization creates due process and manifestation determination clause for students with disabilities. Relevant Legislation 2001 - No Child Left Behind - Established accountability for schools to demonstrate academic progress for students by measuring performance on high stakes tests. The original law established school year 2013 as when 100% of students would reach a ‘proficient’ status.
Rosie D. v. Romney, 2007. Justice Ponsor ruled in favor of the plaintiffs alleging that the state of Massachusetts was providing inadequate services to youth with serious emotional disturbances. The Commonwealth was ordered to create a continuum of care for young people with SED that was responsive, coordinated and lasting enough to provide a reasonable chance at a happy life for these children with disabilities. Many were being held in more restrictive environments due to a lack of available step-down services.
2010 - Chapter 92, Anti-Bullying legislation. More relevant legislation What we say and how we say it matters. Here are 5 strategies to communicating well and safely with kids in schools.
Be Direct. No sarcasm. Tell students what you want them to do, and what you don’t.
Convey faith in student’s abilities and intentions. ‘Show me how you will follow the rules in the hallway’.
Focus on observable actions, not abstractions. “When someone is speaking, we will listen carefully and wait until they are finished to raise our hand.”
Keep it brief. “Who can tell us one way to include everyone in the game during recess?”
Learn when to be silent. Resist the impulse to jump in with your solution, interpretation, words, etc. The Power of our Words - Paula Denton Responding to a crisis - The antidote to anxiety is control.
- Teachers and Administrators are anxious about student well-being and performance.
- Controlling them through rewards and punishments teaches students (who can learn) to avoid punishments and seek rewards.
- But it's the relationship that makes meaningful change. When both parties feel listened to, a lasting plan can be created.
-Shift the question from "Why aren't you doing this? (I don't know)" to "What are your concerns?" Addressing Teacher and Student Concerns How a traumatized child can look to a Teacher Active symptoms:
Hypersensitivity
Outbursts
Fidgeting
Physical acting out
Aggression/Irritability
Passive Symptoms
Inattentiveness
Withdrawal
Risk-averse
Decreased motivation
'Spaceyness' Trauma informed practice examples Don't: 'Do you want to be here or not?' Do: 'We want you to be here - here's what it will take'.
Don't: 'You aren't trying hard enough'. Do: 'You need to participate in your own rescue.'
Three pillars of effective schooling: The Tripod Project (Ron Ferguson):
'This is important.
You can do this.
We will help you." Academic Press vs. Sense of Community To what extent does the school as a system value academic achievement and relationships?
What is the culture of the school? Trusting? Paranoid? Defensive?
How mentally healthy is the system of the school? Hierarchy? Communication? How is information understood and transmitted?
How are parents viewed? Treated? What happens when there's a conflict? Blaming? She's crazy? The whole family is crazy? I had the brother - he was crazy too? Proving your worth Operating in a host environment as a non-teacher Be present
Work hard
Wear comfortable shoes
Solve Problems
Remove barriers to learning Enhancing motivation for change Use scaling questions to determine degree of surety/ambivalence.
Miracle question to identify primary obstacles.
If your goal is to ____, then how far away are you from that now?
What is one thing that would have to change to help you start?
What are the obstacles in the way of that thing?
Sometimes the goal is to avoid pressure/consequences - just to relax. There are natural consequences to avoiding work. Brief Assessment Topics Nutrition
Sleep habits/routine
Substance Use
Dating and relationships
Friendships
Parent conflict
Family stress (illness, job loss, divorce)
Loss of a loved one
Subject-specific stress
Teacher-specific stress Healthier frames of reference No one wants to be this miserable.
His intention is not to make your life miserable.
"I don't know" could mean he doesn't know, has never thought about it, or doesn't know how to say it.
If you had to parent this kid, you'd be crazy too.
Can't Can is a developmental task. He's not done yet. CBT Techniques and worksheets http://www.specialtybehavioralhealth.com/wp-content/Common%20Unhealthy%20Thought%20Patterns.pdf
http://www.specialtybehavioralhealth.com/wp-content/Ways%20to%20Challenge%20Your%20Own%20Beliefs.pdf
http://www.specialtybehavioralhealth.com/wp-content/New%20Responses%20Worksheet.pdf
http://www.specialtybehavioralhealth.com/wp-content/CBT%20Model%20of%20Panic%20Disorder.pdf Substance abuse intervention Believe in their ability to change.
Emphasize control and choice, esp. in recreational use.
Establish discrepancy between stated goals and current behavior.
Weigh the pro's and con's of change.
Stay in touch; notes or calls can serve as reminders of therapeutic goals.
Be ready with options - day treatment, detox, rehab, etc.
http://www.ncbi.nlm.nih.gov/books/NBK64967/pdf/TOC.pdf pp. 30-32. Trauma and Academic Performance -From HTCL, Mass. Advocates for Children Children who are hyper-aroused cannot attend to new information or express themselves verbally.
Emotional language may be hampered - language is used for utilitarian purposes only.
Neglect is associated with deficits in receptive and expressive language.
Impaired language negatively impacts one's ability to problem solve.
Unpredictable environments hamper the development of sequential memory (a sense of order in one's life) and can inhibit the sequential learning of new information (i.e. school).
These environments also impair the development of self-efficacy, cause and effect on the world. Can lead to problems with delayed gratification, goal setting and object constancy.
Having to assess the mood of the parent first impairs the development of a sense of self.
Anxiety and hypervigilance lead to misinterpretation of stimuli in the classroom, innocuous or not.
Difficulty regulating emotions, which is developmentally appropriate, is that much harder when the emotions are so intense. Not knowing how to express emotions can lead to outbursts and somatic complaints.
Traumatized children do not Plan. They Act. Interferes with executive functioning development.
Excessive dependency and social wariness can lead to reduced exploration and personal mastery. Key factors in effective student discipline Opportunities Suspended: Losen & Gillespie (2012)
3 million students were suspended and lost instructional time in 2009-2010.
1/6 African American Children were suspended at least once, compared to 1/20 White Children
Effective discipline requires an increase in adult attention and supervision. Many of those suspended had less adult supervision
Out-of-School suspension should be a measure of last resort.
Principals who believed punishment led to improved behavior tended to suspend more than those who believed it should be used sparingly.
Teachers with less engaging pedagogy and poor classroom management skills had increased rates of student suspensions.
No academic benefits associated with higher suspending schools. Alternatives to Suspension Teacher training on classroom management.
PBIS.
Restorative Justice vs. Punishment.
In-school Suspension, Saturday School, Detention.

"If we heard that our schools were sending their worst readers home to watch TV, we would be dismayed. Many struggling readers resist instruction, and others may have disabilities that contribute to their challenges. So why not kick out the bad readers so the good readers can learn more? After all, it costs more to educate struggling readers, teachers need more training and support to achieve success with such students, our under- resourced schools don’t have any easy solutions, and parents don’t read to their children often enough.
However, most would agree that these children can learn to read and that it is in the public’s interest that our schools invest in succeeding with all of them, including the reluctant ones and those whose parents did not help prepare them to succeed in school." Bullying Intervention Protocol (PSB) 1. Staff will not ignore bullying. Aggressors count on adults to ignore bullying behaviors, and this allows them to continue bullying activities. 2. Staff will intervene immediately; bullying is common and not benign.
3. Staff will separate alleged aggressor(s) and target(s). The PSB does not condone the use of mediation or attempts to force students to confront one another.4. Bullying is different from conflict.
5. Staff will remain neutral and calm dealing with alleged bullying situations.6. Staff will reassure reporter(s) and target(s) that they have done the right thing by reporting. 7. Staff will make sure that reporter(s), target(s) and witness(es) know that they will be protected from retaliation. 8. Staff will seek to empower aggressors to change by reminding aggressors that they have power to stop the bullying.9. Staff will teach strategies to assist aggressors to stop.10. Staff will maintain confidentiality but ACT.
11. Staff will be objective in note-taking.
12. Staff will be timely. The faster that all students are spoken to by an adult, the less likely that the students will feel social pressure to change their stories. 13. Staff will ensure that all applicable laws and policies related to students with disabilities are followed. School Social Work and IDEA How does IDEA Define Social Work Services in Schools?
Issues or problems at home or in the community can adversely affect a student's performance at
school, as can a student's attitudes or behaviors in school. Social work services in schools may
become necessary in order to help a student benefit from his or her educational program.
Social work services in schools include —
(i) Preparing a social or developmental history on a child with a disability;
(ii) Group and individual counseling with the child and family;
(iii) Working in partnership with parents and others on those problems in a child's living
situation (home, school, and community) that affect the child's adjustment in school;
(iv) Mobilizing school and community resources to enable the child to learn as effectively as
possible in his or her educational program; and
(v) Assisting in developing positive behavioral intervention strategies Chapter 92 of the acts of 2010, an Act Relative to Bullying.
Definition: The repeated use by one or more students [aggressor(s)] of a written, verbal or electronic expression or a physical act or gesture or any combination thereof, directed at a target that: (i) causes physical or emotional harm to the target or damage to the target's property; (ii) places the target in reasonable fear of harm to him/herself or of damage to his/her property; (iii) creates a hostile environment at school for the target; (iv) infringes on the rights of the target at school; or (v) materially and substantially disrupts the education process or the orderly operation of a school. This includes cyberbullying. Bullying in Schools “Cyber-bullying”, bullying through the use of technology or any electronic communication, which shall include, but shall not be limited to, any transfer of signs, signals, writing, images, sounds, data or intelligence of any nature transmitted in whole or in part by a wire, radio, electromagnetic, photo electronic or photo optical system, including, but not limited to, electronic mail, internet communications, instant messages or facsimile communications. Cyber-bullying shall also include (i) the creation of a web page or blog in which the creator assumes the identity of another person or (ii) the knowing impersonation of another person as the author of posted content or messages. Cyber-bullying shall also include the distribution by electronic means of a communication to more than one person or the posting of material on an electronic medium that may be accessed by one or more persons. Cyberbullying As defined in Chapter 92. Bullying and retaliation, as defined  herein,  are  prohibited:    On school  grounds  and  property  immediately  adjacent  to  school  grounds; at  a  school  sponsored  or  school-ュrelated  activity,  function,  or  program  whether  on  or  off  school   grounds; at  a  school  bus  stop,  on  a  school  bus  or  other  vehicle  owned,  leased, or  used  by   the  school;  or  through  the  use  of  technology  or  an  electronic  device  owned,  leased,  or   used  by  the school; and at  a  location,  activity,  function,  or  program  that  is  not  school related,  or  through  the   use  of  technology  or  an  electronic  device  that  is  not  owned,  leased,  or  used  by  the  school,   if  the  bullying  creates  a  hostile  environment  at  school  for  the  target,  infringes  on  the  target’s rights at  school,  or  materially  and  substantially  disrupts  the  education  process   or  the  orderly  operation  of  a  school. What must schools respond to? Developmentally, children are more likely to be impulsive.
In the past, when an upsetting event occurred, a child would have to wait to get home to talk about it, or even email or blog about it.
With current technology, that critical buffer of time is removed.
Time allows us to process, calm down and choose a healthy option.
Without time, children are more likely to have impulsive actions, thoughts and words.
Once said, posted, texted, videoed or photographed, they are permanent.
Since this information can reach huge numbers of people quickly, there is little chance to take back what you said.
Efforts at damage control and restoring relationships, or the possibility of losing relationships, can cause overwhelming distress. Clinical factors of cyberbullying Imposition of Adult will.
If you don’t wanna, I’ll make you wanna.
Pretty much how most of the world works.
Kids who don’t know how won’t learn this way. Plan A Step 1. Notice what is happening. I’ve noticed…what’s up? Keep it neutral.
Dig deep. Listen. Define the real problem. If he doesn’t know maybe he never thought about it before. Plan B - Collaborative Problem Solving Define the problem. There are two concerns, his and yours. Don’t blow his off. “I’m concerned you won’t get this material and will fail the test. You’re concerned that it takes too long to write what I am saying so you give up”. Step 2 Brainstorm solutions. “I wonder if there is a way to help you get all the information you need to pass the test”.
Don’t be a genius. Don’t predetermine the solution. Let it go. It’s about a win-win.
Agree to return to plan B if necessary. Step 3 CPS: Plan A, Plan B, Plan C and Steps to CPS Interpersonal Effectiveness Core DBT Skills from DBTself-help.com
DEARMAN
Describe what you see and keep it about that - not always without judgment. "This is the third time you've asked me that".
Express feelings clearly. How you feel and what you believe. "This puts me in an awkward situation".
Assert your wishes. Say no clearly. Tell them what you want them to do, not what they should do. "No, I can't do that".
Reinforce others' positive responses to you by saying thank you, and telling them the positive effects of doing what you want. "Thank you for listening. I appreciate it". "This will help me feel much more comfortable and probably more productive".
Mindfulness. Keep your focus on your current objective. Maintain your position. Ignore attacks. "I am telling you I can't do that".
Appear Confident. Sit up straight, appropriate eye contact.
Negotiate. Offer and ask for alternative solutions. Ask for their solution. "I can't say yes, but you want me to. How can we solve the problem?"
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