Vittoria Anello, Ami flammini and Mark Weist

1. Readiness to Interconnect Positive Behavior Interventions and Supports (PBIS) and School Mental Health (SMH): Development and Testing of a Stakeholder Survey Vittoria Anello, Ami flamminiand Mark Weist University of South Carolina, and illinoispbis network

2. Overview • Background • PBIS • SMH • PBIS-SMH interconnection • Need for assessment of readiness • Survey development • Survey testing in Illinois • Future directions

3. Background: PBIS • Framework for promoting and reinforcing positive behaviors • Sugai & Horner, 2002 • System of employing positive behavior strategies • Prevention and early intervention perspective

4. Background: PBIS Not an intervention Ideal for incorporating other school-based interventions and services

5. Background: PBIS PBIS can “render problem behavior irrelevant, inefficient, and ineffective by helping an individual achieve his or her goals in a socially acceptable manner, thus reducing, or eliminating altogether, episodes of problem behavior” (Carr et al., 2002) Aligns with mandates of NCLB and Successful, Safe, and Healthy Students Program (ESEA)

6. Background: PBIS 3-tier system Tier I: Primary interventions to promote appropriate behavior across student population Tier II: Secondary interventions targeting students not responding to Tier I interventions (~15%) Tier III: Tertiary interventions to assist students not responding to Tier II interventions (~5%)

7. Background: PBIS

8. SCHOOL-WIDE POSITIVE BEHAVIOR SUPPORT: What is meant by “layering” interventions? Tertiary Prevention: Specialized Individualized Systems for Students with High-Risk Behavior ~5% Secondary Prevention: Specialized Group Systems for Students with At-Risk Behavior ~15% Primary Prevention: School-/Classroom- Wide Systems for All Students, Staff, & Settings ~80% of Students

9. School-Wide Systems for Student Success:A Response to Intervention (RtI) Model Academic Systems Behavioral Systems • Tier 3/Tertiary Interventions 1-5% • Individual students • Assessment-based • High intensity • 1-5% Tier 3/Tertiary Interventions • Individual students • Assessment-based • Intense, durable procedures • 5-15% Tier 2/Secondary Interventions • Some students (at-risk) • High efficiency • Rapid response • Small group interventions • Some individualizing • Tier 2/Secondary Interventions 5-15% • Some students (at-risk) • High efficiency • Rapid response • Small group interventions • Some individualizing • Tier 1/Universal Interventions 80-90% • All students • Preventive, proactive • 80-90% Tier 1/Universal Interventions • All settings, all students • Preventive, proactive Illinois PBIS Network, Revised May 15, 2008. Adapted from “What is school-wide PBS?” OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports. Accessed at http://pbis.org/school-wide.htm

10. Background: PBIS • Main focus is behavior, but PBIS aims to improve quality of life and functioning for all students • Improved behavior  increased academic achievement • Much research and implementation of Tier I • Relatively few resources needed for implementation • Much less research and very inconsistent implementation of Tiers II & III • Most at-risk students may not receive assistance

11. Background: PBIS • Uneven dissemination across U.S. and within states • Just 7.90% of schools using school-wide PBIS • 47 states report using PBIS • Need for improved data collection and analysis systems, ongoing training and technical support, and adequate resources

12. Background: SMH • Many youth with behavior problems also have mental health issues • 13.1% of youth ages 8 to 15 have a diagnosable mental disorder • Only 50.6% of them receive treatment

13. Background: SMH • Good mental health  • Increases in: • Prosocial behavior • Family engagement in school • Socio-emotional development • School functioning • Decreases in: • Discipline referrals • Special education referrals • Emotional and behavior problems

14. Background: SMH • SMH services are varied in scope and focus • Assessment • Counseling • Individual, group, and family • Mental health education and promotion • Collaboration/wraparound supports

15. Background: SMH • SMH: Providing mental health promotion and services at school • Benefits: • Reduces barriers to participation (stigma, lack of transportation, etc.) • Reduces stress on special education system • Reaches a large number of youth and families • Challenges • Funding • Lack of coordination among school and community mental health service providers • Buy-in and support from administrators and key stakeholders • Training and technical support

16. PBIS-SMH Interconnection

17. PBIS-SMH Interconnection PBIS and SMH currently not interconnected PBIS can support SMH services Both operate on multi-tier service delivery systems Emphasis on evidence-based interventions and data-based decision making Common goal: promoting success of students across domains

18. PBIS-SMH Interconnection Other benefits: Resolves issues of accessibility Normalizing mental health issues and help-seeking behaviors Promoting mental health awareness  prevention and early intervention

19. Need for PBIS-SMH Interconnection • Must consider readiness for change • Transtheoretical model of change (Levesque, Prochaska, & Prochaska, 1999) • Do schools and communities view PBIS and SMH as important issues? • Are they thinking about making changes? • Do they have the resources to do so?

20. Need for PBIS-SMH Interconnection Change process framework (Fixsen et al., 2005) 1. Exploration and adoption 2. Program installation 3. Initial implementation 4. Full implementation 5. Innovation 6. Sustainability

21. Need for PBIS-SMH Interconnection Exploration and Adoption is key Readiness for change examined here Important to clearly identify needs of the school and community Support and buy-in from key stakeholders is critical for successful adoption and initial implementation Compatibility between intervention and stakeholders’ beliefs and values

22. Need for PBIS-SMH Interconnection • Other factors to consider: • Acceptability • Goodness of fit • Iatrogenic effects • Long-term results • Leadership team • Communication • Support from district, administrators, and community • Community and family readiness

23. Need for PBIS-SMH Interconnection • No measure for readiness to integrate PBIS and SMH • Existing measures examine : • PBIS implementation and fidelity • Practitioners’ attitudes toward particular interventions

24. Need for PBIS-SMH Interconnection • Existing measures do not evaluate: • School and community attitudes about change • Perceptions of intervention outcomes • Knowledge of PBIS and SMH • Support from various constituents • Administrators, teachers, parents, community members, other school professionals

25. Purpose of Current Study To develop a measure of readiness to interconnect PBIS and SMH To be used with professionals and other stakeholders involved with PBIS and/or SMH

26. Pilot Study and Survey Development

27. Pilot Study Survey of professionals and stakeholders attending CSMH 16th Annual Conference in Charleston, SC (September 2011) Survey of top factors facilitating/hindering PBIS, SMH, and PBIS-SMH integration

28. Pilot Study • N = 25 key PBIS/SMH stakeholders • Government officials, family members/advocates, directors of state PBIS centers, technical assistance providers • 72% female • Working in field: M = 21.58 years (SD = 8.89 years) • Using PBIS: M = 7.00 years (SD = 2.83 years) • Survey responses aggregated and distilled into 20 main themes

29. Selection of Key Themes • Support/buy-in from principal and other key staff • Data-based decision-making • Active family and community involvement • Effective leadership of teams focused on behavior and mental health • Belief in impact on • School behavior • Academic performance • Promotion of a positive learning environment

30. Selection of Key Themes Adequate funding Active, comprehensive training and implementation support Staff understanding of PBIS and SMH Staff endorsement of benefits of collaborative PBIS and SMH Active student involvement

31. Survey Development • 20 themes were used to develop a 35-item survey • Survey was distributed via e-mail to key informants • Experts in PBIS, SMH, and/or related fields • Key informants evaluated the survey’s content, wording of items, and the importance of the items and concepts to PBIS-SMH interconnection • 3 items were dropped • Based on importance ratings and scatter plot data

32. Survey Development Revised version of survey distributed to several members of the National Community of Practice (CoP) for School Behavioral Health Individuals with particular interest in PBIS-SMH interconnection Survey revised again based on comments from this group and consultation with collaborators on this project (Eber, Barrett, Cashman, & Bazyk)

33. Survey Development Consultation with survey expert Robert Johnson of USC College of Education Survey wording and formatting revised based on Johnson’s recommendations Final survey was disseminated via SurveyMonkey from June – August 2012 Potential participants reached via email, listservs, and CoP conference calls

34. Current Study and Survey

35. Design • Mixed method design • Qualitative analyses: interviews with key informants • Quantitative analyses: survey development and psychometric analyses • Online survey • 98 items

36. Participants Individuals working in a setting using PBIS and SMH Those delivering mental health services to youth enrolled in schools Community members who support PBIS and SMH Examples: teachers, PBIS staff, SMH staff, school administrators, family members of students, and older youth N=346

37. Reaching Participants • Collaborations with various groups • Communities of Practice through the IDEA Partnership • Discussion of survey on conference calls • Promotion of survey on listserv announcements • Reaching out to • Teachers • School principals • School nurses • Other school professionals

38. Utility of Survey • Initiates conversations among stakeholders • Issues of readiness • Benefits of PBIS-SMH interconnection • Frank look at resources • Compare and contrast domains that are ready for change with areas needing progress • Opportunities for building buy-in with administrators, staff, and community

39. Utility of Survey Online format Available for free Can be used at multiple time points in the stages of preparing to adopt and implement combined PBIS and SMH Can be used to identify potential “pilot schools” in a district for PBIS-SMH interconnection

40. Future Directions

41. Implementation Factors The power of buy-in and support from key persons in the school and community Positive working relationships Use of data to show schools and communities the link between academic performance and mental health

42. Implementation Factors • Less restrictive funding streams • Increased flexibility for schools and communities to meet students’ needs • District PBIS and SMH coaches • Similar to instructional coaches

43. Paradigm Shifts • Person-centered approach to intervention planning • Can be expanded to community-centered approach • Emphasis on data-based decision making • Moving away from reliance on anecdotal records

44. Paradigm Shifts • Use of survey results to assist with resolving the fragmentation of youth mental health services • Improving coordination and communication among service providers to reduce redundancy and increase consistency in service provision • Increased collaboration across disciplines • Pooling resources to effect greater change

45. Future Research Development of readiness-increasing activities based on areas identified by the survey Development of measures of systemic change

46. Future Research • Development of more succinct measures and screeners for readiness for PBIS-SMH interconnection • Development of in-school mental health screening to identify at-risk students • Similar to brief reading and math screenings

47. Future Research • Measuring the impact of PBIS-SMH interconnection on the community at large • Cases of DSS involvement, founded cases of child abuse, number of children removed from families • Number of children receiving mental health services (counseling, medication, etc.) • Number of students exhibiting self-injurious behavior (e.g. cutting) and suicidal thoughts or behaviors

48. Future Research • Investigation of the link between readiness for interconnection and subsequent implementation and sustainability • Improvement in tools needed for proper PBIS-SMH implementation • Data collection systems • Communication methods among school professionals • School-community communication

50. Implementing PBIS Schools Over 14 Years as of June 30, 2012 * Excludes CPS data