The “RYSE Program”: Intensive school-related clinical services that work

1. The “RYSE Program”:Intensive school-relatedclinical services that work U.S. Department of Education Thursday, April 19, 2007, 12:00-1:00 Paul Block, Ph.D., Co-Director Psychological Centers

2. Four years later • 11/30/2002- series of meetings with impressive, helpful representatives of U.S. Department of Education • Result: Conviction that the RYSE model was different from anything we’ve been able to find • Now: 4 years of inconsistent experience, looking forward to more feedback

3. Fundamental error of school-based services for children whose psychological/emotional problems interfere with their learning: • Focus on the relationship between psychological/emotional problems and learning

4. Psychological Centers • Developed in response to frustration with • a lack of community-focus in academic psychological settings but • lack of commitment to state of the art quality in community-focused settings in which we’d worked

5. Psychological Centers • Program development process: • Identify critical community needs, gaps in services, gaps in the quality necessary to reach desired effects, gaps in access • Determine scientific foundations for best approaches to addressing these needs • Because Psychological Centers has no obligation to serve any individuals or group, we can seek funding to offer best approaches rather than having to take available funding and doing the best possible with it

6. Psychological Centers • Flexibility to adapt services to community needs and preferences: • No board (just argument between 2 partners) • No licensing requirements • No accreditation • Resources devoted instead to • Staff • clinically-driven quality assurance • sliding scale services • flexibility to bring services to where people and needs already are

7. Chariho Regional School District • 3 towns (chronic issues) • Relatively rural and isolated from the rest of the state (1 hour away) • Main collaborative program: “Comprehensive Alternative Program” • A “comprehensive, integrated, community school model, alternative to out of district placement • Still referred to as a “clinical day program” though not solely clinical, solely day, or even solely a “program” • Current bond initiative for district buildings including a (cheaper) permanent building for RYSE, inc. the ALP

8. Chariho Regional School District • Initial RYSE success led to expansion to add small “At-Risk” and Autism Spectrum Disorders programs, district-wide consultation, and on-site outpatient services through a rental agreement • Currently proposing a 3-year renewal for all three programs • School board and community members have questions about RYSE and about the building bond proposal

9. RYSE- The history • Psychological consultation about management of students’ behavioral and clinical needs • District staffs’ frustration with out of district day programs for SED and severely behaviorally disruptive youth: • Questionable educational quality • Questionable quality of clinical services • Black hole placements • Lack of information, coordination, joint planning • Extremely expensive placements • Final straw: restraints resulting in broken bones- “not required to follow RI DOE restraint standards”

10. RYSE- The Model Overview • Start with Multisystemic Therapy (MST) • Most evidence for effectiveness addressing seriously disruptive behavior (including acute and critically dangerous psychiatric conditions) • High quality special education services following the district’s standards-based curriculum • Tailored to the educational needs of the population • Not only addressing the factors leading to behavioral problems but offering rewarding positive alternatives

11. RYSE- The Model Overview (cont.) • Integration • One team • multiple viewpoints • complimentary strengths • supporting each other • most important, vs. coordination or case management of services: Unified decision making

12. “RYSE Method” (paraphrased) • Jointly developed: • Formulation targeting school-focused goals (determining the biggest barrier to progress) • Integrated educational/clinical plan • Concrete intervention steps to persuade (not convince) relevant parties to perform targeted behaviors. This includes mutually determined understanding • of how many contacts of what sort and format will be needed • to do what specific interventions are necessary to get what movement started and to keep progress going • This is the time for presentation of clinical judgment, argument about approach • Interventions implemented as described, based on explicit rationale

13. “RYSE Method” (paraphrased)(cont.) • Interventions monitored for adherence and outcomes • Daily check-ins • Joint home visits to observe & consult • Notes organized around formulation, plan, steps, outcomes • Results reported to the team • Jointly developed next steps • This is the time, again, for presentation of clinical judgment, argument about approach Notes: • Interactions (inc. pattern of contacts) and interventions are focused on formulated targets and steps as agreed/described • Interventions are action-oriented, designed to persuade performance of specific behaviors that have been formulated to be necessary to reach the formulated intermediate goals (understanding or acceptance of need to take actions are unnecessary, even if potentially helpful, and thus are secondary goals; enactment of targeted actions is the goal and focus) • Supervision is focused on supporting and monitoring implementation of steps as described

14. RYSE- The Model Overview (cont.) • Unlike any therapeutic classroom, clinical school program, or school-based service we’ve found: • Clinical team works to address ALL systems involved with youths’ problematic behavior • Family, peers, neighborhood, community organizations such as churches, sports teams, child-centered activities and agencies, police, courts, DCYF, etc. • In all settings and at all times (24/7/365) as needed to have the desired effects • Especially with family- monitoring, control, parental mental health and substance abuse, and family issues affecting children’s problems

15. Back to the premise: • Fundamental error of school-based services for children whose psychological/emotional problems interfere with their learning: Focus on the relationship between psychological/emotional problems and learning

16. The new premise: • To have the necessary effect on psychological and emotional problems preventing access to appropriate education, services cannot be focused on functioning in school • To be successful, services must focus on • all of the reasons for these problems • across all systems • especially those at home and in the community which have the greatest effect on the problems that have to change for students to be able to learn

17. The new premise: • Examples we like to give #1: • Youth doesn’t come to school, clinical staff have the only relationship that could help him/her decide to attend (with adequate individual clinical intervention) • Such intervention would not lead to sustainable change in the factors leading to the youth’s truancy

18. The new premise: • Examples we like to give #2: • Youths’ serious outbursts in classroom disrupt the class, interfere with educational programming and their own learning • The clinician is called in, consults with the teacher and behavior management assistant, understands the factors causing the outburst, and… • Says, “I got it,” and runs out of the classroom to call the parents or visit the home

19. Details of the RYSE model • Educational Services- Intervention targets • School correlates of behavior/educational problems: • Low achievement • Dropout • Low commitment to education • Unfavorable school features • Poor structure • Large class sizes • Inadequate educational approach for population (inc. special education services) • Lack of access to resources

20. Details of the RYSE model • Educational approach: • An individualized standards-based application of the Chariho curriculum • Project-Based Learning • Vocational Preparation • Work-Based Learning and Work Study Programs • Weekly community-based service-learning and community service

21. Details of the RYSE model • Educational approach: • Extended school day and extended school year educational programming • Small, structured classrooms • Positive behavioral programming • Case management services • An integrated and coordinated clinical and educational team for each student • High school transition plans for post-school planning

22. Details of the RYSE model • Educational approach- Behavioral program • Point and level system • Positive behavioral supports • Structure and environmental management • Positive options • Clinically driven management • Clinically focused management

23. Details of the RYSE model • Clinical approach- 1. Alternative approaches • Traditional services occur in “un-natural” settings and thus generalize poorly back to youths’ real lives • Most traditional interventions focus on the individual level and insufficiently on the main factors leading to behavioral and educational problems • Out of district placements, residential centers, hospitals, and other un-natural placements have little if any evidence of sustainable benefits (requiring transitions back to the natural setting without the supports that enabled success in placement) • Traditional service providers often do not have expertise in the known causes or effective interventions for significant psychological and emotional problems

24. Details of the RYSE model • Clinical approach- 2. Intervention targets • Youth: low verbal skills, positive attitude about negative behavior, psychiatric disorders • Family: inadequate parental monitoring, ineffective discipline (control), low warmth, parental problems (substance abuse, negative attitudes and behaviors, psychiatric disorders) • Peers: association with deviant peers, poor relationship skills • Neighborhood/Community: high mobility, criminal subculture, low availability of support (church, neighbors, etc.)

25. Details of the RYSE model • Clinical approach- 2. Intervention targets • Not school-based community mental health services • Services as necessary to decrease the effects of psychological and emotional problems on learning

26. Details of the RYSE model • Clinical approach- 3. Intervention details • Youth: individual treatment for psychiatric and interpersonal problems as central to ability to function • Family: parent engagement (motivational enhancement), parent training, consulting/coaching/support, family therapy, parent substance abuse and psychiatric treatment, case management and resource development • Peers: removal from deviant peer groups, engagement with positive peer activities • Neighborhood/Community: identification and connection with local supports

27. Clinical team • Up to 29 students (inc. 45 day assessments) • Doctoral Psychologist Clinical Director • 3 Masters level clinicians • 1 service learning coordinator/case manager • Part time psychiatrist • Agency consultation (inc. specialty psychological evaluations and consultation) and oversight

28. Details of the RYSE model • Clinical approach- 3. Intervention details • MST decreases behavioral problems, improves long term pro-social adjustment and outcomes, decreases out of home placements, reduces recidivism for legal problems and psychiatric hospitalizations • Often perceived as “like <other programs>”

29. Distinguishing characteristics of MST: • Focus on factors found in scientific research to cause target problems, as relevant for each youth and family • Vs. focus on factors identified as important by individual clinicians (usual practices) • Use of interventions that have been proven effective for addressing identified targets • Vs. use of interventions based on “treatment as usual” (usual practices) • Ongoing training and consultation from international experts in severe childhood behavioral disorders (who themselves receive ongoing training, consultation, and feedback from independent evaluation regarding their support for community providers) • Vs. ongoing training and supervision by local program directors (usual practices)

30. Distinguishing characteristics of MST: • Direct, independent measurement of interventions actually used in treatment interactions • Vs. reliance on clinician (and family) report of interventions actually used in treatment interactions (usual practices) • Independent measurement of outcomes including post-treatment evaluation of maintenance of gains • Vs. no outcome evaluation, or pre-post evaluation implemented by treatment personnel (usual practices) • Multiple controlled trials proving greater effectiveness than alternatives, and evaluations from community-based application in 30 states and several countries proving success at achieving real world desired outcomes • Vs. no scientific evidence of effectiveness, especially compared to alternatives (usual practices)

32. RYSE vs. MST • Services provided as long as students need assistance to succeed in school • IEP driven services require parental consent • Focus on any psychological/emotional factors affecting educational success • Services provided in and offered through school (inc. resulting relationship and expectations)

33. RYSE vs. MST • Increased case loads (9 or 10, vs. 5-6) • Increased need for and focus on alliance and engagement • Closer collaboration with educational staff and integration with educational services • Less external pressure to comply/succeed • Greater need to focus on educational outcomes and school behavior

34. RYSE vs. MST • Similar focus on factors at all levels and in all systems formulated to be driving problems • Similar flexible availability when, where, and as needed at that point • Similar focus on sustainable, real-world outcomes • Similar commitment to do whatever it takes • Similar intensity and urgency of services addressing problems in time to prevent negative consequences

35. RYSE vs. MST • Both differ significantly from typical therapy or treatment services: • Focus on mutually defined goals, translated into specific immediate goals to be met • Focus on whatever is currently driving targets • Focus on caregivers or other key members of youths’ lives taking specific actions required to achieve immediate goals

36. RYSE vs. MST • Unlike therapy focus on engagement in a process of becoming ready to do what is necessary to achieve targeted improvements • Intervening aggressively to effect changes in behavior now that are necessary to reach immediate goals now • Building on strengths • Addressing barriers (pushing through them, not working them through) • Intensity sufficient to reach immediate goals as necessary • Contact and intervention format tailored to what will be needed to effect needed change as quickly as needed

37. RYSE Outcomes • Clinical results: • 21 students (30%) moved out of district • 3 students (4%) were residentially placed by DCYF • 3 students (4%) were residentially placed by Family Court • No students have been remanded to the RI Training School for Youth (juvenile detention) • We identified 5 students (7%) arrested during enrollment at RYSE

38. RYSE Outcomes • Educational results: behavior at school (is it risky to have these children on campus?) • 86-89% daily attendance • Only 2 students have been brought to the school committee for disciplinary reasons in 4 years (vs. 20-25/year for High School) • No instances of drugs or weapons within the school and only one on campus • No physical alterations between students and staff; only two minor physical altercations between students • No disciplinary removals from regular district transportation • No incidents at sports, dance, or other extracurricular activities

39. RYSE Outcomes • Educational results: (can these students learn?) • 96% of all students have earned the grades and credits to be promoted to next grade • 25% of students have completed one or more classes within the Middle School, High School, or regional Career and Tech Center • 86% of eligible students recouped lost credits to regain appropriate academic standing • 5 of 69 students (7%) dropped out prior to graduation, 2 of whom left for full time jobs

40. RYSE Outcomes • Educational results: (can these students succeed?) • 92% graduation rate (11/12 eligible) • Only RI school in 2006 to be listed as having 100% graduation rate • Post-graduation success • 3 enrolled in or accepted to college, 1 in adult education and vocational apprenticeship • 4 with full time employment, 1 business owner • 2 receiving adult mental health services for SPMI • 2007: 4 seniors, all expected to graduate • 1 accepted to college, 2 applying, 1 seeking employment

41. RYSE Outcomes • Educational results: (Does this educational model work?) • All Chariho’s schools, including RYSE meet standards as “High Performing” • RYSE is Chariho’s only school that is High Performing “with Regents Commendation” • Note that this is the only clinical school program in the state reporting results independently • Note that private clinical program students’ test scores are reported out of the home district • Note that this is the only clinical school program in the state that is required to have highly qualified teachers

42. Conclusion • It is necessary to move beyond the fundamental error of school-based services for children whose psychological/emotional problems interfere with their learning • Services can have the desired effect on psychological and emotional problems to enable access to appropriate education • Services that focus on • all of the reasons for these problems across all systems • especially those at home and in the community which have the greatest effect on the problems that have to change for students to be able to learn • WILL lead to improved outcomes, both during school years and into later life

43. Contact information: • Paul Block, Ph.D. Director, Psychological Centers 765 Allens Avenue Providence, RI 02905 (401) 490-8935 Paul.Block@PsychologicalCenters.com Paul.Block@PCRI.US Don’t stop yet!

44. The question I’m waiting for • Anything can be done with enough resources. Is this approach affordable?

45. The answer I was waiting to give • We have saved the district at least between $200-300,000 every year, and could save somewhat more. • This not only works, but it’s affordable.