A Web-Based, RWJF Caring Across Communities Sponsored Seminar October 22, 2007 Joshua Kaufman, LCSW School Mental Health Services, Los Angeles Unified School District Mental Health Screening in Schools
MH Screening in Schools • Screening as a public health approach • Implementation • Considerations
Screening as a Public Health Approach • Increasing access to Health Care • Universal Precautions as a guiding principle. • Current policy climate and controversy.
Access Disparities • Who’s insured? Who’s not? • 22% Latino children uninsured 7.4% White children 14.5 African-American children 12.4% API Children (us census bureau, 2005) • Anti-immigrant climate • Linguistic access • Citizenship requirements for Medi-Caid • Community distrust secondary to anti-immigrant policy/practice
Mental Health Screening • Mental health screening is a brief, culturally sensitive process designed to identify children and adolescents who may be at risk of having impaired mental health functioning warranting immediate attention, intervention or referral for diagnostic assessment. The primary purpose for screening is to identify, using a valid, reliable screening instruments, the need for further assessment. Mental Health Screening in Schools Workgroup Report, Minnesota 2007
Mental Health Screening in Schools • Has the potential to be a cornerstone of a transformed mental health system. • Complements the mission of schools • Identifies youth in need, • links them to effective services, • Contributes to positive educational outcomes . • Weist, et al. 2007
Why Screen? • Information gathering/Prevalence • Epidemiology • Prevention and Early Identification INCREASE ACCESS TO SERVICES
National Survey of AdolescentsPrevalence of Violence History No Violence(27%) Witness Only(48%) Assault + Witness(23%) (N=1,245) Kilpatrick et al, 1995 Direct Assault Only (2%)
Prevention and Early Intervention • (R)outine screening for child mental health problems, should be a part of programs and services designed to assist immigrant families whose children are at risk for violence exposure. • Guarnaccia & Lopez, 1998 • (I)mmigrants (and) not necessarily refugees have high levels of posttraumatic stress symptoms, comparable with or higher than other high-risk samples of inner-city, minority youths. • Jaycox, et al, 2002
Why is Mental Health Screening so Important? • 4,000,000 children and adolescents in this country suffer from a serious mental illness . • 21% of our nation’s children have a diagnosable mental or addictive disorder causing minimal impairment . • Only 20% of children and adolescents with mental illnesses are identified annually. • Early identification and intervention. NAMI 2006
Why is Mental Health Screening so Important? - 2 • Suicide prevention. • Drop –out prevention. • Juvenile Justice Issues NAMI 2006
Policy • Achieving the Promise: Transforming Mental Health Care in America • Goal 4: Early mental health screening, assessment, and referral to services are common practice • 4.1: Improve the mental health young children • 4.2: Improve and expand school mental health programs • 4.3: Screen for co-occurring mental and substance use disorders • 4.4: Screen for mental disorders in primary health care President's New Freedom Commission on Mental Health, 2003.
Controversy • Universal mental health screening without parental consent. • Screening leads to labeling children and forcing them onto medications. • Conspiracy between the Bush administration, organized psychiatry and the pharmaceutical industry to get as many children as possible onto psychotropic medications.
Implementation • Trajectory • Screening Strategy • Screening Tools
Trajectory Screening Universal Identification Selective Assessment Targeted Intervention Individualized
Screening Strategies • Universal: target the general public or a whole population group that has not been identified on the basis of individual risk. • Selective: target individuals or a subgroup whose risk of developing mental illness is significantly higher than average
Screening vs. Assessment • Screening is a • Preliminary evaluation • Identifies key features • Indicates likelihood. • Assessment • Thorough evaluation • Establishes presence or absence of a diagnosable condition. • Results suggest most appropriate type of treatment.
Screening Vs. Referral • Screen students • Consent for screening • Screening tool selection • Validity in with immigrant/refugee population • Referral response • Miss the quiet ones, anxious and depressed • Over-identify behavior problems • Can staff identify kids in need?
Screening in an Educational Setting • Entry and PR • School Adaptations • Timing • Location • Consenting process • School-Friendly instruments
Working in Schools • When you work with the ocean you’ve got to understand the tides • School Culture • Academic pressures • Confidentiality • Stigma • Space, time, logistical constraints • School calendar
Screening Tools Life Experiences Survey (LES) • Assesses exposure to violence through direct experience and witnessing of events • Twenty-six items are used to assess exposure in the past year • Acceptable to schools – no specific questions about home.
Screening Tools, cont’d Child PTSD symptom scale (CPSS) • 24-item scale assesses PTSD symptoms and functional impairment • Good validity and high reliability • Used in CBITS studies involving school-based populations
Screening Tools, cont’d Beck Depression Inventory( BDI-II ) • 21-item self-report inventory • Widely used as an indicator of the severity of depression • Evidence for its reliability and validity across different populations and cultural groups.
Screening tools, cont’d Beck Anxiety Inventory ( BAI ) • 21-item self-report inventory • has been used in peer-reviewed studies with younger adolescents aged 12 and older
Screening tools, cont’d Strengths and Difficulties Questionnaire-Child Report ( SDQ-Child ) • Internationally used brief behavioral-screening instrument assessing child positive and negative attributes across 5 scales: • 1) Emotional Symptoms, • 2) Conduct Problems, • 3) Hyperactivity-Inattention, • 4) Peer Problems, • 5) Pro-social Behavior. Translated into over 40 languages.
Screening tools, cont’d Pediatric Symptom Checklist—Youth Report (Y-PSC) • Consists of 35 items that are rated as “Never,” “Sometimes,” or “Often” • Can be administered to adolescents ages 11 and over • Cognitive, emotional, and behavioral problems http://psc.partners.org.
Screening tools, cont’d Children’s Depression Inventory • Children and adolescents 6 to 17 years old. • 27 items, describes feelings for the past two weeks. • Designed for schools, child guidance clinics, pediatric practices, child psychiatric settings
Considerations • Cultural • Linguistic • Ethical
What Do We Know? • Broadly, communities express distress in culturally syntonic ways – somatic complaints, hyper-arousal, intrusive thoughts, etc. • More than we used to, but relatively speaking, very little. • Culture-specific diagnostic and treatment issues tremendously underfunded
The Trap • While human beings share a common biological heritage, each person belongs to not one, but many ethno-cultural groups and has a unique family and cultural heritage and genetic makeup—all of which interact to shape development and the experience of trauma. One must exercise caution applying categorical delineations of ethno-cultural variables (e.g., refugee, urban residence, ethnic group, primary language, socioeconomic status, nationality)because doing so runs the risk of obscuring significant differences within these larger groups. • Cook, et al, 2003
Immigration and Exposure to Trauma • Pre-migration, flight, and resettlement experiences psychological well being. • War time violence and combat experience • Displacement and loss of home • Malnutrition • Separation from caregivers • Detention and torture
Immigration and Exposure to Trauma – cont’d • Anxiety, recurring nightmares, insomnia, secondary enuresis, introversion, anxiety and depressive symptoms, relationship problems, behavioral problems, academic difficulties, anorexia, and somatic problems linked to exposure to trauma prior to migration • With high prevalence of posttraumatic stress symptoms among refugee children reported to be between 50-90% . • Birman et al, 2005
Cultural Considerations • Assessment of trauma history and PTSD outcomes should always occur in a cultural context . • Exposure to different types of trauma is variable across diverse ethno-cultural backgrounds. • People of different cultural, national, linguistic, spiritual, and ethnic backgrounds define key trauma-related constructs in many different ways. • The threshold for defining a PTSD reaction as “distressing” or as a problem warranting intervention differs.
Translation Issues • Know target population’s language needs. • Select a qualified translator. • Get consumer feedback • Translation advisory committee • Work in progress • No to translation on the fly • Try to avoid one-way translations. • Use two-way translations.
Interpretation Issues • Interpreters are not familiar with mental health terminology • Accurate interpretation • Interpreters own views of mental health can influence the sessions • Confidentiality issues when the interpreter is a member of the community. • Reliability / Scheduling issues • Dialect or accent differences • Use of family members • Shortage of trained interpreters • Language Lines costly and impersonal
Ethical/Legal Considerations • Treatment capacity • Consenting issues • Mandated reporting
We are the Experts • It is up to us to pour though available literature and glean whatever we can In the service of our communities. • As treatment providers working in immigrant and refugee communities, we have the opportunity to utilize our programs to define, collect and evaluate the evidence. • Outcomes from these three year grants could have a tremendous impact on our knowledge of “what works” with our communities in question.
Thank You for Your Time. Joshua Kaufman, LCSW School Mental Health Services Los Angeles Unified School District 213-241-2173 firstname.lastname@example.org
Q & A Questions for the presenter: Q: Did you get parental consent to administer the screenings? A: Yes, we did get parental consent, as we were asking questions regarding psychiatric content. We got consent in an active way. Parents had to sign consent forms that students would return Q: We’ve done some screening in the schools trying to find trends in the community and to advise institutions, eg. corrections, human services, the schools. We’re increasing our immigrant population and we need to use interpreters. How does that affect the care? How has LA Unified addressed needing interpreters in the process? A: In LA Unified, we have a large number of mental health professionals and a large portion are bilingual and bicultural. We’ve developed partnerships with community agencies, too. The goal has always been to provide services in the clients’ language of origin. It’s not always possible, but it’s what we are pushing for and the ultimate goal. There are some of those concerns around using interpretation in the work that we do, and I know that it certainly is a big concern and needs to be addressed just about everywhere and if we have to use interpreter services how can we do it in the best way possible? How can we make it as useful as possible? Q: Can you talk about the 10 group session? We are beginning to develop groups as a way to reach more youth. Are you following a specific curriculum? A: The 10 week group is called Cognitive Behavioral Intervention for Trauma in Schools (CBITS). You can see our website at www.tsaforschools.org.
Q & A continued… Q: Stigma a huge issue for everyone. Can we talk in relation to screening? One possible negative is that you’ve identified kids and will they be stigmatized. How can we lessen stigmatization? A: Don’t label it as mental health because that’s considered mental illness. Try using other types of language. Have consumers inform other consumers. A: Describe the process and rationale as relieving suffering of someone who is suffering in silence or is in distress. Emphasize that there is no direct line between screening and diagnoses. It is really a first step in the process toward getting someone help. Bring it down to the human level. A: Language has been focused on normalizing. There is a normal response that all of us have when something scary happens. Psychoeducation and “helping your child be as successful as they can be in school.” Successful educational outcome is less threatening to parents than PTSD, which is almost never mentioned in the work that we do. A: The school is a key partner in accomplishing effective communication with the families who are wary and stigmatized by the mental health label. Partnering with the school does help alleviate some of that stigma. Part of normalizing the experience is able to share information. They think that they may be the only ones going through these experiences. Sharing that they are not alone seems to reduce some of the barrier and open liens of communication. Have all of the meetings at the school and include advisory members that are part of the populations they are engaging. Have pastor services and families get around a table and talk about the issues and provide insight on how they can do better. Perhaps a volunteer could come to the houses with us, but that raises confidentiality issues. We’ve thought about having a liaison and a bridge, but then that person has access to a lot of information that the family will not be comfortable with. We’re trying a lot of strategies. A: Regarding stigma in mental health and trusting relationships – the school has developed that with many of the parents. Having us in the schools and on the campus helps build that relationship with us as well. One specific way to reduce stigma is through education. We plan to do a number of on-going parent groups talking about mental health issues and child development issues and this will become more of a trusting relationship. They’ll see us then as someone they can rely on and not some clinic out there.
Q & A continued… Questions for the grantees: Q: The Somali community has very high illiteracy rates. Have you come across this issue and how have you handled it related to sending home consent?A: We back up a few steps and do a lot of explanations of services, but also explain consent verbally at schools and in the homes. We talk directly with parents or over the phone with interpretation about the consent process and what we are doing with the screen. Q: We are using the CAFAS (Child and Adolescent Functional Assessment Scale). This is a first for us and I wonder if anyone else has experience with this, particularly with refugee communities and what the experiences have been? It is clinician administered, verbal, includes interviews with teachers and parents, and it’s good to not rely on paper. A: In Minnesota we moved away from the CAFAS. We didn’t feel it was sensitive to change. We’re now using the CASII (Child and Adolescent Service Intensity Instrument), a level of care assessment tool. Minnesota is also encouraging the use of the strength and difficulties questionnaire. Those are the two things that people are using at screening and then use at follow-up or post-treatment to measure outcomes. CAFAS wasn’t that sensitive. Most the kids we see here are coming up outpatient – that’s what we already know. It could be used to see who needs more intensive levels of care, but doesn’t seem to be used that way in Minnesota. It’s not a stand alone tool. A: We do use the CAFAS and the CASII and we have not seen marked differences with our refugee/immigrant clients compared with native-born clients. For both groups we are about to discontinue these tools, as they are not showing significant sensitivity to progress. Very general tools in terms of functioning. Not symptom oriented.