what is the state of rural america? · alaska “lower 48 ” adapted from ... and meat packing...

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What is the state of Rural America?

Rockville, MDMay 17, 2018

Karen B. Francis, Ph.D.Principal Researcher

American Institutes for Research (AIR)Washington, D.C.

Disclaimer

• The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

5/17/2018

Kasehagen - SAMHSA Rural Mental Health Meeting

2

A View of Rural America

Alaska

“lower 48”Adapted from WICHI-

Mental Health Program

Presenter

Presentation Notes

Setting the stage - This is an aerial view of the US at night – a good depiction of the vast area of what is called rural America ( all the dark areas). Rural areas cover 97 percent of the nation’s land area but contain 19.3 percent of the population (about 60 million people),” Census Bureau, Director John H. Thompson.

http://www.noaanews.noaa.gov/stories/images/usa-nightlights1994-1995b.jpg

Definition of Rural Rural definitions can be based on administrative,

land-use, or economic concepts, exhibiting considerable variation in socio-economic characteristics and well-being of the measured population. (Cromartie, Bucgoltz, 2008)

Presenter

Presentation Notes

The Census defines “rural” as anything that exists outside of “urban clusters” with upwards of 2,500 residents or “urban areas” with 50,000 or more. Now having said that – as we try to provide some understanding of rural - let me just say that - There is no one definition of rural. Rural definitions can be based on administrative, land-use, or economic concepts, exhibiting considerable variation in socio-economic characteristics and well-being of the measured population For example the US Census Bureau defines “rural” as anything that exists outside of “urban clusters” with upwards of 2,500 residents or “urban areas” with 50,000 or more. We even often here the terminology “non-metro” being used to describe rural areas. We also hear the term “small town America” Several federal agencies have developed definitions to encompass distinction relative to population size, population density, economic activities, proximity to urban areas. Counties that are considered rural in the Community and Environment in Rural America (CERA) survey are classified by the Office of Management and Budget as nonmetropolitan. Although several federal agencies use the word frontier to describe specific rural communities – based on their remote nature – the use of the term frontier has often been a point of caution when working with tribal entities who take offense to the term – frontier as a description of their communities and lifestyle. All these definition acknowledge the diverse and complex nature of rural communities.

“Rural America” is a simple term describing a complex place

Rural America’s complexity is reflected in:• The varying definitions of “rural.”• Rural demographic trends.• The varying opportunities and challenges

in rural communities.• The need for place-specific policies and

programs.

Presenter

Presentation Notes

It is safe to say that there is obvious complexity in defining rural communities. Our appreciation of the complexity and diversity of rural areas across the county is critical to our understanding to the successes, challenges and issues that children, youth and families experience in rural areas– and by extension allows us to explore opportunities for the development and delivery of programs and services.

Changing Demographics of Rural America

Description of trends:

Increasing out -migration of young adults for education and employment.

In-migration of ethnic minorities for jobs in construction, manufacturing, agriculture, and meat packing.

Growing numbers of retirees moving to rural areas.,

Source: https://wrdc.usu.edu/files-ou/publications/pub__3471631.pdf

Presenter

Presentation Notes

Honoring the principle - People First and being people centered as we do this work – we need to first focus on the demographics of rural America – and more specifically on the changing demographics of rural areas. This issue of demographic change is not just an urban phenomenon, but very much a part of how we define rural American today and in the future. As was mentioned at the beginning of this presentation – about 19.3 percent of the total U.S. population (about 60 million people), live in rural areas. Historically, rural places have lost population. However, since the rural rebound of the 1970s, the story of migration into and out of rural areas has become more complex. Some researchers point to these changing demographics as being a result of jobs in construction, manufacturing, agriculture, and meat packing that have brought immigrants to new places in rural America in recent decades.. For much of the 20th century, most rural communities experienced population loss as millions of rural residents left for the opportunities in booming cities. Rural growth picked up again after 2001, although recent gains remain smaller than in the early 1990s. We also see that rural communities are increasingly attracting retirees from the cities and others seeking a slower pace of life Source from the: Occasional Policy Brief Series THE CHANGING DEMOGRAPHIC PROFILE OF RURALAMERICA Annabel Kirschner, E. Helen Berry and Nina Glasgow The demographic profile of rural and small town America has changed rapidly and significantly in recent decades. The continued out-migration of increasingly educated young adults, in-migration of ethnic minorities, and growing numbers of retirees, have transformed rural economies and influenced a range of public policies. Non-metro residents are older, more ethnically diverse, and more likely to be female than in the recent past.

Four Rural Americas

Amenity-Rich

Declining Resource-Dependent

Chronically Poor

Transitioning areas with amenities (Amenity Transition)

Presenter

Presentation Notes

The complexity and diversity of rural America is exemplified by what the Carsey Institutes (University of New Hampshire) calls – Four Rural America’s (1) Amenity-Rich (2) Declining Resource-Dependent, (3) Chronically Poor and (4) Transitioning areas with amenities (Amenity Transition) Each type of rural place faces its own type of: economic challenges, demographic changes and environmental pressures (social determinants), and its own opportunities for development. So what do these four types of rural America really mean…………………..

Amenity-Rich Rural Places• High population growth

• Natural amenities

• High education levels, income, and employment

• Impact of sprawl on the natural environment, and the changing character of their communities

(Carsey Institute, 2011)

Presenter

Presentation Notes

Example – Jackson Hole Wyoming

Declining Resource-Dependent Rural Places

• Past strong resource-extractive industries

• Stagnant economic conditions

• Population decline

• Education and employment rates remain relatively high and poverty rates relatively low

(Carsey Institute, 2011)

Presenter

Presentation Notes

Example The Great Plains – Eastern Montana

Chronically Poor Rural Places •Persistent poverty

•High unemployment

•Long-term underinvestment

•Attracting few newcomers and are losing many young adults who are essential to healthy civic and economic life

(C I tit t 2011)

Appalachia (Kentucky)

Presenter

Presentation Notes

Examples – the Mississippi Delta, Eastern Kentucky

Amenity Transition Rural Places• Mix of amenity-rich and declining resource-dependent places

• Decline in their more traditional industries but have been able to attract some newcomers

• Modest to low population growth and relatively high employment and education levels

Presenter

Presentation Notes

Example – Berlin New Hampshire The convergence of Economic challenges, Demographic changes and Environmental pressures contribute to disparities faced in rural communities – disparities related to health and education outcomes. Let us examine what those disparities look like within a rural context

Gains and Persistent Disparities in Rural Communities

Institutional

Social

Cultural

Presenter

Presentation Notes

Our understanding of these 4 rural America’s gives us insight into some of the challenges and disparities that exist within rural communities and among its members. It also forces us to ask questions about the protective factors that exist within rural communities and how we can work to enhance those protective factors. Generally, we can say that disparities exist at an institutional, social and cultural level. What does that mean – and in particular what does that mean in a rural setting. Institutional – structural issues that perpetuate disparities Laws, policies and practices Structural/Institutional racism Fragmented service delivery system Social Socio-economics/Poverty Geography Transportation Housing Access to services Discrimination/Prejudice by social grouping (e.g., race, gender, or class) Social or environmental stressors Stigma and mistrust Cultural Differences World view Historical trauma - Issues of trust Health/wellness/illness/curative beliefs Values, traditions, practices and rituals These are all issues what must be grappled with as we focus on developing comprehensive school mental health in rural communities.

http://en.wikipedia.org/wiki/File:Ageev_5X_circle_graph.svg

Highlighting Rural Disparities• Inadequate access to care.

• Limited availability of skilled care providers.

• Inadequate transportation to service delivery points.

• Poverty/low incomes.

• Less access to private health insurance benefits (mental health care)

Presenter

Presentation Notes

Rural children are one of the groups least likely to have access to mental health services, many rural communities are challenged by the lack of public services - Difficulties in access, availability and acceptability of mental health services are of increased concern in rural and frontier communities- Many rural communities continue to lack many of the public services and access to these services that are much more commonplace in metropolitan areas. Programs to specifically train and promote the placement of rural mental health professionals are few in number, and those that do exist are not often located in rural areas. More than 90% of all psychologists and psychiatrists, and 80% of MSWs, work exclusively in metropolitan areas More than 60% of rural Americans live in mental health professional shortage areas Given the growing diversity in rural communities - Need a workforce that is comparably multi-cultural and multi-lingual – there is a workforce shortage in rural communities and a shortage of mental health providers. Quite often - The mental health crisis responder for most rural Americans is a law enforcement officer. In many rural communities, other barriers to access of services and supports include a lack of transportation Family poverty is a risk factor for behavioral health concerns and increase the risk of child abuse and neglect and children, youth and families living in rural communities are less likely to have access to private health insurance. Incidence and prevalence rates of mental illness and substance abuse are comparable to urban residents, but they are less likely to have access to services or providers. Rural teens and rural older adults have a much higher rate of suicide than their urban peers. Social stigma.

Availability – does it exist?

Accessibility – ease and convenience to obtain and use services

Affordability – cost?

Appropriateness – effectiveness and quality of services

Acceptability – is it congruent with the world view, cultural beliefs and values?

Adapted from Jackson, 2008 - NCCC

Implications for RBH Policy and Programming

Presenter

Presentation Notes

Suggestions for looking at a Comprehensive School Mental Health in Rural Communities, questions and issues to think about and decisions to make about how we can address Comprehensive School Mental Health in Rural Communities. The Five A’s…………

15

Presenter

Presentation Notes

End with the train as an analogy for a call to action.

Karen B. Francis, Ph.DPrincipal ResearcherAmerican Institutes for Research (AIR)1000 Thomas Jefferson Street, N.W.Washington, D.C. 20007(202) [email protected]

16

Contact Information

mailto:[email protected]

Rockville, MDMay 17, 2018

State of School Mental HealthWhere are we and where are we going?

Sharon A. Hoover, PhDNational Center for School Mental

Health

May 17th, 2018

Comprehensive School Mental Health

What is it?

Why grow it?

Current Status of the Field

Elements of School Mental Health Quality

Elements of School Mental Health Sustainability

Shaping your System

WHAT IS COMPREHENSIVE SCHOOL MENTAL HEALTH?

What School Mental Health is NOT

MTSS School-Community Partnerships

Kathy Short, 2016, Intl J. of Mental Health Promotion

Presenter

Presentation Notes

In order to create schools that support both the mental health and the safety of our students, we must build multi-tiered systems of support that rely on school-community partnerships

WHY GROW SCHOOL MENTAL HEALTH?

Reflection Question

If you could pick one quality or skill that all young people would possess by the time they graduate from high school, what would it be?

Roger Weissberg, CASEL

CASEL Core Competencies

Roger Weissberg, CASEL

Median Age of Onset: Mental Illness

Age 40

Age 80

Age 20

Birth

Age 60

Psychosis

Phobias & Separation Anxiety

ADHD Conduct Disorder

Opposition Defiant Disorder

Intermittent Explosive Disorder

Source: WHO World Mental Health surveys as reported in Kessler et al. (2007)

Major Depression

Substance Abuse

Mid-teens

Mid-20s

Autism Spectrum Disorders

Sharon Hoover, 2018

Advantages of Mental Health in the School Setting

• Greater access to all youth mental health promotion/prevention

• Less time lost from school and work

• Greater generalizability of interventions to child’s context

• Less threatening environment• Students are in their own social context

• Clinical efficiency and productivity

• Outreach to youth with internalizing problems

• Cost effective

• Greater potential to impact the learning environment and educational outcomes Sharon Hoover, 2018

Kase, C., Hoover, S. A., Boyd, G., Dubenitz, J., Trivedi, P., Peterson, H., & Stein, B. (2017). Educational outcomes associated with school behavioral health interventions: A Review of the Literature. Journal of School Health, 87(7), 554-562.

• Findings from 36 primary research, review, and meta-analysis articles

• 2000-2017

• Benefits of school behavioral health clinical interventions and targeted interventions on a range of academic outcomes for adolescents.

Sharon Hoover, 2018

Presenter

Presentation Notes

So – it is clear – school mental health is critical to promoting healthy and academically successful students. In the context of our national conversation on school safety, our Center is being asked, almost on a daily basis – is mental health critical to promoting safe, secure schools? So – I do want to provide a couple of thoughts on this because we are at a critical juncture in many states for deciding how to shift policies and funding to protect our students welfare.

Two VisionsMarch 2018 Congressional Briefing:School Violence, Safety, and Well-Being:A Comprehensive Approachhttp://www.npscoalition.org/school-violence

Sharon Hoover, 2018

http://www.npscoalition.org/school-violence

MENTAL HEALTH IS ESSENTIAL TO

Sharon Hoover, 2018

What’s happening on the front lines of school mental health?

APPROACHES FOR ALLSharon Hoover, 2018

Presenter

Presentation Notes

Early intervention works to reduce illness, including mental illness. In addition – there are two things I want you to consider about why we need to focus more attention on universal approach or APPROACHES FOR ALL We cannot rely on one clinician in a school – or even two or three – to be responsible for the mental health for all students.

UNIVERSAL Mental Health/Safe Supportive (SS) Strategies

1. Realize 2. Recognize 3. Respond 4. Resist

– Promote supportive positive school culture and climate

– Staff wellness

– Social Emotional Learning (SEL)

– Create trauma-responsive school policies

– Training/coaching on crisis/ trauma and ways to interact with students exposed to trauma

– Mental health literacy for school staff and students

Tier I. All StudentsRegardless of behavioral health risk

Tier II. Some StudentsAt risk for behavioral

health concerns

Tier III. Few Students

Apparent behavioral health needs

Psychological First Aid

School-wide ecological strategies

SSET

Bounce Back (K–5)CBITS (6–12)

TF-CBT

Sharon Hoover, 2018

https://safesupportivelearning.ed.gov/National Center for Safe and Supportive Learning Environments

https://safesupportivelearning.ed.gov/

Why Wellness for School Staff?

Sharon Hoover, 2018

Presenter

Presentation Notes

--> While this is of course a joke (sort of), we do know that teachers report a tremendous level of stress

Sharon Hoover, 2018

But seriously, why wellness for school staff?

Teachers are stressed!– Large class size, Behavioral challenges in students,

Inadequate resources & poor physical space, Bureaucracy,Workload & Paperwork, High responsibility for others,Perceived inadequate recognition or advancement, Gap between pre-service training expectations and actual work experiences

Teachers are leaving the profession in alarming numbers!– 10% of teachers leave after 1 year – 17% of teachers leave within 5 years– In urban districts, up to 70% of teachers leave within first year

Fisher, 2011, Kokkinos 2007, Travers and Cooper , 1996 , Dworkin 2001 Sharon Hoover, 2018

Presenter

Presentation Notes

List some common sources of teacher stressInterpersonal demands Lack of professional recognition Discipline problems in the classroom Diversity of tasks required Bureaucracy Lack of support Workload Time pressure Required paperwork Lack of resources provided (Burke, Greenglass, & Schwarzer, 1996; Chan, 1998; Pithers, 1995) A heavy workload with little time generally features as a stressor in educator studies. They often do not have enough time to achieve the standards of teaching and learning that they would like to, or to meet the needs of their learners (Conley & Woosley 2000; Moriarty et al. 2001; van Dick & Wagner 2001)” (Schulze & Steyn 2007).

Teacher Stress Impacts Students

• Teachers who are stressed demonstrate greater negative interactions with students:

• Sarcasm• Aggression• Responding negatively to mistakes

• Classrooms led by a teacher who reported feeling overwhelmed (high burnout) had students with much higher cortisol levels

Oberle & Schonert-Reichl (2016)

Teacher Stress

Student Misbehavior

Teacher Stress

Sharon Hoover, 2018

Presenter

Presentation Notes

assessed cortisol levels of ~ 400 children and Burnout of their Teachers

Promising School Staff Wellness Programs

• Mindfulness-Based Stress Reduction (MBSR)• Reductions in psychological

symptoms and burnout, improvements in observer-rated classroom organization and increase in self-compassion (Flooket al, 2013)

• Improvement in: self-regulation, self-compassion, mindfulness and sleep quality (Frank et al, 2015)

Sharon Hoover, 2018

Presenter

Presentation Notes

We do have a growing literature on this though - with some specific promising programs on school staff wellness including

Community Approach to Learning Mindfully (CALM)– Improvements in:

• Mindfulness • Emotional functioning • Positive affect• Distress tolerance• Efficacy in classroom management• Physical symptoms• Blood pressure• Cortisol Harris, H.R., Jennings, P. A., Katz, D.A., Abenavoli, R.M. & Greenberg, M. T. (2016)

Cultivating Awareness and Resilience in Education (CARE)

• Improvements in well-being, efficacy, burnout, mindfulness (Jennings et al, 2013) Createforeducation.orgSharon Hoover, 2018

Social and Emotional Learning (SEL)

Students in the Social Emotional Learning(SEL) programs demonstrated :

• Improved Social-emotional skills • Improved attitudes towards self, school, and

others • Reduced conduct problems and emotional

distress

• Improved Academic performance – Average gains on achievement test scores

of 11 to 17 percentile points.Source: Durlak, Weissberg, et al.. (2011) The impact of enhancing

students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development: 82 (1), 405-432.

Sharon Hoover, 2018

Presenter

Presentation Notes

Some of the most compelling evidence for the positive impact of school mental health is in the area of social emotional learning. Roger Weissburg, of the Collaborative for Academic, Social and Emotional Learning (CASEL), has done tremendous meta-analytic work that has demonstrated actual impact of SEL programs on achievement test scores.

www.casel.org

http://www.casel.org/

PSYCHOLOGICAL FIRST AID: Listen Protect Connect/Model and Teach

https://traumaawareschools.org/pfaCopyright M. Schreiber, R.H. Gurwitch, & M. Wong, 2006

Adapted, M. Wong, 2012

Sharon Hoover, 2018

Presenter

Presentation Notes

Developed by Marleen Wong and colleagues in aftermath of school shootings. To help students to reenter their schools and to resume their studies by building their coping skills, reconnecting with important people, places and activities to achieve a “new normal”.

Mental Health Literacy• Understand how to obtain and

maintain good mental health • Understand and identify mental

disorders and their treatments • Decrease stigma • Enhance help-seeking efficacy: know

where to go; know when to go; know what to expect when you get there; know how to increase likelihood of “best available care” (skills and tools)

Kutcher and Wei; 2014; Kutcher, Bagnell and Wei; 2015; Kutcher, Wei and Coniglio, 2016.

Sharon Hoover, 2018

APPROACHES FOR SOME

Sharon Hoover, 2018

TARGETED Mental Health/Safe Supportive Strategies


– School staff training on identifying, approaching, referring students experiencing psychological distress

– Mental health screening

– Support for transitions

– Provide additional check-in support (e.g., mood ratings beginning and end of day)

– Interventions for students with mild impairment –SSET, STRONG



health concerns




School-side ecological strategies

SSET

STRONG

TF-CBT


Sharon Hoover, 2018

Youth Mental Health First Aid

• 8 hour in person public education training program• Teaches participants the risk factors and warning signs

of a variety of mental health challenges common among adolescents (ages 12-18)

• Teaches participants a 5-step action plan:– Assess for risk of suicide or harm– Listen nonjudgmentally– Give reassurance and information– Encourage appropriate professional help– Encourage self-help and other support strategies

• Adult version- SAMHSA NREPP Evidence-based program

Sharon Hoover, 2018

Presenter

Presentation Notes

Youth Mental Health First Aid is designed to teach parents, family members, caregivers, teachers, school staff, peers, neighbors, health and human services workers, and other caring citizens how to help an adolescent (age 12-18) who is experiencing a mental health or addictions challenge or is in crisis.

TEACHER TRAINING: At-Risk Suite for K-12 Educatorswww.kognito.com

• Online 24/7; 50 – 60 minutes• Virtual role-play conversations with at-risk

“emotionally active” student avatars • Created in collaboration with school and

mental health experts and educators• Deliberate practice and personalized

feedback• Listed: SPRC/AFSP Best Practice Registry

• Listed: National Registry of Evidence-Based Programs and Practices (HS only)

• Effectiveness demonstrated in national empirical studies (HS only)

• Widespread adoption – over 100,000 teachers in Texas, NY, Arizona, Ohio (HS only)

© 2013 Kognito Interactive. All Rights Reserved.

Sharon Hoover, 2018

Presenter

Presentation Notes

Many states and districts have also been using human simulation training - like this Kognito training - to give teachers practice at identifying, approaching, and supporting or referring students experiencing psychological distress

Support for Students Exposed to Trauma (SSET) Programwww.ssetprogram.org

http://www.ssetprogram.org/

STRONGSTRONGSupporting Transition Resilience of

Newcomer Groups

Sharon Hoover, 2018

STRONGOntario Launch!

• 10-week, school-based group intervention for newcomer students

• Pilot (Sprin 2018) in four schools in the Peel District School Board and four in the Toronto Catholic District School Board

Sharon Hoover, 2018

SELECT Mental Health Strategies


– Refer for evaluation and appropriate treatment

– School and/or Community Based services

– Special education accommodations

– Ensure good communication between families, community, and school personnel

– Evidence-based interventions – e.g., CBITS/Bounce Back, TF-CBT



health concerns




School-side ecological strategies

SSET


TF-CBT

STRONG

Sharon Hoover, 2018

CBITS developed to help children in schools cope with trauma

• Begun in 1998

• Collaboration with Los Angeles Unified School District, University of California, Los Angeles

Presenter

Presentation Notes

CBITS was created by Dr. Wong's Center - which is supported by our National Child Traumatic Stress Network

Hoover et al., 2018. Statewide Implementation of an Evidence-based Trauma Intervention in Schools, School Psychology Quarterly, 33(1), 44-53..

• Statewide Learning Collaborative

• 2-day training• Bi-weekly consultation• Audio fidelity

monitoring/feedback• Data tracker

• 350 students• 70 groups

• 23 clinicians

• 90.3% completion rate

SHARON HOOVER, 2018

Successes• Increasing emphasis on:

– Multi-tiered Systems of Support (RtI, PBIS-SMH/ISF, etc)– Evidence-based (research-supported) Practice (EBP)– Consideration of cultural context in development,

implementation, and evaluation of EBP– Meaningful partnership with families– School-community partnerships– Workforce training for mental health providers and

educators– Outcomes

• Pockets of funding to support school mental health– Increased federal investments– Creative funding streams at local/state levels

Challenges• Limited, variable funding • Limited system integration (Mental Health-Education)• Poor practice selection • Gaps in training, particularly related to working schools,

engaging families, evidence-based practice“C.O.W. Therapy” – Crisis of the Week

• Poor implementation support• Limited control/accountability of providers and services

provided• Lack of good data metrics and infrastructure

http://www.clipart.com/en/close-up?o=3954470&memlevel=A&a=a&q=cow&k_mode=all&s=1&e=27&show=&c=&cid=&findincat=&g=&cc=&page=&k_exc=&pubid=

We needSTANDARDS,PROCESSES,

and STRATEGIES

for integrating mental health into education

Elements of School Mental Health Quality_________________________________ Teaming Needs Assessment / Resource

Mapping Screening Evidence-Based Services and

Supports Evidence-Based Implementation Data-Driven Decision Making

Elements of School Mental Health Sustainability__________________________________

Funding and ResourcesResource UtilizationQualityDocumentation and

Reporting ImpactMarketing and Promotion

SHAPE your school mental health system

A Resource to Support Quality Improvement and Sustainability

Schools and School Districts Can Use SHAPE To:

Document your service array and multi-tiered services and supports

www.theshapesystem.com


Advance a data-driven mental health team process for the school or district

Strategic Team Planning Free Custom Reports

www.theshapesystem.com


Access targeted resources to help advance your school mental health quality and sustainability

Trauma Responsive SchoolsSHAPE - Trauma-Responsive Schools (TRS)• Developed by the NCTSN, i Treatment and Services Adaptation Center for Resiliency, Hope and

Wellness in Schools (www.traumaawareschools.org and the CSMH

Domains: School-wide Safety (e.g., predictable routines, physical safety) School-wide Programming (e.g., restorative justice, culturally responsive

teaching) Staff Trauma Knowledge (e.g., school/classroom impact of trauma,

neurological impact) Staff Trauma Skills (e.g., trauma-informed communication, de-escalation) Early Intervention Activities (e.g., trauma screening, early intervention

evidence-based trauma practices) Targeted Intervention Activities (e.g., School-based Trauma Treatments,

Referrals) Staff Wellness/Burnout/Secondary Traumatic Stress (e.g., Staff Assessment,

Staff Supports)

All items are on a 6-point Likert scale reflecting degree of implementation

http://www.traumaawareschools.org/

It’s messy work

Find good partners, and invest(in the relationships)

Thank you!

Center for School Mental Healthhttp://csmh.umaryland.eduEmail: [email protected]: (410) 706-0980

@CtrSchoolMH

Sharon A. Hoover, [email protected]

@drsharonhoover

http://csmh.umaryland.edu/



Kurt Michael, Ph.D.Professor of Psychology

Appalachian State University

SAMHSA MeetingRockville, MDMay 17, 2018

Special Considerations for School Mental Health in Rural

Communities

US vs. State vs. Western NC Suicide Rates

Demonstrated Regional Need

• Rural areas experience higher rates of …– Depression and suicide– Alcohol and opiate addiction, particularly among

adolescents/young adults

• Limited access to MH providers in rural NC– 22% of NC counties have no practicing psychologist– Several counties have virtually zero access

(Fontanella et al., 2015; Kessler et al., 2005; Kochanek et al., 2016; Mohatt et al., 2005; Probst et al., 2005; SAMHSA, 2012; Zhang et al., 2008)

Rural SMH Mission: Assessment, Support & Counseling (ASC) Center

Helping educators to educate by:• Providing access to high quality, supervised mental health

services to children and families regardless of their ability to pay

• Training a steady stream of qualified school mental health professionals who join the regional workforce

• Conducting research that informs effective school mental health practices

ASC Service Definitions across Tiers• Surveillance, consultation, education (teachers, administrators)• Assessment & referral• Outpatient psychotherapy (14 sessions of CBT or DBT, 35-40

min/session)• Crisis intervention; Prevention of Escalating Adolescent Crisis

Events (PEACE)– Collaborative Assessment and Management of Suicidality

(CAMS)– Counseling on Access to Lethal Means (CALM)

• Postvention• Evaluation• Continuous Quality Improvement (CQI)

Select ASC Outcomes Clinically significant reductions in psychological symptoms for 65-70% served (Albright et al., 2013) Clinically significant improvements in mood symptoms using modular CBT (Michael, George et al., 2016) Modest changes in academic variables: attendance, discipline referrals, GPA (Michael et al., 2013) Identification and treatment of suicidal ideation/intent (Michael, Jameson et al., 2015; Sale et al., 2014) Rapid reduction in psychological distress (Kirk et al., revise & resubmit) Revision of suicide prevention protocol (Capps et al., under review) In 2017, published the inaugural Handbook of Rural School Mental Health, which included 73 authors from across the U.S., Canada, & Australia

49%

21%25%

5%

Recovered Improved Unchanged Deteriorated

2.4%

6%

National Average Western North Carolina

Adolescent Suicide Attempts Requiring Medical Attention

Post-Treatment Results 2012-2014

Regional Base Rates; Local Results

70% of students who started in a clinical range were significantlyimproved by the end of treatment

Implementation challenges led to innovation

• Address public health problem of suicide via the schools

• Systematize procedures to expeditiously and consistently intervene

• School-wide, community-based intervention• Non-technical jargon

82

Prevention of Escalating Adolescent Crisis Events (PEACE)

• School Safety Paradigm• Easy to understand algorithm assessing evidence-based

risk and protective factors that is implemented across disciplines

• 4 levels of risk: • Green, Yellow, Orange, Red• Each level is associated with a set of behaviorally anchored

action steps, consultative & supervision elements, notification requirements, safety planning, documentation, and follow-up procedures

83

PEACE Descriptive Data

• Last 5 years, plus YTD

• 223 students; 325 crisis events

0

10

20

30

40

50

60

70

80

90

2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

StudentsEvents

Counseling on Access to Lethal Means (CALM; Elaine Frank, Cathy Barber)

Philosophical Underpinnings

• Public health approach• Focuses on the “how” of suicide• Prevention via safety planning & risk reduction• Acknowledges gap in the empirical literature

regarding our capacity to predict attempts

Time Between 1st Thought of Suicide and Attempt

Duration of Suicidal Crises (“Ideation to Action”)Deisenhammer et al., 2009

Self-Harm Case Fatality Rates

85-90% fatal

10-15% nonfatal, treated in hospital ER

Firearms Cutting or Poisoning

1-2% fatal

98% nonfatal, treated in hospital ER

CDC WISQARS

Israeli Defense Force (IDF): An International Example of Means Restriction

Variation in State Suicide Rates (Miller et al., 2013)

* LA, UT, OK, iA, TN, KY, AL, MS, ID, ND, WV, AR, AK, SD, MO, WY** HI, NJ, MA, RI, CT, NY

78% of NW NC firearm deaths are suicides

Regional Firearm Deaths (CDC Wonder, 1999-2014)

Clinical & Prevention Goals

• Create barriers to death by suicide– Time– Distance– Future prevention– Resolution of key drivers to suicidal ideation

Providers Asking about Gun Access (Miller et al., 2013)

what is the state of rural america? · alaska “lower 48 ” adapted from ... and meat packing...

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