School-based behavioral health services for military youth: Essential components of a novel and successful service delivery model
Authors: Stan F. Whitsett, PhD and Albert Y. Saito, MD
The ongoing Military conflicts arising since Sept. 11, 2001 have had extensive behavioral health (BH) repercussions for Service Members involved in the conflict as well as their family members (Chandra et al., 2010; Chartrand, et al., 2008; Flake, et al, 2009; Gibbs et al., 2007; Richardson et al, 2011). Growing awareness of and concern about this issue has led the U.S. Military to pursue novel but effective approaches for service delivery.
The School Behavioral Health Team (SBHT) at Tripler Army Medical Center is one such innovative program, which has been providing highly effective behavioral health (BH) services to military youth for over 10 years. The SBHT utilizes a service delivery model adapted from that of the University of Maryland's Center for School Mental Health (Lever, 2002; Weist, 1999; Weist & Murray, 2007), and built through a Community of Practice (collaborative care) approach. By integrating a multidisciplinary team of behavioral health providers with school and community staff, the SBHT “embeds” programs and personnel in schools attended by military children. Use of this service delivery model has resulted in significant enhancements in the quality and efficacy of BH care for military connected youth (and families); enhancements that are associated with improved access to care, reduced stigma associated with receiving BH care, and both clinically and statistically significant clinical outcomes.
Our evaluations of the SBHT program have identified three interrelated, essential components of the service delivery model which underlie these improvements: The use of a Community of Practice (CoP) approach; the “embedding” of BH specialists in the school community; and the application of evidence-based therapies (EBTs) with training and Continuous Quality Improvement involving the school community. We have successfully reproduced these components with separate teams of providers, and in different schools; each time resulting in similar gains. Each component will be discussed below to illuminate their role in the observed systemic and clinical outcomes.
Use of a Community of Practice (CoP) Approach
The goal of developing a COP is to bring together people who “share a concern or a passion for something they do and learn how to do it better as they interact regularly” (Wegner, 2006; c.f. Cashman, Linehan, & Rosser, 2007). In the school setting, there are many individuals and groups — stakeholders — who have “concern” about the students in that school, and their psychological well being. In addition, these individuals have “concern” for the social-emotional climate of the entire school. In establishing a new CoP at a school, the SBHT works first to bring together as many stakeholders as possible to evaluate the needs of the school according to the stakeholders, and to collaboratively develop goals and strategies for addressing those needs. The CoP needs to address both BH issues arising from individual students or small groups of students (e.g. stress/anxiety), and also issues confronting the larger student body or school culture (e.g. bullying). In doing so, programs growing out of the CoP’s efforts will address a “continuum of care”, ranging from health promotion, to prevention, to early intervention, to specialty interventions.
In practical terms, the CoP can work best on these two levels of concern through the formation of two working groups: An Advisory Group, which addresses non-clinical, school-wide concerns and initiatives; and a Triage Group, which focuses on the clinical BH concerns of individual students. For protection of privacy and confidentially, the Triage team consists of individuals with a “need to know” about individual students and their clinical care. Members of the triage group also sit in the Advisory Group so that issues pertinent to individual students may be fed back (anonymously) to the larger Advisory Group. Similarly, goals and strategies developed in the Advisory Group may be rolled back into clinical care of individual students, so that therapy is consistent with school-wide themes.
In both groups, the goal is to work as a CoP to “get better” at enhancing the BH functioning of the student and the student body. The SBHT has examined objective evidence of attainment of this goal in two of the schools with which we are involved. For example, “behavioral reports” (i.e. reports to school Administration for incidents of disruptive/inappropriate behavior by students), showed an approximately 50 percent decline over the course of two years in two separate schools in which an SBHT CoP was started, despite a concomitant increase in student enrollment.
“Embedding” Behavioral Health Specialists
Integration of SBHT with school and community BH personnel through a CoP effectively “embeds” SBHT providers in the school environment. This proximity to the students has enabled SBHT staff and their services to be viewed by the students (as well as school staff) as seamlessly connected to the school. Most importantly, embedding BH providers in the school has led to three very positive changes in BH service delivery which appear to contribute to enhanced clinical outcomes. Embedding providers in the school reduces the stigma often associated with seeking BH care (especially in Military families), dramatically improves access to BH care, and enables point-of-performance delivery of BH interventions.
Stigma reduction occurs because SBHT providers are viewed by students as part of the school environment/staff, and there is consequently little apprehension about involvement with SBHT providers. SBHT staff are regularly observed by students interacting with numerous other students (e.g. as part of a health-promotion program), and in virtually every classroom (e.g. performing in-class observations, or working with a teacher on behavioral programming). This familiarity with the embedded SBHT staff affects parents of students as well, often enabling parents to seek SBHT assistance when they might previously have felt reluctant. “Customer Evaluations” returned by parents show that they are comfortable accessing SBHT services, and are very satisfied with their children’s care.
Also, because of the proximity of SBHT providers to individual patients (students and parents), access to care is dramatically improved, especially from the parents’ perspective. We compared the length of time that a parent had to be away from work, home or their Military duty when their child’s therapy was provided in a traditional BH clinic vs. through the SBHT. For appointments involving both the parent and child, on average, parents needed to be away 120 minutes for clinic appointments, but only 60 minutes for SBHT appointments. For “child only” appointments (i.e. parent not involved in the session), it took an average of 120 minutes of the parent’s time to bring the child to the clinic, but essentially no time (0 minutes) if the child was seen for therapy at school.
Finally, embedding enables many non-pharmacological therapeutic interventions to be delivered where/when the behavior or emotion of concern occurs. This “point-of-performance” intervention has been suggested to be most effective for ADHD (Goldstein & Goldstein, 1998), a disorder which constitutes a sizable portion of the referrals to the SBHT. However, many child-focused therapies benefit from the in situ opportunity to reinforce appropriate response patterns when and where they occur — an opportunity seldom available with clinic-based care. A related, additional benefit arises when the embedded BH providers are also able to work with adult caregivers (teachers, counselors) of the student to assist in the point-of-performance implementation of new therapeutic strategies in multiple school settings.
Application of Evidence-Based Practices (EBPs) with Training and Continuous Quality Improvement
Much has been written in Psychology and other fields about the need to utilize best-practices, derived from the best evidence, implemented in a precise fashion, to attain optimal outcomes for “patients” (e.g., Hunsley & Lee, 2007; Institute of Medicine, 2001; Lehman, Goldman, Dixon & Churchill, 2004). However, when utilizing a CoP model within a non-clinical community with individuals from diverse backgrounds, special procedures are needed to attain good implementation of EBPs. We use ongoing training in best practices (organizational and clinical), with feedback and revision of practices through a Continuous Quality Improvement (CQI) strategy, implemented through the Advisory and Triage Groups.
Whether the goals are to enhance the school-wide social-emotional climate or to improve behavioral functioning of an individual child, the CQI process involves similar steps. A needs evaluation (for the school environment or an individual child) from the group’s perspective is followed by discussion from subject matter experts on the best evidence-based practices for that need. The group (again, led by the “expert”) identifies the best strategy for approaching the need, and devises a plan for implementing this strategy. Note that in the case of an individual child’s clinical needs, there is still a benefit in discussion by the entire Triage group of the strategy and its implementation to ensure that all who have contact with the child will have input to and be aware of the treatment plan. At each subsequent meeting of the respective group (Advisory or Triage), outcomes are reviewed, successes and problems are analyzed, and the plan is revised or reinforced as appropriate.
Out of the CQI process emerge areas in which specific members of the “team” need additional information and training to carry out their team functions. Training in programs and methods is essential for all within the CoP, but the specific nature and even topics of the training comes directly from the CQI process. In addition, the CQI process is applied to any training that is undertaken to make certain that it — like the school-wide programs and individual therapy efforts — achieve the highest possible level of quality implementation by each member of the team, by the team as a whole and ultimately by the program itself.
Based on the promising program effectiveness evaluations to date, it is our view that School Behavioral Health Programs, utilizing these essential components, provide an optimal service delivery model to improve the health and well-being of military children and youth.
Cashman, J., Linehan, P., & Rosser, M. (2007). Communities of Practice: A new approach to solving complex educational problems. Alexandria, Va.: National Association of State Directors of Special Education.
Chandra, A., Martin, L. T., Hawkins, S. A., & Richardson, A. (2010). The impact of parental deployment on child social and emotional functioning: Perspectives of school staff. Journal of Adolescent Health, 46(3), 218-23.
Chartrand, M. M., Frank, D. A., White, L. F., & Shope, T. R. (2008). Effect of parents’ wartime deployment on the behavior of young children in military families. Archives of Pediatric and Adolescent Medicine, 162(11), 1009-1014.
Flake, E., Davis, B.E., Johnson, P.L. & Middleton, L.S. (2007). The Psychosocial Effects of Deployment on Military Children. Journal of Developmental & Behavioral Pediatrics. 30, 271–278.
Hunsley, J., & Lee, C. M. (2007). Research-informed benchmarks for psychological treatments: Efficacy studies, effectiveness studies, and beyond. Professional Psychology: Research and Practice®, 38, 21–33.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press.
Lehman, A. F., Goldman, H. H., Dixon, L. B., & Churchill, R. (2004). Evidence-based mental health treatments and services: Examples to inform public policy. New York, N.Y.: Milbank Memorial Fund.
Richardson, Amy, Chandra, A., Martin, L.T., Setodji, C.M., Hallmark, B.W., Campbell, N.F., Hawkins, S. & Grady P. (2011). Effects of Soldiers’ Deployment on Children’s Academic Performance and Behavioral Health, Santa Monica, Calif.: RAND Corporation, MG-1095-A.
Weist, M.D. (1999). Challenges and opportunities in expanded school mental health. Clinical Psychology Review, 19, 131-135.
Weist, M.D., & Murray, M. (2007). Advancing school mental health promotion globally. Advances in School Mental Health Promotion, Inaugural Issue, 2-12.
Wegner, E. (2006). Communities of practice: A brief introduction.
Stan F. Whitsett, PhD, completed his Doctoral training at the University of Tennessee in Knoxville. He then completed a post-doctoral Fellowship at the Alberta Children’s Hospital in Calgary, Alberta, where he remained on staff as a pediatric psychologist for a number of years. He was subsequently on faculty in the Department of Psychiatry and Behavioral Sciences at the University of Washington, and Clinical Attending Staff at the Seattle Children’s Hospital as a clinical and research Psychologist before moving to Tripler Army Medical Center in Hawaii. He is currently a supervising psychologist and clinical director of the School Behavioral Health Team, Child & Adolescent Psychiatry Service, at Tripler Army Medical Center.
Albert Saito, PhD is the director of the School Behavioral Health Team at Tripler Army Medical Center. He is also the clinical director of the Child and Adolescent Psychiatry Service. Dr. Saito received his BEd and MD from the University of Hawaii at Manoa. His post MD training in General Psychiatry was at the University Hospitals of Cleveland and his Fellowship in Child and Adolescent Psychiatry was at Langley Porter Institute at the University of California at San Francisco. His current interests include the delivery of behavioral health in the community setting as well as continued interest in education at all levels from the early years through graduate medical education.