lawyer referral service ohio

(joanne oshel)welcome, everybody. welcome to the now is the timetechnical assistance center webinar for todayon best practices in referral,or systematic referral, in schoolsand communities. so with that,i will pass the webinar on to meagan o'malley who's with the nitt-ta centerto get you started. (meagan o'malley)good afternoon, everyone.

just a quick overviewfor project aware. many of you have attendedwebinars with us before. but just an overview,project aware is intended to improvemental health awareness in communities serving schools to increase access to mentalhealth care for youth through school-based and community-basedmental health services and to improveinteragency collaboration around building mental healthsupports for youth.

today we are very pleasedto welcome dr. beth doll to present on best practicesin referral. we are very pleasedto have beth. dr. doll is an associate deanfor academic affairs and professorof education psychology in the college of educationand human sciences at the university of nebraska,lincoln. dr. doll's research addressesmodels of school mental health that foster resilienceand enhance the well-being

of students in naturallyoccurring communities and programevaluation strategies that demonstrate impactand accountability of educational and schoolmental health services. she has consulted withstate and community mental health departmentsas they piloted integrated service models forconference assistance of care, and she's consulted with schooldistricts as they implemented database planning for schoolmental health services.

dr. doll's recent publicationsrelated to children's mental health systems include "transforming schoolmental health," and "the handbookof youth prevention science." dr. doll is the right personto be presenting to our sea and lea partners, and with thati'll hand it over to dr. doll. (beth doll)thanks to meagan for thatwonderful introduction, and thanks to all of youfor signing on. i think that this topic is nearand dear to my heart.

so let me point out to you thatwhat we're going to be talking about todayis actually very related to the last webinarthat many of you attended on universal screening. this was presentedby katie eklund, and katie was talkingabout how you would screen a populationof a school, an enrollment of a district,or a community or a school to identify the kids that hadsignificant mental health needs

and how you would map yourresources of mental health services that you hadin your community onto the children's needsand coordinate services based on a universalscreening model. i want to take that severalsteps further today and talk aboutthe next step referral and referral fromschool districts into community-based servicesand mental health agencies so that some of the studentsthat might be

identified in a universalscreening might be getting services outsideof the schools themselves. so the first thing that i reallyhave to call your attention to is that schoolsand school districts, in working with the entirecommunity's school population, children and adults, are really thinking aboutmental health services in a very different waythan was tradition. when i was trained and whenmany of your community providers

might have been trained, we weretrained to think about kids one child at a time. so you would be working withthe child in front of you, clarifying just what thosechild's needs were, determining whetheror not there was a category or a diagnosis thatmight fit that child, and then making a mentalhealth service plan based on that child's needsand diagnostic category. so it's very muchlike we were thinking

about forestry and gardening. this analogy--trust me,this analogy works. it's very much likethe gentleman that came out to my home and planteda tree in my front yard where four trees had died, and he knew what weneeded to do to have a healthy tree grow inthat toxic spot in our yard. so he was very much an arborist. but what we are doingwith kids in schools

is more like a forest tree,extension specialist that's working withthe whole forest and not with a single tree. what you are essentiallydoing in school districts is trying to supportthe competence and the well-being ofan entire population of children and adolescents thatare enrolled in your school, and that's a verydifferent phenomena than many of ourcommunity providers

are thinking about yet, and frankly it'sa very different phenomena than i was trained to considerwhen i was in graduate school in the '70s. so if i can tie this back toschools and the way schools think about children and theiremotional well-being, one of the things thati want to remind you of first is our pyramids. we talk about three tiersof services.

we have tier one, which isuniversal services for all children, tier two, services for childrenwho are most at risk, and tier three, which areintensive services for children who are still strugglingdespite having tier one or tier two services. that pyramid model is verymuch a treat-the-forest model. it's a population-wide model,and it's our representation in schools of a verydifferent framework

for thinking aboutthe well-being of the children that we are serving. so if you're imaginingreferral in a one-tree model, a one-child-at-a-time model,then what teachers and other educatorsin that school building are going to need to knowis how to recognize when a child hasa psychiatric disorder or disability so theywould know which children to refer intospecialty services.

but we're working ina population-based model. we're taking careof a forest and not a tree, and in a population-basedsystem what teachers needto know and other educators are, what are the strategiesthat we can use to promote educationand life success, school success, job success,despite the fact that some of our childrenhave significant mental disorders,psychiatric disorders,

or emotionaland behavioral needs. and so if you missedkatie eklund's discussion of multi-tiered systemsof support, you may want to goback and think about that particular framework,because that's going to help you understand the first steptowards referral, which is figuring out whatkids can be successful despite mental health needsif they are in our schools. the reason that this isso important is because

we can't refer allof the kids in a school that have an emotionaldisorder or psychiatric disorder or mental health condition. we can't refer all of these kidsinto our community agencies. the reality that we havediscovered in the last 25 years is that as many as1 in 5 children in our public schoolsqualify for 1 or more of the disordersthat are listed in the "diagnosticand statistical manual"

of the americanpsychiatric association. that is a huge number. it means that if youhad a classroom in an elementary schoolwith 25 kids in that classroom, 5 of those kids qualifyfor 1 or more of the dsm disorders. if you have a high schoolwith 1,000 students, then 200 of thosestudents qualify, and because of thosevery compelling numbers

we have to face the factthat we are providing educational servicesto children and adolescents, many of whom meetour traditional criteria for havinga mental health disorder. that kind of numbercan quickly swamp a communitymental health system. we are seeing in generalthat about 5% of the school-agepopulation are receiving mental health servicesthrough community agencies

and communitymental health systems, but 5% is onlya 1/4 of the kids that have a significantmental health need if you use the dsmas your criteria, or a significantmental health need. so you will have large numbersof kids that simply would outstrip the capacity ofyour community to serve them. in our pyramid model,in our three-tiered, multi-tiered systemic system

most of the kids that wouldbe identified as having a dsm disorder wouldprobably be in our tier two, but some of themwould be in tier one, that is, they find waysto be successful despite some of the mentalhealth conditions that they are living with, and some of themwould be in tier three, which is that even withthe system of supports that they have in school,they're not showing us

minimal success inour school district. so then the question comes, howis it even possible in schools to foster the well-beingof these students so that they'resuccessful in school and successful in life, when if we were thinking of thisin a very traditional way, they qualify as havinga mental health problem, a mental disorder? and we've seen quite a bitof luck in the last 25 years,

quite a bit of good,solid research come forward that's talking about howwe promote the well-being of students despitethe fact that they qualify for a diagnosis, and these arethe four major principles. and we're going to come backto these in the future. but one is that it has becomereally important that we create care-taking environmentsthat nurture students because if we have strong,caring environments in school, even many of our childrenwho are at risk

are going to overcomethese minor risks and challenges to be successful. and then we're going to havesome protective support for our vulnerable students,so we try and intervene early, knowing that theymay be at risk. we're going to have somestudents that will have to have some remedial serviceswhere we're teaching them how to overcomethe effects of and cope with theirmental illness,

but knowing that such a largeproportion of our students are likely to be strugglingwith one or more conditions like anxiety or depressionor attention deficits, we're going to alwayshave to work to promote the mental healthand the well-being of all the students. i've been ableto distill this down to seven specific activitiesthat schools can take. this is not insteadof referring students,

but it is a systemiclevel of support, such that some studentswill be able to cope well and not need usto refer them out to more extensive services. and you'll notice thatat the top of my list i've put promotingstudents' friendships. relationships betweenstudents and their peers and students and adults are one of the mostcritical protective factors,

and there are ways thatwe can create in schools and in communitiesmany opportunities for children and adults to havefun doing things together. and having fundoing things together is the currency of friendships. we also want to rememberthat we're raising children to be self-determinedand self-directed, so always in our interactionsand our programs that we create for students,we're fostering

their self-determinationand locus of control. we're strengtheningtheir sense of success. efficacy means thatwe are working to reinforcestudents' expectations that they can be successful,and that sense of success is the key part of promotingtheir psychological well-being and their ability to managetheir behavior so it's consistentwith their own goals and the goals that other peoplehandle for them.

so many ofthe students' behaviors, if they're goal-promoting, will help them overcomesome of the detrimental side effectsof mental health problems that they may bestruggling with. i would see uscreating communities where there are manyopportunities for adults to nurture students,'cause we know that not all of our studentsare receiving the nurturing

that they need in their homesand communities and neighborhood,but also that we provide students with opportunitiesto give back to the community,to be the nurturers. and with that combinationof being nurtured and offering nurturing,we reinforce our students' senseof well-being. so this--these arethe tier-one programs and interventionsand support systems

that we're routinelyoffering in schools. it's important to mention thesebecause mental health is not just about curingor solving disorders. it's also aboutpromoting well-being, and schools are well posedto promote well-being in ways that isfar more difficult for other community agenciesand in some cases for families to do. so we will have, then,a certain number of students,

which despite the tier-onesupports that we offer, even despite some ofthe tier-two services we offer in schools for kids at risk, may not be succeeding in schoolthe way we need them to succeed. and i would suggest they maynot be succeeding in life the way we would liketo see them succeeding, and so our question comes, who should we be referringon for additional services in the community?

it's not just which servicesbut which students-- when do we refer students, to who do we refer them,and what do we expect to be the outcomeof those services? so we struggle with thesequestions in schools as well as in our decisionsaround referrals. that is, if we have a certainamount of resources or funding or time that we can give,should we be giving priority to services that will servethe most children,

or should we insteadbe giving priority to services that are helping children withthe most severe disorders? when we know more aboutthe services and the outcomes, should we be emphasizingservices that we have data to show it's producingdemonstrable outcomes that benefit our children, or should we be emphasizingthe services that children believe in or thattheir families believe in? services that will havethe longest impact

or the fastest impactor that are most relevant to our students'school success or to their social successor their life success? these actually arevery difficult decisions. so i have--there'sa very prominent program in kansas city. it's a program that is promotedby the university of kansas. it's called the intensivemental health program, and it's from the pediatricchild psychology program

offered in public school forchildren with the very severe mental disordersthat have made them extremely difficult to educatein the classroom. however, we have a conflict inpriorities in that this program concentrates extensive serviceson children who are having some severe behavior problemsin the classroom, but children whose problemsaren't quite severe enough don't qualify for this levelof service provision. and there is--from the perspective

of the school administrator-- there's an inequity there,so there are sometimes conflicts in principles betweena school administrator or a school programand a community program if one of these programsemphasizes a priority that's different thanwhat the school is. we've seen a lotof controversy around the d.a.r.e. program. the data is not very strongfor d.a.r.e.

it doesn't appear to be showingus demonstrable improvements when researchers examine it, but it's a very prominentprogram in some communities because the communitybelieves in the program. we have shown thatzero tolerance programs sometimes createa very immediate impact on certain behaviors,but there are questions about whether these havelong-term impact. i've done a lot of workwith schools around recess

and playground interventionsto minimize the number of conflicts on the playground, but there's real questions aboutwhether those interventions are relevantto a school's primary mission of academic achievement. so i'm emphasizingthese priorities because i do believethat at the point you're making a referral forcommunity services, you're choosing a priority,and i think that you should

be explicit about what itis that you and others in your community think arethe most important priorities for the services that you'rereferring a student for. and so this is the firstpolling question. joanne, if you would pull upthe question about which students your localeducation agency is most likely to refer for community-basedmental health services. so you're beginning to seesome results up here now, and i think that we'reall being very frank

and honest about what we thinkis happening in our buildings. i, too, believe thatwe often refer students with the mostdisturbing behaviors, and the question is,is this what we intend to do, or is this what we'vemade a decision to do? i think oftentimes weactually see these decisions are occurring, i wouldn't sayaccidentally, but implicitly. so let's assume nowthat you have your decision about what you thinkis the biggest priority

for the studentsthat you'd like to refer for more intensive services. what i'm hoping to show youbetween now and the end of the webinar isthat to some extent that has to bea community decision and not simplya school decision. in traditionalmental health services-- and i started out working in a residential treatmentcenter for children

with what i would call mild ormoderate mental health needs. in traditional serviceswe would simply say this is the child's need. they need some parenttraining to set up a structured interventionin the home, and then we would sendthat parent out into the world with a phone numberand a recommendation, usually a two-or three-page report and wish for the best.

but what we're finding is thatif we sent too many children at once for the same services, very quickly someof those children that we referred would besitting on a waiting list, not based on their needor the urgency, but kind of on the orderin which that phone call was made. and so some of the services thatwe need to refer children to, because they're limitedin number,

those services are goingto have to be rationed. and i would like to thinkthat the school is part of the decision howto ration those and which kids needwhat services. we've already talked aboutthe fact that approximately 20% of students in schoolhave a diagnosable disorder. i don't know the proportionof students whose needs can't be managed well in schools because it will dependon the school and the classroom.

there's so many individualdifferences by school that can change the successthat that school has in managing students' needs,but i can tell you that in generalwhen we talk to communitymental health agencies they are usuallydescribing around 12% of the full populationof students who have a significantfunctional impairment, meaning that they eitherhave impaired relationships

with peers, with adults,in community settings, or in school that isdiminishing their success. and 1% of our populationis generally identified as a student witha social-emotional or behavioral disorderin the school's special ed decision-making process. those labels may differfrom state to state, but we generally identifyaround 1% of the students in any state witha special education need

that requiressome segregation. so i'm going to suggestthat you think of your referral to a communityservice as a skilled handoff instead of as a slip of paperwith a phone number, and so i task-analyzedsome of the key criteria in making this skilled handoff. you start out--certainlythere needs to be an opening phone callto a referral agency to the service provider.

anymore it may sometimes bean internet connection, but there has to bean opening introduction. there's usually then immediatelya decision as to whether or not the student qualifiesto receive those services through the community provider. you know in schools anychild that's a resident of the community is qualifiedfor educational services, but in the tradition of community mental healthand related services,

some childrenqualify for services, and others may not. then we want the familyto actually go to the first appointment, and here's where we startto have some research, depending on whetherthe research was conducted withadolescents or children. it may differ depending onthe social economic class, but anywhere from halfto 60% of referrals

actually result insomeone showing up for the first face-to-faceintake appointment, so you see that there'sa lot of slippage between the first attemptfor a referral and the students whoactually become engaged. really what we want is for thesestudents that we've referred to go to several appointmentsand continue attending long enough to completethe services. and so we have more slippage.

forty to sixty percent of kidsthat are referred for services will attend morethan one appointment, and only about nineto forty percent-- depending on the studyand the community it was conducted in--actuallyattend the services long enough to complete them to the benefit. so a successful referralis a phone call but also qualifyingfor services, then going to the appointment,continuing,

and ultimately achievingthe outcome. there are thingsthat you can do to increase thatreferral success. some of those things have to dowith the logistical barriers to community services,so for example, we know that theseservices will be more successful if families can gettransportation, if there is evening appointments if they needevening appointments

or morning appointmentsif they need morning, if they can afford to payfor the services or the services--we payattention to those things. it's also importantnot to have families end up on a waiting list, so finding out in advancethat the families qualify and that the waiting listis either very short or that there isn't one,that's a critical part of making thesereferrals successful.

one of the things that i usedto be able to do was with one of ourcommunity agencies we would talk to the familiesabout the first appointment as being to get themon the waiting list, and then the agencyand i would work together so that as soon asthe family was at the top of the waiting listwe could then make the referral that gotthem into services. so any way that you can bypasswaiting lists is going

to make it more likelythat those services actually are usedby the families. families don't know whatto expect if they're going in for mental health services. they don't know whatthe rooms look like. they may have seena television show or a movie about therapy sessions,but those tend to be comedies, and they can be veryoff-putting for families. so they need to have a senseof who they're going to see

and what it's goingto look like, what the room is like,what they're going to be doing, what questionsthey'll be asked. one of our most successfulreferral practices was when we would routinelyhave one or more people from the referral,from the community service, would be an occasionalpresenter at the school, or they'd write notesin the newsletter, so by the time we weresetting up an appointment

with the family in their agency, that agency was morefamiliar to the family. our families oftenalso needed reminders just to know to goand what to do. but here's the glitch. i think you can see that thesekinds of communications between the communityagencies and the schools are going to require more thanjust a loose-leaf notebook with a listof who to refer to.

it's going to takesome pretty strong school-community partnerships. and those partnerships havebeen very, very hard to do. we've had some researchand history going back to the 1900s of schoolsworking to create strong partnershipswith community agencies, and what they're findingeven in the 1900s is that partnershipstend to get started with a couple of reallyenthusiastic people

in the school and inthe community agency, and then when those peopleretire or move on, partnerships tend to fall apart. so, your job-- if you're really going to bereferring into these agencies, your job is going to beto create partnerships that are goingto endure over time. by necessity, these are goingto require that you have some equal participationin the partnership,

a few people from the schools, a few people fromthe community agency that you are in tune with what'simportant in your community. you're capitalizingon the strengths and the resourcesin your community. so strong partnerships are hard. here's some of the reasons. schools and communityagency employees often don't speakthe same language.

it was very obvious to meyears ago when i was working in coloradowith a mental health agency that they assumedthat a child with a serious emotionaldisorder was any child that met the criteriafor a dsm diagnosis, and they read the law,the idea law, as suggesting that schoolshad to pay for therapy for any child that hada dsm diagnosis. schools understoodthat a significant

emotional disability meantthat the child met the criteria for special educationqualification for emotional andbehavioral disorders, and they knew that that wasabout 1% of the population, not 20%, and theyunderstood that they were only responsiblefor providing for community agency servicesif they couldn't be provided through the school. there was languageand communication breakdowns

from the very beginning. we've come alongquite a bit further now. we speak differentlanguages still, but we're more aware of that. however, we still havemany different missions between schools and communities. schools have to serve all kids. community providers areresponsible for qualifying kids. we still havedifferent professionals.

we train peoplein different sites, and some of our principlesare very different from schools to communities. and so our partnershipsoften founder on these kinds of rocks whenwe're trying to build them. i'm going to suggest that wecue up the second poll question. okay, so it's clear fromthese results, once again, that we have a verystrong trend now in our communitiesthat our schools are part

of established partnerships,but the partnerships haven't yet progressedto the point that they're going to supportthe kind of referrals that we need to make to balanceout the mental health services for all the studentsin our building. this is light years ahead ofwhere we were 25 years ago. twenty-five years agoin most cases, the partnershipsdidn't even exist. so let's celebrate our progress,but let's talk about

what you can do thento strengthen that partnership that you're going to bereferring through and into. and there's a couple thingsthat have become very clear from the successful partnershipsthat have emerged in the literature. one is that these needto be collaborative teams of both school-employed and community-employedprofessionals, and there needs to besome balance in the team

as well as mutual respect of the school-employedprofessionals for the community-employedprofessionals, and vice-versa, the community-employedprofessionals for the school-employedprofessionals. when these teams get to bemore than a dozen members, then they tend to become moreof a formal reporting out like we might tend to seein a large assembly or a congressional group,

and they tendnot to make decisions. so while we need to be surethat there's at least one or two team members who have somedecision-making authority, at least some influenceover decisions in their community agencyor their school, we also don't want the teamsto become too large. the key thing that willbe important to keeping these teams successfulis to intentionally

minimize turf problems. turf problems will come if youhave someone from the school who is really intenton restricting the access of community programsinto the school, if someone from the community who is minimizingthe competent success of a school-employedprofessional. i would like to emphasizethe importance of watching turf problems

all the way throughthese partnerships. one of the partnershipsi respect a lot, the partnership in kansas around the intensivemental health program, eventually wasweakened significantly because of turf problems. so you have to step back inand make sure that people are still respectingthe competence of each other and the shared ownershipof the partnership.

if you have these kindsof partnerships, then you can createsystems of services that complement each other, and so what schoolsmay be able to make as unique contributionsto this array of services will have to do withtheir access to students in their everyday lives,their familiarity, not just their abilityto implement population-wide supports,

but some of the researchhas demonstrated that school-employed providersare more facile at working in population-wide,class-wide, school-wide, and community-wideservice delivery systems. and schools also havethe capacity to start to monitor the dailyprogress of kids in response to services, whereas agenciescan't do that as readily, but agencies will haveaccess to a whole array

of health and mentalhealth services that are much more difficultfor schools to assess. and agencies canfirewall services, by which i meanfor some children in families having services embeddedinto the daily routines is frightening or disturbing. they want some privacyfrom the people that they see every day, and agencies have the capacityto create those firewalls.

one thing that i reallyneed to point out is that schools are--in general-- are funded for providingservices to children. agencies are fundedfor providing mental health services. however, in both caseswe struggle because schoolsaren't directly funded for mental health servicesto children to a large extent, and agencies,while they're funded

for mental health services, their funding for childrenis minimized. so in both caseswe're challenged, but if we can createthese partnerships, we can streamline referralsby identifying programs in schools that can servecommunity-agency clients and vice-versa, knowingwhat the community programs are that can serve students,making sure that professionals in each group know aboutthe purposes of the programs

and the strategiesand the outcomes so we really have a familiaritywith the appropriateness of those programs for kids. and we know what needs to bedone so that a child can qualify for the program but alsoaccess those services. good teams will educate eachother about intake procedures. they'll develop sharedconfidentiality forms so that there can becommunication as needed, and they can create somedatabase monitoring procedures

so that people knowwhether the referrals are or aren't successful. unsuccessful referralscan then be pursued with another agencyor another program rather than itsimply being a student that's in the unsuccessfulcolumn. so i want to talka bit more about the problem of confidentiality and point out to you that thereare statutes and regulations

in both schoolsand in communities. so, schools requirethat everything they do has to be consistent withthe family educational rights and privacy act,but community agencies may be regulated from somevery specific state language around therapistconfidentiality. schools and communitieshave different kinds of supervision structures, so when i wasa school psychologist

working foran elementary school, my immediateadministrative supervisor was the director ofspecial education services who had no mentalhealth training, but it was also truethat if i was working with a child with significantbehavior disorders in that school buildingthat the principal had some knowledge thatthat was occurring as well so that i had fine linesthat i had to follow

to protect confidentialityfor this child and family but also so that people inthe school with the need to know were able to knowwhat was happening. that might have occurred verydifferently if i was employed by a community agencyin which my supervisor would have always beena mental health professional, and i would not have had a dutyto the school principal. but, of course,if we were creating a school-based mentalhealth services,

i can see that wewould have to negotiate both administrative need-to-knowwith the building and the community agencyconfidentiality requirements that met their statutesand licensing. a special piece of ferpa that'sreally important to realize is that under ferpa parentscan control the consent and privacy rights untilthe students are legal adults, and especially for adolescents, community agenciesare sometimes permitted

by statute to have servicesmaintained confidential from the parent. so if schools and communitieshaven't had these conversations, they may not realizethat there are these kinds of challengesaround confidentiality. so all this meansthat for referrals, we have to have consentsthat fit both school and agency rules. we need to be sure thatboth schools and agencies

understand when informationis subject to ferpa reviews, and we have to haveconversations about access of administrative services-- or administrative supervisorsto services. one more brief comment,and that is around the issue of progress monitoring. you know, schools havethe capacity to monitor progress but only within somevery practical limitations of what kinds of datais possible to collect

in simple and reliable ways. one of the things thati've been working on in another project--we call itthe nu data project. it's teaching teachers somevery simple and reliable ways that they can useprogress-monitoring data to answer questions abouttheir classroom modifications. the teachers have taught ushow very stringent the limits are around keepingdata practical, so the kinds ofprogress-monitoring tools

that might be used withina community mental health agency are probably not goingto meet teachers' standards of practical, brief,easy-to-use while still reliableand meaningful data. i'm going to gloss overthese last two slides, but just to point outthat there are ways that we can monitorthe psychological well-being of children and adolescentsin routine ways within a school district.

these actually relatevery carefully to the kinds of measures that katie eklundwas talking about in her last webinar,and we can use these indicators of psychological wellnessto aggregate it to talk about the well-beingof the school enrollment as opposedto individual students. what i wantto reinforce, though, is the broader frameworkthat we've talked about this afternoonabout referrals,

and that is that ina local educational agency, you are supportingthe mental health of a forest and not a tree. you are supportingthe well-being of all students, so when you're making referrals,making those referrals requires that you makesome choices about where and who and how you willrefer which students out for additional services. schools shouldn't be makingthese choices alone.

they occur withinthe context of a community and the entire communityagency environment that you're working in. so if you areworking well within a very comprehensive partnershipwith your community agencies, then your referralsare going to be skilled handoffs to services thatyou know about from your partnersand you collaborate with. these partnerships aregoing to make it possible

for you to monitorthe impact of your referrals and know how you'regoing to manage confidentiality in the aftermath of thatfirst step of the referral, how you're goingto monitor whether or not the services are working and how you're goingto build referrals in which more familiesfollow through and see these servicesthrough to completion. you can look at the ucla centerfor mental services in schools

if you want more informationabout streamlining referrals. i have given you the websitefor our nu data project for more informationabout how teachers were monitoringstudent progress, and i suggest youlook at the center for school mental healthin maryland for more information aboutfunding and sustainability in school mental health. (meagan)we do have about15 minutes of open time

if you don't mindsticking around. (beth)i am available. (meagan)okay, fantastic. so i want to bring everyone'sattention to two resources that were emailedout this morning to all folks who had registered. they are a referralpathways resource, which is about 15 pages long, just a kind of bibliographyof available resource--

or availablereferral-related resources in the marketplace right now-- and then also a studentinformation systems menu grid which talks aboutmonitoring referrals using student informationsystem. so we will email that out againthrough the constant contact and nitt newsletter. we'll email bothof those resources out as well as dr. doll's slideswith her name corrected

on the third slide. we apologize about that. now, at this point, folkscan either enter questions into the chat log,or you can unmute yourself by hitting star-sixand ask your question directly to dr. doll. (kathleen guminer)this is kathleen guminerfrom ohio. maybe i'll just go aheadand ask one on the phone while other people are writing.

what questions have come upin this work that you've done about liability thata school faces when they are doing the workthat tends to bring out issues that are going on, but there really are no goodplaces to refer people? this, in a sense, i thinkthis has a little more to do with substance use issuesthan mental health, per se, but then so much of it isco-occurring that i thought it would be relevantto ask it here.

(beth)the question hascome up certainly regarding substance abusebut also regarding suicide and suicide prevention,and i know that school districts have been reluctant to doscreening for suicidality if they don't havesomeone sitting there in the community sayingthat they will work with those students. i am assuming that nothing thatwe would be doing in a school would be to identify thatthis child is definitely using

dangerous substances;although if we identify that we, of course, would notifya parent that that is happening. but in our screening, askatie eklund was talking about in the last webinar, in ourscreening we may identify a child at significant riskfor a variety of dangerous behaviors. i am not a lawyer,but i think that if we have worked withour families in advance so that they know that weare asking these questions

and that we will let them knowif we believe their child is at risk of harmingthemselves or others, i think that we are finein terms of liability. i don't believe that we are-- if we have enough informationin data that we know that a child is engagingin something that's illegal, we would be lettinglaw enforcement know if it happens in schooland we've-- if we know that we have a childthat is in serious danger

of harming themselves,then we usually are acting on that with our localmental health authorities. when it's less than that,i think the biggest risk that we struggle with isthat we're including parents in on some information that students may not wanttheir parents to know. (kathleen)thank you. (meagan)beth, you have anotherquestion from kelly stern. can you discussdata sharing agreements

and how data sharingagreements work? (beth)about data sharing,you're talking about practices for triage for mental health, or is this a question that'sfurther up in the string? (meagan)oh, did i miss--oh, yeah, kelly stern-- yeah, kelly askedtwo questions, so one was, can you talk about datasharing agreements? and, two, are there practicesfor triage for mental health when there are minimal resourcesor accesses to resources?

(beth)okay, so let's talk about-- it's not so much data sharing.it's information sharing. when we are--we're talkingabout confidentiality agreements between schooland community agencies. am i on the right track,meagan? is that howyou're reading this too? (meagan)yes, and, kelly, feel freeto unmute yourself and clarify your questionif you need. (kelly stearn)okay, i'm on.i'm on.

i just wanted to find out,because there's sometimes you partner withcommunity agencies to share, you know, maybeshare data if, you know, if we can do that,but we have that-- in the school systemwe have the pii, the personallyidentifiable information, that we have to protect. (beth)yeah, in the school system wehave to follow the ferpa rules. our community agencies,they have to follow hipaa rules,

and hipaa rulesand ferpa rules are similar, but they are not identical. and so i have not pulled up the sharedconfidentiality forms, but in many communitiesthey have worked to create a consent for releaseof information that is compatible both withferpa and with hipaa so that it meetsboth sets of rules. but we also havedifferent traditions,

so in schools ourtradition around information within the schoolis need to know, so that--because a childis enrolled in the school, if someone in the schoolneeds to know information about the child in orderfor them to provide the educational services, that might bethe classroom teacher or the principal, then they--that information. in a community agency,there is no need to know.

the assumption is that the onlyperson that would have access to confidential informationwould be the therapist and the therapist's supervisor,professional supervisor. so in the sharedconsent forms, they not only haveto be compatible with ferpa and hipaa,but there has to be a decision made about who willhave that information. so you can't just say it will bewho needs to know. you have to really talkin advance about

even such basic informationas that they're going for services, that they'remaking satisfactory progress, and so inthe partnerships that-- the one i wasa part of for a while in denver and jefferson countyin colorado, there was some negotiationaround this consent form. so it might be a consentreleased to a person and not to the whole-- it wouldn't be a releaseto the school.

it would be to a person, and informationwould not be maintained in writing in the schoolrelated to these services because ferpa rulesrefer to written records, not to verbal conversations. so we can just-- it was possible for thereto be some exchange of information thatwas confidential but without havingthat become part

of the school'sneed-to-know network. (kelly)okay, and then the otherone was the triage. like, are there any bestpractices when you do have minimal resourcesor access to resources? i mean, of course, harmto self or others is always going to take priority,but are there any guidelines or anything out there thathelp you understand triage? (beth)if you want to talkabout best practices as it's been supportedin the research and literature,

i would say that the biggestchange in the last 25 years has been acknowledgement, one, that there will never be enoughservices to go around, that there will haveto be triage, and there is, de facto,there's some rationing of children's mentalhealth services. and two is the acknowledgementthat we can't continue to spend all of our resourcesin the top of the pyramid, tier two and--i'm sorry,tier-three level services,

that we have to providesome preventive services, psycho-education in schools, parent training for kidsthat may not have reached the criteria of diagnosisbut are starting to develop significant behavior problems. so that would bethe best practice. it's not which kidsshould be getting services. best practices are that youhave the conversations and you decide howyou're going to retain

some of your resourcesfor prevention and early intervention. (kelly)so that would be likebuilding the protective factors and building up, like,some of those programs you said earlier that you,you know, that might be culturally-based or otherkinds of based situations? (beth)yes. (kelly)things like that.okay, thank you. (beth)nobody has come up witha way to stretch our funding--

even when we putit all together-- to stretch our funding around all the mental healthservices that are needed by children and adolescentsin communities. meagan, you're gettingthe katie eklund webinar back up for this group,is that true? (meagan)yeah, i sent out, for thoseof you who had requested the url to katie's webinar,i've now emailed it out. the nitt-ta center website isstill in the approval process

at samhsa,so in the meantime all of the webinar urlswill be on the website at some point. but in the meantime, you needto email your ta specialist, and they willget you those urls, or if you put yourinformation in the chat box here i'll do it right now,but otherwise, go ahead and connect withyour personal ta specialist. (beth)so, katie talked aboutsome specific screening tools,

and it is very nicely laid outin her powerpoint, the student riskscreening scale. there's the strengthand difficulty scale, and by laying these outyou can see the alternative strategiesfor screening, and that would provide youwith some options for screening the entirepopulation of your school to identify who has the mostsignificant needs. the one thing i don't knowif she mentioned it,

but it's not in her powerpoint, the strengthand difficulty scale, it has been translatedinto multiple languages around the world. it's been used in somewherebetween 30 and 40 different nations, and because it'spublic domain and the authors have made itavailable for translation, many different peoplehave translated that.

so if you're in a districtthat has a lot of languages being spoken, you may wantto look at that measure, and the referencesare in katie's materials. yes, i don't know ifit's useful, meagan, but you're welcome to send myemail out to the participants if they think of a questionafter the fact. (meagan)sure, i think your emailmight be in here. no, it won't.it's not, but we will. we'll add a slidewith your contact information

and send that outto all participants, as well as the two resourcesthat were referenced and the webinar recording. so it was really a pleasurehaving you today. thank you very muchfor sharing your expertise with our community. i think everything youshared was really very helpful. okay, bye-bye, everyone.thank you.