Mental Health Education and Support at School can be Critical

A Brief Overview

  • Alarming statistics indicate the pandemic has worsened behavioral health outcomes for young people. Governor Jay Inslee on March 14, 2021, issued an emergency proclamation declaring children’s mental health to be in crisis.
  • Students eligible for special education services through the federal category of Emotional Disturbance are more than twice as likely as other disabled peers to quit school before graduating.
  • These outcomes make adolescence a critical time for mental health promotion, early identification and intervention. Read on for further information and resources.
  • Seattle Children’s Hospital has a referral helpline. Families can call 833-303-5437, Monday-Friday, 8-5, to connect with a referral specialist. The service is free for families statewide.
  • Help is available 24/7 from the Suicide Prevention Lifeline: 1-800-273-TALK.
  • Text HEAL to 741741 to reach a trained Crisis Text Line counselor.
  • For youth who need support related to LGBTQ issues, the Trevor Projectprovides targeted resources and a helpline: 866-488-7386.
  • A place to connect with other families is a Facebook group called Youth Behavioral Healthcare Advocates (YBHA-WA).
  • Family caregivers can request support and training from A Common Voice, a statewide non-profit staffed with Parent Support Specialists who have lived experience parenting a child with mental illness or behavioral health challenges. Contact Jasmine@acommonvoice.org/253-732-4944.

Full Article

Alarming statistics indicate the COVID-19 pandemic has worsened circumstances for young people who were already struggling to maintain mental health. Washington’s most recent Healthy Youth Survey, from 2018, revealed that 10 percent of high-school students had attempted suicide within the year. Governor Jay Inslee on March 14, 2021, issued an emergency proclamation declaring children’s mental health to be in crisis.

The governor’s order requires schools to provide in-person learning options and directs the Health Care Authority and Department of Health to “immediately begin work on recommendations on how to support the behavioral health needs of our children and youth over the next 6 to 12 months and to address and triage the full spectrum of rising pediatric behavioral health needs.”

The Children and Youth Behavioral Health Work Group (CYBHWG) was created in 2016 by the Legislature (HB 2439) to promote system improvement. CYBHWG supports several advisory groups, including one for Student Behavioral Health and Suicide Prevention. The work groups include representatives from the Legislature, state agencies, health care providers, tribal governments, community health services, and other organizations, as well as parents of children and youth who have received services. Meetings include opportunities for public comment. Meeting schedules and reports are posted on the Health Care Authority (HCA) website.

A press for more school-based services

Advocacy for more school-based mental health services comes from the University of Washington’s SMART Center. SMART stands for School Mental Health Assessment Research and Training. The SMART center in 2020 provided the legislative work group with a report: The Case for School Mental Health. The document includes state and national data that strongly indicate school-based behavioral health services are effective:

“Increased access to mental health services and supports in schools is vital to improving the physical and psychological safety of our students and schools, as well as academic performance and problem-solving skills. Availability of comprehensive school mental health promotes a school culture in which students feel safe to report safety concerns, which is proven to be among the most effective school safety strategies.”

The statewide Student Behavioral Health and Suicide Prevention advisory group has recommended widespread implementation of Multi-Tiered Systems of Support (MTSS). Through MTSS, schools support well-being for all students through school-wide programming and offer higher levels of support based on student need. Social Emotional Learning (SEL) is a key component of an MTSS framework, which also creates a structure for providing Positive Behavioral Interventions and Supports (PBIS) at various levels of need.

The Office of Superintendent of Public Instruction, the guidance agency for Washington schools, prioritized 2021 budget requests to Empower all Schools to Support the Whole Child, including through MTSS. In January, 2021, OSPI was awarded a five-year, $5.3 million grant from the U.S. Department of Education to build regional coaching capacity to support districts in their MTSS implementation. As a local control state, Washington districts determine their own specific policies and procedures.

TIP: Families can ask school and district staff to describe their MTSS framework and how students are receiving support through the various levels/tiers.

Special Education is one pathway for more help

Students may access mental health support through the special education system. Emotional Disturbance is a federal category of disability under the Individuals with Disabilities Education Act (IDEA). Appropriate support can be especially critical for these students: According to the U.S. Office of Special Education Programs (OSEP), students eligible for school-based services under the ED category are twice as likely to drop out of high school before graduating.

Note that a student with a mental health condition could qualify for an IEP under the category of Other Health Impairment (OHI), which captures needs related to various medical diagnoses.

In Washington State, the ED category is referred to as Emotional Behavioral Disability (EBD). If the student’s behavioral health is impaired to a degree that the student is struggling to access school, and the student needs specially designed interventions, then the student may be eligible for an Individualized Education Program (IEP). Keep in mind that academic subjects are only a part of learning in school: Social Emotional Learning (SEL) is part of the core curriculum. 

An educational evaluation determines whether a student has a disability that significantly impacts access to school and whether specially designed instruction and/or related services are needed for the student to receive a Free Appropriate Public Education (FAPE). FAPE is the entitlement of a student eligible for special education services and an IEP team determines how FAPE/educational services are provided to an individual student.

Behavioral health counseling can be part of an IEP

Counseling can be written into an IEP as a related service. When included in a student’s IEP as educationally necessary for FAPE, a school district is responsible to provide and fund those services. School districts can receive reimbursement for 70 percent of the cost of behavioral health services for students who are covered by Medicaid and on an IEP.

A student with a mental health condition who doesn’t qualify for an IEP might be eligible for a Section 504 Plan. A disability that impairs a major life activity triggers Section 504 protections, which include the right to appropriate and individualized accommodations at school. Section 504 is an aspect of the Rehabilitation Act of 1973, a Civil Rights law that protects against disability discrimination. Students with IEPs and 504 plans are protected by Section 504 rights.

Behavioral Health encompasses a wide range of disability conditions, including those related to substance use disorder, that impact a person’s ability to manage behavior. Sometimes students with behavioral health disabilities bump into disciplinary issues at school. Students with identified disabilities have protections in the disciplinary process: PAVE provides a detailed article about student and family rights related to school discipline.

Placement options for students who struggle with behavior

IEP teams determine the program and placement for a student. In accordance with federal law (IDEA), students have a right to FAPE in the Least Restrictive Environment (LRE) to the maximum extent appropriate. That means educational services and supports are designed to help students access their general education classroom first. If they are unable to make meaningful progress there because of their individual circumstances and disability condition, then the IEP team considers more restrictive placement options. See PAVE’s article: Special Education is a Service, Not a Place.

Sometimes the IEP team, which includes family, will determine that in order to receive FAPE a student needs to be placed in a Day Treatment or Residential school. OSPI maintains a list of Non-Public Agencies that districts might pay to support the educational needs of a student.

A precedent-setting court ruling in 2017 was Edmonds v. A.T. The parents of a student with behavioral disabilities filed due process against the Edmonds School District for reimbursement of residential education. The administrative law judge ruled that the district must pay for the residential services because “students cannot be separated from their disabilities.”

Strategies and safety measures for families

With the release of the Healthy Youth Survey in Spring, 2019, the state issued a two-page Guide to Mental Health Information and Resources to provide more detail about the survey and to direct families and school staff toward resources for support.

Included is a list of factors that help youth remain resilient to mental health challenges:

  • Support and encouragement from parents/guardians and other family members, friends, school professionals, and other caring adults
  • Feeling that there are people who believe in them, care about them, and whom they can talk to about important matters
  • Safe communities and learning environments
  • Self-esteem, a sense of control and responsibility, and problem-solving and coping skills
  • Having an outlet for self-expression and participation in various activities

The handout includes tips for parents and other adults supporting teens who feel anxious or depressed:

  • Bond with them: Unconditional love includes clear statements that you value them, and your actions show you want to stay involved in their lives.
  • Talk with teens about their feelings and show you care. Listen to their point of view. Suicidal thinking often comes from a wish to end psychological pain.
  • Help teens learn effective coping strategies and resiliency skills to deal with stress, expectations of others, relationship problems, and challenging life events.
  • Have an evening as a family where everyone creates their own mental health safety plan.
  • Learn about warning signs and where to get help
  • Ask: “Are you thinking about suicide?” Don’t be afraid that talking about it will give them the idea. If you’ve observed any warning signs, chances are they’re already thinking about it.
  • If you own a firearm, keep it secured where a teen could not access it. Lock up medications they shouldn’t have access to.

State options for behavioral health services and support

For Washington children and youth with Medicaid insurance, the highest level of community-based care in behavioral health is provided through Wraparound with Intensive Services (WISe). The WISe program was begun as part of the settlement of a class-action lawsuit, TR v Dreyfus, in which a federal court found that Washington wasn’t providing adequate mental-health services to youth. WISe teams provide a wide range of therapies and supports with a goal to keep the young person out of the hospital.

Young people under 18 who need residential care to meet medical needs may be referred to the Children’s Long-Term Inpatient program: PAVE’s website provides an article about CLIP.

If a person ages 15-40 is newly experiencing psychosis, Washington offers a wraparound-style program called New Journeys. This website link includes access to a referral form.

The Family, Youth and System Partner Round Table (FYSPRT) provides a meeting space for family members and professionals to talk about what’s working and what isn’t working in mental healthcare. FYSPRT groups provide informal networking and can provide ways for families to meet up and support one another under challenging circumstances.

Federal parity laws require insurers to provide coverage for behavioral health services that are equitable to coverage for physical health conditions. The National Health Law Program (NHLP) provides information and advocacy related to behavioral healthcare access and offers handouts to help families know what to expect from their insurance coverage and what to do if they suspect a parity law violation:

Family Initiated Treatment (FIT) is an option in Washington

Youth older than 13 have the right to consent or not consent to any medical treatment in Washington State. Parents and lawmakers throughout 2018-2019 engaged in conversations about how that creates barriers to care for some teens struggling with behavioral health conditions. The Adolescent Behavioral Health Care Access Act (HB 1874), became law in May 2019. PAVE provides an article about the law and its provision for Family Initiated Treatment.  

Places to seek referrals and information

Seattle Children’s Hospital in 2019 launched a referral helpline. Families can call 833-303-5437, Monday-Friday, 8-5, to connect with a referral specialist. The service is for families statewide. In addition to helping to connect families with services, the hospital is gathering data to identify gaps in care.

PAVE’s Family-to-Family Health Information Center provides technical assistance to families navigating health systems related to disability. Click Get Help at wapave.org or call 800-572-7368 for individualized assistance. Family Voices of Washington provides further information and resources.

Key Resources

For information, help during a crisis, emotional support, and referrals:  

  • Suicide Prevention Lifeline (1-800-273-TALK)
  • Text “HEAL” to 741741 to reach a trained Crisis Text Line counselor
  • Trevor Project Lifeline (LGBTQ) (1-866-488-7386)
  • The Washington Recovery Help Line (1-866-789-1511)
  • TeenLink (1-866-833-6546; 6pm-10pm PST)

Further information on mental health and suicide:  

Tips to Help Parents Reinforce Positive Behaviors at Home

A Brief Overview

  • Positive Behavioral Interventions and Supports (PBIS) is a strategy schools use to teach children expected behavior. Read on for PBIS strategies families can use at home.
  • A key PBIS principle is that punishment fails to teach children and youth what they should do instead. Adults can direct a child toward a better choice or interrupt an escalation cycle.
  • The easiest way to change a behavior is to point out what a person does right. Remember this catchy phrase, “5:1 gets it done,” to ensure five positive interactions for each negative interaction.
  • Parents might find success with strategies they can share with school staff eventually.
  • For additional strategies unique to COVID-19, the Office of Superintendent of Public instruction (OSPI) offers a series of 3 webinars for family caregivers. For information and links to the videos, see PAVE’s article: Webinars offer Parent Training to Support Behavior during Continuous Learning.

Full Article

Schedule changes and seasonal transitions cause emotional upheaval for some families in typical years. Summer 2020 includes unique conditions, with families moving into a summer with fewer-than-usual options to keep children busy after months of learning from home due to the COVID-19 building closures. A few strategies, described below, might help families keep things chill this summer.

Experts in education use a framework for creating a positive environment called Positive Behavioral Interventions and Supports (PBIS). PBIS has been implemented in more than 26,000 U.S. schools. The PBIS framework has been shown to decrease disciplinary removals and improve student outcomes, including grades and graduation rates. When done well, PBIS provides positive social skills, communication strategies and “restorative justice,” (working it out instead of punishing) and may prevent 80-90 percent of problem behaviors.

Punishment does not teach

PBIS requires an understanding that punishment fails to help a child know what to do instead. Researchers have learned that a child who is being punished enters an emotionally dysregulated state (fight/flight/freeze) that blocks learning. Adults who calmly direct a child toward a new way of problem-solving can interrupt or prevent an escalation.

Keep in mind that adults need to stay regulated to help children. For strategies related to mindfulness, see PAVE’s article: Stay Home Help: Get Organized, Feel Big Feelings, Breathe. PAVE also provides a library of short videos with mindfulness and breath practices for all ages and abilities: Mindfulness Videos.

Within a PBIS framework, de-escalation strategies might include:

  • Remove what is causing the behavior
  • Get down to eye level
  • Offer empathy—the ability to understand and share the feelings of another
  • Provide choices
  • Re-teach expectations
  • Reinforce desired behaviors
  • Communicate care instead of control

Behavior is a child’s attempt to communicate

Simple, consistent, predictable language is a critical component. Insights about these strategies and more were shared in a webinar by Change Lab Solutions on April 30, 2019.

Among experts talking about PBIS are staff at the University of Washington’s School of Mental Health Assessment, Research and Training (SMART) Center. Staff from the SMART center lead the School Mental Health supplement of the Northwest Mental Health Technology Transfer Center (NWMHTTC). These agencies, in collaboration with the League of Education Voters, in June 2019 hosted a webinar: How to Implement Mental Health Supports in Schools, focused on the importance of blending school and community supports with PBIS.

A University of Washington (UW) expert who participated in the webinar is Kelcey Schmitz, a former OSPI staff member who has written articles for PAVE about positive behavior supports and state initiatives and has experience helping families and schools implement PBIS.

“PBIS is a game changer for children and youth with behavior challenges and their teachers and caregivers,” Schmitz says. “In fact, everyone can benefit from PBIS. Behavior is a form of communication, and PBIS aims to reduce problem behavior by increasing appropriate behavior and ultimately improving quality of life for everyone. The same approaches used by schools to prevent problem behaviors and create positive, safe, consistent and predictable environments can be used by families at home.”

Schmitz, an MTSS training and technical assistance specialist, provides the following specific tips for creating a successful PBIS home environment.

Support Positive Behavior before there is a problem

PBIS is set up with three layers—called tiers—of support. The parent-child relationship is strengthened by loving and positive interactions at each tier.

Tier 1 support is about getting busy before there is a problem. Much like learning to wash hands to prevent getting sick, expected behavior is taught and modeled to prevent unexpected behaviors.  Parents can look at their own actions and choices and consider what children will see as examples of being respectful, responsible, and safe.

Tiers 2 and 3 are where adults provide more support for specific behaviors that are getting in the way of relationships or how the child or youth functions. In a school setting, Tier 2 is for students who need a social group or some extra teaching, practice, and reinforcement. Tier 3 supports include a Functional Behavioral Assessment (FBA) to find out why the behavior is occurring, and an individualized Behavior Intervention Plan (BIP).

Any student may access supports that include aspects of Social Emotional Learning at all three Tiers. At home, Tiers 2 and 3 naturally will be more blended and may include support from a community provider. Note that targeted interventions in Tiers 2-3 work best when Tier 1 is already well established.

Define, teach, and routinely acknowledge family expectations

  • Discuss how you want to live as a family and identify some “pillars” (important, building-block concepts) that represent what you value. Talk about what those pillars look like and sound like in every-day routines. To help the family remember and be consistent, choose only 3-5 and create positive statements about them. Here are a few examples:
    • Speak in a respectful voice.
    • Be responsible for actions.
    • Be safe; keep hands, feet, and objects to self.
  • Identify a couple of “hot spots” to begin. Challenging behaviors often occur within routines.  Perhaps mornings or mealtimes create hot spots for the family. After discussing 1-2 ways to be respectful, responsible, and safe in the morning, teach what each looks like. Have fun with it! Set up “expectation stations” for practicing the plan and assign each family member one pillar to teach to the rest.
  • Behaviors that get attention get repeated. Notice when a child does the right thing and say something about each success: “I noticed you stopped to pick up your shoes in the hallway. Thanks for putting them away and keeping the walkway safe for others.” The easiest way to change a behavior is to point out what a person does right!
  • Remember this catchy phrase, “5:1 gets it done” to ensure five positive interactions for each negative interaction. When the expected behavior becomes routine, the reinforcement can fade away.

Create engaging and predictable routines

  • Children crave structure and routine. Adults may look forward to a relaxing evening or weekend, but kids often need regular activity and engagement. Consider that either the kids are busy, or the adults are busy managing bored kids!
  • Use visuals to create predictability. A visual schedule can display major routines of the day with pictures that are drawn, real photos or cut-outs from magazines. Create the schedule together, if possible.  Parents can ask a child to check the schedule – especially when moving from a preferred to non-preferred activity. It’s hard to argue with a picture!

Set the stage for positive behavior

  • Teach, pre-teach, and re-teach. Children need to learn behavior just like they learn colors and shapes. A quick reminder can help reinforce a developing skill: “When we get in the car, sit up, buckle up, and smile!”
  • Give transition warnings or cues to signal the end of one activity and the beginning of another: “In five minutes, it will be bath time.”
  • First/then statements set up a child for delayed gratification: “First take your bath; then we can play dolls.”
  • Focus on Go instead of Stop. Children often tune out words like NoDon’t and Stop and only hear the word that comes next, which is what an adult is trying to avoid. Tell a child what to do instead of what not to do: “Take your plate and put it in the sink.” Save Stop and No for dangerous circumstances that need a quick reaction.
  • Choices prevent power struggles: “Would you rather play for five more minutes or get in the bath now?”  “Feel free to choose the pink pajamas or the green ones.”

While these strategies may not eliminate all problem behaviors, they create consistency, predictability, and a more positive atmosphere. They teach new skills to help children get their needs met. The solid foundation will help even if challenging behaviors persist by creating a bedrock for additional layers of support.

Here are places to seek additional information:

Parenting with Positive Behavior Support: A Practical Guide to Resolving Your Child’s Difficult Behavior 

Home and Community Based Positive Behavior Support Facebook Page

Home and Community PBS Website

Parent Center Hub Positive Behavior Supports Resource Collection

Intensive Intervention: An Overview for Parents and Families

The Association for Positive Behavior Support

Getting Behavior in Shape at Home

Family Resources for Challenging Behavior

The National Center for Pyramid Model Innovations (NCPMI) Resource Library, articles in multiple languages