Promoting Positive Behavioral Health

Analysis of student health incident data highlights behavioral health issues as experienced in schools. In SY 2011-12 there were 345 injury incidents related to aggression, compared to 326 in SY 2010-11 and 332 such incidents in SY 2009-10. Student aggression is a substantial cause underlying significant injuries at the secondary level. In SY 2011-12 aggression-related injuries accounted for more than 50% of all middle school and high school injury incidents. It is important to note that these numbers do not reflect the total number of aggressive incidents on campus, but rather the most severe incidents that involved SHS staff. Nor do they reflect disciplinary events related to aggression, which are tracked and addressed separately.

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Elementary student injury incidents are more likely the result of non-aggression-related incidents such as playground falls. In SY 2011-12, of the 41 EMS contacts across the district due to injury, 3 involved aggression.

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A Program of AISD: Social Emotional Learning

These findings highlight the importance of behavioral health as a component of comprehensive school health services. AISD uses a three-tiered approach to intervention for both instruction and student support services, including health. Tier one forms the base and reflects universal intervention/prevention that all students receive, such as regular classroom instruction. Tiers two and three reflect progressively more intensive services targeted to smaller numbers of students based on their level of need and response to earlier interventions. For behavioral health, tier one interventions include health instruction and Social Emotional Learning (SEL), a curriculum-focused evidence-based approach to teaching self-management, awareness and social interaction. The SEL program is being implemented over a multi-year time frame across all campuses, by vertical team.

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Aggression-induced injuries are not the only behavioral health incidents that are tracked and trended by SHS. Substance abuse, suspected abuse/neglect of students and student suicidal intent episodes involving health staff are also monitored. Behavioral health incidents increased across all four categories during SY 2011-12, compared to the prior year. Though comparatively infrequent events, the increase in episodes over prior year of suspected abuse/neglect and suicidal intent incidents is noteworthy. SHS and AISD staffs participate in community adolescent suicidality prevention and postvention efforts. SHS has worked with Seton Shoal Creek Hospital to insure post-discharge continuity of care for students hospitalized for significant mental health needs.

In addition to the SHS data, over 50% of students seen by the Travis County Juvenile Probation Department, many of whom attend AISD, are identified with mental health issues; and within AISD more than half of students receiving disciplinary placement at the Alternative Learning Campus (ALC) prior to SY 2011-12 were identified to have a behavioral or mental health issue. Beginning in SY 2012-13 as AISD implements a new policy to decrease ALC placements through enhanced campus-based services, behavioral health will be a significant consideration affecting staffing at the campus level. The annual AISD School Safety and Substance Use and Survey (SSSUS), completed by a random sample of secondary students, provides information on the general behavioral health of AISD students. Behavioral health maps addressing school and community safety, substance use, discipline, clinical care and community supports are available at www.cohtx.org. Analysis of more recent SSSUS data will include neighborhood level (Zip code) results.

Understanding and responding effectively to student behavioral and mental health needs is an area of on-going collaborative development for SHS, AISD and community partners. School RNs have been identifying increasing acuity in social/emotional needs, particularly in secondary level students, for the past several years. Professional development in identifying and addressing behavioral health issues has increased, combined with information system improvements to capture care plans electronically, resulting in improving identification and documentation of student behavioral health needs. In SY 2011-12 nurses managed 1251 students with individualized health care plans for significant and ongoing behavioral or mental health needs. This marks a decrease of 28.7% over the prior year.

A Systems Transformation Program: The ACCESS Project

Responding to student behavioral health needs must be systemic and systematic. Under the Safe Schools/Healthy Students ACCESS grant, resources were used to facilitate ‘fast track’ referral of highest need students to Austin Travis County Integral Care (ATCIC), the local mental health authority, for non-emergent but urgent care needs. About 60 students were served per year. At the end of the SY 2011-12 school year, ATCIC announced it would continue the fast track program, sustaining the initiative at no cost to AISD.

During SY 2011-12, the final year of the ACCESS grant, a pilot was developed for a campus-based counseling referral center on one high school campus. A fulltime licensed, Medicaid-certified therapist, a PhD Psychologist employed by Lone Star Circle of Care (LSCC), was embedded at Crockett High School, providing clinical assessment and therapeutic counseling on-campus. AISD staff identified students whose behavioral health needs were interfering with factors such as attendance, grades, and classroom behavior. This integration of allows for the delivery of crucial behavioral health services at the place where students spend most of their waking hours: at school. Of students served, 44.8% were Hispanic, 37.9% White and 17.2% were African American. Additionally, 86.2% were economically disadvantaged, 75.9% had either public or commercial insurance while 20.7% were uninsured. In addition to providing an average of 5.3 appointments per student to 29 students over a 6 week period, the pilot was intended to develop a replicable model of care including progress monitoring of the impact of campus-based services on school outcomes such as attendance and behavior.

Students receiving behavioral health therapy had lower attendance rates than those students in the comparison group. Prior to the start of the intervention (between the 1st and 5th six-week grading periods), attendance among targeted students decreased by 12%, compared to 6% in the comparison group. Between the 5th and 6th grading periods, after start of the intervention, targeted students experienced a 4.1% improvement in attendance, compared to only 0.01% in the comparison group.

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Systemic changes within AISD included the implementation of the Positive Behavior Support (PBS) system to most AISD campuses. PBS concepts were integrated into the AISD Learning Support Services Child Study Team design. In SY 2011-12, each campus had a Child Study Team to monitor and address student behavioral, academic, and attendance issues; and to consider systems issues. The Child Study Team model uses Social Service System experts serving vertical teams to build campus capacity, rather than in a direct helping role. Technology tools such as eCST, YSM, GIS, SAR and integrated case management (ICM) are used to support direct helping functions and progress monitoring at the student, campus, district and community levels. Collectively these initiatives support the development of the whole child. Clinical managers and school nurses have been participants in the design and implementation of these systemic changes within AISD.

There are several evidenced-based anti-bullying, violence prevention, and mediation programs being implemented in AISD. One example is the Safe Start program, a collaboration between SHS and SafePlace to encourage healthy dating behavior, reducing vulnerability to domestic abuse. In SY 2011-12, an external evaluation of AISD’s Social Emotional Learning (SEL) program, the district’s primary prevention program for behavioral health, noted multiple initiatives and staff confusion, and recommended improved alignment and coordination of behavioral health initiatives.