I am now going to turn it over to
David Miller who is NASMHPD's Project
Director
and even as I say David's name my
heart just deepens because David is just an
absolutely amazing person
I am thrilled to work with you David
and so glad that
you can be part of this session I'm
going to turn it over to David Miller
thanks
thank you Megan and hopefully this
time my check won't bounce
so it's definitely in the mail 
likewise to with with you as well
so very excited to
introduce our speaker today and
facilitate this session
on a very very important topic which is
how crisis services interact with
children and adolescents
I will reiterate what Megan had said as
our presenter
is presenting if you... as the questions
pop into your head
if you throw them in the chat box I will
make sure to get to them
at the end of her presentation and
uh it is my honor to introduce our
presenter today Dr. Sharon Hoover
Dr. Hoover is a licensed clinical
psychologist and a professor
at the University of Maryland School of
Medicine
she co-directs the National Center for
School Mental Health
and is the Director of the Center for
Safe Support of Schools
she is one of our nation's preeminent
experts in school-based mental health
and a long-time friend of NASMHPD's Dr.
Hoover's commitment to the study
and implementation of quality children's
mental health services is second to none
she has trained school and community
behavioral health staff and educators
in districts all across our country and
as well internationally
in that international role Dr. Hoover
serves as an advisor to the World Health
Organization
for many many many years Dr. Hoover's
been a close friend of NASMHPD's
presenting
to these multiple commissioners meetings
and even more children's youth and
family divisions meetings
she's always gracious with her time when
our members have issues that need her
expertise
and guidance and is with gratitude and
great pleasure
I welcome Dr. Sharon Hoover
thank you so much David and to the
NASMHPD team I'm grateful to be
here and really excited to talk with you
about the topic today I'm going to go
ahead and share my screen I think now is
the time to do that
so let me go ahead and do that
all right got my sound shared
can you see it okay yeah
all right thumbs up thank you fabulous
okay so I'm really
looking forward to speaking with you all
today about improving our
child and adolescent crisis system I
spend much of my time
as David said in the school arena really
thinking about how do we best support
children
and adolescents and adults who serve
them in the school context
but I certainly have spent time in other
contexts
related to the crisis system including
many many overnights in training in our
emergency departments with families
in crisis and I think as many of us have
acknowledged over the years emergency
departments are really
not great places for our young people
and families when they're experiencing
behavioral health crises
and we need to really re-imagine what
this system could look like and I think
we're well positioned to do that so
I'm excited to talk with you about some
ideas in that realm today
and hear some of your questions and
and also some of your ideas and
innovations in this arena so again thank
you for the invitation
so I found this statement from SAMHSA's
National Guidelines which were just
released and I imagine all of you have
had your hands in
for behavioral health crisis care from
the toolkit to be
particularly poignant the practices
laid out in the toolkit are fantastic
I was eager to dive in and and learned a
lot
and I think they will make for a much
more robust and comprehensive crisis
system but at the end of the day it
really is the humanity that is
experienced during a crisis
that can make all of the difference and
I would
say that this is even perhaps more true
for our children
and you know how we engage with them and
their family during their most
vulnerable moments can literally shape
the trajectory of their lives so
I hope we can keep this in mind as we
think about this re-imagining
you know SAMHSA emphasized the
importance of crisis services that are
available to anyone
anywhere anytime or as some have said
everyone everywhere and every time
and which did not lead to any delays or
detainment
or denial of services or really create
any you know undue burdens on those who
are experiencing crisis or on our
emergency department's law enforcement
justice system
and in this best practice tool kit they
laid out several core principles that are
are indicated here and one of the things
that I hope we can do today is just to
consider how these practices apply
to our child and adolescent system and I
know the toolkit really did speak a bit
to that but I'm hoping to go in a little
bit more depth
uh so you know as we all know we can't
simply fit children into an adult system and
this photo may look familiar to some of you
it's the kid version of Tom Hanks right
also known as Josh Baskin from the movie
Big as he tries to fit into his adult suit
at the end of the film
so you know we know that there are
adjustments and considerations that we
need to take into account as we
consider how we can address crisis in
the child and adolescent system
and the good news is really that many of
the core principles laid out in that
best practice tool kit
align well with the principles that many
child systems of care
embrace those listed here may look
familiar to many of you
these have been adopted and adapted
really by many state and local systems
particularly important are the
principles around family-driven and
youth-guided or youth-driven care
so again I imagine quite familiar to
many of you family-driven care is really
the idea that families have a primary
decision-making role in the care of
their own children
as well as in the policies and
procedures that govern
care for children in their communities
and states and tribes and territories
and youth-guided care really similarly means
that youth have the right to be empowered and
educated and given a decision-making
role as well
and that as youth develop and mature
that
this may move from youth-guided to youth-driven in fact some communities and
states just call it youth-driven from the
get-go we also know that the principle
of community-based services
is really critical in the children's
system a lot of folks talk about home
and community-based services
and it's especially important as we are
reimagine
uh crisis systems for children so
community-based services again is
you know there are those that take place
in the most inclusive, most responsive,
most accessible,
least restrictive environment for our
young people in a way that still ensures
safety and promotes child and family
integration into home and community life
so I just want us to keep these
principles in mind as we go through
so why are we talking about children
when it comes to crisis
we do know the data is good to tell us
that pediatric
behavioral health visits to emergency
departments have risen tremendously
in the last few years across the U.S.
and this we would say aligns with the
data that the prevalence of chronic
mental health disorders
is growing among youth doubling
by some counts in the past decade
and impacting roughly a fifth to a
quarter of school age youth
we know some of the most common
challenges among children
and those are indicated here and these
are all
some of the precipitants to emotional
and behavioral health
crises in our young people
the benefits of prevention and early
intervention for physical health care
are well recognized I would say routine
screenings checkups
awareness of signs and symptoms that
allow for
early detection and intervention are
increasingly implemented in pediatrics
but I would say that in our mental
health systems routine screening and
mental health checkups have lagged
we know that for those under 25
they have the longest delay to initial
treatment after initial symptom onset
and we also know that currently less of
less than half of young people,
children, adolescents with a mental
health condition will receive treatment
it's very costly for our system a lot of
factors contribute
uh to this uh we know that um there's
persisting stigma
there's limited child mental health
specialists
um and ultimately this often leads to
really more costly downstream
intervention
so we have a number of concerns
in our child mental health system
broadly but
let's speak just to some of those in our
crisis system
and again some of these are quite
overlapping in the struggles we see
in our adult crisis system not that
they're always separate
but there are some nuances when we think
about children
and adolescents
so first we've already alluded to the
limited prevention
early identification and intervention
but we essentially wait for crises to
occur in some respects before investing
resources in them
emotional and behavioral health
challenges in our young people
can often be prevented or diminished at
least
with early immediate identification and
action
yet our care systems don't really reflect
that reality we know that children in
crisis are met with emergency department
care often
brief inpatient visits or stays that are
often followed by readmission or in many
cases
by juvenile detention and frequently we
would argue that they
are going these routes for concerns that
likely would have been better addressed
with home or community-based models
with appropriate wrap-around services
so then there's the issue of our
emergency departments which we've
already spoken to and certainly
in many ways as parallels concerns we
have with the adult system
but I think there are some unique things
with our child
system that we have to be thinking about
with respect to emergency rooms so this
is Lydia this is a picture of an
adolescent
she is 18 years old
and she spent a week seven days
in an emergency room at a hospital this
was in California
her family had called 911 after Lydia
began banging her head on the shower door at
her family's home saying she wanted to die
and we know just in looking at this
picture for any of us who have spent
hours days in emergency departments this
is not where you want to go
when you're in crisis yet we know that
emergency departments are typically the
first point of contact for children
having mental health crises and as I
mentioned
our pediatric behavioral health visits
to EDs have dramatically increased
nationally in recent years researchers
have identified a lot of reasons for
this
including limitations in our health care
system even a lot of
behavioral health specialists or some of
our educators
find that they don't have the tools that
they need to work with these young
people
it's also estimated that a quite a large
percentage
of the referrals to pediatric emergency
departments
for psychiatric reasons are not urgent
and some data has suggested that about
half of school-based psychiatric
referrals
are actually inappropriate and
you know as seen here with Lydia
children are often boarded for hours two
days until viable placements are identified
and this is just unacceptable
you know we have good evidence in fact
that the care that's received during and
following emergency department visits is
more expensive and even less effective
than when kids are routed immediately to
home and community-based services
so we need to do better as with adults
we also struggle with the role of law
enforcement in addressing child
behavioral health crises
this you may have seen these pictures
before this these
went viral in some circles this is a
nine-year-old student
he's a student who's been diagnosed with
autism
he's a student from Indiana and he had
lashed out at a teacher
after experiencing bullying
persistently in his school for some time
and he was arrested
and handcuffed and forcibly removed from
the school
and this is one incident of course but
this is not uncommon especially with the
increased presence of law enforcement in
the school setting we know that many
emotional and behavioral health crises
among children
are dealt with through law enforcement
and discipline
and there's some other data that I think is
striking and important to consider when
we think about the intersection of law
enforcement and crisis and children
so a young person with a mental health
condition is about six times likely to
get arrested and 16 times more likely to
get injured or die during police
encounters
and this is disproportionately more true
for our young
people of color nearly 70 percent of
children in the juvenile justice system
have a diagnosable mental health
disorder 60 percent
of children with an emotional
disturbance will be
arrested at least once within four years
after leaving high school and
about 40 percent report being on probation
or parole
and then when we look to some of the
police training
we find that very little time is
dedicated to interactions with
adolescents
and then when you look at some of the
data that exists on why
young people are arrested it's often uh
described as contempt of cop or
you know disrespecting which is the same
for discipline response in schools as
well it's often kind of vague
descriptions that are subject to
the biases that we know you know exist
in all of us
including our law enforcement and our
educators
and kind of speaking to some of that
racism and inequity in our system
we know that despite many emotional and
behavioral health crises in schools
resulting from unmet mental health needs
crisis events are often responded to
with discipline or legal action
especially in the school setting
we know that these disproportionately
affect black and Latinx students
compared to white youth
we know that among these youth they're more
likely to be suspended expelled and also
routed to juvenile services
and we also know that system challenges
contribute to a preference for
disciplinary versus mental health
response in schools
including implicit bias and racism among
our educators
but also in our communities of color
when we look to the data we find that
there are fewer mental health resources
in these schools and greater law
enforcement
there was a great report put out by the
ACLU
a couple of years back about called
counselors not cops or something
akin to that so at the end of the day
there's no question
I would I would argue that we need a
paradigm shift in the child adolescent
crisis system
just as we do for adults and let's just
consider some ideas
about how we can do this and and then
save some time for discussion
okay so first uh
the paradigm shift you know calls for
significant expansion of telehealth
technology
to advance our crisis system for young
people
and during COVID-19 you know our systems
have witnessed a dramatic increase
in the utilization of telehealth to
support the mental health needs
of children and families we were talking
before this call about
there being a strong precedent
for using telehealth for children and
families I remember
I was saying to Dr. Hepburn about 15
years ago working in schools I remember
rolling big carts into my office and you
know channeling our child psychiatry
fellows in to do the work we've been
doing this for a long time but
not to the extent of course that we need
to you know in this expansion that
we've seen in
in our recent months uh has occurred of
course with significant federal, state,
and local infrastructure support and
some policy adjustments to ease use
and some increases in technical
assistance and training to both
providers
and to consumers of care so there's been
a lot of
rapid momentum in this area in the last
few months that I'm hoping we can
leverage
we know that a transformation of our
children's crisis system towards this
robust telehealth capacity would require
continued infrastructure improvements
things like enhanced broadband systems
up-to-date telehealth delivery equipment
internet connectivity services for
providers and consumers we see a lot of
this happening now
policy expansion to include things like
reimbursement parity for telehealth and
expanded access of Medicaid and
and CHIP telehealth programs
and then finally you know we there's a
lot more we need to be doing
uh in terms of ongoing guidance and
support to providers and families to
increase adoption and facility of
telehealth
I was on a clinical supervision call
this morning with a
one of our clinicians in Baltimore City's
schools
and we were just talking through the
nuances of
you know working with families and
children to
start feeling you know more comfortable
increasingly comfortable with
the telehealth environment and what that
means and what it means for privacy and
all of the things that we're contending
with as we
increasingly adopt telehealth the good
news is as I've already mentioned you
know there's
there's a good precedence for using
telehealth in our child and adolescent
mental health system
including in some of our crisis systems
this is one example
this was out of the Children's Hospital
of Colorado
they were working to address the absence
of child adolescent behavioral health
specialists
in their system and they started using
telepsychiatry to link specialists into
their pediatric emergency departments
but also into their crisis centers
and their telepsychiatrists were based
in their central academic
medical center and the goal of course
was to improve care
decrease patient transfers to more
restrictive settings
and you know the data was quite
compelling
compared to usual care that children who
received the
telehealth had shorter emergency
department stays
you know fewer or much lower costs
charges for care
but then also higher satisfaction among
the providers
and the families and again this is you
know specific to
emergency departments and some crisis
centers but
you know this can I think well be
translated into the crisis
care environment so one of the other
areas that we know is
critical for us as we think about
reimagining the crisis system for
children is
a turn to more upstream thinking so
let's just take a moment to
to see what that means
you're standing on the edge of a river
all of a sudden a flailing
drowning child comes floating by without
thinking you dive in
grab the child and swim to shore before
you can recover
another child comes floating by so you
dive in and rescue her as well
then another child drifts into sight and
another and another
eventually hopefully some wise person
will ask
who keeps chucking these kids in the
river and they'll head upstream to find
out
such a simple video but I think it
captures so well this idea that we need
to be moving further and further
upstream so
I was looking to a 2018 brief that
NASMHPD
put out for states and communities and
you know states were described in that
brief
as increasingly shifting to delivery
systems for children's behavioral health
to upstream
but upstream was really described as
mobile crisis response and stabilization
as an approach to identifying problems
earlier which makes good sense
but I would argue that our
conceptualization of crisis systems will
best be served if we move even further
up the river so to speak further
upstream
uh than than our mobile crisis response
to consider
the myriad resources and interventions
that could prevent and intervene
early to diminish our emotional
behavioral health concerns among our
young people
so we know that many mental illnesses
that lead to mental health crisis could
have been identified and treated earlier
in their trajectory likely lessening the
negative outcome for children and
families including the experience of crisis
we know that many of our youngest
citizens especially
our youth of color are routed to
disciplinary and juvenile
services and incarceration for behaviors
that could have been prevented
or at least addressed with a mental
health response
and I just think this can't be
overstated
in terms of it needing to be a part
of every conversation we're having on
building crisis
response systems so we know that we have
to repair our crisis response systems
for children but we should only do so
while we're simultaneously building out
our universal mental health promotion
and early identification
and intervention systems for our young
people
so I'm just going to talk about two
settings in particular
where I think we need to be focusing
some of those efforts as schools and
pediatric primary care and share a
couple of resources
with you so increasingly we know
that schools are installing what many
are calling behind supplemental health
systems reflecting partnerships between
education and behavioral health sectors
to provide this full continuum of
supports
some refer to this as a multi-tiered
system of support in schools all the way
from mental health promotion for all
students
to early intervention and even treatment
in the school setting
as I mentioned earlier we've long had
psychiatrists working in partnership
with us and our Baltimore City schools
but this model
has extended throughout the U.S.
to schools in partnership with
community behavioral health
these systems really rely on those
partnerships between
school systems and community programs to
ensure their school-based mental health
professionals, our school psychologists,
school social workers, school counselors
are supported in a meaningful way by
community behavioral health and this
doesn't just mean
setting up an outpatient shop in a
school
it really is you know in a much more
meaningful partnership
where community partners are brought in to
augment in a very strategic way what's
already happening in the school
and we know and there's good data to
show us now that when treatment is
delivered in the school setting
in the school building that young people
are much more likely to start care
but also to complete care um
you know I want to make the case also
that as we think about crisis systems we
should be thinking about them
in our school building so an essential
component
of our multi-tiered system of supports
in schools
is crisis prevention and response and
what you're seeing here is actually a
crisis system that
was funded by us by the National
Institute of Justice
we had a three-year study this was
done in partnership with
a large school district in Maryland
and we did a randomized controlled trial
looking at
usual crisis response versus a
multi-tiered
emotional and behavioral health crisis
system that involved
universal supports a couple of unique
things I'll point out for example
there was at the universal level we had
a system
for peer training for students from
various social groups in the schools
each trained in conflict management and
bullying prevention
at tier two you can see here we use
something called cognito
and it's a a virtual simulation
technology to train teachers and how to
support
students in psychological distress
in addition you know we created a clear
referral
assessment and coordination of school
and community supports
but one of the most important things I
would argue that we did is not just
train the student support staff and
crisis response but also every teacher
in the school building was trained in
crisis response using something called
the life space crisis intervention
and then we utilized something that the
school system called for
when we were applying for this was a
very
structured process for post-crisis
relapse prevention because they
articulated that very often after
student crises
you know they there no plan was put in
place no engagement with the family
happened and the students if they did
show
back up into the school would very often
be routed out again
so this is just one example of a
system that was put in place and studied
there are others but often it's a
piecemeal approach to crisis response
this was a bit more of a comprehensive
approach
and we saw good impacts it's been
designated as a promising
approach at this point because there's
just been one randomized control
study but we saw not only just increases
in knowledge
and preparedness among the staff but the
students also
demonstrated improved actions and
behaviors
around school climate and then quite
compelling to our school partners was
that our intervention schools
had significantly fewer suspensions and
office referrals
and more on-site crisis response and
threat assessments as opposed to
off-site referrals to emergency
departments or law enforcement so prices
were being handled
in the school setting by people who
interact with young people on a daily
basis
so how about pediatric primary care
we know that you know in in many
communities our pediatricians
remain a well-trusted and utilized venue
for children and families
and we know that pediatricians may be
particularly helpful in apprising
families of the 988 system
as that emerges providing family
strategies to promote mental health
de-escalation
there's also child psychiatry access
programs established in about 35 of our
states provide direct support from child
behavioral health specialists including
child adolescent psychiatrists via
consultation
and many pediatric primary care offices
are now offering collaborative mental
health care on site so if families know
they can make an appointment with a
behavioral health provider
in their trusted pediatrician's office
they may be much less likely to go to
the emergency department or call
and this in this moment in time so we
have to be leveraging these systems
so what about best practice
considerations that are aligned with
kind of this new set of guidelines that
came out much of what's in that toolkit
can reasonably apply
I would argue to the child and
adolescent crisis system but
there are some considerations of course
at each level of the system
and I know we just have a handful of
minutes here so I'll touch on some of
these quickly
you know and I've broken it down just as
the the guidance did around someone to
talk to
someone to respond a place to go which I
think is a really nice
framework for thinking about crisis
response
so you know to meet the needs of our
children and families in crisis our
regional
crisis call hubs you know should be
considering
a expanding technology options for
callers and that would include of course
the use of texting telephone telehealth
and we know that many young people
prefer to seek
crisis support via texting or video
conferencing
as they may feel that these are either
more familiar, less stigmatizing
we also know that you know akin to kind
of how we teach children
about 911 in preschool we want to
be educating children beginning in
preschool through k-12 about how to
access
these types of crisis supports uh
through 988 and so forth this shouldn't
be something that we're only relying on
adults to do
most five or six-year-olds know
911 and what it does and so this can
be a part of our way of teaching young
people
that mental health you know is part
of our community and here's a way that
we can address it this is what crisis
looks like
um we would argue that this should be
right it built right into the curriculum
many
I shouldn't say many yet but a few
states have now started mandating mental
health literacy as part of the k-12
curriculum
all regional calls pertaining to child
and adolescent
concerns should be staffed by individuals
who have specialized training
in child adolescent development and
mental health and illness
you know this would include an
understanding of developmental
milestones how to promote mental health
how to distinguish typical
challenging behaviors from child and
adolescent
behaviors that might reflect more
serious concern we would argue that they
you know should be equipped with the
skills to navigate family systems during
a crisis call how to diminish conflict
increase safety that they should be
developmentally attuned in terms of
their guidance for
de-escalating children and adolescents
and maybe family members
this may include how to support family
and school
personnel in managing conflict calls to
be delivered
in a culturally responsive manner really
with center staff receiving training and
ongoing support around racism and bias
and the unique strengths of our
black, indigenous, and people of color and
youth and families
and how these intersect with mental
health crises
we know also that there are specific
areas that crisis call
personnel should receive training in or
have an understanding
you know in one example adolescent
reactivity to peer rejection or romantic
breakups which we know are both
predictors of suicidality and risk
behavior in our young people
and the list goes on here in terms of
kind of some of these specific
considerations but for the sake of time
I'll just touch on a couple of other
areas of our
continuum of supports this just really
illustrates how calls coming in
about child concerns might differ from
those of adults if some people are
saying well do they really need
specialized training in child you know
for children
with autism as one example a parent who
may be concerned that something's
different but doesn't
understand exactly how or why you know
it maybe
doesn't speak or look at me won't listen
and respond freaks out if we don't do
our usual schedule or change plans
to someone not familiar with child and
adolescent mental health concerns
this may not be clear as to what this
could reflect
for children anxiety we may hear
specific concerns
again that are in the child context
for our mobile crisis team services um
you know again we would argue we must
expand technology options for crisis
response teams including the use of
telehealth and
again they may prefer to engage in this
way we would argue again they should
have specialized training
as outlined before about our crisis call
responders
but including ways for example for our
crisis teams to co-regulate with
children
understand how that impacts attachment
understand how to assess for child abuse,
neglect, family violence
assessing parent readiness and ability
to implement recommendations and
interventions
we would argue that both call responders
but also
mobile crisis teams need to be familiar
with school specific concerns and even
procedures
related to 504 plans and individualized
education programming
because these will be asked during
crises or
they can serve to help support advocacy
around this
then I'll finally just touch on a place
to go we know that
there are many considerations that need
to be taken into account for young
people and we've seen in some of our
crisis centers that have been
established they have separate areas
from adults to
to be received and supported during a
crisis
uh it can be distressing or frightening
even for young people
to witness adults in crisis including
the likelihood that the child's crisis
will escalate and diminish in that
situation
the climate needs to be calming, positive,
welcoming, compassionate, and
developmentally attuned
places to play and move for younger
children
um you know for adolescents there are
particular concerns around stigma of
seeking help and there's some
good examples in the community of spaces
where it's adolescent friendly
we know that telehealth should be
available or we believe it should be
available for
care provision but also the engagement
of support of others who can help during
the crisis process
medical staff should have
training and child and adolescent health
and also spaces for family support and
gathering should be offered
so I'll just conclude with a few lessons
and innovations
from COVID that I think can guide us as
we re-imagine our children's crisis system
so first you know we know that COVID
has illuminated
the desperate inequities that occur in
our systems and for our children in
particular in terms of education and
health
as we develop these systems we want to
take into account the unique bias and
safety considerations
for our youth and families of color as
well as provide culturally responsive
supports
we know that telehealth supports and
services are needed
and feasible in many cases and in fact
may be preferable
for young people policy has to move
toward parity such as state parity
laws offer comparable payment um
a require comparable payment we know
that prior to COVID only
five states had implemented telemental
health parity laws
and when it expanded during COVID 21
states actually
you know did this expansion but only
13 I want to say required parity so we
have to evolve in this area
COVID has further highlighted I would say
that emergency departments are really
not suited for mental health or
substance use crises
we have many families experiencing
significant psychological deterioration
in the context of COVID who have
grave concerns about going to the
emergency department and we need a place
for these children to go
we know many children during COVID or
increased risk of abuse, neglect, family
violence and we've seen decreases in
calls to protective services during
COVID likely due to schools being closed
providing children and families with an
accessible way to get help and you could
argue that 988 could be one of those
ways
is critical and then finally even with
brick and mortar schools closed
schools remained during COVID and even
over the
summer period and will continue to
remain a hub for a full continuum of
support so we should continue to
leverage them as a way to support social
emotional health of our young people
so just in recap we know adjustments
need to be made for the child system
we need to keep in mind our system of
care principles
and how those are similar to yet
slightly different
than our adult core principles we must
engage in a paradigm
shift to reimagine our child adolescent
crisis system
we must expand telehealth at all levels
with policy and practice change
think upstream including how to leverage
schools and pediatric sites
as a way to prevent and address crisis
take into account the unique needs of
children adolescents from the call
response to the mobile crisis teams to
our receiving and stabilization services
and also
just keep in mind that during covid
we are learning lessons and identifying
innovations that really can inform
our crisis systems so with that I'll
stop and I think we wanted to open it up to
some reflections and questions
great Dr. Hoover thank you so much I
will remind folks
that if you have a question for Dr.
Hoover to type it into the chat box
and we do have a few that have
already come in
so Dr. Hoover you talked a little about
moving upstream
we have one question I am curious if
anyone is working on pre-crisis
or even pre-pre-crisis work with young
people we all know that children learn
differently in the traditional academic
settings
and approach is not always conducive for
learning for all
is anyone possibly working on the
identification of skills strengths and
passions
that might help young people compensate
or overcome generational poverty
domestic violence or abuse
many of the things that you touched on
in your in your presentation
yes and I would love to hear I mean
truthfully I think
you know this is a helpful opportunity
also for networking so
and hearing innovations from other
sites so
if folks want to share some of their
innovations or sites that are doing
pre-crisis or pre-pre-crisis in the chat
box please feel encouraged to do so
I mean as I already mentioned
schools and you know states and
communities
are certainly leveraging schools and
school partnerships with behavioral
health
to think about pre-crisis we don't often
think talk about it as pre-crisis
um but certainly as a way to prevent
uh crises and also to promote mental
health so one of the things I liked in
that question was how are we
you know really identifying and
leveraging the strengths and assets of
our young people
and we are seeing that I would say in
a more robust way
in some of our states and local systems
that are
installing social emotional learning
into their
curriculum for example and then
you know and so if you're looking for
specific examples at the state level
Wisconsin, Colorado both have
beautiful multi-tiered system of support
frameworks for supporting mental health
in the school setting
including how to identify young people
who may be experiencing challenges and
intervening early
at the local level we have a number, several
examples
of that in fact I'll share in the chat
box we put out a guidance document with
about
75 organizations including many of our
federal partners but state and local
communities as well
that highlight some of the state and
local examples
of where this is happening well that was
just put out in September of last year
so again I would argue that
in many ways our schools are doing
some of this work in kind of
the most clear ways right now
great Dr. Hoover another question
while delivering services in the school
setting has many benefits
it also can present new barriers to
family and parent involvement
especially for families who haven't felt
safe or supported
in the school environment what is being
done to mitigate those barriers and
support families and make sure
they continue to drive their children's
care in these situations
yeah I think it's a great question
and schools will not be
the preferred place of service for every
family
nor will you know our traditional
outpatient mental health setting so I
don't think a one size fits all we know
that some families have
had their own personal difficult
experiences with the education system
there's a couple things I would point to
I mean first of all I think
within our special education system
there has been increased
movement kind of aligned with our
person-centered care movement to
person-centered planning or
child-centered planning within
individualized education programming for
example having
it used to be and still is in many
communities that young people aren't
involved in their planning
that families you know come to the table
feeling very
unsupported and ill-equipped to
engage and it's a very top-down process
we've seen a movement with tremendous
advocacy from young people and families
to
shift that so that they are more
kind of in charge of their care or
their education planning so that's one way
that I would say
families have been more engaged in the
process but also just within the school
mental health
systems that we've been growing across the
across the U.S. there has been more
intentionality around
engaging families in care in the school
building I think there you know there's
a myth that when you're doing school
mental health care you're not seeing
families you're not engaging families
and I certainly have heard school
clinicians
you know say oh I work in school so I
don't you know I don't have to work with
I don't have to deal with families and
that's
quite counter-thetical to how we see
school mental health and in fact in the
national practice guidelines around
school mental health we argue that
family engagement has to be a part of it
we have a large randomized trial right
now funded by PCORI (the Patient-Centered
Outcomes Research Institute)
that's looking at specific strategies
for family engagement and
part of that is cultural responsiveness
and attunement to the families we're
serving
and so we're studying that as well so
I'd say there's been a number of
strategies to best engage families
in school systems and in you know the
school mental health systems in
particular
but that schools will not be the answer
for everybody but I...
I wouldn't use that as a reason not to
install school mental health because in
fact there is compelling
data that for many families they far
prefer the school environment
to receive care they find it less
stigmatizing, less threatening, and much
more accessible
because children can receive care often
during the school day
great a question that's very timely
given the current situation that we're
in with COVID
Dr. Hoover as we move into the new
school year
how do we detect children who are in a
toxic situation
if we continue to start school virtually
yeah I mean I know we're all contending
with what this is going to look like
and one of the areas of innovation that
we saw in many school districts in the
last few months
was systems being built for
distance check-ins on well-being now
first and foremost we have a whole sub
group of
kids that have not been reached by our
schools or mental health systems
in weeks at this point months
and we know that there are strategies
that need to be put in place for that
subgroup of students or young people
and that may involve more you know home
visiting
more tele-outreach to those families
some of it may be accessibility issues
whether it's internet
or technology so that's one piece
but for those who are engaging with the
schools through distance learning and
that is a vast majority of young people
there have been systems built that are
as sophisticated as have it so
there's one called close gap for example
where teachers have a mechanism at the
beginning of every one of their classes
it's a free platform for teachers to use
and they... every child checks in this
is more for the elementary level they
check in with how they're doing do they
need to speak with anybody
and it gives the teachers a dashboard
of their classroom at the beginning
of every class and it's simple
in theory but it you know
educators have reported that it's
incredibly helpful
as a way to take the pulse of
the students and then systems have been
using things as simple as a google form
with similar kinds of things you know
for high school students for example
just you know how are you how would you
describe
your mood today and who do you need to
be contacted by so those kinds of things
in the context of distance learning
that don't require children to be in
crisis to go
see the counselor are essential one more
thing on that I
I was on a panel yesterday with some
young people
who said who basically were arguing
please don't wait for us to come to you
and don't expect us to turn our video
cameras on we're not going to do it
it doesn't feel right during distance
learning because you know we were
saying well how can we
you know get get our students to turn
the cameras on so that teachers can get
you know can do what you're saying David
kind of get an assessment of their
well-being and they said just and this
may be easier said than done
don't wait for us to come to you
schedule 15-minute appointments
have students identify a trusted teacher
or counselor in the school
and every week have a 15 to 30 minute
meeting where you're just checking in on
us and let the student
have you know some choice in who it is
that they get to meet with
so simple ideas but I think these things
are critical as we think about how to
you know embark on this next virtual
learning session
it's great ideas great ideas
Dr. Hoover the next question
revolves around many of the things that
we already see with the disconnect
between the children serving systems and
the adult serving systems and
things that all the commissioners have
to deal with overseeing both
somebody writes
localities don't always have funding for
a separate
child crisis system how would a crisis
program integrate so that all ages
that need to be accommodated within the
crisis system is seen
yeah and that's the reality right
there you know is the fiscal reality
and the staffing reality and so I
think
that some of the considerations that
we discussed and you know it'll be laid
out in a paper
that we did you know with NASMHPD
really could be provided from a
combined system approach right so
there's no reason you can't have your
call center staff
trained in both you know adult crisis
response and have some
child training for instance there's no
reason that within a
a locale even if you can't have two
wings of a unit
you know you could have a
space possibly designated that's more
child friendly
and those may seem like simple pieces
or simple kind of factors but they're
they're really important as we think about how
do we understand and respond to
child crises and you know part of it is
training part of it is implementation
support
you know I think using some of our
current technology like the ECHO type
learning for states where they can learn
from each other about how they're doing
child-embedded crisis response
it's you know could be a useful strategy
for those that are
that are not able to do these two
separate
systems and I don't know that two
separate systems is what I'm advocating
for either it's just to have those
considerations for child and adolescent
really embedded within whatever system
is created
great thank you I wanted to
let you know that you director from
California
basically said here in California we
have a strong emphasis on
the aces screening appreciate the
emphasis on social and emotional
learning environments
that support positive youth development
so another question you know
you touched on several times the
the new 988 and the hopes of that
it's going to do a lot of things that
that we're so excited that it has the
possibilities to do
someone wants to know uh if a state is
unlikely to have a strong
child adolescent crisis system by the
time the 988 system is scheduled to go
operable
in July of 2022 do you have any ideas of
what they could do
that would be relatively quick or
cost effective
to have something better than just
continuing to run them through the adult
crisis system
yeah I mean my the two first answers
that come to mind to me are telehealth
in schools
and you know that we have to be
better leveraging our telehealth and
schools not only as a place to kind of
foster these systems of crisis response
but even to
intervene in the school building
when a crisis is occurring or about to
occur
so that you know children are not
routed to our emergency departments to law
enforcement you know there's a... as we
all know there's a large discussion
right now about policing
and states and communities fall in
different
places in that discussion but in some
communities there's likely to be a
reallocation of resources
of policing in schools and
in our communities and and one way to
you know leverage some of those funds I
would argue would be
you know relieving some of the burden on
law enforcement to crisis care
and putting it into creating safe spaces
in schools where
crises can be mitigated
the telehealth piece you know I
think
it couldn't be you know I've said
it over and over and I know we're all
probably singing the same tune but I
think using
telehealth early and equipping
you know schools are such an important
place if we can
educate young people and then have
mechanisms in place for young people and
families as part of mental health
literacy training
to have them access a teleprovider
when they are experiencing kind of
an uptick in crisis um concerns
uh if they can get to someone quickly uh
then you wouldn't... that's a first
step I don't want to say that you
wouldn't need this whole robust crisis
system because you're still going to
need that but in the interim
and for many people that may be
enough building school systems and
having immediate tele-support
for young people and families and
advertising it
um in you know through mental health
literacy in schools
David if I could just speak to 
the comment from California thank you
for that I appreciate the
recognition of the importance of
positive youth development, social
emotional
competency focus and there was a
mention of ACEs and the one thing I want
to say is that there has been this
you know important focus
on adverse child experiences and the
connection
to adult health outcomes
and you know how can we address
adversity and detect it one of the
more concerning trends we're seeing
is screening without a
kind of follow-up or an understanding of
how to address it in the settings that
are being asked to screen whether that be
schools or pediatric settings
so I think a very well intended push
toward screening for
ACEs but not always
followed up with and so what do I
as a pediatric primary care provider
what do I as an educator
do about this you know do we have
components in place to address those
social influencers of health that might
be kind of responsible for the
adversities
because our fear my fear one of the
things that keeps me up at night
is you know the idea that these
ACEs screeners are going to be
used as a way to just route kids into
individual treatment when we know that
so many of the adversities kids are
experiencing are
are really much more related to those
environmental social influencers or
social determinants as they're
traditionally called
so I just want to point that out
or kind of lift that up in the discussion
great point great point I think we
have time for one more question
and this is the one that I think
you've heard before
because I know I've heard it from the
children's family children's youth and
family division members
Dr. Hoover we have places in our state
that have great collaboration with
education
but we still have places where
education is very reluctant to
collaborate with us
and it has a lot of stigma
related to what we do and the children
we serve
are there certain things that you've
seen in your work across the country
that were sort of aha's or things that
folks on the behavioral health side use
as a catalyst to begin the conversation
and to begin a collaboration that then
we could be built upon
yeah it's a great question and I think a
call out that it's not always easy to
integrate mental health into
education systems and I think
um it needs to be a true partnership one
of the
aha's that I think we try to
bring to light for our education system
partners is that they very much
should be can be in the driver's seat of
those partnerships
well we want them to be collaborative
you know in terms of education and
behavioral health systems what we often
find is that you have behavioral health
providers who
are you know as I alluded to earlier
kind of coming and setting up shop
and treating the schools as an
outpatient center and I think
for many schools they don't even
necessarily recognize their ability to
ask certain things of the behavioral
health provider coming in you know by
offering
space by offering time during the school
day they're offering a tremendous asset
to behavioral health providers who have
a very high inertia rate in most
communities
and struggle to have reimbursement for
for services whereas in the
school building the show rates are quite
high so one aha or one thing that's
quite compelling to schools is that they can
establish memorandum of understanding
with behavioral health partners
uh that ask for things like 10
of the services you know that are
offered by the behavioral health
provider are for
underinsured or uninsured children
they can require you know that that the
provider comes in and supports
a certain piece of their multi-tiered
system of support
they can require or ask in the MOU that
there are certain interventions that are
delivered by the behavioral health partner
so that's one of them I mean certainly
the literature is very
compelling on the link between behavioral
mental health
and academic performance so
for some school administrators that's
useful you know the
meta-analysis that came out in 2011 that
showed when you do social emotional
learning in classrooms there's
higher standardized scores on state tests
was all it took for some school
administrators
and you know we have kind of how do
you market
mental health to educators but
I have to say we're seeing less and
less and I'm not
suggesting it doesn't exist but we're
seeing less
of educators saying we don't want mental
health in the building
I think they just need sometimes more
guidance on how they can integrate
behavioral health providers
and still remain in control of
who's coming into their building and how
it's going to augment
what their mission is we have a document
on teaming and how to do this
effectively
and I'll stick that in the chat box
great Dr. Hoover thank you and again
thank you for
your time today your expertise and all
that you've done
and continue to do with NASMHPD over
the years we really appreciate your
talking about collaboration we
appreciate your collaboration
and your partnership
thank you well thanks everyone for all of
your work in this space I'm just happy to
be a part of the conversation thank you
you're welcome now I will turn it back
to the glue that holds NASMHPD together
Meighan Haupt
thank you so much you know
David great job with the questions
Sharon just fantastic presentation
thank you very very much
