Child and Adolescent Mental Health and Virginia Public Schools – Big Complications and Major Changes

Credit JAMA Pediatrics, April 6, 2020

by James C. Sherlock

Rebecca Aman, a member of the Newport News School Board, is frustrated. She told me in an interview that:

Without sufficient discipline and access to clinical mental health services, behavioral intervention does not work to make schools safer and healthier.

She believes that Newport News schools need to improve both discipline and the effectiveness of behavioral interventions.

She is absolutely right.

But school-based mental health services offer different, very complex and rapidly changing challenges.

The profession of psychology has recognized that the one-on-one clinical treatment model is permanently out of reach for the broad communities needing assistance because the supply of qualified professionals cannot now and will never meet the demand.

So the delivery model is in the midst of profound change.

Three key changes being pursued are

  • a far bigger emphasis on prevention, much of it to be delivered by school staff;
  • better diagnosis; and
  • “school based” (their term) group treatments.

Which raises at least three questions:

  • Are the pediatric mental health delivery models changing so much that the schools are “shooting behind the rabbit” in the hunt for more services?
  • What does the profession of psychology mean when it describes massively expanded “school-based” services? The schools and parents better find out.
  • Should schools even be in the hunt for more in-school services? I say no. They are already trying to do too much.

New directions in psychology. While schools are trying to adopt their earlier recommendations and models of delivery, leaders in the field of psychology are trying to “rebrand” the profession. From an article from January in the American Psychology Association’s Monitor on Psychology:

Experts are finding innovative new ways to reach more people and take a more preventive approach by shifting away from the perception of psychology as the practice of diagnosing and treating mental health disorders and broadening the lens of behavioral health.

What would we do without experts? From that article:

  • In Population and Prevention, they discuss their aim to shift psychology from one-on-one counseling toward population and behavioral health;
  • Behavioral health for youth recommends new child psychological screening to primary care physicians without acknowledging the many children don’t have one. Virginia primary care shortage areas feature the poorest zip codes in the state;
  • To supplement the current child psychology diagnosis and treatment model to add a school-based prevention effort, with large-scale participation by the schools;
  • Fixing broken systems positions the psychology profession to deal with “larger social and structural issues.”.  The entire focus of that section is racism.  They need to change the model, but whether one agrees with the focus on race or not, if carried forward, it will poison the effort;
  • Brain science as a brand describes attempts to “legitimize psychology as a hard science” by emphasizing “a connection to neuroscience and the brain.” The brain science pathway seems like they are adding more educational requirements to a profession already desperately short of practitioners, but that is their business.

Some additional observations:

  • The term “rebranding” is more than a little flippant, but they are going down that path because they they cannot staff the current model to meet the demand.  Fair enough.
  • The “primary care provider” recommendation will work for some kids but is blind to the gaps in the availability of such providers and assumes training that many of them may not possess.

Finally, a quixotic, dogmatic focus on race and racism picks fights both within and outside the profession that America does not need and most will not accept in the schools.

UVa. We note that the APA article features Youth-Nex, one of at least two “research centers” at the University of Virginia School of Education laser-focused on race.

Youth-Nex’s faculty features: Derrick Alridge, the founding director of the same school’s Center for Race and Public Education in the South; the ubiquitous PBIS guru Senior Associate Dean Professor Catherine Bradshaw; and another woman who posted in her biography

Through equity-driven school climate intervention and effective use of strengths-based, culturally sustaining, restorative, and critically conscious practices, she theorizes that teachers can cultivate emotionally safe relational spaces in the classroom, which in turn can prevent excessive use of punitive and exclusionary discipline, promote youth safety and wellbeing, and nurture youth’s agentic, and ultimately liberatory, engagement in learning.

She actually wrote that.

Forget if you can the pretentious ed-speak.

If race-centric thinking is able to influence the direction of school mental health services design, new and necessary services models will be rejected widely.

Virginia schools, driven by changes in state law and funding, for several years have been on a hiring binge. They have hired more counselors, more school psychologists to increase screenings, more teacher aides for special education, and more school social workers.

It has not proven easy to fill those positions.

Some have also sought to provide varying levels of post-screening clinical mental health services.

The record in that effort was spotty before COVID and has been worse since.

Newport News. Newport News Schools made multiple efforts to provide Qualified Mental Health Providers (QMHPs) for treatment, initially through its local Community Services Board and Behavioral Health Authority (CSBs/BHA) hereafter referred to as CSB.

The Hampton/Newport News (H/NN) CSB at one time cared for the mental health of more than 200 Newport News students.

That direct support reportedly fell apart during the schools’ extended COVID shutdown.

At the H/NN CSB, Newport News Healthy Families services are offered for families with children from birth to age five.

Case Management and Intensive Care Coordination (ICC) is offered there in two programs, one for minors and the other for adults 18 and over.

The child and adolescent program currently serves some patients, but reportedly on an independent basis, not in direct coordination with the schools. (I await a promised call back from the Director of H/NN CSB to tell me how many Newport News kids they are supporting and confirm the CSB relationship with NN schools, but at publication time had not received the call. I will fill in the information when I get it.)

Newport News schools, after the CSB connection dried up, tried a private provider for direct support, but that contractor was unable to fulfill the contract.

To make things more complex, QMHP contractors and the CSB’s are funded by different pots of money.

Medicaid is heavily involved, making decisions of whether and how much to pay for various services for each student they insure. As, of course, do private sector insurers.

A fourth pot of money under yet another oversight structure, Children’s Services Act (CSA) funding, is used in Newport News to pay private schools for kids with significant enough developmental deficiencies or more severe mental health problems (two different kinds of schools) that they need a specialized environment for learning.

Newport News sends about a hundred kids a year to those schools at an average cost of $40,000 each.

The local interagency teams who plan and oversee services to youth with CSA money are different by law than the boards providing CSB oversight.

Newport News has tried to leverage all of those approaches.

The programs could obviously benefit from integration, but Virginia law currently separates them.

The Youngkin administration, having inherited this hall of mirrors, is trying to tackle the issues.

A person familiar with administration thinking on this subject admits there are many hurdles to overcome and they don’t have all the answers, especially in a changing delivery landscape.

All schools and school divisions are not equal in their abilities to address mental health problems. Mental health solutions, as Ms. Aman said, are linked to discipline and order in the schools as co-dependent variables.

Schools, especially teachers, are overwhelmed.

The supply of Qualified Mental Health Professionals (QMHPs) is profoundly maldistributed across the state. Arlington, Fairfax County and Albemarle County have ample providers, as does Richmond.

But some entire school divisions have not a single mental health provider in their districts, much less child and adolescent specialists.

The administration official admits, refreshingly, that they do not have a handle on all of the moving parts. They have seen some good programs and outcomes in a variety of places, but many depend upon local conditions not present in other areas of the state.

The administration has not identified a best-in-class model or models yet, especially with the delivery models under transformation by the profession of psychology.

But the Governor has made mental health a signature program, and they are working hard to improve the mental health of kids.

What to do? In the United States, approximately 17% (multiple sources) of children between the ages of 3 and 17 live with at least one neuro-developmental disorder like attention deficit hyperactivity disorder (ADHD), Autism Spectrum Disorder, or Asperger’s Syndrome.

Kids with dyslexia have higher rates of ADHD, developmental language disorders, and difficulties with numbers.

Schools are at least nominally staffed and trained to deal with those and can, again at least nominally, seek outside support for particularly difficult cases. They need more help.

But we are going to have to decide as a society, sooner rather than later, what roles, if any, we want our schools to play in the prevention, diagnosis and treatment of conditions listed in the DSM-5-TR Diagnostic and Statistical Manual of Mental Disorders that the schools are not staffed to deal with.

These include but are not nearly limited to:

  • Eating disorders — such as anorexia nervosa, bulimia nervosa and binge-eating disorder — can result in emotional and social dysfunction and life-threatening physical complications;
  • Depression and other mood disorders. Bipolar disorder results in extreme mood swings between depression and extreme emotional or behavioral highs that may be unguarded, risky or unsafe. It is particularly dangerous in schools;
  • Post-traumatic stress disorder (PTSD) that can result from extreme mistreatment outside of school; and
  • Schizophrenia, which can appear in the late teens. 

I personally:

  • am a proponent of community schools, and
  • think the schools themselves are already overtasked.

I hope the mental health community is planning to offer support, in whatever models they settle on, nearby, not actually in the schools.

But they don’t say that is what they mean to do.

Schools have to avoid being caught in a new model they cannot support.

The latest recommendations are of such a large scale and in such new directions that they can potentially break the schools by trying to help them.