The Interconnected Systems Framework:

School Mental Health within a Multi-Tiered System

of Behavioral Supports in Schools
The Wisconsin PBIS Conference
August 20-21, 2013
Lucille Eber, IL PBIS Network
National PBIS TA Center
acknowledgements
Susan Barrett, Sheppard-Pratt Health systems, Baltimore MD
Kelly Peralis, Community Care Behavioral Health, Pittsburg, PA
Mark Wiest, University of South Carolina
Jill Johnson, IL PBIS Network

PBIS: Equity in
Education

Making Education Work for All
School Mental Health Strand:

Integrating SMH & PBIS: Examples at All 3 Tiers
Integrating SMH & PBIS: Using Data
Integrating SMH & PBIS: Selecting Evidence-based Practices
Interconnected Systems Framework Monograph: Lessons from
the Field
Implementing an Interconnected System Framework in an
Urban School System
Integrating SMH & PBIS at the State Level
The Changing Role of School-based Clinicians
2013 National PBIS Leadership Forum | October 10-11, 2013 | Donald E. Stephens Convention Center | Rosemont, Illinois
Content:
Describe the features of an Interconnected
Systems Framework (ISF) for Integrating
Mental Health in Schools
Describe efforts and resources from blended
efforts of National Centers to promote a
broader continuum of evidence-based
practices to support the mental health of all
students
Describe emerging examples of ISF
BIG Ideas
How Multi-tiered Systems of Support (MTSS)
can enhance mental health in schools
Installing SMH through MTSS in Schools
The Interconnected Systems Framework (ISF)

SMH +MTSS=ISF
History-Rationale
Sparse availability of MH providers in schools
Labels and places confused with
interventions
Separate delivery systems (Sp.Ed., Mental
health, etc)
Minimal accountability for outcomes for most
vulnerable populations



Why Partnership Are Needed
One in 5 youth have a MH condition
About 70% of those get no treatment
School is defacto MH provider
JJ system is next level of system default
Suicide is 4th leading cause of death among
young adults

SMH and PBIS
Common Purpose
Schools supporting/promoting MH of ALL
students
Prevention, early access, interventions
commensurate with level of need (vs label)
School personnel feel confident and
competent in identifying and intervening with
accuracy and effectiveness

Logic
Youth with MH needs require multifaceted
education/behavior and mental health supports
The usual systems have not routinely provided a
comprehensive, blended system of support.
Supports need to be provided in a clustered and
integrated structure,
Academic/behavior and mental health supports
need to be efficiently blended
Promotion and Prevention
Simple and complex supports require integrated
systems with foundation of a school-wide system
Schools and community serve as protective factor
problem-solving teams with
school/family/youth/community voice
use of data for decision-making (screening/ selection
and monitoring/outcomes)
layers supports from the foundational/universal to the
more complex


Tier 3/Tertiary Interventions 1-5%
Individual students
Assessment-based
High intensity
1-5% Tier 3/Tertiary Interventions
Individual students
Assessment-based
Intense, durable procedures
Tier 2/Secondary Interventions 5-15%
Some students (at-risk)
High efficiency
Rapid response
Small group interventions
Some individualizing


5-15% Tier 2/Secondary Interventions
Some students (at-risk)
High efficiency
Rapid response
Small group interventions
Some individualizing

Tier 1/Universal Interventions 80-90%
All students
Preventive, proactive
80-90% Tier 1/Universal Interventions
All settings, all students
Preventive, proactive
School-Wide Systems for Student Success: A Response to
Intervention (RtI) Model
Academic Systems Behavioral Systems
Illinois PBIS Network, Revised May 15, 2008.
Adapted from What is school-wide PBS?
OSEP Technical Assistance Center on Positive
Behavioral Interventions and Supports.
Accessed at http://pbis.org/schoolwide.htm
Primary Prevention:
School-/Classroom-
Wide Systems for
All Students,
Staff, & Settings
Secondary Prevention:
Specialized Group
Systems for Students
with At-Risk Behavior
Tertiary Prevention:
Specialized
Individualized
Systems for Students
with High-Risk Behavior
~80% of Students
~15%
~5%
SCHOOL-WIDE
POSITIVE BEHAVIOR
SUPPORT:
What is meant by
layering
interventions?
Positive Behavior Intervention and Support
(www.pbis.org)
Decision making framework to guide selection
and implementation of best practices for
improving academic /behavioral functioning
Data-based, measurable outcomes, evidence-
based practices, systems to support effective
implementation

Core Features of a Response to
Intervention (RtI) Approach
Investment in prevention, screening and
early intervention for students not at
benchmark
Multi-tiered intervention approach
Use of progress monitoring and problem-
solving process at all 3-tiers


Core Features of a Response to
Intervention (RtI) Approach
Research-based practices and active use
of data for decision-making at all 3-tiers
Use of progress monitoring and problem-
solving process at all 3-tiers


3-Tiered System of Support
Necessary Conversations (Teams)
Check-In
Check-Out
Skills
Groups
Group w.
individual
feature
Complex
FBA/BIP
Problem Solving
Team Meeting
Tertiary Systems
Team Meeting
Brief
FBA/BIP
Brief
FBA/BIP

Wraparound

Secondary
Systems Team
Meeting
Plans
schoolwide &
classroom
supports
Uses process data;
determines overall
intervention
effectiveness
Standing team; uses
FBA/BIP process for
one student at a time
Uses process data;
determines overall
intervention
effectiveness
Rev. 11.19.2012
Universal
Team
Meeting
Universal
Support
Illinois PBIS Network

Tier 1/Universal
School-Wide Assessment
School-Wide Prevention Systems
SIMEO Tools:
HSC-T, RD-T, EI-T
Check-in
Check-out (CICO)
Group Intervention with
Individualized Feature
(e.g., Check and Connect - CnC
and Mentoring)
Brief Functional Behavior Assessment/
Behavior Intervention Planning (FBA/BIP)
Complex or Multiple-domain FBA/BIP
Wraparound
ODRs,
Attendance,
Tardies, Grades,
DIBELS, etc.
Daily Progress
Report (DPR)
(Behavior and Academic Goals)
Competing Behavior
Pathway, Functional
Assessment Interview,
Scatter Plots, etc.
Social/Academic
Instructional Groups (SAIG)
Positive Behavior Interventions & Supports:
A Response to Intervention (RtI) Model
Illinois PBIS Network, Revised October 2009
Adapted from T. Scott, 2004
Tier 2/
Secondary


Tier 3/
Tertiary
Individual Student
Information System (ISIS)
Definition of school mental health

Involves partnership between schools and
community health/mental health organizations, as
guided by families and youth

Builds on existing school programs, services, and
strategies

Focuses on all students, both general and special
education

Involves a full array of programs, services, and
strategies- mental health education and promotion
through intensive intervention
(Weist & Paternite, 2006)
Expanded School
Mental Health
Full continuum of effective mental health promotion and
intervention for ALL students
Reflecting a shared agenda involving school-family-community
partnerships
Collaborating community professionals (augment the work of
school-employed staff


The Context
Over 18,000 schools engaged in
implementation of SWPBIS (MTSS )
prevention based system
Current focus on capacity to scale-up
MTSS as platform to install effective
interventions for youth w/or at-risk of EBD

The Context (cont.)
Emphasis now on scaling with expansion and
connection to other systems
i.e. academic, juvenile justice, mental health, child welfare,
systems of care

Emphasis on deliberate actions that foster
connections w/families & community

Development of ISF
2002-2007: Site Development with PBIS Expansion
(informal and independent)
2005 CoP focus on integration of PBIS and SMH
2008: ISF White Paper: formal partnership between
PBIS and SMH
2009- 2013 Monthly calls with implementation sites,
national presentations (from sessions to strands)
2009-2011 Grant Submissions
June 2012- September 2013 ISF Monograph
Monograph Advisory group


Interconnected Systems Framework
paper
(Barrett, Eber and Weist , revised 2009)
Developed through a collaboration of the
National SMH and National PBIS Centers

www.pbis.org
www.pbis.org http://csmh.umaryland.edu

Define the common goals of SMH and PBIS
Discuss the advantages of interconnection
Identify successful local efforts to implement
collaborative strategies and cross-initiative efforts
Define the research, policy, and implementation
agendas to take us to the next action level

ISF Monograph Development
June 2012 September 2013

ISF Defined
ISF provides structure and process for education and mental
health systems to interact in most effective and efficient way.

ISF is guided by key stakeholders in education and mental health
system who have the authority to reallocate resources, change
role and function of staff, and change policy.

ISF applies strong interdisciplinary, cross-system collaboration.


ISF Defined
ISF uses the tiered prevention logic as the overall
organizer to develop an action plan.
ISF involves cross system problem solving teams that
use data to decide which evidence based practices to
implement.





ISF Defined (cont)

ISF involves ongoing progress monitoring for both fidelity and
impact.
ISF emphasizes active involvement by youth, families, and
other school and community stakeholders.
Interconnected Systems Framework
Tier I: Universal/Prevention for All
Coordinated Systems, Data, Practices for
Promoting Healthy Social and Emotional Development
for ALL Students

School Improvement team gives priority to
social and emotional health
Mental Health skill development for
students, staff/, families and communities
Social Emotional Learning curricula for all
Safe & caring learning environments
Partnerships : school, home & community
Decision making framework guides use of
and best practices that consider unique
strengths and challenges of each school
community

MH/PBIS: An Expanded Tier One
Universal screening for social, emotional, and behavioral at-
risk indicators
Universal screening for families who may request assistance
for their children
Teaching social skills with evidence-based curricula to all
students
Teaching appropriate emotional regulation and expression
to all students
Teaching behavioral expectations to all students
Mental health professionals are part of the Tier 1 systems
team, providing input and progress monitoring data
Opportunity to review community data and expand Tier 1
intervention options based on data


Interconnected Systems Framework

Tier 2: Early Intervention for Some

Coordinated Systems for Early Detection, Identification,
and Response to Mental Health Concerns

Systems Planning Team coordinates referral
process, decision rules and progress monitors
Array of services available
Communication system: staff, families and
community
Early identification of students at risk for
mental health concerns due to specific
risk factors
Skill-building at the individual and groups
level as well as support groups
Staff and Family training to support skill
development across settings

MH/PBIS: An Expanded Tier Two
Mental health/community professionals part of
secondary systems and problem solving teams
Working smarter matrix completed to ensure key
resources are both efficient and effective (i.e., initiatives
are aligned and combined such as bully prevention,
discipline, character education, RtI behavior, etc.)
Groups co-facilitated by school staff and community
partner (example guidance counselor and community
provider clinician)
Opportunity to expand the continuum of interventions
based on data (i.e. trauma informed interventions)
Out-reach to families for support/interventions

Interconnected Systems Framework

Tier 3: Intensive Interventions for Few
Individual Student and Family Supports

Systems Planning team
coordinates decision
rules/referrals and progress
monitors
Individual team developed to
support each student
Individual plans have array of
interventions/services
Plans can range from one to
multiple life domains
System in place for each team
to monitor student progress

MH/PBIS: An Expanded Tier Three
Mental health professional(s) part of tertiary
systems team
FBA/BIP and/or person-Centered Wraparound
plans completed together with school staff
and mental health provider for one concise
plan, rather than each completing paperwork
to be filed
Quicker access to community-based supports
for students and families


Traditional Preferred
Each school works
out their own plan
with Mental
Health (MH)
agency;
District has a plan
for integrating MH
at all buildings
(based on
community data as
well as school data);
Traditional Preferred
A MH counselor
is housed in a
school building 1
day a week to
see students;
MH person
participates in
teams at all 3 tiers;
Traditional Preferred
No data to
decide on or
monitor
interventions;
MH person leads
group or individual
interventions based
on data;
Structure for Developing an ISF:
Community Partners
Roles in Teams
A District/Community leadership that includes
families, develops, supports and monitors a
plan that includes:
Community partners participate in all three
levels of systems teaming in the building:
Universal, Secondary, and Tertiary
Structure for Developing an ISF:
Community Partners Roles in Teams (cont.)
Team of SFC partners review data and design
interventions that are evidence-based and can
be progress monitored
MH providers from both school & community
develop, facilitate, coordinate and monitor all
interventions through one structure
3-Tiered System of Support Necessary Conversations
CICO
SAIG
Group w.
individual
feature
Complex
FBA/BIP
Problem Solving
Team
Tertiary
Systems Team
Brief
FBA/
BIP
Brief
FBA/BIP
WRAP

Secondary
Systems Team
Plans SW &
Class-wide
supports
Uses Process data;
determines overall
intervention
effectiveness
Standing team with
family; uses FBA/BIP
process for one youth
at a time
Uses Process data;
determines overall
intervention
effectiveness
Sept. 1, 2009
Universal
Team
Universal
Support
Family and
community
Family and
community
Family and
community
Community
SPARCS IL HS
5 students participated in group
1 student internalizer
1 student participated last year as well
Time 1 = Seven weeks before starting SPARCS
Time 2 = First seven weeks on intervention
Time 3 = Second seven weeks on intervention
(with a total of 14 weeks of group)
ODRs Over Time
0
2
4
6
8
10
12
14
16
ODR Time 1 ODR Time 2 ODR Time 3
O
D
R

T
o
t
a
l

Time Period
Total Number ODR All Participants
Total Number ODR
13%
80%
ODRs by Student
0
1
2
3
4
5
6
7
8
9
Student 1 Student 2 Student 3 Student 4 Student 5
N
u
m
b
e
r

o
f

O
D
R
s

Students
ODRs Over Time
Time 1 - 7 weeks before SPARCS
Time 2 - First 7 weeks SPARCS
Time 3 - Second 7 weeks SPARCS
OSS Data
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
ISS Time 1 ISS Time 2 ISS Time 3 OSS Time 1 OSS Time 2 OSS Time 3
N
u
m
b
e
r

o
f

D
a
y
s

O
u
t

Time Period
ISS/OSS Days Out
Student 1
Student 2
Student 3
Student 4
Student 5
Grades
0
2
4
6
8
10
12
14
A B C D F
N
u
m
b
e
r

Grades
Overall Grade Distribution Over Time Periods for All Students
Time 1
Time 2
Time 3
TRAC-Nom Data
Increased (Moving in Right Direction)
Life satisfaction .67 Significance Level
Anxiety/depression symptoms .34
Drug use .46
Time spent living outside of the home
(e.g. in jail, an emergency room, or
psychiatric hospital) .37
Decreased (Moving in Wrong Direction)
Unexcused Absences .42
Support Systems

Youth Outcomes Questionaire
On the Youth Outcome Questionnaire (self report) it
measures six subscales: Somatic; Social Isolation;
Aggression; Conduct/Delinquency;
Hyperactivity/Distraction; Depression/Anxiety
Students reported a decrease in symptoms/problems on all six
scales from pre to post
The largest reported improvement was on Aggression, second
was Hyperactivity/Depression and third was Depression/Anxiety
Out of the 5 students that completed the group, we had 2
parents that completed both the pre and post YOQ and both
reported a reduction in symptoms/problems in their childone
score dropped from 40 to 18 and the other from 22 to 15

PA example

Accountable Clinical Home
Accountable TO the family and FOR the care
Accessible, coordinated, and integrated care
Comprehensive service approach
Increased accountability and communication
Single point of contact for behavioral health
School is launching pad for services delivered
in all settings
Youth continue on the team with varying
intensity of service
SBBH Service Components
CLINICAL
INTERVENTIONS
CASE
MANAGEMENT
CRISIS
INTERVENTION
CASE
CONSULTATION AND
TRAINING
for educational staff
District and Community Leadership
Team
Quarterly meetings
Stakeholder representation System of Care
Implementers blueprint
Systems, data and practices
Scaling and sustainability
Time Line
School Year Activity
2008-09 Community Care engaged district through ICSP regarding SBBH
Team
2009-10 SBBH Team begins work within district September 2009
District and Community Leadership Team is established, district
commitment signed, tertiary demonstration project begins spring
2010
2010-11 Tier One SWPBIS is fully implemented with kickoff at the start of
the school year
Tier Two training begins in the spring of 2011 with some
implementation
2011-12 All three tiers are being implemented at both elementary schools
Montrose Junior High receives Tier One training in fall, with soft
kickoff in January 2012
Discussion of SBBH Team model expanding into Junior and Senior
High
1-5% 1-5%
5-10% 5-10%
80-90%
80-90%
Tertiary, Tier 3, Individual

Child Outcomes Survey
Strengths and Difficulties Q.
Teacher feedback
Academic data



Tertiary, Tier 3, Individual

Guidance counselors see
individual students
SBBH Team
Secondary, Tier 2
Group/Individual

Data from Tier One team
Progress monitoring
Data decision rules



Secondary, Tier 2
Group/Individual

Guidance counselors run
Targeted groups
IST
CICO
mentoring

Universal, Tier 1
Whole School

ODRs, teacher nominations,
Card system, MMS,

(lessons learned)
Universal, Tier 1,
Whole school

Guidance counselors teach
I Can Problem Solve lessons
Treehab D and A awareness
Bully prevention/Character Ed
Peer Mediation

Montrose Elementary Schools
K-6
th
Grade
Data
Practices
Scranton School District
Year One
2009-10
Year Two
2010-11
Year Three
2011-12
Year Four
2012-13
Year Five
2013-14
Year Six
2014-15
District and Community Leadership Team established.
District commits to implementing SWPBIS with fidelity across the district.
SBBH Teams begin implementation at Frances Willard Elementary, George Bancroft Elementary, and Scranton High. A Tier Three support.
Frances Willard Elementary, George
Bancroft Elementary, and Scranton High
all receive training to implement Tier
One SWPBIS.
Frances Willard Elementary, George Bancroft Elementary, and Scranton High all implement Tier One SWPBIS.
Frances Willard Elementary reaches implementation fidelity.
Frances Willard Elementary receives training for implementation of Tier Two and
begins implementation.
Frances Willard Elementary implements three tiers of Interconnected Systems Framework.
Isaac Tripp Elementary, McNichols Plaza
Elementary, and South Scranton
Intermediate all receive training to
implement Tier One SWPBIS.
Isaac Tripp Elementary, McNichols Plaza Elementary, and South Scranton
Intermediate all implement Tier One SWPBIS.
George Bancroft Elementary and Scranton High receive training for implementation of Tier Two and begin implementation
Scranton High receives training and begins implementation of RENEW.
SBBH Teams begin implementation at Northeast Intermediate, John F. Kennedy Elementary, McNichols Plaza Elementary, and
John G. Whittier Elementary.
John F. Kennedy Elementary, John G.
Whittier Elementary, and Northeast
Intermediate all receive training to
implement Tier One SWPBIS.
John F. Kennedy Elementary, John G.
Whittier Elementary, and Northeast
Intermediate all implement Tier One
SWPBIS.
Tier 3/Tertiary Interventions 1-5%
1-5% Tier 3/Tertiary Interventions
SBBH Team
Outpatient therapy
SB Partial
Guidance individual support
SAVES/school aged mothers
Tier 2/Secondary Interventions 5-15%
5-15% Tier 2/Secondary Interventions
SAP
Guidance groups
Community Partners groups
Resource Officer
Tier 1/Universal Interventions80-90%
80-90% Tier 1/Universal Interventions
SWPBIS
Drug and Alcohol
Prevention
School-Wide Systems for Student Success:
A Response to Intervention (RtI) Model:
Resources
Illinois PBIS Network, Revised May 15, 2008.
Adapted from What is school-wide PBS?
OSEP Technical Assistance Center on Positive
Behavioral Interventions and Supports.
Accessed at http://pbis.org/school-wide.htm
Needs
Scranton High School
Key features
Systems
District and building teaming models
Facilitation, technical assistance, coaching
Stakeholder participation and buy-in
Practices
Mental health and school staff work in an integrated way to
support students across tiers
Using assessment and screening in order to determine which
EBPs to use, progress monitor
One plan for both education and mental health
Data
Shared decision rules
Used for decision making with all stakeholders at the table school,
mental health, other child serving systems, family

Outcomes
Change in Family Functioning
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Change at 3 mos Change at 6 mos Change at 9 mos
Not Implementing Low Fidelity High Fidelity
I
m
p
r
o
v
i
n
g
Outcomes
Change in Child Functioning
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Change at 3 mos Change at 6 mos Change at 9 mos
Not Implementing Low Fidelity High Fidelity
I
m
p
r
o
v
i
n
g
The Smith Family
Jason was referred to the SBBH Team in November. He
is a seven-year-old first grader who was having
difficulty coming to school and being separated from
his mother.
When he was four, Jason and his family were in a car
accident in a rural area. The members of the family
were taken to different hospitals and Jason did not
know where his mom was or if she was okay.
Every day, since the first day of school, Jasons mom
would bring him into the school and the school staff
would literally have to peel Jason off of his mother and
hold him so she could leave.
The Smith Family cont.
Once referred to the team, they were immediately able
to work with Jason and his family to create strategies
to help him separate more smoothly.
Jason found the SBBH Team office/room a safe place to
be. His mother also spent time there to help create a
nice transition area.
After the Holiday break, Jason began riding the bus for
the fist time, accompanied by one of the BHWs from
the team.
Soon, Jason was able to ride the bus on his own,
increasing his confidence and allowing him some relief
from his anxiety.
Lessons Learned
Return on investment
Funding efficiency
Scaling and sustaining SBBH Teams size
Community politics
For More Information:
www.sharedwork.org
www.pbis.org