Middle School Student Wellness Centers: The community feedback period for this project began on 8/29/18 and ended on 10/28/18

What is the problem that needs to be addressed? Please describe how it is related to mental health.

Warning signs indicating issues in children and adolescents’ mental health are often overlooked and dismissed. In many cases, these issues fester and manifest into tragedies such as school shootings and suicides. Fifty percent of chronic mental health illnesses begin by the age of 14 (NAMI OC, 2017). This demonstrates the need for greater access to comprehensive support systems throughout a child’s education, especially during the middle school years.

Lack of knowledge and fear of stigma are key barriers to using mental health services. Negative stereotypes, prejudices, and cultural norms play into the fear of stigma that limits access to available mental health services. However, there are ongoing challenges with how young people access mental health care. A teen focus group participant for CalOptima’s Member Health Needs Assessment (2018) expressed the difficulty and frustration many teens face in navigating the healthcare system and finding mental health services: “There’s not a lot [of mental health care] in my city, I don’t think. There are therapists, but it’s really hard to reach out and see what insurance they take, or how much they cost. There’s always those out-of-pocket fees, which really get to me. It’s kind of hard. You have to reach out, and sometimes there’s no one really there guiding you where to go.” This teen’s experience is grounded in some troubling statistics. There is a significant gap in the mental health service system in Orange County. Among California regions, Orange County falls below the state average for Licensed Mental Health Professionals — Psychiatrists, Psychologists, and Licensed Clinical Social Workers (California Health Care Almanac, 2013).

School-based mental health services in the form of student wellness centers within the school would provide students with increased access to mental health professionals in order to meet the above-stated problem/need. More importantly, the Student Wellness Center (SWC) approach at middle school sites will present an opportunity to take proactive measures to address mental health for this population of students.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?

Orange County has the largest suicide-rate increase among the nation’s 20 most-populous counties (U.S. Centers for Disease Control and Prevention, 2014). Orange County has a higher rate of self-harm hospitalizations among youth than the statewide average of 4.3 (Orange County Community Indicators Report, 2017). Depression-related hospitalizations, self-harm, suicide ideation, and committing suicide drive the pervasive suicidality that is plaguing Orange County.

Pervasive suicidality and the causal factors including untreated mental illness, depression, substance use, and adverse childhood experiences (ACEs) are disrupting healthy development. Shonkoff et. al. (2012) examine toxic stress and its disruptive impacts, suggesting that these disruptions lead to impairments in learning, behavior, and both physical and mental well-being. Persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress during childhood and adolescence.

In 2015, 7th grade students in Orange County reported experiencing the following in the past 12 months (Orange County California Healthy Kids Survey, 2015-17):

  • 33% reported experiencing harassment or bullying
  • 36% reported having mean rumors or lies spread about them
  • 29% reported being pushed, shoved, slapped, hit or kicked by someone who wasn’t just kidding around
  • 23% reported experiencing chronic sad or hopeless feelings
  • 19% reported experiencing cyberbullying
  • 18% reported having their property stolen or deliberately damaged
  • 12% reported being in a physical fight
  • 12% reported seeing a weapon on campus

From this project, Orange County can learn:

  • Mental and physical health needs of the middle school community
  • School community awareness on mental and physical health
  • Services provided to the school community that produce the best long term outcomes
  • A true comprehensive system of care that is accessible and addresses the spectrum of need regardless of economic and social barriers

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?

Healthcare providers are addressing the knowledge gap through strengthened connections with existing systems, but the challenges of accessing mental health services with respect to middle school students still persists. Of deeper concern is that mental health services through healthcare providers are prone to steer services towards members and center them around their facilities. A comprehensive student wellness center (SWC) in school sites is a new approach to bring needed mental and physical health services directly to the students in a space they regularly attend. A SWC will not only serve as a more accessible means to mental and physical health resources for students, it will: be adaptable to meet the needs of that school’s student population; be part of a broader network of support, beginning with a cadre of SWC Coordinators who can discuss best practices; build capacity for a network of school social workers, school nurses, and school counselors; and align its services and resources to existing providers in the community.

In California, Rialto High School’s R.I.S.E (Restorative Interventions for Student Empowerment) and San Francisco Unified School District (SFUSD) Wellness Initiative have piloted wellness centers at the high school level. The proposed Student Wellness Centers (SWC) will expand on the model used successfully at the high school level in Rialto and San Francisco, and replicate it in Orange County middle school sites to serve the middle school population.

In Orange County, there are eight identified School-Based Health Centers (SBHC). However, none of the SBHCs comprehensively address mental and physical health. HOPE Clinic, a SBHC that provides mental health services, is not located within the school site. The closest example of a SWC-like space within a school is the El Sol Family and Children Learning Center, a SBHC based in a charter school.

The OC Innovations proposal for comprehensive SWCs aims to bring wellness centers that are school-based and physically on a school site, not an off-site community resource center, with a mental and physical health focus. SWCs would be in a public middle school site and would include a school nursing component, as well as nutrition, youth outreach, and drug intervention supports. The SWC will also serve as a hub for youth to engage in prevention campaigns, such as Alcohol, Tobacco, and Other Drug (ATOD) prevention and mental health stigma reduction. This work will be youth-driven and align with Substance Abuse and Mental Health Services Administration’s (SAMHSA) prevention and treatment efforts. The SWC will also support comprehensive health education, including: nutrition education and cooking; physical activity/fitness; sexual health education; and physical education. Other healthy school campaign efforts at the SWC may include: wellness policies, health promotion/marketing, and creating healthy school environments that include healthy food choices and opportunities to be active (including yoga and other mindful movement). OCDE Health Sciences may also lend support for staff wellness and parent education at the SWC to promote healthy school environments.

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.

Through an approach grounded in strategic integration of care (Adelsheim, 2014) focused at the middle school level, the comprehensive Student Wellness Centers (SWC) can fundamentally change how young people access mental health care. They can increase access to care for those who would not seek out mental health services because of the stigma or inconvenience of reaching out to a mental health provider; they can identify those who need care earlier and reduce the impact of mental illness on individuals, family, and community through early identification and treatment; they can purposefully embed integration into training programs and self-care services. Since the services will align with both primary care and mental health providers, the SWC can help bridge the gap in mental and physical health care access.
To ensure sustainability, districts will provide in-kind support through staffing, facilities costs, and maintenance of the SWC. Additional in-kind support can be provided through OCDE’s Tobacco Use Prevention Education (TUPE) and Friday Night Live (FNL) programs for brief intervention counseling and youth outreach leader training.

In Rialto High School’s R.I.S.E, staff benefit from the wellness center once a week for self-care during their “Wellness Wednesdays”. The proposed middle school SWCs in Orange County will expand on this by providing designated times for staff to engage in occasional mindfulness practices, workshops on stress-reduction techniques, and introducing self-care apps/resources that they can use and also encourage their students to use. As evidenced in the research examined by Koenig (2014), teacher burnout factors can be contagious for emotionally empathetic teachers and should be addressed to protect teachers, and in turn, provide reciprocal support to students.

For statistics on mental health in Orange County, we consulted:

  • California Health Care Almanac (2013), Mental Health Care in California: Painting a Picture. Licensed Mental Health Professionals, by Region.
  • Orange County Community Indicators Report (2017). Children’s Health and Wellbeing, pp. 4-9.
  • National Alliance on Mental Illness (NAMI) Orange County
  • Member Health Needs Assessment (2018). CalOptima
  • Orange County California Healthy Kids Survey (CHKS) 2015-17: Main Report. San Francisco: WestEd Health & Human Development Program. California Department of Education.
  • Substance Abuse and Mental Health Services Administration. (2015). 2015 National Survey on Drug Use and Health: Table 9.6B (United States) and Table 20 (California) Rockville, MD.

For research on strategic integration of care, we consulted:

  • Adelsheim, S. (2014). From School Health to Integrated Health: Expanding Our Children’s Public Mental Health System. Academic Psychiatry. Volume 38, Issue 4, pp 405–408.

For research on compassion fatigue and teacher burnout, we consulted:

  • Koenig, A. (2014). “Learning to Prevent Burning and Fatigue: Teacher Burnout and Compassion Fatigue”. Western University. Electronic Thesis and Dissertation Repository. 1928.
  • Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2, 1-15.
  • Chan, D. (2006). Emotional intelligence and components of burnout among Chinese secondary school teachers in Hong Kong. Teaching and Teacher Education, 22, 1042-1054.
  • Hatcher, S. S., Bride, B. E., Oh, H., King, D. M., & Catrett, J. F. (2011). An assessment of secondary traumatic stress in juvenile justice education workers. Journal of Correctional Health Care, 17, 208-217.
  • Borntrager, C., Caringi, J. C., van den Pol, R., Crosby, L., O’Connell, K., Trautman, A., & McDonald, M. (2012). Secondary traumatic stress in school personnel. Advances in School Mental Health Promotion, 5, 38-50.
  • Zhang, Q., & Sapp, D. A. (2008). A burning issue in teaching: The impact of teacher burnout and nonverbal immediacy on student motivation and affective learning. Journal of Communication Studies, 1(2), 152-168.

For research on the the disruptive impacts of toxic stress, insights into causal mechanisms that link early adversity to later impairments in learning, behavior, and both physical and mental well-being, we consulted:

  • Shonkoff, J. and Garner, A. (2012) The Lifelong Effects of Early Childhood Adversity and Toxic Stress. American Academy of Pediatrics.

What is the project idea? Please describe how this project will operate.

The Orange County Department of Education (OCDE) proposes the development of comprehensive Student Wellness Centers (SWC) at middle schools throughout Orange County. A SWC is a safe and welcoming place where all students can access support, resources, and information on a variety of topics around mental and physical health, right at their school site, improving their overall physical and emotional well-being in order to maximize educational outcomes. Spaces will be designed to promote mindfulness, serenity and well-being. The SWC will meet the needs of all students by using data to identify their level of need and tailor services accordingly. SWCs created in middle schools for middle schools will offer a preventative self-care and wellness services for students.

This initial proposal would be to pilot twelve Student Wellness Centers (SWC): one demonstration wellness center at a middle school in each unified school district in Orange County, with the goal of establishing future SWCs. The demonstration school site within each Orange County district will serve as a model for other school sites. OCDE, as a county office of education representing all districts in Orange County, is well-suited to implement this project countywide, allowing more schools to provide comprehensive mental health support systems that are accessible to ALL students and the school community at-large. OCDE can be the backbone agency, and community-based organization (CBO) partnerships will be essential to do programming. SWCs will be embedded into the fabric of the middle school site in such a way that they become as common as a school library or cafeteria.

Other potential uses for the SWC space include self-care and training/professional development supports for middle school teachers to align with student mental health services. These layers of support will help create a common language, value system, and culture between teachers and students within middle school sites.

Staffing for each SWC includes, but is not limited to, the following:

  • SWC Coordinator (full-time) – Masters of Social Work (MSW) background; manage facility, staff, and service offerings. A Counselor on Special Assignment may be a potential candidate for SWC Coordinator.

Part-time (as needed):

  • District provided (in-kind)
    – School Nurse – Registered Nurse (RN)
    – School Wellness Counselor – PPS in School Counseling, School Social
  • Work, CWA, or School Psychology
    – School Social Worker – currently enrolled in a Graduate program with an internship component and in year two of program
  • OCDE provided (in-kind)
    – Nutrition Specialist – Registered Dietitian Nutritionist (RDN) or Dietetic
  • Technician, Registered (DTR) or Certified Health Education Specialist (CHES)
    – Youth Outreach Leaders – Conflict Resolution, Mindfulness Practice for Youth
    – Drug intervention counseling – TUPE and Prevention Coordinator

A needs assessment of the middle school community will help determine the greatest needs for each SWC. Modeled after SFUSD Wellness Initiative at the high school level, OCDE’s middle school SWCs will implement customized staffing configurations—different from traditional Wellness Centers—to accommodate unique student needs at each site.

Each participating school will determine the most optimal location for its SWC. The SWC can be an open-space conversion, re-purposed facility, or new facility construction.

Expected School/Community Outcomes:

  • Increase school community awareness on mental and physical health
  • Increase access to a multi-tiered system of behavioral, social emotional, and mental health supports
  • Increase access to care, education/information, and resources on mental and physical health
  • Improve school climate and student engagement
  • Develop a true system of care addressing spectrum of need regardless of economic (low wealth or high wealth) and social barriers (language, culture, geographic location)

Expected Student Outcomes (Including but not limited to):

  • Increase student wellness
  • Improve academic performance (Grades, SBAC test scores, A-G rates, etc.)
  • Improve Social Emotional Development
  • Impact preparedness for college and careers
  • Improve stress management skills
  • Develop skills for accessing health services
  • Reduce use of alcohol, tobacco, and drugs
  • Reduce mental illness stigma
  • Reduce suspensions, expulsions, and office referrals
  • Reduce truancy and chronic absenteeism
  • Reduce suicidal ideation

Additional Information

There is a growing body of knowledge on teacher burnout and compassion fatigue, also referred to as secondary traumatic stress (Hatcher et al., 2011). Teacher burnout can lead to emotional exhaustion, depersonalization, and a sense of a lack of personal accomplishment (Maslach et.al., 1981), and can even lead some teachers to experience mental health issues (Chan, 2006). Teacher burnouts have negative impacts to affective student learning and motivation (Zhang and Zapp, 2008). Research findings, examined by Koenig (2014), suggest that burnout factors can be contagious for emotionally empathetic teachers and should be addressed to protect teachers, and in turn, provide reciprocal support to students. Numerous quantitative and qualitative studies on compassion fatigue and teachers, examined by Koenig (2014), have shown significant levels of compassion fatigue in special education, juvenile justice education, and education settings in areas with high Native American populations. However, Koenig (2014) calls for further study on compassion fatigue, as the above examples were difficult to generalize to the broader teaching population. While no research examining the impact of compassion fatigue on student learning was evident, Koenig (2014) suggests that student learning must be negatively impacted by teacher burnout factors, regardless of the teachers’ student population.

The proposed comprehensive Student Wellness Center (SWC) project at Orange County middle schools will provide self-care and training/professional development supports to middle school teachers to align with student mental and physical health services. A self-care resource at the wellness center would include a tablet with mindfulness apps and a space to practice mindful breathing and other related exercises.

 

June 8, 2018

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How is this idea different from the Wellness Centers within San Francisco High Schools?

The proposed SWCs aim at earlier Intervention/Prevention in reducing the stigma of identifying and treating mental health issues, and accessing services to address vulnerabilities that come with early adolescence. This will provide the opportunity for students to practice and incorporate the skills needed for a healthy lifestyle before entering the additionally stressful high school setting.

The Orange County SWC model is innovative in that it proactively addresses middle school student needs, which evidence indicates are vulnerable to risk factors (fifty percent of chronic mental health illnesses begin by the age of 14). The proposed SWCs have the potential to reach a much larger number of students and sites (16,000 high school students at 19 sites in SFUSD vs. 113,000 middle school students at 87 sites in OC).

What needs assessments have been utilized in school districts and how will this needs assessment for this project be different?

Rialto’s R.I.S.E looked at discipline data such as Office Discipline Referrals (ODRs), suspensions, and expulsions. Group surveys were also used to assess indicators of school climate and Schwarzer’s Self-Efficacy Scale. Goals focused on reducing/improving benchmarks in these areas.

San Francisco Unified School District (SFUSD) contracts with ETR Associates for evaluations/surveys and uses data to guide their service needs. Evaluations consist of the following: Student Individual & Group Satisfaction Surveys; Staff Satisfaction Surveys; and Focus Groups. The professional development, capacity building, and technical assistance offerings through ETR, while holistic in nature, focus on organizational development to implement a program, curriculum, or strategy. Staff Satisfaction surveys only address reported changes in student behavior, school climate, and [teacher] capacity to support students. Orange County’s SWCs will focus on assessing teacher wellness needs directly with respect to stress management, resiliency promotion, and mindful awareness practices.

Orange County’s SWCs will assess school community needs at each site to determine degree of intervention counseling, youth outreach leader training, and nutrition education needed. Process and impact evaluations, pre- and post-tests, surveys, focus/discussion roundtables, photo documentaries, and case studies may be used. Each SWC will also assess middle school teacher wellness needs and provide tailored self-care and training/professional development supports for middle school teachers that aligns with their students’ mental health services.

Orange County is sorely lacking in school-connected centers that support student’s mental and physical health needs. However, like the rest of the country, OC is experiencing far too many attempted and completed suicides in our youths, as well as seeing an unprecedented number of diagnoses of anxiety and depression in our students. Additionally, many of our teachers are stressed and overwhelmed; as such they are not adequately equipped to provide the interventions that will help students that are struggling, and will also be compromised in their ability to provide effective instruction.
Schools are trusted entities in the community. By offering on site support services; students (and staff) are much more likely to avail themselves of available resources when they are comfortable with and secure in the institution offering them.
The recent and all too common violence that we have seen in our country’s schools is only one indicator of how badly needed student support services are. There are far too many students that are suffering emotional distresses in silence, and are slipping through the educational system’s cracks while never coming close to achieving their academic potential.
Offering our county students and the dedicated teachers of OC help, resources, and education via Wellness Centers to ensure their health and well-being, and subsequently increasing the chances of academic success, is a win-win for all; the teachers, the students, and our community as a whole.

Innovation:
• How is this innovative or different from other wellness center models that currently exist (emphasizing the Mental health aspect)?
Orange County’s SWC will provide a localized approach to providing on-site, school-based mental health services and coordination of care, with the capacity to leverage countywide partners and resources.
The Mental Health Services Act identifies fragmentation of mental health services as a key finding and declaration. The OC middle school SWCs will aim to bring together adolescent health services to the school site. Particular attention will be focused on ensuring SWCs provide unimpeded access to mental health care and recovery services, remain connected to the students and their families, and promote clear navigation of the mental health care system. SWCs will also promote restorative practices to strengthen positive school culture and enhance pro-social relationships within the school community. This innovative approach will serve the following purposes: 1) Increase access to underserved groups (particularly Latinx adolescents); 2) Increase the quality of services, including better outcomes; 3) Promote interagency collaboration; and 4) Increase access to services. The SWC model will use data to identify the level of student’s needs and offer mental health services accordingly on a continuum of care spectrum: Tier I (Universal – schoolwide support for all students); Tier II (Supplemental – group counseling and one-to-one support); and Tier III (Intensified – crisis-level support). Tier III service offerings may be referred to a partner organization that has an established presence and familiarity in the school-based setting.
The SWCs will also focus on connecting physical health to mental/emotional health. Evidence from the National Alliance on Mental Illness (2009) shows that increased physical exercise may provide some benefits to treating depression, the most common type of mental illness reported by adolescents. Physical symptoms are common for many anxiety disorders, including chest pains, palpitations, shortness of breath, dizziness, syncope, nausea, vomiting, recurrent abdominal pain, as well as disturbances in sleep patterns, appetite, and energy levels. Bringing in clinician support and providing restorative justice processes as an alternative approach will aim to improve these ongoing problems.
SWC staff will connect the student and families to appropriate community resources and continue case management as necessary to ensure the student receives the care needed. Local community and hospital organizations that provide outpatient services as well as family resource centers throughout Orange County have expressed interest in working with OCDE’s proposed middle school SWC model. A potential partnership with these organizations would include a staff sharing arrangement to provide on-site school-based mental and physical health services and, where needed, a direct line for referrals.
• How will the 5 districts work together to improve outcomes?
Participating districts would attend the Community of Practice (CoP) for Orange County districts who have completed the California Multi-tiered Systems of Support (CAMTSS) series. Through this CoP, ongoing technical assistance would be provided to each SWC for behavioral and social emotional learning (SEL) services needed. OCDE has expertise in Trauma-Informed Practices, including Certified Trainers in Restorative Practices who provide regional trainings in Basic Restorative Practices, Community Circles, and Restorative Conferences. OCDE also has trained trainers in the Eliminating Barriers to Learning evidence-based curriculum on student mental health and the Cultural Competency approach. Through its work in CAMTSS, OCDE coordinates PBIS professional learning trainings and provides consultation and technical assistance for over 250 county schools and a countywide PBIS Sustainability Schools’ Network. OCDE also has experience in building school districts’ capacity for prevention and early identification of student mental health issues.
• How does it meet the Mental Health focus?
The Mental Health Services Act declares that untreated mental illness is the leading cause of disability and suicide. The Orange County SWCs aim to bring client-centered, family-focused, and community-based services that are culturally and linguistically competent and are provided in an integrated services system, starting in the school setting. The Act identifies this integrated services model as a successful program approach. In addition to a full-time SWC Coordinator (Masters of Social Work background) – responsible for managing facility, staff, and service offerings – a Program Director (Licensed Clinical Social Work background) would be considered for coordinating the entire program across all SWCs.
Learning Objectives:
• What will they/we be able to learn from this project that enhances the system of care in the county of orange?
This innovative project will aim to improve attendance, achievement, school climate (suspension and expulsion rates), mental health of middle school students (pre- and post- evaluations), coordination of services for students/families, coordination/collaboration of schools/districts to improve the practice of using a SWC model, and for sharing best practices between districts. SWCs will be part of a broad network of support, beginning with a cadre of SWC Coordinators who can discuss best practices. Capacity building for a network of school social workers, school nurses, and school counselors will help align its services and resources to existing providers in the community. A regional or county collaborative will be created with the districts implementing the SWC model and the partner service providers and organizations will meet regularly to coordinate and improve services and communication. This system of care will bring together concerned adults who interact with and care for adolescents to better understand early warning signs. At the same time, the SWCs can serve as a venue to provide caring, supportive relationships, encourage healthy behaviors, and teach effective coping strategies.
• How will these time limited dollars for this project eventually be sustained by district?
LCFF can be used for school-based mental health programs and staff, including social workers, counselors, nurses, and psychologists. Additional support will include: in-kind services; partnerships to reduce cost burden on districts; school foundation dollars; and local grants. The state priorities most linked to student mental health include pupil engagement as measured in part by attendance, and school climate as measured in part by suspension and expulsion rates.
• Why middle school students?
The Mental Health Services Act defines transition age youth as between the ages of 16 to 25. However, there is overwhelming evidence that suggests warning signs of mental health issues begin to develop as early as ages 12 to 14. Adolescence is a critical time when many mental disorders first arise, and medical science recognizes a vital link between a person’s physical health and his or her mental health. More than half of all mental disorders and problems with substance abuse (such as binge drinking and illegal drug use) begin by age 14. In Orange County, many community stakeholders agree that adolescents between 12 and 14 years of age are one of the populations with higher mental health needs, particularly Latinx adolescents. School health centers are often helpful in identifying the mental health care needs of adolescents, providing access to students in low-income and underserved communities who are more likely to be without health insurance. The proposed middle school SWCs will provide culturally and linguistically competent approaches for underserved populations. Services will be developed in partnership with youth and their families so that they are culturally competent and individualized to the strengths and needs of each child and his or her family.

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