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Introduction

By the time students enter Frank Church, an alternative high school for at-risk teens in Boise, life for them has been anything but easy. All have endured crushing challenges — including homelessness; sexual, physical and emotional abuse; parental addiction; domestic violence; foster care; divorce; and poverty.

Not surprisingly, many of these students also have serious, untreated behavioral health issues.

Until recently, staff struggled mightily to help these students. But many students’ issues were so profound that a few sessions with a school social worker or counselor were not enough to make a lasting difference.

“I felt like we were putting on Band-Aids or plugging up a leaky bucket,” says Amy Rust, a social worker at Frank Church. “Students really needed a higher level of care.”

So Optum stepped up.

Working with local educators, Optum, the managed care contractor for the Idaho Behavioral Health Plan through Medicaid, launched a pilot program in September 2018 that placed behavioral health care providers on site at Frank Church and six area elementary schools for 14 months.

All were community schools that offer essential health and social supports as well as other services. The goal was to have a clinician at school for a least one day per week.

As word about the Optum effort rippled through academic circles, several other schools, including Parma High School, on their own also brought therapists to their schools.

The need

Though students at Frank Church are exceptionally challenged, recent data shows significant mental health issues affect youth and teens across all demographics in Idaho.

A snapshot of Idaho high schoolers in distress emerges in the results from an anonymous survey developed by the Centers for Disease Control and Prevention and conducted by Idaho’s State Department of Education in 2019 — even as survey officials concede the outcomes are likely understated.1

Having already dropped out of school, many high-risk teens did not participate in the effort. The results are based on student experiences in the 12 months before taking the survey.

About 39% of students reported feeling so sad and hopeless almost every day for two weeks or more that they stopped doing some of their usual activities. And one in 10 students attempted suicide one or more times.

Idaho has one of the highest suicide rates in the nation. “We are number 7 per capita for suicide for adolescents and adults,” says Dr. Dennis J. Woody, a pediatric neuropsychologist and senior clinical program consultant for Optum.

Other behavioral health issues affect children, adolescents and youth across the state. About one in five children and teens have a diagnosable mental health condition, most commonly anxiety, ADHD, and mood or aggressive behavior disorders. About half that number, overall one in 10, have serious emotional disturbance that disrupts their daily functioning, estimates the Idaho Department of Health and Welfare.2

Suicide among Idaho’s young

For several years, the suicide rate among the state’s youth and teens has climbed steadily.

The Idaho Bureau of Vital Records and Health Statistics tracked the suicide rate among children, adolescents and youth from 2009  to 2018. During that time, the number of teens, ages 15 to 19, who took their lives tripled — from 10 to 30. For youth, ages 20 to 24, the rate more than doubled, from 22 lives lost to 48.3

In 2017, suicide was the second leading cause of death among youth ages 10 to 19 in Idaho.4

Impact on school

Schools across the state feel the fallout of untreated behavioral health and emotional issues — poor attention, failing grades, disruptive conduct and disciplinary problems.

Most schools lack the training to identify children in distress. So, not every teacher sees a student’s defiant behavior as a red flag for a mental health or emotional issue. “If you have experienced traumatic stress as a child, your initial response is likely to be anger,” explains Dusti Huddleston, LMSW, a therapist at Real Solutions Counseling and on-site clinician for Frank Church.

Distracted behavior and failing grades may signal ADHD or a more serious mental health condition. “Imagine having to solve a math problem when you are grappling with thoughts of not wanting to be here, wanting to die,” says Ms. Huddleston.

Even if they identify students in need, schools lack the long-term resources to assist them. When Monique Jensen became principal at Parma High School in 2018, she collected data on student trauma. The results were sobering: 52% of her 340 pupils “had real trauma in their lives” but couldn’t get services to work through these issues.

Many of the students’ parents worked in low-paying jobs in the area’s agricultural business. About 68% of the students received reduced or free lunches.

“In order for our kids to be successful academically, we knew that we needed to address these issues first,” says Ms. Jensen.

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The barriers

Many students with mental health issues are unable to get the care they need. At Parma High School, counselor Cory Anne Fortin referred multiple students for outside counseling. But the nearest behavioral health provider was at least a 30-minute drive away.

And that distance became a barrier to parents. “The families would say, “I can’t take off work.” Or, “I can’t afford the gas to drive them to counseling.” Others lacked insurance. The option of a ride service also meant likely missing a half-day of school — another deal-breaker.

Some families didn’t recognize that their child was struggling and needed help. Stigma about having a mental health concern also plays a role in a community that values “rugged independence.” “Students are struggling more than they let on. Because it’s not considered OK. There are a lot of barriers that you don’t really think about,” observes Mrs. Fortin.

Overcoming the barriers, with a helping hand and more

Early and appropriate intervention is key, says Dr. Woody. About 50% of all mental health disorders begin before age 14, and 75% before age 24.5 If left untreated, many disorders affect kids’ ability to learn and function in school.

“It’s pretty clear that kids with mental health problems are more likely to drop out,” says Dr. Woody. “If you can put a mental health clinician in school, we can get a kid into treatment three years earlier than without that help,” Dr. Woody says. “Not only will students get treatment sooner, they will get the coping skills to help them resolve the problems that drive them away from school.”

In fact, young people with access to mental health services in school-based health centers are 10 times more likely to get the care they need than those who do not.6 Research also shows that children and teens who are treated tend to do better as adults.

Addressing distance. Fed from the city’s four other high schools, all Frank Church students are bused to campus located in a subdivision in West Boise. “It’s not very accessible,” says Ms. Rust. So, having therapists on site was essential at Frank Church and Parma, as well as the other schools in the Optum pilot program.

Addressing financial need. The providers at Frank Church and other schools in the pilot program have all been part of the state’s Medicaid network. Many of these students were Idaho Medicaid program members; their therapy cost was absorbed by Medicaid. For students without insurance, Optum pitched in.

Addressing stigma. At Frank Church, therapy became yet another offering from the cluster of services that the community school offers — food bank, clothing, twice-yearly dental care, and so on. “There wasn’t a whole lot of stigma surrounding it,” says Ms. Rust. “We have a food bank. No one really cares about kids walking through halls with bags. Everybody is struggling.” 

At Parma High School, officials used a color-coded, permission slip system to disguise visits to the therapist, reports Ms. Jensen. “On the other end, we also have been in the classroom where kids would get a call slip and they would say, ‘It’s time for me to go counseling’ and when they come back it’s just a normal day.”

Initially, Ms. Jensen expected some backlash and bullying about the counseling, but none occurred. “I talk to our student body all the time about being kind and helping each other.”

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Healing the wounds

For several years, Ms. Rust and her co-workers had worked at a relentless pace, tending to students in need and gaining their trust; they embraced help from Optum. “With a therapist we have a better shot at healing the wound rather than just putting a Band-Aid on it,” says Ms. Rust.

When therapist Dusti Huddleston arrived at Frank Church last August, she quickly transformed an office into an oasis of care with green plants, soft lighting, Zen rock gardens and cozy chairs. Initially, she worried that the students might not be so open to her help.

But with Ms. Rust acting as a bridge between her and the students, her fears proved unfounded. “I was surprised at how willing they are to participate in therapy,” says Ms. Huddleston. "For the most part, the kids wanted 100% in. And they wanted their families involved.”

From the start of school to its abrupt dismissal due to the COVID-19 pandemic, Ms. Huddleston saw a total of 89 students, carrying an average weekly caseload of about 25 students. Ms. Rust, the school psychologist, two other counselors, the nurse and other staff serving the students referred the students.

In some cases, students sought help themselves and for their friends. A waiting list developed, and a second therapist was brought on a month before the pandemic closure.

“We knew the need was there,” says Ms. Rust.

Students are resilient and brave

Trained in trauma therapy, Ms. Huddleston is amazed at how students have responded to the distressing events in their lives.

“The amount of student resilience is extraordinary, despite the challenges that they have been faced with in life,” says Ms. Huddleston. She ticks off common experiences: physical and emotional abuse, sexual violence, incest, trauma due to separation because of immigration status, foster care, neglect, witnessing parental addiction and violence in the home.

“I have kids that have a list of things that have happened to them. Most people couldn’t imagine going through one of them.”

Though at times the therapy was difficult, students made the most of their sessions. Observes Ms. Rust: “What surprised me was the students’ willingness to engage in therapy and deal with long-kept secrets. That they were so willing to face some demons.”

Their perseverance and courage touched her. “My kids are the best,” she says. “They are some of the grittiest human beings. They are raw and real. And I learn more from them about how to deal with adversity.”

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Successes

The therapy produced changes, large and small. Students became sober. Many got off probation. Moods lifted.

“You see these huge shifts with these kids. Their load is lightened,” says Ms. Rust. One high-risk student, his life characterized by drugs, drinking and legal problems, shut down at school. But working with Ms. Huddleston, says Ms. Rust, “he lifted his head up and made eye contact.” 

Another young man, known for his angry outbursts, began to regulate his ire. “The whole school remarked on his change,” she says. Teachers also noted academic progress. “I asked 'so-and-so' to do a lab project. For the first time ever, they were able to do it,” one teacher told Ms. Rust.

At Parma, Ms. Jensen has seen fewer discipline issues. “Now they have an outlet and can focus in the classroom. They are not lashing out at another student or teacher.” Grades improved. So did students’ demeanor and attire. And students showed a new kindness to each other.

At Frank Church, Ms. Huddleston watched five of her clients graduate. “It was a huge success. They didn’t think that they could do it — to have a life outside of the pain they were in.” Another less visible victory: a student now able to tell her mother when she felt suicidal or wanted to cut.

To prepare them for life after therapy, Ms. Huddleston helped her students learn how to identify and seek help from a caring adult in their life.

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The future

The pilot program ended in December 2019, helping 180 students overall. Some participating schools as well as others not in the pilot continued to keep clinicians on site. But in March, the COVID-19 pandemic shut down the schools and their on-site therapy.

For 2020–2021, Parma, Frank Church and other schools are planning to offer therapy services again.

“In small-town, rural Idaho this is one of the most powerful tools that you can use in your toolbox,” says Ms. Jensen.

The pilot program revealed best practices for starting and operating school-based services. The goal: create an overall framework that integrate mental health providers, school staff, families and other community partners into a single system of support. Within that framework, adopt an evidence-backed, three-tier strategy.

Using a variety of simple strategies, the first tier promotes positive mental health across the entire student body and screens all students for mental health concerns. At tiers two and three, students identified with emotional and psychological issues receive graduated interventions, with the most seriously affected, receiving one-on-one treatment with behavioral health providers.

“We want to light the fuse and provide direction on how to get started,” says Dr. Woody.

By December, Optum plans to hold a free webinar, followed by a one-day, in-person session and distribution of a “toolkit” to schools, providers and other community partners throughout the state.

Overall, the Optum instructional effort provides step-by-step help for setting up the overarching framework, including creating a team, assigning roles to each member, establishing how and when they will communicate and meet, and assessing outcomes. Also included: identifying existing resources and income streams.

The pilot program, for example, highlighted a major challenge: finding sources to reimburse care for students who are under-insured or without public or private insurance. Schools will have to tackle another hurdle: securing funds to reimburse therapists for time spent at Individualized Education Plan and other school meetings involving students in their care.

Research shows that effective programs incorporate therapists into school life. Case in point: Ms. Huddleston brought invaluable insights to the school team that addressed students’ behavior issues. “The student is struggling because mom is an alcoholic and the student is afraid to leave her,” recalls Ms. Rust. “It softened the response.”

In the pilot effort, Ms. Huddleston’s agency comped her for time at meetings. “Realistically, you are not going to be able to do good care unless you integrate into the school,” says Jim Grigg, LMFT, LCPC, clinical director at Real Solutions.

As for Ms. Rust, she is looking forward to helping students again in the coming year. “I am so grateful that we have this program. We are so lucky to have it at our fingertips.”

Three-tier strategy for school-based programs

Based on national data, the most successful school-based initiatives use a three-tier strategy, backed by evidence-based practices that respond quickly to students in need.

  • Tier 1: Programs for all students that use positive behavioral expectations to improve academic performances and reduce disciplinary problems; also, screen all students for behavioral and mental health issues.
  • Tier 2: Group interventions for students identified as at-risk; with support, the goal is to return these students to Tier 1.
  • Tier 3: One-on-one care with behavioral health providers for students with significant behavioral, emotional and academic issues.

References:

  1. State of Idaho Department of Education. Idaho youth risk behavior survey, 2019. sde.idaho.gov/student-engagement/school-health/files/youth/Youth-Risk-Behavior-Survey-Results-2019.pdf. 
  2. Idaho Department of Behavioral Health and Welfare. When your child has a serious emotional or behavioral disorder. healthandwelfare.idaho.gov/Default.aspx?tabid=480. 
  3. Suicide Deaths: Idaho Residents, 2014–2018, Idaho Department of Health and Welfare, Division of Public Health, Bureau of Vital Records and Health Statistics, December 2019.
  4. Community Suicide Prevention. Facts and statistics about suicide: Idaho state facts. communitysuicidepreventioneid.org/facts/. 
  5. Child Mind Institute. 2016 children’s mental health report. childmind.org/report/2016-childrens-mental-health-report/. 
  6. Kaplan DW, Calonge BN, Guernsey BP, Hanrahan MB. Managed care and school-based health centers: Use of health services. Archives of Pediatrics and Adolescent Medicine. 1998;152:25–33.

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