Program Evaluation: Hawaii Department of Education School-Based Behavioral Health Program
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This report examines the systemic issues (legal, educational, clinical, administrative), that impact this approach and the strengths and weaknesses of the present model of service provision. It will outline suggestions for system change within DOE, and will describe changes that will be necessary in other systems in order for DOE activities to yield the greatest benefit.
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The state of Hawaii has undertaken an unprecedented move towards ensuring full access to children’s mental health services. Within the last few years, the bulk of outpatient services have been under the oversight of the Department of Education (DOE). This report examines the systemic issues (legal, educational, clinical, administrative), that impact this approach and the strengths and weaknesses of the present model of service provision. It will outline suggestions for system change within DOE, and will describe changes that will be necessary in other systems in order for DOE activities to yield the greatest benefit.
I have reviewed Pauli Schick’s proposal for SBBH system redesign. In order to make recommendations about switching to this administrative model, it is necessary to first address the “bigger picture” context issues in which SBBH operates. As these issues are very complex and interrelated, I will describe the nature of these issues, their impact on DOE and SBBH, and possible first steps in addressing their implications. Finally, I will address the redesign proposal within this framework.
Overview of School-Based Mental Health
In order to objectively review the strengths and weaknesses of the SBBH program, it is helpful to compare it to best-practices methods of addressing students’ mental health disorders.
Ideally, a school-based approach has the following components:
I have reviewed Pauli Schick’s proposal for SBBH system redesign. In order to make recommendations about switching to this administrative model, it is necessary to first address the “bigger picture” context issues in which SBBH operates. As these issues are very complex and interrelated, I will describe the nature of these issues, their impact on DOE and SBBH, and possible first steps in addressing their implications. Finally, I will address the redesign proposal within this framework.
Overview of School-Based Mental Health
In order to objectively review the strengths and weaknesses of the SBBH program, it is helpful to compare it to best-practices methods of addressing students’ mental health disorders.
Ideally, a school-based approach has the following components:
- The school system partners with other systems (Public Health, Social Services, Juvenile Corrections, community physicians, community mental health providers, health plans, etc.), and each system takes responsibility for their share of addressing students’ and their families’ mental health needs.
- Students’ mental health disorders are identified early in the course of their development, and treated before emotional, behavioral and academic problems become severe. If their disorders are treated in the pre-referral stage, some students will not require Special Education evaluations or services due to their significant improvement.
- All efforts will be made to assure that Emotionally Disordered students are not untreated, under treated or inappropriately treated for their mental health disorders, if such disorders are present. This avoids the all to common situation of failed behavioral interventions in Special Education.
- IEPs provide accommodations and modifications based on the underlying causes of a student’s difficulties rather than on the external behavioral manifestations of those causes. Services are tailored to each student’s unique needs
- Behavioral interventions are applied in situations where students’ difficulties stem from functionally inappropriate behavioral responses. When behavioral problems stem from psychiatric disorders, the disorders are treated effectively.
- Services are provided on-site, being user-friendly to families, school staff and the students
- Educators, administrators, social workers, psychologists, health aides, counselors and other school professionals have clearly defined roles in regard to their activities with students who have mental health disorders
- All school staff have training in the nature of behavioral and mental health difficulties seen in at-risk and affected students
- Data is collected and analyzed to provide a clear picture of individual student’s needs, and of the collective needs of all students who are served. Data includes level of functioning, academic progress, behavioral difficulties, mental health symptoms, health and mental health diagnoses, etc.
- All necessary information is documented while maintaining data privacy and confidentially
- Cost-shifting is avoided, and all available funds are tapped for provision of services
- Legal and financial firewalls are maintained between the school district and outside systems that provide mental health diagnostic and treatment services.
- Clear lines of supervision are maintained. This allows for system efficiency, improved quality control and greater accountability while avoiding duplication of efforts, redundant budgets, and inconsistent practices of supervisees.
- Services are provided in a culturally-sensitive manner, with active family and community participation in the process..
DOE and DOH programs do not provide a full spectrum of children’s mental health services. DOE services are essentially based on IEPs or 504 plans. Thus, for example, if a student suffers from an eating disorder or a mood disorder, but is not manifesting problems that adversely affect his/her education, then SBBH services will not be provided.
Hawaii is clearly ahead of most states in the U.S. in many of these areas, and there is a clear commitment at the state level to address students’ mental health needs. The SBBH program has gone a long way in this regard. The goal of this report is to assist the Hawaii DOE in preserving the gains made to date, while moving forward to increase system effectiveness and reduce system liability.
Background
It is assumed that the reader of this report is familiar of the history of the development of a children’s mental health infrastructure that resulted from the Felix Consent Decree in the early 1990’s and from subsequent legal decisions. Briefly, it was found that there was a dearth of services for at-risk and affected children and adolescents, and the State responded by providing funds to rectify this situation. In the last few years, most of the outpatient services funds and personnel were transferred from the Department of Health (DOH) to DOE. DOH continues to provide more intensive services, and also provides some less-intensive outpatient services for Medicaid (MedQuest) patients and for other categories of students in need of services.
Accompanying the transfer of outpatient services to DOE was the conceptual reframing of the nature of these services. There was a perception that the medical model had disadvantages, being diagnosis-based, in that many students who may not have been diagnosable could benefit from school-based behavioral interventions. For other students who may have been diagnosable, but whose parents may have chosen to not seek mental health diagnosis or treatment, school-based services would still be available.
Also, the CSSS model has been adopted. Its goal is to assure services at all levels of problem severity, from minimal supportive services available for level 1 students to inpatient hospitalization for level 5 students. School-Based Behavioral Health (SBBH) staff replaced a number of previously contracted positions, and focused mostly on the more severe population. However, they have also been available for service provision for the less severe population of students as well.
Contracts have been written with providers for provision of a variety of mental health services. The reimbursement rate for these contracts has been significantly higher that rates paid by MedQuest. As a result, there have been numerous instances of parents being encouraged by community mental health and medical providers to have mental health services provided through the DOE contracts. There are few non-DOE, non DOH-funded community mental health services for children and adolescents that provide outpatient individual therapy. Thus, one of the unfortunate consequences of the Felix decree has been the dearth of non-DOE, non-DOH children’s mental health services in Hawaii.
DOE and DOH programs do not provide a full spectrum of children’s mental health services. DOE services are essentially based on IEPs or 504 plans. Thus, for example, if a student suffers from an eating disorder or a mood disorder, but is not manifesting problems that adversely affect his/her education, then SBBH services will not be provided.
Mission of Project
Given that the present system has developed from a patchwork of agreements, transferred services, and transformation of non-educational activities into an educational system, the challenge for DOE is to execute its educational mission while at the same time addressing students’ mental health and medical needs. It will be necessary to ensure that DOE has a system that consistently identifies students who have educational difficulties, behavioral problems and/or mental health disorders and assures that the necessary services are available. This report will address methods of sustaining efforts to assure that students who have mental health needs will continue to receive services. The ultimate goal will be a gradual system transformation that provides better legal and financial firewalls, a broader range of mental health services, and an efficient service model that uses resources wisely and prudently.
An Educational/Behavioral Approach vs. a Clinical Approach?
The basic issues for SBBH to address are:
A review of the Felix Decree suggests that, at the time of the decree, there were minimal children’s mental health services available in the state of Hawaii. Funding was increased dramatically, and a wide array of services, including outpatient treatment, day treatment, residential treatment and inpatient hospitalization were expanded. Initially these were provided by DOH, more recently, outpatient services by DOE.
Although related services are defined in IDEA as services that are needed to educate a student with a disability, the services provided under the Felix Decree often go beyond what would be considered a related service in other states. The definitions of the roles of social workers and psychologists have also been expanded from the IDEA descriptions (appendix #1) to include a significant degree of direct services to students who have mental health disorders.
There are a number of advantages to having DOE provide direct school-based services to students who have mental health disorders.
These include:
There are also a number of disadvantages. These include:
Background
It is assumed that the reader of this report is familiar of the history of the development of a children’s mental health infrastructure that resulted from the Felix Consent Decree in the early 1990’s and from subsequent legal decisions. Briefly, it was found that there was a dearth of services for at-risk and affected children and adolescents, and the State responded by providing funds to rectify this situation. In the last few years, most of the outpatient services funds and personnel were transferred from the Department of Health (DOH) to DOE. DOH continues to provide more intensive services, and also provides some less-intensive outpatient services for Medicaid (MedQuest) patients and for other categories of students in need of services.
Accompanying the transfer of outpatient services to DOE was the conceptual reframing of the nature of these services. There was a perception that the medical model had disadvantages, being diagnosis-based, in that many students who may not have been diagnosable could benefit from school-based behavioral interventions. For other students who may have been diagnosable, but whose parents may have chosen to not seek mental health diagnosis or treatment, school-based services would still be available.
Also, the CSSS model has been adopted. Its goal is to assure services at all levels of problem severity, from minimal supportive services available for level 1 students to inpatient hospitalization for level 5 students. School-Based Behavioral Health (SBBH) staff replaced a number of previously contracted positions, and focused mostly on the more severe population. However, they have also been available for service provision for the less severe population of students as well.
Contracts have been written with providers for provision of a variety of mental health services. The reimbursement rate for these contracts has been significantly higher that rates paid by MedQuest. As a result, there have been numerous instances of parents being encouraged by community mental health and medical providers to have mental health services provided through the DOE contracts. There are few non-DOE, non DOH-funded community mental health services for children and adolescents that provide outpatient individual therapy. Thus, one of the unfortunate consequences of the Felix decree has been the dearth of non-DOE, non-DOH children’s mental health services in Hawaii.
DOE and DOH programs do not provide a full spectrum of children’s mental health services. DOE services are essentially based on IEPs or 504 plans. Thus, for example, if a student suffers from an eating disorder or a mood disorder, but is not manifesting problems that adversely affect his/her education, then SBBH services will not be provided.
Mission of Project
Given that the present system has developed from a patchwork of agreements, transferred services, and transformation of non-educational activities into an educational system, the challenge for DOE is to execute its educational mission while at the same time addressing students’ mental health and medical needs. It will be necessary to ensure that DOE has a system that consistently identifies students who have educational difficulties, behavioral problems and/or mental health disorders and assures that the necessary services are available. This report will address methods of sustaining efforts to assure that students who have mental health needs will continue to receive services. The ultimate goal will be a gradual system transformation that provides better legal and financial firewalls, a broader range of mental health services, and an efficient service model that uses resources wisely and prudently.
An Educational/Behavioral Approach vs. a Clinical Approach?
The basic issues for SBBH to address are:
- What are mental health related services on IEPs?
- Which students should receive them, and under what circumstances? How should they be provided?
- What are the legal, clinical, educational and political implications of provision of these services by DOE employees?
A review of the Felix Decree suggests that, at the time of the decree, there were minimal children’s mental health services available in the state of Hawaii. Funding was increased dramatically, and a wide array of services, including outpatient treatment, day treatment, residential treatment and inpatient hospitalization were expanded. Initially these were provided by DOH, more recently, outpatient services by DOE.
Although related services are defined in IDEA as services that are needed to educate a student with a disability, the services provided under the Felix Decree often go beyond what would be considered a related service in other states. The definitions of the roles of social workers and psychologists have also been expanded from the IDEA descriptions (appendix #1) to include a significant degree of direct services to students who have mental health disorders.
There are a number of advantages to having DOE provide direct school-based services to students who have mental health disorders.
These include:
- Services are on-site, and user friendly to families and students.
- Awareness is raised among school professionals about the impact and implications of students’ mental health disorders.
- Services can be more easily coordinated.
- There is greater opportunity to identify disorders that are treatable by psychiatric intervention, with treatment resulting in improved school performance, less behavioral difficulties, and reduced educational costs.
- IEP teams have members who are directly familiar with students’ emotional needs.
- There is greater ability to oversee quality control, follow protocols for interventions, measure outcomes, and provide consistent supervision.
There are also a number of disadvantages. These include:
- There is a lack of confidentiality of very private information, as all records regarding a student’s mental health issues are ultimately school records. These records are private, not confidential; parents have access to information that might be withheld, for clinical reasons, by an independent mental health professional. Parents also have concerns about private family and student information being recorded in school district files.
- If a DOE staff refers a Special Education student for a mental health evaluation and/or treatment, the District is the payer of last resort for those services. This may not be the case if the referral is made by a professional working for another system (e.g. a County public health nurse).
- The district is responsible for payment of services. If third party billing is done, the district is required to develop an infrastructure to do this.
- DOE-provided services results in a disincentive for the development of a community mental health infrastructure, resulting in DOE services, by default, becoming the major provider of children’s mental health services in the state.
- SBBH staff who have inadequate training to address the needs of severely psychiatrically disturbed students may not intervene appropriately when clinical symptoms dictate certain clinical responses.
- Behavioral Specialists described an alarming frequency of significantly dangerous behaviors exhibited by a number of students, including suicide attempts that were nearly fatal. If there were problems in service provision (lack of documentation, lack of definition of role of the Behavior Specialist, provision of behavioral interventions when clinical interventions were necessary, lack of referral for psychiatric treatment despite evidence of a potentially fatal psychiatric disorder, etc.), the district would be in significant legal and financial liability. If the district remains self-insured, without malpractice coverage, a multi-million dollar lawsuit would be highly problematic.
There is no ‘function’ to the irritability of Bipolar disorder any more than there is a ‘function’ to the irritability caused by low blood sugar in diabetics.
The shift of focus from the medical model to the educational model creates a number of educational, clinical and legal challenges. There are a variety of causes of psychiatric disorders. These include:
This latter group of disorders are essentially medical/biological disorders, and are often minimally responsive to behavioral interventions. Also, a functional behavioral analysis may mistakenly identify the source of their manifestations as behavioral in nature, when in fact the problem stems directly from the disorder itself. Thus, there is no ‘function’ to the irritability of Bipolar disorder any more than there is a ‘function’ to the irritability caused by low blood sugar in diabetics. Although Functional Behavioral Analyses can be helpful in delineating antecedents to dysfunctional behaviors, they are problematic when behaviors stem directly from the psychopathology of a psychiatric diagnosis. It is important for FBAs to have an option of “none of the above” in regards to potential behavioral antecedents or functions of maladaptive behaviors.
DOE and SBBH are standing with feet on two sides of a philosophical divide- Although mental health diagnoses been reframed as behavioral manifestations, and mental health treatment has been reframed as behavioral interventions, DOE is also involved in referral of some students for psychiatric diagnosis and in the payment for psychiatric treatment. This raises significant liability issues, as a student at one site with behavioral manifestations of clinical depression may be referred for a psychiatric evaluation, whereas a student with the same symptom cluster at another site may receive behavioral interventions only and not be referred for diagnosis or clinical treatment. If the second student were to commit suicide (the SBBH staff reported a number of recent near-suicides on their caseloads, so this is not a theoretical issue), DOE would have significant legal and financial liabilities. This issue is of special concern, given the frequency of suicidal behaviors noted in students served by SBBH staff, and given the fact that approximately one quarter of the students served by SBBH had documented evidence on BASC screening of clinically significant depression.
Also, if a student has a psychiatric disorder that would respond to treatment, it is problematic to have a model whereby behavioral interventions must fail before a referral for a diagnostic evaluation is requested. I recognize that early referrals may occur for more severely disturbed students, but it is my understanding that, in general, referrals for diagnosis and treatment generally only occur after school-based behavioral interventions are unsuccessful. Ideally, there would be a method of screening and triage, separating individuals who require diagnosis and treatment early on in the process.
It is inappropriate to assign clinical services to the more severe cases, and behavioral services to the less severe ones, because some of the less severe situations are at risk of becoming more severe without clinical interventions. (This model is equivalent to providing a humidifier to a patient with mild tuberculosis, and antibiotics to a patient who has severe T.B.). Referral based on symptom severity (providing behavioral interventions to the less severe students while referring the more severe students for clinical evaluation and treatment) is not consistent with the course and development of many psychiatric disorders. Ideally, disorders such as clinical depression, bipolar mood disorder, obsessive compulsive disorder, panic disorder, post-traumatic stress disorder, etc. would be referred early in the course of development, when they are in the milder stages and more effectively treated with less intensive services. The challenge, of course, is in separating early psychiatric disorders from run of the mill behavioral difficulties. Decisions regarding the need for referrals for diagnostic evaluations should be based on evidence of symptoms and signs that are consistent with a disorder that can be evaluated, and should be made, with the help of protocols, consistently from one site to another, in my opinion.
DOE has attempted to address the dichotomy of the educational model vs. the medical model by defining SBBH services as educational/behavioral interventions for students with behavioral difficulties, rather than clinical/treatment interventions for students who have disorders. In fact, this approach is the norm in school districts across the U.S. The difference in Hawaii is that SBBH, by taking over outpatient mental health services from DOH, has the added responsibility of clarifying what happened to these mental health services now that they are under DOE’s purview. In my opinion, it is not acceptable to simply redefine the services as behavioral, as it is clear that some students have major psychiatric disorders that require diagnosis and treatment if improvement is to take place, and that do not improve with behavioral interventions. Some of these students are at risk of harm to self or others, adding significant liability, as noted above. Even the guidelines for SBBH interventions include discussion of “cognitive-behavioral therapy”; it would be difficult to argue that this activity is not therapy. Discussions with behavioral specialists indicates that many of them believe that they are providing therapy, despite the redefinition of their activities. ILCs provide social skills services, family therapy, individual counseling, medication management and cognitive behavioral interventions. Whether they are called learning centers or day treatment programs, their functional activities are consistent with mental health treatment provision.
Thus, SBBH is in the midst of identity confusion, and this situation has significant potential for legal and financial liability, as well as potential for “Felix, Part 2”, if it is not effectively addressed.
It is necessary for SBBH to more clearly define its interventions as behavioral or clinical, and to proceed accordingly. Although I appreciate the philosophical reasons and concerns for potential liability that underlay the redefinition of SBBH services as educational, I would note that there may in fact be greater liability in having an SBBH staff provide educationally-labeled interventions to a student in need of clinical interventions.
If SBBH decides to only provide educational/behavioral interventions, and to clearly define its activities as non-clinical, then it will be necessary to clarify which students, under what circumstances, will be referred for diagnostic assessment and treatment to other providers. At this time, these decisions are made on a case by case basis, depending on team decisions. These teams are comprised of professionals with different levels of clinical expertise. Different teams may also have different criteria and thresholds for referral for clinical services. Policies, protocols, procedures and guidelines need to be established regarding screening and identification of SBBH-served students who require clinical rather than educational interventions. This is true whether or not SBBH staff provide the treatment themselves or refer to outside providers.
If a decision is made that SBBH staff will only provide educational interventions, then it will be necessary to create an infrastructure of expanded outpatient services, and a method of paying for those services beyond the funding already allocated to the SBBH program. In my opinion, this might be able to be done with funds gained through billing of indirect/administrative Medicaid. Otherwise, it would be necessary to reduce SBBH staff, who I believe are providing needed services.
Another option would be to clarify which SBBH staff, under what circumstances, are providing clinical treatment services. Clinical services are diagnosis-based, and require staff who have appropriate licensing, skill sets and supervision, as well as appropriate in-service training, psychiatric consultation and psychiatric treatment availability. This approach is more of a middle path between the poles of the previous DOH medical model and the present DOE educational/behavioral model. This approach would still rely on referrals to outside contracted service providers, especially for more intensive services, when indicated.
The Middle Path: Combining an Educational Approach with a Public Health Approach
In an ideally integrated system, school districts focus on educational interventions while other systems (public health, social services, private providers, community mental health centers, health care professionals, etc.) provide mental health diagnostic and treatment services. Services can still be co-located in the schools, but they are ‘in the schools’ but not ‘of the schools’, and the school districts have a legal and financial firewall between the district and the providers. (The major barriers to school districts providing the treatment themselves are lack of malpractice coverage, records confidentiality issues, the need to develop additional reimbursement infrastructures, boundary issues and supervision issues).
For example, Public Health nurses could provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening for at-risk students, and refer these students to appropriate professionals for diagnosis and treatment. On-site contracted Family School Coordinators, working for outside agencies, could provide confidential family interventions that screen not only the student but other family members as well for mental health and/or chemical health disorders, and refer for treatment as necessary. Treatment records under these circumstances would be confidential, and the district would have limited liability, because these referrals for treatment were not generated by the district.
If primary care physicians were fully trained in identification of mental health disorders, if all eligible students were screened for EPSDT, if all health plans had outreach efforts for mental health diagnosis and treatment, if all parents and students were motivated to seek necessary treatment, if there were an infrastructure of fully funded mental health services available to provide a full array of mental health and chemical health services, then schools could go about their business of educating students. Unfortunately, this is rarely the case.
Hawaii has been given funds and resources to provide a significant amount of mental health/behavioral health services to children and adolescents. If the DOE’s goal were to eventually provide less services, then steps would need to be taken to assure that some other system would ‘come up to bat’ to provide those services. If DOE plans to continue to provide these services, then I would recommend that DOE refines their decision-making procedures to provide greater clarity in the identification of students who need only behavioral interventions, students who require mental health treatment with therapy and possibly with medication, and students who require both behavioral interventions and treatment services.
Problems with the IEP-Based Services Model
There are a number of problems inherent in the IEP and 504-based services model. These include:
The IEP-driven model does not address the mental health needs of students who have psychiatric disorders, but whose disorders are not affecting their educational progress. This could include students, for example, who have eating disorders, moderate depression or obsessive compulsive disorder. Girls who have inattentive ADHD also frequently go unidentified in school settings. This is not to say that the educational system should be responsible for treatment of these children and adolescents, but, by default, DOE has become the major mental outpatient mental health provider in the state. An infrastructure will need to be developed for these non-IEP non-504 children and adolescents to receive services.
A focus on IEP Students can be counterproductive to a focus on early interventions that could prevent the need for Special Education services. The IEP-driven model does not focus adequately on early screening, diagnosis and treatment of mental health disorders before the disorders become severe enough to require special education services. Although the CSSS model theoretically provides early intervention activities, it is my understanding that these activities are behavioral in nature, and that students are rarely referred for mental health diagnostic evaluations until they already are receiving special education services.
Since DSM 4 psychiatric disorders are present in nearly all students who qualify for the E.D. category, and, given the poor outcome nationally for E.D. students who are not effectively diagnosed and treated, DOE could consider a focus on assuring that these students are diagnosed, and when appropriate, referred for treatment. Ideally, this would take place at the pre-referral stage, as treatment at this point can often eliminate the need for special education assessments and placement, or at least reduce the intensity of special education interventions.
IEP-driven services do not address the full spectrum of students’ problems. Many students who have mental health disorders that affect their education also have significant family difficulties that contribute to their problems at home and at school. When the problems are mainly manifested in the home environment, it would be difficult to argue that family interventions should be Related Services on IEPs. Nonetheless, the family may require this service, and the parents may also require their own mental health and/or chemical health treatment.
Alternately, students who are placed in foster care due to abusive or neglectful home situations may improve significantly in the foster home, and that improvement may be reflected in the school environment as well. If the student is prematurely returned to a home where severe problems persist, and if that student then begins to have significant school problems as a result, then it important for DOE to have a good working relationship with DHS to assure that SBBH services are not being misdirected.
IEP-driven services require that IEP teams have individuals who are knowledgeable about the nature of the related or supplemental services, and are able to determine when this service is needed. This raises concerns about specialized services such as medication management, with liability concerns that could arise from a lack of a referral and an allegation that the district did not have a professional who could have correctly identified the need for medication management.
In my opinion, the situation has gone to such an extreme in Hawaii that “the cart is driving the horse”; i.e., services won’t be provided unless they are on an IEP, resulting in services that would be very unusual on IEPS (e.g., foster care) to be listed as either related services or supplemental services. I would encourage DOE to obtain legal counsel on this issue from the Attorney General’s office or, if necessary, from a more specialized school-law attorney.
Problems with Special Education Eligibility Criteria in Regards to Student Mental Health Issues
Hawaii is using, with some modifications, the federal definitions of Autism, E.D. services and Other Health Impaired Services. Although these definitions may be adequate for educational purposes, they don’t necessarily translate well into mental health models of services.
For example, (Citing Chapter 56 eligibility criteria), eligibility for E.D. services require the presence of one or more symptom over a long period of time. The criteria do not clarify the duration of “a long period” Also, some symptoms such as the mania of bipolar mood disorder may have a sudden, severe onset, with symptoms that quickly and severely impact a student’s education. The criteria require that symptoms are present to a marked degree, but the term “marked” is also not defined. The term, “social maladjustment” is also not defined. Other states expand the definition of the Emotional Disturbance category in order to clarify these and other issues. Some also add other factors, such as the need to rule out chemical abuse as a primary cause of the student’s behavioral problems.
The Autism criteria mandate that verbal and nonverbal impairments are required for inclusion in that category. This rules out Asperger’s Syndrome, as these affected individuals have intact communication skills, yet they are significantly impaired for other reasons. The category defines Autism as a developmental disability when it is in fact a developmental disorder. The definition notes that the student may have (not “must have”) one or more symptom of repetitive/stereotyped behavior, a need for routines or unusual responses to sensory stimuli. These criteria do not jibe with DSM 4 criteria for Autism. Finally, the criteria require that the student should not be categorized under the Autism criteria if he/she meets the criteria for E.D.. This is very problematic, because an inability to learn, inability to build relationships, inappropriate behavior and feelings, unhappiness and fears/physical symptoms are all common symptoms in autistic disorders.
The other problem with Hawaii’s approach to IEPs as they relate to students’ mental health disorders is the practice of only listing one Special Education category even when several categorical requirements are met. This can be problematic, for example, in emotionally disturbed students who have learning disabilities, if the learning disabilities are under appreciated by educational staff due to the student’s ongoing behavioral difficulties.
Mental Health and Chemical Health Disorders Experienced by Students Served by SBBH Staff
Mental Health Disorders
I was not able to obtain recent diagnostic information from all sites for SBBH-served students. The data that I did receive indicated that students who were hyperactive, disruptive, oppositional and/or conduct disordered were the most common group of students served, although students who had internalizing
disorders (e.g., anxiety disorders) were also served. Internalizing problems were also noted in BASC date that indicated that one fourth of students served had evidence of significant depression.
Given that students who have externalizing behavioral problems are more problematic in schools, and often require educational interventions in the school setting, this is not surprising. However, this suggests that, compared to the demographics of all mental health disorders experienced by children and adolescents, IEP-driven services are directed to a disproportionately larger group of acting out students.
Some of these students may simply have behavioral difficulties that do not stem from underlying psychiatric pathology. These students are best suited for behavioral interventions. Others may have disorders (e.g., Bipolar Mood Disorder) that trigger behavioral problems and that do not respond well to behavioral interventions. Still other students have a combination of the two contributing factors.
Autism Spectrum Disorders
Although Autism Spectrum Disorders (ASD) are addressed administratively in another branch of DOE than SBBH, some ASD students also receive SBBH services. Students who have Autism, Asperger’s Syndrome and Pervasive Developmental Disorder NOS often have, in addition to their core ASD symptoms, co-morbid psychopathology that is caused by other co-existing psychiatric disorders. Thus, some ASD students also have ADHD, Obsessive Compulsive Disorder, Depression, Bipolar Mood Disorder, Panic Disorder, Conduct Disorder or Oppositional Defiant Disorder, alone or in combination. These students are especially difficult to serve, as the combination of ASD and other psychiatric pathology has a synergistic effect, producing problems greater than the sum of their parts. Also, medication interventions for one target symptom (e.g., ADHD symptoms) can produce exacerbation of other co-morbid disorders (e.g., Obsessive Compulsive Disorder).
Thus, it is essential to have a close working relationship between the ASD and the SBBH programs in DOE to assure that these students receive a seamless set of appropriate interventions to meet their needs.
Chemical Health Issues
SBBH staff uniformly reported that, for the high school students who they serve, approximately 75% had drug and/or alcohol abuse problems. This is of great concern, especially since SBBH staff are not providing focused drug treatment for these students, and because many of these students are receiving no services other than SBBH services. DOH will accept referrals of students who have drug and/or alcohol abuse if they also have a co-morbid psychiatric diagnosis. There are some programs that provide chemical dependency treatment, but it is my understanding that there is a significant relapse rate when students finish the program and return to school environments where drug use is the norm. To date, there are no “sober schools” or “sober classrooms” in the Hawaii educational system.
Act 44, and subsequently, act 213, addressed the need to do assessments of students who were dismissed due to drug/alcohol issues. At this time, there are no personnel from SBBH on the Advisory Task Force that addresses this issue. Given the pervasiveness of drug and alcohol problems in SBBH-served students, I would recommend that SBBH have a representative on this task force.
A number of contracted agencies provide neither drug testing nor chemical abuse/dependency services for their clients. Given the high percentage of drug/alcohol problems experienced by SBBH students, it is important to not refer students who have these problems to providers who are not in a position to address these problems. Although referrals could be made to multiple programs for mental health and chemical health issues, it is preferable to make referrals to one agency for all services.
It is my understanding that DOH receives federal funds for substance abuse assessment and treatment. It is not clear whether they can provide services for the treatment of substance abuse/dependency only through another branch of their department, for students who do not have co-morbid psychiatric conditions.
Different programs provide different models of Chemical Abuse treatment. Some use the harm reduction approach, whereas others use the abstinence approach. It would be helpful to contract with chemical dependency programming with the same evidence-based criteria that DOH is using to evaluate mental health programs, so that appropriate referral decisions can be made for these affected students. It would be helpful, for example, to have data about relapse rates for students served by the Teen Care program.
Chemical health issues were also identified as being problematic in the majority of students’ families who were served by SBBH programming. It would be helpful to create an expanded infrastructure of services so that family members could access appropriate Chemical Dependency services.
Given the inherent nature of denial in individuals who have these problems, approaches such as Motivational Interviewing could be helpful in interventions with students and their families.
Some states (e.g. Minnesota) have expanded the criteria for placement in E.D. programs. These criteria require that Districts to rule out drug and/or alcohol abuse as the primary cause of a student’s educational difficulties. Hawaii may want to consider doing this, so that this group of students will be effectively identified and referred for appropriate services, rather than being placed in Special Education programming that is unlikely to be effective if they continue their abuse patterns.
The bottom line on drug and alcohol issues is this: “Abuse” means that a drug and/or alcohol is causing significant disruption in an individual’s life. If the majority of secondary students served by SBBH staff are abusing drugs/alcohol, and if they do not receive services to address this problem, then I would expect SBBH interventions to be ineffective for them.
SBBH Behavioral Specialist Issues
The SBBH Behavioral Specialists have been doing an excellent job in providing on-site, accessible services to students at all risk levels. A number of systemic issues need to be addressed so that services can take place in the most efficient manner, with the best outcome and the lowest level of liability for DOE and its providers.
The common themes, and areas in need of improvement raised by SBBH and other DOE staff are:
The Relationship Between DOE and DOH
It was notable, on a number of occasions during my consultation with both DOE and DOH staff, that there was considerable degree of disagreement, misperception and miscommunication between DOE and DOH staff. For example, several Behavioral Specialists noted difficulty in accessing DOH services, noting that they had waited months for services for one student, and even noting that they had received an E-mail from DOH telling them to not make any referrals to DOH.
DOH staff, on the other hand, noted that they felt that DOE was not making referrals early enough to them, often waiting until students had developed severe psychiatric problems that could have been prevented through early intervention. They noted that a student would only need a CAFAS score of 80 to qualify for SEBD services, but that they often had much higher CAFAS scores (e.g. 110) at the time of referral. They noted concern that students were often referred for placement rather than for treatment, and that the placement could have been avoided if an earlier referral had been made.
However, DOE staff described instances in which the CAFAS was high enough to qualify for DOH services, but that the DOH staff (who did not know the student’s circumstances as well as the Behavioral Specialist did) would re-do the CAFAS, come up with a lower score, and then deny services. Behavioral Specialists also noted that they often had to “jump through hoops” to access DOH services, and were often asked whether they had done enough interventions prior to considering making the referral. The process of referral to DOH from DOE was a major source of concern. DOE staff expressed opinions that, for students who presented with severe psychopathology, it was inappropriate to have to obtain and initiate a behavior support plan, an FBA, a clinical assessment, a CAFAS, etc. and to demonstrate that services from DOE had been ineffective prior to DOH opening the case.
DOH staff expressed concern that early intervention coordination was not taking place adequately at collaborative Peer Review meetings, while DOE staff from one SBBH program stated that DOH staff had only shown up for one out of the last five Peer Review meetings.
DOE staff also expressed concern about the difficulty having their calls or emails returned when referrals were being made. DOE staff expressed frustration at difficulty reopening cases in DOH, for a student who had recently received CAMDH services, with DOE staff having to start all over with documentations for the need for services despite the student’s severe problems.
DOE staff expressed concern that DOH had refused to pay for the placement of at least one student in a mental health residential treatment center, arguing that the student was not there for mental health needs, but for behavioral problems that stemmed from educational, not mental health needs.
DOH staff expressed concern about problems with communication from DOE administration to DOH administration. They were aware of considerations by DOE to no longer consider medication management as a DOE service, but were frustrated that this had not been directly communicated to DOH so that DOH could plan and budget for this service, if this was indeed the plan.
It was of interest that a CAMDH contracted therapist noted that she was not in a position to make a diagnosis of a student, but that she relied on diagnoses made by DOE. This disconnect between two systems presents significant potential for poor therapeutic outcomes, if the individual providing treatment is someone different than the one who did the diagnostic evaluation.
Other DOE/DOH issues raised included the change in provision of services by DOH for students who have 504 plans but not IEPs. There was a perception in DOE that 504 students previously had received these services, but no longer were, and there was a lack of awareness of changes in the memorandum of agreement between the two agencies about this type of policy change.
DOE staff also expressed concerns that they perceived some care coordinators as being conduits of information between DOE’s requests for services and DOH’s authorizations. DOE staff were concerned that information was lost in the process, and noted that, if the care coordinator had no authority to authorize services, DOE staff would prefer to communicate directly with decision makers in DOH.
Concerns were also raised about the functionality of the QA team, in that staff were frustrated with ongoing systemic problems between the two agencies despite a mechanism being theoretically available to address these issues.
What was notable about these problem descriptions was their anecdotal nature, and what was absent was any systemic method of determining the accuracy of either side’s concerns, the frequency or nature of these problems, or the differences in levels of coordination, cooperation and collaboration between DOE and DOH at the different complexes.
Part of the difficulty of having a seamless, functional relationship between DOE and DOH is that each system has its own unique infrastructure, mandates, philosophies, and methods of service provision. DOH is based on public health models, county jurisdictions, and a diagnostic model, whereas DOE relies on educational models of service provision. Concerns expressed by DOH staff and CAMDH providers included the perception that, since DOE took over outpatient services, there has been a marginalization of a mental health perspective, culture and knowledge base in DOE. Clearly, there is a need for reintegration of services.
The Felix Decree mandated a good working relationship between DOE and DOH. Also, Hawaii is one of the sites promoting the IDEA Partnership model that relies on a shared agenda by all participants. It appears that there are a number of issues that are unresolved, and these pose significant risks for student deterioration and potential liability for both departments if they are not addressed.
I would expect that integration of services and an improved relationship between DOE and DOH will prove to be a significant challenge, for a variety of reasons. However, I believe that it will be possible, if each system can work within a model of principled negotiation, keeping in mind that the needs of children and families are foremost in this process. The positive working relationship between DOE and DOH on Kauai is a good example for the rest of the system.
I would recommend that a monitoring system be established to provide oversight into the nature of referrals to DOH, the severity of students referred, the timing of the referrals in the course of development of the student’s problems, the timeline of the DOH response to referrals, etc. It would be very helpful to clarify whether the concerns expressed are valid, whether they are the exception or the rule, and whether they are particular to some sites and absent at others.
Relationship between DOE and DHS
Several DOE staff expressed concerns that they had been placed in a position of providing services to students who they felt were being abused or neglected in their home environments, and for whom out of home placement was not a consideration by Child Protection Services. Some noted that they had served students who had, in their opinion, been prematurely returned to their homes. Staff noted concerns about their perception of the high threshold for case opening by Child Protection, and the potential that this could produce clinical deterioration in affected students. One DOE staff described a situation where a student deteriorated in school once he returned home, but that the Child Protection worker described this as “a school issue” that was not relevant to Child Protection placement considerations.
I would note that this is a scenario not unique to Hawaii, but one that plays out throughout the U.S.. It would be helpful to have clarification by DHS regarding thresholds of service provision and mechanisms for communication about concerns between the two departments.
The Role of Public Health
A public health approach to children’s mental health relies on early identification of disorders when they first appear, when they can be treated most effectively, and when levels of disability can best be limited. All students who are on Medicaid are entitled to EPSDT (Early, Periodic Screening, Diagnosis and Treatment), a Medicaid benefit that includes both a health screen and a mental health (social-emotional-behavioral) screen periodically between the ages of 0-21. This can be done in physician’s offices, or in some states, it can also be done by Public Health nurses, even within the school setting. I have not been able to obtain data from DHS regarding the percentage of children and adolescents in Hawaii who receive EPSDT screening, nor the percentage of those screened who are referred for a mental health evaluation. Since research indicates that approximately 25-30% of children and adolescents in this population have evidence of mental health disorders, a similar yield from screening would be expected.
At this time, screening for mental health problems are done in the school system as part of the CSSS process. I would encourage DOE to work with DOH, DHS and the counties to encourage mental health screening as a Public Health practice in the community. This would provide early intervention mental health activities that would not be tied to DOE, would not be IEP-driven, and would not make DOE the payer of last resort for recommended evaluations and treatment.
Data Gathering and Analysis
SBBH has made significant progress in gathering and analyzing individual and group data about SBBH students. For example, BASC baseline and follow-up data is valuable in identifying student needs and monitoring student progress in response to SBBH interventions.
However, other data that would be very useful for program planning and development have not been systematically obtained and analyzed. This includes information about the DSM 4 diagnoses of students referred for evaluation, the types of psychiatric treatments provided, and the outcome of treatment in terms of academic progress, reduction of behavioral problems and reduction of dropout rates. It is important that data gathered by DOH about these issues be shared with DOE, and analyzed conjointly by both departments.
As different systems use different tools to assess students needs, it is difficult to compare data from the different systems for baseline and outcome analysis. For example, DOE uses the BASC whereas DOH uses the CAFAS tools- the former being more symptom-specific and the latter being more focused on level of functioning.
Given the concerns about excessive paperwork getting in the way of providing direct services, it will be important to assure that all data-gathering activities be carried out in the simplest, most efficient and user-friendly manner for both SBBH staff and for students and their families.
Examples of useful data analysis to consider include:
It would also be helpful to assure that ISPED can work closely with SBBH to generate useful data analysis reports on these and other topics.
Roles of School Staff
Few school districts have clearly defined roles for staff working with Special Education and Regular Education students who have mental health disorders. This poses an even greater challenge in Hawaii, where SBBH staff are retrofitted to school programs, and are providing additional services. I received feedback from a number of school staff noting that it would be helpful to have greater clarity in role definitions of the staff (counselors, social workers, psychologists, etc.) who work for the schools in traditional capacities. There is also a need to more clearly define the roles of SBBH staff, in regard to their own activities, and to clarify their relationship with school professionals who are carrying out their own roles. Without clear role definitions, there is the risk of overlap of services in some areas while leaving dangerous gaps in other areas. Also, there is the risk that SBBH staff will be seen as able to carry out whatever function is needed in a school, offering principals, for example, the option of laying off counselors and expecting SBBH staff to take their place. This would result in SBBH staff having less time to provide services for CSSS students in the higher severity categories.
I would recommend clarifying the roles, description of work requirements, supervisory requirements and accountability standards for all school staff who work with students who have mental health and/or behavioral disorders. Examples of activities that require role definition (e.g., who performs this function? Who provides supervision? What documentation is necessary? etc.) include:
It is essential that roles for various professionals are defined for a school system, that there is ongoing quality assurance regarding each professional’s activities, and that there is a method of providing outcome measurement of these activities.
Documentation
Behavioral specialists describe the bind that they are in regarding documentation of mental health issues that are addressed in their interventions. Some note that they are reluctant to document the content of their sessions with students, as all information ultimately goes into school records. Some of the information discussed by students is very sensitive, reflecting very personal thoughts, feelings and behaviors, or describes potentially sensitive issues affecting family members. If the student were seen in therapy by an outside professional, these records would be confidential, and only could be available to the school with an appropriate release of information. Also, school records do not have the degree of confidentiality present in clinic records; thus all confidential issues discussed with behavioral specialists and documented in school records are available for parental review as well. School records also may follow the student to other districts if the student moves out of town or out of state, and this could be potentially embarrassing or could have other adverse consequences. As a result, some behavioral specialists write minimal notes describing their interventions with students. One behavioral specialist described a student who was seen in weekly sessions who was presenting with significant depressive symptoms. When asked what was being documented about the student’s self-report and about the content of the sessions, either in school records or in the behavioral specialist’s private notes, the response was that almost nothing was documented.
Behavioral Specialists, by their own report, are seeing students who have potential risks of harming themselves and/or others, or risks of clinical deterioration from disorders if they are not effectively treated. The lack of adequate records that define issues such as changes in clinical symptoms, potential for danger to self and/or others, etc. creates significant liability for DOE. Also, the lack of documentation makes it very difficult to establish the nature of interventions, the students’ responses to those interventions, and the ultimate outcome of the interventions. It also makes transition to another professional difficult, as the new treating professional does not have adequate documentation to clarify the nature and types of interventions that have already been used.
Thus SBBH staff are in a very difficult position in regard to documentation. Being district staff, they face a dilemma of either protecting confidentiality or being potentially negligent in their duties to document.
This is less of a problem when only strict behavioral/educational interventions are provided, as minimal confidential information is revealed that would cause the behavioral specialist to be reluctant to chart it in school notes. The fact that so much information is discussed with Behavioral Specialists is considered very personal suggests that the Behavioral Specialists’ activities often go beyond strict definitions of educational interventions and reflect, instead, clinical interventions. Until there is greater clarity on this issue, there is significant potential for negative clinical, legal, financial and political repercussions.
I would recommend that guidelines be established for all DOE staff including behavioral specialists that mandate documentation of crucial issues such as evidence of clinical symptoms, evidence of improvement or deterioration of those symptoms, evidence of danger to self and/or others, and documentation of referrals for diagnosis and treatment when appropriate.
Supervision Issues
Clearly, there are benefits to site-based management of staff. Each complex, even each school, has unique needs, staffing patterns, student characteristics, parental attitudes about mental health and behavioral issues, etc..
However, there is a significant disadvantage to a lack of oversight at the State level of SBBH activities. As noted above, there are a number of areas (role definition, screening, documentation, referral thresholds, consistency in identification of IEP driven services, etc.) in which administrative oversight from a single site is appropriate, in my opinion.
The chain of supervisory responsibility for DOE activities needs to be clearly defined. The “buck stops” with the superintendent, who needs to assure that all activities performed by DOE employees are accountable and adequately supervised. This is a straightforward process with strictly educational activities, but can become highly problematic when other activities, are considered. For example, health-related activities of nurses and health aides need to be supervised by individuals who have expertise in health related services issues, and these individuals would be health professionals (e.g., nurses and physicians) rather than educators. If psychiatric medication management is provided by DOE employees, then there would be a need for appropriate supervision of the process. I will address recommendations for supervisory activities under the System Redesign and Medication Management sections of this report.
Liability Issues
A number of potential liability issues have already been raised. Unfortunately, DOE faces liability if it is the provider of mental health services, but also faces liability if it maintains that it is only providing behavioral interventions.
Major areas of liability under the present system model include:
Retention of Staff and Filling of Vacancy Positions
There has been an ongoing struggle to fill vacancy positions (e.g. for psychologists), and to retain staff in SBBH. Although there are many contributors to this problem, it is my opinion that the primary contributor is due to salary issues (exacerbated by the high cost of living, especially housing, in Hawaii.) I would expect this problem to worsen if bonuses are eliminated for new psychologists.
Contracting out for SBBH activities creates a vicious cycle, as professionals who are hired by contracted programs are generally paid higher salaries than DOE-hired employees. Thus, DOE is indirectly paying higher salaries for the same service anyway, but is providing disincentives for professionals to work for DOE rather than for contracted programs, and increasing the likelihood that, for example, psychologists will leave DOE for better paying jobs once they have their necessary supervision requirement hours met.
In my opinion, it will be very difficult to manage an effective SBBH program until this issue is resolved. Although I appreciate that staff salaries are not under the direct control of SBBH, I would hope that there will be some way in DOE to ameliorate this problem by providing wage increases for DOE-hired staff. The next section, (“Funding”), will illustrate the untapped funds that could more than pay for such salary increases.
Funding
It is laudable that DOE will be billing for Medicaid services for direct treatment reimbursement. I would note, however that, since few of SBBH interventions at this time are diagnosis-based (Medicaid requires a diagnosis for reimbursement for direct services), and since few of the SBBH providers are qualified to bill Medicaid, that the amount yielded in reimbursement for direct services may be helpful, but not as high as expected. (One estimate is that only 15% of SBBH activities would be billable, and that as few as 25% of students served by SBBH may be Medicaid-eligible).
However, I believe that reimbursement for indirect services through Medicaid is likely to yield a very significant payback. I would expect that this would provide far more dollars than direct service reimbursement, as indirect reimbursement is not strictly tied to licensed professionals and student diagnoses. If both the direct and indirect project cannot be started at the same time, I would recommend consideration for beginning a random time study for indirect billing as soon as possible. I believe that it would be appropriate to have legislation direct funds from the general state fund to the DOE, and believe that it would be ideal to direct the funds to Student Support Services including Special Education, if at all possible.
I believe that millions of dollars could be made available for DOE and DOH services if the legislature and DHS addressed Medicaid reimbursement rates. I sent an email to Angie Paine, Hawaii Medicaid Director, requesting information about the percentage of Medicaid eligible children and adolescents who received mental health services through either DOE or DOH, vs. those who received them through other sources. I have not received an answer to date, but I would suspect that the vast majority of children and adolescents who are receiving mental health services under Medicaid are receiving them through DOE, DHS or both. Since both DOE and DOH are paying providers at a rate considerably higher than the Medicaid rate, the state budget is paying millions of dollars to supplement Medicaid rates. If Medicaid rates for these services were increased to the amount that is now paid by DOE and DOH to providers, then a significant amount of federal dollars would be brought in, reducing expenditures from the Hawaii state budget. Also, increasing Medicaid reimbursement rates would provide the incentive for the creation of a community mental health infrastructure in Hawaii, which could ultimately provide many of the services that are not covered through DOE or DOH system designs.
At this time, Hawaii is considering a Medicaid Waiver category for adults who have severe psychiatric problems. There is no plan at this time to consider a similar waiver for children and adolescents. Given the severity of many students served by DOE and DOH, and given the success in other states of drawing down federal funds for these waivered services, I would recommend that DOE and DOH approach DHS on this issue.
Some states have options for parents whose income is too high to qualify their children for Medcaid to obtain Medicaid eligibility for the children if they have significant disabilities, including psychiatric disabilities. Since the Medicaid benefit set is significantly broader than many private insurance benefit sets, and since it doesn’t have a co-pay, I would recommend that DHS consider this option as well.
At this time, funding is not sought from non MedQuest third party payers for services provided by contracted providers. As DOE is the payer of last resort, it would be worth considering encouraging billing, when families are receptive to it, in situations where this would be appropriate. For example, a contracted provider who is serving a student and his/her family for IDEA-based services may also be available to provide services that are not school related (e.g. family interventions, treatment of siblings or parents, etc.) and bill these services to a third parthy payer. Even IDEA-based services could theoretically be billed to a third party, with the parent’s permission. This would be more palatable for families in situations where there is no co-pay for services and where there is a generous benefit set. I am not familiar with the relationship between DOE and families who have military insurance coverage, but this would be an example of potential billing, if it is not already taking place.
The System Redesign Plan
DOE has some major policy decisions to make regarding the direction that it will take in serving the needs of students who have behavioral problems, mental health disorders, or the combination of the two. As noted above, continuation on the present track is fraught with potential financial and legal liabilities, and, although services have been helpful for many students, there are significant gaps in service provision.
The proposed system redesign focuses on creating a more efficient system, with greater accountability, less duplication of effort, and increased cost-effectiveness. It focuses on consistency of activities throughout the state, and this focus is beneficial for educational, clinical and legal reasons. Finally, it provides a framework for effective system change in a unified direction that will be based on evidence-based best practices in both the educational and mental health frameworks.
I would note that the proposed system redesign makes sense regardless of the approach that DOE decides to take in providing services to students with behavioral and/or mental health disorders. It provides a more effective framework within which to flexibly and effectively address systemic change.
The educational system has a tendency to perceive SBBH in terms of the activities of the Behavioral Specialists. System redesign, with consolidation of services, will result in a greater awareness of the multiple roles carried out by SBBH staff- Behavioral Specialists, school psychologists, clinical psychologists and support staff.
For the reasons noted earlier in this report, supervision is an essential component of any system addressing behavioral and mental health issues. It is even more essential than supervision about educational issues in an education context, as mental health and behavioral problems are more complex, can lead to significantly adverse consequences for the student and his or her peers, and can lead to significant liability if there is evidence of negligence or inconsistency in supervision. The proposed plan has a more streamlined supervision process. It also separates clinical supervision activities from administrative supervision, thus setting more clear parameters for each activity.
By placing all psychologists under one system, and combining funding and streamlining the line of supervision, this plan allows greater flexibility of psychologists’ roles, more efficient utilization of resources, less duplication of efforts, more accountability and an increased ability to measure outcome of professional activities. It would eliminate the present problem of crossed lines of supervision (e.g. SBBH psychologists supervising Special Education funded psychological examiners) It also makes it easier to assign and fund psychology intern positions, which are essential for both training and staffing functions within the system. Finally, it would promote consistent compliance with mandates for utilizing standards of practice within SBBH.
This system redesign will require increased capabilities for generating and analyzing data that pertains to SBBH activities. This data will reflect individual and group student issues throughout the state, and will provide information for effective program planning and development activities.
The plan allows for improved supervision of the Psych 6 positions by a Psych 8 professional. (Without this supervision, the Psych 6 staff would need to leave the system after two years.)
This plan will also create licensed behavioral specialists who will provide more effective clinical supervision to social workers and behavioral specialists. Technical support will also be provided to counselors. In my opinion, consideration should also be made for increased clinical consultation to counselors as well.
There are many financial and systemic drawbacks to paying “dollars for hours’’ to contracted professionals. This is a disadvantage to the professionals, who are not paid for missed appointments. It is also problematic to DOE, as it is very difficult to manage budgets using contracts that have open-ended potential needs for therapeutic services. If DOE continues to contract for services, the new plan of contracting for whole positions makes more sense. I would note that there is a downside to contracting for behavior specialist positions for many of the reasons previously noted (salary, no direct supervision from SBBH, etc.)
In summary, I would endorse the system redesign plan, as it clarifies lines of authority, eliminates overlapping supervisory and direct service functions, provides consistency in service provision, avoids system fragmentation, increases cost-effectiveness and encourages integration of services. It encourages a seamless system that has increased flexibility, that is more responsive, has improved communication capacities, and is more able to respond to requirements for system change. It also positions DOE more strategically in its relationships with other agencies, and it allows for the increased capability to institute systemic changes that will be necessary to more effectively meet the needs of SBBH students.
In my opinion, the system redesign proposal does not go far enough in addressing supervisory issues. At this time, the State Director of SBBH services is in more of an advisory position than in a supervisory position with the District Education Specialists. They receive their supervision from their Complex area superintendents, who may not be adequately familiar with the complexities and perspectives of SBBH activities. This model makes it difficult to have consistency in SBBH approaches to service provision. Given the complexities of the issues involved, and the potential for liability if there is inconsistency in approaches at different sites to the same types of clinical situations, I would recommend a redefinition of the role of the State Director to be an administrative supervisor, providing supervision and direction to the SBBH District education specialists., ultimately responsible for SBBH services at all sites. This will result not only in greater oversight and consistency of services, but in an increased ability for DOE to have a more accurate understanding of system issues outside of DOE, and a greater ability to negotiate and partner with other systems (e.g., DOH, DHS, the private sector, etc.)
Next Steps
Behavioral or Mental Health Approach?
In my opinion, DOE needs to make some major decisions about the roles and directions of SBBH-provided services. For the reasons outlined above, I believe that it is detrimental for DOE to continue to maintain that it is not providing diagnostic or treatment services when an analysis of its activities suggests otherwise. The basic decision needs to focus on whether DOE wants to restrict the activities of all SBBH and non-SBBH employees to assure that they, in no way, are providing what could be interpreted as mental health services. If DOE decides to do this, then it will be incumbent on DOE to assure that someone else comes to the plate to provide these services, as DOE made an agreement that students’ mental health needs could be provided for by DOE when it transferred positions and funding from DOH.
If, on the other hand, DOE chooses to continue to provide the types of services that it now provides that would be construed by mental health professionals, courts and laypeople as constituting mental health services, then DOE needs to address a number of issues.
First of all, it needs to be clarified whether DOE has the statutory authority to be a provider of mental health treatment services. If it does have this authority, then it is more likely that an insurance company would be willing to provide malpractice coverage for the District. (Generally, school districts cannot obtain malpractice coverage because insurance companies only cover entities that have the authority to be treatment providers). Since the District self-insures, and since there are no limits of liability if the State is sued as a co-defendant in a malpractice case, it would be appropriate for DOE to seek actuarial advice about the limit of self- insurance, and then seek “catastrophic” coverage above that amount.
Given FERPA requirements, information gathered and documented by SBBH staff is an educational record. There is the “desk drawer rule” that private notes that are not shared with others can be kept separate, and, if destroyed within the year, do not have to go into the school record. Unfortunately, some school districts encourage highly confidential information that reflects severe student problems to be kept separate in this regard- this is very problematic if an untoward event (e.g. suicide or homicide) occurs, and the school staff has destroyed all documentation of the content of meetings with the student. A general rule is, the more potentially dangerous, clinically significant, or legally sensitive the information is, the more that it needs to be preserved and not separated and destroyed.
SBBH staff note concerns about putting very sensitive information in school records. Despite the “need to know” nature of school files, families are often reluctant to tell District-hired staff the type of information that they would share with mental health professionals who are working in a confidential setting. School files also differ from mental health clinic files in that, in clinics, if an adolescent shares information with a therapist that is best not shared with a parent, the therapist has an option to keep that information confidential. This is not an option with school files.
If SBBH staff are providing treatment services and gathering information, it is essential that the information be documented adequately. If DOE is going to provide this type of service, I would recommend that DOE seek legislation to create a data practices act that allows the information that is gathered for clinical purposes to be deemed “non-educational” thus allowing it to be kept confidential and separate from the educational record. The information may then be covered under HIPAA rather than FIRPA statutes.
Medication Management
The most pressing issue, and the most complex and difficult one to solve at this time, is what to do about medication management. This is a service whose provision was a DOH responsibility prior to transfer of outpatient mental health services to DOE, and it also was transferred to DOE.
IDEA is clear regarding school district payment for medical treatment provided by physicians- districts may be responsible to pay for diagnostic evaluations, but are not responsible to pay for medical care provided by M.D.s. However, case law over the years has produced a number of (sometimes contradictory) opinions that have, in some situations, required districts to pay for treatment by psychiatrists. In fact, some districts in some circumstances have had to pay not only for the educational component but for the treatment component of psychiatric hospitalizations and residential treatment. The key issue in these cases was whether the treatment was needed for the student to benefit from an educational program. The opinions stated that the students’ psychiatric needs were “inextricably intertwined” with their educational needs, that they could not be separated, and therefore both the educational component and the treatment needed to be IEP covered services.
The key word is, “needed services”. I would note that the Felix Consent Decree also focused on the need for the provision of necessary mental health related services on IEPs.
Because DOE services are IEP driven, it appears that, since medication management was transferred to DOE, these services, by definition, became IEP services (regardless of whether they are “related” or “supplemental”, they are the district’s responsibility to pay (payer of last resort), if they are on the IEP). The general rule is, “If this service were not provided, the student would not be able to benefit from the educational program provided by the district”. The rule is not, “Could the treatment help?”, or “Does the student need this service in order to have the maximal educational progress?”
Although there are circumstances where districts are obligated to have psychiatric treatment as IEP related services, in my opinion Hawaii is identifying a much larger population of students whose IEPs require this treatment.
The issues that need to be addressed are:
I would recommend the following:
As this issue is very complex, I would expect that further explorations of this issue may be necessary before a definitive decision can be made.
- Manifestations of medical disorders (e.g. the depression accompanying hypothyroidism)
- Emotional problems resulting from life stresses
- The chemical imbalances and neuropsychiatric abnormalities that result in the symptoms of the major psychiatric disorders (ADHD, Depression, Bipolar Disorder, Schizophrenia, Panic Disorder, Obsessive Compulsive Disorder, etc.).
This latter group of disorders are essentially medical/biological disorders, and are often minimally responsive to behavioral interventions. Also, a functional behavioral analysis may mistakenly identify the source of their manifestations as behavioral in nature, when in fact the problem stems directly from the disorder itself. Thus, there is no ‘function’ to the irritability of Bipolar disorder any more than there is a ‘function’ to the irritability caused by low blood sugar in diabetics. Although Functional Behavioral Analyses can be helpful in delineating antecedents to dysfunctional behaviors, they are problematic when behaviors stem directly from the psychopathology of a psychiatric diagnosis. It is important for FBAs to have an option of “none of the above” in regards to potential behavioral antecedents or functions of maladaptive behaviors.
DOE and SBBH are standing with feet on two sides of a philosophical divide- Although mental health diagnoses been reframed as behavioral manifestations, and mental health treatment has been reframed as behavioral interventions, DOE is also involved in referral of some students for psychiatric diagnosis and in the payment for psychiatric treatment. This raises significant liability issues, as a student at one site with behavioral manifestations of clinical depression may be referred for a psychiatric evaluation, whereas a student with the same symptom cluster at another site may receive behavioral interventions only and not be referred for diagnosis or clinical treatment. If the second student were to commit suicide (the SBBH staff reported a number of recent near-suicides on their caseloads, so this is not a theoretical issue), DOE would have significant legal and financial liabilities. This issue is of special concern, given the frequency of suicidal behaviors noted in students served by SBBH staff, and given the fact that approximately one quarter of the students served by SBBH had documented evidence on BASC screening of clinically significant depression.
Also, if a student has a psychiatric disorder that would respond to treatment, it is problematic to have a model whereby behavioral interventions must fail before a referral for a diagnostic evaluation is requested. I recognize that early referrals may occur for more severely disturbed students, but it is my understanding that, in general, referrals for diagnosis and treatment generally only occur after school-based behavioral interventions are unsuccessful. Ideally, there would be a method of screening and triage, separating individuals who require diagnosis and treatment early on in the process.
It is inappropriate to assign clinical services to the more severe cases, and behavioral services to the less severe ones, because some of the less severe situations are at risk of becoming more severe without clinical interventions. (This model is equivalent to providing a humidifier to a patient with mild tuberculosis, and antibiotics to a patient who has severe T.B.). Referral based on symptom severity (providing behavioral interventions to the less severe students while referring the more severe students for clinical evaluation and treatment) is not consistent with the course and development of many psychiatric disorders. Ideally, disorders such as clinical depression, bipolar mood disorder, obsessive compulsive disorder, panic disorder, post-traumatic stress disorder, etc. would be referred early in the course of development, when they are in the milder stages and more effectively treated with less intensive services. The challenge, of course, is in separating early psychiatric disorders from run of the mill behavioral difficulties. Decisions regarding the need for referrals for diagnostic evaluations should be based on evidence of symptoms and signs that are consistent with a disorder that can be evaluated, and should be made, with the help of protocols, consistently from one site to another, in my opinion.
DOE has attempted to address the dichotomy of the educational model vs. the medical model by defining SBBH services as educational/behavioral interventions for students with behavioral difficulties, rather than clinical/treatment interventions for students who have disorders. In fact, this approach is the norm in school districts across the U.S. The difference in Hawaii is that SBBH, by taking over outpatient mental health services from DOH, has the added responsibility of clarifying what happened to these mental health services now that they are under DOE’s purview. In my opinion, it is not acceptable to simply redefine the services as behavioral, as it is clear that some students have major psychiatric disorders that require diagnosis and treatment if improvement is to take place, and that do not improve with behavioral interventions. Some of these students are at risk of harm to self or others, adding significant liability, as noted above. Even the guidelines for SBBH interventions include discussion of “cognitive-behavioral therapy”; it would be difficult to argue that this activity is not therapy. Discussions with behavioral specialists indicates that many of them believe that they are providing therapy, despite the redefinition of their activities. ILCs provide social skills services, family therapy, individual counseling, medication management and cognitive behavioral interventions. Whether they are called learning centers or day treatment programs, their functional activities are consistent with mental health treatment provision.
Thus, SBBH is in the midst of identity confusion, and this situation has significant potential for legal and financial liability, as well as potential for “Felix, Part 2”, if it is not effectively addressed.
It is necessary for SBBH to more clearly define its interventions as behavioral or clinical, and to proceed accordingly. Although I appreciate the philosophical reasons and concerns for potential liability that underlay the redefinition of SBBH services as educational, I would note that there may in fact be greater liability in having an SBBH staff provide educationally-labeled interventions to a student in need of clinical interventions.
If SBBH decides to only provide educational/behavioral interventions, and to clearly define its activities as non-clinical, then it will be necessary to clarify which students, under what circumstances, will be referred for diagnostic assessment and treatment to other providers. At this time, these decisions are made on a case by case basis, depending on team decisions. These teams are comprised of professionals with different levels of clinical expertise. Different teams may also have different criteria and thresholds for referral for clinical services. Policies, protocols, procedures and guidelines need to be established regarding screening and identification of SBBH-served students who require clinical rather than educational interventions. This is true whether or not SBBH staff provide the treatment themselves or refer to outside providers.
If a decision is made that SBBH staff will only provide educational interventions, then it will be necessary to create an infrastructure of expanded outpatient services, and a method of paying for those services beyond the funding already allocated to the SBBH program. In my opinion, this might be able to be done with funds gained through billing of indirect/administrative Medicaid. Otherwise, it would be necessary to reduce SBBH staff, who I believe are providing needed services.
Another option would be to clarify which SBBH staff, under what circumstances, are providing clinical treatment services. Clinical services are diagnosis-based, and require staff who have appropriate licensing, skill sets and supervision, as well as appropriate in-service training, psychiatric consultation and psychiatric treatment availability. This approach is more of a middle path between the poles of the previous DOH medical model and the present DOE educational/behavioral model. This approach would still rely on referrals to outside contracted service providers, especially for more intensive services, when indicated.
The Middle Path: Combining an Educational Approach with a Public Health Approach
In an ideally integrated system, school districts focus on educational interventions while other systems (public health, social services, private providers, community mental health centers, health care professionals, etc.) provide mental health diagnostic and treatment services. Services can still be co-located in the schools, but they are ‘in the schools’ but not ‘of the schools’, and the school districts have a legal and financial firewall between the district and the providers. (The major barriers to school districts providing the treatment themselves are lack of malpractice coverage, records confidentiality issues, the need to develop additional reimbursement infrastructures, boundary issues and supervision issues).
For example, Public Health nurses could provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening for at-risk students, and refer these students to appropriate professionals for diagnosis and treatment. On-site contracted Family School Coordinators, working for outside agencies, could provide confidential family interventions that screen not only the student but other family members as well for mental health and/or chemical health disorders, and refer for treatment as necessary. Treatment records under these circumstances would be confidential, and the district would have limited liability, because these referrals for treatment were not generated by the district.
If primary care physicians were fully trained in identification of mental health disorders, if all eligible students were screened for EPSDT, if all health plans had outreach efforts for mental health diagnosis and treatment, if all parents and students were motivated to seek necessary treatment, if there were an infrastructure of fully funded mental health services available to provide a full array of mental health and chemical health services, then schools could go about their business of educating students. Unfortunately, this is rarely the case.
Hawaii has been given funds and resources to provide a significant amount of mental health/behavioral health services to children and adolescents. If the DOE’s goal were to eventually provide less services, then steps would need to be taken to assure that some other system would ‘come up to bat’ to provide those services. If DOE plans to continue to provide these services, then I would recommend that DOE refines their decision-making procedures to provide greater clarity in the identification of students who need only behavioral interventions, students who require mental health treatment with therapy and possibly with medication, and students who require both behavioral interventions and treatment services.
Problems with the IEP-Based Services Model
There are a number of problems inherent in the IEP and 504-based services model. These include:
The IEP-driven model does not address the mental health needs of students who have psychiatric disorders, but whose disorders are not affecting their educational progress. This could include students, for example, who have eating disorders, moderate depression or obsessive compulsive disorder. Girls who have inattentive ADHD also frequently go unidentified in school settings. This is not to say that the educational system should be responsible for treatment of these children and adolescents, but, by default, DOE has become the major mental outpatient mental health provider in the state. An infrastructure will need to be developed for these non-IEP non-504 children and adolescents to receive services.
A focus on IEP Students can be counterproductive to a focus on early interventions that could prevent the need for Special Education services. The IEP-driven model does not focus adequately on early screening, diagnosis and treatment of mental health disorders before the disorders become severe enough to require special education services. Although the CSSS model theoretically provides early intervention activities, it is my understanding that these activities are behavioral in nature, and that students are rarely referred for mental health diagnostic evaluations until they already are receiving special education services.
Since DSM 4 psychiatric disorders are present in nearly all students who qualify for the E.D. category, and, given the poor outcome nationally for E.D. students who are not effectively diagnosed and treated, DOE could consider a focus on assuring that these students are diagnosed, and when appropriate, referred for treatment. Ideally, this would take place at the pre-referral stage, as treatment at this point can often eliminate the need for special education assessments and placement, or at least reduce the intensity of special education interventions.
IEP-driven services do not address the full spectrum of students’ problems. Many students who have mental health disorders that affect their education also have significant family difficulties that contribute to their problems at home and at school. When the problems are mainly manifested in the home environment, it would be difficult to argue that family interventions should be Related Services on IEPs. Nonetheless, the family may require this service, and the parents may also require their own mental health and/or chemical health treatment.
Alternately, students who are placed in foster care due to abusive or neglectful home situations may improve significantly in the foster home, and that improvement may be reflected in the school environment as well. If the student is prematurely returned to a home where severe problems persist, and if that student then begins to have significant school problems as a result, then it important for DOE to have a good working relationship with DHS to assure that SBBH services are not being misdirected.
IEP-driven services require that IEP teams have individuals who are knowledgeable about the nature of the related or supplemental services, and are able to determine when this service is needed. This raises concerns about specialized services such as medication management, with liability concerns that could arise from a lack of a referral and an allegation that the district did not have a professional who could have correctly identified the need for medication management.
In my opinion, the situation has gone to such an extreme in Hawaii that “the cart is driving the horse”; i.e., services won’t be provided unless they are on an IEP, resulting in services that would be very unusual on IEPS (e.g., foster care) to be listed as either related services or supplemental services. I would encourage DOE to obtain legal counsel on this issue from the Attorney General’s office or, if necessary, from a more specialized school-law attorney.
Problems with Special Education Eligibility Criteria in Regards to Student Mental Health Issues
Hawaii is using, with some modifications, the federal definitions of Autism, E.D. services and Other Health Impaired Services. Although these definitions may be adequate for educational purposes, they don’t necessarily translate well into mental health models of services.
For example, (Citing Chapter 56 eligibility criteria), eligibility for E.D. services require the presence of one or more symptom over a long period of time. The criteria do not clarify the duration of “a long period” Also, some symptoms such as the mania of bipolar mood disorder may have a sudden, severe onset, with symptoms that quickly and severely impact a student’s education. The criteria require that symptoms are present to a marked degree, but the term “marked” is also not defined. The term, “social maladjustment” is also not defined. Other states expand the definition of the Emotional Disturbance category in order to clarify these and other issues. Some also add other factors, such as the need to rule out chemical abuse as a primary cause of the student’s behavioral problems.
The Autism criteria mandate that verbal and nonverbal impairments are required for inclusion in that category. This rules out Asperger’s Syndrome, as these affected individuals have intact communication skills, yet they are significantly impaired for other reasons. The category defines Autism as a developmental disability when it is in fact a developmental disorder. The definition notes that the student may have (not “must have”) one or more symptom of repetitive/stereotyped behavior, a need for routines or unusual responses to sensory stimuli. These criteria do not jibe with DSM 4 criteria for Autism. Finally, the criteria require that the student should not be categorized under the Autism criteria if he/she meets the criteria for E.D.. This is very problematic, because an inability to learn, inability to build relationships, inappropriate behavior and feelings, unhappiness and fears/physical symptoms are all common symptoms in autistic disorders.
The other problem with Hawaii’s approach to IEPs as they relate to students’ mental health disorders is the practice of only listing one Special Education category even when several categorical requirements are met. This can be problematic, for example, in emotionally disturbed students who have learning disabilities, if the learning disabilities are under appreciated by educational staff due to the student’s ongoing behavioral difficulties.
Mental Health and Chemical Health Disorders Experienced by Students Served by SBBH Staff
Mental Health Disorders
I was not able to obtain recent diagnostic information from all sites for SBBH-served students. The data that I did receive indicated that students who were hyperactive, disruptive, oppositional and/or conduct disordered were the most common group of students served, although students who had internalizing
disorders (e.g., anxiety disorders) were also served. Internalizing problems were also noted in BASC date that indicated that one fourth of students served had evidence of significant depression.
Given that students who have externalizing behavioral problems are more problematic in schools, and often require educational interventions in the school setting, this is not surprising. However, this suggests that, compared to the demographics of all mental health disorders experienced by children and adolescents, IEP-driven services are directed to a disproportionately larger group of acting out students.
Some of these students may simply have behavioral difficulties that do not stem from underlying psychiatric pathology. These students are best suited for behavioral interventions. Others may have disorders (e.g., Bipolar Mood Disorder) that trigger behavioral problems and that do not respond well to behavioral interventions. Still other students have a combination of the two contributing factors.
Autism Spectrum Disorders
Although Autism Spectrum Disorders (ASD) are addressed administratively in another branch of DOE than SBBH, some ASD students also receive SBBH services. Students who have Autism, Asperger’s Syndrome and Pervasive Developmental Disorder NOS often have, in addition to their core ASD symptoms, co-morbid psychopathology that is caused by other co-existing psychiatric disorders. Thus, some ASD students also have ADHD, Obsessive Compulsive Disorder, Depression, Bipolar Mood Disorder, Panic Disorder, Conduct Disorder or Oppositional Defiant Disorder, alone or in combination. These students are especially difficult to serve, as the combination of ASD and other psychiatric pathology has a synergistic effect, producing problems greater than the sum of their parts. Also, medication interventions for one target symptom (e.g., ADHD symptoms) can produce exacerbation of other co-morbid disorders (e.g., Obsessive Compulsive Disorder).
Thus, it is essential to have a close working relationship between the ASD and the SBBH programs in DOE to assure that these students receive a seamless set of appropriate interventions to meet their needs.
Chemical Health Issues
SBBH staff uniformly reported that, for the high school students who they serve, approximately 75% had drug and/or alcohol abuse problems. This is of great concern, especially since SBBH staff are not providing focused drug treatment for these students, and because many of these students are receiving no services other than SBBH services. DOH will accept referrals of students who have drug and/or alcohol abuse if they also have a co-morbid psychiatric diagnosis. There are some programs that provide chemical dependency treatment, but it is my understanding that there is a significant relapse rate when students finish the program and return to school environments where drug use is the norm. To date, there are no “sober schools” or “sober classrooms” in the Hawaii educational system.
Act 44, and subsequently, act 213, addressed the need to do assessments of students who were dismissed due to drug/alcohol issues. At this time, there are no personnel from SBBH on the Advisory Task Force that addresses this issue. Given the pervasiveness of drug and alcohol problems in SBBH-served students, I would recommend that SBBH have a representative on this task force.
A number of contracted agencies provide neither drug testing nor chemical abuse/dependency services for their clients. Given the high percentage of drug/alcohol problems experienced by SBBH students, it is important to not refer students who have these problems to providers who are not in a position to address these problems. Although referrals could be made to multiple programs for mental health and chemical health issues, it is preferable to make referrals to one agency for all services.
It is my understanding that DOH receives federal funds for substance abuse assessment and treatment. It is not clear whether they can provide services for the treatment of substance abuse/dependency only through another branch of their department, for students who do not have co-morbid psychiatric conditions.
Different programs provide different models of Chemical Abuse treatment. Some use the harm reduction approach, whereas others use the abstinence approach. It would be helpful to contract with chemical dependency programming with the same evidence-based criteria that DOH is using to evaluate mental health programs, so that appropriate referral decisions can be made for these affected students. It would be helpful, for example, to have data about relapse rates for students served by the Teen Care program.
Chemical health issues were also identified as being problematic in the majority of students’ families who were served by SBBH programming. It would be helpful to create an expanded infrastructure of services so that family members could access appropriate Chemical Dependency services.
Given the inherent nature of denial in individuals who have these problems, approaches such as Motivational Interviewing could be helpful in interventions with students and their families.
Some states (e.g. Minnesota) have expanded the criteria for placement in E.D. programs. These criteria require that Districts to rule out drug and/or alcohol abuse as the primary cause of a student’s educational difficulties. Hawaii may want to consider doing this, so that this group of students will be effectively identified and referred for appropriate services, rather than being placed in Special Education programming that is unlikely to be effective if they continue their abuse patterns.
The bottom line on drug and alcohol issues is this: “Abuse” means that a drug and/or alcohol is causing significant disruption in an individual’s life. If the majority of secondary students served by SBBH staff are abusing drugs/alcohol, and if they do not receive services to address this problem, then I would expect SBBH interventions to be ineffective for them.
SBBH Behavioral Specialist Issues
The SBBH Behavioral Specialists have been doing an excellent job in providing on-site, accessible services to students at all risk levels. A number of systemic issues need to be addressed so that services can take place in the most efficient manner, with the best outcome and the lowest level of liability for DOE and its providers.
The common themes, and areas in need of improvement raised by SBBH and other DOE staff are:
- The need to clarify the roles of all individuals serving students, both within and without the SBBH program. Teachers’ roles are of especial importance in this regard.
- A need for other systems to more clearly delineate and clarify their roles in relation to student needs and to SBBH activities. These systems include DOH, DHS, and the Juvenile Justice system. This goes along with the need for improved collaborative relationships within the educational system, and with these other systems. There is a perception that, although system guidance & procedural references are in place, (i.e. CSSS, SBBH Manual, DOH “Purple Book”), these lack both integration and full implementation.
- Improve methods of consistent data gathering and analysis.
- Need for consistency and quality improvement in designing Behavioral Support Plans that are based on accurate depictions, generated from Functional Behavioral Analyses and from other sources of information.
- A need for analysis of the outcome of behavioral consultations with educational staff. (For example, are the recommendations being followed? Are behaviors improving as a result?)
- A need for training for behavioral specialists in the art of consultation, to assist them in more effectively communicating student needs, in clarifying issues that are behavioral in nature vs. due to other factors (e.g., mental illness), etc..
- A need for training of behavioral specialists in the nature, manifestations, identification, evaluation of and treatment of psychiatric disorders in children, adolescents and adults. This training would also focus on methods of differentiating behaviors that stemmed from psychiatric disorders vs. those that stemmed from maladaptive behavioral patterns or other behavioral contributors. They are also interested in training in developmental, social, educational, psychological and ecological issues, and they recommend that teaching staff and administrators have training in these issues as well.
- A need to clarify the factors required for IDEA eligibility (see IDEA section in this report).
- A need to more effectively make significant changes in antecedent and consequence strategies when behavioral interventions are not successful.
- A need for establishing state-wide policies and procedures for implementing CSSS strategies (feedback from behavioral specialists indicates a wide variation in the use of CSSS implementations).
- A need to impact the regular education environment to assure that school-wide positive behavioral support activities dovetail with SBBH activities.
- A need to assure that Standards of Practice are implemented and followed in all schools.
- A need to assure that Peer Review is implemented and consistently followed in all schools, and that principals take the lead in this regard.
- Provide consistent, comprehensive and continuing clinical supervision for behavioral specialists
- A need to increase community infrastructure of mental health and other related services so that students who do not require SBBH services can be served appropriately through community based services.
- The need for development of DOE supervised CBI programming.
- The need for efficient use of contracted services, avoiding payment for empty positions in these programs.
- The need to assure that SBBH staff are not used to perform activities that would be best performed by school-hired staff (e.g. counselors).
- Some staff believe that their workload is greater than their ability to provide quality services (e.g. enough time in individual sessions for needy students).
- Paperwork and documentation requirements get in the way of providing direct services. At times, these are perceived as hoops to jump through in order to obtain services (e.g. DOH services).
- As social maladjustment can cause significant problems in the school environment, but because it is excluded from IDEA services if it the primary cause of a student’s difficulties, there are no programs to address this problem.
- Salary issues and permanency of positions were raised by a number of behavioral specialists.
- Lack of activities in the summer was a concern for staff working year-round in schools where students had the summer off.
- Behavioral specialists even raised concerns about potentially unethical practices- including lack of qualifications to work with severely mentally ill students and lack of adequate clinical training and supervision to assure that appropriate behavioral and clinical decisions are made.
- Liability issues were also raised. A student may have severe psychiatric pathology, (e.g., severe Bipolar Mood Disorder), but may only be receiving services from an SBBH staff member. If a parent does not allow a referral for clinical treatment, it is not clear what the behavioral specialist should do.
- Need for clarification of roles re: behavioral vs. clinical interventions. Many behavioral specialists believe that they are providing therapy, despite DOE assertions that they are providing behavioral interventions. For example, the issue of cognitive-behavioral therapy provided by behavioral specialists had arisen. This is clearly a mental health therapeutic service.
- There is a need to parcel out the time of behavioral specialists to the different CSSS levels. If they are to spend more time doing levels one through three activities, who will make up for the time taken away from level four and five activities?
- There is a need for more consistent and unified levels of supervision. If a school principal is the supervisor of a behavior specialist, then there may be problems with the specialist carrying out activities in a manner consistent with programming in other areas. This can lead to lack of clear role definitions, potential diluting of roles, and potential legal liabilities.
- Medication management as a DOE activity raises concerns for SBBH staff, as many of them feel that educational personnel do not know how to address medication management issues in the context of an educational model of services. Staff are also concerned about the lack of availability of psychiatric services in the community, if students require psychiatric treatment but do not have IEP-directed needs for this treatment. They are concerned that, if psychiatric services including medication management are transferred out of DOE, they may have difficulty accessing these services and obtaining appropriate levels of integration (communication, feedback, outcome-based approaches, etc.) with these services.
The Relationship Between DOE and DOH
It was notable, on a number of occasions during my consultation with both DOE and DOH staff, that there was considerable degree of disagreement, misperception and miscommunication between DOE and DOH staff. For example, several Behavioral Specialists noted difficulty in accessing DOH services, noting that they had waited months for services for one student, and even noting that they had received an E-mail from DOH telling them to not make any referrals to DOH.
DOH staff, on the other hand, noted that they felt that DOE was not making referrals early enough to them, often waiting until students had developed severe psychiatric problems that could have been prevented through early intervention. They noted that a student would only need a CAFAS score of 80 to qualify for SEBD services, but that they often had much higher CAFAS scores (e.g. 110) at the time of referral. They noted concern that students were often referred for placement rather than for treatment, and that the placement could have been avoided if an earlier referral had been made.
However, DOE staff described instances in which the CAFAS was high enough to qualify for DOH services, but that the DOH staff (who did not know the student’s circumstances as well as the Behavioral Specialist did) would re-do the CAFAS, come up with a lower score, and then deny services. Behavioral Specialists also noted that they often had to “jump through hoops” to access DOH services, and were often asked whether they had done enough interventions prior to considering making the referral. The process of referral to DOH from DOE was a major source of concern. DOE staff expressed opinions that, for students who presented with severe psychopathology, it was inappropriate to have to obtain and initiate a behavior support plan, an FBA, a clinical assessment, a CAFAS, etc. and to demonstrate that services from DOE had been ineffective prior to DOH opening the case.
DOH staff expressed concern that early intervention coordination was not taking place adequately at collaborative Peer Review meetings, while DOE staff from one SBBH program stated that DOH staff had only shown up for one out of the last five Peer Review meetings.
DOE staff also expressed concern about the difficulty having their calls or emails returned when referrals were being made. DOE staff expressed frustration at difficulty reopening cases in DOH, for a student who had recently received CAMDH services, with DOE staff having to start all over with documentations for the need for services despite the student’s severe problems.
DOE staff expressed concern that DOH had refused to pay for the placement of at least one student in a mental health residential treatment center, arguing that the student was not there for mental health needs, but for behavioral problems that stemmed from educational, not mental health needs.
DOH staff expressed concern about problems with communication from DOE administration to DOH administration. They were aware of considerations by DOE to no longer consider medication management as a DOE service, but were frustrated that this had not been directly communicated to DOH so that DOH could plan and budget for this service, if this was indeed the plan.
It was of interest that a CAMDH contracted therapist noted that she was not in a position to make a diagnosis of a student, but that she relied on diagnoses made by DOE. This disconnect between two systems presents significant potential for poor therapeutic outcomes, if the individual providing treatment is someone different than the one who did the diagnostic evaluation.
Other DOE/DOH issues raised included the change in provision of services by DOH for students who have 504 plans but not IEPs. There was a perception in DOE that 504 students previously had received these services, but no longer were, and there was a lack of awareness of changes in the memorandum of agreement between the two agencies about this type of policy change.
DOE staff also expressed concerns that they perceived some care coordinators as being conduits of information between DOE’s requests for services and DOH’s authorizations. DOE staff were concerned that information was lost in the process, and noted that, if the care coordinator had no authority to authorize services, DOE staff would prefer to communicate directly with decision makers in DOH.
Concerns were also raised about the functionality of the QA team, in that staff were frustrated with ongoing systemic problems between the two agencies despite a mechanism being theoretically available to address these issues.
What was notable about these problem descriptions was their anecdotal nature, and what was absent was any systemic method of determining the accuracy of either side’s concerns, the frequency or nature of these problems, or the differences in levels of coordination, cooperation and collaboration between DOE and DOH at the different complexes.
Part of the difficulty of having a seamless, functional relationship between DOE and DOH is that each system has its own unique infrastructure, mandates, philosophies, and methods of service provision. DOH is based on public health models, county jurisdictions, and a diagnostic model, whereas DOE relies on educational models of service provision. Concerns expressed by DOH staff and CAMDH providers included the perception that, since DOE took over outpatient services, there has been a marginalization of a mental health perspective, culture and knowledge base in DOE. Clearly, there is a need for reintegration of services.
The Felix Decree mandated a good working relationship between DOE and DOH. Also, Hawaii is one of the sites promoting the IDEA Partnership model that relies on a shared agenda by all participants. It appears that there are a number of issues that are unresolved, and these pose significant risks for student deterioration and potential liability for both departments if they are not addressed.
I would expect that integration of services and an improved relationship between DOE and DOH will prove to be a significant challenge, for a variety of reasons. However, I believe that it will be possible, if each system can work within a model of principled negotiation, keeping in mind that the needs of children and families are foremost in this process. The positive working relationship between DOE and DOH on Kauai is a good example for the rest of the system.
I would recommend that a monitoring system be established to provide oversight into the nature of referrals to DOH, the severity of students referred, the timing of the referrals in the course of development of the student’s problems, the timeline of the DOH response to referrals, etc. It would be very helpful to clarify whether the concerns expressed are valid, whether they are the exception or the rule, and whether they are particular to some sites and absent at others.
Relationship between DOE and DHS
Several DOE staff expressed concerns that they had been placed in a position of providing services to students who they felt were being abused or neglected in their home environments, and for whom out of home placement was not a consideration by Child Protection Services. Some noted that they had served students who had, in their opinion, been prematurely returned to their homes. Staff noted concerns about their perception of the high threshold for case opening by Child Protection, and the potential that this could produce clinical deterioration in affected students. One DOE staff described a situation where a student deteriorated in school once he returned home, but that the Child Protection worker described this as “a school issue” that was not relevant to Child Protection placement considerations.
I would note that this is a scenario not unique to Hawaii, but one that plays out throughout the U.S.. It would be helpful to have clarification by DHS regarding thresholds of service provision and mechanisms for communication about concerns between the two departments.
The Role of Public Health
A public health approach to children’s mental health relies on early identification of disorders when they first appear, when they can be treated most effectively, and when levels of disability can best be limited. All students who are on Medicaid are entitled to EPSDT (Early, Periodic Screening, Diagnosis and Treatment), a Medicaid benefit that includes both a health screen and a mental health (social-emotional-behavioral) screen periodically between the ages of 0-21. This can be done in physician’s offices, or in some states, it can also be done by Public Health nurses, even within the school setting. I have not been able to obtain data from DHS regarding the percentage of children and adolescents in Hawaii who receive EPSDT screening, nor the percentage of those screened who are referred for a mental health evaluation. Since research indicates that approximately 25-30% of children and adolescents in this population have evidence of mental health disorders, a similar yield from screening would be expected.
At this time, screening for mental health problems are done in the school system as part of the CSSS process. I would encourage DOE to work with DOH, DHS and the counties to encourage mental health screening as a Public Health practice in the community. This would provide early intervention mental health activities that would not be tied to DOE, would not be IEP-driven, and would not make DOE the payer of last resort for recommended evaluations and treatment.
Data Gathering and Analysis
SBBH has made significant progress in gathering and analyzing individual and group data about SBBH students. For example, BASC baseline and follow-up data is valuable in identifying student needs and monitoring student progress in response to SBBH interventions.
However, other data that would be very useful for program planning and development have not been systematically obtained and analyzed. This includes information about the DSM 4 diagnoses of students referred for evaluation, the types of psychiatric treatments provided, and the outcome of treatment in terms of academic progress, reduction of behavioral problems and reduction of dropout rates. It is important that data gathered by DOH about these issues be shared with DOE, and analyzed conjointly by both departments.
As different systems use different tools to assess students needs, it is difficult to compare data from the different systems for baseline and outcome analysis. For example, DOE uses the BASC whereas DOH uses the CAFAS tools- the former being more symptom-specific and the latter being more focused on level of functioning.
Given the concerns about excessive paperwork getting in the way of providing direct services, it will be important to assure that all data-gathering activities be carried out in the simplest, most efficient and user-friendly manner for both SBBH staff and for students and their families.
Examples of useful data analysis to consider include:
- What are the reasons for high male:female ratios in higher levels of CSSS services, despite demographics that suggest significant mental health problem frequencies in female students?
- What are the factors for the significantly different lengths of stay (e.g. one program was twice as long as another) in ILC programs?
- Is there a reduction in the need to make referrals for E.D. Special Education services as a result of SBBH activities?
It would also be helpful to assure that ISPED can work closely with SBBH to generate useful data analysis reports on these and other topics.
Roles of School Staff
Few school districts have clearly defined roles for staff working with Special Education and Regular Education students who have mental health disorders. This poses an even greater challenge in Hawaii, where SBBH staff are retrofitted to school programs, and are providing additional services. I received feedback from a number of school staff noting that it would be helpful to have greater clarity in role definitions of the staff (counselors, social workers, psychologists, etc.) who work for the schools in traditional capacities. There is also a need to more clearly define the roles of SBBH staff, in regard to their own activities, and to clarify their relationship with school professionals who are carrying out their own roles. Without clear role definitions, there is the risk of overlap of services in some areas while leaving dangerous gaps in other areas. Also, there is the risk that SBBH staff will be seen as able to carry out whatever function is needed in a school, offering principals, for example, the option of laying off counselors and expecting SBBH staff to take their place. This would result in SBBH staff having less time to provide services for CSSS students in the higher severity categories.
I would recommend clarifying the roles, description of work requirements, supervisory requirements and accountability standards for all school staff who work with students who have mental health and/or behavioral disorders. Examples of activities that require role definition (e.g., who performs this function? Who provides supervision? What documentation is necessary? etc.) include:
- conducting educational evaluations with a focus on the educational implications of the student’s disorder(s)
- attending IEP meetings
- providing ongoing documentation of special education interventions and their outcomes
- monitoring target symptoms (e.g. off-task behavior, behavioral outbursts, etc.)
- documenting the nature, frequency and severity of the target behaviors
- communicating this information to the treating physician and/or mental health professional
- obtaining information about diagnostic and treatment information
- reviewing the information, and translating it into accommodations and modifications specific to the student’s disorder
- assisting teachers in understanding the nature of the student’s underlying disorder, and working with the teacher to assure that appropriate modifications take place
- clarifying whether the student is just beginning treatment and is likely to demonstrate improvement in target symptoms, or is seen as having reached maximum benefit from mental health treatment
- providing counseling as a related service on IEPs
- providing other related services as needed (social skills groups, help with study skills and organizational skills)
- assuring that the student is not a victim of harassment by peers
- communicating with the student’s parents on a regular basis about both problems and successes in school
- communicating to the treating professional about situations where problems continue, despite the student’s treatment (e.g. ongoing severe hyperactivity, impulsivity and distractability despite the use of medication). This could suggest a diversion of medication, non compliance with medication use, medication side effects, the wrong dose of medication, the wrong type of medication, or even the wrong diagnosis and the wrong treatment (e.g. treating a bipolar student as if he or she had ADHD).
- monitoring of symptoms presenting in the classroom that are not being treated, and communicating these symptoms to the treating professional
- seeking psychiatric consultation if it appears that the student may be misdiagnosed or if the treatment remains ineffective and the treating professional is not willing to reconsider treatment options.
It is essential that roles for various professionals are defined for a school system, that there is ongoing quality assurance regarding each professional’s activities, and that there is a method of providing outcome measurement of these activities.
Documentation
Behavioral specialists describe the bind that they are in regarding documentation of mental health issues that are addressed in their interventions. Some note that they are reluctant to document the content of their sessions with students, as all information ultimately goes into school records. Some of the information discussed by students is very sensitive, reflecting very personal thoughts, feelings and behaviors, or describes potentially sensitive issues affecting family members. If the student were seen in therapy by an outside professional, these records would be confidential, and only could be available to the school with an appropriate release of information. Also, school records do not have the degree of confidentiality present in clinic records; thus all confidential issues discussed with behavioral specialists and documented in school records are available for parental review as well. School records also may follow the student to other districts if the student moves out of town or out of state, and this could be potentially embarrassing or could have other adverse consequences. As a result, some behavioral specialists write minimal notes describing their interventions with students. One behavioral specialist described a student who was seen in weekly sessions who was presenting with significant depressive symptoms. When asked what was being documented about the student’s self-report and about the content of the sessions, either in school records or in the behavioral specialist’s private notes, the response was that almost nothing was documented.
Behavioral Specialists, by their own report, are seeing students who have potential risks of harming themselves and/or others, or risks of clinical deterioration from disorders if they are not effectively treated. The lack of adequate records that define issues such as changes in clinical symptoms, potential for danger to self and/or others, etc. creates significant liability for DOE. Also, the lack of documentation makes it very difficult to establish the nature of interventions, the students’ responses to those interventions, and the ultimate outcome of the interventions. It also makes transition to another professional difficult, as the new treating professional does not have adequate documentation to clarify the nature and types of interventions that have already been used.
Thus SBBH staff are in a very difficult position in regard to documentation. Being district staff, they face a dilemma of either protecting confidentiality or being potentially negligent in their duties to document.
This is less of a problem when only strict behavioral/educational interventions are provided, as minimal confidential information is revealed that would cause the behavioral specialist to be reluctant to chart it in school notes. The fact that so much information is discussed with Behavioral Specialists is considered very personal suggests that the Behavioral Specialists’ activities often go beyond strict definitions of educational interventions and reflect, instead, clinical interventions. Until there is greater clarity on this issue, there is significant potential for negative clinical, legal, financial and political repercussions.
I would recommend that guidelines be established for all DOE staff including behavioral specialists that mandate documentation of crucial issues such as evidence of clinical symptoms, evidence of improvement or deterioration of those symptoms, evidence of danger to self and/or others, and documentation of referrals for diagnosis and treatment when appropriate.
Supervision Issues
Clearly, there are benefits to site-based management of staff. Each complex, even each school, has unique needs, staffing patterns, student characteristics, parental attitudes about mental health and behavioral issues, etc..
However, there is a significant disadvantage to a lack of oversight at the State level of SBBH activities. As noted above, there are a number of areas (role definition, screening, documentation, referral thresholds, consistency in identification of IEP driven services, etc.) in which administrative oversight from a single site is appropriate, in my opinion.
The chain of supervisory responsibility for DOE activities needs to be clearly defined. The “buck stops” with the superintendent, who needs to assure that all activities performed by DOE employees are accountable and adequately supervised. This is a straightforward process with strictly educational activities, but can become highly problematic when other activities, are considered. For example, health-related activities of nurses and health aides need to be supervised by individuals who have expertise in health related services issues, and these individuals would be health professionals (e.g., nurses and physicians) rather than educators. If psychiatric medication management is provided by DOE employees, then there would be a need for appropriate supervision of the process. I will address recommendations for supervisory activities under the System Redesign and Medication Management sections of this report.
Liability Issues
A number of potential liability issues have already been raised. Unfortunately, DOE faces liability if it is the provider of mental health services, but also faces liability if it maintains that it is only providing behavioral interventions.
Major areas of liability under the present system model include:
- SBBH staff may not be adequately documenting information related to students’ potential risk of harming themselves and/or others.
- Placing related or supplemental services on IEPs without having staff who are knowledgeable enough about determining when there is or is not a need for that service can lead to significant legal liability.
- There is inconsistency in decision-making from site to site regarding the criteria and threshold for referral for diagnostic evaluations and treatment including medication management
- Lack of adequate training can lead to liability. It is crucial that SBBH staff are not put into a position of providing services to students whose problems are of a complexity and severity that is beyond the professional competencies of the staff.
- Lack of supervision can also lead to significant liability problems, as can inconsistency in supervisory practices from site to site. This includes the supervision of SBBH staff, but also includes the supervision of those who are providing other IEP-driven services, including health aides, nurses and psychiatrists.
- Inconsistency of service guidelines, protocols and policies from one site to another also raises significant liability concerns
- The model of IEP-driven services, and of services that focus solely on students who are having problems in the classroom can lead to significant liability claims of negligence. One behavioral specialist described a situation where a student reported having auditory hallucinations to her. However, because the student was not having problems in the classroom, no referral for an evaluation was made. I would note that Paranoid Schizophrenia is a psychiatric disorder that carries a significant risk of harming others, and is a disorder that can manifest with auditory hallucinations and, at times, minimal or no obvious problems at work or at school.
- Although DOE has taken over psychiatric medication management, this does not include payment for prescriptions. As some medications (e.g. atypical antipsychotics such as Olanzapine) are very expensive, and since some families may have limited prescription coverage, there may be situations where prescriptions are written under DOE auspices, but are never filled due to family financial difficulties. If this led to deterioration or other untoward events, DOE might hold liability as the overseer of medication management services.
- There is always potential liability when services are provided to individuals who are at risk of harming themselves and/or others. DOE has particular vulnerability, as DOE has no malpractice coverage for lawsuits that could result from negligence, inappropriate treatment, inappropriate behavior perpetrated by an SBBH provider, etc.
- If the provision of medication management is a DOE service, and if a psychiatrist is sued for malpractice for activities performed while providing IDEA-driven services, then it is likely that DOE will be named in the suit as well. This could lead to very significant financial liability for the State, as DOE does not have malpractice coverage at this time that would protect it in this scenario.
Retention of Staff and Filling of Vacancy Positions
There has been an ongoing struggle to fill vacancy positions (e.g. for psychologists), and to retain staff in SBBH. Although there are many contributors to this problem, it is my opinion that the primary contributor is due to salary issues (exacerbated by the high cost of living, especially housing, in Hawaii.) I would expect this problem to worsen if bonuses are eliminated for new psychologists.
Contracting out for SBBH activities creates a vicious cycle, as professionals who are hired by contracted programs are generally paid higher salaries than DOE-hired employees. Thus, DOE is indirectly paying higher salaries for the same service anyway, but is providing disincentives for professionals to work for DOE rather than for contracted programs, and increasing the likelihood that, for example, psychologists will leave DOE for better paying jobs once they have their necessary supervision requirement hours met.
In my opinion, it will be very difficult to manage an effective SBBH program until this issue is resolved. Although I appreciate that staff salaries are not under the direct control of SBBH, I would hope that there will be some way in DOE to ameliorate this problem by providing wage increases for DOE-hired staff. The next section, (“Funding”), will illustrate the untapped funds that could more than pay for such salary increases.
Funding
It is laudable that DOE will be billing for Medicaid services for direct treatment reimbursement. I would note, however that, since few of SBBH interventions at this time are diagnosis-based (Medicaid requires a diagnosis for reimbursement for direct services), and since few of the SBBH providers are qualified to bill Medicaid, that the amount yielded in reimbursement for direct services may be helpful, but not as high as expected. (One estimate is that only 15% of SBBH activities would be billable, and that as few as 25% of students served by SBBH may be Medicaid-eligible).
However, I believe that reimbursement for indirect services through Medicaid is likely to yield a very significant payback. I would expect that this would provide far more dollars than direct service reimbursement, as indirect reimbursement is not strictly tied to licensed professionals and student diagnoses. If both the direct and indirect project cannot be started at the same time, I would recommend consideration for beginning a random time study for indirect billing as soon as possible. I believe that it would be appropriate to have legislation direct funds from the general state fund to the DOE, and believe that it would be ideal to direct the funds to Student Support Services including Special Education, if at all possible.
I believe that millions of dollars could be made available for DOE and DOH services if the legislature and DHS addressed Medicaid reimbursement rates. I sent an email to Angie Paine, Hawaii Medicaid Director, requesting information about the percentage of Medicaid eligible children and adolescents who received mental health services through either DOE or DOH, vs. those who received them through other sources. I have not received an answer to date, but I would suspect that the vast majority of children and adolescents who are receiving mental health services under Medicaid are receiving them through DOE, DHS or both. Since both DOE and DOH are paying providers at a rate considerably higher than the Medicaid rate, the state budget is paying millions of dollars to supplement Medicaid rates. If Medicaid rates for these services were increased to the amount that is now paid by DOE and DOH to providers, then a significant amount of federal dollars would be brought in, reducing expenditures from the Hawaii state budget. Also, increasing Medicaid reimbursement rates would provide the incentive for the creation of a community mental health infrastructure in Hawaii, which could ultimately provide many of the services that are not covered through DOE or DOH system designs.
At this time, Hawaii is considering a Medicaid Waiver category for adults who have severe psychiatric problems. There is no plan at this time to consider a similar waiver for children and adolescents. Given the severity of many students served by DOE and DOH, and given the success in other states of drawing down federal funds for these waivered services, I would recommend that DOE and DOH approach DHS on this issue.
Some states have options for parents whose income is too high to qualify their children for Medcaid to obtain Medicaid eligibility for the children if they have significant disabilities, including psychiatric disabilities. Since the Medicaid benefit set is significantly broader than many private insurance benefit sets, and since it doesn’t have a co-pay, I would recommend that DHS consider this option as well.
At this time, funding is not sought from non MedQuest third party payers for services provided by contracted providers. As DOE is the payer of last resort, it would be worth considering encouraging billing, when families are receptive to it, in situations where this would be appropriate. For example, a contracted provider who is serving a student and his/her family for IDEA-based services may also be available to provide services that are not school related (e.g. family interventions, treatment of siblings or parents, etc.) and bill these services to a third parthy payer. Even IDEA-based services could theoretically be billed to a third party, with the parent’s permission. This would be more palatable for families in situations where there is no co-pay for services and where there is a generous benefit set. I am not familiar with the relationship between DOE and families who have military insurance coverage, but this would be an example of potential billing, if it is not already taking place.
The System Redesign Plan
DOE has some major policy decisions to make regarding the direction that it will take in serving the needs of students who have behavioral problems, mental health disorders, or the combination of the two. As noted above, continuation on the present track is fraught with potential financial and legal liabilities, and, although services have been helpful for many students, there are significant gaps in service provision.
The proposed system redesign focuses on creating a more efficient system, with greater accountability, less duplication of effort, and increased cost-effectiveness. It focuses on consistency of activities throughout the state, and this focus is beneficial for educational, clinical and legal reasons. Finally, it provides a framework for effective system change in a unified direction that will be based on evidence-based best practices in both the educational and mental health frameworks.
I would note that the proposed system redesign makes sense regardless of the approach that DOE decides to take in providing services to students with behavioral and/or mental health disorders. It provides a more effective framework within which to flexibly and effectively address systemic change.
The educational system has a tendency to perceive SBBH in terms of the activities of the Behavioral Specialists. System redesign, with consolidation of services, will result in a greater awareness of the multiple roles carried out by SBBH staff- Behavioral Specialists, school psychologists, clinical psychologists and support staff.
For the reasons noted earlier in this report, supervision is an essential component of any system addressing behavioral and mental health issues. It is even more essential than supervision about educational issues in an education context, as mental health and behavioral problems are more complex, can lead to significantly adverse consequences for the student and his or her peers, and can lead to significant liability if there is evidence of negligence or inconsistency in supervision. The proposed plan has a more streamlined supervision process. It also separates clinical supervision activities from administrative supervision, thus setting more clear parameters for each activity.
By placing all psychologists under one system, and combining funding and streamlining the line of supervision, this plan allows greater flexibility of psychologists’ roles, more efficient utilization of resources, less duplication of efforts, more accountability and an increased ability to measure outcome of professional activities. It would eliminate the present problem of crossed lines of supervision (e.g. SBBH psychologists supervising Special Education funded psychological examiners) It also makes it easier to assign and fund psychology intern positions, which are essential for both training and staffing functions within the system. Finally, it would promote consistent compliance with mandates for utilizing standards of practice within SBBH.
This system redesign will require increased capabilities for generating and analyzing data that pertains to SBBH activities. This data will reflect individual and group student issues throughout the state, and will provide information for effective program planning and development activities.
The plan allows for improved supervision of the Psych 6 positions by a Psych 8 professional. (Without this supervision, the Psych 6 staff would need to leave the system after two years.)
This plan will also create licensed behavioral specialists who will provide more effective clinical supervision to social workers and behavioral specialists. Technical support will also be provided to counselors. In my opinion, consideration should also be made for increased clinical consultation to counselors as well.
There are many financial and systemic drawbacks to paying “dollars for hours’’ to contracted professionals. This is a disadvantage to the professionals, who are not paid for missed appointments. It is also problematic to DOE, as it is very difficult to manage budgets using contracts that have open-ended potential needs for therapeutic services. If DOE continues to contract for services, the new plan of contracting for whole positions makes more sense. I would note that there is a downside to contracting for behavior specialist positions for many of the reasons previously noted (salary, no direct supervision from SBBH, etc.)
In summary, I would endorse the system redesign plan, as it clarifies lines of authority, eliminates overlapping supervisory and direct service functions, provides consistency in service provision, avoids system fragmentation, increases cost-effectiveness and encourages integration of services. It encourages a seamless system that has increased flexibility, that is more responsive, has improved communication capacities, and is more able to respond to requirements for system change. It also positions DOE more strategically in its relationships with other agencies, and it allows for the increased capability to institute systemic changes that will be necessary to more effectively meet the needs of SBBH students.
In my opinion, the system redesign proposal does not go far enough in addressing supervisory issues. At this time, the State Director of SBBH services is in more of an advisory position than in a supervisory position with the District Education Specialists. They receive their supervision from their Complex area superintendents, who may not be adequately familiar with the complexities and perspectives of SBBH activities. This model makes it difficult to have consistency in SBBH approaches to service provision. Given the complexities of the issues involved, and the potential for liability if there is inconsistency in approaches at different sites to the same types of clinical situations, I would recommend a redefinition of the role of the State Director to be an administrative supervisor, providing supervision and direction to the SBBH District education specialists., ultimately responsible for SBBH services at all sites. This will result not only in greater oversight and consistency of services, but in an increased ability for DOE to have a more accurate understanding of system issues outside of DOE, and a greater ability to negotiate and partner with other systems (e.g., DOH, DHS, the private sector, etc.)
Next Steps
Behavioral or Mental Health Approach?
In my opinion, DOE needs to make some major decisions about the roles and directions of SBBH-provided services. For the reasons outlined above, I believe that it is detrimental for DOE to continue to maintain that it is not providing diagnostic or treatment services when an analysis of its activities suggests otherwise. The basic decision needs to focus on whether DOE wants to restrict the activities of all SBBH and non-SBBH employees to assure that they, in no way, are providing what could be interpreted as mental health services. If DOE decides to do this, then it will be incumbent on DOE to assure that someone else comes to the plate to provide these services, as DOE made an agreement that students’ mental health needs could be provided for by DOE when it transferred positions and funding from DOH.
If, on the other hand, DOE chooses to continue to provide the types of services that it now provides that would be construed by mental health professionals, courts and laypeople as constituting mental health services, then DOE needs to address a number of issues.
First of all, it needs to be clarified whether DOE has the statutory authority to be a provider of mental health treatment services. If it does have this authority, then it is more likely that an insurance company would be willing to provide malpractice coverage for the District. (Generally, school districts cannot obtain malpractice coverage because insurance companies only cover entities that have the authority to be treatment providers). Since the District self-insures, and since there are no limits of liability if the State is sued as a co-defendant in a malpractice case, it would be appropriate for DOE to seek actuarial advice about the limit of self- insurance, and then seek “catastrophic” coverage above that amount.
Given FERPA requirements, information gathered and documented by SBBH staff is an educational record. There is the “desk drawer rule” that private notes that are not shared with others can be kept separate, and, if destroyed within the year, do not have to go into the school record. Unfortunately, some school districts encourage highly confidential information that reflects severe student problems to be kept separate in this regard- this is very problematic if an untoward event (e.g. suicide or homicide) occurs, and the school staff has destroyed all documentation of the content of meetings with the student. A general rule is, the more potentially dangerous, clinically significant, or legally sensitive the information is, the more that it needs to be preserved and not separated and destroyed.
SBBH staff note concerns about putting very sensitive information in school records. Despite the “need to know” nature of school files, families are often reluctant to tell District-hired staff the type of information that they would share with mental health professionals who are working in a confidential setting. School files also differ from mental health clinic files in that, in clinics, if an adolescent shares information with a therapist that is best not shared with a parent, the therapist has an option to keep that information confidential. This is not an option with school files.
If SBBH staff are providing treatment services and gathering information, it is essential that the information be documented adequately. If DOE is going to provide this type of service, I would recommend that DOE seek legislation to create a data practices act that allows the information that is gathered for clinical purposes to be deemed “non-educational” thus allowing it to be kept confidential and separate from the educational record. The information may then be covered under HIPAA rather than FIRPA statutes.
Medication Management
The most pressing issue, and the most complex and difficult one to solve at this time, is what to do about medication management. This is a service whose provision was a DOH responsibility prior to transfer of outpatient mental health services to DOE, and it also was transferred to DOE.
IDEA is clear regarding school district payment for medical treatment provided by physicians- districts may be responsible to pay for diagnostic evaluations, but are not responsible to pay for medical care provided by M.D.s. However, case law over the years has produced a number of (sometimes contradictory) opinions that have, in some situations, required districts to pay for treatment by psychiatrists. In fact, some districts in some circumstances have had to pay not only for the educational component but for the treatment component of psychiatric hospitalizations and residential treatment. The key issue in these cases was whether the treatment was needed for the student to benefit from an educational program. The opinions stated that the students’ psychiatric needs were “inextricably intertwined” with their educational needs, that they could not be separated, and therefore both the educational component and the treatment needed to be IEP covered services.
The key word is, “needed services”. I would note that the Felix Consent Decree also focused on the need for the provision of necessary mental health related services on IEPs.
Because DOE services are IEP driven, it appears that, since medication management was transferred to DOE, these services, by definition, became IEP services (regardless of whether they are “related” or “supplemental”, they are the district’s responsibility to pay (payer of last resort), if they are on the IEP). The general rule is, “If this service were not provided, the student would not be able to benefit from the educational program provided by the district”. The rule is not, “Could the treatment help?”, or “Does the student need this service in order to have the maximal educational progress?”
Although there are circumstances where districts are obligated to have psychiatric treatment as IEP related services, in my opinion Hawaii is identifying a much larger population of students whose IEPs require this treatment.
The issues that need to be addressed are:
- What is the threshold for putting medication management on an IEP?
- What does it mean to be not only the payer but the provider of medication management services?
- What are the legal, financial, clinical and educational implications of a school district being the provider of psychiatric services?
- Given the history of the Felix response and the potential implications of changing services at this time, what is the best approach to medication management at this time?
I would recommend the following:
- The District needs to closely examine the potential implications of more strictly defining the concept of “necessary” psychiatric services at this time. I appreciate that, given the recent termination of the Felix Decree, that this timing could be construed as “going back on” previous agreements for service provision, and thus lead to significant problems with the advocacy community and the medical community, thus producing significant political backlash. The District could use a counter-argument that its inclusion criteria are much broader than those used by other states, and that its goal is to be more in line with national norms. The advocacy community could counter this argument by stating that national norms reflect an egregious neglect of student needs, and that, if “Felix Decrees” were instituted in other states, many more psychiatric services would be placed on IEPs throughout the country. My expertise is in psychiatry, not politics, and I would encourage the Department to weigh all factors in this decision and to act accordingly. I would suspect that the Department is unlikely to radically change this issue in the near future, and regardless of the number of students who receive medication management on IEPs, the District will have some responsibility to fund this service. The question is whether the District, in addition to funding the service, is responsible to provide the service.
- The District first needs to determine the answer to the questions raised in this report regarding its intended approach to SBBH services- i.e., whether these services will truly be behavioral/non-treatment, whether they will be treatment services, or a combination of the two. If the District wants to move in the direction of being the provider of treatment services in SBBH (diagnostic, therapeutic, etc.), the District could consider the provision of psychiatric care as part of this package. Provision of services also carries the responsibility of supervision of the service, as well of quality control, assurance that access is available, providing background checks, licensure clearance, peer review, etc.
- If the district wants to avoid being the provider of psychiatric services, then it will be necessary to build a legal “firewall” between the district and the responsibilities for service provision. For example, the District could create a relationship with a contracted provider who would take on all responsibilities, clearly outlined in a contract with DOE, of service provision. These would include assurance of malpractice coverage, access to psychiatric care, criminal background checks, adequate continuing medical education, peer review, case consultation, etc.. In this situation, the District would be responsible only for payment, not provision of psychiatric diagnostic and treatment services.
As this issue is very complex, I would expect that further explorations of this issue may be necessary before a definitive decision can be made.
In summary, I would endorse the system redesign plan, as it clarifies lines of authority, eliminates overlapping supervisory and direct service functions, provides consistency in service provision, avoids system fragmentation, increases cost-effectiveness and encourages integration of services.
Recommendations
ASD Students in SBBH
Assessments
Contracted Provider Relationships
Behavioral vs. Clinical vs. Combined Perspective
Community Mental Health Services
Data
Documentation
DOE/DOH Relationships
DOE/DHS Relationships
Drug and Alcohol Issues
Early Identification
Funding
IEP Driven Services
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Gaps
Public Health
Referrals
Roles
SBBH recommendations
Special Education Categories
Statutory Changes
System Analysis
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Appendices
Appendix #1
Social work services in schools includes-- (i) Preparing a social or developmental history on a child with a disability; (ii) Group and individual counseling with the child and family; (iii) Working in partnership with parents and others on those problems in a child's living situation (home, school, and community) that affect the child's adjustment in school; (iv) Mobilizing school and community resources to enable the child to learn as effectively as possible in his or her educational program; and (v) Assisting in developing positive behavioral intervention strategies. Psychological services includes-- (i) Administering psychological and educational tests, and other assessment procedures; (ii) Interpreting assessment results; (iii) Obtaining, integrating, and interpreting information about child behavior and conditions relating to learning; (iv) Consulting with other staff members in planning school programs to meet the special needs of children as indicated by psychological tests, interviews, and behavioral evaluations; (v) Planning and managing a program of psychological services, including psychological counseling for children and parents; and 1. Assisting in developing positive behavioral intervention strategies. Emotional disturbance is defined as follows: (i) The term means a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance: An inability to learn that cannot be explained by intellectual, sensory, or health factors. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. Inappropriate types of behavior or feelings under normal circumstances. A general pervasive mood of unhappiness or depression. A tendency to develop physical symptoms or fears associated with personal or school problems. (ii) The term includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance. Other health impairment means having limited strength, vitality or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that-- (i) Is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, and sickle cell anemia; and (ii) Adversely affects a child's educational performance. (i)Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child's educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child's educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in paragraph (b)(4) of this section. (ii)A child who manifests the characteristics of “autism” after age 3 could be diagnosed as having “autism” if the criteria in paragraph (c)(1)(i) of this section are satisfied. §300.23 Qualified personnel. As used in this part, the term qualified personnel means personnel who have met SEA-approved or SEA-recognized certification, licensing, registration, or other comparable requirements that apply to the area in which the individuals are providing special education or related services. (Authority: 20 U.S.C. 1221e-3) Social work services in schools includes-- (i) Preparing a social or developmental history on a child with a disability; (ii) Group and individual counseling with the child and family; (iii) Working in partnership with parents and others on those problems in a child's living situation (home, school, and community) that affect the child's adjustment in school; (iv) Mobilizing school and community resources to enable the child to learn as effectively as possible in his or her educational program; and (v) Assisting in developing positive behavioral intervention strategies. Psychological services includes-- (i) Administering psychological and educational tests, and other assessment procedures; (ii) Interpreting assessment results; (iii) Obtaining, integrating, and interpreting information about child behavior and conditions relating to learning; (iv) Consulting with other staff members in planning school programs to meet the special needs of children as indicated by psychological tests, interviews, and behavioral evaluations; (v) Planning and managing a program of psychological services, including psychological counseling for children and parents; and (vi) Assisting in developing positive behavioral intervention strategies. §300.125 Child find. General requirement. The State must have in effect policies and procedures to ensure that-- (i) All children with disabilities residing in the State, including children with disabilities attending private schools, regardless of the severity of their disability, and who are in need of special education and related services, are identified, located, and evaluated; and (ii) A practical method is developed and implemented to determine which children are currently receiving needed special education and related services. The requirements of paragraph (a)(1) of this section apply to-- (i) Highly mobile children with disabilities (such as migrant and homeless children); and (ii) Children who are suspected of being a child with a disability under §300.7 and in need of special education, even though they are advancing from grade to grade. Documents relating to child find. The State must have on file with the Secretary the policies and procedures described in paragraph (a) of this section, including-- The name of the State agency (if other than the SEA) responsible for coordinating the planning and implementation of the policies and procedures under paragraph (a) of this section; The name of each agency that participates in the planning and implementation of the child find activities and a description of the nature and extent of its participation; A description of how the policies and procedures under paragraph (a) of this section will be monitored to ensure that the SEA obtains-- (i) The number of children with disabilities within each disability category that have been identified, located, and evaluated; and (ii) Information adequate to evaluate the effectiveness of those policies and procedures; and A description of the method the State uses to determine which children are currently receiving special education and related services. Child find for children from birth through age 2 when the SEA and lead agency for the Part C program are different. In States where the SEA and the State's lead agency for the Part C program are different and the Part C lead agency will be participating in the child find activities described in paragraph(a) of this section, a description of the nature and extent of the Part C lead agency's participation must be included under paragraph (b)(2) of this section. With the SEA's agreement, the Part C lead agency's participation may include the actual implementation of child find activities for infants and toddlers with disabilities. The use of an interagency agreement or other mechanism for providing for the Part C lead agency's participation does not alter or diminish the responsibility of the SEA to ensure compliance with the requirements of this section. |
M Minnesota Definitions of EBD and OHD:
3525.1329 EMOTIONAL OR BEHAVIORAL DISORDERS. Subpart 1. Definition. "Emotional or behavioral disorders" means an established pattern of one or more of the following emotional or behavioral responses: A. withdrawal or anxiety, depression, problems with mood, or feelings of self-worth; B. disordered thought processes with unusual behavior patterns and atypical communication styles; or C. aggression, hyperactivity, or impulsivity. The established pattern of emotional or behavioral responses must adversely affect educational or developmental performance, including intrapersonal, academic, vocational, or social skills; be significantly different from appropriate age, cultural, or ethnic norms; and be more than temporary, expected responses to stressful events in the environment. The emotional or behavioral responses must be consistently exhibited in at least three different settings, two of which must be educational settings, and one other setting in either the home, child care, or community. The responses must not be primarily the result of intellectual, sensory, or acute or chronic physical health conditions. Subp. 2. [Repealed, 26 SR 657] Subp. 2a. Criteria. A pupil is eligible and in need of special education and related services for an emotional or behavioral disorder when the pupil meets the criteria in items A to C. A. A pupil must demonstrate an established pattern of emotional or behavioral responses that is described in at least one of the following subitems and which represents a significant difference from peers: (1) withdrawn or anxious behaviors, pervasive unhappiness, depression, or severe problems with mood or feelings of self-worth defined by behaviors, for example: isolating self from peers; displaying intense fears or school refusal; overly perfectionistic; failing to express emotion; displaying a pervasive sad disposition; developing physical symptoms related to worry or stress; or changes in eating or sleeping patterns; (2) disordered thought processes manifested by unusual behavior patterns, atypical communication styles, or distorted interpersonal relationships, for example: reality distortion beyond normal developmental fantasy and play or talk; inappropriate laughter, crying, sounds, or language; self-mutilation, developmentally inappropriate sexual acting out, or developmentally inappropriate self-stimulation; rigid, ritualistic patterning; perseveration or obsession with specific objects; overly affectionate behavior towards unfamiliar persons; or hallucinating or delusions of grandeur; or (3) aggressive, hyperactive, or impulsive behaviors that are developmentally inappropriate, for example: physically or verbally abusive behaviors; impulsive or violent, destructive, or intimidating behaviors; or behaviors that are threatening to others or excessively antagonistic. The pattern must not be the result of cultural factors, and must be based on evaluation data which may include a diagnosis of mental disorder by a licensed mental health professional. B. The pupil's pattern of emotional or behavioral responses adversely affects educational performance and results in: (1) an inability to demonstrate satisfactory social competence that is significantly different from appropriate age, cultural, or ethnic norms; or (2) a pattern of unsatisfactory educational progress that is not primarily a result of intellectual, sensory, physical health, cultural, or linguistic factors; illegal chemical use; autism spectrum disorders under part 3525.1325; or inconsistent educational programming. C. The combined results of prior documented interventions and the evaluation data for the pupil must establish significant impairments in one or more of the following areas: intrapersonal, academic, vocational, or social skills. The data must document that the impairment: (1) severely interferes with the pupil's or other students' educational performance; (2) is consistently exhibited by occurrences in at least three different settings: two educational settings, one of which is the classroom, and one other setting in either the home, child care, or community; or for children not yet enrolled in kindergarten, the emotional or behavioral responses must be consistently exhibited in at least one setting in the home, child care, or community; and (3) has been occurring throughout a minimum of six months, or results from the well-documented, sudden onset of a serious mental health disorder diagnosed by a licensed mental health professional. Subp. 3. Evaluation. A. The evaluation findings in subpart 2a must be supported by current or existing data from: (1) clinically significant scores on standardized, nationally normed behavior rating scales; (2) individually administered, standardized, nationally normed tests of intellectual ability and academic achievement; (3) three systematic observations in the classroom or other learning environment; (4) record review; (5) interviews with parent, pupil, and teacher; (6) health history review procedures; (7) a mental health screening; and (8) functional behavioral assessment. The evaluation may include data from vocational skills measures; personality measures; self-report scales; adaptive behavior rating scales; communication measures; diagnostic assessment and mental health evaluation reviews; environmental, socio-cultural, and ethnic information reviews; gross and fine motor and sensory motor measures; or chemical health assessments. B. Children not yet enrolled in kindergarten are eligible for special education and related services if they meet the criteria listed in subpart 2a, items A, B, and C, subitems (2) and (3). The evaluation process must show developmentally significant impairments in self-care, social relations, or social or emotional growth, and must include data from each of the following areas: two or more systematic observations, including one in the home; a case history, including medical, cultural, and developmental information; information on the pupil's cognitive ability, social skills, and communication abilities; standardized and informal interviews, including teacher, parent, caregiver, and child care provider; and standardized adaptive behavior scales. STAT AUTH: MS s 120.17; L 1999 c 123 s 19,20 HIST: 16 SR 1543; 17 SR 3361; 26 SR 657 Current as of 01/31/05 OHD 3525.1335 OTHER HEALTH DISABILITIES. Subpart 1. Definition. "Other health disability" means having limited strength, endurance, vitality, or alertness, including a heightened or diminished alertness to environmental stimuli, with respect to the educational environment that is due to a broad range of medically diagnosed chronic or acute health conditions that adversely affect a pupil's educational performance. Subp. 2. Criteria. The team shall determine that a pupil is eligible and in need of special education instruction and services if the pupil meets the criteria in items A and B. A. There is: (1) written and signed documentation by a licensed physician of a medically diagnosed chronic or acute health condition; or (2) in the case of a diagnosis of Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (ADD or ADHD), there is written and signed documentation of a medical diagnosis by a licensed physician. The diagnosis of ADD or ADHD must include documentation that DSM-IV criteria in items A to E have been met. DSM-IV criteria documentation must be provided by either a licensed physician or a mental health or medical professional licensed to diagnose the condition. For initial evaluation, all documentation must be dated within the previous 12 months. B. In comparison with peers, the health condition adversely affects the pupil's ability to complete educational tasks within routine timelines as documented by three or more of the following: (1) excessive absenteeism linked to the health condition, for example, hospitalizations, medical treatments, surgeries, or illnesses; (2) specialized health care procedures that are necessary during the school day; (3) medications that adversely affect learning and functioning in terms of comprehension, memory, attention, or fatigue; (4) limited physical strength resulting in decreased capacity to perform school activities; (5) limited endurance resulting in decreased stamina and decreased ability to maintain performance; (6) heightened or diminished alertness resulting in impaired abilities, for example, prioritizing environmental stimuli; maintaining focus; or sustaining effort or accuracy; (7) impaired ability to manage and organize materials and complete classroom assignments within routine timelines; or (8) impaired ability to follow directions or initiate and complete a task. Subp. 3. Evaluation. The health condition results in a pattern of unsatisfactory educational progress as determined by a comprehensive evaluation documenting the required components of subpart 2, items A and B. The eligibility findings must be supported by current or existing data from items A to E: A. an individually administered, nationally normed standardized evaluation of the pupil's academic performance; B. documented, systematic interviews conducted by a licensed special education teacher with classroom teachers and the pupil's parent or guardian; C. one or more documented, systematic observations in the classroom or other learning environment by a licensed special education teacher; D. a review of the pupil's health history, including the verification of a medical diagnosis of a health condition; and E. records review. The evaluation findings may include data from: an individually administered, nationally normed test of intellectual ability; an interview with the pupil; information from the school nurse or other individuals knowledgeable about the health condition of the pupil; standardized, nationally normed behavior rating scales; gross and fine motor and sensory motor measures; communication measures; functional skills checklists; and environmental, socio-cultural, and ethnic information reviews. STAT AUTH: MS s 120.17; L 1999 c 123 s 19,20 HIST: 16 SR 1543; L 1998 c 397 art 11 s 3; 26 SR 657 |