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BridgeUp at Menninger A toolkit for schools and communities supporting adolescent mental health

More than half of all mental health disorders are diagnosed by age 14, making it a pivotal time in adolescent development. As part of The Menninger Clinic's commitment to improving the emotional and mental well-being of this population, we formed the BridgeUp at Menninger Model. The BridgeUp Model comprises social-emotional learning as organized by the Collaborative for Academic, Social, and Emotional Learning (CASEL), positive behavioral interventions and supports (PBIS) organized in multi-tiered systems of supports (MTSS), and principles of collective impact to include schools and school districts with their community partners operating with accountability in cycles of continuous improvement. Our results to date reflect gains in students' social and emotional skills, improved mental health, fewer disciplinary referrals and stronger academic performance.

The mission of The Menninger Clinic is to create a healthy world by excelling in the art and science of mental health care. Menninger was founded in 1925 in the rolling hillside of Topeka, Kansas, by Charles F. Menninger, MD, and his physician sons William and Karl. In 2003, Menninger affiliated with Baylor College of Medicine and moved its operations from Topeka to Houston.

For nearly 100 years, Menninger has been a leader in psychiatric treatment, education and research. The Clinic offers five inpatient treatment programs, as well as outpatient therapy and psychiatric assessment services. Menninger educates 150 trainees each year, including social workers, licensed professional counselors, psychiatric nurses, psychologists, psychiatrists and undergraduate medical and nursing students. Through The Gathering Place, it provides free services to 250 local adults with persistent mental illness. Menninger also impacts the behavioral health of thousands of adolescents through BridgeUp, an innovative school-based program.

Menninger is currently ranked the No. 8 psychiatric hospital in the nation by US News & World Report.

Since COVID-19 and the related social injustices brought to light during 2020, there has never been a more critical time to address young people’s mental health. The goal of BridgeUp is to provide prevention and early identification of mental and behavioral disorders for vulnerable adolescents, resulting in equitable access to care and decreased stigma. By partnering with school districts, nonprofits and behavioral health providers, we create a collaborative system of mental health supports for students.

BridgeUp at Menninger builds partnerships with Houston-area schools and community-based organizations by providing Magic Grant funding. We augment the funding with guidance for social and emotional learning, behavioral health support and collective impact – all essential to the BridgeUp at Menninger Model. The results of our initiatives have shown improvements for adolescents regarding social and emotional skill development, overall mental health and well-being, behavioral disciplinary referrals and academic success.

More than half of all mental disorders are diagnosed by age 14, making it a pivotal time in adolescent development. One in every five youth meet the criteria for a mental disorder. Mental disorders are serious changes in the way youth typically learn, behave or handle their emotions, causing distress and problems getting through the day. Depression, anxiety, mood and substance use disorders significantly affect a student’s behavior and performance in school. While the national high school graduation rate is 75%, only 50% of students with emotional, behavioral and mental health disorders graduate.

In Texas alone, 67% of teens experienced a major depressive episode with no support or treatment, putting the state in the bottom quartile on this measure.

Many students try to manage their mental health needs on their own, often with devastating effects. For adolescents aged 10 to 19, suicide is the second leading cause of death, with the rate increasing by 57% from 2017 to 2018. Recent research suggests that rates may be even higher now due to COVID-19.

We know vulnerable youth from low-income and culturally diverse communities face the most challenging barriers to care, such as lack of resources, limited accessibility and social stigma. Equity requires a response to each student in proportion to that student's need.

There is hope. Prevention and early identification of mental and behavioral disorders lead to higher rates of success and recovery. At BridgeUp at Menninger, we’re transforming the lives of vulnerable children and adolescents from the ground up through social and emotional learning (SEL) programs and adaptive mental health care in schools.

We believe all children and youth can grow and be resilient. We believe they are “at promise,” not “at risk.”
Meet Jo Jo, a BridgeUp student who received inpatient and outpatient care at Menninger in 2019. Her mom reported that although Jo Jo faced major obstacles in school, she has made significant progress since her treatment. Last summer, Jo Jo found out that her dad was sentenced to 40+ years in prison. She was devastated but immediately used the coping skills she learned through BridgeUp and chose to remain positive. Mom disclosed that there was a recent bullying incident where a group of girls made up hurtful rumors about Jo Jo. The old Jo Jo would have been consumed by the rumors, but instead she reached out for help from her school counselors. She is doing well at school, and last fall, she placed second in her school spelling bee. She is now a sophomore in high school and plans to continue playing elite volleyball.
“The Menninger Clinic is proud to partner with our BridgeUp schools to serve the mental health needs of students. As an early advocate for social-emotional learning, we are excited to share the BridgeUp at Menninger Model of collaborative behavioral health and SEL in schools." - Armando E. Colombo, President and Chief Executive Officer at The Menninger Clinic

The BridgeUp Model

  • Our work focuses on prevention and early intervention of behavioral and mental health disorders through the BridgeUp Model of (1) schoolwide SEL programs, (2) behavioral health supports and (3) collaboration.
  • School leaders work side by side with the nonprofit programs and behavioral health providers that deliver services in their schools.
  • Tailored to each school and district, the primary program components include a campus SEL committee, SEL training for teachers and administrators and classroom SEL instruction for students. Supporting SEL activities include messaging in morning announcements, mindfulness, and restorative practices.
  • Through a multi-tiered system of supports, students struggling with attendance, academic or behavioral issues are identified early and receive needed care, including individual or group counseling.
  • Students considered high risk are referred to The Menninger Clinic or a local mental health provider.
Social emotional learning (SEL) is the process through which young people develop healthy identities, manage emotions, achieve goals, feel and show empathy for others, build relationships and make responsible decisions.

The Collaborative for Academic, Social, and Emotional Learning (CASEL) Framework

School-wide SEL programs:

  1. Enhance students' social and emotional competencies and classroom behavior;
  2. Improve attachment and attitudes toward school;
  3. Decrease rates of violence and aggression, disciplinary referrals and substance abuse; and
  4. Improve academic performance.

The CASEL Wheel &

Five Core Competencies

  1. SELF-AWARENESS: The ability to understand one’s own emotions, thoughts, and values and how they influence behavior across contexts.
  2. SELF-MANAGEMENT: The ability to manage one’s emotions, thoughts and behaviors effectively in different situations and to achieve goals and aspirations.
  3. SOCIAL AWARENESS: The ability to understand the perspectives of and empathize with others, including those from diverse backgrounds, cultures and contexts.
  4. RELATIONSHIP SKILLS: The abilities to establish and maintain healthy and supportive relationships and to effectively navigate settings with diverse individuals and groups.
  5. RESPONSIBLE DECISION-MAKING: The ability to make caring and constructive choices about personal behavior and social interactions across diverse situations. This includes the capacity to consider ethical standards and safety concerns, and to evaluate the benefits and consequences of various actions for personal, social, and collective well-being.

Key Settings

  • CLASSROOMS: Research has shown that social and emotional competence can be enhanced using a variety of classroom-based approaches such as: (a) explicit instruction through which social and emotional skills and attitudes are taught and practiced in developmentally, contextually and culturally responsive ways; (b) teaching practices such as cooperative learning and project-based learning; and (c) integration of SEL and academic curriculum such as language arts, math, science, social studies, health and performing arts.
  • SCHOOLS: Effectively integrating SEL schoolwide involves ongoing planning, implementation, evaluation and continuous improvement by all members of the school community.
  • FAMILIES/CAREGIVERS: When schools and families form authentic partnerships, they can build strong connections that reinforce students’ social and emotional development. Families and caregivers are children’s first teachers, and bring deep expertise about their development, experiences, culture and learning needs. These insights and perspectives are critical to informing, supporting and sustaining SEL efforts. Research suggests that evidence-based SEL programs are more effective when they extend into the home, and families are far more likely to form partnerships with schools when their schools’ norms, values and cultural representations reflect their own experiences.
  • COMMUNITIES: Community partners often provide safe and developmentally rich settings for learning and development, have deep understanding of community needs and assets, are seen as trusted partners by families and students and have connections to additional supports and services that school and families need.

Note: High-quality SEL instruction has four elements represented by the acronym SAFE: Sequenced - following a coordinated set of training approaches to foster the development of competencies; Active - emphasizing active forms of learning to help students practice and master new skills; Focused - implementing curriculum that intentionally emphasizes the development of SEL competencies; and Explicit - defining and targeting specific skills, attitudes and knowledge.

Schools often have multiple initiatives aimed at promoting student achievement and well-being. A multi-tiered system of supports is required to help align these programs. Comprehensive multi-tiered systems of support often emphasize students’ academic performance and pay less attention to social and emotional wellbeing – if they treat it at all. Consistent with our primary mission, MTSS in BridgeUp focuses on social-emotional learning and mental and behavioral wellbeing, and less on academics.

Note that the above video starts with academic supports, while BridgeUp in MTSS deals exclusively with mental and behavioral health supports. Also, the video focuses on the school setting and MTSS whereas BridgeUp collaboratives took on MTSS as a school-community challenge.

Multi-Tiered System of Supports (MTSS)

A multi-tiered system of supports can help schools align multiple initiatives aimed at promoting student achievement and well-being, for example: positive behavioral interventions and supports (PBIS), restorative practices, service learning, mindfulness, mentoring and behavioral health programs. Additionally, behavioral and mental health needs must be identified, assessed and addressed for students at risk or already experiencing social, emotional and behavioral difficulties.

  • Tier 1 (Universal): Universal SEL programs and activities for all students in the target population, ideally school-wide. Classroom-based programming using evidence-informed curriculum and instruction that is aligned with CASEL is required. These supports, over time, should prove to be sufficient for 80% of the students in the defined population.
  • Tier 2 (Targeted): Small group programs that respond to the needs of students whose behavior is problematic for success in school, even after Tier 1 universal interventions are in place. On average, the number of students in Tier 2 will be approximately 15% of the students being served. In other words, Tier 1 programming should be effective enough so that no more than 15% of the students need more targeted (Tier 2) supports.
  • Tier 3 (Intensive): Behavioral and mental health services for students who do not respond to Tier 1 or Tier 2 interventions and supports. Typically, Tier 3 students will represent 5% of those served. Schools may refer these students to community mental health providers or a psychiatric hospital, like The Menninger Clinic. In other words, Tier 2 programming should be effective enough so that no more than 5% of the students need more intensive (Tier 3) supports.

Going from Tier 1 to Tiers 2 and 3

All of the BridgeUp school/community collaboratives choose a population of students in a school to support with preventative, Social-Emotional Learning (SEL) programming. In some cases, the collaborative serves the entire school population. In others, they choose a more limited set of grade-level classes.

In the terminology of Multi-Tiered Systems of Support (MTSS), this initial selection of students constitutes the collaborative’s “Tier 1” students who receive “universal” programming. That programming is a classroom-based SEL curriculum.

Some students, however, need more than whole-class SEL and preventative support.

Those in dire circumstances – in an emergency or chronic state – need to be identified so they can receive “Tier 3” or “urgent” support.

Those students whose behavior and mood suggest that Tier 1 support is not enough but whose condition is not urgent (at a Tier 3 level) need to be identified for “targeted” or “Tier 2” support.

Some of the most important process decisions a collaborative can make have to do with identifying the students for Tier 2 and Tier 3 services and monitoring the effects of those services on student behavior, attitude, and classroom performance.

Processes for Identifying Tier 2 and Tier 3 Students

BridgeUp collaboratives take a variety of approaches to identifying and supporting Tier 2 and Tier 3 students depending on the personnel and budgetary resources available to them, and their ability to work in and out of the school-day schedule.

Despite the variations, we can draw some generalities from the approaches that our collaboratives took.

An identification plan usually involves assessment by at least three parties.

The “assessment teams” use a variety of data to make their initial “short list” of students needing more support than the Tier 1 program provided.

Data gathered by assessment teams is reviewed by a set of decision-making partners who determine which students will receive “urgent” support (Tier 3) and which ones get “targeted” support (Tier 2).

Processes for Supporting Tier 2 and Tier 3 Students

The most frequent mode of “targeted” support (Tier 2) in BridgeUp is the small group session. Usually comprising 4-6 students, small groups are facilitated by trained classroom teachers, school counselors, or community agency specialists. Timing for small group sessions depends on options available at the school.

  • During the school day, Tier 2 students might be pulled together during homeroom or an elective period.
  • Some Tier 2 groups meet during the time that other students are receiving Tier 1 SEL instruction.
  • In some collaboratives, Tier 2 support programming is offered afterschool.
  • And at least one collaborative brings some Tier 2 students together on weekends.

Tier 3 students in BridgeUp are served either by The Menninger Clinic or a community partner, typically a Federally Qualified Health Center or non-profit mental health organization.

Processes for Monitoring Tier 2 and Tier 3 Students with Follow-Up

Identifying and treating vulnerable adolescents are the first two steps in a good SEL/mental health program. The next steps are equally important: monitoring the effectiveness of their care and making continuous improvement decisions.

BridgeUp collaboratives usually have a designated individual or small team whose responsibility it is to track students referred for Tier 2 and Tier 3 supports.

Monitoring Tier 3 students proves to be the most challenging because they are treated in out-of-school settings. Simply knowing if they attend treatment requires special attention; getting critical evaluations from their providers requires additional effort.

That said, any student whose Tier 3 support is effective usually joins a small group (Tier 2) in-school for “maintenance” or receives one-to-one “check-and-connect” support from a teacher or community partner.

Tier 2 students who respond well to their small group experiences either stay in them – sometimes becoming peer counselors – or discontinue group activity altogether. Those who leave Tier 2 groups usually have a teacher or community partner who touches base with them periodically.

Collaboration is important for sustaining and scaling social and emotional learning practices.

What is collective impact? How is it different from other forms of collaboration? We know that these questions aren’t always easy to answer, even for collective impact practitioners.

Collective Impact Approach

The systems idea of collective impact is most often applied at a comprehensive community level, such as an entire city.

BridgeUp employed the principles and practices of collective impact to add intentionality and rigor to the work undertaken by the collaboratives BridgeUp has funded.

Much of the collective work in BridgeUp takes place through partners collaborating with shared accountability. Their members work together to agree on what they want to accomplish and how they will go about it by developing a theory of change. They also commit to tracking their progress and grappling with the sometimes thorny issues of how to measure "outputs" and "outcomes" through constructing a logic model. Finally, they set up a time table for monitoring their work based on a monthly (rather than yearly) review of data by conducting rapid-cycle continuous improvement.

While undertaking their individual tasks, the collaboratives come together several times a year in the BridgeUp Impact Network to trade solutions - including the incorporation of PDSA cycles from the IHI Model for Improvement - and celebrate accomplishments.

Partners in BridgeUp-funded collaboratives work in an environment of “shared accountability” with “differentiated responsibility.”

Collaborating with Shared Accountability

Central to the BridgeUp Model is the idea of partners working in collaboration to serve vulnerable adolescents, guided by shared accountability. At a minimum, collaboratives that received BridgeUp funding were required to include leaders from schools and community nonprofit organizations.

Those leaders had to have equal status as decision makers, and they had to share accountability for outcomes. While each collaborative member brought its own programming to the collective effort, the BridgeUp Model made sure that the partners were not engaged in random “parallel play.” Partners had to agree on how their individual activities would align with the outcomes that they were pursuing collectively.

To foster shared accountability, BridgeUp introduced Magic Grant recipients to visualizing tools like theory of action and logic model.

Developing a Theory of Change

Each BridgeUp partnership developed its theory of change – a mapping of its intentions – as a way to connect programming and activities to the outcomes they wanted for students. Partners had to answer a series of questions, like:

  • What activities comprise your programming?
  • How and when will program activities engage teachers and students?
  • How are your activities logically connected to the outcomes you want?

This line of inquiry then built toward the first-order question of accountability: How will you know if your activities took place as planned? Without assurances around this question, looking at positive changes for students and attributing them to the efforts of the collaborative are moot issues.

Each BridgeUp collaborative team articulates its Intended Impact and Theory of Change
Using theories of change and logic models generates a key BridgeUp feature: rapid-cycle continuous improvement.

Constructing a Logic Model

After laying out its theory of action, a collaborative would construct its logic model as a way to elaborate and visualize its program. The logic model helps the members of a collaborative agree on near-term outcomes of mutual interest. But just as important, the logic model introduces the idea that “outputs” are as important to specify and measure as “outcomes.”

Rapid Cycle Logic Model (Template)

In a logic model, outputs include such things as whether students are in attendance during SEL classes, small group sessions, or intensive therapy. The quality of program training (for teachers, for example) and program delivery to students are also outputs.

Example BridgeUp SEL Teacher Capacity Logic Model

Conducting Rapid-Cycle Continuous Improvement

In the BridgeUp Model, specifying and measuring outputs is prerequisite to tracking outcomes. Without data on outputs, we were convinced that data on outcomes would have little or no meaning. And even if desired outcomes showed improvement, there could be little assurance about the degree to which positive change could be attributed to a collaborative’s programming. In this way, rapid cycle continuous improvement involves short-cycle gauges of effectiveness such that regular corrections can be made in real time while programs are being implemented.

Uniting the Work of the Separate Collaboratives: the BridgeUp Impact Network

BridgeUp created a learning community for the collaboratives it funded. The group was called the BridgeUp Impact Network.

"We are grateful for the opportunity that BridgeUp has provided this program and community. BridgeUp has continued to be an advocate for such necessary work. Our Impact Meetings are a needed opportunity to be in fellowship with other grantees and deepen our understanding of the work." - BridgeUp Magic Grant Grantee

Incorporating PDSA Cycles from the IHI Model for Improvement

Realizing that the collaboratives funded by BridgeUp had similarly defined outcomes and similar pathways to achieve them, BridgeUp created a learning community on a model for improvement promulgated by the Institute for Healthcare Improvement (IHI).

IHI Model for Improvement

The IHI started with the traditional Plan-Do-Study-Act (PDSA) process for continuous improvement. Next, it convened the faculties of medical units that were facing common problems to use PDSA and periodically share their experiences – with a goal that each unit would employ its own improvement methodologies but all would commit to common indicators of progress.

Multiple PDSA Cycles in IHI Model for Improvement

Lessons Learned

Continuous improvement was a core construct for BridgeUp at Menninger. We applied it to the collaboratives we funded and we held ourselves accountable for continuous improvement as well. Those pivotal moments of improvement for us are summarized in the following "lessons learned":

  1. The most important component in any system of supports for the social and emotional wellbeing of students is the school.
  2. While our focus was vulnerable adolescents, we quickly learned that the emotional wellbeing of teachers was a key ingredient.
  3. It was not an easy task for schools and community organizations to coordinate their efforts and agree on how to track the outcomes they were pursuing.
  4. Learning shared among our collaborative teams was just as valuable to them as the dollars they received from BridgeUp.

Personal Testimonies

Before social and emotional learning (SEL), Keylen felt stuck - struggling with teachers and schoolwork, unable to talk about the problems he was going through and exploding whenever he got angry. Now, he's confident in his ability to manage his emotions and is helping others do the same.

Principal Melissa Garza developed a strong and welcoming community for her students and teachers with the implementation of a schoolwide social and emotional learning program. Academics and attendance have improved, and parents are choosing to stay where students have champions in Melissa and her team.

When Andrés was in middle school, his mom noticed that her child had transformed from a happy and smiling boy into a withdrawn teenager having suicidal thoughts. Help came at a critical point when a school counselor referred the family to The Menninger Clinic for mental health treatment.

A coalition of schools and community service organizations have combined forces to make joint decisions, share social and emotional learning best practices and multiply their impact. Today, that coalition, Causeway Galveston, is working to expand the BridgeUp model to every school and child on Galveston Island.

Acknowledgements

Menninger Team: Patricia Gail Bray, PhD, Isabella Acuña, Stephanie Cunningham, Anissa Anderson Orr, Jennifer O’Bryant

Consultant: Robert (Bob) Wimpelberg, PhD, All Kids Alliance, University of Houston

Design: Edward D. Pettitt II, MPH

BridgeUp at Menninger is generously funded by the Helen Gurley Brown Foundation.

During the implementation of BridgeUp, we have employed “Brown Fellows” – part-time interns who have an interest in community mental health. The BridgeUp at Menninger Brown Fellows participate in planning and documenting activities, and they carry out research for the Director.

BridgeUp at Menninger Brown Fellows (Left to Right): Prianka Legasse-Singh, Yasmine Al Abdul Raheem, Albert Wei, Karuna Atani, Oana Pop, and Isabella Acuna.

The BridgeUp at Menninger toolkit is made possible by funding from Origin Bank.

BridgeUp at Menninger also thanks its Magic Grants grantees, BridgeUp Advisory Committee members, and Project Support and Grantee Capacity contributors. We also recognize the many contributions from Linda Civallero, and the generous in-kind support provided by the Menninger Clinic for the BridgeUp Model.

Credits:

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