N717a-Context of Care
Dear Dr. Nieva:
I am writing to share with you my thoughts on the following innovation described within the AHRQ's Health Care Innovation Exchange: School-Based Transition Program Connecting High-Risk Adolescents to Mental Health and Support Services Improves Academic and Familial Functioning (http://innovations.ahrq.gov/node/5536). The innovation was developed by the Brookline Community Mental Health Center and piloted in Brookline High School in 2008. This innovation received a rating of moderate for its impact on improving the functioning of children who are returning to school after experiencing treatment for serious emotional disorders, medical issues, substance abuse, or other issues.
As an advanced practice nursing student of family psychiatry, I am particularly interested in interventions that aim to address the gaps in systems of care for youth with mental health illnesses. The landscape for adequate mental health care for children and adolescents is one of many silos: discrete agencies or organizations providing non-integrated mental health care. Rather than services being available within the youth's natural environment, such as home, or school, they are accessed through separate, third-party agencies (Rogler & Cortex, 1993). As a result, a youth's involvement within mental health services may result in a period of separation from school.
Many families may deal with a gap in comprehensive care between treatment discharge and community reentry. One of the biggest challenges in reentry for is reenrollment into school (Bloch, 1986). Prior to reenrollment, youth present with anxiety related to several factors ranging from their ability to assume the role of a student to feeling accepted from their peers (Simon & Savina, 2007).
Over the course of my graduate education, I have come to appreciate the importance of strategies that aim to provide services during these gaps in care. For example, I recently spent six months providing therapeutic services to a ten year-old female who had undergone neurosurgery to remove a tumor growing on her pituitary gland. Following her surgery, this child was out of school six months. When we began treatment, she had just begun school again and was not yet attending full school days. The school worried that this young girl would not be able to handle the demands of a full day and determined it would be best to slowly integrate her back into school. Though this decision was likely developed with having her best interests in mind, it actually had the reverse effect of triggering the child's anxiety towards school even more. The girl was particularly worried about her ability to transition from a “sick” child role to a student role and to perform academically. She would become tearful when confronted with new information and would often need to call her mom to be picked up early.
The decision to stagger her reentry into school likely resulted in exacerbating her anxiety. One of the core elements of anxiety treatment is to continue to remain in the situation that is provoking the anxiety. This strategy helps the child learn to tolerate discomforting feelings and rely on healthy coping mechanisms (Kaplan & Sadock, 2005). Had the school been able to consult with a mental health clinician, they might have developed a more therapeutically appropriate plan where the child would be expected to attend school the full day and receive therapeutic support school-based. Her story, as well as my other experiences of working with children who have experienced significant separation from school because of treatment, informed my interest in the Brookline school reentry program. I have become acutely aware of the gap experienced between treatment discharge and community reentry.
The intervention in Brookline aims to close that gap by integrating mental health clinicians in a school based setting. Very often, clinically trained personnel are not school-based, so the care is provided in a separate location. The therapist and child cannot experience the work in vivo, where it is most therapeutically useful. For example, when working with the young girl with a history of brain tumors, she would deny any feelings of anxiety with me, but I would be provided a completely different report from her mother and school. Had I been able to work with her within the school setting, we may have been able to more quickly resolve some of her anxieties because we would have directly confronted these symptoms together.
Another strength of this intervention is the emphasis on care coordination to bridge the experience from treatment discharge to community reentry. Rather than the school appearing to be another silo agency, the clinician within the school takes a comprehensive approach to supporting a child's reentry. Clinicians work with youth and family to develop specific goals to decrease the risk of school disruption. Clinicians advocate for internal changes, such as scheduling improvements or locating a tutor. They also support the families in referring them to external resources, such as on-going therapy services, social service programs, and support groups. Indeed, youth are not the only ones stressed by their reentry; parents and family members of these youth require support, as well.
Despite the many strong elements, I am concerned about the practicality of this intervention. Given the decline in school budgets across the country, funding this program with school dollars seems unlikely. The Brookline program consisted of a respite classroom, two licensed clinicians, and an academic assistant. This model may be overly cumbersome for schools operating with limited resources. It may be that the most important element to the success of this intervention is the partnership between a local community health clinic and the school. Clinicians from these health centers can be dispatched to various schools to support reentry for high-risk youth.
Another concern I have is the lack of an evidenced-based approach. The value of this program is that it is designed to serve a wide target population, ranging from youth separated from school due medical needs and those separated from incarceration. Despite this diverse target population, they share a common concern of anxiety related to school reentry. The best approach to treating this problem is cognitive-behavioral therapy, where clients identify triggers and develop coping strategies to manage discomforting thoughts and feelings. Cognitive behavioral therapy (CBT) for anxiety related school refusal is effective at improving school attendance (Last, Hensen, & Franco, 1998). Master's prepared clinicians, such as the ones utilized in Brookline, are well-prepared to administer this therapeutic intervention. An advantage of CBT is that borrowing core elements may be just as effective as administering a time intensive manual-based treatment (Weersing, Rozenman, & Gonzalez, 2008). Rather than full fidelity to a manual-based treatment plan, the mental health clinicians could administer core elements, particularly psychoeducation on anxiety, recognizing cognitive misinterpretations, and summoning coping skills, as needed.
The critical elements to this innovation are a dedicated school-based clinician trained in both therapeutic and social services to assist youth in their reintegration and emphasizing their role in case management. The licensed clinician is enabled the flexibility to provide time-limited therapy and encouraged to connect families to resources to ensure a smooth academic transition. However, the summary of the innovation or subsequent papers did not indicate whether an evidenced-based approach was applied to manage youth's anxieties. Cognitive-behavioral therapy is an appropriate and effective treatment for anxiety related to school reentry and should be specifically used given the staffing resources.
American Nurses Credentialing Center. (2011). Family psychiatric & mental health nurse practitioner certification eligibility criteria. Retrieved from http://www.nursecredentialing.org/FamilyPsychNP-Eligibility.aspx.
Bloch, A. (1986). Chronic illness and its impact on academic achievement. Pediatrician, 13, 128-132.
Clemens, E.V., Welfare, L.E., & Williams, A.M. (2010). Tough transitions: Mental health care professionals' perception of the psychiatric hospital to school transition. Residential Treatment for Children and Youth, 27(4), 243-263.
Connecticut Department of Public Health. (2011, April 14. Advanced practice registered nurse licensure. Retrieved from http://www.ct.gov/dph/cwp/view.asp?a=3121&q=389398
Kaplan and Sadock's Comprehensive Textbook of Psychiatry (9th ed). (2005). New York, NY: Lippincott, Williams, and Wilkins.
Last, C.G., Hensen, C., & Franco, N. (1998). Cognitive-behavioral treatment of school phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 404-411.
Nursing License Map. (2011). Your nursing license in Connecticut. Retrieved from http://nursinglicensemap.com/states/connecticut-nursing-license/
Rogler, L.H., & Cortex, D.E. (1993). Help-seeking pathways: A unifying concept of mental health care. American Journal of Psychiatry, 150, 554-561.
Simon, J.B, & Savina, E.A. (2007). Facilitating hospital to school transitions: Practices of hospital-based therapists. Residential Treatment for Children and Youth, 22, 46-66.
Weersing, V.R., Rozenman, M., & Gonzaelez, A. Core components of therapy in youth: do we know what to disseminate? Behavior Modification, 33(1), 24-47.