Silver Award: Student Outreach and Teacher Training to Ensure Prevention, Early Recognition, and Treatment of Mental Health Problems

Mental health clinicians are all too familiar with this scenario: “If only someone had recognized the onset of these symptoms years ago, before this person became so ill. If only this bright and unhappy individual had been given some skills to cope with adverse life events before this illness had a chance to take hold.” No clinician wants to experience an “If only” moment in the wake of a suicide. For the past 15 years, the Mental Health Association of East Tennessee (MHAET) has been working in schools to prevent such moments and to promote the mental and emotional well-being of students.

MHAET has implemented a two-pronged integrated approach to reach both students and teachers: Mental Health 101 for middle and high school students and in-service training for teachers, including Typical or Troubled?, a program of the American Psychiatric Foundation. In the 2014–2015 school year, these programs had a direct impact on 23,928 students in 83 middle and high schools in the MHAET catchment area, which includes the urban areas of Chattanooga, Knoxville, and Johnson City/Kingsport and surrounding rural areas—a population of 2.5 million residents in 35 counties.

In 2000, in an effort to augment the mandated state high school wellness curriculum, MHAET launched Mental Health 101 in four high schools in two counties. In 2008, when data from the Knox County Youth Risk Behavior Survey underscored the program’s effectiveness, Knox County Schools selected teachers to work with MHAET to develop age-appropriate curricula for students in sixth, seventh, and eighth grades. Mental Health 101 is now taught in schools in 23 of the 35 counties in MHAET’s catchment area. The primary focus of Mental Health 101 is to teach students to recognize the signs and symptoms of mental illness and suicidal behaviors in themselves, peers, and family members; to understand the symptoms that require their immediate intervention; and to encourage students to seek help from trusted adults. The current curriculum also addresses bullying and teaches coping skills to prevent stressful situations from escalating into crises. From year to year, beginning in sixth grade, the curriculum presentations have an additive effect. Health Department data for 18 East Tennessee counties showed that from 2004 to 2014, the suicide rate for children and adolescents ages ten to 19 declined 24%. This decline occurred during a period when the suicide rate in this age group increased 48% statewide in Tennessee.

As Mental Health 101 was achieving positive outcomes with students, teachers began to report that they felt poorly equipped to deal with mental health issues when approached by students. In 2008, MHAET became a Typical or Troubled? partner of the American Psychiatric Foundation, delivering the in-service training and other specialized training to teachers across East Tennessee. Teachers are trained to notice shifts in academic performance and behaviors that might indicate the onset of escalating stressors or mental health problems. These trainings prepare teachers to talk with their students by asking open-ended questions, help teachers determine who is typical and who is troubled, and, importantly, help them determine whether a child should be referred to school-based mental health services. To date, 3,000 teachers have received training on a variety of topics, allowing them to better serve their students.

In recognition of its integrated, school-based outreach programs that provide prevention and early intervention for thousands of students annually, MHAET was selected to receive APA’s 2015 Silver Achievement Award. The award will be presented October 8, 2015, at the opening session of the Institute on Psychiatric Services in New York City.

Mental Health 101

According to the National Institute of Mental Health, half of all mental illnesses begin by age 14, and, on average, six students in every classroom will develop a mental disorder. Nonetheless, the average delay between symptom onset and receipt of treatment is ten to 12 years. Such delays often lead to poor outcomes, including emotional and behavioral impairments, poor academic achievement and school dropout, diminished employment opportunities, life-long disability, and even suicide. The concept of early intervention originated in developmental theory and was first applied to infants and very young children who were victims of abuse and neglect. More recently, research has shown that intervention with older children who are experiencing the onset of serious disorders, such as psychosis, has the potential to alter an illness trajectory. Early intervention can prevent or delay the onset of illness or provide access to care before the consequences of illness have become entrenched.

The Mental Health 101 program is managed by a full-time coordinator, and MHAET employs three other part-time (PRN, or “as needed”) instructors. These individuals meet students on familiar turf—in their classroom, a nonclinical setting that promotes student engagement. The ideal class size is 30 students. The program is based on a flexible curriculum that can be tailored to the sophistication of students and modified to address special topics or circumstances at the request of an instructor. For example, information on self-harming behaviors has been included in response to student concerns. Instructors and program administrators use feedback, such as student comment cards, thank-you notes, and teacher evaluations, to adapt the program to meet evolving student needs.

Since 2008, Mental Health 101 has had a direct impact on the lives of more than 116,000 children. The MHAET Web site and Mental Health 101 promotional materials feature quotes from student participants:

Typical or Troubled

The Typical or Troubled? program includes a compendium of educational materials developed by the American Psychiatric Foundation in partnership with high school teachers and other school personnel. The materials continue to evolve and are regularly reviewed for medical accuracy. The program is designed for middle and high school teachers, social workers, school psychologists, counselors, nurses, or other licensed mental health professionals, who are trained not only on the program materials but also on how to train teachers, staff, and parents. In addition to the training, the program provides technical assistance and works with grantees to evaluate program outcomes. A PowerPoint training session, which can be presented in about two hours, is designed to educate high school and middle school teachers and other school personnel about adolescent mental health and the importance of early recognition and treatment. Teachers learn how to open a dialogue in a population that is known for its reticence. They learn to help students work through problems and identify roadblocks to solutions. The training enables teachers to recognize students truly in need of mental health services and to refer them appropriately. Other materials include brochures on adolescent mental health, a “Tips for Talking to Teens” handout, and bookmarks with warning signs of mental disorders.

Since MHAET implemented Typical or Troubled? in 2008, more than 3,000 teachers have received training. As a result, the number of youth referrals made increased substantially. Helen Ross McNabb Center’s Children and Youth Division in Knoxville has grown 453% since 2008—a clear indication that more youths are accessing needed resources. The Children and Youth Services of Ridgeview Center and Cherokee Health system, both rural Tennessee providers, grew 136% and 64%, respectively. The larger growth at McNabb Center is attributed to higher numbers of personnel from Knox County Schools who are trained in Typical or Troubled? or who receive other in-service training. Some students are referred back to MHAET for assistance with harder-to-treat issues that cannot be addressed by school-based services alone. MHAET works with the family and student to find the right services to address the problem.

Outcomes in East Tennessee

Prepost tests for Mental Health 101 participants have consistently shown positive outcomes. For the 2014–2015 school year, the following outcomes were documented: an increase of 325% in the number of high school students who could identify a sign of mental illness, a 191% increase in the number of high school students who could identify a warning sign of suicide, a 175% increase in the number of middle school students who could identify a warning sign of suicide, and a 50% increase in the number of middle school students who could identify the correct duration of symptoms before seeking help. In addition, the number of students who meet diagnostic criteria for depression has decreased by 13% since 2005—a decline that has been attributed to the coping and stress management skills taught to all students.

There is strong evidence that MHAET’s implementation of these two programs has saved lives. Mental Health 101 has enjoyed a constant presence in Knox County schools since 2000, whereas participation outside of Knox County has fluctuated over the years because of teacher transition. From 2005 to 2013, data from the Knox County Health Department and the Youth Risk Behavior Survey showed a 57% decrease in suicide attempts among high school students in Knox County—an average of 133 individuals per year, or a reduction in suicide attempts by 1,197 students over nine years. In addition, no suicides occurred in Knox County among individuals under age 18 in 2010, 2011, and 2012.

Not only is youth suicide a devastating event for communities, it also places a substantial financial burden on these communities. The average completed suicide costs $1,061,170 in medical and work loss costs, according to estimates from the Suicide Prevention Resource Center, and the cost estimate for a suicide attempt resulting in hospitalization ranges from $19,000 to $25,194. Thus the notable decrease in the number of youth suicides and the reduced number of suicide attempts in the East Tennessee region, including Knox County, not only saved lives but also contributed to a cost savings for Tennesseans—an average of $2,527,000 in annual community savings or $17,689,000 over a span of seven years, according to MHAET estimates. The savings equate to an annual return on investment of approximately $20 for each dollar invested by funders. When suicides are prevented, children can graduate from high school, go to college, and grow up to become emotionally healthy adults—and, in turn, ensure the emotional health of their own children.

Funding and Challenges

MHAET provides these two programs at no cost to schools. It is able to do so by blending funding from an array of sources: the State of Tennessee Department of Mental Health, East Tennessee Foundation’s Youth Endowment and other local foundations, the United Way of Greater Knoxville, Knox County Government, the American Psychiatric Foundation, and corporate giving.

The main challenge has been securing the financial and staffing resources to grow the programs. Mental Health 101 is frequently scheduled to visit more than two schools on the same day. Adopting a PRN trainer model in 2008 helped MHAET stretch resources to additional schools while remaining within budget. However, the 2014–2015 school year brought 30 new middle and high schools to the program, stretching resources considerably. Over the program’s history, each subsequent growth spurt has been met with increased financial support from the community.

Key Personnel

Mental Health 101, Typical or Troubled?, and other teacher in-service training would never have been possible without key partners: founding teachers Jim McGowan and Jerrilyn Carroll; Knox County School administrators Laura Boring, Clovis Stair, Ph.D., Melissa Massie (Executive Director of Student Support Services), Aneisa McDonald (Director of Coordinated School Health), and Sandra Rowcliffe (President of Knox County PTA); MHAET staff Caitlin Ensley, M.S.S.W., Deborah Caulder, L.C.S.W., Jen Tedder, M.S.S.W., Stacy Hicks, M.S.S.W., and Alice Brown, L.C.S.W.; PRN mental health instructors Bethanie Poe, Poppy Beach, and Kelly Karnes; the MHAET Board; and health and wellness teachers at all of MHAET’s school partners.

By providing an integrated outreach approach—both student outreach and teacher in-service training—MHAET has successfully built a strategy that works. Youths who need help are identified earlier, suicidal behaviors are reduced, and, more important, as evidenced by significant growth at the community mental health center level, troubled youths have accessed treatment. In addition, MHAET has built strong relationships with East Tennessee schools and by doing so has improved the mental health and well-being of thousands of young people in Tennessee and provided teachers with the knowledge and skills to better serve their students.