Engaging Students in Virtual Tier 3 Mental Health Services: What Have We Learned
By: Princess Parker, LPC, Alyssa Haley, LCSW and Gerard Barone, LCSW
For at least 10 years before the COVID-19 pandemic turned the lives of students, parents, and school personnel upside down, mental health professionals and educators had been sounding alarms about the growing mental health needs of America’s youth. Faced with increasing rates of depression, anxiety, and suicidality, over half of the states had already enacted laws to require a mental health curriculum in schools. Recognizing that 35% of the nation’s children receive mental health services exclusively in schools, many districts had already begun a process of assessing and enhancing their onsite services.
And then came the global health crisis. Data about the negative effects of school disruption and social isolation on students are mounting, and educators across the country are scrambling to prepare for a dramatic increase in the numbers of students who will require some level of mental health care. Given the growing cries of parents and child development experts to find a way to safely and consistently re-open schools, this can’t happen soon enough. At the same time, given the uncertainty associated with newly identified strains of the virus and delays in the vaccination process, many schools will likely need to continue offering some level of virtual classes and services for the balance of the current school year, and remain prepared beyond that for periodic closures until the virus is sufficiently contained.
Educators, mental health, and other special services professionals faced a steep learning curve as they shifted from in-person to virtual services in the early weeks of school shut-downs. Arguably, despite a sea of troubles, most would agree that engaging stressed, isolated, and increasingly dejected students has been the biggest challenge. Over the course of the past year, the staff at Effective School Solutions (ESS) have learned a lot about how to achieve comparable clinical outcomes in a virtual environment with even the most fragile of students, and we are eager to share our findings.
The MTSS Framework Within A Virtual Environment
In recent years, Multi-Tiered Systems of Support (MTSS) have been growing in popularity as administrators worked to balance increased service needs with limited resources. ESS delivers in-school mental health services with this framework, and like other school-based professionals, had to adapt its model to a largely virtual delivery environment.
The MTSS framework includes 3 service tiers, with Tier 3 programs offering the most intensive level of support for students who are deemed to be the most at risk. These students are usually referred for out-of-district placements by districts that do not have onsite services. The typical ESS Tier 3 program places one or more full time mental health professional at each contracted school who offer intensive services to a number of students each year. These services include at a minimum daily process and psycho-education groups, weekly individual and family therapy sessions, parent support groups, and ongoing collaboration with teachers, administrators, and special services individuals. Over the years, we have come to realize that the true magic of ESS Tier 3 programming is that the symphony of multiple, evidence-based interventions that occur repeatedly over the course of each week create a powerful support system that helps to stabilize students’ mental health symptoms while safely keeping them within their home districts. This model not only helps students stay within the least restrictive and most normalized environments, but also preserves precious funding for other school-wide mental health initiatives.
In the early weeks of quarantine, ESS’s goal was to master the numerous technical and scheduling challenges of both staff members and students/families. The next phase was to ensure that all service components were transferred to a virtual environment, using telehealth platforms, phone calls, text, and email.
However, as time passed it became clear that additional program enhancements were required to offer the same level of safety and intervention that is provided for students receiving in-person Tier 3 services. Although some students and families adapted reasonably well to virtual learning and therapy services, others struggled. And, with the passage of time, as many schools have shifted back and forth between hybrid and all-remote learning, we have had to be creative in partnering with districts to keep students engaged. “Research shows that the school environment is critical for fostering academic motivation and social development” … “Kids are not used to learning in isolation,” and “relationships at school inspire motivation for many kids.”
ESS is pleased to report that despite the challenges of COVID-related school disruption, Tier 3 students in our care continue to be safe and are progressing in achieving their mental health goals, while in a virtual environment as a result of the “above and beyond” strategies implemented within contracted school districts. Data collected from 3/13/20 (the beginning of school closures) through 2/1/21 reveals that 89% of students engaged fully with virtual services, averaging 3.4 contacts per student per week. Almost 121,000 remote sessions or check-ins (individual, family, group) were provided, as well as over 9,200 educational check-ins (clinician virtual “drop-in” to student’s classroom) during the same time period.
What We Learned: Strategies for Success
When ESS first began to adjust to the reality of school closures, the novelty of remote learning and of using Zoom and other platforms propelled our student contacts. As time went on, however, we realized that we needed another set of interventions to keep both ongoing and new Tier 3 students engaged in treatment. Multiple other contact modalities were added, including phone and FaceTime calls, texts and emails, and attention was turned to fostering engagement and regular session attendance.
With great attention to detail, ESS staff added a robust set of intervention strategies that are tailored to “grease the wheel”. These strategies precede typical Tier 3 service elements and prepare students to be ready and available to engage in mental health services. Many of these techniques, of course, are part of in-person service delivery, but tend to occur more organically and casually within the school environment. Within a virtual environment, however, these strategies must be planful, targeted, and consistent.
To maximize program participation, staff members make morning wake up calls to each student and reach out frequently during the week via FaceTime and other reminder calls and texts. Clinicians send out students’ individual weekly schedules, including links for easier access to each planned service. Frequent classroom check-ins are coordinated with students and teachers, and individualized Google-Classrooms have been created for personalized clinical-educational consults. Extra efforts have been made to connect families to community resources and supports, and to offer parents/guardians more flexible and frequent contacts with clinicians. Student incentives/rewards (e.g., Uber-eats gift cards) have been expanded, and customized to suit at-home learning.
The various clinical components of Tier 3 programming have also been modified to suit a virtual environment. Each service (e.g., individual therapy) is shorter in duration, but is offered more frequently during the week, helping to minimize “Zoom-Fatigue”, and allowing for closer monitoring of each student. In addition, session content focuses more on day-to-day safety and functioning, and on the key aspects of mental health recovery such as medication compliance; healthy sleep, eating, and exercise practices; adherence to daily routines; and the regular reinforcement of self-regulation strategies.
Virtual sessions are more highly structured and follow a consistent opening/middle/closing format. The opening section includes a review of goals for the visit as well as a brief mental status exam to ensure the safety of the student. Parents or guardians are included in this and the closing sections only, or for the entire visit, depending on the age and capacities of the student. The middle section focuses on whatever topic is a priority for the student and/or parent. In addition, medication compliance, social interactions, and activity levels (including exercise, sleep and eating habits) are addressed in this section, along with an assessment of the level of family conflict and support. Psychoeducational content and social-emotional skills development are reinforced in this section as well. The closing section includes a summary of the session along with important take-aways and recommendations, and a review of the schedule for upcoming sessions/check-ins.
To support students in both Tier 3 and Tier 2 (students with moderate symptoms, less intensive services), and the entire school community, ESS team members have continued to foster strong partnerships with school professionals by enhancing Tier 1 services. These services promote mental health awareness, enhance social-emotional (SEL) curricula, and support the mental health and well-being of school staff. ESS is conducting a comprehensive, year-long professional development program based on the Nurtured Heart Approach® and the Trauma-Attuned Model®. Regularly scheduled webinars cover a wide range of topics to help teachers recognize and respond appropriately to mental health symptoms in students, to build knowledge and confidence in providing SEL curricula, and to attend to their own mental health and well-being. These webinars have been extremely popular, with hundreds of attendees signing on to each one.
During the early days of the pandemic, there were fears that mental health and other services could not be delivered at all, or that virtual services would somehow be seen as deficient or “less than”. We have come to find out, however, that with persistence and attention to detail we were able to provide a robust Tier 3 program with engagement levels that have met or exceeded previous in-person levels. The simple but significant connecting activities that were added to string together and support Tier 3 program elements can be adapted across all age levels, and customized as needed (e.g., for elementary students, reminder calls or texts would go to parents instead of directly to the student). Parents and guardians have reported high levels of satisfaction given the flexibility of blended and all-virtual service delivery models. District leaders as well have been pleased that the ongoing delivery of services via remote, telehealth models has offset the need for compensatory services. And, most importantly, the most vulnerable of students, those who require Tier 3 services, have remained safe and are progressing both academically and emotionally.