Structuring In-school Support for Students Returning from Out-of-District Placements
By Lucille Carr-Kaffashan, PhD
Spring is traditionally a time of hope and renewal. COVID-19 vaccination rates are accelerating, and the possibility of achieving herd immunity in the United States by late summer may be within reach. The relief from living in a constant state of threat cannot come soon enough, and school professionals will need that relief as they tackle the educational setbacks and mental health challenges of students returning from fully remote or hybrid schedules.
Many school districts have already begun preparations to deliver enhanced mental health services, evaluating the various tiers of support already offered, as well as those services that need to be added. A major part of this planning, of course, is financial: how can budgets be increased, stretched and/or re-allocated to accommodate the anticipated surge of students in need of help, as well as the increased needs of previously identified youngsters whose mental health symptoms have been exacerbated by the pandemic.
One important area for analysis is a district’s roster of students in out-of-district placements (ODPs) who might be ready to return-to-district if the appropriate layers of support were available. These students are often referred with the hope of a reasonably short length of stay at an ODP, but they may end up staying for years because in-district supports are lacking. Students, parents, and school personnel are often on board with a return-to-district, but these transitions can be stalled or halted entirely because there are no services to acclimate returning students, or to maintain them in the least restrictive school environment.
Developing a Structured & Comprehensive Therapeutic Program
There are several key steps that districts must complete to assess the scope and appropriateness of their student mental health program, and its ability to support students returning from ODPs. The first task is to describe and codify existing services. Perhaps the most critical question is “Are the district’s mental health services organized within a robust, Multi-Tiered Systems of Support (MTSS) framework?”
Within an MTSS framework, Tier 3 services are designed for the most vulnerable students and should include at a minimum the following components: individual psychotherapy, process and/or psycho-educational groups, educational support, clinician-teacher collaboration, family/caregiver consultation and support, the capacity for ongoing risk assessment, and coordination with medication prescribers and other community services. Students being considered for return from an ODP will most likely need this level of support for some time, depending on how long they have been in the ODP setting, and how successful that setting was in helping to stabilize the child’s mental health condition. The strength and capacity of Tier 3 services within a district will also determine whether certain at-risk students can be successfully educated and treated within a school-based wrap-around program instead of being referred directly from Tier 2 services to an ODP or NPS (Non-Public School).
Tier 2 services are for students with mild to moderate symptoms and can include short-term individual and/or group counseling for students, caregiver education/support/consultation groups, educational supports, and referral/coordination with community providers.
Tier 1 services are designed to ensure mental health awareness and education throughout the school community. Prominent within Tier 1 should be professional development opportunities for teachers to build skills and confidence in educating students with mental health challenges, to cultivate a trauma-attuned perspective, and to develop the capacity to teach social-emotional (SEL) skills. Tier 1 services should also include a robust SEL curriculum across all grade levels, a universal screening tool/methodology for all students, mental health education/promotion activities for caregivers, and wellness services for all employees.
Relevant to the success of all tiers of an MTSS is the availability of an alternative to suspension programs within the district. In addition to developing a trauma-attuned perspective, staff members need to learn de-escalation strategies, and how to set up classrooms as welcoming, non-triggering, environments. The ability to bypass or stop the destructive cycle of disciplinary action and disengagement by fostering self-regulation and other trauma-survival skills can affect whether a student stabilizes or goes on to need more and more intensive services.
In assessing the district’s MTSS, it is also important to consider special needs/populations and the program’s capacity to address concerns such as school avoidance, substance abuse, eating disorders, autism, complex trauma, and acting out/behavioral problems. The size of the district, the availability, and flexibility of physical space, as well as the skill sets of existing staff and potential new hires, should be considered in assessing whether students with these specialized needs can be appropriately served in-house. The proximity and quality of community resources should also be considered: having excellent and accessible substance abuse, eating disorder or DBT (Dialectical Behavior Therapy) resources, for example, might obviate the need to duplicate these components within the school’s MTSS. There would be a need, however, to develop constructive and mutually responsive relationships with these community entities.
While it is not necessary nor practical for every Tier 3 program to be equipped to handle all specialty areas, all clinical staff should have a good foundation in a variety of evidence-based approaches. These include CBT (Cognitive Behavior Therapy); DBT and other self-regulation strategies; a trauma-attuned, strength-based perspective; and family systems interventions.
Finally, it is critical to consider infrastructure supports for Tier 3 levels of care. These include staff credentials and requirements for ongoing supervision; staff-student ratios; clinical record standards; protocols and frequency expectations for each therapeutic component; clear entrance and exit criteria for each level of care; the ability to offer ESY (extended school year) programming for continuity of care; and quality indicators to assess both individual and program outcomes. These success metrics can include grades, disciplinary actions, attendance, parent/guardian participation, and student retention.
Assessing the Students’ Educational Needs
Once a district has a clear idea of both the strengths and gaps within its MTSS, the next step is to consider those students who are currently in ODP or NPS placements to assess their specific needs.
The first determining factor, of course, is “can the school educate this child?” “If this child returns to the district, are the resources to address the specific educational needs of this student available?”
Consider, for example, the resources available for students with learning disabilities, who are on the autism spectrum, who have dyslexia, or who have severe ADHD. What is the best educational setting within which each student can flourish? Does the student need a self-contained classroom, a therapeutic day school, an inclusion program, mainstreaming, etc.?
An educational consideration relevant to all returning students is the experience and skillsets of the district’s teaching staff. The number one question/complaint from parents considering a return-to-district for their children is often “will your teachers be educated and trained on how to work with my child, and how is the district planning to train teachers to work with my child’s particular psychiatric needs?” Group training activities, as well as one-to-one coaching/supervision activities for teachers, should be evaluated. Teachers need to be involved in these discussions to reflect on their own stress levels and available bandwidth for dealing with higher acuity students within the classroom.
Assessing the Students’ Clinical Progress and Needs
Along with the assessment of educational needs, the district must consider the clinical status and needs of each child who might return from an ODP. There are two types of students to be considered first: those who have thrived at the ODP placement, and those who are struggling and/or barely attending the ODP.
Students who have shown moderate to high levels of improvement at their ODPs are obvious choices for considering a return-to-district. Among the things to assess are the types, frequency, and intensity of mental health symptoms and how these interfere with academic and social functioning. It is also important to assess school attendance vs avoidance and acting out/disciplinary issues. Is the student eager to return-to-district for social, sports/clubs, or other reasons, or does the student find the thought of returning highly aversive because of a history of bullying or other traumatic or embarrassing events or situations? Perhaps the child and caregivers were highly resistant when the idea of an ODP was initially raised? If so, this can be a great starting point for discussion, as all involved parties consider the pros and cons of a return-to-district.
It is also relevant to consider where the student is in his or her education and how long he or she has been out-of-district. A graduating senior might relish the idea of returning to the district to participate in typical senior year activities, or conversely be eager to stay put to finish out his high school career. Similarly, would it be less disruptive for a student in middle school with one more year to go to finish up middle school at the ODP and return-to-district for high school, or would the familiarity of her middle school be a welcomed stepping-stone back to the district? Each child’s situation is complicated and unique. It can also be extremely helpful to ask the staff at the ODP, as well as the student and her family, what aspects of the program seemed most helpful to determine whether the school’s Tier 3 services can supply the same components.
Those students who are struggling or not attending their ODPs should also be considered for a return-to-district. A careful assessment of the relevant contributing factors can inform the decision about how to proceed. Were the student and/or caregivers opposed to ODP right from the start, thus precluding a “settling” in and acceptance of what the program had to offer? Was the commute to the ODP long and arduous? Was the placement a “mismatch” in any way, and if so, in what way? Did the student or parents feel that academic or enrichment opportunities were inadequate? Were there any unfortunate circumstances that soured the placement, such as an unexpected change of teacher or clinician, or unanticipated social problems or bullying?
Once the educational and clinical assessments of individual students are completed, discussions with parents and other caregivers are needed to begin laying out provisional return-to-district plans. Worries of both students and caregivers must be addressed, with customized re-entry plans and specified supports. Close coordination with community providers and support organizations is recommended to calm fears and plan for inevitable bumps in the road.
On a more general level, just as with educational services, it is important to consider the experience and skill sets of the district’s clinical team. What is the breadth and depth of clinical expertise, and the team’s comfort level in handling specialty issues such as substance abuse and eating disorders? What additional training or supervision might be required if Tier 3 services are to be created or expanded? And as with the teachers, it is important to gauge the stress level and bandwidth of existing staff, as well as the need for adding staff should the enrollment in Tier 3 services be increased.
Developing a Cost Savings Analysis
Once a district’s MTSS capacity is documented and analyzed, and the needs of individual students who might return-to-district are spelled out, it is then time to work the numbers. The budget officer(s) needs to examine the financial return on investment (ROI) for ODP students who can come back to the district. This information should be coupled with an accounting of the added costs associated with providing services for current in-district students who are at-risk for being referred to an ODP. The potential savings from returning students, combined with savings from students on the verge of ODP referral, can be balanced against the financial investment of creating a Tier 3 program, plus any other clinical investments (e.g., outfitting space, purchase of SEL curriculum, etc.) and staffing costs to ramp up services across all three tiers.
While it seems unlikely that ODPs will ever be totally unnecessary in the continuum of care for students, it is also important to remember that ODPs are not always the answer to a district’s mental health challenges. First, the cost can be prohibitive, with fees being as much as $100,000 per student, exclusive of transportation costs. In addition, the long commute to a special therapeutic school is often burdensome for students and families, and students placed in ODPs are not being served in the least restrictive environment. And, although the smaller size of an ODP is an advantage for a sense of safety for most students, there may not be a critical mass of students to ensure the academic rigor, extensive enrichment programs, and socialization opportunities that are available in large district schools. It is also especially important for the 2021–22 academic year to consider the increased demand for ODP slots given the pandemic-exacerbated mental health crisis. This could mean that a district’s high-risk students may have no options other than to remain in-district.
Planning for the Future
Districts often overuse ODPs as a source of care for students with intensive needs because resources have not been allocated to build in-house, comprehensive levels of care. As a result, instead of being temporary placements, students can be out-of-district for multiple years, sometimes past the point of diminishing returns.
At this critical time, while administrators are gearing up to face a growing student mental health crisis exacerbated by a global pandemic, it is important to step back and reconsider the structure and funding of onsite student mental health services. One logical starting point is to evaluate the costliest of services — ODPs — and to re-imagine how high-quality services can be offered to our most at-risk youth, while also freeing up funding to bolster Tier 1 and 2 levels of care for the entire school population.
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