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HomeMy WebLinkAbout2006-02-06 Youth Services in Lexington Report Youth Services In Lexington Report to the Board of Selectmen February 6,2006 "Solo practitioners, mental health practitioners within the agencies, and others we contacted in the course of this project concur generally that Lexington, with all of its abundance of helping talent, displays a serious lack of services for adolescents There is also a lack of collaborative coordination between the solo practitioners and between professionals within Lexington High School and these practitioners " MENTAL HEALTH SERVICES IN LEXINGTON,MASSACHUSETTS: A REPORT TO THE BOARD OF SELECTMEN The Human Services Committee,December 2002 Introduction and History Prior to the effects of the failed 2003 Override, the Town of Lexington contracted for many years with Replace (which became Wayside RePlace)to provide services to high-risk youth in Lexington. Through collaboration with Lexington Public School administrators, and at a cost to the town of$74,087, RePlace provided the community with these services: • Clinic based counseling- For individuals, families and groups. Issues included development of social skills, substance abuse, racism, academic motivation, bullying, anger management, family problems, self-esteem, grief and addressing risky behavior. • Outreach Counseling & Community support- For issues such as suicide, child abuse, runaways and other family conflicts. • Prevention services - Including information and referral and development of a student outreach program for issues such as substance abuse, bullying, community violence and general positive health promotion. In response to the loss of RePlace, the Human Services Committee made a recommendation for a task force to be convened under the guidance of Selectman Bill Kennedy,to review services and gaps in services. The group determined that there were a wide variety of services in the community, but they lacked overall coordination. The goal, as defined by the task force, was to develop a continuum of services for youth and their families, building on what is working well, and filling identified gaps in services. The task for emphasized the need for strong and continued communication and collaboration among the schools, police and social services personnel as well as outreach to community agencies and committees focused on youth and family services. To achieve this goal, the task force recommended (1) the development of the Youth Services Council, (2)the creation of a youth services clinician position, (3)the creation of a fund, to be administered by the Department of Social Services,that would allow youth without insurance coverage to access services from local practitioners, and (4) the reinstatement of the School Resource Officer position at the Senior High School. With the successful Override in 2004, the community supported the establishment of the Youth Services Coordinator's position and reestablished the School Resource Officer's position at the senior high school. Accomplishments of the Town of Lexington Youth Services Council The Youth Services Council is an independent community council made up of representatives from the Board of Selectmen, the School Committee, the Lexington Schools (administration/special education, health education), Social Services Department, Police Department, Fire Department, Recreation Department, private therapists, Human Services Committee, Clergy and the youth of Lexington. The Council meets monthly (with subcommittees meeting more frequently) for the purpose of identifying youth needs for community-based services for mental health and substance abuse counseling and education. The Council has focused on improving the availability of services, and facilitating networking and collaboration among existing community services providers. Youth and Family Services Coordinator The youth services clinician works to coordinate and strengthen a wide range of youth related programs, provide case management services to at risk youth, and conduct outreach to community based youth and family service providers and the schools. School Resource Officer The Lexington High School Resource Officer is assigned full time to the campus and collaborates with others on prevention, education, intervention and investigative strategies. The police department contributes additional support services to youth and in particular youth at risk, through the family services officer, Minute-Man Regional High School Resource Officer and police prosecutor (who is liaison to juvenile probation officers, court officials and district attorney's staff). Highlights of Activities of the Youth Services Council • Facilitating communication and sharing of information regarding critical incidents, stressors, and crises affecting youth and families in the community. • Expanding original council membership to now include representatives of the Fire Department and the Lexington Clergy. • Creating Lexington's "Forum for Youth"—a volunteer network of private therapists who provide therapeutic services to children, adolescents and families. Currently this 29-member group is working on establishing consistent, on-going consultative services to schools, parents and town groups regarding youth at risk and general youth and family issues. • Identifying a specific need for middle school half-day initiatives and then promoting coordination and collaboration with the schools, parents and Town departments to provide programs. Youth Services Coordinator: Examples of Activities and Responsibilities • Staff representation for the Youth Services Council and their subcommittees and task forces • Implementing and coordinating the Youth Services Coordinator's Regional Group to include Belmont, Lexington, Bedford, Arlington, Cambridge, and Winchester, Concord, and Burlington. • Co-facilitating and coordinating private school network meetings the Director of Student Health Services, Lexington Schools (seven private schools in Lexington participate two times per year). • Co-facilitating three parenting workshops with an elementary school counselor in Spring 2006 at The Avalon. • Implementing & Coordinating intergenerational programs in the community • Coordinating and co-facilitating a book groups for parents • Providing direct services to families with significant case management issues • Responding to 60+ calls a month related to issues, including: ➢ Financial assistance (town, community, state/federal) regarding medical bills/needs, after-school/summer programming, utilities, emergency housing ➢ Information, referral around clinical/mental health needs of youth related to mental illness, pervasive developmental disorder, substance use, and coordination of services post-hospitalization. ➢ Collaboration with school systems and town departments on youth at-risk related to risking behaviors (i.e. cutting), domestic violence, and abuse and neglect issues as well as Issues of basic needs around housing, food, fuel, and transportation. Unmet Needs Identified by the Youth Services Council • A coordinated community system of prevention and outreach services for youth and families. • Accessible services for all youth and families. Furthering discussion of and responses to concerns and needs as evidenced by Youth Risk Behavior Survey and reports from Schools, Police, Fire Departments and youth themselves. (See Attachments.) Proposed services and programs to meet immediate and future needs: • Prevention-based services (e.g. outreach worker, youth center, peer leadership, etc.) ➢ Accessible mental health service to children and adolescents ➢ Office hours in schools and community locations ➢ Collaborative preventive programs • Group therapy/psycho-education programs for youth and families • Restoration of the School Resource Officer position at middle school Level • Resource Guide for youth and families List of Attachments A. Youth Services in Adjacent Communities B. Youth Risk Behavior Survey—2004 Results and 10 year trends C. Mental Health Services in Lexington—Human Services Committee 2002 Report D. Current Crisis Statistics from Lexington Schools, police and fire Submitted by the Lexington Youth Services Council Members include: Norman Cohen(Board of Selectman),Helen Cohen(School Committee),Bill Blout (Human Services Committee), Jennifer Wolfrum and Mary Sullivan Kelley (Lexington Public Schools), Rev. Bill Clark(Interfaith Clergy Association),Becky Rushford and Lauren McSweeney (Social Services Department), Jim Rettman and Christina Demambro(Police Department), Tim Johnson(Fire Department),Karen Simmons(Recreation Department),Amy Berger(Private Therapist), Eric Eid-Reiner and Eliza Duncan(students). Attachment A Youth Services in Adjacent Communities: Town Year #of positions Job descriptions Budget established Bedford 1987 5 Bedford Youth and Family $197,341 consists of a full-time director, admin assistant, prevention coordinator, veteran's agent, and youth activities coordinator Clinical counseling staff from Eliot Community Services currently provide counseling at BYFS Arlington 1970 9 There is one director, one $256,684 psychiatrist, and one group work coordinator There are five social workers/counselors and one psychologist Overall they provides counseling services to adolescents, children and their families, all other related work, as required The psychiatrist provides all psychiatric and medical expertise in directing and assisting a multi-disciplinary staff in the evaluation, care, counseling and treatment of adolescents, children and their families, all other related work, as required Winchester About 1986 Winchester Youth The VVYC programs focus For Youth Services, under the specifically on middle and high Services, recreation department, has school youth The Youth Services excluding 3 full-time positions and 7- Coordinator's additional staff recreation 10 part/full-time members are high school Peer $75,000 coordinators and teachers Leaders (primarily volunteers) in the nursery school, 6 part-time positions in the after school, and countless part-time facilitators for their individual courses One full-time position - Youth Services Coordinator-housed in Winchester Youth Center (out of middle school) Attachment B Executive Summary Youth Risk Behavior Survey Lexington High School 2004 Results and Ten Year Trends Amy Farrell Jack McDevitt March 7, 2005 BACKGROUND INFORMATION • 1,455 students completed the survey in spring 2004 • Given to students in all grades. The following list provides the distribution of survey responses by grade. ➢ 30% 9th grade(431) ➢ 26% 10th grade (380) ➢ 25% 11`x'grade (364) ➢ 18% 12th grade (260) • Similar survey given 1995 (n=655), 1999(n=1,005),and 2002(1,422) • Youth Risk Behavior Survey focuses on various areas of risk facing youth in Massachusetts (alcohol,drugs, sexual activity,nutrition,violence). Lexington High School has integrated a number of specific questions that deal with high risk issues that are being confronted by current programs(stress, academic competition, sexual activity). AREAS OF PROGRESS SINCE 1995 1. Cigarette Smoking • Cigarette smoking has decreased dramatically since 1995. • In 2004 14%of students report they smoked in last 30 days compared to 35% in 1995 2. Marijuana use • Fewer students are reporting using Marijuana in 2004 • 20% of students report that they used marijuana over past 30 days compared to 33% in 1995. 3. Suicide • Fewer students are reporting considering or attempting suicide across the ten year study period. Decreases in consideration, plans and actual reported attempts of suicides • Ever seriously consider Suicide 23% in 1995 — 16% in 2004(231 students) Develop plan to commit suicide 16% in 1995— 9% in 2004(128 Students) Actually attempt Suicide 9% in 1995 — 5% in 2004 (70 students) 4. Body Image and Weight • Fewer students are reporting being concerned about their weight • 54% of students reported that they felt they were the right weight in 1995 and in 2004 59%of students report feeling they are the right weight. • Still may be lingering problems related to young women trying to lose weight. 52% of the females are trying to lose weight compared to 20% of males 5. Fighting • The number of students who report that they have been in a fight in the last 12 months has decreased during the study period(36% in 1995 and 29% in 2004) • Freshman and sophomores continue to be more likely to be involved in a fight(33%)as compared to seniors(18%) AREAS WHERE RISKY BEHAVIOR HAS REMAINED RELATIVELY STABLE SINCE 1995 1. Drinking • In both 1995 and 2004, 49% of students report that they have had at least 1 drink in past 30 days. ➢ 38% of 9th graders ➢ 46% of 10th graders ➢ 51% of 11 t''graders ➢ 65% of 12th graders • Approximately 30%of students report that they ride in cars Driven by someone who has been drinking across the study period • Approximately 13%of student report that they have driven after they have been drinking 2. Other Drug Use • The numbers of students who report ever using cocaine in their lifetime(5% in 1995 and 2004) • The numbers of students who report ever sniffing glue or aerosols in their lifetime(13% in 1995 and 11% in 2004) 3. Gambling • The number of students who have ever gambled(40% in both 1995 and 2004) 4. Theft • Had something Stolen from the student or damaged on school property(34% in 1995 and 32% in 2002) Highlights from 2004 Survey 1. Alcohol and Drug Use Students at Lexington High School report using a number of illegal or unhealthful substances. The most common drug among High School students is alcohol with nearly one-half of the students reporting that they used alcohol at least once during the past 30 days. This number is similar for males and females. • 49% of the students report having at least one drink of alcohol during the prior 30 days • 20% of the students report having used marijuana during the prior 30 days • 14% of the students report smoking cigarettes during the prior 30 days • 11% of the students report sniffing glue or aerosol cans during the prior 30 days • 5% of the students report using cocaine during the prior 30 days 2. Stress • 95% of students being under some stress • 21%report being under"extreme stress" • 90% of students report that their level of stress has increased since they began attending Lexington High School 3. Sex Approximately 23% of Lexington students report that they have ever had sexual intercourse. Not surprisingly, sexual experience varies greatly by age. The following list indicates the proportion of students in each grade who reported that they have had sex at least once. • 11% of 9th graders • 19% of 10th graders • 33% of 11th graders • 40% of 12th graders For those students who reported that they have had sexual intercourse, 72%reported that they used a condom in 2004 (up from 68% in 1995) Due to growing concern about issue of oral sex the 2004 survey has a number of new questions designed to find out more about this phenomena. 35% of Lexington students report that they have ever had oral sex. Like intercourse,the proportion of students who report having oral sex at least once varies greatly by grade. • 21% of 9th graders • 31% of 10th graders • 43% of 11th graders • 51% of 12th graders Of those who have had oral sex, 27% of student report that they have had oral sex with 4 or more partners. 4. Risky Behaviors of Selected Groups of Students a. Students reporting stress Students who report being the most stressed are more likely to have been forced to have sex against their will,to have considered suicide,be trying to lose weight, and have had something stolen. Not Stressed A lot Stressed Extremely Stressed Sex against your will 4% 9% 14% Consider suicide 10% 16% 19% Trying to lose weight 22% 36% 51% Have something stolen 33% 3 2% 42% Perception of students reporting extreme stress Students who report extreme stress are more likely to view academic competition as a serious problem(59%)when compared to their less stressed peers(59%). Reduction in students who have considered suicide Compared to 2002, Lexington High School has experienced a significant decline in the proportion of those extremely stressed students who have considered suicide (40%to 19%). b.Athletes Athletes at Lexington High School are less likely to report being extremely stressed compared to their non-athlete peers. Athletes, however, do appear to engage in more risky behaviors,particularly around the use of alcohol,than their peers. Athletes Non-Athletes Report extreme stress 19% 25% Drink during last 30 days 52% 42% Drank 5 drinks in a row 29% 22% Rode in car with someone who had been drinking 32% 24% Attachment C MENTAL HEALTH SERVICES IN LEXINGTON, MASSACHUSETTS: A REPORT TO THE BOARD OF SELECTMEN By The Human Services Committee Stephen Baran, Social Services Coordinator and Staff to the Committee Robert A. Dentler, Chair William L. Blout Sarah B. Conklin Steven Kelly Mary M. Rommell Russell Schutt Christine Yedica December, 2002 TABLE OF CONTENTS 1. Purpose of the Study 2. Mental Health Service Providers in Lexington and the Sample 3. Agencies and Organizations 4. The Individual Professional Providers 5. Interpretations and Conclusions 6. Recommendations Appendix A. Tables MENTAL HEALTH SERVICES IN LEXINGTON 1. PURPOSES The Human Services Committee study of professional mental health service providers began to take shape in 2001, when representatives of the Middlesex branch of the National Alliance for the Mentally Ill met with the committee to present their current needs and concerns. We decided to conduct a study of the services available in Lexington for citizens, including children and youth, of the town. Our primary purpose was to inform ourselves and the Board of Selectman about the nature, extent, and levels of activity of all types of mental health services by Lexington agencies and solo practitioners. We sought to identify and describe the availability and provision of psychotherapeutic, sociotherapeutic, counseling, and medical services to clients suffering from psychoses, psychoneuroses, related cognitive or emotional distress, and difficulties associated with alcoholism, substance abuse, and the like. Our aim was to gather, interpret, and report on evidence of unmet needs. We believed that subgroups who were found to be under-served should be identified and that the Board of Selectman would entertain ways of strengthening the scope and quality of future services. 14 A report published by the Boston Globe on December 4, 2002, found "Growing numbers of adults and children in Massachusetts are visiting mental health professionals, and are spending far longer in therapy...Americans generally are seeking more therapy, but this trend has turned out to be particularly pronounced in Massachusetts." Harvard Pilgrim Health Care said the number of talk therapy visits among its members increased 22 percent in 2001, and will grow another 17 percent in 1002. This trend intensified our concern. The project was planned during the spring and summer of 2002 and carried out during the fall. Committee members interviewed solo practitioners face to face and one on one and gathered information and interviewed two or more members of the four principal service providing agencies in the town. 2. MENTAL HEALTH SERVICE PROVIDERS IN LEXINGTON AND THE SAMPLE We pooled information from several sources, including HelpPro.com on the Internet, to develop a master list of professional service providers based in Lexington. The total number of private practitioners is 173. These include therapists who have an office in Lexington, even though their primary office is located elsewhere, as well as professional providers on the staffs of RePlace, Eliot Community Health Services, the Edinburg Center Inc. (formerly the Center for Mental Health and Retardation Services Inc.), and the Lexington High School Guidance Department. The Massachusetts Board of Registration informed us of how many licensed therapists - 36 psychiatrists, 179 psychologists, 425 social workers, and 86 allied mental health professionals - list their addresses in Lexington. Many of these individuals reside in Lexington but practice elsewhere. And many people are licensed but do not practice privately. Committee member William Blout, who has expertise in this domain, estimates from these data and from his knowledge of turnover and other changes, that at least 200 professional mental health service providers work in Lexington. We used our list of 173 names and office addresses to draw our sample, taking every sixth name from that list. We are grateful to the many practitioners who gave us their time and shared their expertise. 15 Lexington's population in 2002 was 31,122, with 6,655 of this number under 17 years of age. The hypothetical ratio of providers to citizens was thus 155.6, an exceptionally high ratio compared to communities elsewhere in the nation and in the Boston metropolitan area. If we take the often-utilized proportion in mental health literature of ten percent of a population in need of services, there may be about 3,000 citizens at risk of mental and emotional distress in Lexington, and on this estimation, the residential hypothetical ratio is 1 provider per 15 residents. There is, we believe, an indisputably high number of mental health service providers working in Lexington. Our study interviewed 28 solo practitioners for a sample of 16 percent of this group. In addition, we interviewed from two to five professionals in each of four agencies and organizations. Within the 28, 17.9 percent were psychiatrists, 42.9 percent were psychologists with PhDs, 25 percent were psychologists or counselors with PsyD or EdD degrees, 7.1 percent were social workers with MSW degrees, and 7.1 percent came from other professions. We did not sample pastoral counselors. 85.7 percent of our solo practitioners had 15 or more years of professional experience. 3. AGENCIES AND ORGANIZATIONS Four agencies and organizations serve Lexington, apart from solo practitioners. They include Wayside RePlace, Eliot Community Human Services, the Edinburg Center Inc., and the Department of Guidance Counseling at Lexington High School. Wayside RePlace. RePlace has been in Lexington since 1970 when it began as a youth drop-in center which provided counseling, supervised emergency foster homes, peer counseling, and a child assault prevention program and hotline. In the 1970s, 1980s and until the 1990s, it was identified with the Hancock Church and was housed in the church building. (For the period from November 1994 until late 1995, Eliot Community Health Services took over from RePlace and offered drop-in services and peer counseling for youth from a clubhouse in Depot Square. It proved difficult to reconcile the activities of youth at that location with the business interests of merchants based on the Square. The contract reverted to Wayside RePlace). 16 The present day RePlace, with local headquarters on the second floor at 4 Muzzey Street, retains a tradition carried over from the old RePlace of working to be identified with Lexington, carrying on advocacy for youth and families, and empowering youth as well as being prevention- oriented. It differs from what it was in its earlier decades: it is more bureaucratically organized and professional with a higher level of staff training, documentation of services, and reporting. Since 1996, it has had a solid relationship with its parent agency, the Wayside Youth and Family Support Network, with headquarters located in Framingham, which serves a large, multi- suburban range of communities. In addition to programs of youth skill building, and efforts at bullying and violence prevention which complement the Domestic Violence Task Force work of the Police Department, and health education, RePlace provides counseling and crisis intervention services for emotionally distressed children and youth. In the fiscal year that ended June 30, 2002, the agency provided 459 hours of counseling sessions to 119 Lexington residents and their families on the contract with the town. They also offered group and individual counseling to a few groups of children and middle school youths at Fiske, Harrington, and Clarke schools. Issues addressed in some of these settings included social skills, teasing and bullying, grief and loss, and anger management. The annual operating budget for the year was $108,000, which included $74,087 awarded by the Town of Lexington. This funded the work of five part-time and fee for service staff workers with 1.5 full time equivalents. RePlace generally sees higher functioning youths. It does not treat those with psychotic or mood disorders or psychoneuroses. Some individual youths have been referred to RePlace staff by the guidance counselor at Clarke. The high school staff could use RePlace as a referral resource but does so very rarely. In the judgement of two senior administrators at Wayside Replace, Lexington youth should be involved more in community governance. Adults should reach out to them for their views and recommendations. This was attempted at a youth"summit"meeting in March, 2002, with some success, according to both adult and youth participants. The youth at the summit recommended that efforts should be made to make shops and restaurants youth-oriented, and there should be a mobile youth center. Events should be held in different places and oriented 17 to the middle school students especially. Lexington needs to adopt community mental health and environmental strategies, the youths said. The clinical administrator at RePlace believes that the most serious impediments to adequate mental health services include insufficient funding, limited access to hospitals, and incomplete emergency response capabilities. Many RePlace clients come to RePlace after their HMO insurance benefits have been exhausted. Some never had insurance in the first place. There is also a lack of collaboration among service providers. A provider needs to be known for a long period of time in Lexington before gaining the trust of other providers. They also believe that the quality of services in Lexington is excellent but that there is an inability to meet rising needs. Eliot Community Human Services. This agency serves a sizeable range of suburbs in Middlesex County. The Lexington branch located at 186 Bedford Street was at one time a substantial unit but services have recently been concentrated in Concord and reduced in Lexington. For instance, there had been a psychiatrist in the Lexington office one half day a week, but this has been discontinued. Eliot serves clients with significant mental illnesses, particularly schizophrenia and bipolar disorders, but medication provisions, outreach, and case management services are concentrated in the Concord office. Eliot maintains a 24-hour beeper system and assists parents who phone regarding runaway teenagers or those for whom medication balances get out of control. Psychotherapy is provided at the Lexington office for a few clients. From the point of view of the clinical administrator, there are not enough mental health services to meet needs in our region. Eliot, among others, has recently done little with outreach efforts in Lexington, after making a valiant effort in earlier years. Rates of reimbursement for mental illness and emotional distress are significantly lower than rates for physical illnesses. The state's new mental health parity law makes it sound to the public as if more services will become available, but the law requires proof that the illness being addressed constitutes a"medical necessity," a standard that is very difficult to meet. In fiscal year 2002, Eliot provided 771.5 hours of services - a total of 791 sessions or appointments - to 21 residents of Lexington. The services ranged from individual therapy to family and couples therapy, to family and case consultations, diagnostic evaluations of 18 clients, and medication management. Edinburg Center Inc. Edinburg, known until 2002 as the Center for Mental Health and Retardation Services, has a large headquarters building located at 1040 Waltham Street in Lexington. It is a private, not-for-profit corporation funded by the Massachusetts Departments of Mental Health, Mental Retardation, and Public Health, foundation grants, HMO's and other third party payers. Its director, Ellen Attaliades, is a licensed clinician in psychology, and has 22 years of professional experience, nearly all of them with Edinburg. This agency employs about 300 professionals and support staff who work in the Lexington headquarters and clinic and in clinics in Waltham and Arlington. It serves 18 towns and villages in the immediate county. In addition to providing diagnostic, evaluative, and case management treatment and support planning services, Edinburg maintains these types of services: • Round-the-clock crisis psychiatric intervention services for all persons over 13 years of age. • Adult day treatment services, including two different group programs. Intensive support for daily living assistance, short term psychotherapy, vocational and housing assistance, medication monitoring, and linkages with other service providers. • Outpatient clinics focusing on treating the whole person in community settings. Charles Webster Potter Place, a clubhouse for pre-vocational, social experiences, and psycho social rehabilitation for 40 to 60 members. Five community treatment programs for 39 clients, one of them based in Lexington, and supported housing for 68 adult clients in individual living arrangements. • A variety of programs and services for mentally retarded adults, including two group homes in Lexington. During fiscal year 2002, Edinburg provided mental health services to 96 residents of Lexington. While 82 were whites, the remainder were truly multiethnic. The group included youths from 14 to 20 years of age as well as some adults. The principal services rendered to these 96 included crisis interventions and outpatient counseling. 19 Edinburg collaborates with Emerson Hospital, Eliot Community Mental Health Center, Wayside/RePlace, and a range of individual mental health service providers. It bid, incidentally, on the service contract funded by the Town of Lexington that went to Eliot Community Health Services before it reverted to RePlace. Its collaboration with the Lexington Police Department has been especially fruitful in recent years. Typically, a local police officer phones and brings in a person referred by family or friends as in an emotional crisis. Edinburg gave an award to the Lexington Police for the dedication and quality of their services this year. Agency professionals evaluate the client's problems and capabilities, utilizing placement at Emerson Hospital if necessary for the immediate short term. They assign a case manager, create a team of staff, and begin a program of therapy, medication, and day program participation. Edinburg copes as well as it can with what it deems to be a number of serious impediments to the provision of adequate services. These impediments include the difficulty of achieving coordination between the many towns and jurisdictions they serve; seriously insufficient funding for outpatient services; and very inadequate transportation services - no public buses operate between Lexington or Waltham and the Center. In addition, this large and bustling professional center has no budgeted resources for research and development,program planning, or staff training and development. The director also noted that the Center's overall annual funding is not growing. Lexington High School Guidance Department(LGD). LGD consists of eight full time professionals, a psychologist, counselors and social workers, and a director. The director referred us to his staff because he was new to the town and the school in 2002. We interviewed five members. LGD serves a caseload of 200 students per staff member. About 80 percent of their time is devoted to college and job placement counseling. Social adjustment and mental health issues received 20 percent or less of their time. The mental health service provided by staff in LGD is of an emergency kind - disruptions and episodes that come up unexpectedly during the school day in particular - and is devoted to very short term problem solving. 20 The Lexington school district does not permit professional staff to engage in therapeutic counseling. This is part of the district's risk management strategy as devised by the legal counsel for the school committee. As part of the same strategy, LGD members cannot refer or make related arrangements with outside mental health practitioners. They are permitted only to lend a student or a parent or guardian a notebook listing names, specialties, and addresses and phone numbers. Their book of listings contains numerous solo practitioners but very few clinics, group treatment resources, or networks and agencies. The zero tolerance policy of Lexington High School concerning drug and alcohol use and threats or instances of weapons or violence has the effect, in the judgement of those we interviewed, of"killing the possibility of preventive work with students". Students who have these and related problems now tend to avoid the staff of the LGD, whom they know to be obliged to report student suspects to the administration. Health education about these behaviors is worked upon by the High School Health Department with state grant resources. The theme of the LGD is "coordinative communication". This includes intramural advocacy for students, a parent information and support group which convenes weekly and is open to all interested parents, and assistance to the special needs educators and administrators working the school. Lexington High School faculty in general give very major attention, as do many parents, to time on academic tasks in the classroom and to homework. Time out for counseling or for work on mental health challenges is frowned upon by most faculty and parents. An important exception to this pattern came in 2002 with the death of two students, one a murder victim and one an auto accident victim. On that occasion, LGD and other school staff devised a time of support, counseling, and group grieving. The greatest unmet need in Lexington, in the judgement of the staff members we interviewed, is the need for group counseling and group therapy sessions for adolescents. We should also mention the work of the Health Protection Advisory Council (HPAC). This group of more than 20 health educators, special educators, social workers, public health specialists, work on a number of funded projects to improve drug and alcohol awareness and prevention concerns among parents and youth. They work through a special 21 health unit at Lexington High School and through health educators at the middle and elementary schools. HPAC also works on preventing bullying and harassment and related improvements in interpersonal relations among students. 4. THE INDIVIDUAL PROFESSIONAL PROVIDERS Most of the service providers in our sample work with 15 or more clients a year. See Appendix A. All but a very few of them practice alone and are not part of an agency or group of colleagues. Adults and married couples are the clients of concern to 59 percent of the providers, while 15 percent serve children and 26 percent serve youth. All of the providers serve white clients, but many of them have a multiethnic clientele as well. Most of them treat more than one type of problem, of course. The providers include clinical psychologists who specialize in psychological diagnoses (25 percent). Many of the counselors and therapists work on neuroses and general anxiety disorders (31 percent) while a smaller proportion focus on eating and sleep disorders (16 percent). Marital and parenting problems are primary challenges for 30 percent of the providers. We asked each provider to give us a case illustration of how they go about their work as solo practitioners. The responses varied greatly, of course. Some typical illustrations included the following: • A two hour psycho-educational testing and diagnostic session. • Talking therapy, with time given to listening to what the client is in pain about, for instance, grieving over a father's death. • Mine is a psychoanalytic approach, with an emphasis on emotional, affective life. • Providing psychotherapy for a seven year old who was having difficulty with the aftermath of a parental divorce. • Probing in sessions twice a week to try to learn the causes of death threats and violent outbursts by an adolescent. • Play therapy with children and verbal discussions with adolescents, following the taking of medical histories. 22 • Receives a referral, has an initial session for intake of history, scheduling of future sessions, payment terms, and then a period of talking therapy plus medications lasting from 2 to 9 months. • Gets a referral to a boy who appears depressed and uses lots of marijuana. Meets with the youth and sometimes includes the parents. Contacts the school for details, often visits school for a professional meeting. Takes a day to day approach rather than an analytical or historical one. We also asked an open-ended question about whether there are better practices for service and treatment now in use, or better practices from state or local agencies than there were some years ago. Some of the typical responses to this question were as follows: My experience with the state is one of movement toward privatization through agencies which operate like private practices. The state seems to support large corporate institutions. Fewer people are going to work in community agencies. Social and political change has led to lots of isolation for those who are practitioners. No better practices: we're going backwards. Neuropsychiatric rates have gone down. Now, under state laws,parents can no longer get a second evaluation paid for. The state used to pay for an independent evaluation if parents were not satisfied with the one provided by the school. There need to be more connections between services. In some ways, this is improving. HMO referrals, for example, now require a contact with a primary care physician. Employee assistance programs of today are helpful. Replace is a good community resource but is underutilized. It is not thought of as a referral by referring parties. The Lexington Police are wonderful; they use their resources to best advantage! The problem is finding a psychiatrist to just do medications, without therapy due to reimbursement rates from insurers. The Council on Aging is a wonderful program. In general, services in Lexington have gotten worse in recent years. Processes are slow and laborious; there is no coordination of services. Replace is still serving youth well, I believe. 23 There are a lot of suffering kids. They have to rely on their parents to access services and pay with their own insurance, but with more complicated cases they don't get what they need unless the family has sufficient funds. School-based mental health services are needed in order to avoid dependence on the quality of their own health care insurance and resources. Lexington relies on a system of private practitioners to provide services to kids, which is inadequate. In Cambridge, there is a citywide crisis team, and counselors in the schools and teen centers. Newton also has a coordinated response. We asked the providers what they believed were the major unmet mental health needs of residents of Lexington. A paucity of youth services headed the list(54 percent), with an additional 14 percent citing a need for more help for children and for parenting. Support groups and group psychotherapy services were mentioned by 9 percent, and another 9 percent cited a shortage of geriatric services. We also asked the providers to identify serious impediments, if any, they met in the course of their work. HMO regulations and related management actions were named by 31 percent, and insufficient state funding was cited by 27 percent. Burdensome amounts of required paperwork was cited by 14 percent and 29 percent identified a variety of other impediments. When we asked whether each provider estimated the conditions affecting mental health challenges for Lexington residents were changing, 71 percent said they thought that conditions were worsening, 25 percent did not know or were not sure, and 4 percent said they were improving. When we asked whether, in their judgement, mental health services in Lexington are better or worse now than they were a few years ago, 54 percent thought they had gotten worse, 21 percent thought they were as good now as they were earlier, and 14 percent thought they had improved. 24 5. INTERPRETATIONS AND CONCLUSIONS Lexington is blessed with a large, highly trained, and experienced corps of mental health service providers. There is of course no restriction on access to services anywhere in the region so Lexington residents may and often do seek help from providers located outside of the community, while many non-residents are clients of providers whose offices are based in Lexington. No one can measure the in- and out-movement demographics, but we know they are substantial. Lexington also hosts four agencies with highly trained, experienced service staffs. Sizeable as they are, two of these - Eliot and Edinburg - serve very few Lexington residents. Together, they diagnosed or treated a total of 117 Lexington residents during fiscal year 2002. The Lexington High School Guidance Department devotes all but a fifth of its professional energies to college and job placement and related academic advising and paperwork. It is also gravely restricted in the range and depth of counseling and mental health assistance work its staff is permitted to do under school committee policies. RePlace is the one agency which contracts with the Town of Lexington to serve youth. The amount of the contract is less than half of the funding made available annually to the Town of Bedford Department of Family and Youth Services. Bedford has a substantially smaller resident population - 12,361 in the 2000 Census - than Lexington. RePlace currently does a lot with the resources it has to work with, but its parent agency Wayside went into the red in fiscal 2002 and may prove unable to supplement the funding of Lexington's program in fiscal 2003. Our evidence suggests that RePlace is well regarded by professionals in Lexington, but that it is utilized as a referral resource by Clarke Middle School primarily, as well as by some physicians and counselors, but not by Lexington High School or Diamond Middle School. Solo practitioners, mental health practitioners within the agencies, and others we contacted in the course of this project concur generally that Lexington, with all of its abundance of helping talent, displays a serious lack of services for adolescents. There is also a lack of collaborative coordination between the solo practitioners and between professionals within Lexington High School and these practitioners.. This has been a study of mental health service providers and their knowledge and 25 views. We do not have direct evidence of a shortage of mental health assistance for Lexington youth, only the conviction of providers and counselors to this effect. It could be argued, for instance, that adolescents appear to be "managing"their lives in Lexington rather well now, if the criteria used were youth suicides and incidents of violence. We do not subscribe to this argument in the light of what we have learned from our interviews, but more evidence is needed. We could also ask about the standard that should be used in gauging the extent to which public agencies and especially local government should manage the need for mental health services. We would note that the new state parity law equating mental illness and emotional distress with physical illness and injuries places mental health on a footing identical to that given public health concerns of all kinds. Our view, in addition to supporting the existing commitments of the Commonwealth, is that it is strongly in the self-interest of Lexington's governmental leadership to monitor and foster the availability of mental health services. 6. RECOMMENDATIONS The challenge facing this study project has been to arrive at recommendations to the Board of Selectmen that do not contradict that body's urgent quest for ways in which to fill the extreme gap between town expenditure requirements and available revenues. We therefore offer just a few no-cost recommendations for the Board's consideration. Our premise is that the well-being of Lexington's citizens, especially the youth who make up so much of its life as a residential community, depends in part on having ready access to mental health services within the town in the immediate years ahead. 1. The Board should make earnest and sustained efforts to encourage the Lexington School Committee to change its current policies of risk management and avoidance of psychological and counseling assistance to students. The change should be strongly toward the provision of mental health services by appropriate staff now employed by the Lexington Public Schools. 2. Lexington school policy makers and staff practitioners should also be encouraged to better utilize the considerable professional resources available within Lexington as part 26 of consultation and training to support their clinical work. We have a clear impression that some local providers might gladly donate their time if they were approached effectively. For instance, during the first two decades of work by RePlace, volunteer participation was very high. A rescue home for runaway youths who needed a temporary haven was one of the features of this approach. 3. The position of Social Services Coordinator for Lexington should be reconfigured. Presently, the Coordinator is spread thin. He provides information and referral, case management and even counseling help for clients, and runs groups and staffs committees for the Board of Selectmen. We recommend that the Social Service Coordinator be charged as a priority with coordinating mental health services for Lexington that involve Eliot, Edinburg, and Wayside/RePlace. In this model, all adult services and most services for youth with serious and persistent mental illness would be the responsibility of Edinburg and Eliot, as coordinated by the Social Services Coordinator. 4. In the course of renewing its contract with Lexington, Wayside/RePlace should revise its proposed program of services for youth, in collaboration with the public schools and including programs directed both to mental health and substance abuse for children and youth. Support of proposed programs such as "Young and Sober" should become part of the collaboration. The Board of Selectmen should work to secure agreement with the School Committee to have Wayside/Replace take the lead in initiating this collaboration. 5. Taken together, recommendations 3 and 4 should be unified into a concerted effort between the Department of Social Services, Wayside/Replace, and the Lexington public schools to collaborate, coordinate, and reach out to children and youth in need of help. Consistent with that aim, we recommend that the Board of Selectmen consider building the provision of youth services into their policies and programs in the future. The Human Services Committee pledges it support and its future workmanship to this objective. 27 Attachment D Statistics from Lexington Schools, and Community Safety Departments 2004 Firesetters: 5 Section 12 (Required psychiatric hospitalization): 7 Suicide Attempts: 3 OD/Alcohol: 9 Sexual Assaults: 1 Misc./Risky behavior: 10-15 Fights/Assaults: 5-10 Lexington High School: 2004-05: 40+ students hospitalized (including partial and day treatment programs) 2005-06: 30 students hospitalized (including partial and day treatment programs) 25-30 students referred to SPED based on emotional/psychiatric reasons