Ohio Registry of Effective Practices
Red Flags
Contents
- OMHNSS Interview/Site Visit Team
- Program and Contact Information
- General Program Overview
- Evidence of Effectiveness
- Capacity and Resources
- Family Partnerships
- Community Partnerships
- Sustainability Plan
OMHNSS Interview/Site Visit Team: Kathy Oberlin, Sue Mikolic, Abbey Fruth
Schools: Partnering with schools throughout Ohio
Partnering Agencies: Mental Health America of Summit County, 123 schools
Contact Person and Contact Information:
Angela Tucker Cooper, Executive Director
Mental Health America of Summit County
405 Tallmadge Road, Second Floor
Cuyahoga Falls, OH 44221
330-923-7573
General Program Overview
Red Flags is a comprehensive depression education program for middle schools. This program is a toolkit designed to strengthen the school’s infrastructure and promote early access to health treatment. The Center for Disease Control lists depression and depression related suicide as the leading disease-related cause of death and disability in children between the ages of 11-24. Red Flags is a universal prevention program that involves the entire school community, reduces stigma, enhances emotional intelligence, and improves school climate. It is flexible, simple to implement, low cost, and has been proven effective at any level of implementation.
Red Flags consists of three parts: a curriculum for students at a grade level chosen by the school, information for teachers and staff, and educational materials for parents. The program alerts students, parents, and teachers to the early signs of adolescent depression; demystifies the source and treatment of mental illnesses; helps students, parents, and teachers recognize the behavioral symptoms and dangers of untreated depression and gives them a language and process for accessing help; encourages school personnel to develop and know the district policy for recognizing, referring, and accommodating students; and assists parents in getting help. The program was piloted in 1998 and was launched in 1999. While the student curriculum has been designed for grades 6-8, it has been used in 5th and 9th grades as well. The school personnel component is applicable for the entire district at all grade levels. The parent component can benefit parents with any age child.
The program is designed to be flexible for schools. Its components should be implemented yearly. The student portion of the curriculum is the easiest to implement and should be taught at the same grade level, designated by the school, every year. An important part of the curriculum is the video Claire’s Story. Claire, a middle school student, describes her experience with depression during adolescence. Claire is now a middle school teacher and the video includes a beginning and ending segment explaining that she was in 6th grade when the video was created and to ignore the “fashion fads”. She also encourages students to help their friends. It is recommended that the program be conducted over 3-5 days and incorporated into the existing health curriculum, although the subject matter can also be implemented in other subjects i.e., Science in the Genetics Unit ; Language Arts in conjunction with reading “Eye of the Tiger” or “Outsiders”. A half day in-service is ideal for the personnel component but a nine-minute video with handouts, at a faculty meeting is the minimum requirement. A variety of strategies for parent education are suggested and may include sessions at an open house, articles in the school newsletter, or a website. The program website, redflags.org, is currently being updated with more information on adolescent depression and related illnesses for youth, parents and online training for school personnel.
Back to TopEvidence of Effectiveness:
The Red Flags program evaluation was a three year study commissioned by the Ohio Department of Mental Health and conducted by Isadore Newman, PhD, in the Department of Education at the University of Akron using a mixed method research design. There were 149 schools in 54 counties that participated in the evaluation. The following is a summary of the results of the evaluation as recorded in the Executive Summary.
The study consisted of three parts. First, there were qualitative interviews that consisted of focus groups containing program participants and administrators. There was also a quantitative portion that included a school climate survey, the BarOn Emotional Quotient Inventory (EQ-I), and the Red Flags Program Survey. The surveys were completed by students and staff at schools that used Red Flags as well as comparison schools. The last qualitative portion of the study consisted of phone interviews with program administrators.
The initial 12 focus groups that were conducted in five middle schools were used to inform the development of the quantitative portion of the evaluation, including identifying a best practice model, identifying a theoretical framework, and identifying measurement tools. The instruments that were decided upon as a result of the focus group interviews included those mentioned previously: School Climate and School Satisfaction Scales, EQ-I, and a Red Flags Knowledge Survey designed to measure knowledge about the symptoms of depression.
The quantitative analyses found that students who participated in Red Flags had significantly greater awareness of the symptoms of depression than students who did not participate. All students who participated in the program had significant positive improvements in their academic orientation and disruptive behavior as compared to non-participants. Academic Orientation was measured using the School Climate Academic Orientation scale, and disruptive behavior was measured using both School Climate and EQ-I scales.
The second qualitative portion of the evaluation involved conducting eight follow-up phone interviews with individuals who were the Red Flags program coordinators in their schools. The results of this qualitative portion of the evaluation were consistent with the other portions of the evaluation in terms of the impact on participants.
Fidelity was not able to be measured in a consistent way across schools because each school implements Red Flags in a different way. The Red Flags program is very flexible in that schools choose how to implement the program. Each school picks the portions of the program that are most relevant to them. There was a wide range in who implemented the program and how much time was allotted for the program across schools. As a result, an overall assessment of fidelity was not included in the results of the evaluation.
Surveys are also mailed to the schools each year by Mental Health America of Summit County to help keep track of the how the program is going on a yearly basis. Outcomes from this survey show that students are more likely to get screened for depression if they are educated first. Guidance counselors report that more students come to see them after Red Flags as been implemented at their school than before. The number of self referrals to mental health professionals is growing since the implementation of Red Flags as can be seen in Figure 1.
Figure 1. Origin of Referrals to Mental Health Services
In summary, the evaluation of Red Flags has shown that the program is related to improvements in the following areas: knowledge of depression, academic orientation, disruptive behavior, and willingness to make referrals to mental health services.
Capacity and Resources:
Individuals that have successfully implemented the Red Flags program in schools include teachers, school counselors, nurses, mental health professionals, and parent aides. This program has also been implemented in churches and social service organizations. Mental health screening is not a component of this program, but can be included when the appropriate professional assists with the program. When a community mental health agency implements the program in the school, some schools request the screening be included. A Master’s level counselor is needed for screening. If the program will be implemented as suggested without screening, a Master’s degree is not required. In this case, a health teacher will often implement the program. Some schools also pair the Red Flags program with the SOS (Signs of Suicide) program.
In terms of training, there is a regional training where the person who will be implementing the program goes to be trained and get the supplies needed for the program. The supplies include the video Claire’s Story, which can be obtained on either VHS or DVD, and booklets on depression, which are also available in Spanish and Russian. The program consists of viewing the video and performing activities and discussion related to the video. Ideally, the program would involve showing one chapter of the video and doing activities. The next day another chapter would be shown and so on. The program can be incorporated into various classes including Health and English. In an English class students can read certain books that are related to depression such as “The Outsiders” or “Tiger Rising.” Following the student unit, students will be referred to the Guidance Counselors. When warranted, there is communication with the parents, and students should be given an opportunity to write comments to the teacher that may include self or peer referral.
There is no cost for the Red Flags Program materials and staff training in the first year for Ohio middle schools serving 6th, 7th, and 8th grade classrooms. The only cost incurred by the school is the staff time it takes to attend the training and implement the program. There is a $ 0.20 cost per student for each year that the program is implemented thereafter for replacement booklets. Replacement materials are available for minimal fees.
Family Partnerships:
There is a parent education component to the program. A letter goes home to the parent/guardians to inform them of the program and give them an opportunity to opt their child out of participation in the Red Flags program. The education component for parents is unique with each school using their own strategies for reaching the parents. For example, parents are invited to class to watch skits the children create on depression or other related illnesses. Families have access to Red Flags booklets through parent-teacher meetings, open houses, and in school offices. The booklet can also be sent home with the student to review with their parent. The parent answers a few written questions, signs the form and the student returns to school for extra credit. .
The redflags.org website is also being developed to have a larger and more comprehensive parent education portion. Parents will be able to access information on depression and order the Red Flags booklets. The website, will also include a "Word Bank" of vocabulary words to help children express their feelings to family and teachersBack to TopCommunity Partnerships:
Ideally the schools implementing the Red Flags program should develop relationships with their local community mental health board and service providers including public and private counseling agencies, pediatricians, family practitioners, and the National Alliance on Mental Illness (NAMI). NAMI’s educational program for families with young children, Hand-to-Hand, can be very beneficial to parents. Additionally many schools have worked closely with their local libraries and bookstores and in some areas of Ohio the Kiwanis are getting involved.
There are several models in which a community can embrace the program: 1) Passionate Person: Individual Model: A school personnel along with an administrator take forward the program to students and families; 2) Mental Health Agency Tool Kit Model: A Mental Health (MH) agency person includes the program in their tool kit of evidence based practices and delivers it to various schools in their county/community; 3) Embedded Model: the program is embedded into the health, language arts curriculum; 4) Kiwanis model: Community groups are trained and go to their schools to present the program; 5) NAMI Model: Parents and advocates promote and provide the programming in their communities.
Passionate person (Individual implementer)
The initial materials are free to the school. The implementer (passionate person) from the school attends the training and begins the implementation process. The implementer will provide staff training by inviting a mental health professional to present information on depression related illnesses including the early warning signs, and the referral process. The implementer will provide parent and community information by posting on a school website, in newsletters and in Children’s behavior booklets. The student component will be done by the implementer, i.e. Nurse, counselor, teacher, intervention specialist. The school or individual person will pay for additional booklets- $0.20 per student at the grade level. Either the passionate person or the school counselor will be responsible for the program evaluation.
Mental health agency toolkit model
This model is usually funded by the Mental Health Board or a private funder. The materials will be purchased for $350.00 by the agency. They will designate a staff person to promote the program at the local schools. The staff person will provide the student component, the school personnel training and hold a meeting for parents and community members. The staff person will assist with referrals and provide PR information for school newsletter, website or local newspapers. The staff person is responsible for program evaluation. Cost for Red Flags booklets will be included in the agency budget.
Embedded model – health language
The school administrator selects program for curriculum. Red Flags material is taught in a grade level subject yearly (material may be adapted to fit appropriate subject i.e. Science: genetics unit; health: unit on brain; language arts: in conjunction with literary review i.e. “The Outsiders” or “Eye of the Tiger”). The subject teacher will provide the student component every year. A guest speaker may or may not be invited. The teacher is responsible for pre/post testing. The counselor or school nurse is responsible for the staff in-service. The editor of the newsletters/webmaster will put information into publication yearly. Red Flags booklets will be sent home with each student at the selected grade level. The school’s budget will allow for additional booklets and other materials for the classroom.
Kiwanis model
The local Kiwanis members will promote the Red Flags program to the school district and discuss their level of involvement. Many clubs have offered to provide financial assistance to help with the school’s replacement of booklets and other classroom materials yearly. The Kiwanis may also be involved with community education by having materials at their tables and events.
NAMI model
The local NAMI will provide a person to assist with program implementation. They can present all components if necessary or identify a mental health professional that will present student and personnel components. They can provide literature for parents and community and assist with school publications. Parents have a direct contact for support if their child is identified with signs and the NAMI contact can assist the parent immediately with any services. NAMI may assist with additional booklets.
Composite model
A mix and match of any of the above utilizing community, school, and/or agency resources. Regardless of the implementing source, students, parents, and school personnel are provided with access to Red Flags information and materials.
Sustainability Plan:
Red Flags was created by Mental Health America (MHA) and has been endorsed and funded by the Ohio Department of Mental Health (ODMH) since its inception. Other sources of funding are generated from sales of the program and its materials to other locations outside Ohio and through private grants. The Red Flags program is designed to be incorporated into the school curriculum and implemented yearly. Once that is initiated, the sustainability will continue each year in the school. If the school system is implementing the program themselves, the administrators need to be on board in order for sustainability to occur. The program is best sustained if a Mental Health agency or the Mental Health board helps support and/or implement the program.
Each model of the program has its own sustainability plan. In one real life example, a community agency is implementing the program to schools in their county with no cost to the schools. In this example, the county’s Mental Health Board is committed to keeping the program funded in the county through money from the mental health board and from private foundations. This agency reports that they have more demand for the program than they can keep up with.