Education The Growth of Effective Mental Health Services in Schools in the United States
by
Mark Weist, David Riddle, Ashley Quell, Cameron Massey, Crystal M. Kremer
  • LAST MODIFIED: 26 June 2019
  • DOI: 10.1093/obo/9780199756810-0218

Introduction

This chapter provides a review of the movement toward more comprehensive mental health systems in schools through mental health-education system partnerships. We review factors contributing to the growth of this field including experiences in school nursing, school-based health centers, regulations regarding special education, and progressively expanding federal support. We then discuss integration of these expanded school mental health (SMH) programs with multitiered systems of support (MTSS) in schools, such as Positive Behavioral Interventions and Supports (PBIS). Specifically, the Interconnected Systems Framework (ISF) for SMH and PBIS represents a platform for effective programs and services at Tier 1, involving promotion/prevention; Tier 2, involving early intervention; and Tier 3, more intensive intervention. Key strategies associated with the ISF and effective practices at each of these tiers are reviewed, including emphases on effective team and culturally responsive and evidence-based practices. The chapter concludes with a review of future directions for SMH.

General Overview

As presented above, the purpose of this chapter is to review school mental health (SMH) services with emphasis on the experience in the United States. There has been significant development of these services in the United States and in other countries (see Rowling and Weist 2004; Weist, et al. 2016) related to increasing recognition of significant unmet need for children and youth presenting emotional/behavioral (EB) problems. Merikangas, et al. 2010 and Merikangas, et al. 2011 indicate that one in every four to five children and youth presents concerning levels (consistent with diagnoses) of emotional/behavioral problems, yet less than a third of these youth receive any services. Burns, et al. 1995 found that far fewer receive effective services. This picture becomes even more disheartening when viewed through the lens of the almost universal experience of significant life stress and psychosocial difficulties experienced by almost all children and youth in their development (Adelman and Taylor 2006). Results from McLeod and Fettes 2007 show that children and youth experiencing more serious emotional/behavioral problems are less likely to graduate high schools and enroll in post-secondary education, attain lower academic achievement than peers without mental health concerns, and experience a greater likelihood of living in poverty. Negative outcomes such as these strengthen the urgency to bring mental health services to youth “where they are,” in schools as Weist and Murray 2007 reports. This article provides background and review key themes in school mental health (SMH) services, including reviewing origins and key developments, current initiatives, and evidence-based practices and culturally competent services within a multi-tiered framework of promotion/prevention, early intervention and intervention. Emphasis is placed on connection of SMH to systems of Positive Behavioral Interventions and Supports (PBIS) and an Interconnected Systems Framework for accomplishing the same. The chapter concludes with key directions for advancing the SMH field.

  • Adelman, H. S., and L. Taylor. 2006. Mental health in schools and public health. Public Health Reports 121:294–298.

    DOI: 10.1177/003335490612100312Save Citation »Export Citation » Share Citation »

    Discusses how individuals working in the public health arena are able to promote mental health and change public opinion regarding mental health programs. This article focuses on how schools can play an essential role in this process.

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  • Burns, B. J., E. J. Costello, A. Angold, et al. 1995. Children’s mental health service use across service sectors. Health Affairs 14:147–159.

    DOI: 10.1377/hlthaff.14.3.147Save Citation »Export Citation » Share Citation »

    Utilizes the Great Smoky Mountains Study of Youth to examine the roles of different types of professionals who serve children in providing mental health services. The results show that while there is a high level of mental health care use being reported, there is still a significant number of people with unmet needs.

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  • McLeod, J. D., and D. L. Fettes. 2007. Trajectories of failure: The educational careers of children with mental health problems. American Journal of Sociology 113.3: 653–701.

    DOI: 10.1086/521849Save Citation »Export Citation » Share Citation »

    This article presents a framework on understanding the connection between mental health and educational success in children.

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  • Merikangas, K. R., J. P. He, D. Brody, P. W. Fisher, K. Bourdon, and D. S. Koretz. 2010. Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics 125:75–81.

    DOI: 10.1542/peds.2008-2598Save Citation »Export Citation » Share Citation »

    Uses cross-sectional surveys to develop a growing database on mental health prevalence rates in youth and adolescents.

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  • Merikangas, K. R., J. He, M. Burstein, et al. 2011. Service utilization for lifetime mental disorders in U.S. adolescents: Results of the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry 50:32–45.

    DOI: 10.1016/.jaac.2010.10.006Save Citation »Export Citation » Share Citation »

    A study that provides critical information regarding the utilization of mental health services in youth and adolescents. Sheds light on the underuse of such services and provides vital information on why this is such an issue.

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  • Rowling, L., and M. D. Weist. 2004. Promoting the growth, improvement and sustainability of school mental health programs worldwide. International Journal of Mental Health Promotion 6.2: 3–11.

    DOI: 10.1080/14623730.2004.9721925Save Citation »Export Citation » Share Citation »

    Reviews the mental health promotion-oriented network, International Alliance for Child and Adolescent Mental Health and Schools (Intercamhs) and discusses worldwide issues related to youth and adolescent mental health promotion and needs.

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  • Weist, M. D., and M. Murray. 2007. Advancing school mental health promotion globally. Advances in School Mental Health Promotion, Inaugural Issue 2–12.

    DOI: 10.1080/1754730X.2008.9715740Save Citation »Export Citation » Share Citation »

    An introductory article from the inaugural issue of this journal that discusses current international efforts toward advancing school mental health. Highlights barriers that are experienced on a global level and provides a review of various efforts and initiatives from around the world.

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  • Weist, M. D., K. Short, H. McDaniel, and A. Bode. 2016. The School Mental Health International Leadership Exchange (SMHILE): Working to advance the field through opportunities for global networking. International Journal of Mental Health Promotion 18.1: 1–7.

    DOI: 10.1080/14623730.2015.1079420Save Citation »Export Citation » Share Citation »

    Discusses SMHILE and how this group of international leaders, researchers, and practitioners come together to discuss initiatives to promote school mental health and share findings from various countries on the promotion of mental health and well-being.

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Origins and Growth of School Mental Health

This section provides a look at the development of school mental health programs over time, from their roots in early efforts of school nursing to current trends in expanded school mental health. These early efforts to provide health care within the school setting led to action at the legislative level, providing the groundwork and support for later action. Key federal initiatives are discussion in terms of how they opened doors for providers and researchers in this field, as well as how they support this critical work in our current social climate.

Early History/School Nursing

Flaherty and Osher 2003 documents how the history of school mental health (SMH) has been largely shaped by societal and educational developments as well as the growth and development of multiple related professions such as nursing, psychology, psychiatry, and social work. Though not considered to be mental health professionals until more recently, school nurses serve the role of overseeing the health and overall well-being of students within schools. The introduction of school nurses in the early 1900s was a result of an increase of eastern European immigrants moving to the more urbanized areas of the United States who lacked access to proper health care. The presence of nurses in schools was also based on a public health model to address the detection and treatment of illnesses. This basis of a public health model allowed nurses to oversee the instruction of proper nutrition, proper sanitation, and overall health promotion. Nurses also began to address emotional/behavioral issues in students and this role increased progressively in the later in the 20th and in the 21st centuries, according to Bohnenkamp, et al. 2015 and Flaherty and Osher 2003.

  • Bohnenkamp, J. H., S. H. Stephan, and N. Bobo. 2015. Supporting student mental health: The role of the school nurse in coordinated school mental health care. Psychology in the Schools 52.7: 714–727.

    DOI: 10.1002/pits.21851Save Citation »Export Citation » Share Citation »

    Looks at how school nurses can play an integral part in providing mental health services in school settings. Highlights particular strengths and skills that school nurses bring to collaborating with school mental health providers and some of the challenges unique to their involvement in the process.

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  • Flaherty, L. T., and D. Osher. 2003. History of school-based mental health services. In Handbook of school mental health: Advancing practice and research. Edited by M. D. Weist, S. Evans, and N. Lever, 11–22. New York: Springer.

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    A book chapter that explores the history and development of school mental health as well as the policies that helped shape the current field.

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School-Based Health Centers

Lear, et al. 1991 reports how school-based health centers (SBHCs) emerged in the 1960s related to the recognition that many students were not receiving basic health-care services. As students presented for health services (see Flaherty and Osher 2003, cited under Early History/School Nursing), Lear, et al. 1991 realized that many were presenting with emotional/behavioral concerns spurring the growth of mental health services within these centers. These centers are typically staffed by a nurse practitioner or physician’s assistant and a mental health clinician, such as a master’s-level therapist or social worker. The most recent national census indicated around two thousand SBHCs in the United States according to the National Assembly on School-Based Health Care 2009.

  • Lear, J. G., H. B. Gleicher, A. St. Germaine, and P. J. Porter. 1991. Reorganizing health care for adolescents: The experience of the school-based adolescent health care program. Journal of Adolescent Health 12:450–458.

    DOI: 10.1016/1054-139X(91)90022-PSave Citation »Export Citation » Share Citation »

    A collection of progress reports on twenty-three health-care centers that provide mental health services to adolescents. Findings indicate that mental health care was among the most frequently provided services and that the utilization of such services can allow for a continuity of health care.

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  • National Assembly on School-Based Health Care. 2009. School-based health centers: National census, school year 2007–2008. Washington, DC: National Assembly on School-Based Health Care.

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    A census report from 2008 that provides information on school-based health centers, including: services offered, staff on-site, financial information, and levels of engagement with school partners.

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Individuals with Disabilities Education Act

In 1975 Public Law 94–142, or the Individual with Disabilities Education Act (IDEA) was passed in the United States, mandating that schools serve all students, including those with learning or emotional/behavioral disabilities (EBDs). This law became a critical catalyst in the hiring and placement of mental health professionals, such as psychologists and social workers in schools as integral staff members. Researchers have found that the purpose of including such professionals was to provide mental health services to students with EBDs to help determine the degree of their disability and to develop programs to enhance their school functioning (see Flaherty and Osher 2003, cited under Early History/School Nursing). However, Becker, et al. 2011 shows that services for youth presenting EBD remain fairly limited, related to factors such as a paucity of school-employed mental health professionals (e.g., school psychologists, counselors, social workers, as noted in Weist, et al. 2014), and barriers to students receiving them, such as restrictive policies such as denying care to youth presenting concurrent “social maladjustment.”

  • Becker, S. P., C. E. Paternite, S. W. Evans, et al. 2011. Eligibility, assessment and educational placement issues for students classified with emotional disturbance: Federal and state-level analyses. School Mental Health 3.1: 24–34.

    DOI: 10.1007/s12310-010-9045-2Save Citation »Export Citation » Share Citation »

    This review article discusses how education systems classify and describe emotional disturbance (ED) in the special education school settings. Detail analysis of current practices and a discussion of future policy recommendations are included.

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  • Weist, M. D., N. A. Lever, C. P. Bradshaw, and J. S. Owens. 2014. Further advancing the field of school mental health. In Handbook of school mental health: Research, training, practice, and policy. Edited by M. Weist, N. Lever, C. Bradshaw, and J. Owens, 1–16. New York: Springer.

    DOI: 10.1007/978-1-4614-7624-5_1Save Citation »Export Citation » Share Citation »

    Highlights current issues regarding youth and adolescent mental health services. The article then provides a framework that aids stakeholders in collaborating across multiple systems to overcome barriers to the provision of mental health services.

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Expanded School Mental Health

Related to increasing recognition of limitations of and barriers to the receipt of traditional community mental health services, Weist 1997 found that “expanded” school mental health (SMH) services began to be developed in the late 1980s and throughout the 1990s. These programs involved a shared agenda, per Andis, et al. 2002, of families, schools, and community agencies working together to move mental health system staff (e.g., clinical psychologists, social workers, child and adolescent psychiatrists) into the schools to join with school employees (e.g., school psychologists, counselors, social workers, nurses, teachers) to augment and improve the quality of programs and services (Weist 1997). Expanded SMH involves the full range of education, mental health, and health system professionals working together effectively to reduce and remove barriers to student learning and improve promotion, prevention, and intervention efforts, as documented in Flaherty, et al. 1998, and Waxman, et al. 1999. When successfully implemented, Stephan, et al. 2007 found that expanded SMH services have been reported to reduce barriers to receiving assessment and intervention services and lead to relevant positive outcomes including improved emotional, behavioral, and school functioning (Ballard, et al. 2014; Iachini, et al. 2015) with these outcomes helping to justify their funding (Cammack, et al. 2014). Further, ESMH has been shown to significantly improve access to care. For example, Catron, et al. 1998 found that 96 percent of families offered school-based serviced initiated treatment, whereas only 13 percent initiated treatment when services were to be provided in other community settings. Further, Weist, et al. 1999 notes that SMH increases access to care for students presenting internalizing problems such as depression and anxiety.

  • Andis, P., J. Cashman, D. Oglesby, et al. 2002. A strategic and shared agenda to advance mental health in schools through family and system partnerships. International Journal of Mental Health Promotion 4.4: 28–35.

    DOI: 10.1080/14623730.2002.9721886Save Citation »Export Citation » Share Citation »

    Examines the discrepancy between the need for mental health-care services and the availability of resources, with particular attention to how a public health approach may be the best solution to make systemic changes to the process of linking services with those in need.

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  • Ballard, K. L., M. A. Sander, and B. Klimes-Dougan. 2014. School-related and social-emotional outcomes of providing mental health services in schools. Community Mental Health Journal 50:145–149.

    DOI: 10.1007/s10597-013-9670-ySave Citation »Export Citation » Share Citation »

    This study looked at the effectiveness of an expanded school mental health program that placed community mental health workers on-site in schools. Differences in both academic outcomes as well as social-emotional functioning were found for the students who received the school mental health services.

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  • Cammack, N. L., N. E. Brandt, E. Slade, N. A. Lever, and S. Stephan. 2014. Funding expanded school mental health programs. In Handbook of school mental health: Research, training, practice, and policy. 2d ed. Edited by M. Weist, N. Lever, C. Bradshaw, and J. Owens, 17–30. New York: Springer.

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    This review discusses various funding mechanisms at the federal, state, and local levels that are available for expanded school mental health-care programs. Several examples of successfully funded programs are provided in detail.

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  • Catron, T., V. S. Harris, and B. Weiss. 1998. Posttreatment results after 2 years of services in the Vanderbilt School-Based Counseling Project. In Outcomes for children and youth with emotional and behavioral disorders and their families: Programs and evaluation best practices. Edited by M. H. Epstein and K. Kutash, 633–656. Austin, TX: Pro-Ed.

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    This book chapter describes the evaluation project of the Vanderbilt School-Based Counseling Project following two years of intervention. This program was compared against community-based counseling, and academic tutoring, and discusses differences in mental health and psychosocial functioning between the treatment conditions.

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  • Flaherty, L. T., E. G. Garrison, R. Waxman, et al. 1998. Optimizing the roles of school mental health professionals. Journal of School Health 68.10: 420–424.

    DOI: 10.1111/j.1746-1561.1998.tb06321.xSave Citation »Export Citation » Share Citation »

    Discusses the roles of various professionals in the implementation of school-based mental health services.

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  • Iachini, A., E. L. Brown, A. Ball, J. E. Gibson, and S. E. Lize. 2015. School mental health early interventions and academic outcomes for at-risk high school students: A meta-analysis. Advances in School Mental Health Promotion 8:156–175.

    DOI: 10.1080/1754730X.2015.1044252Save Citation »Export Citation » Share Citation »

    A review of quantitative research on school mental health (SMH) interventions and academic outcomes that highlights the need for a more in-depth focus on effective interventions that lead to positive academic outcomes.

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  • Stephan, S. H., M. Weist, S. Kataoka, S. Adelsheim, and C. Mills. 2007. Transformation of children’s mental health services: The role of school mental health. Psychiatric Services 58.10: 1330–1338.

    DOI: 10.1176/appi.ps.58.10.1330Save Citation »Export Citation » Share Citation »

    Uses the President’s New Freedom Commission report in conjunction with proposed guidelines to suggest how schools across the United States can improve school mental health efforts.

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  • Waxman, R. P., M. D. Weist, and D. M. Benson. 1999. Toward collaboration in the growing education-mental health interface. Clinical Psychology Review 19:239–253.

    DOI: 10.1016/S0272-7358(98)00072-5Save Citation »Export Citation » Share Citation »

    An article that introduces the discussion of education and mental health professionals coming together in collaborative partnerships to provide quality expanded school mental health (ESMH) services. Identifies the barriers to effective partnerships and provide insight into both fields and how to overcome such barriers.

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  • Weist, M. D. 1997. Expanded school mental health services: A national movement in progress. In Advances in clinical child psychology. Edited by T. H. Ollendick and R. J. Prinz, 319–352. New York: Plenum.

    DOI: 10.1007/978-1-4757-9035-1_9Save Citation »Export Citation » Share Citation »

    An in-depth overview of expanded school mental health (ESMH) services and how these programs can help to better utilize services provided by school psychologists and social workers. Also provides examples of ESMH programs and highlights the barriers to addressing school systems.

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  • Weist, M. D., C. P. Myers, E. Hastings, H. Ghuman, and Y. Han. 1999. Psychosocial functioning of youth receiving mental health services in the schools vs. community mental health centers. Community Mental Health Journal 35:69–81.

    DOI: 10.1023/A:1018700126364Save Citation »Export Citation » Share Citation »

    An evaluation of students receiving school-based mental health (SBMH) services versus those receiving services through community mental health centers. The findings provide evidence that SBMH services are more likely to reach youth who may otherwise not receive such services.

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Support from the United States Government

In 2002 President George W. Bush announced the President’s New Freedom Commission on Mental Health declaring, “Our country must make a commitment. Americans with mental illness deserve our understanding and they deserve excellent care.” The purpose of this commission was to recognize the need for “a healthcare system which treats mental illness with the same urgency as physical illness” (Hogan 2003, New Freedom Commission on Mental Health 2003) with emphasis on child and youth mental health and overcoming the many barriers constraining mental health care in the United States. The commission enacted goals including: (1) increasing understanding of mental health and effective mental health promotion; (2) creating a mental health care system that is consumer and family driven; (3) eliminating disparities in mental health care; (4) implementing early mental health screening, assessment, and referral; (5) providing excellence in services guided by research; and (6) improving the use of technology to improve mental health services. The report from Hogan 2003 also included a specific recommendation to improve and expand mental health services in schools. During 2013 under the second term of the Obama administration, a document entitled “Now is the Time” was released focusing on reducing violence and its impacts on children and youth, with improving mental health services a central emphasis of the report. Though gun violence is not necessarily linked to mental illness, the recent tragic events throughout the country including large-scale violence in Blacksburg, Virginia; Sandy Hook, Connecticut; Aurora, Colorado; and more recent shootings in Charleston, South Carolina; and San Bernardino, California, highlight the need to improve early identification and intervention services to assist in avoiding violent crises (US White House 2013). As in New Freedom Commission on Mental Health 2003, this report emphasized the significant expansion of school mental health services.

Current Initiatives in School Mental Health

This section reviews Positive Behavioral Intervention and Supports (PBIS), an education-based initiative focused on improving student behavior, as well as more recent efforts to join SMH and PBIS together through an Interconnected Systems Framework (ISF). The ISF is hypothesized to lead to improved economies of scale, effectiveness of both systems working together instead of separately, and improved depth and quality of services within a multitiered framework of promotion, prevention, early intervention and treatment. We review PBIS, followed by the ISF, and key dimensions to enhance the effectiveness of programs and services.

Positive Behavioral Interventions and Supports

According to the National PBIS Technical Assistance Center website, PBIS is currently implemented in over 26,000 schools nationwide, and is considered by Fixsen and Blase 2008 as perhaps the most successful example of a scaled-up evidence-based practice. Founded in behavior analytic principles and a public health model, Lane, et al. 2012 and Sugai and Horner 2009 note that PBIS focuses on preventatively and proactively shaping not only student but adult behavior to achieve desired outcomes. As outlined by Swain-Bradway, et al. 2015, PBIS is reflective of a multitiered system of support (MTSS) providing promotion and prevention services for all students at Tier 1, more intensive prevention and early intervention for students experiencing conditions of risk or beginning to present problems at Tier 2, and intervention services for students presenting established problems at Tier 3. There are increased resources, time, and intensity of services per individual student from tiers 1 to 3. Research suggests (Lane, et al. 2011 and Lane, et al. 2015) that approximately 80 percent of students will respond to Tier 1 efforts; 15 percent of students (or more depending on the community) will benefit from Tier 2 supports that include early identification and focused supports for students individually, within groups or in classrooms; and around 5–10 percent (or more depending on the community) require the most intensive services and resources at Tier 3 such as functional-based interventions and wraparound services as illustrated by Umbreit, et al. 2007. Hallmark to PBIS is the utilization of data-informed decision making to rapidly determine appropriate interventions and intervention success or failure. It is important to note that Lane, et al. 2011 found that students receiving special education services can receive tiered intervention supports throughout the continuum and do not automatically receive Tier 2 and Tier 3 services in reaction to their special education label. A clear strength of PBIS is the use of an interdisciplinary team within a defined implementation structure that is not “siloed” by discipline or domain (e.g., academic team and behavior team) and is representative of the multiple stakeholders that students come in contact throughout their school journey. Barrett, et al. 2013 agrees that although PBIS has many benefits, limitations do exist primarily in (1) viewing student issues through the lens of “behavior,” which can be associated with limited attention to other issues such as internalizing problems, and (2) limited depth in services at Tiers 2 and 3. However, it should be pointed out that in many cases PBIS initiatives in schools and school districts include gaps in programs and services, especially at Tiers 2 and 3, and an additional limitation if a focus on “behavior” that may reduce the focus on other student challenges, such as depression and anxiety (Barrett, et al. 2013).

  • Barrett, S., L. Eber, and M. D. Weist. 2013. Advancing education effectiveness: An interconnected systems framework for Positive Behavioral Interventions and Supports (PBIS) and school mental health. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education). Eugene: Univ. of Oregon Press.

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    This monograph defines the Interconnected Systems Framework as an implementation process that helps to link education and mental health systems, describes implementation efforts of the ISF across multiple states, discusses potential benefits to schools and students, and describes research and policy implications for the ISF.

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  • Fixsen, D. L., and K. A. Blase. 2008. Implementation: The secret to using science in human service settings. Fifth International Conference on Positive Behavior Support, Chicago, IL, 28 March 2008. Tampa: Univ. of South Florida.

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    A presentation on how to successfully and effectively implement school mental health interventions through the establishment of cohesive teams.

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  • Lane, K. L., H. Menzies, A. Bruhn, and M. Crnobori. 2011. Managing challenging behaviors in schools: Research-based strategies that work. New York: Guilford Press.

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    A book chapter that provides various strategies to prevent and intervene when a student engages in problem behavior in the classroom.

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  • Lane, K. L., H. M. Menzies, R. P. Ennis, and W. P. Oakes. 2015. Supporting behavior for school success: A step-by-step guide to key strategies. New York: Guilford Press.

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    This book provides seven PBIS-based strategies to improve classroom management to reduce disruptive behavior and increase student engagement and outcomes.

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  • Lane, K. L., H. M. Menzies, W. P. Oakes, and J. R. Kalberg. 2012. Systematic screenings of behavior to support instruction: From preschool to high school. New York: Guilford Press.

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    A book that provides in-depth reviews for various screening assessments for students with potential emotional and behavioral disorders.

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  • Sugai, G., and R. H. Horner. 2009. Responsiveness-to-intervention and school-wide positive behavior supports: Integration of multi-tiered system approaches. Exceptionality: A Special Education Journal 17.4: 223–237.

    DOI: 10.1080/09362830903235375Save Citation »Export Citation » Share Citation »

    Discusses SWPBS and RTI and compare both systems, leading to a recommendation that the two can be used hand-in-hand within schools. The article then provide guidelines for how school teams can implement both systems.

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  • Swain-Bradway, J., J. Johnson, L. Eber, S. Barrett, and M. D. Weist. 2015. Interconnecting school mental health and school-wide positive behavior support. In School mental health: Global challenges and opportunities. Edited by S. Kutcher, Y. Wei, and M. D. Weist, 282–298. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9781107284241.023Save Citation »Export Citation » Share Citation »

    This book chapter describes the Interconnected Systems Framework (ISF) and how it facilitates the collaboration of various stakeholders in school mental health. The chapter also provides examples of successful implementation of the ISF to demonstrate the barriers and facilitators to improving learning and academic success.

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  • Umbreit, J., J. Ferro, C. Liaupsin, and K. Lane. 2007. Functional behavioral assessment and function-based intervention: An effective, practical approach. Upper Saddle River, NJ: Prentice-Hall.

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    A book that provides a step-by-step system for conducting functional behavioral assessments and the development and implementation of effective interventions.

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Joining School Mental Health and PBIS: The Interconnected Systems Framework

Borrowing from the strengths of PBIS and expanded SMH, the Interconnected Systems Framework interlinks both models into one integrated multitiered model of service delivery to deliver evidence-based practices along the prevention to intervention continuum to address the academic, behavioral, and socio-emotional needs of students in the least restrictive manner (see Barrett, et al. 2013 under Positive Behavioral Interventions and Supports; Monahan, et al. 2014). Evans, et al. 2013 describes ISF practices as “(a) evidence-based; (b) organized within a multi-tiered continuum of support; (c) available across all school contexts; (d) implemented in collaboration with academic, behavioral, and mental health experts; (e) student- and family-centered; (f) culturally relevant; and (g) data-driven” (p. 46). Through the addition of mental health system involvement in PBIS through the ISF, the depth and quality of programs and services are enhanced, particularly at Tiers 2 and 3, with additional benefits of enhanced screening (Splett, et al. 2018) and outreach and provision of services to students with “internalizing problems” such as depression and anxiety (Weist, et al. 2018). A number of related critical themes for the ISF are presented next.

  • Evans, S. W., B. Simonsen, and G. Dolan. 2013. School level practices. In Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support. Edited by S. Barrett, L. Eber, and M. D. Weist, 46–57. Eugene: Univ. of Oregon Press.

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    This chapter talks about specific practices that occur within an Interconnect Systems Framework (ISF) in PBIS and school mental health services. The purpose of this chapter is to provide teams with a process for identifying, selecting, implementing, monitoring, evaluating, and adapting evidence-based practices within an ISF framework. Available online.

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  • Monahan, K., M. W. George, J. W. Splett, D. Riddle, L. Morrison, and M. D. Weist. 2014. The Interconnected Systems Framework and dissemination efforts in the Carolinas. Report on Emotional and Behavioral Disorders in Youth 14.4: 78–86.

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    A review of the strengths of positive behavioral supports and interventions (PBIS) and school mental health (SMH) and how these two systems are disseminated throughout North and South Carolina.

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  • Splett, J. W., K. Trainor, A. Raborn, et al. 2018. Comparison of universal mental health screening and traditional school identification methods for multi-tiered intervention planning. Behavioral Disorders 43.3: 344–356.

    DOI: 10.1177/0198742918761339Save Citation »Export Citation » Share Citation »

    Reviews traditional approaches to mental health screening in schools as compared to systematic screening and advantages of systematic screening based on a study focused on elementary students.

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  • Weist, M. D., L. Eber, R. Horner, et al. 2018. Improving multi-tiered systems of support for students with ‘internalizing’ emotional/behavioral problems. Journal of Positive Behavior Interventions 20.3: 172–184.

    DOI: 10.1177/1098300717753832Save Citation »Export Citation » Share Citation »

    Reviews unmet needs of students presenting “internalizing” problems such as depression, anxiety, and trauma exposure, and ways that the Interconnected Systems Framework for school mental health and PBIS improves programs and services for these youth.

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Readiness

Schools considering the benefits and requirements of installing and implementing the ISF must first assess readiness before building such a framework to identify if structures are already in place to support the framework and if stakeholders are ready to assist in such a partnership (Anello, et al. 2017; Lever and Putnam 2013). Shifting schools to implementing ISF from a PBIS or PBIS+SMH framework will be a paradigm shift for many stakeholders; however, it will be vital to the academic, behavioral, and socio-emotional success of students if strong memorandums of agreements and planning occur between school and community-based entities and that both agencies are working collaboratively to install high quality MTSS frameworks. Lever and Putnam 2013 describe readiness as “a willingness to move beyond a ‘walled’ model in which only school-based staff is part of a child’s support team to one that embraces cross stakeholder and cross system partnership.” When forming these partnerships, communication between families, school, and community agencies must occur with a high level of frequency to ensure all partners are represented and goals of each partner are addressed. Developing memoranda of agreements or understanding (MOA/MOU) prior to implementation is essential in determining readiness and also helps stakeholders to be aware of their roles and responsibilities to the school and students while also gaining awareness of the roles and responsibilities of other partners. Lever and Putnam 2013 recommend a memorandum of agreement be formally written down and documented with clearly defined roles, actions, and timelines for accomplishing actions.

  • Anello, V., M. D. Weist, L. Eber, et al. 2017. Readiness for Positive Behavior Interventions and Supports (PBIS) and school mental health (SMH) interconnection. Development of a stakeholder survey. Journal of Emotional and Behavioral Disorders 25.2: 82–95.

    DOI: 10.1177/1063426616630536Save Citation »Export Citation » Share Citation »

    Discusses the process of developing a survey that evaluates the readiness to interconnect PBIS and school mental health, including focus on the perceptions of teachers, students, administrators, family members, and other stakeholders involved.

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  • Lever, N., and R. Putnam. 2013. The role of school level systems in interconnecting school mental health and school-wide positive behavior support. In Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support. Edited by S. Barrett, L. Eber, and M. D. Weist, 34–45. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education). Eugene: Univ. of Oregon Press.

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    A chapter that discusses the organizational structure of school level systems and how these systems can facilitate the implementation of multitiered frameworks. The chapter also provides unique examples of these system integrations at the school and district level.

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Teaming

Multitiered systems of support as in the ISF should be guided by interdisciplinary teams to include school- and community-employed mental health staff, teachers, school nurses, school administrators, parents and youth leaders (in middle and high schools). Some members of the team (e.g., school administrators) should have decision-making authority, for example to allocate resources toward program implementation. Researchers describe how schools will often establish three teams—one team addressing each tier—or will establish one universal team and a team to address both Tier 2 and Tier 3 jointly (see Lever and Putnam 2013, cited under Readiness). Alternatively, if multiple teams are challenging, (see Swain-Bradway, et al. 2015 under Positive Behavioral Interventions and Supports) noted that the school can have one ISF team, with sub-teams at Tiers 1, 2 and 3 having conversations and planning for actions in between larger team meetings. Successful ISF teams use data to inform decision making and meet on a regular basis (e.g., every two to three weeks) and use agendas outlining clear expectations and goals and create action plans using data to progress monitor individual student and systems successes and challenges, as seen in Lever and Putnam 2013, cited under Readiness.

  • Lever, N., and R. Putnam. 2013. The role of school level systems in interconnecting school mental health and school-wide positive behavior support. In Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support. Edited by S. Barrett, L. Eber, and M. D. Weist, 34–45. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education). Eugene: Univ. of Oregon Press.

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    A chapter that discusses the organizational structure of school-level systems and how these systems can facilitate the implementation of multitiered frameworks. Also provides unique examples of these system integrations at the school and district level.

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  • Swain-Bradway, J., J. Johnson, L. Eber, S. Barrett, and M. D. Weist. 2015. Interconnecting school mental health and school-wide positive behavior support. In School mental health: Global challenges and opportunities. Edited by S. Kutcher, Y. Wei, and M. D. Weist, 282–298. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9781107284241.023Save Citation »Export Citation » Share Citation »

    This book chapter describes the Interconnected Systems Framework (ISF) and how it facilitates the collaboration of various stakeholders in school mental health. Also provides examples of successful implementation of the ISF to demonstrate the barriers and facilitators to improving learning and academic success.

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Benefits of Implementing the ISF

Benefits of the ISF are dependent upon the level of fidelity of implementation; however, research has shown that when implemented well the ISF is expected to achieve many positive outcomes for students, families, schools and community system stakeholder groups (see Barrett, et al. 2013, cited under Positive Behavioral Interventions and Supports and Monahan, et al. 2014, cited under Joining School Mental Health and PBIS: The Interconnected Systems Framework). As before, this is related to the fact that the ISF is leveraging two prominent initiatives, present in most communities. Eber, et al. 2013 describes how school mental health and PBIS to work together more effectively, creating efficiencies and economies of scale and increase the depth and impact of multitiered promotion, prevention, early intervention, and intervention. Foundational to such positive impact is school and staff readiness is the effectiveness of teams, and the commitment of ISF teams and other school staff to data-based decision making and the implementation of evidence-based practices (see Evans, et al. 2013, cited under Joining School Mental Health and PBIS: The Interconnected Systems Framework).

  • Eber, L., M. D. Weist, and S. Barrett. 2013. An introduction to the Interconnected Systems Framework. In Advancing education effectiveness: An interconnected systems framework for Positive Behavioral Interventions and Supports (PBIS) and school mental health. Edited by S. Barrett, L. Eber, and M. Weist, 3–17. Center for Positive Behavioral Interventions and Supports (funded by the Office of Special Education Programs, U.S. Department of Education). Eugene: Univ. of Oregon Press.

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    This introductory chapter provides information related to the Interconnect Systems Framework (ISF) and how it relates to PBIS and school mental health services. This chapter provides background and context of relevant topics and discusses how the ISF can be used to enhance PBIS and SMH.

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Barriers to ISF Implementation

Although the Interconnected Systems Frameworks presents many benefits there are some barriers related to further advancing its implementation. Challenges to ISF implementation and sustainability include the status quo of work in schools characterized by many initiatives going on simultaneously, pressures for students to achieve and to be able to document that achievement, and people operating in relative isolation with little support for effective teaching/practice (see Weist, et al. 2014 under Individuals with Disabilities Education Act). In the area of training, it is essential for teams and school personnel to have high-quality initial training in addition to regular training opportunities to refresh stakeholders on ISF goals and procedures and to train new stakeholders who may be unfamiliar with the framework (see Eber, et al. 2013 under Benefits of Implementing the ISF and Monahan, et al. 2014, cited under Joining School Mental Health and PBIS: The Interconnected Systems Framework). Too often, teachers receive either minimal pre- and in-service training on effective classroom management and behavior support resulting in low self-efficacy to be effective and increased professional burnout (see Evans, et al. 2013, cited under Joining School Mental Health and PBIS: The Interconnected Systems Framework). Professional development can prove to be costly to schools, therefore it is essential to examine the expertise of individuals within the school system and utilize those talents to cost-effectively provide training that enables school staff to move beyond the use of reactive techniques in response to challenging behavior presented by students toward more proactive, evidence-based approaches for the full prevention-intervention continuum (see Kern, et al. 2015). A significant issue for school mental health, PBIS, and the ISF approach is that families and youth play a limited if non-existent role in guiding programs and services, in spite of the importance of their genuine and active voice (Bickham, et al. 1998; Lever, et al. 2003). Garbacz, et al. 2015 found that an additional concern is family involvement in schools tends to progressively decrease as students progress from elementary to middle to high school. Thus, it is essential for mental health staff in the schools, ideally working through a framework such as the ISF, to prioritize strongly family and youth involvement and guidance in all aspects of multitiered programs and supports, including being active participants in team meetings. Here, confidentiality and privacy are presented as barriers to such family involvement, but in reality, should not mitigate such efforts, as only a small portion of decision making for programs at Tiers 1, 2 and 3 involves sensitive information about particular students.

  • Bickham, N., J. Pizarro, B. S. Warner, B. Rosenthal, and M. D. Weist. 1998. Family involvement in expanded school mental health. Journal of School Health 68:425–428.

    DOI: 10.1111/j.1746-1561.1998.tb06322.xSave Citation »Export Citation » Share Citation »

    This article talks about the challenges of involving family members in expanded school mental health services. Particular attention is paid to the benefits of including family members in mental health services and practical techniques are discussed on how to improve involvement from family.

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  • Garbacz, S. A., K. McIntosh, J. W. Eagle, S. E. Dowd-Eagle, K. A. Hirano, and T. Ruppert. 2015. Family engagement within schoolwide positive behavioral interventions and supports. Preventing School Failure: Alternative Education for Children and Youth 60.1: 60–69.

    DOI: 10.1080/1045988X.2014.976809Save Citation »Export Citation » Share Citation »

    Discusses the significance of family engagement in positive behavioral interventions and supports and presents a comprehensive framework for doing so.

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  • Kern, L., M. P. George, and M. D. Weist. 2015. Supporting students with emotional and behavioral problems: Prevention & intervention strategies. Baltimore, MD: Paul H. Brookes.

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    A book that guides the implementation of an effective tiered approach to school and classroom-based interventions to address social, emotional, and behavioral challenges in students.

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  • Lever, N. A., S. Adelsheim, C. Prodente, et al. 2003. System, agency and stakeholder collaboration to advance mental health programs in schools. In Handbook of school mental health: Advancing practice and research. Edited by M. D. Weist, S. W. Evans, and N. A. Lever, 149–162. New York: Springer.

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    This book chapter discusses the importance of partnerships among various systems and stakeholders to advance the state of mental health in schools and provides two examples on how such collaborative relationships can be beneficial.

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Evidence-Based Practices in Multitiered Frameworks

Mental health issues continue to make headlines and have been connected to violent incidents in communities across the United States mentioned earlier. While mental health issues do not increase the risk of violence per se, the perpetrators of these violent incidents were in some level of distress. Such violent incidents have spurred increased interest in student mental health, particularly in regard to recognition and prevention of escalation of emotional/behavioral problems among students in schools (Stiffler and Dever 2015). With increased interest comes increased need for risk management and prevention. It is hoped that universal mental health screening could be one such strategy; a tool to help identify youth at risk for developing a clinical disorder before they acquire increasingly severe symptoms in hope that school and mental health professionals may help to reduce the frequency of these large-scale tragedies. As such, it is not surprising that mental health screening has become a recent topic for consideration. However, it is surprising that even with mental health concerns in the media spotlight, such screening strategies are still rarely carried out in actual practice (Romer and McIntosh 2005; Bruhn, et al. 2014). Studies such as O’Connell, et al. 2009 has shown that a range of negative outcomes may result when mental health problems are not found and treated early enough. Moffitt 1993 found that increased risk of academic failure, substance abuse, delinquency, unemployment, and even incarceration as examples of such failed early identification/intervention efforts. Thus, increased awareness and access to prevention and intervention efforts are only helpful when children and adolescents with or at-risk of developing mental health related difficulties are able to be identified as early as possible (Glover and Albers 2007). The multitiered framework is presented in Macklem 2011 as foundational to mental health services in schools in this chapter, and ideally programs and services are connected together across levels; for example, students not responding to Tier 1 efforts receive appropriate Tier 2 or Tier 3 programs and supports. However, linkage in strategy across tiers does not happen as some students may be simultaneously receiving Tier 2 and Tier 3 services, with many in need not receiving them (see Barrett, et al. 2013, cited under Positive Behavioral Interventions and Supports and Weist, et al. 2014, cited under Individuals with Disabilities Education Act). Across all three tiers, effective mental health services require active use of data and data-based decision making, which is much stronger within PBIS than SMH systems.

  • Bruhn, A. L., S. Woods-Groves, and S. Huddle. 2014. A preliminary investigation of emotional And behavioral screening practices in K-12 schools. Education and Treatment of Children 37:611–634.

    DOI: 10.1353/etc.2014.0039Save Citation »Export Citation » Share Citation »

    This study looked at 454 school or district-level administrators to examine current screening practices for children with behavioral disorders. Results indicate that only 12.6 percent of participants studied implemented school-wide screening measures. Implications for policy and future recommendations were made.

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  • Glover, T. A., and C. A. Albers. 2007. Considerations for evaluating universal screening assessments. Journal of School Psychology 45:117–135.

    DOI: 10.1016/j.jsp.2006.05.005Save Citation »Export Citation » Share Citation »

    A discussion on considerations for behavioral screeners in schools and how studying the current state of universal screening can help influence policy and practice in the future.

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  • O’Connell, M. E., T. Boat, and K. E. Warner, eds. 2009. Preventing mental, emotional and behavioral disorders among young people: Progress and possibilities. Washington, DC: National Academies Press.

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    A book that seeks to reach out to all stakeholders in mental and physical health regarding the importance of prevention and treatment of mental and behavioral disorders.

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  • Macklem, G. L. 2011. Evidence-based tier 1, tier 2, and tier 3 mental health interventions in schools. In Evidence-based school mental health services: Affect education, emotion regulation training, and cognitive behavioral therapy. Edited by G. L. Macklem, 19–38. New York: Springer.

    DOI: 10.1007/978-1-4419-7907-03Save Citation »Export Citation » Share Citation »

    This chapter reviews the three tiers of mental health interventions (Universal, Selected or Targeted, and Indicated programs) in schools.

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  • Moffitt, T. E. 1993. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review 100:674–701.

    DOI: 10.1037/0033-295X.100.4.674Save Citation »Export Citation » Share Citation »

    An article that presents a system for differing between the various forms of antisocial behavior in adolescents.

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  • Romer, D., and M. McIntosh. 2005. The roles and perspectives of school mental health professionals in promoting adolescent mental health. In Treating and preventing adolescent mental health disorders: What we know and what we don’t know. Edited by D. L. Evans, E. B. Foa, R. E. Gur, et al., 598–615. New York: Oxford Univ. Press.

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    A book chapter that explores the roles of school mental health professionals in the identification, intervention, and prevention of youth mental health disorders.

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  • Stiffler, M. C., and B. V. Dever. 2015. Mental health screening at school: Instrumentation, implementation, and critical issues. In Mental health screening at school: Instrumentation, implementation, and critical issues. Edited by R. A. Kamphaus, 77–90.

    DOI: 10.1007/978-3-319-19171-3Save Citation »Export Citation » Share Citation »

    A volume dedicated to mental health screening for youth and adolescents in schools that seeks to aid clinicians, researchers, school personnel, and other stakeholders.

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Universal Screening/Tier 1 Evidence-Based Practices

One way to ensure prevention as well as the timely identification and treatment of mental health concerns is to bring these services to the children in the schools. Generally, schools are an ideal location to carry out mental health screenings for children and adolescents as such settings ensure access to large numbers of youth and are well suited to access children and adolescents for treatment, progress monitoring, as well as follow-up care (Levitt, et al. 2007 and Glover and Albers 2007, cited under Evidence-Based Practices in Multitiered Frameworks). Schools also provide a unique opportunity to engage the children as well as other stakeholders (e.g., teachers and other school staff) who interact with them regularly and for long periods. Also, Splett, et al. 2014 has shown that having access to teachers, administrators, and other school professionals may help to provide unique insight regarding a child’s school performance, behavior, and interpersonal functioning that one would perhaps not have access to otherwise. Ideally, mental health screening in schools helps to identify student problems early and enables early intervention services for students not receiving adequate support from universal or Tier 1 programs and services (Levitt, et al. 2007). However, such screening is challenging on a number of fronts, including having the resources to adequately screen students, assuring parental permission/consent for such screening, and assuring that students are identified as showing signs of problems actually receive supportive services (Weist, et al. 2007a). In addition to screening for students who may present more intensive needs for Tier 2 or Tier 3 services, at the universal level Tier 1 programs should include a focus on assuring that schools are safe and welcoming, that bullying at any level is not tolerated and that positive relationships among students and staff are promoted (see McIntosh, et al. 2010). All of these factors help to promote a sense of connectedness to school by students, a powerful resilience factor (see Kern, et al. 2015, cited under Barriers to ISF Implementation).

  • Levitt, J. M., N. Saka, L. H. Romanelli, and K. Hoagwood. 2007. Early identification of mental health problems in schools: The status of instrumentation. Journal of School Psychology 45:163–191.

    DOI: 10.1016/j.jsp.2006.11.005Save Citation »Export Citation » Share Citation »

    A discussion of the assessment instrumentation for early mental health screening in schools. The article also provides a list of currently available instruments.

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  • McIntosh, K., K. J. Filter, J. L. Bennett, C. Ryan, and G. Sugai. 2010. Principles of sustainable prevention: Designing scale-up of school-wide positive behavior support to promote durable systems. Psychology in the Schools 47:5–21.

    DOI: 10.1002/pits.20448Save Citation »Export Citation » Share Citation »

    This article reviews School-Wide Positive Behavior Supports (SWPBS) and provides a framework for sustaining SWPBS within schools.

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  • Splett, J. W., M. Mulloy, A. Philp, and M. D. Weist. 2014. Mental health screening for school children. In School health screening systems: The complete perspective. Edited by B. McPherson and C. Driscoll, 137–161. Hong Kong: Nova Sciences.

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    An article that begins with a basic review of School-Wide Positive Behavior Supports (SWPBS) and Response to Intervention (RTI) but then delves deeper into systems of mental health screening and tools necessary for selecting proper screening tools.

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  • Weist, M. D., M. Rubin, E. Moore, S. Adelsheim, and G. Wrobel. 2007a. Mental health screening in schools. Journal of School Health 77:53–58.

    DOI: 10.1111/j.1746-1561.2007.00167.xSave Citation »Export Citation » Share Citation »

    An article that highlights the benefits of screening for emotional/behavioral problems in students and how this system can be improved through family, school, and community involvement.

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Tier 2 Evidence-Based Practices

Students who are identified as having mental health related concerns or are considered to be at-risk for various mental-health-related difficulties who do not seem to be responding to the lower level school- or classroom-wide prevention and intervention strategies are then identified and targeted for more specific intervention and/or support services. According to the National Association of School Psychologists 2016, Tier 2 interventions, also referred to as targeted services, may include small group counseling, consultation with parents and other family members, and behavior reinforcement schedules to help reduce undesirable behavior and increase targeted and desirable behaviors. National Association of School Psychologists 2016 also states that addressed concerns may include issues related to social skills, anger management, coping with symptoms related to depression, as well providing consultation and psychoeducation to parents and other family members to help address school-related and behavior concerns (e.g., bullying, conflict, behavioral monitoring and reinforcement.

  • National Association of School Psychologists. 2016. Integrated model of academic and behavioral supports. Bethesda, MD: National Association of School Psychologists.

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    Provides an overview of the National Association for School Psychologists’ position on the delivery of optimal services for youth through a multitiered system of support (MTSS) in which students’ educational needs, both academic and emotional/behavioral, are addressed on a continuum ranging from universal to more intensive, individualized services.

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Tier 3 Evidence-Based Practices

Tier 3 services are considered to be the most intensive and highest level of support and intervention services provided within the multitiered system of support. Again, when services across tiers are linked together and teams systematically evaluate student response to programs and services at each tier, Tier 3 services may be offered to a relatively small percentage of students who are unresponsive to Tier 1 or Tier 2 efforts. Tier 3 services often include psychological, psycho-educational, and/or functional behavioral assessments and related behavior intervention plans. Such services may also include individual, group, and family therapy; case management services; and in some cases, more intensive wraparound and home-based services, as documented in Splett, et al. 2013. Evans and Weist 2004 and Schaeffer, et al. 2005 describe a major challenge in delivering Tier 3 services is to assure competence of clinicians and the delivery of evidence-based practices, which are usually more labor intensive and can be difficult to deliver in the fluid environment of schools.

  • Evans, S. W., and M. D. Weist. 2004. Implementing empirically supported treatments in schools: What are we asking? Clinical Child and Family Psychology Review 7:263–267.

    DOI: 10.1007/s10567-004-6090-0Save Citation »Export Citation » Share Citation »

    This article discusses the development of empirically supported school-based treatment programs. Provides commentary on the need for such programs based on historical information, relevant research, and personal experiences.

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  • Schaeffer, C. M., E. Bruns, M. D. Weist, S. H. Stephan, J. Goldstein, and Y. Simpson. 2005. Overcoming challenges to evidence-based interventions in schools. Journal of Youth and Adolescence 34:15–22.

    DOI: 10.1007/s10964-005-1332-0Save Citation »Export Citation » Share Citation »

    A review based on the implementation of evidence-based programs (EBPs) in twenty-two Baltimore schools. The article uses this review to discuss ways to better implement EBPs and how to overcome barriers to implementation.

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  • Splett, J. W., J. Fowler, M. D. Weist, H. McDaniel, and M. Dvorsky. 2013. The critical role of school psychology in the school mental health movement. Psychology in the Schools 50:245–258.

    DOI: 10.1002/pits.21677Save Citation »Export Citation » Share Citation »

    A unique look into the role of school psychologists within the school system, specifically the role they play in school mental health services and the advancement of such prevention and intervention efforts.

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Evidence-Based Culturally Responsive Services

Another major dimension of high quality services in schools that Clauss-Ehlers, et al. 2013 discuss is their cultural responsiveness, explored recently in the context of President Obama’s Now is the Time Initiative (see US White House 2013 under Support from the United States Government), with a significant emphasis on violence prevention and effective trauma response especially for higher risk populations such as minority and ethnically diverse youth (see Weist and Cooley-Quille 2001). There is a growing array of programs to prevent and address violence and its impacts on students; for example, as found in the National Registry for Effective Programs and Practices (NREPP) sponsored by the Substance Abuse and Mental Health Services Administration. One of the programs included in NREPP is the Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Jaycox 2004). CBITS is considered a culturally sensitive evidence-based intervention involving around ten sessions delivered in small groups or individually focusing on key cognitive behavioral skills important for children and youth to recover from trauma (e.g., relaxation, cognitive coping, exposure). However, an additional challenge for program developers, administrators, and practitioners in SMH programs is it is often hard to discern whether a particular evidence-based program as found in NREPP has been evaluated through the lens of appropriateness for particular cultural/ethnic groups. The implication put forth by Clauss-Ehlers, et al. 2013 is that programs will be implemented for different cultural/ethnic groups based on a presumption that they will be effective, with considerable needs for enhanced research in this area to document the same.

  • Clauss-Ehlers, C., Z. Serpell, and M. D. Weist. 2013. Making the case for culturally responsive school mental health. In Handbook of culturally responsive school mental health: Advancing research, training, practice, and policy. Edited by C. Clauss-Ehlers, S. Serpell, and M. Weist, 3–16. New York: Springer.

    DOI: 10.1007/978-1-4614-4948-5_1Save Citation »Export Citation » Share Citation »

    This introduction chapter discusses the need for evidenced-based practices to be delivered in the school systems. This section makes the case for why school-based programs are of particular benefit to children in need of mental health care.

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  • Jaycox, L. 2004. CBITS: Cognitive behavioral intervention for trauma in schools. Longmont, CO: Sopris.

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    A manual that describes how to implement an evidence-based practice to help reduce symptoms of trauma in school-aged children. The manual provides guidelines for individual and group therapy as well as useful information to educate teachers and parents.

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  • Weist, M. D., and M. Cooley-Quille. 2001. Advancing efforts to address youth violence involvement. Journal of Clinical Child Psychology 30:147–151.

    DOI: 10.1207/S15374424JCCP3002_2Save Citation »Export Citation » Share Citation »

    An introduction article on youth-related violence and how it affects behaviors and problems within schools. The article then goes on to discuss ways to advance this research base and also looks at current resources and efforts made to address this issue.

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Future Directions in School Mental Health

Given the clearly identified need for school mental health services (see Merikangas, et al. 2011 under General Overview and Rones and Hoagwood 2000) and federal support for the same (see US White House 2013, cited under Support from the United States Government), it would stand to reason that the establishment of local policies to bolster these programs would be a priority. However, related to the emphasis on states’ rights and local control, connections between schools and mental health centers to strengthen SMH are highly variable and often ad hoc (see Barrett, et al. 2013 under Positive Behavioral Interventions and Supports). This varied approach to SMH can be particularly problematic since DeLeon, et al. 2003 described how children and youth in many communities do not have access to any quality, accessible mental health care. These inconsistencies call for broader and more standardized policy support for SMH at local levels, as before reflecting a “shared agenda” of youth/families, schools, mental health agencies and other youth serving systems working together to expand and improve the consistency, depth and quality of programs and services (see Weist and Murray 2007 cited under General Overview). Although there is evidence for movement in this direction in some US states (e.g., Maryland, New Hampshire, South Carolina) and in other countries (e.g., Ontario, Canada), presently there is no national or international system for tracking policy and practice development of SMH within jurisdictions such as states or provinces, a clear need for improving policy, research, and practice. While the evaluation of the impact of SMH programs on academic outcomes is associated with a range of methodological challenges that Daly, et al. 2014 documents, there is more support for these programs for positively impacting emotional/behavioral (see Rones and Hoagwood 2000 for more details) and on psychosocial outcomes (see Guzman, et al. 2015). Improving the effectiveness of education by reducing and removing barriers to student learning by proactively preventing, intervening early, and responding to emotional/behavioral challenges in students is the essential task of mental health services in schools and these data underscore their critical importance. Further, SMH programs are being developed around the world, with strength in many nations, including Australia, Canada, Europe, and in other nations (Weist, et al. 2017). There is a need to strengthen global collaboration in the field; for example, as being promoted through the School Mental Health International Leadership Exchange (see Weist, et al. 2017).

  • Daly, B. P., M. A. Sander, E. G. Nicholls, A. Medhanie, E. Vanden Berk, and J. Johnson. 2014. Three-year longitudinal study of school behavior and academic outcomes: Results from a comprehensive expanded school mental health program. Advances in School Mental Health Promotion 7:24–41.

    DOI: 10.1080/1754730X.2013.867712Save Citation »Export Citation » Share Citation »

    This longitudinal study looked at long-term academic and school behavior variables in response to participation in an expanded school mental health program. Particular attention is paid to theoretical and methodological challenges associated with evaluated school mental health programs, with future research implications being discussed.

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  • DeLeon, P. H., M. Wakefield, and K. J. Hagglund. 2003. The behavioral health care needs of rural communities. Washington, DC: American Psychological Association.

    DOI: 10.1037/10489-001Save Citation »Export Citation » Share Citation »

    This book chapter reviews policy and history of health care in rural areas, with particular attention to current issues surrounding implementation of services in rural locations. The chapter stresses the need for providers of different backgrounds to come together to adequately serve people with mental health needs.

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  • Guzman, J., R. C. Kessler, A. M. Squicciarini, et al. 2015. Evidence for the effectiveness of a national school-based mental health program in Chile. Journal of the American Academy of Child and Adolescent Psychiatry 54:799–807.

    DOI: 10.1016/j.jaac.2015.07.005Save Citation »Export Citation » Share Citation »

    A large-scale study conducted in Chilean elementary schools to determine the effects of the school-based mental health program, Skills for Life (SFL). Results show that early intervention in schooling can lead to significant improvements on both academic and behavioral outcomes.

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  • Rones, M., and K. Hoagwood. 2000. School-based mental health services: A research review. Clinical Child and Family Psychology Review 3.4: 223–241.

    DOI: 10.1023/A:1026425104386Save Citation »Export Citation » Share Citation »

    A general review of various school-based mental health programs and how lessons learned from these programs can be used to impact directions for future research.

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  • Weist, M. D., E. Bruns, K. Whitaker, et al. 2017. School mental health promotion and intervention: Experiences from four nations. School Psychology International 38.4: 343–362.

    DOI: 10.1177/0143034317695379Save Citation »Export Citation » Share Citation »

    Provides background to the global school mental health movement, and more intensively describes experiences in four nations—Canada, Liberia, Norway, and the United States. Discusses the need for increased global collaboration in developing school mental health and increasing support to developing nations such as Liberia.

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