Building Strong Partnerships: Education and Mental Health Systems Working Together to Advance Behavioral Health Screening in Schools

Summary

In this article, we have introduced a key challenge confronting the fields of education and mental health: the need for early detection of EBDs among students and a framework for early response to their needs. Next, we offered a potential solution: prioritizing strong, integrated partnerships between education and mental health systems. Following this discussion, we provided two illustrations (1) teacher-completed behavior screening within a Ci3T model of prevention in an elementary school setting and (2) student self-reported mental health screening in the high school setting. The differences in the screening measures used in the two illustrations are important. The first illustrates universal behavior screening conducted as part of regular school practices to inform instruction. Teacher-completed screeners are based on observed student behaviors, with screening as a way to measure and monitor teachers’ observations. The second illustrates the use of mental health screening (student self-report). Additional protections for self-report measures must be afforded, such as parent/guardian permission and opt-out options as discussed in the high school illustration.

Finally, we have offered a call to action, posing considerations for next steps for researchers, practitioners, and policymakers. We hope this concluding article in the four-issue 2017 volume of the Report on Emotional & Behavioral Disorders in Youth will help to propel improvements in research, practice, and policy of the foundational issue of early identification of students in need of successful school behavioral health programs.

Behavioral Challenges in Students

Students with emotional and behavioral disorders (EBDs) include a large and diverse group of children and youth who have a range of externalizing (e.g., aggressive, noncompliant) and internalizing (e.g., anxious, withdrawn) behaviors. Externalizing behaviors are often easily detected in the school setting given that the overt nature of these behaviors frequently disrupts the learning environment and impedes instruction (Lane & Walker, 2015). In contrast, internalizing behaviors are less often recognized—at least initially—because the covert nature of these behaviors rarely impedes the learning environment until the characteristic behaviors become quite severe (McIntosh et al., 2014). Inquiries by Achenbach (1991) and Willner, Gatzke-Kopp, and Bray (2016), suggest students frequently have co-occurring behavioral challenges in both domains. These students suffer from both externalizing and internalizing behavior challenges and demonstrate the greatest need for intervention or support.

Left unchecked, these behavioral challenges result in a range of difficulties for students, their teachers, their families, and society as a whole. Descriptive studies have demonstrated students with and at risk for EBDs experience a host of negative outcomes, such as peer rejection, impaired interpersonal relationships, academic underachievement, limited school engagement, unemployment and underemployment, and high need for mental health supports (Wagner & Newman, 2015).

Although many individuals erroneously conclude that students with EBDs will access special education services under the emotional disturbance (ED) category, the Individuals with Disabilities Education Improvement Act (IDEA, 2004) suggests this is most often not the case. Forness and colleagues (2012) report 20% of school-age youth experience mild to severe EBDs and 12% of students exhibit moderate to severe challenges. Moreover, evidence suggests the majority of adults with EBDs experienced characteristic behaviors during their school years (Merikangas et al., 2010).

Considering fewer than 1% of school-age students receive special education services under the ED category, the general education community must be prepared to support the behavioral and mental health needs of the majority of students with EBDs. Yet, studies of teachers’ experiences suggest general education teachers feel less than optimally prepared to effectively support students with EBDs. Teachers indicate their teacher preparation experiences did not sufficiently empower them with the skill sets needed to meet students’ behavioral and social-emotional needs (Greenberg et al., 2014). In fact, the absence of adequate classroom management skills is one of the main reasons teachers leave the field.

Yet, studies of teachers’ experiences suggest general education teachers feel less than optimally prepared to effectively support students with EBDs.

There have also been concerns about the lack of connections between school and mental health systems, leaving well-intentioned individuals struggling to meet students’ academic, behavioral, and social-emotional needs. Many individuals are seeking a framework for providing students with the full scope of supports needed within effective and efficient partnerships between educational and mental health professionals (Santiago et al., 2014). Essential to this framework is the use of systematic tools to feasibly and accurately detect students with externalizing and internalizing behavioral challenges. School leaders are responding to this need (Oakes et al., forthcoming).

Moreover, many national and state leaders have recognized the importance of meeting students’ mental health needs. For example, in 2014, Michael Yudin offered a compelling keynote address at the Positive Behavior Intervention and Support Implementer’s Forum, in which he urged all educators to place as much priority on students’ behavioral and social skills as they put on academic skills. Kansas Commissioner of Education Randy Watson (2015), called for a similar emphasis on “soft skills” following a one-year listening tour across the state during which he learned from employers that students graduating from K-12 schools lacked the requisite soft skills to excel in employment. Given that lifetime mental health challenges begin during students’ school years (Merikangas et al., 2010), it is encouraging to see schools prioritize graduating students with a comprehensive set of skills, empowering them to succeed academically, behaviorally, and socially. These developments indicate we are well positioned to build strong partnerships between education and mental health systems to advance behavioral health screening in schools and that these efforts are being guided by the full range of stakeholders with interests in this critical work, especially youth and families contending with EBDs Weist et al., 2017).

In this article, we introduce a key challenge confronting the fields of education and mental health: the need for early detection. We also offer a potential solution: prioritizing strong, integrated partnerships between education and mental health systems (Weist et al., 2014). We offer two examples of behavioral health screening in schools. The first involves teacher-completed screenings within a Comprehensive, Integrated, Three-Tiered (Ci3T) model of prevention at the elementary level; the second involves self-reported measures of anxiety and depression by high school students. We close the discussion with a call to action and considerations for next steps for researchers, practitioners, and policymakers.

The Challenge: A Need for Early Detection

Given the breadth of externalizing and internalizing behavior patterns, the magnitude of these challenges for school-age youth, and the long-term negative outcomes associated with these disorders, early detection is critical. Negative behavior patterns (e.g., persistent negative thoughts, aggression) are more amenable to intervention before they have become ingrained through years of practice (Walker, Forness & Lane, 2014).

When selecting a screening tool, it is important to choose a tool with established reliability and validity to accurately detect students with and at risk for both externalizing and internalizing disorders.

Early detection is a core feature of prevention frameworks, and “early” means more than just early in a students’ educational career (e.g., preschool and kindergarten). “Early” also means early in the onset of the behavioral concern (Lane et al., 2013). For example, rather than waiting for aggressive behaviors to emerge and then responding with evidence-based practices such as functional assessment-based interventions (FABI; Umbreit et al., 2007), one could focus on detecting precursors to aggression such as noncompliance or peer rejection (Farmer et al., 2015; Moore et al., 2017). Such behaviors may emerge for the first time in early childhood or as students are transitioning from the elementary to middle school years. This transition, as well as the transition to high school, can be challenging for even the most talented students as curricula become more precise, social standing and peer acceptance become more prominent concerns, and expectations across classrooms and school settings become more varied (Farmer et al., 2015). Thus, “early” detection refers not only to early in a student’s school experience, but also to the early stages of a student’s manifestation of behavioral challenges.

Fortunately, a number of systematic screening tools are now available for use across the PK-12 grade span. Some of these are:

• Behavior Assessment System for Children, 3rd Edition: Behavioral & Emotional Screening System (BASC-3: BESS; Kamphaus & Reynolds, 2015);

• Social, Academic, and Emotional Behavior Risk Screener© (SAEBRS; Kilgus et al., 2013);

• Social Skills Improvement System–Performance Screening Guide (SSiS-PSG; Elliott & Gresham, 2008a);

• Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001);

• Student Risk Screening Scale (SRSS; Drummond, 1994);

• Student Risk Screening Scale–Internalizing and Externalizing (SRSS-IE; Drummond, 1994; Lane & Menzies, 2009); and

• Systematic Screening for Behavior Disorders (SSBD; Walker, Severson & Feil, 2014).

These screening tools provide a range of behavioral health screening options and capabilities, including some free-access tools (e.g., SDQ, SRSS, and SRSS-IE) to ensure all schools have a screening option while being fiscally responsible (Lane, Oakes, et al., 2017). When selecting a screening tool, it is important to choose a tool with established reliability and validity to accurately detect students with and at risk for both externalizing and internalizing disorders. We encourage decision makers to carefully review the evidence for each tool’s psychometric properties to ensure an appropriate selection for the population of interest. All tools have some degree of measurement error, namely, false positives (saying a student has a concern such as internalizing behaviors, when in reality they do not) and false negatives (saying a student does not have a concern, when in reality they do have the concern of interest). In prevention efforts, a false positive is preferred to avoid overlooking a student in need of assistance, and this “screening in” results in additional support and/or supplemental instruction (e.g., self-monitoring, cognitive restructuring; Vannest, Reynolds, & Kamphaus, 2015).

We emphasize that it is also important to select a tool feasible for use within a district, with attention to access to high-quality professional learning to support all stakeholders in understanding the rationale as well as the logistics for conducting systematic screenings. We encourage the interested reader to see Oakes et al. (forthcoming) to learn more about the screening tools available to detect social, emotional, and behavioral concerns in students as well as the practical considerations and recommendations for selecting and installing such systematic screening tools.

In the first illustration that follows, we focus on teacher-completed screening procedures. Teachers completed the selected screening tool for all students in their assigned class three times a year: in the fall, winter, and spring. Screenings were conducted as part of regularly scheduled faculty meetings so as not to encumber instructional or planning time. Unlike academic screening tools, teacher-completed behavior screening tools do not require any time with students to administer. Teachers independently complete these brief screenings following specified procedures and then use the composite scores in conjunction with other data collected as part of regular school practices (e.g., academic screening scores, attendance, office discipline referrals [ODRs]) to inform instruction. For example, these data can be used to examine the overall level of student risk in a school building, inform the use of low-intensity teacher-delivered supports (e.g., instructional choice), and connect students with relevant strategies, practices, and programs should primary prevention efforts be insufficient for meeting a student’s multiple needs (Lane, Oakes, Ennis & Hirsh, 2014).

Data from screening tools can be used to facilitate communication among a range of individuals committed to supporting students’ academic, behavioral, and social-emotional health (Lane et al., 2012). This helps to address the challenge of wide-ranging terminologies and definitions among education, research, and mental health communities that have served to impede communication between professionals, as well as to increase barriers for students to receive needed supports (Weist et al., 2012).

Fortunately, many school systems across the country are emphasizing behavioral and social-emotional competencies in addition to academic competencies (Lane, Oakes, Menzies & Germer, 2014; Weist et al., 2014). To this end, they are constructing tiered systems to provide a graduated continuum of supports that include primary (Tier 1) prevention efforts for all, secondary (Tier 2) prevention efforts for some, and tertiary (Tier 3) prevention efforts for a few. Ideally, each level of prevention is composed of evidence-based practices (Cook & Tankersley, 2013), with movement between the levels determined by data-informed decision making.

There is a wide variety of tiered systems, such as Response to Intervention (RTI; Fuchs et al., 2010) emphasizing academic performance and Positive Behavioral Interventions and Supports (PBIS; Horner & Sugai, 2015). More recently, an emphasis has been placed on developing systems with integrated approaches such as:

• Multi-Tiered Systems of Support (MTSS; McIntosh & Goodman, 2015);

• The Interconnected Systems Framework (ISF; Barrett et al., 2013); and

• Comprehensive, Integrated, Three-Tiered models (Ci3T; Lane et al., 2010; integrating academic, behavioral, and social domains).

Illustration 1: Teacher-Completed Systematic Screening Within Ci3T Models

Ci3T models provide a framework designed to meet students’ academic, behavioral, and social skill needs and to support strong, positive productive partnerships between education and mental health communities. As part of Tier 1 efforts in the social domain, all students have access to primary prevention efforts targeting social and emotional learning. During the Ci3T design process, school-site Ci3T leadership teams and district-level decision makers collaborate to select a validated curriculum to install at Tier 1 (primary prevention) along with validated strategies and practices at Tier 2 and Tier 3 to assist students requiring more than primary prevention efforts. Ci3T models have been designed, implemented, and evaluated in a number of districts for 20 years, with initial development in California to system-wide implementation in a number of districts in Alabama, Kansas, Missouri, Tennessee, and Vermont.

As part of a practitioner-researcher partnership grant funded by the Institute of Education Sciences (IES), Ci3T is currently being implemented districtwide in a medium-size district in the Midwest. Specifically, elementary schools (ES; n = 14) designed Ci3T models in the 2013–2014 academic year; traditional middle schools (MS; n = 4) and high schools (HS; n = 2) designed models in 2014–2015; and the College and Career Center designed a model in 2015–2016. At the launch of this practitioner-researcher partnership, all 20 PK-12 schools were in the first or second year of implementing Ci3T models in 2015–2016, and the College and Career Center was preparing for year one implementation.

As part of their design and implementation processes, school-site Ci3T leadership teams and district decision makers selected a validated curriculum to support students’ social and emotional development according to school board and community priorities.

At this time, all schools are implementing Tier 1 practices according to their individual Ci3T plans with many common district-guided elements. For example, all schools have:

1. Established leadership teams with district representatives;

2. Clearly defined roles and responsibilities for stakeholders;

3. Clearly defined expectations, a system for teaching them, and a uniform system for providing reinforcement;

4. Procedures for monitoring using district-level systems for implementing academic and behavior screenings;

5. A system for responding to student needs at Tiers 2 and 3;

6. Regular communication from the district partner leadership team and principal leaders; and

7. Professional development for Ci3T leadership teams and faculty and staff district wide.

As part of their design and implementation processes, school-site Ci3T leadership teams and district decision makers selected a validated curriculum to support students’ social and emotional development according to school board and community priorities. The decision-making process occurred in two phases: first, for elementary students, and then, for middle and high school students for year one Ci3T implementation. In the next section, we offer an illustration of Ci3T in action at the elementary level.

In our partnership work, elementary Ci3T leadership teams engaged in a systematic process for selecting a behavior screening tool and Tier 1 social skills curriculum. The process followed similar steps:

1. Team review of options and a short list of recommendations;

2. Review of published evidence of tools and curricula for evidence to support their intended use and expected outcomes;

3. Discussion by district and school leaders;

4. Examination of materials and structures for implementation; and

5. Adequacy of resources to support implementation.

The selection of a social skills curriculum followed a process by which Ci3T leadership teams first reviewed information from the What Works Clearinghouse (WWC; U.S. Department of Education), the National Registry of Effective Programs and Practices (NREPP) of the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Collaborative for Academic, Social, and Emotional Learning (CASEL) to identify effective—and feasible—social-emotional curricula. Next, each team provided its district decision makers with a list of its top three curricula for further review. The compiled list was shared with the district leadership team and the principal leadership team, who conducted additional research by reviewing publisher websites, reviewing articles of treatment-outcome studies published in refereed journals, and contacting publishers to access and review sample curricular materials. The curricula were listed in order based on their meeting of the priorities and needs of the district students, evidence for effectiveness, and feasibility given district resources. The top two curricula were made available to school counselors, teachers, and Ci3T leadership team members (which included one parent on each team) for review. Then, in the spring of their designing year, a decision was made to adopt and install Positive Action (2008) at Tier 1 the following fall. Positive Action is a social-emotional learning program developed for students in elementary and middle schools and has been shown to improve school climate as well as to improve student behavior. A classroom-based curriculum (which includes teacher-and counselor-taught lessons) teaches social and self-management skills, with universal support of program implementation school-wide (Flay & Allred, 2003).

To support installation, district leaders offered multiple professional learning opportunities to prepare teachers for fall implementation. First, they allowed each Ci3T leadership team to establish its own implementation schedule, providing district-guided expectations for implementation (e.g., school-wide instruction by teachers and school counselors, a minimum number of teacher-taught and counselor-taught lessons, pacing to provide year-long instruction). Second, they secured a complete Positive Action curriculum with a kit for each teacher and counselor to ensure intervention agents had the full scope of materials needed for instruction. Third, they created optional professional learning sessions prior to and during summer break, followed by a required elementary-wide professional learning session a few days before students returned. Those responsible for teaching the curriculum could attend any or all opportunities, but they were required to attend at least one professional learning session.

To ensure high-fidelity implementation and a coordinated effort for all behavioral and mental health supports, the district invested in a new position, a mental health facilitator. The mental health facilitator supported implementation by developing structures to monitor treatment integrity, meeting regularly with counselors assigned to each building, and providing ongoing professional learning in suicide prevention, crisis training, trauma-informed practices, and social skills instruction. The professional learning provided an understanding of the “why” for school-wide implementation and created structures to support equitable, transparent access to Tier 2 and Tier 3 supports for students requiring more than primary prevention efforts. For example, during the third year of implementation, four elementary schools partnered with university collaborators to install and test the efficacy and social validity of two Tier 2 social skills interventions using a validated curriculum: the Positive Action and Social Skills Improvement Systems–Intervention Guide (SSiS-IG; Elliott & Gresham, 2008b; see Figure 1 for one intervention grid; Lane, Common, et al., 2017).

Figure 1:

Sample Elementary School Comprehensive Integrated Three-Tiered (Ci3T) Model of Prevention Intervention Grid

During the same time, the mental health facilitator collaborated with community mental health providers to create transparent access for Tier 3 supports. As part of their initial conversation, community health providers learned about the Ci3T models in place at each school so they could understand the Tier 1 experience for all students and be able to incorporate common language systems to program for generalization. The goal was three-fold, to:

1. Ensure students are exposed to primary prevention efforts through the use of validated social skills curricula to prevent challenges from occurring;

2. Create opportunities within the school day to support students who have soft signs for externalizing and internalizing behaviors; and

3. Establish strong partnerships with community-based mental health providers available for offering Tier 3 supports for students with intensive intervention needs in social-emotional learning.

For these most intensive intervention efforts, it is important for schools, community providers, and families to partner closely with a carefully constructed plan for assisting students who require community-based supports.

As illustrated in the Tier 2 intervention grid (see Figure 1), systematic screening plays a key role in the early detection of who may need these tiered supports. Namely, systematic screening data are used in conjunction with other data collected as part of regular school practices to connect students to relevant Tier 2 and Tier 3 supports. We emphasize that screening data also provide important information about the overall level of risk for all students in a school for monitoring the intended effects of Tier 1 prevention and that the data inform teachers’ use of low-intensity supports to facilitate engagement and minimize the occurrence of challenging behaviors (Lane et al., 2016). For example, in each elementary school, following each behavior screening window, Ci3T leadership teams reviewed the percentage of students whose scores indicated low, moderate, and high risk for externalizing and internalizing behavior challenges for the school as a whole as well as for each grade level. These data were analyzed with treatment integrity data to determine (1) if Tier 1 efforts were in place as planned and (2) how students were responding to primary prevention efforts.

Ci3T leadership teams also encouraged their teachers to review screening data for their class as a whole. If the percentage of students in their class at moderate or high risk exceeded 20%, the teachers selected and implemented low-intensity supports (e.g., increased opportunities to respond). If these low-intensity, teacher-delivered supports were insufficient, students requiring additional assistance were connected to Tier 2 or Tier 3 supports according to individual needs.

By designing and implementing Ci3T models, schools prioritize healthy academic, behavioral, and social-emotional development for all learners. Schools’ Ci3T implementation manuals make transparent roles and responsibilities, expectations, procedures for teaching, reinforcing, and monitoring, and Tier 2 and Tier 3 supports. These transparencies facilitate communication among all stakeholders: teachers, counselors, administrators, parents, community mental health staff, and community members. The intended outcome is to support the social, emotional, behavioral and academic well-being of all students, including those with EBDs.

Illustration 2: Districtwide Mental Health Screening in a Mid-Sized Urban School District

Methuen Public Schools (permission was obtained to share the name of the district; Crocker, personal communication, 2017) is a district located approximately 30 miles north of Boston, Massachusetts. The district serves approximately 700 students across four K-8 grammar schools and one high school of approximately 2,000 students. The district’s focus on school mental health has dramatically increased over the past two years, owing in large part to its selection to participate in the University of Maryland’s Center for School Mental Health (CSMH) School Mental Health Collaborative for Improvement and Innovation Network (CoIIN). Through its participation in the CoIIN, the district has sought to adopt the CSMH’s School Mental Health National Performance Measures and to establish a Comprehensive School Mental Health System (CSMHS). The impetus to implement mental health screening in Methuen stemmed from the district’s self-assessment during the initial phase of the CoIIN work that no formal method of collecting, analyzing, or utilizing psychosocial data existed and that this lack posed a considerable barrier to improving the quality and sustainability of Methuen’s CSMHS. The mental health team identified the high school as the pilot site for conducting mental health screening after considering the information gained through needs assessments and counseling logs, which indicated mental health concerns were most prevalent in grades 9 through 12. Additionally, logistical considerations, such as availability of technology and number of available mental health staff members at the high school factored into the decision as well. The team also decided that introducing mental health screening to an older population at the outset of the pilot, as opposed to students in the grammar or middle schools, would serve to normalize the idea of mental health screening in a manner that was less threatening to the larger population in Methuen.

By designing and implementing Ci3T models, schools prioritize healthy academic, behavioral, and social-emotional development for all learners.

A number of questions arose as the district mental health team began planning to pilot mental health screening. Associated costs, consent, selection of tools, method of administration, staff readiness, and the ways in which collected data would be used were all considerations that needed to be addressed prior to making mental health screening a reality. For this reason, the district started small and began rapidly testing at the micro-level to ensure that practices and resources could be vetted using a quality improvement approach prior to scaling up implementation. Plan-Do-Study-Act cycles were completed regularly to assess the efficacy of new practices and to evaluate next steps for implementation (Associates in Process Improvement, 2017).

Individual students were screened after securing consent from their guardians as part of the first phase of testing mental health screening. As mental health staff reported back their findings, questions related to the utility of the data gathered were posed, including how the collection of psychosocial data could inform progress monitoring efforts, serve as a measure of the effectiveness of interventions, and, when aggregated, serve as an ongoing mental health needs assessment. It became apparent early on that the collection of psychosocial data had various meaningful applications that supported the decision to begin scaling up to groups of students and, eventually, to whole grade levels.

As the practice of screening students scaled up, preparing for the first large administration became a focus. Selecting the specific screening tool and the means of administering the screening were identified as priorities, and the team also considered the degree to which staff were prepared to provide follow-up services to students who scored in the moderate and severe ranges on the measures used. At this phase of implementation, a number of key practice and policy implications were adopted that have been identified as having a significant impact on the quality and sustainability of the screening program in Methuen.

Methuen Public Schools sought to use only free assessments in the public domain when designing the mental health screening program in order to ensure that sustainability of the program would not be affected by fluctuations in the local budget. The district dedicated time and staffing to ensure that the practice of mental health screening was implemented successfully; however, it is worth noting that there is no dollar cost associated with sustaining this practice in the future. Neither the assessments used nor the means of administering them have associated costs that are contingent on the local budget.

Through an analysis of needs assessments that were conducted in the 2013–2014 and 2014–2015 school years, measures were selected that matched the student population’s reported areas of greatest need. Unsurprisingly, anxiety and depression were identified as the top areas of concern reported by students and mental health staff, and this finding led to the selection of measures that focused on these two presenting concerns. The decision to use more targeted measures also supported the belief that by using multiple measures across several screenings, a robust dataset could be compiled that would lend itself to a richer and more comprehensive understanding of the needs of the students in Methuen.

Because fewer than 1% of parents/guardians have opted out of mental health screening, the mental health team has been able to proactively screen the vast majority of the adolescent student population in Methuen.

For the first large-scale administration, the mental health team selected a measure that focuses on symptoms of generalized anxiety disorder (GAD-7; Patient Health Questionnaire [PHQ] Screeners, 2017a). Because school mental health had become a much greater topic of conversation in the recent past when screening was being implemented, the team decided to select a targeted measure that focused on a presenting problem that would leverage the greatest amount of support from the parent, student, and larger community and that would broach the issue of mental health screening in schools in a manner that would not trigger concerns. The idea of directly addressing and openly discussing school mental health was still a relatively novel concept for a large percentage of the population in Methuen. The mental health team thus took steps toward normalizing the idea of mental health screening in a manner that was safe for the larger population and that would serve as a foundation for future expansion of the type and frequency of screenings.

Securing consent to administer student-completed mental health screening in schools is a major consideration for any district considering implementing this practice. During the initial phase of implementation in which select students were identified for pilot screening, active consent was secured from the students’ parents/guardians. As the first large-scale administration was being planned, the mental health team decided to adopt a passive consent, or opt-out, procedure. This practice involved notifying all parents/guardians in the district that mental health screening would be taking place and creating a process that would provide them with the opportunity to opt out of mental health screening.

A message was developed that described the purpose and intent of implementing mental health screening in Methuen, as well as procedures for accessing the opt-out form on the district’s webpage and other methods for opting out one’s son/daughter. The statement read as follows (Methuen Public Schools, 2017):

In an effort to promote the health and well-being of students in Methuen Public Schools, students will be periodically provided with questionnaires, surveys, and screeners that address issues related to mental health. The information gained will support the school’s ability to provide comprehensive and timely support for your son or daughter if they require any assistance. Students can optout of filling out any questionnaire, survey, or screener that they are not interested in taking and you can optout your son or daughter at any time by contacting the Guidance Office of your son’s/daughter’s school or filling out the opt-out form here. A list of the questionnaires, surveys, and screeners is available below for you to review. We are committed to ensuring your son or daughter is supported academically, socially, and emotionally, and we look forward to partnering with each of you toward achieving this goal.

The opt-out procedures that were established constitute a major success of Methuen’s screening program. Because fewer than 1% of parents/guardians have opted out of mental health screening, the mental health team has been able to pro-actively screen the vast majority of the adolescent student population in Methuen. As an added measure to ensure buy-in from the larger community and account for student input, prior to the administration of all screenings, a slightly adapted message is read to students, which indicates students may opt out of completing any screeners that they are uncomfortable taking.

One practice adopted early on and piloted for the first large-scale screening was the use of computer-based administration for screening. This practice constituted one of the greatest innovations associated with implementation of mental health screening in Methuen because it served to establish an efficient system for the administration of screening, collection of data, and identification of students who required follow-up. Methuen High School has made a significant investment in technology in recent years, the hallmark of which is the issuing of iPads to all students at the high school. During the high school advisory block, the adapted opt-out message was read to students, and they were then given an opportunity to complete the screener on their school-issued iPad.

Owing to the use of computer-based administration, data were readily accessible to mental health staff immediately following the screenings. Student responses populated a secure data sheet that could be filtered by score to produce a referral list for mental health staff to use in order to conduct follow-up clinical interviews. The need to hand-score screeners, organize the results, and generate a referral list has traditionally posed a significant barrier to scaling up this practice in many districts; however, the use of computer-based screening allowed for a coordinated follow-up to be conducted with identified students approximately 20 minutes following the screening administration. Additionally, collecting data in this manner allowed the mental health team to quickly aggregate results to assess the needs of the larger population.

Follow-up and response are of primary importance when considering a district’s readiness to engage in mental health screening (Weist et al., 2007). Therefore, it is imperative to determine whether or not the school has the mental health staffing not only to administer screenings, but also to conduct follow-up interviews and provide services to students who are identified. Implementation of mental health screening is not recommended if a school lacks the capacity to respond to identified students’ needs. It is inadvisable and highly questionable from an ethical standpoint to screen for the sake of screening or as a means of solely collecting data.

Professional development was provided to the mental health staff in Methuen in preparation for and throughout the process of scaling up mental health screening. Additionally, procedural manuals were developed that outlined best practices related to conducting a clinical interview, interpreting screening results, and referring students for therapeutic services. The readiness of the staff allowed for the adherence to follow-up procedures that were established at the outset of the planning phase. All students who scored in the moderate to severe ranges received follow-up by a mental health staff member within 72 hours. As screening scaled up and other measures were used that contained questions related to suicidal ideation, the corresponding window of time for follow-up was significantly reduced, resulting in students who indicated any level of self-harm or suicidal ideation receiving follow-up on the same day as the screening. Additionally, as a proactive measure, local mental health agency partners were alerted in advance of the screenings to ensure they were prepared to manage a potential uptick in referrals for evaluation following the screenings.

Aside from the obvious use of screening data to identify students who may require services, mental health screening supports a number of other important features of a healthy and well-functioning CSMHS. Individual results serve as a baseline for ongoing progress monitoring, which is conducted using the same tools that are used for the screenings. In this manner, the psychosocial functioning of students and the effectiveness of the therapeutic interventions provided are continually being assessed, which improves the quality of the services provided and adds a layer of accountability to the system. As previously discussed, aggregated results serve as an ongoing needs assessment to determine which Tier 2 and Tier 3 interventions would best serve the needs of the student population.

Data from each screening yielded important information about the prevalence of mental health concerns in Methuen. The first large-scale screening was conducted in January of the 2015–2016 school year and used the GAD-7 anxiety screener, a widely used measure in the public domain with adequate psychometric properties (Spitzer et al., 2006). Of the students screened (N = 839), approximately 22.5% scored in the moderate to severe ranges for anxiety. These findings supported not only the identification of specific students who would require mental health services and supports, but also a larger understanding of the population’s needs and an underscoring of the importance of designing and implementing interventions that would directly address the prevalence of anxiety in schools.

The success of the first large-scale screening prompted the mental health team to scale up this practice to include additional measures, including the PHQ-9 (PHQ Screeners, 2017), a screener that focuses on symptoms of depression, and the Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001; Youth in Mind, 2017), a global scale that yields a total difficulties score and a number of subscales that are focused on specific problem areas (e.g., hyperactivity and peer problems), with both measures also having adequate psychometric properties. The first screening using the PHQ-9 underscored the degree to which depression was also a considerable concern in Methuen. Of the 852 students who completed the PHQ-9 in April 2016, approximately 20% scored in the moderate to severe ranges for depression.

Plans for administering mental health screening in the 2016–2017 school year included replicating the previous two screenings and adding a third administration using the SDQ. In October 2016, students completed the SDQ, with 12.5% (N = 1,344) of students scoring in the high or very high range on total difficulties. Following that screening, students were administered the PHQ-9 in November 2016, resulting in a larger sample (N = 1,135) completing the screening and approximately 16% of students scoring in the moderate to severe range for depression. Finally, the GAD-7 was administered in January 2017. A sample of 943 students was screened, with 18.5% of students scoring in the moderate to severe ranges for anxiety (Table 1).

Table 1:

Summary of Elevated Mental Health Screening Scores by Administration

Screening Measure	Screening Date	N	% of Students in the Moderate or Severe Ranges
Generalized Anxiety Disorder (GAD-7)	Jan. 2016	839	22.53
Patient Health Questionnaire (PHQ-9)	Apr. 2016	852	20.07
Strengths and Difficulties Questionnaire (SDQ)	Oct. 2016	1,344	12.73
Patient Health Questionnaire (PHQ-9)	Nov. 2016	1,135	16.04
Generalized Anxiety Disorder (GAD-7)	Jan. 2017	943	18.56

Note: The Moderate and Severe score ranges for each measure are as follows: GAD-7: Moderate (10–14) and Severe (15–21); PHQ-9: Moderate (10–14), Moderately Severe (15–19), and Severe (20–27); SDQ: High (18–19) and Very High (20–40).

School staff reached out to all of the above students with identified anxiety and/or depression concerns and connected them, as appropriate, with treatment services matched to the intensity of presenting needs. Without these data, the degree to which a district can document and report on the impact of the therapeutic interventions being offered is limited, and the level of need of the student population is difficult to ascertain. Through the adoption of practices that generate psychosocial data, the ability to generate a data-rich accountability system for the CSMHS has become a reality. Progress monitoring data related to students receiving Tier 2 and 3 supports is used to highlight the efficacy of therapeutic interventions offered, and aggregated data gathered at key points throughout the year show how the level of need of the larger student population changes as a function of the services offered through the tiered system of mental health.

A Call to Action: Considerations for Next Steps

As we move forward with the goal of prioritizing strong, integrated partnerships between education and mental health systems, we offer the following considerations for implementing districtwide screening and response systems using tiered systems such as Ci3T models of prevention as a framework to structure and facilitate service delivery within these partnerships. We respectfully offer the following considerations for research, practice, and policy.

Research

• Design, test, and install free-access and low-cost screening tools that are reliable, valid, and feasible for use in detecting preschool through 12-grade students with characteristic patterns of externalizing and internalizing disorders.

• Design, test, and install feasible on-demand resources for professional learning for various stakeholders (e.g., administrators, general and special education teachers, related service providers, clinicians from the community, parents, community members, and students) to learn more about the rationale, procedures, and uses for conducting behavior screenings in schools.

• Design, test, and install district-level data structures that enable efficient access by teachers, principals, and district leaders to multiple sources of data (e.g., academic and behavioral screening scores, ODRs, and attendance) in an integrated manner to inform decision making.

• Develop, test, and install effective and socially valid interventions for general and special education communities to support PK-12 students who are experiencing externalizing and internalizing behavior challenges.

Practice

• Select and install systematic screening three times per year (fall, winter, and spring) to support early detection of externalizing and internalizing behavioral challenges as well as academic challenges.

• Provide high-quality, ongoing professional learning to support the installation of systematic screening tools along with explicit instruction on how to use these data to inform instruction and provide tiered supports within the school setting and through community partnerships.

• Build and implement with integrity tiered systems of support composed of evidence-based practices, with data-informed decision making conducted using data from systematic screening tools to connect teachers and students to appropriate supports.

• Commit to a systems change perspective that supports high-quality implementation of systematic screening, honoring the lessons learned from implementation science literature about the time needed (two to three years) for high-fidelity implementation before seeing desired shifts in student performance.

• Create systems for transparency in practices and a fully informed parent/guardian community.

• Develop practices that are responsive to parent/guardian and community concerns.

Policy

• Make transparent state and federal laws that support early detection efforts.

• Enhance communication between education and mental health systems by committing to common language frameworks to ensure transparency and clarity in communication among educators, mental health providers, and families.

• Address issues of funding to provide for students’ access to needed mental health supports within the regular school day.